Generally, rare goods - and skills - are valuable. So going to school for a long time to learn an unusual skill well means that your services are more valuable.
Also, providing a large amount of value in a small amount of time (like accurately interpreting the results of a scan) leads to providing huge amounts of value over the course of a year. Part of the explanation is the sheer volume of individuals he can give a reasonable amount of value to.
Wouldn't radiological and physician services, in general, be less "rare" if medical schools started to train more physicians (admit more students)? I have read studies that suggest that in certain markets and certain practice specialties we are and will face shortages of physicians in part because medical schools are training too few physicians. When I ask academic physicians they seem to think admitting more students would erode the quality of students. In other words, scarcity is a public good in this case as it helps to ensure that the "most talented" will ultimately become practitioners. I don't know how this view squares with the large number of foreign-trained residents in some residency programs.
The Planet Money podcast covered this topic once. In proper markets, increasing the supply of a good or service decreases its cost. However, in the US, the more doctors we train, the more we spend on healthcare.
A reason this is the case is because the average healthcare consumer is totally removed from the cost of healthcare and the doctor has a perverse incentive to make work for him or herself and other specialists.
Right idea, but wrong bottleneck. Admitting more students to medical school would enlarge the pool of applicants to Rads residency, but it would by no means force Rads programs to admit more applicants.
So going to school for a long time to learn an unusual skill well means that your services are more valuable.
It's only a rare skill because of licensing/board requirements. I'm fairly certain if you told other people they could make $250k as a radiologist, they could self-teach.
The same thing could be said of programming if the only people that could practice had to be certified.
This may be possible in some medical fields (I doubt it), but not radiology. There is simply too much to learn. I completed 4 years of medical school followed by a 5 year residency. Some radiologists go through additional sub-specialty training. I've been practicing for 5+ years, and I'm still learning everyday.
I am a doctor's doctor, meaning my customers are doctors from every specialty, who order studies and read my reports looking for answers they can't answer clinically. I can talk to Orthopedic surgeons in their language, Neurologists in theirs, and Gastroenterologists in theirs. I'm familiar with the radiological manifestation of most pathological processes a human can experience.
The notion that someone could self-teach what I know seems impossible.
There are licensing and board requirements, but conspiracy theories aside they are not designed to create artificial scarcity, they're supposed to keep dangerously ignorant doctors from practicing.
This may be possible in some medical fields (I doubt it), but not radiology. There is simply too much to learn. I completed 4 years of medical school followed by a 5 year residency. Some radiologists go through additional sub-specialty training. I've been practicing for 5+ years, and I'm still learning everyday.
But what can you say that about? I did 4 years undergrad in CS, followed by 5 years for a PhD. Followed by more than a decade in industry. And I still learn everyday too.
The notion that someone could self-teach what I know seems impossible.
I should be clear, as the term is ambiguous, they'd likely learn from experts, but not by going to a board approved medical school. But through things like online schools, programs, books, etc... It wouldn't be someone trying to recreate a curriculum from scratch.
There are licensing and board requirements, but conspiracy theories aside they are not designed to create artificial scarcity, they're supposed to keep dangerously ignorant doctors from practicing.
Given the lack of policing after becoming a doctor I'm skeptical of this claim. At the college level I'd like to see a wider swath let in to medical school, and then a more rigorous approach to filterning, based on not only medical proficiency, but ethics. The big problem I see with doctors isn't in expertise or proficiency, but in ethics.
And given the data on sleep deprivation and learning, I think loosening the requirements even a tad would result in less scarcity and better prepared doctors on average.
Radiology is a very difficult field to get into after medical school, something like 2/3 of American grads who apply get turned away. Additionally, for those who get in, up to 1/3 never pass all the board exams. It almost seems like you want to lower the bar, and I'm telling you it needs to be raised.
My guess is that if your system was developed and worked, the intelligence and drive required to complete it, the time spent studying and working to become competent in radiology would end up being no different than the current system. There are no short cuts.
"Radiology is a very difficult field to get into after medical school, something like 2/3 of American grads who apply get turned away."
