Being a doc, I can confidently tell you you are totally incorrect as to why things happen the way they do in healthcare. That won't surprise you, I guess. I long tried to make outsiders, and especially tech people, understand what our job is, but discussions always lead to the same stereotypes.
Myself a med-school-dropout, I've found myself several times telling doctors how I really feel: "You aren't paid enough for the sacrifices you made just to be able to help people that probably aren't going to listen to your advice, anyways."
Thank you for your sacrifices, including to the oncoming ML "clinicians."
Come on, doctors are some of the most highly compensated wage earners.
Every working stiff at all income levels sacrifices disproportionately to their income, and if I were a high school teacher, I'd belly laugh at this doctor pity party.
Sure, but it's extremely hard to overcome the hole that medical school and residency puts you into. 4 years of tuition, then 4 years of pitiful wages is a long time. The top, most competitive fields have astronomical wages, but most doctors salary is closer to that of an engineer.
Anecdotally, I'm a software engineer. My wife is a physician. We'll be in our 50's before my wife's career out earns mine. That financial hole of med school and residency is so deep and the salaries on the other side just aren't _that_ much better than other paths. I didn't even pursue FAANG level salaries, either.
That being said, job security and availability is far, far better for my wife. We can basically live anywhere we want and she can find a job.
Lets not lump in nurse practitioners. I'm absolutely in favor of giving more responsibilities to NPs and paying them more than they currently are.
Data on doctor salaries is very difficult to come by publicly, however H1B salaries indicate the average pay for H1B PCPs is $200k [0]. These are the lowest paid physicians. If you look at the data, many many physicians are making much more than that - with many specialities averaging $300k+. Generally H1B workers make less than comparable native-born (even though that's illegal) so we should view this as a lower-bound.
That puts hourly pay for average PCPs lower than the top SWEs, but comparing average with average or specialty with average and you're already quickly outpacing large majority of SWEs.
From what I understand, the primary care physicians that work for a large medical company don't make much, but ones that run their own practice can make double or even triple, but then they take on enormous risk.
> Come on, doctors are some of the most highly compensated wage earners.
You mean it's not us tech workers? :P
Seriously though, I've seen the pay scales in some countries, they're nice and all, but they come with many extra years of training (expensive plus limited income while you do that), plus shift work and overtime that is bad for everyone (staff and patients) and which shouldn't be necessary — and wouldn't be necessary, if most nations all hired about twice as many of them… but that would require us to also train twice as many and politicians who do that get the budget shortfall today while their successors (possibly in other countries) get the reward for the benefit of their being more trained doctors and nurses.
I'd pay them the same for less hours. Mandatory less hours — go home and sleep, let someone else tend to this patient while you rest.
I will be honest, I've had better luck with google than most doctors. I've had doctors say things which were completely incorrect. I've had doctors prescribe unnecessary and not advised meds for what they diagnosed me with(incorrectly).
I have friends who are pharmacists and they agree with my opinion, and they interact with doctors daily.
I have had the opposite experience. I have had professionals find and treat problems in weeks after wasting years using books and the internet.
I am not saying it is impossible, but find good info on the internet, but it has its limits.
There's gotta be errors on both sides, now the question is if we are assessing their risks properly or not. Maybe giving a shot to a low risk thing you read on the internet is worth a try, and maybe booking a doctor visit and getting examined will be worth the time and money.
It'd be nice to have this decision tree being built out in the open, ultimately everyone needs it.
Doctors are people doing a job just like anyone else. The old joke, 'what do you call someone who graduated last in their med school class? Doctor.' Just like software, there are good ones, bad ones, and average ones. By definition, most are average.
I know a few surgeons who are nerds about surgery like many on HN are about technology. But they are also the first ones to tell you not all doctors are the same.
I had to fight with numerous doctors to finally get treated for scabies despite having extremely severe symptoms and despite my partner at the time having scabies. My immune system was apparently good enough to keep it from being easily detected under a microscope, but lo and behold, I had complete symptom remission once the dermatologist I saw went ahead and prescribed an antiparasitic anyways.
