Posted by Danhale93 1 day ago
There are exceptions of course but when my brother was considering medical school he visited about 10 different top physicians to seek input and advice and nearly all said if given a Time Machine they wouldn’t do it all over again. That was a real wake up call.
If you go into medicine as a business entrepreneur and build a successful medical business then there’s opportunities for one to still taste some of the glory of the medical profession that once was. Outside that it’s basically a reasonably well paid life of indentured servitude. Yes you’re “helping people” but that only carries you so far which is why so many just burn out and leave.
Massive reform is needed but the powers that be between the AMA and insurance companies seem unlikely to let that change happen unless it’s forced on them by Congress, and that too seems unlikely for now. Something more alike to an apprenticeship model where one grows up from EMT, to nurse, to physician fits the current business model much better than trying to preserve the old world “Officer vs enlisted” model where folks enter the profession directly as officers (physicians).
That's no where near true for a mid level developer or most tech execs or most senior developers. If you exclude faangs a top developer doesn't make as much as a doctor.
You cannot compare the median physician who endured the years of grueling med school and residency to an average developer. FAANG is probably a more apt comparison.
If you want to compare FAANG engineers to doctors the most accurate comparison is to the top 10%.
Those developers are almost all concentrated in extremely high cost of living cities as well.
Physicians also get special loan programs, better insurance rates etc…
People on HN vastly overestimate SWE pay as an industry, biased by FAANG as we are :).
It's the difference between compound interest working for you vs compound interest working against you.
I still don't know what my own objective function is.
It does, actually.
Physicians have high early career earnings. It’s not like grinding your way up the ladder until you get paid a lot.
Developers only make more if you only look at the very top end. Like a Stanford grad who goes straight to FAANG earning $200K the day after they graduate.
Developer compensation talk always gets biased toward top companies and high cost areas. The median developer or even top 10% developer isn’t living in the Bay Area working at FAANG, but that’s what gets talked about.
That's what should be talked about in comparison to doctors. A FAANG position is comparable to the level of effort, competition, and accomplishment involved in becoming a doctor.
On the other hand, the "median healthcare professional" (counting only those requiring a college education) is a registered nurse, and that's the healthcare profession most comparable to the median developer in education, competition, and income.
The FAANG equivalent of being a doctor are select professions that pay a lot.
Comparing Bay Area salaries to the median across the country is the second fallacy.
Both made it through the first filter (admission to medical school/being hired at FAANG), then succeeded so well in the early stages (med school/junior employee) that they were chosen for those coveted positions.
If you aspire to work at FAANG and fail you can be a software developer somewhere else. If you aspire to be a doctor and aren't admitted to med school, those years of education, volunteering, shadowing, test prep, etc. are fairly useless.
And even if you succeed, the hours are as bad as can be and the pay isn't much better than FAANG. It's not a logical choice unless you really want it, while software dev is (was?) a great career choice even if you don't care about software.
For all these reasons, a lot of people are filtered out long before applying to med school.
It’s more selective. So comparing FAANG salaries to the average doctor salary isn’t useful. To find something equally selective, you’d need to pick a higher paid subset of doctors.
In the same way, there are many filters before filling out a med school application.
Anyway I can't see any way anyone could believe the "median software developer" writing CRUD web pages or in-house apps is comparable to the average physician.
I live in a capital city of 60,000. Unemployment 4.5%, median household $79,000. Here, you're not seeing >$150K in IT unless you're a Director, or more likely a VP level employee.
Conversely, I drive by multiple homes that are being built or were recently built by physicians living in the area that are in the $2M range (our median home price in the area is just under $530K.
You can't say "the subset of one thing compared to the spectrum of another", because testers, tech writers (the "median IT professional") are not generally clearing high six digits even at FAANG (well, Netflix maybe, which is an outlier of an outlier).
Where are testers and tech writers the median (50th percentile) jobs in IT?
... and they're variably being compared to physicians, specialists, "median healthcare professionals" (whatever that means).
I'm more breaking up that these comparisons... don't really make a lot of sense, the way many of the arguments here are going.
But this being a forum for software engineers, the discussion naturally has a lot of content about that group. And many average software engineers, with a bit of amusing hubris, apparently think they are roughly comparable to physicians.
(Actually, they may be in terms of raw intelligence. You don't have to be a genius to become a doctor. But on average they aren't in the same league in terms of work ethic and dedication.)
You have to be living in a VHCOL to get that, but if you make >$300k TC you are outearning most doctors.
Damn really? Years ago I saw a post of someone asking for advice. They had been offered two positions on in SF at ~$500,000 another in Minnesota at $300,000. Granted they were an anesthesiologist, but a few years back I met a doctor in a bar (lol) and they were telling me you can clear half a million as a GP if you're willing to work in rural states with a big shortage.
There must be one mother of a guild protecting anaesthesiologists supply in the USA. Where I live, the governments (ie the people who are supposed to represent the other 99.999% of people who aren't anaesthesiologists) ruthlessly crush such behaviour in any profession that lets it become a real problem. We've fired most airline pilots and imported them, live without electricity for a while, imported doctors from anywhere and everywhere until the medical admission boards got the hint.
The USA really needs to get itself a decent democracy, where the pollies actually represent the people who elected them.
Some of the best and brightest definitely are getting discouraged, I too have similar personal anecdotes from my daughter's peers. But anecdote does not necessarily correspond to data. Competition for spots is the data.
> burn out and leave.
Here the data definitely supports your argument. Doctors are leaving the industry at far younger ages than they did in the past.
https://www.aamc.org/news/medical-school-enrollment-reaches-...
Maybe no one should be tortured by those metrics
And do they have experience working any other job as a comparables? The question you ask is the equivalent of saying do you think there are better jobs out there? Being a doctor is about the lowest risk job you can get if you are smart and capable. You get high status in society, excellent paycheck and on net are helping people.
I know a doctor and a couple PAs and RNs who have left the profession. The US medical industry is horrible to everyone involved, except the hospital and insurance profits.
