Hacker News Board Hacker News, browsed like a classic message board
Live data from Hacker News

The Dark Side of Doctoring

ericlevi.com

Post reply on HN
Print view View original

71–80 of 241 posts

Re: The Dark Side of Doctoring

#71

Post by hkmurakami »

nkurz wrote: post #63
karpodiem wrote: post #49

Earlier quoted context omitted.

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…

> 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.

Capital gains costs bases are currently "stepped up" during the estate transfer. No need to pay anything to lawyers. If your estate is below $10.5M (or thereabouts, I forget what the exact number is since it's now inflation adjusted), you won't be liable for any of that capital gains, nor will you owe any estate tax since you're within the exemption.

Re: The Dark Side of Doctoring

#72

Post by hkmurakami »

mikeyouse wrote: post #62
abandonliberty wrote: post #53

Earlier quoted context omitted.

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.

The CJR pay for performance and move to bulk insurance payment is a good illustration of this.

https://innovation.cms.gov/Files/x/cjr-faq.pdf

Re: The Dark Side of Doctoring

#73

Post by atotic »

pc2g4d wrote: post #45

So... because the supply of doctors is restricted but demand for doctors grows proportionally to the population, the amount of work per doctor gradually increases and doctors, persuaded by their ethical obligation of care, put up with it as long as possible until they snap. Yeah? I just recently had a friend completely burn out of medicine, sell his house, and start traveling the world. He was brilliant, a good docto…

My feeling is that we have two opposing modes of work developing:

Scalable work, where tools multiply worker effectiveness exponentially (tech, finance, manufacturing),

Non-scalable work, where tools multiply worker effectiveness linerarly/constant (everything else).

It is a little bit of a Taleb's world where exponentials live side by side normal distribution.

Scalable work is much more profitable than linear work. Where I work, being scaleable is a requirement. If it is not scaleable, we are not doing it.

This creates incentive to make everything scaleable. Which is a big problem for those whose work is inherently linear: teachers, doctors, waiters. They get put in optimization straightjackets for marginal improvement. And it sucks the soul of what they do. It makes world a less happy place, filled with 15min doctor appointments, restaurants where tables must be turned every 2 hours for profitability, etc.

The compound problem for doctors has been that they have to perform highly creative, high impact tasks while inside the optimization straighjacket. That's got to hurt.

Re: The Dark Side of Doctoring

#74

Post by riahi »

killjoywashere wrote: post #35
maxerickson wrote: post #31

Earlier quoted context omitted.

In recent years residency slots have become the bottleneck.

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...

This is a bit more nuanced than this.

There's 31,757 positions offered. However, if you are applying into a specialty, you apply simultaneously for a PGY1 and PGY2 position, so those people are being double counted.

As a result, you need to subtract 2,677 advanced positions from the 31k positions, yielding 29,080 PGY1 + PGY2. There are 18,539 US MD applicants, but with the merger of the ACGME and COCA, DO applicants must be counted, adding 3,590 to the US graduate pile. That gives 22,129 US graduates competing for 29,080 spots. Yeah we take a lot of "foreigners" but a lot of them are actually American citizens who went to school in other countries and many of whom have US medical education debt, 5,069 in fact (look on page 1, "IMGs"). If you add in the IMGs, that's 27198 US graduates and US citizens applying for 29,080 spots. Only space for about 2000 Foreign Medical Grads.

[1] - There are 5346 osteopathic graduates per year. http://www.osteopathic.org/inside-aoa/about/aoa-annual-stati...

Re: The Dark Side of Doctoring

#76

Post by hkmurakami »

djsumdog wrote: post #47
pc2g4d wrote: post #45

So... because the supply of doctors is restricted but demand for doctors grows proportionally to the population, the amount of work per doctor gradually increases and doctors, persuaded by their ethical obligation of care, put up with it as long as possible until they snap. Yeah? I just recently had a friend completely burn out of medicine, sell his house, and start traveling the world. He was brilliant, a good docto…

This is what I felt when I read the article. It was surprised even the Australian system is just as overloaded as our American system. I feel like a lot of these problems could be deal with if there were simply more doctors. That being said, it's a difficult profession. Not a lot of people want to do it. Even fewer in such specialised positions as surgery, where mistakes literally cost people lives. There's no rollin…

>That being said, it's a difficult profession. Not a lot of people want to do it. Even fewer in such specialised positions as surgery, where mistakes literally cost people lives. There's no rolling back to a previous release or taking a break. Everything that happens, happen on that table with that body open.

