Why doctors in America earn so much
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My wife is a doctor. I’m a software engineer. While she now makes more than I do, it took nearly 10 years. That whole time, we were racking up tuition/debt on tuition. Residency was demanding and severely underpaid.
Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
In other word, medical training had a huge opportunity cost. Even if you solve the bottleneck of residency placement, salaries need to offset the insane burden of training.
That model doesn’t really work to fund higher education. The public won’t accept doubling or tripling their property tax.
[citation needed]
And I can give you a citation against. In my local municipality the tax base is roughly $1.5 billion. The annual expenditures for the local vo-tech school for that municipality is $30 million. If all of the state and tuition funding for the vo-tech school suddenly vanished the property owners would see a rise of ... wait for it ... a grand total of 2%. Certainly a far cry from the doubling or tripling you suggested.
Amortizing the tuition across all public post-secondary institutions in the state via income and property tax bases of the entire state would likely be somewhere in the neighborhood of 1-2% total every year. Based on that analysis it seems monumentally stupid to NOT publicly fund post-secondary education.
Ditch the NCAA sports programs and it probably gets cheaper. The whole sales pitch for sports is that scholarships provide a pathway for some students to go to college that otherwise could not afford it. Get rid of tuition and suddenly that reason goes away, too.
I'm not arguing with your numbers, I guess my point is that I don't think taxpayers will accept a huge "freebie" for one group which results in their taxes going up. The optics are terrible.
Still, if I had 2 kids, doubling my property tax would be cheaper for me than my paying for their tuition at current rates.
Are you suggesting that people should be locked to the school in their district? Because that's the way primary education works.
Since GP says State Universities I would assume the State they were in would, through whatever tax policy they like.
And those taxes would replace the insurance premiums employers and individuals are currently paying out the ass for. It's a difference in who writes the checks, not how much actually goes out of individuals' pockets.
Claiming "$2.8B in new taxes" is like claiming "I Venmo you $5, you Venmo me $10" costs me five bucks.
> That’s not an accounting change—the government doesn’t have a joint bank account with the private sector.
That "joint account" is the GDP you're on about.
America needs to stop letting their University systems bloat everything unrelated to actual education and research.
- Implement ACA-style budget efficiency minimums
This much of tuition must be spent on direct-teaching expenses. Only this much may be spent on everything else. Otherwise the university in ineligible for any federal educational assistance grant/loan.
- Increase funding via increased state contributions to public universities (returning to historical averages), to lower tuition costs
Who is lobbying for this system to be improved? Because almost certainly loan companies and universities are lobbying against that.
Look no further: https://www.nrmp.org/wp-content/uploads/2023/03/Match-Rates-...
Now, I don't know how you would ever include people who don't apply. I mean there are 5 million americans of age every year, so i guess that's a denominator.
what's a all time match high ? The number of spots and students ? Yeah, so ? The concern was that the number isn't high enough, and where the bottleneck is.
The real answer to why doctors in america earn so much, is that everyone in america earns so much. If you compare doctor to median salaries in the us, vs. doctor to median salaries in europe, maybe its not so different ?
No, they are absolutely not. About 5% of medical school graduates do not placed into a residency program. There's a slew of Caribean medical schools that take only US based students. They have about a 20% non-placement rate.
Med schools have a lot more flexibility in slots. Once established, it's far easier to increase class size by 10% than it to get 10% more residency slots.
What I heard was emergency departments suffered brutally during covid, and that has had a chilling effect on anyone wanting to go into it. The med students matching now were all rotating through departments during covid.
It's pretty foolish to take out private loans for medical school. Most people avoid it unless they need to cover living costs.
Federal loans have the chance of being forgiven with PSLF.
Ergo, like education in general, it's funded from the federal government.
I think government involvement in the residency program is problematic distortion, causing hospitals to chase a scarce resource instead of working to expand the supply pipeline.
https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_...
Relying on Medicare to pay for residency programs isn't an ideal situation. But the reality is that there are no other major players in the system with both the money and incentive to cover those costs. That won't change without a complete restructuring of the entire system, and achieving the political consensus to do that will be extremely difficult.
If you have a few million dollars to spare then feel free to donate it to your local teaching hospital. They'll be happy to take your money to expand their residency program. There is an opportunity for philanthropists to do some real good in reducing the physician shortage.
I would argue that it is easier and more realistic to simply include it in the price than expect congress accurately predict future demand, and continually pass legislation to that effect. We dont need a congressional act to subsidize hospital janitors- Somehow hospitals figure out how to include them in their operational expenses because they need them.
Furthermore, it wouldnt break the bank of most of these hospitals. Take one of the largest teaching hospitals in the world, Cleveland clinic, with 2000 residents. at typical resident grant of 100k, that is 200 million. The Cleavland clinic annual revenue is >13 Billion.
Cleveland Clinic is a non-profit. Their total revenue is irrelevant. If you'd like them to spend an extra $200M on their residency program then they would have to spend less on other stuff. Take a look at their financial statements and then you can tell them exactly where they ought to cut back in order to fund your proposal. Please be specific.
https://my.clevelandclinic.org/about/overview/financial-info...
That is my specific proposal. If they refuse to raise prices, then they should grow the endowment by 200 million less per year and provide the same services. It is bad enough that a non-profit charges 20% more than the cost of their services. They would be fine if they were only making 18% more than their costs.
It is basicity the same as if Harvard college claimed it cant afford to train teachers aids while charging students more than enough to cover expenses and sitting on a 50 billion endowment that grows ever larger each year.
Observation that the lead/training time for additional hospital janitors is a couple weeks.
An additional resident takes 4+4=8 years.
Medicare does not need to pay for residents, they are massively net positive revenue. The AMA boards create artificial scarcity and "medicare" is the boogeyman word.
Or, to put it another way, if hospitals have difficulty balancing the books with free resident labor, adding additional paid residents wouldn't necessarily fix the financial problem in most hospitals.
Paying residents is not the blocker here, Residents are already paid by hospitals. They are paid a fraction of revenues, which is normal for any profitable business.
https://www.ziprecruiter.com/Salaries/First-Year-Medical-Res...
Some hospitals allow residents to moonlight (e.g. practice in off hours) and pay $300+/hour.
https://www.cms.gov/medicare/payment/prospective-payment-sys...
There are other GME funding sources such as private charitable foundations but still the majority of the money comes from Medicare.
Do they though? Or is that mostly creative accounting. I've heard claims in both directions but like anything in medical billing in the US, it's all pretty murky.
Most states are begging for more qualified providers. Many are looking to mid-levels to fill the gaps. If the AMA were serious, they'd be working with all of these states to fill those gaps with physicians.
https://www.ama-assn.org/education/gme-funding
And if you think they're saying something else in private then let's see proof. This is not a place for baseless conspiracy theories.
With all due respect, not everything that lacks proof is a conspiracy theory. I've spent a bunch of time in discussions with physicians. There's a consensus that AMA is largely ineffective and it's implied that it's ineffectiveness is valuable for inflating physician salaries.
This is a great write up that highlight how the AMA created the situation to begin with: https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...
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I did find a great example of AMA's double speak on this issue. A bunch of states have started looking for alternatives for providing care to their populations. Some states are now loosening regulation to allow mid-levels to practice. 6 states are now allowing physicians to practice (in certain fields) without completing residency.
That sounds great right? All of these groups have completed 3 to 4+ years of graduate medical education. They might not be as skilled as a physician, but they can certainly provide basic care. AMA doesn't think that's great.
> The AMA opposes enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state’s requirements for licensure to engage in the practice of medicine and surgery.
https://www.ama-assn.org/sites/ama-assn.org/files/corp/media...
The AMA doesn't actually want to engage in any of these solutions because it threatens their golden goose.
There is literally no path to becoming a physician other than the blessed med school + residency path. By contrast, you can become a lawyer simply by passing the bar exam.
Some states are starting to allow physicians to practice without residency and the AMA is vehemently against it.
I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.
Compare a doctor to almost anything beside an engineer - and it won't seem so terrible.
Most people that have been in engineering for >10 years got into it because it's what they liked doing - and then it just so happened to be ridiculously lucrative and not require you to go into hundreds of thousands of debt to get trained to do the job (medical, lawyer, etc).
Even most trades (electrical, plumping, beauty, the taxi medallion system, etc) are designed similar to the medical industry - and require ever more schooling (debt, opportunity cost) to get the job - to artificially reduce the work force to benefit current workers at the cost of future workers and everybody who uses those services.
I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
We're all gonna need medical help some day...
Maybe we can do our own plumping and cut our own hair and be good law abiding citizens and not need a lawyer. But we're all going to have severe medical problems at some point.
While that is the result I think emphasizing that it isn't made easier is important.
Electricians need to install high voltage wires that are safe in the home for untrained individuals for potentially a century.
Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)
Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation.
Lawyers need to know a phenomenal amount of information to meaningfully know what o research when it comes to prepping for court cases.
All of these jobs are hard to prepare for and their is value to everyone else that you can prove you actually prepared.
The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.
But it isn't made up boundaries just to benefit existing members.
>But it isn't made up boundaries just to benefit existing members.
I would argue that it largely is just made up boundaries to benefit existing members. That is to say, regulatory capture has increased the barriers so far that any benefit from additional quality of service is far outweighed by the increased scarcity.
It doesn't matter if you have the best doctors and electricians in the world, if they are so few and expensive that the public does not have access to them.
The fundamental problem is that is both easy and popular to error on the side of "caution", creating increasingly stringent licensing requirements. These benefit established interests and sound attractive to the public.
My dad was a plumber and I’m preparing to pass the certification that permits me to work on home electrics. They are, to be blunt, easy. An average person can pick up most of it in a couple of months. Electrics and gas plumbing carry a certification requirement because an error can kill someone, but it’s easier than passing a driving test.
Obviously, there are higher tiers of those trades that require a lot more training, but even those aren’t really comparable to the level of knowledge and study needed to become a qualified doctor, let alone a consultant.
In the UK, shortages of tradespeople are less to do with the difficulty of training, or lack of course capacity, and more to do with people really just not wanting to do the job, for various reasons.
For example, we force most doctors to take a 4 year degree before medicine (sometimes pre-med, but often an arts or non-biological science degree). Wasting 4 years of a future doctor’s prime career on an expensive and often irrelevant screening program is extremely wasteful for society as a whole.
I have a cousin who's doing his residency right now and he has an interesting take on this.
You don't want to have a 21 year old in a cancer ward directly treating patients. They may lack the personal skills and life experience needed to convey empathy. In addition, they will not be taken seriously by patients due to their youth.
He is speaking from experience as someone who is doing his residency at a slightly younger age than average.
I just don't buy this take.
You don't let the junior engineer wild in production. You place guardrails around them until they learn and prove themselves as capable. The exact same thing can be done in medicine.
Shadowing/Interning is already done in your MD program.
In Engineering, you will generally have 1 engineer paired with 1 intern/NCG. In a hospital setting that is an unrealistic ratio given the relative lack of staffing.
Add to that liability related issues because unlike CS, you as a medical professional can be held legally liable. This of course leads to high malpractice insurance rates subsidized by the hospital, who then in turn also need to show insurers that they are doing the needful.
The complaint "we can't spend the time to train new employees" isn't specific to the medical field, but the solution is the same: they can't afford NOT to, and the lack of staff is proof of it.
The last plan ended in the failure we're at now (no staff available to train new staff). The best time for staff to start training more staff was before they ran out of staff. The next best time is now.
The rub is that lack of staff isn't what prevents this, nor is even lack of staff time. It's a conscious, short-term-focused decision by hospitals to focus efforts outwards on making more money, rather than inwards on training or changing the status quo. And honestly, the long-term herculean task of changing the existing resident system seems, in my opinion, out of scope and fantastical for the average hospital.
Maybe if a sufficient number of hospital systems were sufficiently motivated to sufficiently lobby the government for change. I don't know what that would take.
You mean like a residency?
Clinical clerkship is not an internship, interns are first year residents. Shadowing does not teach you medicine.
It's a difficult problem to fix, I finished my residency training in Canada where we don't have ACGME protections in place and while it was far more abusive than US programs (where I currently work) it certainly made us very competent at the end, better than I am seeing in the average US trainee I supervise.
I'm not sure what the solution is to be honest. Competency is almost entirely driven by clinical volumes and exposure, you don't train to handle the 90% of normal cases but the 9% that are challenging and the 1% that's incredibly complex. If you're not working long hours (or spending many more years in training) chances are you won't get that exposure.
With that said one could argue with the current expectation that everyone does 1-2 fellowships we're already training longer.