I would like to see RCTs on whether the current approach of care gatekept by doctors (ie. prescription for glasses, can't use this melanoma diagnosis tool unless you visit and pay for a derma) actually has any measurable impact on downstream health.
It's interesting that we have all these RCTs for drug interventions, but never conduct the RCTs on policy like letting NPs do more procedures, etc.
Ah, RCTs! The final truth, the end all of all arguments. I've been working for enough profs to know that the best thing to do with 90%+ medical papers is to transfer them directly to the wastebin, and that includes RCTs.
Yeah, what is a randomized controlled trial when we have your 'gut feel' to rely on. Great showing from the physicians in the comments here, now I can clearly see why we should have trust in your evidence-based practice.
X says "I would like RCTs on this subject", and you reply that most RCTs are worthless. Great, what do you want, a cookie? Presumably they want good RCTs, not low-quality ones.
Yeah, I'd like a cookie. I'd also like medicine to become real science. Unfortunately, you can't say by reading the paper, whether the paper corresponds to what's truly been done. In my experience, it often doesn't. What's your personal experience you wish to enlighten us with?
In a nutshell, no amount of lobbying will stop equivalent service for 100x cheaper. Tech does not permeate healthcare for 2 reasons: 1. mostly inapplicable. Everyone is focusing on ML model performance, but really information retrieval in healthcare is dismal and prevents the use of such new tech altogether except in very niche cases. 2. no integration in the workplace. Tech people and docs don't understand each other at all, so docs ask for impossible things, and tech people deliver perfectly functional, totally inapplicable tech.
If there are algos out there (and there are) that can accurately provide a strong heuristic on melanoma from a photo and this is being blocked by the state - that seems like an obvious instance of regulatory apparatus stopping an equivalent 100x+ cheaper service.
I've discussed with a number of people who work directly on DL for imaging at a major hospital system in Boston. They say that (outside of the doctors they work directly with) fear over competition and losing out on the pricier billings are one of the largest barriers to getting their (very accurate) tech deployed more widely.
Yes, so as usual it's so superior but it's never used. And the people building it say it's stellar, promise! Here's a clue: instead of building a tool, and try teaching people already practicing how and why they should use it, maybe we could actually go see what practitioners are doing and try to integrate into that without requiring 30 additional mouse clicks and the use of a new soft that nobody understands ?
You can find the studies on the recent melanoma classifiers. There are tons showing in various settings that they pretty clearly outperform physicians.
If 'additional mouse clicks' is a major barrier to physicians using a tool that leads to far better diagnosis outcomes of a fast-progressing and deadly disease, I'm not sure why that is an argument for why things should continue to be as physician-gated as they are.
I will happily perform the 30 extra clicks myself if it is my potential melanoma. But if I were to offer it as a self-serve app ($2 for melanoma diagnoses too cheap to meter), I would be thrown in jail.
Yes, we have so many models that completely outclass docs. It's really strange, they're not more widely available don't you think ? Providing so much value, one would think there would be a black market for those, at this point. Or maybe, just maybe, the setting necessary to make things work in large-scale realistic practice is more difficult than what the paper authors would have you believe? No, they would never do that...
I'm being very specific about melanoma because this is one of the cases with very compelling evidence. You can broaden the discussion if you want - but that is not what I'm discussing. Here's a study of this technology with 67k real-life practitioners showing obvious increases in accuracy. [0]
Apologies if the link to that article is one mouse click too many for you.
I never denied the performance. Now make it usable to the average doc. That's where we disagree. You believe it's usable, but you've never seen clinicians handle computer stuff.
exactly… this is tech that could be used by literally anyone if it were legal but I am supposed to believe it is just too difficult to bring into practice
I doubt that measurements outside a standardized environment would grant satisfactory performance. But, perhaps. I don't know.
You're just too sour, man. I'm not saying it won't work, not even saying with certainty it doesn't work now. I'm not refuting protectionism plays a role either. What I'm saying is just that clinical integration of new tech, especially involving computers, is much more difficult than you seem to believe. And that the primary reason for that is not the greed of docs, which in my experience holds far less political influence than you think. I'm all for new tech, so chill out a bit.