I can't stress this enough: a percentage of executive bonuses should absolutely go toward employee bonuses to boost morale especially if everyone's end goal is automation.
Ok but the writing is on the wall for that mid-level developer. He'll get laid off next week and replaced with an AI agent or dirt cheap offshore team.
The doctor seems like a safer choice now.
I used to enjoy this blog:
https://web.archive.org/web/20101218031844/http://www.medsch...
This dude hated US medical school and it shows. I can't blame him, either.
> the powers that be between the AMA
AMA is working to keep salaries high. That's the only reason why this profession is still attractive. Probably unwise to change that.
Yes, but: that's an even narrower elite group than doctors.
I’ve had access to various compensation data products and I’ve done hiring at distributed companies across dozens of US states. This is not true unless you’re defining “decent mid-level” as working for FAANG. Conversations about developer comp always get skewed toward the top end for top 5-10% devs, with the median numbers being a lot lower.
> If you go into medicine as a business entrepreneur and build a successful medical business then there’s opportunities for one to still taste some of the glory of the medical profession that once was.
I don’t know what you mean by “glory of the medical profession” if your definition of achieving it is… not being a medical professional?
Are you just talking about the money and social prestige that comes from being wealthy? The medical professionals I know didn’t go into the career because they wanted to maximize salaries. The days of becoming a physician primarily to seek money and social status are dwindling because there are better ways to make a lot of money where you get to sit at a desk and write emails, and honestly that may not be a bad thing. Let those people go be lawyers and finance bros or mediocre product managers.
I know personally of one big famous tech firm that has QA devs making literal minimum wage, because they are contracted from an outsourced firm. But 100% of those people's work is directed by and exclusively for the big tech firm so like all contracting it is an obvious paperwork scam to just mistreat their workers.
What the author of article is describing is just bureaucracy ever expanding (anyone who’s worked at the same place for a decade knows that bureaucracy rarely gets better), mostly decided by mediocre admin people who have never heard of Goodheart’s law. Bureaucrats loves KPIs, shitty average metrics (because distributions are hard to understand for bureaucrats for some reason), and generally does not have to field the consequences of their actions (notably because they don’t measure them!).
There's no solution other than training a lot, lot, lot, lot more doctors.
Their salaries need to be lower, training needs to be cheaper and faster, and we need a lot more of them.
Speaking from Romania: here medicine is prestigious. So many parents push their kids towards medicine. There's a glut of newly minted doctors every year, but rumour has it that the quality drops every year. Sure, they pass the exams and residency and what not, but... They're just not into medicine as much.
Do you want to get treated by such a person?
This year I had to go to a neurologist. I went to one locally, they dismissed me in 5 minutes, told me to take some vitamins basically. Went to another one in a much bigger city, they talked to me for an hour, ordered a ton of tests.
Would it help if we get a lot more of the first kind of doctors?
The prior post was specifically talking about the US. (I assure you, arrogant dismissive doctors are also a thing in the US)
In the US, there are a number of things that artificially increase the barriers to becoming a doctor.
1) You typically need a four year college degree to apply to medical school
2) Medical schools are accredited by the AMA, which is controlled by doctors. The AMA makes it very difficult to start a new MD-granting medical school.
3) Medical school in the US is very competitive to get in. They are likely turning away a lot of people who could complete the degree.
4) Since 1997, the federal government has a fixed number of Medicare (Medicare is a federal health insurance program for people over 65) supported residency positions. That number was basically flat for 25 years. We lost about 20% per capita of doctors being trained with support from this program. The caveat to this is that the total number of residents per capita has increased over time, particularly the past 15 years or so. My understanding is that they are less likely to be fully funded, so they spend more money getting trained, and then have higher students loans (on average graduating with debt above 200k going back to the late 2000s) that they need to pay off, so they charge more.
And you can add to this that it can be very difficult to be a doctor in another country and come to the US to practice here.
There are arguments that these are factors that filter out the people who are not sufficiently motivated, but it's hard for me to imagine there aren't a lot of bright young people who might be interested in medicine, but see one of the various paths that exist today to making doctor-level money with only an undergraduate degree and in an environment that doesn't require a working schedule that actively harms your health.
The entire salary for the resident can be earned back in 3-4 days. You still have 360 days left to pay back admin overhead, facility overhead, supplies, etc. That is earned back in the next several weeks. After that, the next ~300 days of the year are profit.
In states with balance billing, the doctor can set any price and bill you for the remaining figure with a balance bill. In NY and NJ these can be thousands or tens of thousands. If you dont pay, it goes to collection and the provider still gets 10 to 15 cents on the dollar. So no...the $75k annual salary of a resident is not a barrier to training more doctors according to any math i'm seeing. What am I missing?
What seems more likely is that supply is artificially constrained to increase scarcity and prices.
Several things.
First, private practice docs see patients with very good employer provided insurance, but residents are largely seeing patients that private practices wont see - patients who are far too medically complex to fit into a 10 minute slot and who also have particularly stingy insurance.
So as opposed to a private practice doc who is seeing 30 patients per day and billing an a average of $250 to $300 per patient (certainly not $1000 - that is unrealistic in my experience), a resident is seeing more like 10 to 15 patients per day (30 minute slots) and billing less than $100 per patient.
Second, residents have to be supervised. You have not included the salary of the physicians supervising them in your calculation.
Third, and I have mentioned this many times before on HN, training is limited by chiefly by the number of training sites that can offer quality training. For example, most hospitals will not see a single case of Guillan-Barre in a single year. Would you want to be treated by a nuerologist who trained at such a hospital? This is why neurology training is generally limited to places with a high volume of neurologic cases that would be considered rare at the average hospital, and these hospitals can only accommodate so many residents. Even for general medicine, you probably do not want to be treated by a doctor who trained at a hospital where any case that passed a certain complexity was transferred out to a bigger center.
Anyone here should be familiar with the ""sAfEtY"" argument at this point.