From my experience they don't. If you have any problem off the beaten path you may spend years and multiple doctors to figure out what's going on.
Aka it doesn't always happen but that is the goal.
Honestly disease diagnosis is the one area I could see AI being super helpful in which might lower this burden from extreme memorization to facilitating collecting data for analysis and being a guard on false positives.
Taking radiology as an example (because that's my specialty) ~90% of studies are normal and some types (e.g. CT for pulmonary embolism, CT for transient ischemic attack/vertigo) are closer to 98-99% normal.
Every diagnostic AI application I've seen implemented as of 2023 that merely replicates the work of a human has done nothing but increase false positives.
The extreme class imbalance makes this a non-trivial problem.
In fact, it even has a wikipedia page: https://en.wikipedia.org/wiki/Zebra_(medicine)
There is no shortage whatsoever of licensed plumbers who will do incompetent work. Fortunately there is a decent collection of companies making excellent plumbing products that are quite robust.
Current personal favorite failure modes:
Use of inappropriate water-insoluble flux. This usually doesn’t cause a leak, at least not quickly. It is, however, disgusting (petroleum crud and not-very-good salts being released slowly over months to years in cold water pipes) and is a code violation.
Use of copper in boiler condensate pipes.
Use of essentially arbitrary mixes of pipe tape and pipe dope.
Overtightening of plastic threaded connections.
Incorrect combinations of tapered threaded fittings and gasketed straight threaded fittings.
There was a plastic line there already and that line hadn't been used in atleast a year (previous tenants kept their fridge in the garage). I remember asking the plumber if we should replace that plastic line and he said no, I even told him it hadn't been used in over a year.
A week or so after he did this work I'm walking through my living room and my socks are getting wet. At first I couldn't figure out what was going on until I realized that line had split (as I expected it to) and was leaking, said leak having moved into the living room where it was making the wood floors damp.
To this day I don't understand why that plumber thought that would be ok when I, as a complete layman, understood what happens to plastic lines that go unused for that long (they dry and crack).
I have had issues with compression connectors at the ends (they don't like to be too loose or too tight), and I've seen plenty of failures of the really crappy washers that get used in "female compression" connectors.
Also, contrary to popular opinion, there's little stigma or awareness of "bad doctoring", for a number of systemic reasons.
So you have someone who doesn't give a fuck about anything, certainly not your situation, not listening to you, and trying to prevent you from receiving medical treatment.
This doesn't look so necessary to me. I know there will still be medical experts and surgeons and so forth, but much of this medical infrastructure doesn't benefit the average citizen (I know there's an argument that it does or for a change in perspective, but that's a whole different can of worms.
Similar to policing, if you think of the typical way you interact with the medical system, you start to realize there's very little in there to help you. 99.99% of the infrastructure is built to benefit powerful people with tons of money; helping you is an after thought.
What happens when you're a victim of crime? Turns out there's very little in place to help. Oh, someone is actively trying to murder you? well give us a call after it happens and maybe we'll investigate.
How many of us have experienced something like this? I'm not saying there's no reason for the arrangement, but we should stop trying to pretend these people are looking out for the public.
I know people may be tempted to chime in regarding some situation a police officer or doctor helped you. I'm not saying you're wrong, just explaining why some people are asking questions; if you honestly think about it, your naive assumptions about safety and health will be shattered.
A doctor, in many ways, arguably has a patients WORST interests at heart, in a similar manor to a police officer, in it's interaction with the public. They have, as their most important responsibilities, to detect certain things, and take actions to hurt the person.
This is priority #1, virtually everything else comes after. This is an important observation, is not obvious, and should cause us to reconsider these institutions.
Likewise, there's such a range of outcomes, and when it's involving chronic diseases combined with an apathetic or bad doctor, you can be stuck realizing you've wasted months with no resolution (not even getting into any potential costs) only to now have to start all over again potentially several more times just for a sliver of hope that you'll find a doctor who's caring and competent enough to finally help you out. So sitting on the receiving end feels like being bled dry by people who couldn't care less about your suffering or if you die, so long as you keep paying them, with little realistic recourse other than accepting that you got burned and moving on.
In any case, just my two cents from what I think seems like a somewhat related view but with a different "spin".
People are treated based on convenience to the doctor and their moral judgements. EVERYTHING in medicine works the opposite from the propaganda. I've been convinced it's part of a trope.
Any time a profession tries to convince you it's not something (eg. do know harm, treat regardless of morality, ect.), it is ALWAYS because they were doing exactly that, people correctly detected it, and now they're doing damage control.
is that really the purpose? or is it that an entire industry has been built on top of the trades, and that industry does whatever to continue to grow?
After undergrad, master’s, PhD, a postdoc or two, one would still make low income. After that, there is a never ending path where one has to constantly chase ever changing technologies. The older you get, the harder it will be to keep up and remain employed.
In medical science, you finish the residency (roughly equivalent to 1-2 postdoc in engineering), and you start to practice. Already, income is OK in residency. The older you get, the better!
All the while spending 60-80 hours a week on clinical service and 5-10 hours on research and education so you can maybe get a job somewhere not remote when you're done.
95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.
I wonder how much doctoring is due to negligence of a healthy lifestyle, or perhaps chronic choices (addictive substances like alcohol, shift-work).
> But we're all going to have severe medical problems at some point.
Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.
Maybe 70%? Genetics play a huge role. You will likely need a doctor if your family has a long history of cancer.
You're young, aren't you?
The percentage is significant, but nowhere near 95%.
I might be over-estimating the percentage. I might also be over-estimating how much we can affect diabetes, weight, fitness, addiction.
I can say that the chronic health problems of my peer-group often appear to be self-inflicted.
Of my dead acquantances there are maybe a few groups: (1) health problems caused by childhoods of poverty, (2) health problems that we haven't solved yet which the medical system helps little, (3) suicides, (4) crashes/accidents, and (5) health problems caused by smoking, drinking and drugs (e.g. HepC).
Also acquaintances with chronic conditions often don't follow medical advice anyway e.g. diabetic friends that abuse their bodies. Or people told to quit drinking or smoking that do not stop.
I'm not saying it is easy. I am saying I know plenty of acquantances that have made difficult choices to improve their lifestyle choices (presuming cause not correlation), and others that have not made positive changes.
Context: I'm in New Zealand, so healthcare is mostly free and of reasonable quality. We have lots of immigrants so I have some exposure to people from other (often adjacent) cultures.
https://bowelcancernz.org.nz/about-bowel-cancer/early-detect... says about prevention: While no cancer is completely preventable, a healthy diet and regular exercise can lower your risk of bowel cancer. Numerous studies have indicated that a diet too rich in red meat and processed foods can heighten the risk of bowel cancer. However I would guess the percentage amount you can lower your risk by is below 1%. Across all health outcomes, healthy food choices and a daily walk can have a large effect overall.
It seems to me a hell of a lot of our healthcare funding goes towards people that make no preventative effort towards health. I have friends and acquittances with chronic conditions due to alcohol (diabetes, excessive obesity, gout, Korsikov's, accidents), smoking (emphysema, cancers), severely damaged joints (impact sports, car accidents), drugs (hepC, OD, teeth, accidents and worse).
Personally I eat "risky" foods , occasionally I drink excessively, I heartily enjoy high risk sports and activities, and I definitely don't exercise enough. I am not trying to preach: my point is many close their eyes to known risks.
I certainly am not blaming your cancer on your lifestyle. I sincerely hope the best for remission.
> I didn't have insurance, $800k
I'm in New Zealand and our taxes pay for reasonable quality cancer care for all - probably not $800k worth often. The sticker price for the US insurance system is often grossly[1] overstated (for reasons). I've seen our healthcare system mostly work (and I've seen some failures too).
[1] e.g. Hospital billed $100K, insurance negotiated to about $20K. The actual doctor only got $2-3K. https://news.ycombinator.com/item?id=37977337
> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.
This is a statistic pulled out of nowhere.
>> But we're all going to have severe medical problems at some point.
>Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.
Again this is pulled out of nowhere. All types of joint replacement, stents and heart surgery are major procedures which are common and not prophylactic. Prostate cancer surgery has an 85% success rate in eradication where I live, and no, I didn't get it from bad lifestyle choices.
I don't disagree. However, I certainly am not a top earner in the industry. Much of my career has been remote. My income is not out of line with most STEM fields. The main benefit for me was the ability to work remotely, moving with my wife to various small towns/cities.
Keep in mind, my wife had almost 10 years of med school and residency to start her career. I was making income the whole time. That's essentially a $1M difference 10 years into careers. It takes a while to overcome that gap.
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> I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
Yep. There's also a huge personal burden of carrying that non-dischargable debt. If residency doesn't work out for some reason, you're in a huge hole.
We know many physicians who say they wouldn't do it again if they had know how shitty the journey would be.
And by workload, I don't mean just hours on the job, I mean amount of material to learn. It is overwhelming to most
I don't see how the ability to work long hours is necessary to heal the sick. They don't train airline pilots like this, or nuclear plant operators. What's so special about doctors?
The long hours are much less now, though nowhere close to pilot or trucker hours. they're trying to give the future the most experience they can while still under supervision.
It'd be better to have a 5 year residency and go back to a 3 year med school, but that would reduce med school income so not likely.
But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
I imagine your wife will be seen the same way. She can comfortably work until retirement age, in an profession that sees experience as a positive thing, while you might be a pariah before you know it.
Yes, we make good money when we're young in tech. But we age out much more quickly due to the bias common in our industry.
20 years of a normal US tech salary won't let you retire. A top-few-percent one, maybe.
[EDIT] Further:
"The lowest 10 percent earned less than $54,310, and the highest 10 percent earned more than $157,690." (in 2022, still).
The ones who can retire in 20 years are making (ballpark) top-5%-of-field wages most or all of that time.
[EDIT EDIT] I didn't pick the best category for this, but the numbers only skew up 25ish % for the most-relevant one. Not a single BLS computer job category has a median particularly close to "retire in 20 years at this income" money. FAANG, finance, and a small segment of the startup market that's in that same category—yeah. Almost all the rest? No.
https://www.bls.gov/ooh/computer-and-information-technology/...
But still, even the top-median category, "Computer and Information Research Scientists", doesn't have "retire in 20 years" median wages.
I think one must have a very-skewed, bubble-bound definition of "competitive" for that to be plausibly true. Programming jobs don't pay enough to grant easy-mode early retirement for most of our field—even in the US.
Instead I'd suggest looking at Software Developers (1.5M positions) with median income at $127K.
Second, by definition median is not a competitive salary. I'd think top 25% of devs are getting competitive salary. Which is $161K [1]
20 years of savings at 30% of income will get you $2M. Which is not a fat retirement, but still doable.
Yes, it is. For the field as a whole? Yes, it absolutely is. For specific segments of it? No. Some of those are higher. And others are lower.
> 20 years of savings at 30% of income will get you $2M. Which is not a fat retirement, but still doable.
Healthcare complicates early retirement badly in the US. Retire at (say) 45 with only $2m in the bank and you are... gambling. To put it mildly. Even if you live reasonably frugally.
100% this. I'm almost 50, and as I look towards retirement, I think I should try to find a cushy job that'll last me to 65 without causing too much stress, because until you qualify for Medicare it's really hard to afford health insurance premiums unless you're fashionably wealthy.
> Healthcare complicates early retirement
You don't have to stay in the US when retired. With 4% SWR one will be getting $80K/year. Which is more than median household income in the US and majority of the other countries. I am not advocating retiring at 45 with $2M, I am just saying it is not that crazy.
This is not a standard usage of the term in this context.
[EDIT] If you don't believe me, I'd encourage searching "competitive salary definition"
Uhh... Why? A very good health insurance is about $10k a year (PSA: the open enrollment period for 2024 has started today).
Even if you are unlucky to get a chronic condition that needs expensive care, that's still capped at around $6k a year by the out-of-pocket maximum.
So that's $16k a year per person maximum, over 20 years (until Medicare eligibility) that's $320k. If you want to include family, that's going to be around $500k. And that's the worst case.
It's going to be a huge chunk of the expense, but not insurmountable.
They had to raise my salary to $165k because this was the _minimal_ allowed competitive salary for my position ("Senior Software Developer"), and the USCIS doesn't take stock grants into account. This was 2 years ago.
You were paying ~$3,000 per month for rent 20 years ago? I remember renting a place 22 years ago for $250 per month.
Maybe you were in some super insane cost of living area, but if that's the case, why would you accept just an average developer salary? Average salaries are for average places.