Last I heard, they were very sensitive to things like imaging equipment, so they could diagnose well if imaging was done by the same gear that provided the training data. It worked fine in the hospital that developed it, but unable to deploy widely. If that issue has been fixed, I look forward to an online service running from a less regulated region. It would be a money printer, even if the US blocked it.
Me and my team made a piece of successful software for patients and clinicians. It is really difficult, mostly for the reasons you state, but it is possible. It's used in about half the NHS, and I personally know three people who've used our app to successfully manage their pregnancy complication, which is great.
My company/team is an unusual exception. The UK has a much bigger problem with creating tech than the US does. That's why almost all NHS trusts in the UK use US-created EHR systems: Cerner and Epic, mostly.
The UK is bad at creating a pro-business/pro-investment environment, so we have to buy in stuff from elsewhere, even though it's not well-suited to our needs. Or best case we find US-based investment for our companies.
Can you explain why optometrist is necessary to buy glasses? Eye exam is already automated to a large extend, and it shouldn't be hard to make it 100% automated by having machine ask questions instead of optometrist. Optometrist already follows a well defined algorithm to come up with prescription by putting a series of lens pairs in phoroptor and asking patient which one is better.
It's not entirely required. You can go on Zenni (and other online stores) and buy a pair of glasses with whatever correction you want.
Though, I do largely agree that the actual assessment by an optometrist is literally unnecessary. I've personally had to adjust my prescriptions because the optometrist pushes me to something that strains my eyes.
> That won't surprise you, I guess. I long tried to make outsiders, and especially tech people, understand what our job is, but discussions always lead to the same stereotypes.
You can explain all you want, but the US is the only country that has exorbitant bills for healthcare culturally normalized for some reason, despite outcomes being roughly the same as other developed countries.
Unless your explanation sufficiently addresses that (which I doubt, since you are not an economist), no one will care to listen.
So maybe a little less confidence and a bit more humility and empathy (for those that need healthcare and can't afford it).
So, if I tell you: 'I'd like help, but when I ask for it I get something worse than what I had at the start', that's me being a typical insufferable doctor, I guess ? We both fit our stereotypes really well, then !
Most docs are overworked for many, mostly bad reasons. Clinical overload is one thing, but healthcare is more like drowning in admin work, these days. So mostly yes, but the true answer is more complex than I can write about in a comment.
The US has 26.1 doctors per capita, while Germany has 42.5, which is a middle-of-the-road number for the developed West.
Do you accept the criticism that the US simply artificially limits the supply of doctors, which leads to overwork for physicians, and worse health outcomes for patients?
Do you think most doctors would take less hours for a somewhat lower salary if you it was possible?
All countries control rather strictly who can practice medicine. Yes, there is some amount of protectionism, but that happens almost everywhere. The reason is not only money, but also cultural issues. So yes, I expect that to be a valid criticism, but I don't think opening the floodgates would have the result you expect either. Access to care is a complex problem, and IMO not primarily limited by doc counts in the US.
Young docs would absolutely work less for less if possible, I think. Old docs wouldn't. IMO, that's reflected in the rise of big network providers such as Kaiser and friends.
In Europe, access to care is better IMO mainly because both patients and docs are far less aggressive, and often quite happy just doing nothing. Which is in fact the true problem about US healthcare: the culture of absolutism.
There is always a strong sense of national pride in medicine. Many people both inside and outside healthcare believe their nation has the best care, and make it an institution of sorts. It really seems stupid and insignificant, but the fact that foreigners are not feeling welcome has consequences. For example, US people often compare to german docs. Except I'm from Europe and having worked in the US, I can tell you I wouldn't go back to the US even for a million bucks. Why go somewhere you do 1.5x the hours, have a miserable quality of life and be treated like s##t, just to earn a little more ? So, if the US was to open the floodgates to foreign grads, I don't think the 'brain drain' would go the way people expect.
Within the US, the limitation of admission of US students into med school is another matter. And I think people are probably right to call out protectionism in this case. But I have no first hand experience, being a foreign graduate myself.
I'm just a random bloke having worked in Boston, though. So YMMV.
> All countries control rather strictly who can practice medicine
To pretend that the restrictions in other countries like Germany are at all comparable to the restrictions in the US is laughable. Just look at the work involved for a German doctor to legally practice in the US vs the reverse if the controls are so similarly strict (they're obviously not).