In my country, there's a big feud between cardiologists and radiologists right now, big enough to be a regular topic in national media. Inside sources tell me it has nothing to do with quality of care, and is entirely about the march of technology allowing radiologists to perform some diagnostics that previously required cardiological procedures, and those procedures happened to be the major funding source for the cardiology departments.
In the US, medical school is extremely expensive (like $400,000 expensive). There are many people who are excellent doctors who are just priced out of the profession. If we could make medical school less expensive (by subsidizing it and by reducing the amount of instruction), we would probably get many more excellent doctors.
We have the Public Service Loan Forgiveness program where qualifying public servants pay 10 years of their loans and the rest is forgiven tax free.
Removing financial stress from doctors seems like a public good most people could get behind
You do the math: over a 10 year repayment period with compound interest, their education cost them MILLIONS and they'll be well into their 40s before they start saving a dime for retirement. The cost and scarcity of medical education is extremely punitive to doctors and prices out many would-be great physicians. Many I know who have gone through this ended up regretting it due to the enormous financial burden they are saddled with for many years after becoming an attending.
Maybe folks believe these professions should be reserved to those who inherit great amounts of generational wealth.
The average debt is a little over $200k. Only 30% of graduates have over $300k in debt and they are considered high debt graduates.
Family Medicine salaries are above $200k in every state in the nation for full time doctors.
None of the doctors I know come from families with generational wealth.
Here is the nationwide average for resident salaries by year and its higher in higher cost of living areas.
Program year 1—$68,166.
Program year 2—$70,499.
Program year 3—$73,301.
Program year 4—$77,593.
Program year 5—$81,807.
Program year 6—$84,744.
Program year 7—$89,187.
Program year 8—$94,215.
Your entire picture is inaccurate.
The resident salaries that you listed are an average taken across all specialties. Family Medicine is the lowest paid specialty with 2026 PGY-1 salaries at $58,500 (representing an increase of over 15% since 2021) [2] That is simply not enough to pay the cost of living in a state like Massachusetts where the median household income is more than double that [3] and the average rent in Boston metro is almost $40,000 annually [4]. Not only can you not afford to pay down your student loan debt, you are extremely likely to accrue additional consumer debt on things like credits cards or vehicles.
My main point is that training to become a doctor carries so much financial risk that it selects against folks from poor socioeconomic backgrounds that would otherwise make great physicians. In 2018 the AAMC published a study showing that 51% of medical school matriculants were from families in the top quintile for family income [5] and if I were a betting man, I'd guess that proportion has only increased.
1. https://www.kff.org/state-health-policy-data/state-indicator...
2. https://www.inspiraadvantage.com/blog/how-much-do-medical-re...
3. https://fred.stlouisfed.org/series/MEHOINUSMAA672N
4. https://www.zillow.com/rental-manager/market-trends/boston-m...
Sure. But that’s not what you said. You said you had many fiends that graduated med school with $500k-$750k in debt. I think you were lying or your definition of many was highly exaggerated.
> That is simply not enough to pay the cost of living in a state like Massachusetts
$58k is the national average. Not the average in a high cost of living area like Massachusetts.
> My main point is that training to become a doctor carries so much financial risk that it selects against folks from poor socioeconomic backgrounds that would otherwise make great physicians.
There is almost zero financial risk.
Eventual graduation rate is 96%. Eventual match rate is around 99%.
Are there doctors that could have make more money going into finance sure. Are there doctors who are financially ruined, not meaningfully.
>In 2018 the AAMC published a study showing that 51% of medical school matriculants were from families in the top quintile for family income
1. Doctors kids are more likely to become doctors.
2. High income is correlated with intelligence and intelligence is partially heritable.
3. Kids from high income families are more likely to have extended family and friends who are editors who encourage them to become doctors.
4. Med school requires college and college and children from income families are much more likely to have college degrees.
5. Medical school entrance is competitive and high income kids are much more likely to go to better colleges.
6. High income kids are much more likely to have higher grades in college because they don’t have to work.
7. High income kids are much more likely to go to better high schools which impacts what college they get into and how well they do there.
The list goes on and on. The cost of medical school is so far down that list.
https://www.reddit.com/r/whitecoatinvestor/comments/1jayeai/...
Residency match rates for American graduates from American MD or DO programs are more like 93%. Also worth considering that thousands of Americans go abroad for medical school due to limited seats in the US. For American IMGs the match rate is only 70%. If you dig into things a little bit further, it’s actually worse than that because the figures do not include applicants who did not submit a rank list because they did not receive any interviews.
I agree that the vast majority are able to match into a residency program, but I certainly would not consider that “almost zero financial risk”
https://www.nrmp.org/about/news/2026/03/nrmp-releases-result...
Also the bottleneck is residency slots, so even if this is the case, it wouldn’t change anything.
The average med school debt is half that and only 30% of borrowers end up owning $300k or more.
Fewer than 1% of us med school graduates never find a slot. And that includes people who start families, move into industry etc and voluntarily leave.
The bottleneck is residency slots not med school slots.
Right, because they are paying for it out of pocket
https://students-residents.aamc.org/medical-school-admission...
Hard to tell when you don't let us know which of those doctors ended up solving the issues that made you seek a doctor.
Dismissive doctors are bad but so are those that waste your time and risk complications from unnecessary invasive tests.
Depends? Did the tests actually find anything, or did they just make you feel better?
I had a talk with my GP about this at some point, and he more or less told me that he can just say "Go home, rest, come back in two weeks if it doesn't get better.", and 95% of the time that'll be exactly what is necessary. The hard part of his job is figuring out which of the visits are those 5%.
Speaking from Poland, we see the same outcome: doctors rushing patients out after 5 minutes. The reasons may be different, though: since COVID, many doctors here have, in my view, become more arrogant and focused on money. Over the past few months, an uproar over doctors’ pay has swept through Polish social media.
Reports have emerged of doctors billing for overlapping work under multiple contracts. In one case, a doctor’s records showed 72 hours of work in a single day!
Meanwhile, the Polish Chamber of Physicians and Dentists (NIL) continues to defend caps on medical school admissions, adding fuel to the national debate.
We actually do have a better model in the form of physician assistants. They're taught the same kinds of things physicians are taught, just in less depth.
AI isn't perfect, but even loosely scaffolded generalist systems show promise in the field of medicine now. And the alternative isn't some hypothetical "perfect healthcare" - the status quo is often closer to "nurses running near the limits of their competence" or "physicians stretched thin almost to the breaking point".
The fundamental problem of healthcare is that it struggles to scale. The need for well educated, well paid professionals is inescapable. Or, was inescapable? We might be at the point where this can start changing.
I would say not much. AI is still often wrong and a clinician needs to know when the LLM is saying something crazy. I think AI has the most promise for increasing the productivity of well trained professionals, not replacing them (or their training) entirely.
Are AIs wrong more often or less often?
Would the healthcare get better or worse if the "first opinion" was AI more often than not?
"Increasing the productivity" and "replacing them" is two sides of the same coin. If a human can do five times the work, because AI does most of the work and the human performs "exception handling"? You need less humans. And healthcare, historically, is almost always human-constrained. That's why you get insane wait times and overworked clinicians. Most other inputs scale more readily than human expertise.
Thus the impetus to figure out where "human expertise" can be substituted for that of a scalable machine system - and what would be the best ways to implement that.
I'd argue they aren't being factored into automation land if they're still the responsibility of a human expert, even if there are fewer more productive human experts.
(Though I do think AI will have a role in pathophysiology and pharmacology, initially catching errors, and probably some day taking responsibility, but not soon.)
lmao even
I'll give you some N=1 sample on older doctors since I'm also from Romania: a lot of these older doctors haven't opened a book in a very long time and are still using older practices instead of providing their patients with the latest and most effective treatments available because they're too lazy and/or prestigious to go and learn new things. Would you say that they "into medicine"?
> Would it help if we get a lot more of the first kind of doctors?
It would certainly help hypochondriacs a lot. Ordering "a ton of tests" needs to have some basis behind it, and doing it just to make the patient "feel seen" is not a great way to do your profession. People being dismissed quickly also happens in the US quite a lot, sometimes with disastrous results though it's not incredibly common, it's typically labeled under "diagnostic error" https://qualitysafety.bmj.com/content/23/9/727.long
Earlier you just need to find a doctor and they were probably good. Now you have to take your luck with many till you find a good one (if you are still alive by then)..
I don't know why people think that they can mass produce competence..
I have the impression that some people imagine that you can produce now 10x more doctors at the same cost that you were producing one doctor 10 years ago. Mostly because some tasks (even programming) got many times "more efficient" I feel people transfer to easy to other topics.
Even worse, education expenditure is decreasing for many countries! (see some examples: https://ourworldindata.org/grapher/education-spending?tab=li...)
Edit: I should have mentioned that pediatrics and family medicine represent a large proportion of available residency spots each year and are rarely full.
https://www.fsmb.org/siteassets/advocacy/policies/states-wit...
I hear people say "we need more doctors" all the time. It would seem to me, the people deciding how many new doctors we train per year, are doctors. Their pay is proportionate to their scarcity, if we had 5x as many doctors, existing doctors would make far less.
Imagine if existing software engineers got to decide how many juniors entered our profession each year. I think things would look very, very different.
Congress decides how many slots get funded and they have been way too slow to fund them.
I think it's time we stop allowing institutions to rule. We elect our leaders to lead. They need to start fucking leading, or people are going to start voting for some radical alternatives.
One area where we can perhaps legitimately criticize the AMA is for their lobbying state governments to limit the scope of practice for lower licensed PA/NP clinicians. While some of their concerns about care quality and patient safety might be legitimate, the reality is that we're not going to have enough primary care doctors to ensure adequate patient access. Some of that work has to be delegated down.
I feel I made this distinction very clear in my comment, so I'm surprised to see you repeat it. I make it clear that it is our elected officials which hold the power, *but who have deferred that power to institutions like the AMA.* For example, the AMA and Association of American Medical Colleges jointly sponsor the Liaison Committee on Medical Education (LCME), which accredits US MD programmes. LCME accreditation is extremely consequential because most state licensing boards require graduation from an LCME-accredited US programme, and LCME accreditation establishes eligibility for the USMLE and ACGME residency programmes. This gives the accreditation system considerable influence over expansion. LCME standards require a school to admit only as many students as its resources can support, including faculty, facilities and clinical training capacity. Schools must also notify the LCME when class-size increases exceed specified thresholds, currently a cumulative increase of 10% or 15 students, whichever is smaller, relative to the class size at the previous full accreditation survey.
It’s called physicians assistants and nurse practitioners. They are essentially exactly what’s you’re talking about. They make less and they have less training.
The time demands also differ widely between specialties. You can't really be a part-time neurosurgeon. But we see a lot of doctors in other specialties like pediatrics, internal medicine, radiology, and emergency care downshifting to part-time schedules after they have established careers.
It's like claiming that one needs to cram hours upon hours of leetcode practice to be a quality software developer. It might be necessary for some companies to hire you, but that's to meet a filter that is less and less predictive over time, not an actual performance requirement.
Back in the day religious books were copied by scribes educated in a monastic tradition. Now printers can print them in a completely godless manner but the result isn't any worse.
The quality of the average physician is already so low I am not sure what you are hoping to accomplish with lower salaries and faster training.
Doctoring isn't a matter of more warm bodies
> “Better examination performance was linked to improved adherence to mammography screening recommendations, appropriate prescribing practices, improved care of patients with diabetes, lower patient morbidity and mortality, fewer complaints to regulatory bodies, and lower malpractice payments. The association was observed across examination formats and medical specialties.”
https://academic.oup.com/academicmedicine/article-abstract/1...
Unfortunately, it’s very clear.
Q: What do you call the worst student to be admitted to medical school?
A: Doctor.