The (just under) $100k is pre-tax.
You won't get much social security when you hit "retirement age" if you retire after only 20 years of working at that level of income, so you'll need more savings at that age than others do.
$100k/yr is a 5% withdrawal rate on $2 million, which might be a "safe" rate at normal retirement age (debatable) but is risky as hell if you start doing it at 45 and don't plan to die in your 60s.
If you've been saving that aggressively (as cash/investments), you won't own your own house, or at least, you definitely won't be anywhere near paying it off. That significantly raises your costs in retirement.
You have significant risk from healthcare costs until you hit medicare age (and even then...). You're probably looking at $5k-10k a year in premiums (individual) at age 45+, and still five figures of annual risk exposure despite already paying that much.
Retiring on $2m at 45 would be very likely to end in failure, even as an individual supporting only yourself.
Yes, that's what the previous comment said. Of course, you don't need anywhere close to $100k, so you would still be reinvesting the bulk of it, just as you did throughout your career. That will see your returns continue to increase as you grow older.
> you won't own your own house, or at least, you definitely won't be anywhere near paying it off.
You'd have no trouble buying a home on a $30k income 20 years ago. They could barely give houses away back then.
> You have significant risk from healthcare costs
You still have $70k to play with each year. If you have to miss a year of reinvestment it won't hamstring you that much. As before, bad luck happens. It is possible you are the unlucky one. But generally speaking the money is there.
I made a bit more than that 20 years ago and can guarantee you it wasn't anywhere near enough money to buy a house. Finding affordable apartments to rent on that salary was difficult enough. I lived in New Orleans, which wasn't a high cost of living city at the time. Maybe if you lived in the middle of nowhere that would be doable, but almost certainly not in a city.
my experience agrees with yours.
You're absolutely right - the banks would give you a loan you couldn't actually afford. I seem to recall this leading to some sort of financial problem in 2008, unfortunately.
I’ve worked for the past 20 years and am as far from not needing to work anymore as my first day. Well, that isn’t strictly true, but my 401k only has about 33-50% of what it needs for me to retire. I have no savings beyond that.
Not everyone can get into med school (~5% acceptance rate?), but even more disturbingly some people get out of med school with tons of debt, and then either fail their step 2 or don't pass quickly enough to get a residency. Or fail boards after residency. Then you're in a really shitty position, with hundreds of thousands of debt but no ability to practice medicine.
Most people aren't saving ~43% of their take-home pay, no matter how much they earn.
Developer and marketer/technical writer - selling to other devs is a giant business now and it often takes devs to make that content.
Developer and SRE - we live in the world of huge scaled our saas businesses where there are always support issues too advanced to be handled by non-devs
Developer and project manager - everybody has worked with non-dev project managers and it’s usually terrible.
Developer and people manager - there are so many more eng manager roles than there used to be, and moving to the management side is a well worn path now.
Developer and product manager - you have to develop a lot of new skills but in this role a past life as a developer can give you super powers.
That said, I moved first into people management and then into running a small software company which sort of demands a little bit of all of those skills
I'd say these are pretty interchangeable in one's career if they wanted to. The others not so much.
If you've just been a "turn the crank" developer implementing someone else's sprint-scoped tickets for 20 years, you probably topped out after around five years. (Or you're doing all the interesting stuff outside work, in which case... you definitely have project management skills.)
A strong senior should be able to do any of the roles all the way up and down the chain, including "product manager", "business analyst", etc. It's an issue of time and scope rather than skill.
note: I'm aware that most business analysts are domain experts, my point there is that a senior can both analyze a problem and create a solution and can interface with domain experts where needed.
https://www.amazon.com/Docs-Developers-Engineers-Technical-W...
I'm think I could do with reading that. As could the team I'm on.
(But I'd agree with you: you should be supporting, in the form of debugging & problem solving, the thing you're writing. Separate SREs are an anti-pattern in my book … somewhat comically since I'm basically an SRE at the moment…)
> I'd say these are pretty interchangeable in one's career if they wanted to. The others not so much.
They are? Now I'm pretty new to this (despite my age) but my impression has always been, with the former you mostly focus on one project and maybe even just a small part of it, with the latter you are keeping an eye on half a dozen systems, have to know their ins and outs to babysit them, and occasionally firefight when something breaks in production.
I don’t know about anybody else, but I would see experience in both as a plus on a resume. I think it’s a good idea for SREs in particular to get a dev job on their resume since the person hiring you is going to be a developer a massive amount of the time so it never hurts.
I honestly find it shocking, but there it is.
I'd also point out that if people forget the growth-aspect, they will overestimate the problem of ageism in the industry.
Yes, there aren't that many grizzled 60-year-old programmers today... but much of that is because 40 years ago there were only a handful of 20-year-old programmers to start with.
Even if advancing age turned people into happy rockstars, they'd still be outnumbered today just because there are more jobs.
One was working at Google and got shit for taking time off when he planned it 6 months out. He quit and decided to retire early instead of putting up with it. He's 42.
A lot of people my age also retired because they had too much money to work :)
Which also explains that the more youth you see competing for the gigs helps crowd out those of us elderly tech folk who are left.
Recent figures are not readily available, but as of 10 years ago a yearly income of $32,000 was enough to put you in the global top 1%. Adjusted for inflation, that is around $42,000 today. Interestingly, the median income in the USA is $41,535, so it is likely that half of all Americans are in the top 1%.
Although I would think that "good money" would cast a larger net than just the top 1%. Surely at least a 75th percentile income would be considered "good" by most? As such, it is likely that a $20-30,000 income is "good money".
If you have not even made that much at some point over the past 25 or so years that you have been of working age, how can you afford to be here?
yes, it's technically true, but no one with a 3rd world income would ever be able to afford to live in the US, they'd be homeless. its apples and oranges.
There's a reason why discussions of salary have to happen around the area the salary is made in.
One may need to spend more x to live in a certain location, sure, but that's a completely different topic. One where the money made is not relevant, for reasons already stated. As we are talking about money made, you know we are not talking about that.
10k USD/year is "good money" for many people in other countries but no one would ever describe that as "good money" for someone living IN the US.
and yet, the poster YOU chose to respond to said this:
> I'm almost 40, never made good money... this makes me sad
Yes, as you can clearly see, he added the operative word "made". A word you conveniently left out from your message in your ongoing quest to change the subject. Had you included it like in the original comment, it would completely change your message.
either way I'm done with this conversation. Come back to this when you're sober and read my post more closely.
While I am not sure what you think you can be done with given that you have not yet joined the conversation that we were having before you arrived, no amount of drug use is going to give me interest in your off-topic tangent.
I get it. You misunderstood what was written earlier and now you are grasping at logical errors in order to avoid having to come back now and ask questions for clarification to save your pride. But, why are you letting your emotions drive you like that? Who cares if you made a mistake? I certainly don't. I don't care about you at all.
For anyone reading this, you can clearly see where the word 'made' is in the quote given, yet this person decided to claim I left it out on purpose. The implication being that I cherry-picked a quote when I quoted the _entirety_ of the post in question.
If it is me who misunderstands you, go on. You have already been given the floor for quite some time to explain yourself and reason for interjecting in a rational manner instead of spouting nonsensical logical errors, but I'm generous enough to give you another chance.
If I, in wintery Canada, made what is considered by most to be a good car and then put it on a boat to ship it to the hot African desert, does it magically become a bad car? The car hasn't changed. It is still the exact same car.
I'd be more concerned abouta human going insane than malware.
I'd imagine they're mostly fly by wire anyway, so a virus could theoretically just disable the human input.
There's a big difference between isolating a single control link vs an entire control system comprising of, at least, a corpus database and all the supporting code that streams inputs and actuates outputs.
Modern U.S. submarines are also fly-by-wire, but hydraulic overrides are in the engine room in case of emergency.
"Person there just in case to take over in the rare case of emergencies" might not be as well paid as "person who's responsible for the plane at all times". Plus, if you're concerned about malware, you'll probably want a person still involved in vetting the code outputted by some hypothetical AI, so there would still be at least some engineering jobs.
Almost everyone requires the same "kind of currency", but that doesn't stop salaries from being different.
> The person flying all the time will be much more capable than the person watching the plane fly, and acquiring experience only in specific training.
If the plane can be piloted mostly automatically, that doesn't necessarily matter. What matters only is if the emergency person can handle the emergencies that do occur.
To be clear, I don't have any strong belief that human pilots will disappear any time soon; I just don't think the arguments people are making here are that compelling, because they seem to be assuming that the skill level of flying a plane is much too high for an automatic pilot. As someone who's been skeptical of fully automated driving for a long time now despite popular opinion seeming far more optimistic about it in the short term, it's kind of ironic to see "humans will always be better at flying" presented as axiomatic.
Certainly things like the ghimli glider are better for having a human at the helm, but those sorts of things shouldn't happen.
but there may also be enough kinds of failure—and routine—scenarios where computers do a better job, so on balance they could be much better, just killing a few people in the most absurd situations that would never fool a human. You can't guesstimate reason these things, need statistics.
also, if automated systems have a bright future for us, maybe we have to sacrifice a few people on the QA team in order to get there.
Regardless of what naive optimization might suggest, I doubt the airlines are going to risk the headline "217 Dead In Pilot-less Plane Crash" any time soon.
We'll have terrible Roomba boxes replacing flight attendants long before anything replaces pilots.
For American-run airlines (and many European ones too), terrible Roomba-like boxes would be a big improvement in service.
Not for Asian airlines, though.
There is also a sensing issue. If aircraft sensors fail then they might feed the AI faulty data. And sensor redundancy or fault detection logic can't necessarily cope with that. Whereas experienced human pilots have a pretty good record of using their organic senses to handle such failures safely.
There's no such guarantee in any of the professions.
But, public mistrust of a pilotless plane might very well put the kibosh on that for a long time. People have trouble trusting air travel as it is, doesn't matter if it's irrational, and they usually know that it is.
That's flying. You enter into an aluminium can, and from that point you are completely helpless, whatever happens. The only thing you can do if something goes wrong is assume the fetal position and hope.
And yes, life is pretty much like that. You could get cancer or get hit by a car or a meteorite for that matter, but even these things feel more controlled. I can pay attention to my surroundings to avoid getting hit by a car. I can potentially treat cancer. I could probably not do much against a meteorite or gamma ray burst or whatever cosmic thing might happen but that stuff feels less real anyway.
I agree that the fear of flying is somewhat irrational, but at the same time I think it's a valid fear especially in light of things like Russia shooting down passenger planes, the whole Boeing Max 8 thing etc.
But if someone wanted to be rich by capturing more of the value they could produce, it's highly unlikely as someone else's employee.
Errr, I'm 64, generally get a title like "senior programmer", and have switched jobs a few times recently and didn't have a day out of work. I expect to be going for a few years yet - in fact I expect your husband will be forced into retirement, whereas I will chose my time.
Moreover, I have quite a few software engineering friends or about the same age. It's the same for them. Some are still working, some not. But in every case it's been their choice, they weren't forced into it by the industry.
I wonder if it's more about skill level (certainly I'd like to think so :])
Its hard to imagine that 5,10,15 years of distributed systems and system design experience and knowledge along with domain knowledge and social skills will be all of a sudden be so irrelevant that it is worth phasing all of us "old guys" out for someone who happened to learn the newest programming language straight out of school.
We are constantly expected to learn the new stuff and will just a project assigned with a mandate "okay this is to be done in spring boot, using this DB, this HTTP layer, etc...
HP: https://news.ycombinator.com/item?id=38043552 ("It took seven years but over-40s fired by HP win $18M settlement")
IBM: https://www.diversityjobs.com/career-advice/team-building/ho... (Control-f "Sources")
https://features.propublica.org/ibm/ibm-age-discrimination-a... ("ProPublica: Cutting 'Old Heads' at IBM")
https://www.forbes.com/sites/jackkelly/2023/02/17/prior-agei... ("Prior Ageism Allegations At Google, Facebook And IBM Raise Concerns About Older Workers Being Targeted For Termination")
https://news.ycombinator.com/item?id=14932680 ("HN: Ageism is forcing many to look outside Silicon Valley")
https://www.orangecountyemploymentlawyersblog.com/dfeh-90-ag... ("DFEH: 90 Age Discrimination Complaints Filed Against Tech Firms Since 2012")
Most devs aren’t terminally online, they treat coding as a job not a lifestyle and for them it’s just like any other industry - so you don’t hear from them.
Also, some devs retire into SQL and DBA like work since you can basically make yourself unfireable if you want to coast out the last decade of your career.