I don't agree with kenjackson that the field can be self-taught, but saying that most people don't get into Radiology residencies tells me only that there aren't enough Radiology residencies to go around. The 1/3 board failure rate notwithstanding, my intuition is that there are far more people capable of practicing radiology than are currently allowed to try to get into the field. The intelligence level of medical students does not exceed that of PhD students in engineering, math, chemistry, etc., but the medical profession puts up much, much higher economic barriers to entry.
If the government decided to tax radiology providers and use the profits to increase the number of radiology residencies by 10 or 100-fold, I find it hard to believe that the lucrative profit margins of your industry wouldn't decline. Medicare reimbursement rates would go down as the number of providers increased.
Radiology is a very difficult field to get into after medical school, something like 2/3 of American grads who apply get turned away. Additionally, for those who get in, up to 1/3 never pass all the board exams. It almost seems like you want to lower the bar, and I'm telling you it needs to be raised.
All you've said is that some tests aren't being passed. Can you correlate them with improved medical care? Again, in my alternate world, I can construct a CS test that 90% of those w/ undergrad CS degrees would fail. That's not hard to do. The question is "does my ability to pass such a test correlate with my ability to do a website?"
You're pointing to scarcity and arguing that this is proof that we require scarcity. I'm saying that if you dropped the bar on these tests, but increased other policing practices that yielded a net increase in the number of doctors, I think you'd see an increase in medical care. My thesis is purely speculative, I grant you that.
I suspect we're likely to find out if this does work out in non-US countries once as medical information and training becomes more prevalent on the web.
Of course, I cannot prove that the tests insure quality. In fact, this is not what the radiology board exam does.
The board exam is designed to weed out dangerous doctors, which is probably the best we can hope for. So, I guess you can take my word for it or not, but dropping the bar at all would let dangerous people practice, which I see as a mistake. The people that I know who failed the exam should not be working in Radiology.
>There are licensing and board requirements, but conspiracy theories aside they are not designed to create artificial scarcity, they're supposed to keep dangerously ignorant doctors from practicing.
Thanks for the comments in this thread, they've been very informative.
I'm happy there are certifications, and I believe you that the bar should be raised, but given the huge demand for doctors, why aren't we increasing the number of medical schools?
If we have a supply problem, and we don't want to lower the bar, it seems like the answer is to let more people in at the front end, and let the filter do its job.
Just wanted to point out that while it may seem intuitive that increased supply = cheaper prices, thats not how it works with doctors
Doctors have the ability and incentive to increase demand, and I remember seeing data that this is what actually happens historically when you increase doctor supply.
How do these ability manifest? I suspect what you might be seeing is latest demand. There are a lot of people that would see the doctor more often, but often don't due to prices. Once access and prices become more reasonable they seek out medical services they normally wouldn't have.
Or doctors see their profit-margins / wages declining, and lower the threshold level for various kinds of specialised testing. So, you complain about a mole or a lump, and instead of a quick diagnostic poke and an "It's probably fine", it's off for an invasive biopsy, "Hmm, the results were inconclusive, better safe than sorry" surgical removal, and maybe a few extra scans for follow-up.
I'm sure that there a many areas where a GP would like to schedule a follow-up, but can't justify it on the current evidence, and lets it slide.
Because there's this level of subjectivity in medicine, any increase in supply can easily be countered by the suppliers pumping up demand, keeping D/S exactly the same.
(I'm not a doctor, although I'm friends with a few)
I'd argue this happens today at almost the maximal level they can extract. In fact this was my point earlier. The problem with doctor's is less proficiency, but more ethics. I honestly have more faith in my car mechanic than virtually any doctor I've worked with. I'm not sure how increasing supply can make an already worst problem worse -- except to expose more people to it.
I really, really don't think that's true. Most people are not able to do this, and most of those few who could don't want to put themselves through it.
And then separately, how many people would trust a self-taught diagnostician?
Most people are not able to do this, and most of those few who could don't want to put themselves through it.
Most people don't have to be able to do it, just more than are allowed to do it now, but a factor of say 10.