You are very clearly engaging in motivated reasoning in this thread.
I agree the US is especially restrictive. But that's just the US doing its usual thing: treating everywhere else as a 3rd world country. Docs from developing countries also have a hard time in Europe. You clearly have an axe to grind with MDs.
The comparisons between countries is hard because roles, processes and existence of other practitioners will vary a ton.
High doctor-per-capita could be a sign of inefficient use of resources rather than being a good thing.
Examples: Do you need a prescription for stuff that's otherwise over-the-counter elsewhere?
Is over-the-counter stuff paid by (state) insurance if you get a prescription for people that don't value their time?
Do people go to the doctor anyway for every possible matter (e.g. cough/cold/flu in otherwise healthy people)?
Do you have to make a pointless appointment with your GP every year to confirm you still have that incurable disease in order to keep seeing your specialist? Or renew that allergy med prescription every allergy season? Or go once for a lab test, and then again in-person just to find out the results, even if they're negative?
Who puts in most IV lines? In some places it’s a doctor, other places, nursing staff.
If we're going to talk about inefficient use of resources, maybe we could start with the education requirements. In the US and Canada, doctors spend years getting useless degrees before they are allowed into medical school.
In Europe, they somehow get through medical school without them.
(Not that any of this would matter because the incentives of the residency system are perfectly set up to make it impossible to train any more doctors.)
100%. The US/Can approach also limits/compresses the potential career length. Make it ~6 years and out, straight from high school (if you so please). It kinda works like this already in Quebec: you can enter medical school straight out of CEGEP.
It's also a meritocratic matter: you have to take a lot of risk to make a go for medical school, and the best candidates may not be able to afford the risk of failing to achieve their med school goal and ending up with a degree with ??? value, so the best may not take that path.
Or worse, taking an easier degree program (to beef up their grades and have time for other application-enhancing activities) and not getting themselves educated to their full potential.
> Do people go to the doctor anyway for every possible matter (e.g. cough/cold/flu in otherwise healthy people)?
I lived in Hong Kong for many years and observed this habit amongst local staff with private insurance. (If they did not have private insurance, I highly doubt this behaviour would persist.) It was bizarre. And the "doctor" would happily prescribe medicines for a common cold!
US supply is artificially limited. There's literally no arguing this. There are essentially a fixed number of residency spots and that's basically the only way to become a physician.
> Do you think most doctors would take less hours for a somewhat lower salary if you it was possible?
It is possible. Lots of doctors work fractionally. It's one of the easiest fields to do it in. Given the artificial shortage, hospitals essentially have to accept it.
The reality is many doctors are simply driven people. They don't really mind the hours, but they do mind the type of work. A lot of it is just terribly unfun.
> US supply is artificially limited. There's literally no arguing this. There are essentially a fixed number of residency spots and that's basically the only way to become a physician.
Isn't this true in all highly developed countries?
I was under the impression that the limitation is a bit different in other countries. There is no hard, fixed limit. However, there is still practical limitations around how many institutions want to go through the accreditation process and support the education system. "Anyone" (hand waves a little bit) can start a program, as long as they meet the requirements.
In the US, it's a hard limit set by Congress. Even if you want to run a residency program, you can't.
Technically, there are ways around the hard limit, but they're extremely challenging to implement.
How is a 26.1 per capita calculated? Various unrelated sources state that there are 1.1M physicians (MD and DO) in the US. The US has a population of 360M?
It's per capita * 10,000. 26.1 doctors per citizen would definitely be a surprising standard of care.
26.1 / 10000 * 336M Americans = 876960 active physicians, and the error is probably a measurement artifact (how do you define 'active physician') and the fact that both the population and number of doctors vary over time.
I could probably automate hugging my children, but I sure as hell wouldn't want to.
We should try to build a world where people get to live with as much safety, dignity, meaning, and reward as we can. We should build a world where if people were given the choice between it and some other world with different parameters, they would choose the former.
Automation is a piece of that, but absolutely not an end goal. Often people are happiest when doing things that are not automated.
