How the American Medical Association Screws Doctors | Hacker News Reader

How the American Medical Association Screws Doctors

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74 pointstoomuchtodo90 comments

This could be straight out of Systemantics, written about systems in general by a physician.

One of the observations goes something like:

Systems grow to perpetuate themselves, not provide the service for which they were created.

similiar to the iron law of orgs / oligarchy. all orgs that live long enough eventually exist to just perpetuate the org. the “reasons” become marketing and politics but are no longer seriously considered in their effectiveness.

That's probably taken from Systemantics

AMA screws doctors too? I thought its main job was to screw patients by keeping the amount of doctors artificially low to keep prices high.

Looking at how their revenue from membership dropped and are now relying on royalties, they are screwing themselves too. If they had more doctors, they wouldn’t have to rely on royalties.

Maybe they're just not relevant any more. What would they do if their money came from doctors instead of royalties? TFA says they're like a startup incubator, which is fine but why should anyone be funding them in that case?

AMA is not the main culprit in supply of doctor's, that would be available spots for residents (and further downstream, available slots for sub-specialties e.g., pediatric nephrology; pulmonary critical care). You can expand med school enrollment until the cows come home, but you'll just be increasing the number of aspiring doctors who don't "match" to a program to continue their training.

Solving this is complex and complicated, in large part due to the fact that residences and many fellowship programs are funded through medicare/medicaid via congressional actions, sometimes with additional state funding.

Also keep in mind that most doctor's have high salaries and high debt load, they're not as rich as people think. There are sub-specialties though that are aboslutely rolling in cash (interventional radiology, dermatology, ortho as some).

> AMA is not the main culprit in supply of doctor's, that would be available spots for residents

The AMA has actively lobbied to lower the number of residency spots.

> In 1997, the AMA lobbied Congress to restrict the number of doctors that could be trained in the United States, claiming that, "The United States is on the verge of a serious oversupply of physicians."[12] The AMA successfully lobbied Congress to cap how much Medicare could reimburse hospitals for resident physicians

It was not my intention to defend the AMA, and organization I generally don't like (though I don't think they are villainous either).

I will note that you're referencing 30-year old legislation, which I don't think necessarily speaks to the AMA's role or position now. The AMA is not de facto against increasing slots. Please refer to this position from the president of the AMA penned last year: https://www.ama-assn.org/about/leadership/more-medicare-supp.... They have consistently asked members to support legislation increasing funding for GME positions.

But ultimately, their opinion is just that. Advanced medical education required congress to act, and expanding availability of trained professionals requires either:

1) Increasing slots for advanced training one way or the other, which will almost necessarily carry increased costs or 2) Allowing more US-trained immigrants to stay in the US after their education or 3) Creating an easier pathway for trained foreign doctors to practice in the US

Do you think there's ANY chance of #2 or #3 happening? In 2021 Congress funded 1000 new positions, the first expansion since 1997. They added 200 more spots in 2023. I imagine we'll be waiting awhile for the next expansion that the AMA actively desires.

>Also keep in mind that most doctor's have high salaries and high debt load, they're not as rich as people think.

I suppose it depends on what people think, but doctors do alright.

I didn't say they needed violins of sympathy, but the majority of them are not the wealthy upper crust they are often perceived to be. This goes double for family medicine, and double-double for pediatric specialties that are paid less since Medicaid covers so much of the cost.

>I didn't say they needed violins of sympathy, but the majority of them are not the wealthy upper crust they are often perceived to be.

Sure early in their careers, just like every other well paid profession isn't "rich" early in their career. After a decade or so into their career though, they are either rich or really dumb with how they spent their money.

The worst impulse in me wants to get highly specific and detailed about how you are confidently painting with too broad of a brush, but I just don't have the energy. I'll just say two things:

1. Physicians earning story is very unique from most other professions (e.g., higher debt load; later career start; limited salary increases after starting) and doesn't correspond as well to the mental models you've constructed.

2. I'm not a physician myself, but I'm friends with several AND my professional experience includes two projects setting physician and surgeon compensation strategy across multiple geographies. I'm familiar with the macrodata and anecdata.

But I will say this: when it comes to surgeons or physicians on the "ROAD to success" (i.e., radiology [increasingly less so as the work is offshored], ophthalmology, anesthesiology, or dermatology) you are mostly right.

Another commenter already mentioned their caps. I'll add that the cost of medical school is one of the true reasons for short supply and one of claimed reasons healthcare is high. For the latter, they have to recover the cost of their expensive education.

Getting education costs down to community college levels would knock out a major source of high prices. Or they'd stop pretending it was. Whichever it actually is. :)

> one of the true reasons for short supply

No, it's not. The reason for the short supply is the CAPPED number of advanced education spots after medical school. Open up 100 more med schools with class sizes of 1000 each at half the cost or typical schools and you'd still end up with pretty much the same sized cohort of doctors with advanced training.

Some states have looked into legislation allowing graduated med students to serve rural communities without having undergone a residency. I don't think this is widely available if available at all, nor do I think it's scalable.

> I don't think this is widely available if available at all

It was, a long time ago. Then states started requiring an internship (first year of residency) for a full license - which is still generally the case in the US for graduates of US medical schools (foreign school grads regardless of citizenship usually have to complete at least three years of residency before getting a permanent license). Getting privileges at a hospital will nearly always require finishing a residency. That's a matter of the hospital's medical staff bylaws, so changing them is not really in the purview of the state except to prohibit discrimination based on a protected class - and "hasn't finished residency" isn't a protected class.

It definitely would further ghetto-ize rural general practitioners. They wouldn't even be eligible to get a job outside of those rural clinics.

On that topic, do you have any proposals aside from lifting caps?

I think of healthcare problems in America like a watershed: the issues are not the result of any one problem but a concentration of small, medium, and large problems that all drain into the same humongous river. Things that could happen (and let's just take more socialized medicine off the table since it will never happen):

1. Increasing caps (funding) for advanced education

2. Allowing Medicare to negotiate drug prices, it's preposterous that they cannot do this

3. Increase price transparency at hospitals to enable some downward pressure on prices. This is much harder than it sounds, not that it's my problem to solve.

4. