It’s extremely beneficial to the people who are already doctors (dramatically increases salary, prestige, power), and that is a powerful group in most societies.
I think it comes down to, if you read the history of the American Medical Association, that some doctors simply didn’t like a free market pushing down prices for their services.
The point was nobody likes their own salaries being depressed due to the free market. One difference is that doctors even under very free market conditions enjoy high salaries so it's comparatively pretty easy for them to set aside some money to lobby to tighten up that market - which gives them more money, which makes it even easier to ...
Yeah, but why is the same situation present, and the same explanation given, in Poland, EU? Or, seeing from other comments, plenty other countries around the world?
I'm seconding 'viraptor here - this isn't a good enough explanation. It doesn't stand up to scrutiny, and doesn't mesh well with day-to-day experience. Individual doctors I know seem to have very little influence over anything, and they're first in line to the protests about working conditions and pay.
One way to drive "medical costs" down is to ensure that the supply of medical care is low. This also drives prices up. This means that the incentives of the regulatory body are directly contrary to the incentives of the people supposedly benefiting from the regulation.
(And doctors and hospitals are happy with this, because such a system boils down to telling them "we want you to do less work, but for more money".)
3. (Tangentially, note that the general model of "restrict supply, subsidize demand" is incredibly common. It's popular both ways; the first part helps a small but politically active and highly motivated group, and the second part pretends to help the populace in general.)
> 2. State provision of medical care corrupts the system, as I describe sidethread
How is this at play (from the article we are commenting on)?
The article does not mention once: "medicare", "medicaid", "regulation", "law", "government" - once.
If anything, it's the inverse. You have it bass-ackwards, the private hospital, the for-profit system is driving things like:
> I delivered my third child with my own hands because the obstetrician was stuck in a traffic jam. The following morning I went to work because if I didn’t 12 patients have to miss their surgeries, 2 anaesthetists and about 8 nurses will miss out on their day’s income. More importantly, admin would not be happy because a cancelled operating list is a huge financial loss to the hospital.
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> 1. Doctors have a lot of political influence because they are popular. This means they can get away with things that other industries mostly can't.
Can you clarify how this doctor exerts any type of political influence? They have a sleeping bag in their car they sleep at their job so often and are lamenting they barely get to see their family. I don't see your point at all being illustrated in this article, at all.
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> "And doctors and hospitals are happy with this, because such a system boils down to telling them "we want you to do less work, but for more money".
I get the feeling this doctor is on the verge of suicide from being over-worked. Do you think the person that wrote this article would agree with your statement?
To the contrary, it would be strange if other mixed economies were somehow immune to this. There's a reason agricultural subsidies are corrupt in both the US and EU, and why zoning laws are a problem in both the US and EU. The same incentives will lead to the same outcome.
I'm not sure that's a good enough explanation. There's minimal if any impact from a given doctor on country wide policies, especially the ones funded by state. Junior doctors in the UK couldn't push basic improvements to both their working conditions and pay. That doesn't seem to match the idea that they can meaningfully influence the doctors intake numbers.
I don’t know about other countries but that’s absolutely the case for the US.
The culprit is the AMA.
> In the 20th century, the AMA has frequently lobbied to restrict the supply of physicians, contributing to a doctor shortage in the United States.[10][11][12] The organization has also lobbied against allowing physician assistants and other health care providers to perform basic forms of health care. The organization has historically lobbied against various of government-run health insurance.
Milton Friedman discusses this in depth in his book Free to Choose (from the 1980s), for anyone who’s interested. Here we are 40 years later, problem still unsolved.
Obviously, they are a big problem, but they're not the only problem. It is received wisdom among doctors that increasing the number of doctors causes medical costs to go up, and it is generally also the position of the state.
The doctors are simply wrong; the state is correct from a pernicious point of view.
Because the state is responsible for buying so much of the total supply of medical care, they generally view things from the perspective of "how much are we spending on the category 'medical care'?", rather than the perspective of how much any given treatment costs.
Increasing the number of doctors lowers the cost of all treatments and is unambiguously good.
However, it does raise the total amount of medical spending, which, in the eyes of the state, is bad.
This makes sense in the IS, and the AMA does indeed try to limit the number of graduating medical students. But in the UK most doctors will work for the state where they are all on the same pay scale (I think) so a lack of supply shouldn’t be expected to push up the price of labour much.
One reason you could imagine is that the health trusts determine roughly how many student doctors they are able to train and then the government limits graduation rates based on this. But I don’t know if that’s the actual reason, and it could be a half-reason, eg the number was set a long time ago and not updated.
In the UK, the NHS primarily exists as a mechanism for rationing medical care. If you compare how much every industrialized country spends on medical care, there’s a very strong correlation with GDP—the richer a country is, the more money they spend on medical care, and the higher proportion of GDP goes to medical care. The UK is uniquely below this trendline, indicating a de facto policy of artificial rationing.
And training doctors is very expensive. This is subsidised by the state through capped tuition fees. Plus to train a doctor you need enough doctors for junior doctors to train the junior doctors presumably.
