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America’s aging population is leading to a doctor shortage crisis (cnbc.com)
56 points by spking 38 days ago | hide | past | web | favorite | 49 comments



The doctor shortage has to do with the American Medical Associate (AMA), a cartel, that successfully lobbied to reduce the number of residencies available for doctors. They also make it difficult for new medical schools to be created -- this is intentional, since as a cartel they want to limit the number of doctors so that they can demand hire wages.

https://www.forbes.com/2009/08/25/american-medical-associati...


Came here to say the same thing. They were intentionally (and arguably still are) limiting the number of doctors admitted to medical school and number of graduate/medical schools.

https://skeptics.stackexchange.com/questions/4561/does-the-a...


I also heard that doctor's salaries in general are significantly impacted by hospitals and insurance companies and it's hard to make the same sort of money now as you could in the past. Is there any truth to this?


I don't know, but apparently they make a lot more in the United States than in most other countries?

https://journal.practicelink.com/vital-stats/physician-compe...


Usually. But there can be a lot of variation amongst the specialties, to the point where practicing in the US isn’t the best option.


Curious where it isn't the best option. A lot of other countries have more restrictions which forces down wages.

My guess would be somewhere without taxes?


For reference, it's $200-400k base for anybody with a medecine degree right out of school, depending on the specialty. https://h1bdata.info/highestpaidjob.php

If you thought Silicon Valley engineers had it well, think again. The 500-1000k doctors are real and listed right there, unlike the mythical staff engineer who hit the jackpot at a GAFA and can only live in the valley.

Keep in mind that H1B workers are always paid 10-20% less than local workers, so doctors actually make more than these numbers.


I knew a guy who went to Stanford then became a doctor. While his friends were living in luxury in their 20s, he was working 90-100 hours a week and sleeping in a dingy old bed in a hospital room without AC, while he was on call.

It was that point I truly understood what people mean when they say you don't become a doctor for the money.

very few exceptions. Although you do see some in plastic surgery and other cosmetic medical fields.


The cost of their degree is an order of magnitude greater, though.


Is is though? I am not familiar enough with US degrees but I don't think that a master or PhD in medicine is significantly more expensive than in another discipline (computer science, engineering, electronics, maths and statistics if we're talking about the HN and GAFA population).


Yes it is more expensive. “The median cost of medical school attendance, including living expenses, was $60,945 a year for public medical school and $82,278 for private medical school.”

https://www.nytimes.com/2018/08/16/nyregion/nyu-free-tuition...

Effectively all PhD’s in hard sciences are fully funded including a (small but livable) stipend for expenses.


That's also because of the AMA.


What is GAFA?


Yep, everybody and their mother that I went to school with aspired to become a doctor. There should be absolutely no shortage. Getting to more reasonable numbers doesn't seem like it would worsen the already abysmal quality we're getting now with sleepwalking insanely overworked physicians.


>> Yep, everybody and their mother that I went to school with aspired to become a doctor. There should be absolutely no shortage.

There is a shortage...sort of...there is a very limited quota of Medical Resident spots opened up by various AMA medical boards (read: cartel.) There are a line of aspiring physicians, but they can only practice as board certified specialists if the boards open up seats, and there is a forced constrained supply (probably to increase wages for those inside the club.)


Plot a graph:

1970 to now: US Population (or US senior citizen population)

1970 to now: Medical schools

1970 to now: Medical school graduates

1970 to now: Medical Resident spots for "shortage" specialties

I'm willing to bet the shortage is due to these plots not growing proportionally. Also, you cant increase medical school graduates w/o also increasing resident spots, otherwise, graduates go into other fields.


And they actively prevent nurse practitioners and nurses from performing many functions they're perfectly capable of doing.


Such as?


Most, if not all, primary care functions can be performed just as well by nurse practitioners, physician assistants, or other types of providers, especially if you allow for additional postgraduate training.

There are three basic ways the AMA cartel hurts healthcare:

1. First, as others have pointed out, there is an significant artificial restriction in supply of physicians. Many more people could be admitted to medical school, successfully finish training, and practice well than there are now.

2. There's an artificial restriction in the supply of providers, and more deeply, an artificial restriction in the schema we have about who we get services from and how they're trained. The AMA uses FUD to reinforce a model where the only appropriate training model is undergraduate -> MD -> residency -> post residency, and because almost everything pertaining to well-being is health, those who have undergone that training model supercede others regardless of training history.

At least in the US, we don't really question this assumption at all, even though there's no evidence it's superior to a different model that has different routes, like undergraduate -> specialty training -> broadening of training, or undergraduate -> broad non MD medical training -> additional training. Mix and match however you want. Whenever other provider types have broadened their training (dentists, psychologists, optometrists, etc.) there has always been pushback from the AMA, and the scientific evidence has never supported that pushback. So why not allow LPNs, PAs, pharmacists, optometrists, dentists, psychologists, audiologists, etc. to broaden their scope of practice, with the appropriate background and training?