Here right now the age vibe is coming from ;) It's not like a doctor can coast it out (or maybe I'm also naive).
(I'm an employer as of now)
I run a contract shop and all my best DB guys are greybeards... coasting. It doesn't matter, after so many years with postgres & MySQL they are amazing.
I would probably differentiate by work visibility: good work in DBA/sysadmin/security/accounting/quality is invisible, you only notice those folks when they have screwed up.
With product/UX/new features it's the other way around, coasting is not possible.
That very much depends on the application. I maintain some enterprise solutions for customers. Clients get upset if UI has flow changes. Also, changes don't make me money unless they are required for a new customer. I will do it on request and invoice for the work but no one is interested in change for the most part. I think this is VERY common in enterprise software.
There was a time when machismo was my middle name (much younger) and would have seen that as necessary for a successful startup. Now that I have several startups behind me I see it as simply bad management which decreases your chance for success which is stacked against you from the beginning anyway.
That was several years ago. I don't think that startup exist any longer.
Shhh... please don't tell the tech bros that there is a world outside of the Silicon Valley bubble!
Where you can raise a family and make a good living working 9-5.
Where you are not constantly trying to ruin and exploit the lives of normal people to make a short term gain.
Where most of the actual work keeping the world afloat happens.
It is better for us working dinosaurs that way.
There are people earning good scratch well into their "golden years" in the tech sector, but the demand for them is much weaker.
Ageism in tech starts at 50+ (probably even earlier). Ageism in healthcare probably starts at around 80 and at that point it's only because the doctor's not physically able to perform safely.
Many programmers started making money to invest in their teens, and save those who pursued other careers before pivoting, all were making money to invest by the time they are in their early 20s. Meanwhile, the doctors were racking up the debt until nearing 30. That decade plus is a huge setback – never mind the debt burden on top, and how the tax code greatly favours those who build up savings over a long period over receiving large lump sums in a single year.
In other words, 55 year old programmers are talking about retiring because they can. 55 year old doctors on the other hand, even with a higher income, need to work decades more to financially catch up.
It's not "age" it's current-ness.
Since most people aren't expected / empowered to learn what's next 'on the job', currentness decays, making age a stereotypical proxy for dinosaur.
Here at HN, by virtue of being here reading these comments, "this isn't you". You are making yourself aware of what's going on outside your backlog. The stereotype arises because most devs aren't here or anywhere besides chopping wood.
In fact any long term plans at this point seem silly. AI is going to make all human labor irrelevant.
And if he wants to make the big bucks, there are not that many companies to work for (~10 mainline carriers in the US at the moment), and the seniority rules suck.
If you stagnate skills wise or stop trying to grow/evolve your abilities then you definitely will have issues but that's true in many industries, not just ours.
But career changers will have a rough time - e.g. I remember a social worker who went back to school in his late 30s looking for an internship(as a developer), he had a much harder time getting hired than someone in the same position in their early 20s.
I disagree. Go to some technical meetups.
At practically all of them I have seen people offering jobs to both juniors and greybeards. The biggest problem everybody is having right now is connecting. The garbage in the middle is clogging everything up. So, everybody is going back to the old tried and true, the weak social network of in-person acquaintances.
Yeah, you have to not suck and you have to keep your skills up-to-date. But, that's true whether you are 20 or 60.
It's been a rough couple of decades afterall.
Vanguard 500: 3x return over last 10 years
Vanguard total stock market index fund: 2x over last 10 years
SWPPX: 3x over last 10 years.
Google is telling me inflation from 2013 to 2023 is 41%.
So even with inflation accounted for you're looking at a 50-150% ROI over 10 years. Maybe I just got incredibly lucky picking index funds, so I googled the total market capitalization of US domestic companies and that grew from about 15 to 30 trillion. This stat seems to be wonkier, other estimates claim 45 trillion (probably a more inclusive estimate counting smaller companies).
But TL;DR: No, inflation did not gobble up the returns on investments
The standard way is to measure the amount of stuff money can buy, where "stuff" is daily necessities and so on. But prices are just relative. It can be argued that such daily necessities like food, clothes, etc. have actually gotten "cheaper", and the increases in stock and other asset prices are a function of how much money is printed by central banks. (There's a strong correlation there, at least.)
It's not the standard narrative, but it's something to think about in such cases where these numbers are absolutely crucial to your life plans.
There's also the element of the US stock market basically outperforming everyone else in the past decade. (And it's mostly because of tech.) If you pick a couple non-US indices the numbers look much more shaky.
One “problem” in software: it’s really difficult to coast for a long period of time without training up new skills. You can certainly do it, but eventually the industry shifts underneath you. So the cushy senior Java dev position in a particular service might be able to last you for a decade or more at some companies, but I think most developers agree that if you want to keep getting better salaries you need to stay on top of trends and keep reeducating yourself.
And I don’t really see this as a problem as much as a feature of tech, but if you’re looking for predictability in a career I think it’s a tough thing to get in tech.
Just prove you lost a job or weren't hired due to age, and you'll have a lawsuit that results in a large enough settlement you will once again be paid more than your spouse and won't even need to work.
If you have reason to believe you were terminated or not hired because of age, meet with a lawyer. If a lawsuit it filed, discovery is a powerful tool in litigation to help gather evidence that is generally required to prove the claim. Often this will be data about the other employees they have let go or in the case you weren't hired the age of the person ultimately hired and those that were interviewed but not hired.
There are about 10,000-15,000 a year, like all areas of law probably about 90% settle pre-trial.
So do you pursue it paying some lawyer an hourly rate to sift through a thousand emails just to find that the company hired a younger but still fully qualified candidate? If you are a person at the sunset of your career and still need a job it’s likely that you will not bankroll the effort…so you just move on.
Can confirm, but it’s more like around 50. That is why you tend to not see a lot of senior folks wanting to bounce gigs every three years like the younger folk do. I hope to ride out another 7 years at my current gig and retire. Hopefully they won’t have other plans because at that point I’ll likely have to shift to WalMart greeter.
My dad is in his 60s and is still doing cutting edge work on Kubernetes, Golang, eBPF, etc in a big tech company in the Bay Area. It honestly isn't that hard to keep yourself up to date with technology looking at his experience.
If you can't get yourself interested in upskilling or learning the next new paradigm you're in the wrong field.
52. Gimme 10 more years, I won't care. I don't want to be working any job after that even though I love programming and it's all I ever wanted to do (for a living).
People used to believe this, but it's not true at all in my experience.
Tech is also slowing down in how much it is changing, which makes it easier to do the work while older, which again takes the edge off of ageism.
My grandfather made good money fixing systems for y2k in the 1990s and retired shortly after.
There's plenty of work for dinosaurs. Plenty of systems quickly hacked together today will be around for much longer than planned for.
A 40 year old doctor is insanely young. A doctor in his late 60s can easily be in their prime, especially in some practice areas or research. Provided they are okay health-wise, even an 80 year old doctor can still be working, especially if they have a strong team. They'll probably be in a mentorship role or a more laid-back practice, but they'll still be earning a meaningful income and having a very real impact on their patients.
And generally speaking, doctors in the West live longer than the general population, so that longevity is better as well.
So far, that really hasn't been a factor for us. It is worth noting that job security becomes much less important as you build wealth. It's a lot easier to build wealth when you're not racking up debt and being underpaid in your 20's.
1. https://www.nytimes.com/2023/03/08/opinion/noam-chomsky-chat...
It is possible that everyone will become a programmer, like everyone has become an elevator operator, but unlike an elevator button press that takes milliseconds and you're done, does it behoove "the boss" to spend their day describing their ideas to GPT? I suspect, like today, they will still want to hire other humans to bridge that gap so that they can spend time doing more important things.
There's so much hype around AI right now, it's absolutely unhinged. Yes, we have semi-conversational AI. Yes, image detection is pretty good. It's all supervised.
Can we please touch grass?
Other than surgeons, a ton of what we would traditionally think of as doctoring has already been abstracted away and work specialized and divvied up to technicians, with MDs pulling strings in the background.
They chose a profession that appears to scale to investors. When software _actually_ scales rather than being a subpar substitute for an existing mechanism is when the people involved were indeed smarter and worked much harder (typically).
Essentially, physicians have been so bottlenecked for so long that a bunch of states has simply said "screw it" and started paving the way for mid-levels (NPs and PAs) to operate in certain roles physicians have previously covered. The physician lobbies seem unwilling to address this, so I expect that mid-levels will continue to move up the chain. They know the market is desperate for a solution and physician interest groups are completely unwilling to provide that.
I think this is the part that's going to break.
IMO, a model where a doctor leads a group of mid-levels seems pretty much ideal. It's like the senior dev leading junior engineers.
Unfortunately, it seems AMA has been so resistant to any change that enough places are simply saying screw it to oversight and allowing mid-levels to practice independently (with limited scope). i
Yeah, rural areas that can’t support a full time doctor have no choice but to let midlevels practice medicine if they can even get a midlevel.
do you believe this is the case now?
The product of mechanical engineering also naturally scales. Once you design a machine, you can build it an infinite number of times. However, in neither case does the labour scale. One engineer, whether their focus be on software or mechanical, can only do so much in a day.
Software engineers lucked out in this era because it is a new, relative to other industries, field that saw a rapid rise in demand for labour, with comparatively few people able to fulfill the need for that labour. By virtue of supply and demand, incomes had to run high to attract workers.
> and scaling is really how you can make a lot money.
That is true, but engineering doesn't scale. It is highly doubtful that engineers will continue to benefit into the long future. The owners of the software built by engineers will be able to continue to reap the benefits of scalability, but the labourer – who does not scale – will undoubtedly start to get squeezed as the industry matures and demand is no longer growing exponentially.
What about the people who did make a lot of money but like to work and create things?
At every company I've been at, the most senior people are the ones with the most pull, with the strongest direction and advice.
I've worked with a few people 60+ who suck. I bet they sucked at age 30, though.
A cycle here is that student loans rise with expected earnings and banks are fairly open ended about it, institutions happy to justify the use of the cash.
Salaries wouldn't need to be nearly as high if you didn't walk out of residency with 200k+ [medical school ] debt at a point that is effectively mid-career. As a society we'd probably be better off if the both the median salary and median debt was much lower. I've also seen the "guarantee" of a high salary later lead many young doctors and med students to be foolish with money, as "eh, what's a little more debt" is easy to fall into.
It's also part of the driver to overspecialization, more available GP's and fewer people reliant on emergency visits would obviously improve the system, but the economics and QOL for a general practice keep getting harder.
Residency bottleneck and the high barrier for foreign trained mid-career people are the two other areas for potentially major impact.
All in, at the end of my wife's training, we would have been $1M ahead if she had simply worked a normal career. That's huge in your 20's and 30's when your trying to establish a house/family/etc.
As a baseline, university education in Finland costs about €10k/year on the average. Medical education is more expensive than the average, probably between €15k and €20k a year. Universities in the US are generally better funded than those in Finland, which allows them to provide more personal attention to the students. And university salaries are higher in the US than in Finland.
Overall, I would estimate something like $20k/year for the undergraduate degree and $30k to $40k/year for the medical school, for a total of $200k to $240k. And that's just for the education, not including costs of living as a student.
There are a handful of state medical schools near the $40k/r, but they are on the much cheaper end
This is such a hard problem to fix. I doubt anyone is interested in hearing any solutions that involve worse-trained doctors, or longer training schedules, or massive pay increases for what are viewed as some of the highest-paid people in the nation. There is a lot of talk about opening up medical care for more people - which, naturally, means there will be a surge in demand. I can only imagine this would exacerbate the problem. It feels like we're running out of time to fix this.
It's basically a firm of hazing
And god forbid you think you can handle it at 18 years old and then being stuck on the medical track for... decades.
This has quite frankly zero relevance to anything. The analysis depends on what you her husband does (I mean seriously how does that prove a point at all) and your choice and abilities (totally arbitrary based on a host of factors especially given the tech scene over the last decade.
I mean ROI? So someone makes a career decision by comparing to what their partner makes or what ROI is?
> AMA is unwilling to fix this
This has to do with residency slots and residency slots are determined by how many hospitals can accept residents. Now you can say AMA is a roadblock to that but there are a slew of other roadblocks in addition (if true not sure it is) to having more residency slots.
You can think idealistically that you can re-imagine the whole system but massive change in something entrenched like that (where lives matter) most likely is not practical.
In my country the government flooded the market with doctors and the results weren't pretty to say the least.
TL;DR: Becoming a physician requires sacrificing an additional 6-10 years of your life to education and training beyond what you'd expect for most careers, and assuming something like $250K in additional debt. It'll take the average physician about 16-years out of college before they start to out-earn the average engineer.
Details:
Let's imagine that two smart people start college in the United States. One goes into engineering, the other into med school.
The day they graduate, on average the engineer will get job that pays them $74k their first year.
Year 4, the engineer is likely making $84k/yr, and they have earned a total of about $315k in their career.
Meanwhile, our doctor friend has so far accrued about $250k in debt. A delta of about $560k in just 4 years, but it's gonna' get worse before it gets better.
For the next ~3-5-years (for most specialties, there are outliers), our doctor friend is gonna make about $50k/yr . (Yay, positive cashflow!) We'll generously assume their debt doesn't accrue interest in this period.
Assuming our engineer friend assumes an average career path, he's gonna be up to $92k/yr at the end of this period, with a lifetime total earnings of $669k, while our doctor friend has clawed their lifetime earnings all the way back up to -$52k.
This is also the biggest delta between the two careers. At year 8, our engineer friend has out-earned our doctor friend by a delta of $720k.
Now, on average, our doctor friend starts making $202k/yr. Good money, right!
To make the math easy, we'll assume that their debt still doesn't accrue interest.
With all that, it's not until 16-years out of college that the average American physician will start to out-earn the average American engineer.
So if they both graduated at 23, our Engineer friend is gonna out-earn our doctor friend until they both hit just about 40.
Of course, if our doctor friend has to pay some interest on their med school debt, and our engineer friend is able to invest a chunk of their salary in those early years, the magic of compound interest will be on their side as well.
And that says nothing of the fact that our doctor friend probably had to sacrifice about 4-years of mandatory 80+ hour work weeks. It also assumes that our doctor friend doesn't drop out/fail out of med school and manages to match to and complete a residency. None of which are givens.
Which is a very long way of saying: physician compensation is wonky because it's a career where you sacrifice a ton and take a ton of career risk very early on, for the promise of higher compensation and quite high job security later on in your career.
For medicine, undergrad debt is pretty tough since you really have no way to pay it off. It just accrues.
Assumedly, an engineer would be able to pay off their undergrad debt much quicker than an MD.
Wait, you're getting paid?
I have a child I’m encouraging to become a doctor, and it’d be great to know some actual economics before I push too hard this profession.
My teenager wants to be a radiologist but I have no idea if it’s even possible to do that in a way that isn’t a path to depression and burnout
Most doctors end up making between 265k and 382k per year, this varies wildly (from pediatrician on the low end to brain surgeon on the high end).
Here is a good article: https://www.whitecoatinvestor.com/how-much-do-doctors-make/
One thing that rarely discussed in this kind of conversation is taxes. A doctor spends 12 years earning next to nothing and going into debt for training costs. Then the second they start making a real doctor salary, the IRS thinks they are 'rich'. They are taxed at the highest tax bracket even though it might take them another 10 years to surpass someone who was earning barely a six-figure salary the whole time.
If you spend 9 years earning nothing and then make $1M in your tenth year, you will pay much more taxes than someone earning $100K for 10 years (even though both earned a total of $1M over those 10 years).
Life will always get you. There’s no way around work if you are a well paid professional. Maybe nepotism or fraud can get you there.
I’m not sure what leet code entails but these tests required a lot of preparation:
MCAT (hundreds of hours, thousands of questions, 10 practice exams)
USMLE Step 1 (hundreds of hours, 5,000 questions, 1 practice test)
USMLE Step 2 (maybe 40-60 hours, probably less than 2,000 questions)
USMLE Step 2 CS (4 hours a few dozen practice clinical scenarios. this thing doesn’t exist anymore)
USMLE Step 3 (30 hours, less than a 1,000 questions
Radiology CORE 1st board licensing exam (hundreds of hours, 5,000+questions)
Radiology Certifying 2nd board licensing exam (8 hours, 2,500 questions)
My next one is the CAQ and I haven’t started grinding for that yet. I do wake up every morning and do practice q’s though.
I still have a deeply negative networth and hate my job. Maybe others don’t, good for them.
I'm not even sure where you're getting 5000+ questions for the ABR Core.
-Another radiologist.
Kevlar Radprimer Board vitals
Radprimer has probably more than 5,000 basic and intermediate questions by itself. Are you saying I lowballed it? I was pulling numbers out of my ass
The 5000 questions are how you're supposed to learn radiology, as an alternative to reading a textbook.
Everyone I know from multiple residencies and in fellowship all reset radprimer and redid the questions for core. It’s not like people save it, they do it twice. Anyways, like I said, I was pretty average for prep. Also I forgot to add - everyone I know also used the Radiology Core Physics app, that’s like an additional 300 or 500 questions.
Ben White is pretty well known, he pretty much gives a road map that includes rad primer
https://www.benwhite.com/radiology/approaching-the-abr-core-...
“Looking back, in an ideal world: I would have read Core Radiology and started RadPrimer in the fall. Done CTC and physics Feb/March and then filled in the rest of the time with questions, probably primarily via the A Core Review Series. Qevlar is nice for the phone app with offline capabilities and probably would’ve made it in too. Most of the latter would have been important mostly for anxiolysis or possibly long-term retention, as passage wasn’t an issue.”
I felt like Radprimer and the physics app were the highest yield Then board vitals Last Kevlar
Highest yield book was War machine. Crack did OK. Essentials books were solid, especially nucs.
Later gator
When I was in residency most of us just did BoardVitals, Crack the Core and War Machine or the physics app you mentioned. That’s sufficient to pass the exam hence why I said this may be what you did but not the minimum necessary.
Resetting RADPrimer is a good way to review all of radiology but as you may remember the intermediate questions are much harder than the exams, almost all image based, and generally have many image sets and long stems.
It’s a completely different style and aim than BV, ACR DXIT or ABR Core which are generally either quick hitters or don’t have images.
Most people don’t study for the cert exam which is considerably easier. ABR doesn’t give statistics but I’ve never heard of someone failing it.
Crack the Core is now lower yield but War Machine is still go to for physics. Things could change in the future though. Board vitals gives way too much history and text without enough just image based questions, so it’s lower yield but still worth it I think. Maybe they changed qbank up since I used it. Qevlar was a waste - could be different now.
The certifying is easy diagnostically but the nucs/RISE/NIS documents need a read. Those don’t take a huge amount of time but they’re not 0 hours. If someone is confident in their ability to be passed by ABR then not looking at anything is a strategy I suppose.
Anyways, fun time over
Again, basic is intended for first year radiology residents not as board prep. You may have used it for this purpose, but it is neither a prerequisite to pass the ABR Core nor is it the most efficient way to prepare.
You can make the statement that a lot of work goes into becoming a radiologist without the inaccurate claim that the one exam requires 5000+ practice questions.
The official description:
"RADPrimer helps radiologists fine tune their diagnostic skills and enhance their knowledge:
Comprehensive radiology training for all levels
RADPrimer allow physicians to customize their educational path, focusing on the topics that matter most. RADPrimer allows radiologists to use their time efficiently as they work toward professional advancement. Topic-focused lessons present specific diagnoses, anatomy, differential diagnoses, and assessment questions related to the topic. RADPrimer provides over 5,300 case-based learning and traditional questions."
Rad Primer Basic 2,173 Qevlar - 2,000 Board vitals - 1300 PhysicsApp - 572
At University of Texas we did this for prep and in fellowship at the University of Washington I checked with their residents and they were doing that too.
Ben White from UTSW gives something like that as road map for study questions (which I already linked to you).
Here's another random perspective that matches mine https://www.nellymd.com/2015/07/american-board-of-radiology-...
> You can make the statement that a lot of work goes into becoming a radiologist without the inaccurate claim that the one exam requires 5000+ practice questions.
I keep providing links and data and you keep providing quotes about the definition of RadPrimer and what exactly it is and how exactly residents are supposed to utilize it - without any deviation. I don't know where you did your training but perhaps you're at a more prestigious institution and the trainees had to prepare less to pass the exam. Maybe you're just that much smarter.
The law of one price requires free market competition.
it's that simple.
She is regularly pulling 65-90 hrs/wk with little flexibility in her schedule.
I ask because I didn’t know 65-90 hrs/week (13 hr days / 7 days per week) was typical for non-residents.
Depending on if you're married or brought a home, her education and status already paid off with special rates for doctors/lawyers/high earners/professional mortgages:
https://www.studentloanplanner.com/professional-mortgage-loa...
I regularly hear it is the AMA that is creating an artificial shortage, but this seems to indicate that the logjam is at the level of residency funding.
Does anyone have a good insight or data about this?
There is also the weird thing where, my understanding is that the hospitals can 'sell' the slots to each other and strangely they can fetch more than the funding in question.
But really, so much of the medical residency industrial complex reminds me of a hazing ritual in and of itself.
It's absolutely abusive and I cannot believe there's never been more of a push around patient advocacy. It's bad enough for the residents working 100 hours a week and getting fits of sleep in a shitty spare hospital room they share with multiple other residents. It's even worse for the patients receiving care from a tired, overworked resident.
* Been made clear in no uncertain terms (mafia style) that they were never to log more than the regulated hours, regardless of actual hours worked.
* Weird things started to happen if they did log more than the required hours.
"William Stewart Halsted developed a novel residency training program at Johns Hopkins Hospital that, with some modifications, became the model for surgical and medical residency training in North America. While performing anesthesia research early in his career, Halsted became addicted to cocaine and morphine" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/#:~:tex....
An American can marry a foreign doctor with 10 years experience, get their spouse a green card and everything, and they still can't work as a doctor without redoing residency like a fresh graduate.
Bring in foreign doctor: here's dozens of laws and programs to make that hard.
Bring in foreign low skill labor: Laws? No human is illegal!
There is so much low-hanging fruit to pick before we create a two-class medical system.
Also, “millions” is hyperbole. It’s tens of thousands a year [1]. Two million or so in a lifetime. But half as many as from alcohol [2].
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323087/
[2] https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
You realise it’s this sort of rhetoric that inhibits moderate progress? If I wanted to kill a residency expansion proposal, and a lawmaker were saying we should let doctors trained in the worst medical systems in the world treat poor Americans, I would run that framing on billboards.
That extremist policy positions backfire? Yes. Because it’s consistently true. See: defund the police and abortion.
What you’re suggesting is lower impact and still more radical than a public option or drug price regulation.
The interesting point is that the early deaths are mostly due to selection - people that can't get insurance are more likely to die early e.g. lifestyle choices. Giving them access to the medical system might not help as much as we might hope.
> Upthread: willcipriano said: Millions are pro[j]ected to die simply due to lack of access to medical care.
No. The risk of death is 100%. People can die earlier than otherwise due to lack of medical access - or better said we can delay death but it usually gets harder and harder to delay as we accumulate chronic health conditions. And some people avoid chronic conditions better than others.
Aside: Meanwhile the richer your country, the more you can take the best doctors and nurses from the poorer countries. New Zealand trains a lot of great doctors and nurses for the USA. And we take a lot from other countries too.
1. https://www.aha.org/news/headline/2023-07-27-hhs-awards-15-g...
Here's a breakdown for funding for one year in the recent past: https://www.ncbi.nlm.nih.gov/books/NBK248024/table/tab_3-1/?...
So if you're a hospital, and you can get cheap doctors in residency who basically need to work whatever workload you give them, why wouldn't they hire as many of them as they could? I figure the limiting factor should be their ability to manage them, not federal funding. They are paying pennies on the dollar for doctor labor that they are NOT giving patients a discount on.
The AMA has lobbied to limit federal funding for medical residency. This is the bottleneck.
The fundamental problem is that the US government should not be in the business of funding residencies to begin with. That should the on the hospitals.
Right now the problem is that no hospitals want pay the 150k cost for residency when there is the option for the federal government or another hospital to pay it. It basically leads to a tragedy of the commons/prisoners dilemma, where all the hospitals defect and try to fight for limited grants.
This article has some general details: https://thesheriffofsodium.com/2022/02/04/how-much-are-resid....
Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.
Here: https://www.washingtonpost.com/archive/politics/1997/03/09/r...
> Last week a powerful coalition of medical groups, including the American Medical Association and the Association of American Medical Colleges -- the umbrella group for medical schools -- proposed their own plan. Their idea is to limit residency slots financed by Medicare to the number needed for the 17,000 annual graduates of U.S. medical schools.
There's other things like this that folks say "Well, where's the evidence?" and the truth is that the evidence was all around us back then. Now that people have changed their minds on this stuff, it's harder to find as the perpetrators go quiet about it. And you have to search the past which isn't that easy.
