Live data from Hacker News

The Dark Side of Doctoring

ericlevi.com

61–70 of 241 posts

Re: The Dark Side of Doctoring

#61
post #7

Where does the AMA stand on this?

They actively pursue minimizing the number of medical school seats and their lobbying has been tightly aligned with Republican health care policies for decades. Check out Paul Starr's The Social Transformation of American Medicine

The limiting factor to creating more skilled physicians is not medical school admissions. It's residency training slots. Most residency training slots rely on federal government funding. Pretty much everyone, including the AMA, agrees that there is a looming undersupply of physicians. There may be disagreement on the best way to address the issue, but there is little disagreement among physicians about the fundamental problem.

I have seen comments talking about "physician cartels" purposely encouraging a labor shortage to drive up physician pay. There is no physician cartel. Only about 15% of physicians even belong to the AMA, and only a subset of those have any political involvement at all. It just doesn't exist.

One of the things that I think contributes to the general dissatisfaction of physicians in 2017 is the increasingly negative public opinion of the medical profession and the imputation that there is some sort of evil conspiracy at work. A lot of the negative opinion is misdirected. It should be aimed at the for-profit health care system itself. Most physicians I know have very little control over the things people complain about, including cost.

Re: The Dark Side of Doctoring

#62

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

How much selective pressure do doctors experience on their performance? Healthcare is one of those fields where there's no guarantee on the quality of the service. There's no pay for performance. Actually, doctors who perform too well would reduce healthcare spending. There are plenty of reasons to keep developers happy because it directly affects the end product and profit.

You should do a lot more reading about healthcare if you think there isn't pay for performance. The payers in the system all have massive incentives to reduce healthcare utilization.

Docs and hospitals have been dealing with 'P4P' for decades and the ACA ramped it up significantly for the CMS.

Re: The Dark Side of Doctoring

#63

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

Western medicine has turned into a ponzi scheme. The verifiable proof of this is to have an elderly family member in a nursing home who goes through the usual monthly trips to the hospital from 'falling'. While Medicare covers almost all of it, it became so nauseating to read the outrageous EOB totals that I tried to put a end to it - I requested that unless the on call nurse (after hours) or physician (during busine…

We have two family members in an assisted car facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount.

Oh, but it gets worse. It's bad enough that the government is being bilked for hundreds of thousands of dollars on behalf of those without the ability to pay, but even for those with significant assets, there are "perfectly legal" tax dodges that can be set up for $XX,XXX so that Medicaid pays the $XXX,XXX bills while the family inherits the $X,XXX,XXX estate. And if you pay the lawyers a little more, they can probably even figure out how to avoid paying capital gains on the distributed assets if they are below $10 million.

I don't see much hope for the insurance reform in the US until we can get end-of-life costs under control. I don't if "Ponzi" is quite the right term, but it's definitely a system rife with fraud.

More generally, "House of God" is a stunning inside look on how the US medical system actual works: http://slatestarcodex.com/2016/11/10/book-review-house-of-go...

Re: The Dark Side of Doctoring

#64
post #58
post #52

Here is some context for this article: Dr Levi is n Australian surgeon. He is responding to a letter from the wife of a gastroenterologist who committed suicide recently. Last week was the Royal Australasian College of Surgeons Annual scientific Congress in adelaide so physician wellbeing is well and truly on the radar, in particular following 3 suicides in the last 6-9 months of junior trainees, one of whom was a fr…

I wish I could applaud this. But what sort of professional organisation waits until its members are actually dying before putting well-being in the radar? The RACS, RACP etc are sclerotic organisations run by old white men in bow ties (I've met several of them) with no real incentive to improve conditions for trainees. The only way I have seen actual change happen is when junior staff band together and effectively go…

Couldn't agree with you more re RACS, I attended their 'gala ball' at the end of their ACS last year and was sickened by the pomp and bullshit. The (female) RCS president, visiting from England, also appeared weirded out by the pomp (and that the RACS had not had a female president).

Having said that within both organisations there are people who strongly and fiercely advocate for innovation and change, but you are right, they are severely sclerotic (even to the point of RACS making an absolute motza out of their trainees, they've got over $60m in the bank and our exams cost $4,000)

Re: The Dark Side of Doctoring

#65

The FAA enforces work limitations on pilots, but we schedule our health care workers like this? How are there not even civil cases against errors caused by this kind of administrative foolishness? Overworking doctors like this is insane.

ER doctors work on a shift schedule, which has many documented advantages and disadvantages. Health issues are among the disadvantages. In my opinion, they can be pretty serious. Many medical specialities have concerns with depression and suicide. ER and ICU are among the two with which I have personal experience that face these issues quite acutely. If you have a loved one in one of those departments, the last thing…

Can you go into more detail about this? I'm currently a medical student in the US near the end of my training, and I'm weighing multiple specialties (including ED). From my personal experience in the ED, it's actually the best schedule I've worked. Yes, it's irregular, but you're always working a fixed amount of time per shift and a fixed amount of hours per week (seems to be around 40). You know when you're on, and you know when you're off. Working three 12 hour shifts per week felt very doable. Most other specialties have call at least once a week, and there are days where you end up staying several hours longer than you expected. True weekends (Friday evening through Sunday evening off) seemed uncommon in other specialties as well. Not doubting what you're saying—I'd just like to hear more about your side of things.

Re: The Dark Side of Doctoring

#66

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

There's one big difference between software engineers and healthcare: regulation.

A software engineer is hired for their skills (at least ostensibly). No one is required by law to hire someone with a specific degree and specific post-degree training and specific exams.