The attrition for lawyers is higher, neither has anything on PhDs where the number of "practicing" doctors drops off constantly during and after the degree, and only really levels off when O(10%) of them land faculty jobs.
[1]: https://www.ama-assn.org/medical-students/preparing-residenc...
[Doctors only spend around 18% of their time with patients in the U.S.](https://pubmed.ncbi.nlm.nih.gov/40500897/) The rest is spent on administration. I respectfully contend that the bigger issue is not the number of doctors per patient (though I admit that it could be a contributing factors), but rather that successive bureaucracy and compliance and laws and insurance requirements and policies have resulted in a system which forces doctors away from patients and towards ass covering. Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.
> Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.
That’s a huge leap and not at all evidenced by your comment.
I’m all for simplifying all these administrative stuff. But no, that will not solve the fact that we have way more people who are way sicker and fewer doctors for them.
There's basically no need for GP to be a doctor.
Out of respect for you as a fellow intelligent HN commenter — you are deeply misinformed, and I would urge you to reconsider your perspectives on this.
Every study shows that utilization of APPs and nurse practitioners Leads to decreased quality of care and a significant increase in utilization of other healthcare resources, like the emergency department and imaging, that better-trained physicians don't need.
Less-trained providers misdiagnose cancers, refer patients to the wrong specialists, overprescribe antibiotics, and generally cost the system significantly more in overall health load than if we had better-paid general practitioners.
There is an argument that not enough physicians go into general practice, which is true, but it's because subspecialties are in such high demand that they're generally better paid. The unfortunate fix is that we need to find a way to better compensate primary care, even though Medicare physician reimbursement rates continually decline and our health insurance system is not well structured to support this kind of primary care model.
I've left a few links below if you'd like to read them:
General burden of NPs higher than physicians even with lower appointment cost: https://static1.squarespace.com/static/615326dd2c363f1e2a5c8...
Skin cancer misdiagnosis: https://www.ovid.com/journals/jaderm/abstract/10.1001/jamade...
Antibiotics overprescribed: https://pmc.ncbi.nlm.nih.gov/articles/PMC5047413/
And I'm not saying NP + ChatGPT - it should be properly calibrated system which would defer to a 'proper doctor' in more complex cases.
If the prompt is an expert-written board question! Not so with inferior prompts [0]. Critically, you need deep medical knowledge to interact correctly with the agent.
What you're asking is basically: "If we take someone out of a three month dev bootcamp, and have them prompt Claude, why can't they be as good as a four year CS grad?"
I doubt that you would feel similarly about expertise in your own field.
I'd wager GPT-6 would not depend on high-quality prompts, although it might still be good to get a trained person to enter information and do a sanity check.
But the core problem still exists based on the clarity of the prompt and the prompter.
Seeing my wife's depth of intuition and expertise as a physician, compared to my comparatively caveman-like prompts when asking for health advice, there's a massive delta in accuracy.
Have you ever had a significant health issue and tried to get help from a model? Even something like GPT 6 Pro? The firehose and confusion you will generate trying to figure out answers are far less helpful than having directed interaction with a physician.
The issue is that the AI is at best what's in papers and medical records, which often forgoes the core thing that might lead a physician to uncover something or take a different approach with the patient.
You have to create a healthy system, that takes social engineering and government cooperating on a general plan. And in the US such a thing is basically not possible, even if they wanted to do it.
Ideally your transportation, agricultural, educational policies should all work together to produce healthy population. But this simply isn't the case.
But it will not 'reduce pressure' in a practical way, because such changes purely private or public take decades to work themselves threw the population.
I can’t even get basic foot stuff covered, they won’t care until my feet and knees land me under “disability,” so people like me - but unlike me they can’t afford to spend hundreds more a year on special inserts and shoes - just keep doing what they’re doing until they’re hurt.
People go to the grocery store and marketing teams are trying to sell them “vitamin water” which is neither of those things, so they have to do tons of research and pay constant attention to literally every food they buy. Then when they get hurt they can’t afford to go to a doctor and the insurance that is sucking up huge amount amounts of their annual pay doesn’t pay for it either.
Meanwhile we have a US administration that is telling everybody, a population that is incredibly predisposed to heart disease already, to go eat more red meat. Also, they have spent a decade telling people that vaccines are shady and maybe they shouldn’t get them. How much damage have we done to preventative care with that one?
I could go on and on, I’m barely covering the breadth and depth of this problem. We can’t just call it “personal responsibility” or whatever
https://www.healthcare.gov/coverage/preventive-care-benefits...
I am clearly not saying they literally don’t cover any preventative care. I think most people agree that insurance companies’ idea of what is “justified” is far too narrow. What is “clear” is also often very opaque. That’s the issue I’m pointing to. US health insurance is a terrible experience.
And who cares if the analysis costs me nothing? Why is that something I should be grateful for?
At a first level the federal government publishes a set of medically unlikely edits used to deny claims when procedure codes don't align with diagnosis codes. It's used by Medicare, and most Medicaid agencies and commercial health plans have also adopted it.
https://www.cms.gov/medicare/coding-billing/national-correct...
At the next level most commercial health plans have adopted clinical care guidelines published by vendors like MCG. These vendors take publications from specialist medical societies and codify them to determine what's medically justified and set step therapy requirements.
https://www.mcg.com/solutions/care-guidelines/
At the final level, providers can appeal denials to human nurses and doctors who do case review at insurance companies (peer-to-peer). In a huge healthcare system there are always patients with unique needs who don't fit the pattern in published care guidelines. Dealing with those appeals is a major administrative burden and often badly managed on both sides of the adversarial interaction.
Most US-based HN users are on commercial self-funded group health plans sponsored by their employers. The Affordable Care Act (ACA / Obamacare) establishes a baseline for what's covered but ultimately the decisions are made by employer HR departments. Insurance companies would be happy to offer custom health plans that paid every claim at 100% with zero denials or prior authorization requirements; it would mean less work and higher profits for them. But no employer wants to pay for that so the insurance companies take measures to hold down costs.