I'm sure the pandemic response will be similarly rewritten, especially the business about telling people masks don't work because they wanted to make sure that average people won't take masks that they wanted to keep for healthcare people. That's being rewritten in front of me to say "Oh there's no evidence that masks ever worked and that's why they said that".
Where's the evidence? Well, in many cases, it was everywhere. Truth casts a small shadow on time. The motivated sceptic stands purely in the light.
From the article: "But why should hospitals be interested in this when, under current law, they automatically get sizable government subsidies for training residents who as part of their education take care of many of the hospitals' patients, work long hours and collect meager salaries?"
If this issue were to arise again in today's political climate, I imagine there would be a redistribution of seats away from in-demand specialties to primary care.
The AMA represents doctors, not hospitals, and doctors benefit from scarcity. Hospitals benefit from residency grants, existing doctors do not.
>Do you have evidence of this lobbying?
Here is a source [1]
>Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.
Optimal only if they can make money from the residents. Due to the bizarre natures of US medical reimbursement, resident physicians do not bill for their services [2]. While they may provide value in other ways, they are viewed as cost on the balance sheet. This is further complicated by the fact that hospitals dont want to bear this cost if they can get a grant, or simply hire a doctor away from another hospital. Getting rid of the grants would be a step in the right direction.
https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...
https://thesheriffofsodium.com/2022/02/04/how-much-are-resid....
Further, residents, by and large, are paid for by Medicare.
> While they may provide value in other ways, they are viewed as cost on the balance sheet.
Are you saying that replacing residents with physicians would be more advantageous to hospitals? I don't have a sense of the numbers or billing processes involved
This would seem to increase the potential productivity of a hospital. So I am confused by why you say residents are a cost on balance sheets (again, considering that their pay comes from Medicare/Medicaid)
Residents are actually more qualified than many other "mid level" professions aka Medical Providers.
Would I rather see a resident, or a nurse practicioner? The resident of course, because he/she actually completed medical school, whereas an NP may have a nursing oriented (no emphasis on diagnosis) masters or terminal degree.
https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope....
I once considered becoming a doctor when I was still a teen, and I'm quite confident I could have gotten into medical school and qualified for a residency somewhere, but it was the decade of hazing while being paid like a ranch hand that dissuaded me.
Also, we have some many people that want to be doctors. We should let them all start medical school, and let them get weeded out from there.
[1] the caveat here is research. But MD/PhD fits far better into the traditional college pipeline.
The US and Canada are globally unique in requiring a 4 year bachelors before 4 more years of med school. Every other OECD country has a single 5-6 year program available straight out of high school.
https://www.niskanencenter.org/the-case-for-shortening-medic...
A stupid amount of my wife's medical education was completely wasted for two reasons:
* "To make sure you know what career to go into". No. You don't need 2 years to see every possible option. Everyone has some idea before they even go to med school. Focus on the 2 to 6 that you care about.
* Residency application. 4th year was a complete joke. Most of it was consumed with travel/distractions while applying to residency. Maybe 2 or 3 months of actual learning fit in their.
----
The med school my wife's residency is associated with is actually a 3 year program. They skip summers and condense a lot of information.
But people still need genuine healers for everyday ills, and so we see the institution move towards restoring that role to those with a less critical role in the institution, like nurses, pharmacists, physical therapists, etc
I will grant you that in some specialties and smaller private practices what you describing is probably true.
But when it comes to the broad swath of everyday ills, someone with far less alignment training and who therefore hasn't been entrusted with the "MRI approved" stamp can often do a perfectly comparable job of taking care of people. That's what most practical medical care demands and it's what US doctors are now too overqualified and overpaid to provided.
Yes, the greedy doctors who are lucky to get a couple hours of medical coding training when they start practicing and get needled constantly by their billing department for underbilling actually have "years of learning" in how to screw over their patients.
Maybe they mean the man-years of time wasted arguing with insurance companies, shuffling around medications and care plans to please them, evenings and weekends spent in the EHR finishing up patient notes (because there's no time to get them done during the working day with 20 minute visits) and correcting and signing off on patient care for the PAs and NPs (cold-heartedly taking 100% of the malpractice risk burden for the nurses who actually care about "healing").
I'd encourage people this far gone on the deep end of visualizing physicians as hand-rubbing greed machines to spend a day actually shadowing one. Because you are very ignorant about how they spend their time and the amount of effort they put into caring for patients in spite of continual soul-crushing roadblocks put in their path.
* Yeah I know it's against site rules to say but I don't care it's true
Doctors are brilliant individuals and often deeply invested in patient care. Many if not most of them pursued the career because they wanted to be healers. But as you beautifully describe, a lot of their actual job is now committed to navigating endless bureaucracy because they are the only people who have been institutionally blessed to do so. Given that many of them do care so much about patients on a personal level, and pursued the field for that reason, it's tragic that paperwork takes so much away from their opportunity to do so.
My perspective even goes so far as to argue that their pay isn't a product of greed at all, but simply a necessary outcome of institutionally mediated medical goods, of which they've been tasked as front-line guardian, being grossly expensive. Reduce the cost of what they control access to, as we see in non-US health care markets, and their pay naturally reduces.
In lieu of that, the US solution is to cleave out the responsibilities that don't require 8+ years of education and residency to get right and allow them to be dispensed by others.
There's no indictment of doctors here, friend. None at all. It's all just mechanisms in a system much much bigger than them, and these mechanisms (as you describe!) frustrate them at least as much as anyone else.
I've spent considerable time tracking down why X costs Y, explaining it to a doctor, only to have the reply be "woah, you should tell people!" No, you should tell people, that's part of your job! Mind blown at some of these people.
(1) the cost is intentionally not displayed to the physician when tests are ordered;
(2) the cost is not provided to the patient before services are rendered;
(3) the price being charged varies by insurance plan; and
(4) the number of different insurance plans is vast
How exactly do you expect physicians to be able to provide these estimates for each of their patients? There are certainly simple examples where the physician ordering a test is also the one providing it, but those simple examples don't really exist in major healthcare systems.
I wish they would, both to "rock the boat" administratively and to empower patients to include price sensitivity in their own choices. They already spend half their time arguing with insurance companies though.
There is bureaucracy surrounding what insurance companies and medicare will pay for, given specific diagnoses (medical necessity guidelines).
But the actual process of diagnosing a patient is not trivial and that function can not be described as that of a "bureaucrat".
Yes, you need a specific diagnosis X to justify procedure Y, and that can feel bureaucratic, but there is nothing bureaucratic about getting to diagnosis X in the first place.
https://image.slideserve.com/488686/physician-satisfaction-w...
My guess is that not dealing with a mercurial insurance industrial complex that tries to constantly deny medically necessary treatment to your patients makes your day to day work more enjoyable.
[0]: https://www.census.gov/library/publications/2023/demo/p60-28...
Cuba isn't poor because of an inefficient command economy. Cuba is poor because it has been denied access to its largest trading partner (and more) for over half a century. And people _still_ have a better healthy life expectancy in that country than in the US. Imagine what it could be like there if the US did more than pay lip service to world prosperity and peace.
"Host" nations agree to pay Cuba for the doctor's work, agree not to pay the doctor directly, and agree to deport them back to Cuba if they attempt to negotiate being paid directly. This is slavery by anyone's definition.
You can squarely place the blame on the AMA who (proudly) lobbied for years to cap Federal funding for medical Dr education and residency.
https://www.aamc.org/news/combined-bachelor-s-and-md-program...
Plus it would let many more people do MD-related jobs like medical researcher.
Consider a doctor or even a plumber. When you have a problem that needs one, that problem is usually important and urgent, and it's not a job you can "afford" to be poorly done by an amateur. So you end up paying a lot to get it done quickly by someone from a small pool of qualified providers.
On the flip side of that is something like a barista. My 3 year old has figured out how to operate the Keurig and while obviously a high-end barista can make a way better coffee, the second-best and "nearly free" option is totally acceptable, putting a hard ceiling on how much a barista can make. That option doesn't exist for doctors and plumbers so they make a lot.
The fee paid to the surgeon is something like 2-4% on the ones I've seen. So, a few grand to save someone's life. I don't think they're paid so much at all. What they are paid seems more than earned to me. We might instead ask why so little of the money paid for procedures seems to be paid to the doctors, and so much to the medical bureaucracy.
Most of what people complain about isn't the plumber charging $500 to fix plumbing, so to speak, but why the Plumbing Center adds another $40,000 to the bill and itemizes things like "$50 Miscellaneous Paper Towels".
What do you say to things like shopping around using newly-transparented prices, telehealth, minute/community clinic visits, and nurse help lines?
The guest is the head of the Surgical Center of Oklahoma. You can see prices of procedures very easily on their website. That's what you'll pay, even if something goes wrong. Surgeons earn more when working there than they earn at a regular hospital while patients pay less. However, no insurance wants to work with them. Supposedly because they have a price and won't negotiate with insurance who get part of their money as reward from large customers for negotiating prices down.
Indeed, in this case the scarcity is, at least in part, artificial, but the cost still comes down to supply and demand at the end of the day.
Plumbing is maybe a good example, in the sense that if I own a home and feel comfortable with something, I can do whatever repairs I want. I could hire my friend John Smith to do it if I trusted him. The limit is the inherent risk I take, and knowing that if I screw something up, I could cause problems that cause problems to me. There are code issues, but that gets complicated and is orthogonal to the issue of who does the work that meets code.
In healthcare though, even if you are entirely capable of doing something yourself, you are not able to legally. If there's a medication that you have been taking your entire life, and has been deemed safe in the primary scientific literature, you are still not able to just go buy it from the pharmacy without a prescription. If you want help or advice with the medication, you also can't just go to a provider that you want. You can't take the drug yourself, under the advice of the pharmacist for example — even though the pharmacist often knows more about drugs than an average physician — and you can't take it from a different type of provider that you trust more, for whatever reason.
The point still stands... the number of people who are willing to take plumbing matters into their own hands is pretty low. I am one of them sometimes but 99.9% of households are still competing for the handful of "capable and available when I need him" plumbers.
The are significant structural reasons behind pay. Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates. Or they raise them a little but they don’t have anything like market rates.
The pay of real estate agents, where each side commonly gets 3% of the sale price (shared usually with your firm) is a rediculuous cartel that needs to be destroyed. In my city avg home price is over a million, so the seller/buyer each pay a 30k commission for a few hours work? That high pay comes from a cartel.
Some people are paid high amounts because that’s the expectation. Parity with other jobs might be a support for high pay, but maybe not. I’m skeptical of this argument applied to doctors. I had more years of college than a doctor plus medical school plus a year or two of hospital / internship. I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates. Am I doing more important things for society than teachers in my town? (where they can’t find enough and now they recruit parents to be subs because they don’t pay enough for that either). What I’m doing is useful but probably not more important than public school teachers.
// In my town like in many others they have lots of help wanted signs. All they need to do it pay more and they’d have a much better chance of hiring people.
Right... so apparently they don't "demand" that labor badly enough to pay "whatever it takes" - as you would with a doctor when you're sick or a plumber when your house is flooding.
// Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates.
But it seems like the "government rate" is sufficient to attract the kinds of people that become public school teachers and government programmers, right? Supply and demand...
// The pay of real estate agents... so the seller/buyer each pay a 30k commission for a few hours work
Yeah but how many agents are you competing with and how many houses are you moving a year? The top realtor in my town moved over 20M of property a few years ago, so she cleared 600K in commissions that year. The bottom bunch of realtors in my town sold $0 worth of house and got $0 worth of commission. The reason the first woman made that $600K is because there's a demand for her services... and the reason those other guys made $0 is because there isn't.
I get the point you're making about fixed fees, but these fees don't guarantee you any profit for just becoming a relator.
// Some people are paid high amounts because that’s the expectation
What is an example of that? To whom do you pay more than you have to in the market because of "expectations"
// I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates.
Right, it's supply and demand as I am saying because someone needs you to do the thing you do whatever it is, and they can't find someone to do it for less.
I tend to disagree. There is a very strong halo effect which I just kind of ‘hate’. Let me explain.
Here in the Netherlands we have a numerus fixus (about 500 spots each year on each university). Getting in is part luck and part skill. The skill required is to show eagerness and motivation in an interview with a commitee. That’s the hard part.
Once in, you are very unlikely to drop out. The drop out rates are extremely low compared to other studies. The education is very long and intense: this is very needed, you need to be highly trained.