I recommend reading "When Breath Becomes Air". The author's friend (a general surgeon) has a patient die on the table. He goes into great emotional distress, eventually committing suicide.

Brilliant, good hearted people being pushed to self destruction. Not the way an industry should want to behave.

Re: The Dark Side of Doctoring

#77

Post by pixelmonkey »

kem wrote: post #66
pixelmonkey wrote: post #18

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 think the credentialing in medical practice has more to do with the stakes involved than in some salary-padding or labor-control scheme. Patients want to be able to enter a hospital and have confidence that, when push comes to shove, even the worst MD on call is a better option than a "no-op" treatment.

Also, exorbinant salaries and good hours are not to be found in the hospital system. Yes, specialist doctors get paid "well", but not exorbinantly, when adjusted for required training, education, experience, and opportunity cost. In private practice, the hours are better, yes -- but only in certain subspecialties. But this is like saying major airline commercial pilots should just fly private charters for a better lifestyle, or that software engineers should just work at hedge funds as quants for better compensation.

It's the hospital system, not private practice, that shows us a healthcare system where doctors are being put to their unique purpose of advanced clinical treatment. And that's where the market is failing.

Healthcare requires the hospital system to provide the most advanced and emergent forms of care, and that is where doctors are overworked and undervalued.

As for the free market, I wish you were right that it could fix the US healthcare system. But patient health is, unfortunately, not valued correctly by the market. The market rewards chronic treatment, whereas society prefers one-time cures. The market tries to monetize patient-doctor interactions, whereas society would prefer fewer doctor visits with fewer hospitalizations. The market treats doctors as a cost center whose hours needs to be billed out at a profit, and society would prefer doctors as a value center who are given the professional leeway to use clinical judgment in assigning time to cases and patients.

I love market systems, but only when they work.

Re: The Dark Side of Doctoring

#78

Post by zdw »

ploxiln wrote: post #15
aabajian wrote: post #6

It's worth noting that the incredible success of Epic EMR software is because it tightly controls all of the administrative billing issues, NOT because it makes clinician's lives easier. There are endless check boxes in Epic and each site has its own interface. It's a huge mess and difficult to navigate...but arguably still better than the other vendors.

... sounds like the medical equivalent of Jira ...

As someone who has used both, Jira is lightyears ahead of Epic, which still requires a Windows TS session to run properly, and for many administrative or complex operations still requires you to drop into the MUMPS backend environment, which is >50 years old and predates Fortran.

Re: The Dark Side of Doctoring

#79

Post by nkurz »

hkmurakami wrote: post #71
nkurz wrote: post #63

Earlier quoted context omitted.

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…

> 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. Capital gains costs bases are currently "stepped up" during the estate transfer. No need to pay anything to lawyers. If your estate is below $10.5M (or thereabouts, I forget what the exact number is since it's now inflation adjusted), you won't be lia…

Yes, but I think the trickiness is combining this with the combination of revocable and irrevocable trusts that "protects" the assets from Medicare. Although it's possible that in the case I'm aware of, it's NY state and city rules that required the additional layers. My main point is that the current system is designed so that it can be gamed by those with the money to pay the lawyers, and the lawyers have enough influence to keep the system broken such that they continue to benefit.

Despite this, do read "House of God" --- it's a terrifying and eye-opening book!

Re: The Dark Side of Doctoring

#80

Post by [deleted] »

killjoywashere wrote: post #35
maxerickson wrote: post #31

Earlier quoted context omitted.

In recent years residency slots have become the bottleneck.

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...

[deleted]
Post reply on HN