If I sell garden gnomes wearing knitted hats, but I only make three a year and sell to only people who drive yellow cars, I doubt I could earn a decent living off this
IDK if needs to be reasoned or not. I'm imagining someone making these comments to the author's face after having been read the article. The 'callous' part comes from disregarding everything in the article to go on some great tangent about the AMA and artificial scarcity of doctors.
What's more, it seems that this article has triggered a reflexive anti-union stance, when it's more a hallmark of a place where capitalism does not work well. Why doesn't that hospital have more doctors? Surely, they could have found someone additional if they wanted. The hospital did not have to schedule every surgery as if they all required the average procedure time. The hospital could invest in better IT infrastructure and have software that was not a drag to use. Surely the hospital could have someone help the doctor not make 70+ calls over the course of a shift in addition to everything else they do. This blog post is not about a general scarcity of doctors; there's lots that could be done by the hospital investing in its staff and outcomes without hiring a single additional doctor.
Being a business means they have to optimize for profit (to at least some non trivial degree), or die.
Many hospitals are run by non profit organizations to help reduce this problem. However even they cannot run at a loss overall for long. Bankruptcy doesn’t help anyone actually provide services, after all.
Gov’t has different incentives - but then care is strongly controlled and limited by public policy, for better or worse.
And an organization that is able to optimize to produce more value than they consume (aka is more profitable) can take more risks, expand better, have more capital to invest in training, equipment, etc, be more competitive in who they hire, and have better and more comfortable facilities if they want.
And being a Dr. can be really miserable sometimes, and the training is also really hard and miserable.
Some (surgeons, esp. plastic surgery) optimize for maximum $$ for misery, usually. Others (pediatrics) optimize for maximum ‘feel goods’ for misery, usually. Most others are somewhere in between.
Either way, if they didn’t want/need the money, they’d be going to medicine sans frontiers or working in rural medicine eh?
Skipping some quibbles,would you agree that some optimizations for profit would lead to business death?
Eg, businesses that cheat and get caught. Businesses that over consume and can no longer produce.Also, that optimization can have the opposite effect. Eg, optimize revenue by showing max ads, with max ads users start to flee. A hospital could optimize for patientoutcomes, and then do better because the patients stay around.
This overall though assumes that free market principles work in healthcare. Those principles tend to assume consumer choice.
In the U.S., sure. But in the UK status of a doctor is akin to that of a schoolteacher. Totally not a highly sought-after, profitable career like it is in the U.S.
Doctors are paid a lot more than schoolteachers in the UK and in my experience are respected because of their profession. I think you're totally incorrect.
Seconded. My perception is that here in Britain, medical doctors are highly respected, and pretty well paid. This is different from the US, where medical doctors are highly respected and extremely well paid.
Prestige is, of course, not a function of income alone. Plenty of software developers get paid at least as much as respected professors or top military brass. That doesn't mean they have equivalent prestige.
You took the words right out of my mouth! Money is the elephant in the room here. Why doesn't the author quit surgery and start a small GP clinic? Oh, only half the pay? I see similar behaviour in law firms and investment banking.
Presumably, those who trained as surgeons, want to be surgeons. Sunk cost fallacy might come into play. A better analogy is someone who wants to be a software engineer, get burned out - and you say "hey, why not be a NOC technician if you can't handle it?"
Further, you assume a surgeon could just become a GP. They are different fields.
> They can try. But they would have no idea what they are doing. But legally, they could certainly practice as a primary care doctor. They would not be board certified, and could not sit for the ABIM exam, and would not be able to pass it if they did.
> The professions are also very different, primary care is more allied to the work of a physician, whilst a surgeon is trained to do serious surgery, not the kind a primary care doctor would do. So not sure even if you could be legally certified in both specialties you wouldn't loose your surgical skills if you spend a lot of time in primary care.
> Knowing what I know about the medical world in general I would advice against such a combination, a surgical residency is such a taxing one that you wouldn't have time to do anything else beside surgery, furthermore the required mental approach to do the work well as a surgeon or a primary care physician is also quite different.
The enforced scarcity in the market is what makes sure the money is always enough to prevent you from relaxing. Imagine doctors were as common as McDonald's managers. At the margin doctors would frequently be taking a slight cut in pay to do something fun like sports medicine. Now imagine there was only one doctor in the world. Even if he longed to relax and do pharmacy, ailing kings would offer him mountains of gold until he almost had no choice but to see them.
You're not wrong about the financial aspect but remember surgeons are completely incapable of being GPs. Surgery is its own residency (5 years I think?), and to be an actual GP you have to be either a family (3 years) or internal (4 years) medicine residency graduate. So in addition to the pay cut in absolute terms, you're taking 3-4 years off and making $60k/yr working 80+ hour weeks to do that other residency. So the opportunity cost alone is a few million even ignoring the pay cut.
Let's not pretend we're talking about the difference between $30k and $60k/yr here. We're talking about $400k vs. $800k. "I'll only make half a million dollars a year if I do this" does not set oneself up to be a sympathetic character.
I don’t think many doctors have much choice in the matter. The MBAization of hospital companies and practices bought up by private equity is strip mining the productive capacity of providers to juice profits. This is the MO of financial capitalism: find an established business that someone else built and extract maximum profits until the business collapses, then leave the rubble for others to clean up.