So you’re doing a few things.
1. Moving more training from cheaper colleges to more expensive medical schools.
2. Moving the filter from undergrad to medical school
3. There is no national curriculum in US high schools, so essentially the first 2 years is getting everyone on the same footing. Removing this without changing high school, puts students at poor high schools at an even greater disadvantage.
https://students-residents.aamc.org/medical-school-admission...
Of the ones that do save time, most cut 1 year off not 2. And they do it by having students take more than a full time load during undergrad.
It’s essentially the same thing as taking an extra class or 2 every semester so you can finish undergrad in 3 years instead of 4.
I randomly sample 15 of the programs listed there and 14 were 8 year programs. Only 1 had an optional 7 year program (if you were willing to take more than full time load or go to school in summmer). And there were no 6 year programs.
Seems like having doctors emigrate from other countries would work as well.
Inconceivable that a domestically-trained doc would have made the same mistake.
Not true.. according to most around here, it will be AI and robots all the way.
I have no idea what this might be.
sucks but that's incentives for ya
No, the reality is we should be more healthy, so we need less doctors.
[0] https://www.calculatedriskblog.com/2013/08/us-population-dis...
You could argue specialists should make less but considering how long it takes to become a doctor, how much work it takes to get there, how long you’re putting off real earning potential, school debt, etc., I do not consider 150k overpaid.
From a more practical angle, I don’t know how you could possibly find more doctors by lowering their earning potential.
You certainly could if you were willing to accept people who are terrible at being a physician.
The notion that you can just throw more warm bodies at the problem is ludicrous
I think building a better prevention layer is more important.
Don't get me wrong, I agree that we need more doctors (and nurses, and physios, and dietetists, and ...), but it is much easier to scale a good prevention system than the number of workers in healthcare.
To be clear I'm not suggesting that everyone should be on GLP-1 drugs, and it's obviously better to maintain a healthy lifestyle and body composition without those drugs. But for people who can't or won't do that on their own the drugs seem to work pretty well. There's also promising evidence that they cause reduction in alcoholism and other substance abuse disorders.
A significant amount of cases could be prevented before they need medical intervention (and put burden on the medical system). There are several researches about this, the number of people with type 2 diabetes doubled in the past decades.
This is why some healthcare systems reward for example doing 10.000 steps a day with lower insurance fees. They recognized they save a huge amount of money if they get people to move.
We need to reduce the requirements to be a doctor. I think general ability is way way way more important than the specialisation. I don't think the speciality that doctors spend money and time on add that much value..
And why do you think that? I'm a doctor and I disagree completely - the medicine nowadays is so advanced, that it's impossible to keep up with advances without specialising yourself in narrow area.
It would be the same as someone from Hacker News going to read a medical forum where people are discussing AI, and the takes would feel similarly juvenile and uninformed, simply due to lack of exposure.
You are right, of course… but unfortunately I don't think it's worth arguing too much here.
He’s polluting this damn place.
Many of his posts tend to be down voted for a reason.
What made you think that "things are moving really fast" is an argument for hiring specialists? Doctors smh..
Please at least show an attempt to understand what is said.
I can keep up with my specialized field, but I can’t keep up with entire medicine because it’s too broad. It’s clearly a case where specialization is important. I’m not the one that has problems with understanding here.
At least as first line docs.
But what the author describes - fuck no, this is absolute unsustainable madness. Race to the bottom. I’d rather fix plumbing at my own pace.
The answer: here's some key performance indicator we can improve.
Sigh.
And later
> To some hospitals and their business, I’m not a Surgeon. I’m just an employee. Overworked, burned out, replaceable. The noble call to Medicine has been suffocated by the bureaucratic force exerting itself as the medical industry.
How much of the world has gone this way? Feels like there is something sick deep down in society that is manifesting itself as “you are not a human, you’re a set of metrics”.
Seems like this aspect could have been written by an Academic, a designer, certainly a software developer. The debasement of human dignity.
Sure, we are not an ideal society and over relying on metrics is bad, but it is HARD to decide how we best use the resources to improve the world, and everybody has an opinion.
If only someone had written an explanation of this effect 170 years ago...
Unlike salary position that 300k, at least in my field, is all via private equity and we are all independent contractors--meaning does not include any vacation, any paid time off, any sick days, any retirement or medical care or insurance of any kind.
I have not seen a raise since I started which was prior to covid. I'm not saying I need a raise I am well paid but again to be 500k in debt with zero benefits and I see on Reddit buckees managers or UPS /fed ex drivers making 150 to 200k with benefits and the ability to call out sick and the ability to not lose everything because of a single case where you follow standard practices or guidelines followed around the country but something bad still happens.
I go to work everyday with the understanding that the majority of my colleagues have been sued and even if not career ending the stress is enormous. At work I wear a tracker so that every fart and cough and patent interaction can be tracked. A VIP club of patients that donates to the hospital can ruin me with some bad reviews. A stray comment about poor care by an ems crew can end my career (as they bring the hospitals patients).
I don't believe doctors are overpaid and we need more to bring their pay down. A patient will get billed 2000 dollars if they ask for a burrito out front in triage, walk in, are told by me that Taco Bell is across the street, and they promptly walk out without a single test done.
On the other hand I may see sixty people in a busy night which require procedures such as being intubated and put on a ventilator, fractures being reduced , etc.
A major problem is private equity in medicine. Everyone should be focused on removing these groups which skim money off everyone both doctors and patients included. Even if the argument that somehow their efficiency increases result in extra money to the system they can feed on there is no reason why hospitals can't group up and also be efficient and cut them out and pass down savings to the customer or not overwork us docs or treat us like expendable McDonald's employees. The lack of working directly for the hospital there is no metric for skill or seniority or anything like that you are an expendible piece of meat/fall guy that they load down with as many mid level providers as they can get away with
I understand the point is not getting more doctors to pay doctors less.
However when people mention how getting more doctors will reduce physician pay naturally the argument they are putting forth is that somehow physician pay in America is higher than it should be.
That consumers are being gouged on scarcity. That physician pay is currently a "problem" that could be remedied if there was sufficient workforce and physician pay is responsible for your astronomical bills.
I do not think the salary has as much room to go down as people think given the 500k plus debt , years of schooling and residency , pressures of working the job , enormous liability , the fact the pay includes zero sick days /vacations , paid days of any kind , benefits, retirement, insurance etc.
My argument as a physician is this is the least of the problems in healthcare financing and your bill.
The two thousand dollar charge for waking into the hospital then promptly walking out was a real world example --not an exaggeration. The amount charged for that one patient would pay my wage for the night and it was 1 in 60 and took approximately 5 minutes. You can only imagine what the other 59 patients getting critical life saving procedures , CPR , etc are getting billed.
If anything reading this story made me think maybe physicians should be taken care of better and have vacations , time off , etc instead of everything being designed to grind them down.
Why would a doctor start their career with a 600k debt, though? THAT is the problem.
In Belgium you can start your career as a doctor with zero debt and around 75k salary, working 35 hours per week. It's comfortable and lets you live a normal life.
We still have a shortage of doctors though like everywhere else, regardless of how well or how bad doctors are paid.
I know, never gonna happen.
In the US if a doctor is remotely competent with money then this is very achievable.
I don't think this is really the point being raised. We need to relax the artificial constraints on the number of doctors. This would lead to more doctors. There's likely to be a side effect which is that doctors get paid less.
While the net effect is doctors getting paid less, it's not the reason.
Their work and living conditions are probably quite different from those of American doctors.
I felt this one... Takes all the running you can do, to keep in the same place.
The entire loss of support section is way too real. I'd almost forgotten what that sort of institutional chaos felt like. So glad I don't work in a hospital anymore. It kills you inside.
Loss of meaning was different for me. The author seems to long for patient contact... Just as easy to lose meaning there, I'm afraid. It's just as tiresome but in a different way. The repetitiveness can easily lead to a sort of depersonalization.
> What I am realising is that today in modern medicine, a doctor is just one of the many commodities in this complex industry.
This could be a fourth chapter all of its own: loss of autonomy.
Those nurses saved many people! It was worth it!
We all want more and better health services, but our economies do not have infinite resources.
And few people are reasonable about restrictions because how do we cost life or health?
Death is predictable, our responses are unreasonable.
Keep your ghoulish BS to yourself, it's disgusting and immoral
I just don't get it. Do doctors collectively do something wrong here that allows hospital admins to mistreat them so much, including the mistreatment of interns/residents during med school? And this is international too, I have heard these awful working conditions from doctors in Australia, USA, and the Netherlands. In the Netherlands example the resident intern I spoke to was even in a Dutch union but apparently the union was pretty worthless because he got paid extremely little and had the same 20-30 hour shifts that doctors in the USA have.
https://seiudoctorsunited.org/
But it is weird how doctors have been sort of conditioned to accept bad working conditions and harassment by administrators. The doctors are the ones with licenses and have the power to shut everything down if they choose to use it.
"Cost-effectiveness and increased productivity". A hospital is not a factory. Hospitals should not get benefits as a private company. If you measure how long does it take a surgery is okey, but use it as a goal is mindblowing. Imagine there is something unexpected, what do you do? Or something goes wrong... We are humans. It's unethical to run a hospital like business, as there dealing with human lifes directly.
Thanks a lot for this article. I really like and we should talk more about this.
There are are arguments to be made about private or public but that logic makes no sense.
Some system that have many private aspects outperform other public systems and the other way around. And even in a public system many people will profit as many of the companies that are your suppliers are still for profit.
Sounds like good logic to me, at least for essentials!
https://www.hrw.org/reports/2006/northkorea0506/1.htm
https://www.ebsco.com/research-starters/history/great-leap-f...
Neither food, nor shelter, nor healthcare are natural monopolies. As evidence by the fact that non of them are remotely monopolistic in places where there are no restrictions. Monopolies in these sectors are created and enforced by the state. Unless you are using a completely different definition from all economists.
Ironically major shops sell stables such as rice below price or at basically 0 margin, just to get people into the store where they might buy something of higher margin.
No. The issue is that there is an almost unlimited demand for healthcare.
That is true regardless of capitalism or marxism or whateverism you believe is the right answer.
Avoiding talking about money: it is easy to see the underlying issue of how should we balance a doctor's lifetime versus patients' needs versus the businesses that ultimately pay tax for it all.
We have public healthcare in New Zealand (a huge percentage of our economy is run by our government - almost socialist). Here we restrict healthcare by waitlists, beaurocracy, and other tricks. It mostly works, but the nurses that I know give too much, and are flaming out.
Meanwhile I've done the dirty boring capitalist work of bringing in overseas income to pay for our beautiful services, and I've reached my personal limit of balancing working harder versus gaining extra income (for myself and my government). I'm taxed at a demotivating rate. There's fuck all respect for being the guy bringing in the bacon to the country. I get to look forward to being treated like a boomer in a few years.
I love kumbayaa political beliefs, but not when I'm the donkey.
The vast majority of healthcare here is not profit oriented but instead is run by the NZ govt.
The purpose of most business is money, and few people would choose to be a boss without the financial winnings. I had the opportunity to roll the dice with everything: because fortunately I'm in a country that still has a backstop.
However the boss payout result is quite simply not worth the risk; because the median return for a startup is $0. Remaining an employee would have been a more sensible decision.
Other people like you complain, and I accept that is part of the deal I chose.
I am smart enough to have had the choice of alternative lifestyle paths like teaching or being an artist.
Meanwhile, I'm literally the guy paying for our social welfare and health system because I'm an export earner. Obviously the NZ economy deserves its return on its investment in me and our business environment.
But if you want to imply someone is greedy, then look at yourself or at your government.
I sometimes wonder whether capitalism is an emergent property? Or perhaps it is a dominant strategy. I visited Shenzhen and it was chokka full of entrepreneurs - I'm yet to structure my ideas around that.