The insistence on the undergrad -> MD -> residency model becomes even more absurd when you consider how brief MD training programs are becoming. It's not uncommon for them to only have 2 or even 1.5 years of academic coursework, with the rest clinical training, so how is that actually different from, say, a PA with additional years of experience in practice? Especially when you consider PA programs often require more medical experience before entering than medical school entrants -- it's all 1.5-2 years of coursework plus years of hands-on supervised clinical training.

3. This cartel actually hurts physicians as well, by increasing their workloads to impossible extents, and by creating artificial restrictions in specialty certification. This gets a lot less attention and is maybe harder to explain, but the licensure and specialty certification requirements are also getting more and more absurd, to the point that in many specialties they no longer realistically reflect actual skill, and are simply ways to further increase the rent-seeking advantages within medicine, and to line the pockets of the AMA and specialty organizations.

Practice and provider regulations, in my opinion, are one of the major drivers of healthcare costs in the US, and it almost never gets any discussion, because it's immediately shutdown. The argument is "if you in any way increase the supply of providers providing care, under any other model than an MD, people will get hurt."

I say this as someone who has worked in healthcare and has many immediate family working in healthcare, in a variety of roles, from nurses, to physicians, to other professional roles.

(See also: opioid crisis and cannabis regulation for how well our current regulatory system is working.)


Thank you very much for adding the necessary color on my one liner!


I don't work in the healthcare industry so I have no skin in the game, but in what situations do you consider labor cartels ok because unions are exactly that and many people here seem to advocate them. Becoming a doctor from what I have read sounds like a horrible return on investment: You have to delay real wages for like 8 years while you get educated, those 8 years make you massively in debt, once you become a doctor, you have to pay off those 8 years of debt while also paying massive insurance rates. I'm not suprised doctors are trying to secure some wages after 8 years of investing in themselves while going massively in debt.


I doubt many on HN of all places are for legally mandated unions, which are the ones that produce true cartel like behavior. Most unions maintain authority through their collective bargaining alone - to abstain from the union would mean the loss of most of your workforce, and thus you must negotiate with the union.

Except if you want to call unions cartels because they negotiate on behalf of their members with employers than anyone trying to barter in business is engaging in cartel like behavior. Its deconstructive because in practice unions only exist to counteract the power imbalance between worker and employer. A cartel in business forms not to counteract power imbalance through collective action but to monopolize existing power.

You might call those origin points irrelevant but they make the world of difference to me. In the absence of unions labor is almost universally exploited. In their presence, businesses are hopefully and sometimes forced to bargain on more equal footing. Thats a net benefit. A business cartel likewise exists to imbalance what was closer to equilibrium and thus is a net negative.


The 8 years could be streamlined but it's setup to weed out many and tire out the remaining. Many of the brightest most curious people get turned off by the process the people that remain are the ones who could stand the beatdown. Then they get out start working and have to see 25,000 people a year (100/day) as a gp.

There is a huge burnout process going on. I see so many doctors try to make a business on shark tank/dragons den work or they try to become media personalities.

Many seem stuck because the job isn't what many would expect. They have invested heavily time/effort in study, they have high debt and they have increased expectations from family/community.


Personally I'd rather they set up a more sustainable training approach - I'm not overly keen on having a doctor who's been "tired" out. I've seen a junior NHS doctor treating a partner in such a state of tiredness that they had to rely on mnemonics and tell us the number of things they'd be checking so that he didn't forget two minutes later and miss any out.


Peter Attia discussed on his podcast a time when he fell asleep and fell on top of a patient while operating on them during his residency. Pretty insanely bad system.


> The 8 years could be streamlined but it's setup to weed out many and tire out the remaining.

Undergraduate medical education in Europe is commonly five or six years so yes, it could really be streamlined. If summers weren’t taken off you could fit medical school into four years. “Weed our and tire out” makes it sound like there are people who drop out of medical school when it barely happens at all.


Dropout rates really changes depending where.

In Canada .5 dropout, in the US 3 1/2%, in the UK 5%. In Canada there are very few spots so the effort to get in and have a way to pay for the education happens before. Once you are in the pressure to remain is extremely high. But 11% still seriously think about quitting.

The decisions and effort need to be put in early in life. Very few go to college and decide to become a doctor. They usually have gone to college to become a doctor and select schools/programs based on that. For some it starts earlier than highschool.

When you finally become a doctor after the lifetime of work the job may not be exactly what was envisioned but it is too late.

Offtopic somewhat: I know of smart people who decided to started programming, drawing/painting, inventing, writing, practicing law after age 35 and are enjoying careers. I know of no doctor ever.. is medicine that difficult for someone past 30?


Maybe they are doing it for a reason? Suppose you are 16 now and choosing a profession. Due to exceptionally long training times for doctors, you will become a doctor so will make good money, by 30, which will be in 2033. By then, most boomers will die off and the demand for doctors will collapse, so you will find yourself will a million dollar student debt and no prospects of employment good enough to repay it.

It's cyclic.


Most of the doctors are boomers themselves and getting retired, or dying as you said. The shortage is not about to get better.


> Most of the doctors are boomers themselves and getting retired, or dying as you said. The shortage is not about to get better.