Contrast this with healthcare. To do certain sorts of procedures, you have to hire a physician. Not because it's demonstrably necessary to have someone with an MD and a residency in such-and-such area do this, but because it's required by law.

As someone else pointed out, this is just the tip of the iceberg. That residency? Residents have no bargaining leverage over their conditions by fiat of residency rules--they cannot leave an abusive residency, for example, to change conditions. Financing the residency itself? Businesses won't cover the expenses because it's not actually worth the costs, so the government foots the bill. And once you leave residency? Well, subspecialty organizations are deciding that it's good to carve out even more regulatory capture with subspecialty credentialing.

People do not grasp how much of this insanity is codified by law and rule, and when they are informed of it, they shrug it off in the name of "safety." It's like terrorism or crime: no one wants to be branded as soft on terrorism or crime, so the government becomes more and more invasive and draconian, and the costs of maintaining the military-police-industrial complex increase and increase. Similarly, no one wants to be soft on safety, so the government becomes more and more invasive and draconian, and the costs of maintaining the medical organization-physician-insurance-industrial complex increase and increase.

There's something disingenuous for physicians to complain about being overworked, and then fight against the things that would alleviate their burden the most: letting perfectly competent professionals with different backgrounds do what they do just as well. But that would mean admitting that you don't need an MD at the apex of healthcare.

To some extent, financial market pressures are doing what I'm saying anyway, as hospitals are realizing that MDs are too expensive as they are. So maybe this is just the first sign of things to come. But the downside of the current system is that administrators aren't allowed to go elsewhere for alternatives, so they just crank up the hours expected of MDs. The upshot is they get devalued without even being given the benefit of being let off the hook.

I guess to address your comment directly: if healthcare were actually a transparent free market, my guess is physician salaries would go down, but their workload would also decrease also. What you'd see instead is much more diversity in who you see for any given service.

The biggest sin of the government in the healthcare debate is willfully ignoring the costs of healthcare, by failing to increase competition, choice, and transparency in pricing. We talk about who pays, but not why we're being charged what we are, and whether or not it's worth it.

Re: The Dark Side of Doctoring

#67
post #66

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

There's one big difference between software engineers and healthcare: regulation. A software engineer is hired for their skills (at least ostensibly). No one is required by law to hire someone with a specific degree and specific post-degree training and specific exams. Contrast this with healthcare. To do certain sorts of procedures, you have to hire a physician. Not because it's demonstrably necessary to have someon…

I'll just pick up on one piece of what you said, "meds from a psychologist." While I don't disagree that greed may be a part of it, unless that person's extra training involved a medical degree... that's truly been a crazy idea given the things that can go wrong even with "simple" medications, even when you know what questions to ask about other preexisting conditions and how to interpret the answers.

The other thing is that with the current system (i.e. medical doctor prescribes), there's liability coverage through the doc's liability insurance, which unless psychologists are interested in taking on huge liability insurance premiums...

Re: The Dark Side of Doctoring

#68

Earlier quoted context omitted.

There are ~30,000 PGY-1 spots and only about 18,000 allopathic medical school graduates. (1) All the native allopaths and all the osteopaths together can't fill all the residency spots. We inhale foreign medical graduates. (1) Pages v and 14: http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Re...

Wow surprised to see that almost half of all PGY-1 residents are foreign-trained.

Doesn't surprise me in the least. They are taking the leftovers. Modern psychiatry is almost a laughable speciality.

Even the best psychiatrists dole out dubious drugs; hoping the dosage is low enough to not cause serious side effects--while praying the Placebo Effect will kick in.

Now the worst Psychiatrists actually believe these Pharmaceutical Reps.

You spend $400k on getting through Med school--in the US. You're a serious, precise, ethical person. Why would you go into a part of medicine that's still so much of an Art?

You graduate, you pass your boards, you're the king.

You want to help those really at need. You find out quickly that those people have no money. You end up in the rich section of town. You kiss the right MFCC's egos. (The're on a more dubious situation than you. What they do is even more dubious. Talk therapy, and then the CBT. Then it's looking to slide into a dubious 591C3 somewhere, or invented.) If they like you, they will send you patients.

O.k.--you realize those that need the most help don't have the funds. You hang your shingle in a fancy zip code. You listen to bored housewives, and hand out speed to their kids.

"Exactly how am I going to make my "nut"? Oh, drag my patients in for refills, and regurgitate common sence?

It no wonder the average American Scientist(yes--if you finished meds cool on the US, or equivalent country I consider you a Scientist) doesn't want to be a Psychiatryist. Especially at this point in history.

Re: The Dark Side of Doctoring

#69

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

Western medicine has turned into a ponzi scheme. The verifiable proof of this is to have an elderly family member in a nursing home who goes through the usual monthly trips to the hospital from 'falling'. While Medicare covers almost all of it, it became so nauseating to read the outrageous EOB totals that I tried to put a end to it - I requested that unless the on call nurse (after hours) or physician (during busine…

Since Medicare is largely funded by payroll taxes, would you say that this is a wealth transfer from non-healthcare industry workers to the various participants in "the chain" of the healthcare industry?

https://www.medicare.gov/about-us/how-medicare-is-funded/med...

Re: The Dark Side of Doctoring

#70
post #66

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

There's one big difference between software engineers and healthcare: regulation. A software engineer is hired for their skills (at least ostensibly). No one is required by law to hire someone with a specific degree and specific post-degree training and specific exams. Contrast this with healthcare. To do certain sorts of procedures, you have to hire a physician. Not because it's demonstrably necessary to have someon…

I have a hard time believing that the "free market" can solve healthcare given that the demand for it is more inelastic than pretty much any other product.
Post reply on HN