If you compare the academic level to other studies, it’s quite moderate. Basically, it’s a very pratical education with a lot of “hands on” in 6-8 years (and more if you specialize). For the dutch: people jokingly say that we need to rebrand the education to HBO-G.
I have a friend who started out in Economics, finished the study with a degree with honours and decided to follow his dream to become a doctor. He said: the education was so easy compared to economics, it was a total joke. Mind you: the level of education for doctor is very good in the NL compared to othet countries.
Now, in the NL we have a quite good health care system and still the doctors make an extremely good living. I have friends who are 40- and live in an 1 million+ house, drive a porsche and do luxury vacations three times a year.
And I think it’s fine: you are highly trained, you work shit and long hours and have an very very big responsibility.
But is it a difficult and challenging job? I disagree, you are a highly trained production employee doing 95% on experience because you did this a 1000+ times before.
The elephant in the room is, with the rising care costs here in NL, is this still viable? Earning high 6 figures while the system is under pressure? Also: why is the gap between doctors and nurses so big? Is that fair?
(Sorry for my rant :-))
Unlike software, where you don't even need an education to get started, but you'll be expected to learn a different framework every year
I don't think that's key.
In Europe healthcare tends to be socialised and heavily regulated so that I would argue that average salaries are kept "artificially" low.
Medical services are highly valued by society for obvious reasons, and the level of required training is extremely high. If the market was left to its own devices I have little doubt that doctors in Europe would earn much more than they do now. Of course that does not mean that healthcare would be better on average, in fact most likely the opposite, but the question is about doctors' income.
> Lots of people want to train as doctors: over 85,000 people take the medical-college admission test each year, and more than half of all medical-school applicants are rejected
But I believe that this means applications with a Bachelor degree.
In France, the system is different. Students go to 1st year medical school after highschool where there is a massive selection with limited number of places to get to 2nd year. Only 15-25% of students get to 2nd year, taking into account that only good students will attend 1st year to start with.
In the UK admission rate in 1st year (afte highschool) is about 15%, again taking into account that those who are not straight-As students probably don't bother applying to start with.
This does not sound less competitive. If your French classmate had a bachelor degree but went back to 1st year in France that might have given him an advantage over students fresh out of highschool.
In any case, according to the article it is the shortage of qualified profesisonals that should ultimately impact salaries, and there are shortages. But, again, salaries tend to be in effect regulated one way of another, which I think has much more of an impact.
USA has much less doctors per capita than Europe though, so the problem isn't the same. It would be nice to have more doctors in Europe, but in USA it is a critical problem.
Conversely, I am not convinced that more doctors in the US would lead to a big drop in earnings assuming the market there is 'freer' than in Europe. It's a rich country and healthcare is very valuable with high barriers to entry in any case.
Europe is a big target, and there is quite a bit of variability country-to-country, but in general I would say yes. For example, in France the median physician salary is €120k/year and the median software engineer salary is €55k/year. So the median physician makes 2.1x the median developer.
In the US you have a median of $110k for SWE and a median of $255k for physicians (NOT 350k, as I've addressed on HN previously - see the US CES data [1]). So about 2.3x.
I've been saying this for a long time: doctor scarcity is a red herring. Training more physicians or nurse practitioners or physician assistants will not bring down healthcare costs.
[1] https://www.oecd-ilibrary.org/sites/b39949d7-en/index.html?i...
It’s called “anchoring”.
350k a year was a ton of money that bought you home ownership, supporting a family, saving for retirement, and some if not all of the finer things even in a desirable geography.
15-25 years ago.
350k is relatively a ton of money compared to dystopian nightmare of constant insecurity at the median.
350k is a damned sight better than typical household income, take home is $19,319.25, which is very comfortable but not “lavish” for a childless bachelor with no debt most anywhere.
But throw in funding your 401k, ~18k, renting a single-family home in a desirable geo in a neighborhood you’d park your car on the street: ~13k, couple of car payments/reg/insurance/maintenance, ~11.5k, 4 decent mobile phone plans, decent internet, utilities: 10.5k, couple of grand in student loans: maybe like ~8k, a year’s worth of school clothes and supplies, replace a piece of furniture or two or a TV that craps out, a laptop or iPad or whatever someone broke or lost or was stolen because they’re kids, and the long tail of “major expenses” that you never see coming amortized over a year: ~7k, fund college savings for two public universities: ~5k, healthy groceries you don’t have to ruthlessly optimize and the occasional dinner out with your partner: ~3.5k, save up a robust emergency fund and then build a portfolio that will let you retire before 70 with a life expectancy pushing 90: zero. Hope you’re not passionate about any hobbies that cost money and never want to go on vacation.
You did a STEM-heavy undergrad, passed the MCAT, did years of extremely technical advanced degree education, took years off your life pulling crazy hours in a residency, built a practice. You’re among the most highly educated and indispensable members of society.
And your “lavish” profligate conspicuous consumption is living in California, sending your kids to public universities, and retiring ever?
No, it’s the median that’s barbaric, not a modestly comfortable middle-class lifestyle you worked your ass of for that was pretty mundane for educated folks even a few decades ago.
It covers a lot. I'm sick of reading defenses of people making 250k+ acting like they're in the poor house. I get families are expensive, but lifestyles have inflated to such an absurd degree.
I've been on both sides of this argument, but it's so frustrating. I def agree with the median sucking, however I know plenty of people IN the median that feel differently.
It's so strange to hear all this doom and gloom from people like me. I get that we don't have all the luxeries we were promised. In the 90s it would have been $90-150k and you would have a vacation house. These were really prosperous times if you were in the middle class.
I get that we've experienced a bit of a "darth vader I changed the deal moment". There seems to be more expenses and we're getting less out of the deal (though more in some other ways). All that said, you're comparing against very prosperous people who were getting a pretty good deal.
This is an absolutely baffling statement. Median income in the USA is $76,000:
https://www.census.gov/library/publications/2023/demo/p60-27...
Perhaps it makes more sense if you limited this comparison to top-20 college graduates that could realistically work for top law firms or tech companies. But $350K is still not remotely a slight better than the typical household income.
I would bet that in those sorts of scenarios, we're further away from "enough" than we used to be.
There's a huge disconnect, I don't know where it stems from. The average/median american is not living in destitution, at the brink of collapse.
The fact that 350k feels low, is, I don't know, weird (although, like you, I understand that directionally it _feels_ about right).
And I can't explain the emotional reaction I had. Like, I was relieved and proud that I had done a good job saving, but... I also knew that I was far above average in income and saving, and even with that was only "on target" rather than exceeding. I eventually spluttered out my words to the financial planner, asking about all the other people out there that make less and aren't in a position to see financial planners, and with a sad look on his face, he simply said:
"It is going to change society."
I think there's a huge difference in baseline cost. A lot of people on high incomes have huge spending jumps, that most just don't. e.g. the vacation is international, the house is twice as big, or in the "good" neighborhood, the car is big, the school is private, the kids have trusts, ...
At all that up, and yeah, 350k is barely enough. Take all that away, and 80k is solid.
> "It is going to change society."
socialism (we'll take from thee) or fascism (don't you dare take from me). America is in for a rough ride if he's right.
Agree that "you need a lot more money" feels directionally correct, but at the same time complaining about $350k is dumb. At that level of income it's entirely down to your lifestyle choices.
A lot of things people spending money on feels like status signalling. "I make $x, therefore I need to look like I made $x". Cars, private school, massive house, yearly international vacations, etc all feel over the top to me. If you want to have it all, yes it costs a shit ton.
The fucking economist hit piece said that 350k was "lavishly" high for an absurdly educated and highly socially useful professional because it's connected to a bunch of think tanks that are part of a concerted and coordinated effort funded by Bond Villains to organize society around one goal and one goal only: to drive wealth inequality arbitrarily high as fast as possible no matter if all of mankind has to strain every sinew and destroy the planet to do so.
No cost is too high to have people flying around daily in custom Gulfstream jets carrying a single passenger.
Fuck that.
I'm getting evicted two days after my birthday and not one of my patrilineal relations will help me.
Could you put me up? You absolutely could and it would not burden you at all.
And don't even start because you and the rest have profited greatly.
I know, I know: how dare I.
CMB.
The typical homeowner in a coastal metro doesn't have a massive income, but does have a million plus in home equity. You as a young adult will need dramatically more labor income to reach the same lifestyle on ~$0 wealth. You will even need more labor income than they had capital gains, because high-end labor is taxed much more heavily (~40% effective) than capital gains on primary residence ($500k exemption then ~20%).
Your list of expenses totaled to $58,500.
What happened to the other $171,500/yr??
Looking at health outcomes in other countries, your argument just doesn't hold
The mean wage is 224k/year. https://www.bls.gov/oes/current/oes291215.htm Definitely high earning.
> We don’t need more internists or family med doctors, most of that caseload can be handled by NPs and PAs.
Ok. When someone in your family dies from horrible substandard care from an NP, we'll talk. I don't let anyone in my family deal be under the care of an NP, I've seen them make far too many serious mistakes.
Pretty sure the big shortage is precisely in FM, because it's low-status and not as stimulating intellectually/too routine
There's a huge need for basic, primary care.
As a medical student, I'd like to dispel this myth. The surgeons tell us all the time that they could teach a monkey to do surgery. What matters is putting in the 10,000 hours if takes to become proficient at surgery, and not everyone has the time/resources/opportunity to get that training. However, I believe that almosy anyone taken from the streets and given 10,000 hours of training could become a world-class surgeon
https://veteran.com/military-doctor/
Wouldn’t it be great if this program were expanded to include “civilian service,” as in “rural community and inner city” assignments? e.g. psychiatry?
Oh wait, there are programs for this, as well /s:
https://www.usphs.gov/students/
https://www.ruralhealthinfo.org/topics/scholarships-loans-lo...
Other options: nurse practitioner, social worker, physician assistant, nurse anesthetist, etc.
Bottom line: if a teen wants to be a doctor or healthcare provider, there are many paths to getting there. It’s a lot of hard work and it takes the right person to do it. Good luck and thank you to all of you considering this career choice-it’s your gift to humanity.
And you deserve to be paid well!
This is just med school with military branding. Every year, at the start of med school, the military recruiters rain down on med schools providing the exact same offer.
What you really want to know is, if you deregulated healthcare in general, and removed a lot of the medical licensing restrictions around care provision, what would be the expected decrease in healthcare costs? What if you increased care access?
For example, let's say you dramatically opened access to large classes of drugs that are basically safe, and made various procedures and medicines available through, say, pharmacists or psychologists, or created opportunities for different provider models that don't exist now. What would be the expected decrease in cost, both in absolute dollar amounts and in "intangibles" such as time?
For me the problem is this hierarchical view of healthcare provision, where we assume a physician is omnicient and omniskilled in all areas of medicine, more so than other types of providers who specialize more, and the only safe training path is bachelors -> MD -> residency.
I don't buy the safety argument either because having practicing power so concentrated in one professional group also leads to safety problems. Those highly skilled and trained physicians didn't save us from things like the fentanyl crisis, even though it was literally their job under the current paradigm. If someone was really concerned about safety regulation, you would regulate on a skill basis, not on a degree basis.
There a whole host of problems in US healthcare, including increasing consolidation of healthcare companies, healthcare management and administration, and so forth. But I do think a hierarchical provider model characterized by intense regulatory capture is a big, nonignorable part of it.
(The frequent blindness of The Economist to such critical basic facts was ~80% of why I cancelled my print subscription.)
Medical schools are so far and few between that it is one of the rare places students seek admission in the Caribbean and Latin America to get certified with the hope of clobbering their USMLE exams and getting into a good residency program to make up for it.
The fact that someone can have 2 points lower on the MCAT and not qualify for a good medical school tells you how messed up the priorities are.
There is a limit on the number of seats in US medical schools but this does not affect the number of new practicing physicians in the US directly. Thus the article's discussion of MD matriculations and of DO programs should be ignored.
The article correctly states that all physicians must complete residency programs. The US Medicare and Medicaid programs fund the vast majority of residency slots. Residency slots preferentially are awarded to US medical graduates (i.e., new MDs) but they are available to any graduate of an accredited MD program. Thus, if a bottleneck exists, it exists here.
However, hospitals can - and do - use other funds to train medical graduates in their residency programs. I do not know the thinking about how many such slots a residency program operates, but this would have been a far more interesting area for the article to examine.
Pulling on that thread is pretty interesting in how broad it goes. I'm certain I don't understand it well and the experts are pretty argumentative also.
Plenty of people in tech getting TC like this.