The market for doctors is fairly constant, it's very difficult to mint new doctors. Even if a state or university went through the enormous undertaking to create a new med-school, they would, at best, create 200-300 new doctors a year, a drop in the bucket.

The real solution is in alternative degrees like Physician Assistants or Nurse Practitioners. They can get degrees at half the cost of doctors and yet do 80% of a doctor's work.

Any real cost reductions in U.S. healthcare will have to include these alternative healthcare providers.


yes. and please let it be noted that MD associations in California opposed a law that would have allowed Nurse Practitioners to operate autonomously (as they do in some states)


> you will find yourself will a million dollar student debt

In USA. Definitely not in EU (currently, although there is a increasing pressure to dismantle and privatize university)

On the other hand, robotic solutions are competing for more and more roles in Hospitals. We have robotic helpers for surgeons yet. At some point in the near future they will start replacing many people and this factor should be included in the picture. Specialists will do online surgeries in all country without spending the time traveling from one hospital to other. The future can need less doctors for treating the same people.


What is the reason for so many doctors coming to the US from India and the Middle East?


the real genius of the AMA was finding a way to drastically slow the global MD population as it tried to correct the imbalance by entering the US and setting up practice.


And yet people like Ben Shapiro continue to insist that it is single payer that will lead to less doctors...

If doctors collectivize, then shouldn’t patients?


I think it'd be best if we removed the power of the AMA; allowed the ability to fast track foreign medical staff (doctors, nurses, specialists).

Allowed medical schools to control their curriculum more, allow new ones, change the residency system.

One simple change would be to create a 6 year BS/MD degree that students could start directly from high school -- many other countries do this.


Single payer in the UK has already led to doctor shortages, so I'm not sure what point you're trying to make.

There's many ways to get to a shortage, cartels and single payer are but two.


It's similarly capped in the UK. Upper middle class always knows how to protect their wages, only programmers want voluntarily more people competing for their wages. It's so welcoming field. Also it costs tons, can't compare it with America but compared to other fields. Hence they import doctors when there are shortages.


> Single payer in the UK has already led to doctor shortages

Source? The only news i've read of shortages are Brexit related.


There have been “shortages” of doctors and nurses forever, the usual newspapers were panicking about it in the 80s (source: was there, read them). Probably someone will be along in a minute to say they remember it from the 60s too!

Fun fact: the doctors were the biggest obstacle to the foundation of the NHS and they disappear into private practice at the first opportunity.


That's a lot of talk. How many people in the UK don't have access to medical care due to, say shortages vs how many in the US die every year b/c they cannot afford care?


It appears that Medicare keeps the fee for an office visit low. This causes the doctors to schedule frequent, short exams. They also do frequent diagnostic tests to increase revenue per visit. Less frequent, more thorough visits would seem to be more efficient for all.

Lots of senior care is pretty elastic, since most visits result in no change in drugs or procedures for the patient. They are simply monitoring chronic and/or progressive conditions.


Well the medical debt bubble has gotta burst eventually. My guess is right before it does the state of healthcare in the US will be so bad that women will be giving birth in minute clinics because everyone will be priced out of hospitals by then. We won't have a shortage of anything until we fix our shortage of insurance providers.


The doctor shortage would be lessened if medical resources were allocated more intelligently. As it is, doctors have a tendency to make work for themselves. The system needs lots of doctors simply to keep their charade going.

We all get to a point where we need less doctoring, not more. During the 'obamacare' debates some stupid politicians called this transition in the goals of treatment "death panels" [1], but the realists on the other side of the aisle didn't figure out how to intelligently point out that sometimes letting people die gracefully is kinder than subjecting them to every possible medical treatment.

My brother works with old people in Arizona. He's paid a salary, and makes a game of trying to spend his employer's resources efficiently. On a recent visit I noted his comment about how he's just doing palliative care. Most doctors aren't on salary, and are paid via the standard medicare "fee-for-service" (FFS) [2] model, which is a good way to make people profitable to their medical providers.

[0] My earlier comment about my mom's elderly friend's predicament: https://news.ycombinator.com/item?id=20224523

[1] https://en.wikipedia.org/wiki/Death_panel

[2] https://en.wikipedia.org/wiki/Fee-for-service


Is it just me that feels like recently the word “crisis” is being overused? not just online but by the media also


Shouldn’t this point to the actual report not thin reporting on its publication?

https://news.aamc.org/content/downloadable/209/ [PDF, by way of CDN redirect]

Or at least the (interested sponsors) press release on the study linked in this news article?

https://news.aamc.org/press-releases/article/2019-workforce-...


Rural America really really needs more doctors. The amount of time it takes to get an appointment to diagnose anything is crazy long already.


Nope there's no doctor shortage. There is hospital administration greed and crappy working conditions where patient throughput is valued above all else leading to doctor burnout. I am angry at whomever wrote this for fueling the wrong argument and possibly trying to detract from the real issue.


The doctor shortage isn't really about hospitals.

It's a huge issue with family and primary care physicians, particularly in rural areas. Paper work requirements and misguided reimbursement goals are making it unsustainable for doctors not involved in large health systems.




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