Then I read about those weird papers that use basic trading strategies that result in power-law wealth distributions.
I always wonder when people complain about those that have more than them, because I seldom see them reflect upon themselves to see how much more they have than those below them. This especially applies to anyone living in the USA since everybody is relatively wealthy there, compared against most in the world. Too often I see the 1% complain about the 1%.
All healthcare systems I am aware of are horrors. Compare the US to the UK. We all struggle to understand the driving forces.
One underlying issue is that few people are proactive about the factors they control. Too many people are reckless with their health, and we all are great at excuses and casting blame elsewhere (and there can be evil that deserves some blame).
I'm fortunate enough that I know to chase intangibles.
Too many people let money dominate their worldview.
I'm also incredibly lucky to be born in New Zealand, where plenty of people also want good intangibles. And I see fewer in my circle here fight to get money/power/status.
I thought I disliked philosophy, but perhaps I like it ;)
Why would it be any different here?
Hospital bills causing bankruptcy.
Deciding between meds or food.
Donation jars at gas station checkouts begging for money to pay for a child's cancer treatment.
Putting off preventative care because of endless co-pays.
Out-of-network providers being a thing I have to worry.
Those problems I do know.
The US is #1 in developed countries for infant and maternal mortality.
Americans die from preventable and treatable causes at much higher rates than residents of peer countries, alongside a life expectancy of 79, or two to four years lower than the average for OECD countries.
We spend 18% of our GDP on healthcare, NEARLY DOUBLE the average of other peer countries.
The number one cause of bankruptcy is medical debt.
When will the American people wake up and realize their private healthcare model only benefits the rich that are able to afford the care.
Medical debt is not the number one cause of bankruptcy so you're simply wrong there. Most consumers who file for bankruptcy have some medical debt but the most common cause is a sudden loss of income (like losing their job). When consumers don't have enough cash to make ends meet they prioritize paying for food, housing, and transportation, and stop paying medical bills. Thus the medical debts tend to accumulate but this didn't really cause the bankruptcy.
I do support measures to reduce healthcare costs and improve access for patients but let's be clear about what's actually happening.
Lose your job from injury and you're well and truly screwed.
This is only because the United States is unique in its huge amount of preterm babies, which some other developed countries do not even count within their infant mortality statistics. If we had the same average infant gestation length as Sweden, we would be tied for fourth best with France and Portugal, which considering how obese we are is pretty impressive. If we had that and adopted more restrictive reporting categories like Poland or the Netherlands, we could very well be reporting as the lowest.
The US system is neither fully private nor are those other systems fully public. Its a false binary people use so they don't have to actually engage in the details of how different systems operate.
Nobody is arguing that the US has a good or 'the right' system. And nobody should argue that the British NHS (or systems like it) is some amazing magical place that gets everything right.
> When will the American people wake up and realize their private healthcare model only benefits the rich that are able to afford the care.
And yet one of the countries wit the lowest spending % of GDP on healthcare with very good outcomes has a system that has a lot of private aspects.
The US is #3 in the world for it spending on healthcare as a percentage of it's GDP, actually 16.69% in 2023, right behind Tuvalu and Nauru.
Maybe do some research before you state absurdly wrong things
Not vast. About 55% (workers and the family members) are covered by employer-sponsored health insurance. And that mostly self-selects for the younger and healthier so the coverage is less for random person.
Most retired people are not covered, and ironically very often the sick are not covered.
> absurdly wrong
I think you need to research the HN guidelines a bit more: https://news.ycombinator.com/newsguidelines.html
And it should be said that most 'small' farmers in the US are millionaire scions and shouldn't need subsidies to make a profit in most parts of the US (we have abundant natural resources).
More than half of all calories produced in the US are not even for human consumption. And globally enough calories to feed every human on earth are lost to inefficiency each year.
We can all benefit from a better system of distribution and production without getting lost in the magical thinking of a public/private false dichotomy.
Not sure why you are making an argument about food subsidizes to me, I have not argued in favor of them.
> More than half of all calories produced in the US are not even for human consumption.
Most of those go threw animals and are then consumed by humans. There is a lost factor there but saying its not for human consumption misses the point I would say. For Chicken, Pork and fish the lost factor is pretty small.
There is a huge difference also between subsidizing demand with private supply and providing supply. Exactly the debate that is relevant in healthcare as well. A system can do both, or neither or a combination of the two.
Food is, in general, very accessible, cheap, and elastic (People's food decisions are easily changed depending on the price).
Healthcare in America is not accessible, extremely expensive, and inelastic.
We have not had a famine in the developed world in quite a long time, but the healthcare crises continues.
The fact remains clear: The number one cause of bankruptcy is medical debt.
Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic.
I'm not saying doctors shouldn't be paid well. But what is really clear is that while the rich pay for premium concierge VIP treatment, the poor are regularly turned away for treatment they can't afford. You health insurance here is tied to your job. Lose your job? Pay $2000/month for COBRA or you don't deserve to have healthcare.
Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.
Did I somehow make the argument that the US has a good health care system? I must have missed that.
> Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic.
Most healthcare spending isn't actually 'life and death' either. And even if it in the medium term is 'life and death' only a very small amount of health care is an emergency where you can not potentially consider different options.
Just as most time when you are going to the store its not 'life and death'. But still if don't do anything eventually you will starve.
> The fact remains clear: The number one cause of bankruptcy is medical debt.
My goal would be to achieve the best overall healthcare outcomes at reasonable cost. That's at least the first stab at a definition, I'm sure we could come up with a better criteria.
If you increase payroll taxes as much as a fully public system would required, you would just have more people default on their houses and cars instead. Because there is no world, no matter how many billionaires you disown, that you can implement a universal system without massive increases of income taxes.
Again I'm not even arguing that a universal system is bad or wrong thing to aim for. The argument that I actually made was that 'some people make profit' isn't actually a good argument against any system.
> Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.
You are literally just ranting about shit I have never argued. I guess I must have trigger something.