That would be standard TC for a senior level engineer. But not at at a typical fortune 500, bank, or any other traditional type company that does not have tech as their main strategic business offering.
There's a clear skill and education floor between the fields. It's probably reasonable to compare the top 90% of doctors to the top 10% software engineers. In fact, I'd suspect most doctors would be 1% engineers if they put the same effort being a great engineer as they do for med school/residency.
You will see this in any field that transacts with high value goods: real-estate, enterprise software, weapons of war, investment bankers handling M&A ... the higher the cost of the product, the more the people dealing in it feel entitled to charge for their services.
Why did the Department of Health state there was a surplus? What policy decisions allowed them to make that recommendation? What mechanisms meant medical schools, who have an incentive to increase class size, reacted the way they did? What is the difference in salary for “DO’s”? What part do HMOs and insurance companies play, who surely have an incentive to lower the cost of medicine?
One argument is tacit collusion to “inflate salaries” which may be part of it, but if this accounts for all of the impact then it is a scandal and evidence of institutional corruption that should be paraded in the streets. I’d imagine a class action lawsuit by students who didn’t make it into med school against the DoH. I don’t think this answers it all.
In any case, I think the uppermost level of medicine will get decimated by AI. It’s mostly knowledge work with a focus on experience. It feels like the perfect use case for generative AI. On the other hand having more people doing the manual work (putting in a catheter etc) will likely last a lot longer as robotics has seemed to stall in advancements.
The role of the AMA in restricting the supply of doctors has been paraded for decades, but it just doesn't catch on. People like their personal doctors and refuse to think ill of doctors, though they'll happily blame others in the medical industry. I find it quite believable that the doctors industry would err on the side of undersupply, making their own salaries high, rather than risk oversupply and a drop in salaries.
Is that "collusion"? That's just terminology. It's the standard "regulatory capture", as government officially delegates accreditation to the medical industry, despite the obvious conflict of interest. The AMA argues they're protecting doctor quality, even though they overtly worry about oversupply.
Ideal outcome is accelerated MD for nurses as continuing education. Not having this is plain classist af.
This is like asking an air traffic controller to fly a plane. Air traffic controllers are smart, highly educated, highly technical people. But as a passenger on a flight, would you trust one to fly your plane, even if they just finished a 2-year accelerated training course? No, because a career in ATC doesn't teach you much at all about the actual mechanics of flying a plane. Nor does a career in nursing teach you how to diagnose a patient or formulate a care plan.
So why are so many people willing to accept non-physicians who completed an accelerated training course instead of physicians who completed a residency? It's just bonkers to me.
Nurses and doctors work right next to each other. Years in, how much do you think school long ago vs on-the-job experience informs behavior?
It's not medical school that makes the difference, it's residency, which is > 10,000 hours of on-the-job experience, more or less in an apprenticeship model.
Sure, a nurse can accumulate 10,000 hours of on-the-job experience experience as well, but it doesn't translate when that experience is doing a completely different set of tasks.
Working right next to each other doesn't change things. If a concert violinist and a concert pianist play in the same orchestra for 30 years, does that raise the concert pianist's violin ability to professional level?
I work with nurses every day. They ask questions about treatment plans that, if a resident with more than 3 months experience were to ask me the same question, I would have serious concerns. It's not because the nurses are stupid; it's because they don't have > 10,000 hours formulating treatment plans and (critically) being held accountable for those plans, as a residency graduate does. They see the recipes, but they don't understand how the ingredients are put together.
Do the doctor(s) like go to a different room when they come up with the treatment plans? My lay understanding is everyone is around each other a large portion of the time, at least at the hospital (outpatient maybe is more different?).
Perhaps some nurses are happy to not care about "where the recipes come from" and "just mix ingredients, follow the plan", but surely others are just a bit more naturally curious how those come from.
I am not saying they can just instantly become MDs, but If I spent 10,000 being a line cook, I think I would be pretty well prepared to go to culinary school.
I agree with many of the points made here (doctors aren't overpaid, schooling is too long, etc) but how about addressing how many people constantly believe they need to see a doctor. How much time in the doctors office is actually necessary? There are probably more hypochondriacs today than ever before and I know many IRL. I've gone to the doctor probably less than 5 times in my adult life, but I have friends my age (late 30s) who go dozens of times per year, and don't have chronic issues! Some people suggesting a single payer system would fix this but I see it the opposite, just like in Canada, our system will be flooded for people seeking care for every single thing.
So for now, the second best solution is the "doc-in-a-box"/urgent care outfit that doesn't have all the expensive machines and can therefore charge less, or you can see an NP/PA who can charge less because they have less formal education.
> More than 100m people today live in an area without enough primary-care doctors
I have several friends who are primary care doctors, and their patient panels are 2000-3000 people. That is an absurd number of people, and requires a ton of work on their part, leading to poor work/life balance. Being a primary care physician is becoming more difficult and less attractive, even for people who otherwise would be really interested in being generalists and building the kinds of relationships that come with being a PC.
> the problem is particularly bad in rural areas
Generally, highly-educated people tend to live in urban areas (there are many sources that track this trend). In addition, rural areas tend to imply private practices (because there aren't as many large hospitals in those places), and private practices are even harder to work at — whereas a hospital has an entire department dedicated to billing and dealing with the myriad insurance types their patients have, private practices have to mostly manage on their own with minimal staff. This winds up taking a ton of their time, and is a major reason some folks I know have not gone that route.
> As the baby-boomers age the need for medical care rises and the doctors among them retire
This may be a "usual suspect", but it is a real one.
> it takes 10-15 years after arriving at university to become a doctor in America
IMO, this alone largely answers the question in the title. While training, physicians don't generally earn a lot of money (relatively, and especially since many of them train in large hospitals, which are based in large cities, which have higher costs of living). The expected reward for spending a 10-15 years of your life studying and working hard, long hours, in schools and then residency programs that are short-staffed and have multi-day shifts, must be high enough to justify the cost, even for those that go into it with a very idealistic mindset.
When you consider that there are less doctors per people in the US compared to some countries where healthcare is partially or entirely public, it's quite revealing how this result is achieved: by decreasing the population who can offer one. So that if you were re-adjusting the graph to the population with insurance or sufficient needs, the US would probably be higher than the rest.
I don't know how you can argue to yourself that limiting access to health care is better because now some people can get what they want faster (because others can't get what they need at all).
A lot the distribution, efficiency, and particularly the burnout are due to corporatization and over regulation. The "medical" system is a self-licking ice cream cone of non normal demand curves being served by inefficient systems the generate reasons to intermediate money between the end players of patient and doctor.
So typical to focus on the "doctor" as the problem.
We had a much more robust distributed national system before the"smart" people made it "efficient".
But i'm sure the doctors and the AMA would do everything in their power to stop that from happening
That number should rise with reduced regulation and sentiments toward what affordable healthcare means.
In the meantime, AI offers promise to assist both physicians and non-physicians.
Should our goal be to replace most hospital general checkups, triage, oncology, select emergency room visits, and a number of other medical fields with a non-physician who is trained to use specialized AI technology to deliver with a patient together.
YES.
[1] https://hms.harvard.edu/news/fourth-us-health-visits-now-del...
The AMA should stop opposing single payer, though. That is the key difference in the US health system and other national health systems with better outcomes.
also: just look at the section of the Economist it is in: United States | Medicine’s gilded age - very professional.
also: What percentage of the total healthcare costs in the US are attributed to physician salaries? That is the theoretical maximum improvement to the cost of care delivery, if you dropped it to zero. And is that net or gross take home? Is the data before or after paying malpractice insurance of administrators to navigate the intentional bureaucracy created by providers?
Of course the AMA looks out for the benefit of its own members, which benefit from scarcity, as is reasonable. It is up to the public and their legislators to act in their own interest to increase supply of medical professionals (which is counter to the interests of existing medical practitioners)
In addition to this constraint on supply, the demand is inflated by medical insurance which makes consumers price insensitive and produces a "use it or lose it" mentality where people are compelled get certain services they don't really need to not let the unused budget expire.
The solution is to increase supply by making medical education a 4 year program that has no undergrad prerequisite and no residency postrequisite like it is in many parts of the world and also reducing the unnecessary demand by removing any government requirement that employers provide medical insurance or any subsidy towards getting medical insurance.
Consider opportunity costs for all those hours spent studying. Salary, in isolation, is not a sufficient measure.
They have their own interests to protect, and those interests aren't 100% aligned with the medical needs of the American population at large, nor with doctors struggling to make ends meet after taking on a ton of debt to go to med school.
Is it any wonder that those who enter med school (or residency) with a deep sense of altruism get burned out rather quickly? I think not.
Disclaimer: this is my lived anecdotal experience as an undergrad engineering student in Slovenia. I am a 20-something yo male, with some chronic illnesses. It's ex-Yugoslav status is somewhat important in considering the social safety nets. We've been part of the EU for most of my life. What I'm describing here is probably not completely true, and lacks some nuance. I think you'll nevertheless find some common points with other healthcare systems and other countries. My English can be a bit confusing at times.
In my opinion, we're dealing with a fusion of for-profit and semi-profit insurance companies, private and public practitioners, waiting list manipulation and ever-increasing bureaucracies coming together to create a special sort of hell that you could not imagine creating even if you strove to.
PAY: Where I come from, the salaries for medical staff vary wildly. Doctors, especially dentists, surgeons and other specialists, are getting very well off, while a lot of newcomers and nurses are working under extremely strenuous conditions while paid rather poorly. In Europe, this became especially obvious during the past (hopefully) epidemic. This problem rarely improves despite numerous strikes. In most cases, everyone gets somewhat adjusted for inflation, the top dogs get even better salaries, and the pay gap widens somewhat, with the politically underrepresented majority being about as well off as before.
PUBLIC vs PRIVATE INSURANCE: Mandatory or basic health insurance is mandated and provided by my state, and is valid for all public health service providers and some private ones under a public-private partnership deal. The system is plagued by long waiting lists and endless optimization by the latter public-private "amphibious" health providers (more on them later). A lot of people I know (including a close family member) have relied on paying a private specialist out of pocket to have some emergent issue looked at in an acceptable time, sometimes paying extra for a private insurance plan that keeps a group of specialists at hand. Public waiting lists seems to be shortening a bit at the moment, but this trend, while welcome, isn't expected to persist.
It's also important to notice the ever growing populations of elderly people requiring frequent care and increasingly non-working migrant groups, which both tend to strain our rather thin social safety nets, remaining from our former socialist system where being a NEET was not a state of existence favored by past state institutions, unlike current ones which are rather lenient at providing free services to non-working, non-educating, non-retired persons.
A lot of these "amphibious" providers work half-time public waiting lists (very busy) and half-time private practices (not so much), often luring the wealthier of the public lists patients to the private practice hours to earn more. A peculiar phenomenon of space-time continuity apparently permits them to somehow produce wildly different waiting times for the exact same services. Keep in mind that we're far from US pricing here, so both lists are comparably full. The private half just makes them a lot more money. Forcing these practitioners to pick a side has been a considerable talking point of many election campaigns that has always remained unfulfilled because of endless lobbying, strikes and political pressure.
EDUCATION: As education is 100% free here, it might be a surprise that no-one from my grammar school enrolled in a medical field. I can imagine that bad future pay security, long study program, and miserable stipends are a prevailing reason for that.
SHORTAGE: We could hire from ex-Yugoslav area to relieve our overworked public health centers and hospitals, but most of the admissions get gridlocked by language proficiency requirements (in my opinion an idiotically pedantic edge condition that is killing people as we speak). Unfortunately, a lot of nationalists like to codify their self importance into law, and as a result, some countries suffer a lot more than others.
The end result is, that state-sponsored solutions are degrading at a glacial, but non-zero pace, while private practices get consulted more and more, day by day. Bureaucratic management perpetuated by lukewarm money-loving policies are probably the way affordable public healthcare dies for everyone. It really seems to me like healthcare is one of the things you can't fence-sit about; picking a public or private side is necessary to create a stable and affordable system.
The Economist has framed this problem in terms of "Doctors Earn So Much". It is not framed in terms of corporations making unconscionable profit, buying up medical practices. It is not framed in terms of drug companies charging so much that many people cannot afford medications and so end up going to the doctor many more times than should be necessary. They do not frame the problem in terms of hospitals paying doctors primarily based on how many patients they see rather than how effectively they treat patients.
Many doctors are now leaving primary care because the corporate drive for profits has made their work unbearable.
Our elected officials of both parties are so busy posturing and providing political theater that they have no time to solve the people's problems.