Furthermore, I don't think people would necessarily need to go through med school and residency.
It's like building a website. There's probably some parallel universe where programming requires certification and only a handful of schools have it. It requires doing MITs SICP as the intro course. Requires compiler construction courses, algorithms, theory of computation and complexity, etc... And then a 4 year apprenticeship with other programmers. And then you can start building webpages, if that's what you want to do.
But we live in a world where it is open and so there's instruction available at many different levels. Would you let someone without a PhD in CS build your website? Of course you would.
And then separately, how many people would trust a self-taught diagnostician?
I trust my car mechanics diagnosis despite the fact I have no idea what level of education he has. But I'm fairly certain he's not an ME from MIT or Berkeley. With good self-study tools, I think that one can self-teach in specialized areas and achieve good mastery rather efficiently. I could imagine Khan Academy for Radiology taught by JHU and Harvard professors to be quite good.
> I could imagine Khan Academy for Radiology taught by JHU and Harvard professors to be quite good.
You have got to be kidding me. How would this work for surgery? There are no short cuts to medical competency.
Sure, some of what I do is self-taught, I read books and articles, attend conferences, and complete Continuing Medical Education requirements. But I am able to do this because I attended medical school, then spent five years sitting less than a foot from experienced radiologists while they worked and answered every question I had.
Characterizing it as a "short cut" is disingenuous.
The argument here is that medical boards are too rigorous, and test things that do not matter practically.
To give a ridiculous example, if a medical school required you to climb Mount Everest before becoming a doctor that might result in only 1 person becoming a doctor per year. However that scarcity isn't proof that climbing Mount Everest is needed to become a doctor. Nor is it proof that cutting out that requirement will provide significantly worse doctors than previous.
Additionally, in many things we need quantity more than we need extreme compentancy. For example when cut, its better to have some kind of treatment (e.g. first aid, stitching) rather than waiting for a surgical specialist.
In fact, the medical licensing exams and board exams are too lenient. The general quality of people going to medical school in the US has been dropping for a generation. The standards are sliding, to our detriment.
I'd be quite interested to see evidence to support this assertion. Or is it just generally the case that everyone sees Osler's days as medicine's primetime, with a long slide since then?
I don't have any hard evidence, but I insist that it is true.
Bright and determined baby-boomers became doctors and lawyers and accountants. Today smart and determined people aren't even going to college. The HN demographic is a perfect example of this.
Intuitively, I think I get a different sense of the HN demographic. It's one thing to say that the brightest aren't going to medical school. It's another thing to say that the best and brightest aren't even going to college.
I might argue that going to college is no longer necessary for the purpose of learning, because the material is so widely available. Even though I think that's true (for some fields), I still wouldn't advise people not to go to college because of the signaling problem (which one then has to sidestep by starting their own business or by contributing impressively in open source, etc).
I get hyperbole for the purpose of making a point, but if you go too far, you come off sounding a bit incredible.
Have you seen a typical medical school class recently? The people getting in these days is almost shocking. I have a hard time believing that qualified people are being shut out of admission.
Yes? I mean, I am a medical student, and I'm routinely impressed by my peers. But I'm not trying to claim that my peers are better than their predecessors. I'm just doubting your assertion that medical students now are worse than before. The null hypothesis certainly is that things are the same as they always were.
Instead of writing out a long response, I'll just point out that to compare building websites with diagnosing life-threatening illness many times a day is pretty ridiculous.
Of course you don't need to have gone to MIT, etc to build a website. The room for error is just many many orders of magnitude different between that and radiology. There's a reason you don't generally hire self taught code monkeys to build software with real-time or life-ensuring requirements.
Demand isn't just about how many people want it (although a little competition is good), it's also about how much each person wants it. It seems like medical diagnosis could command a high price, even if only one person needed it.
Also, providing a large amount of value in a small amount of time (like accurately interpreting the results of a scan) leads to providing huge amounts of value over the course of a year. Part of the explanation is the sheer volume of individuals he can give a reasonable amount of value to.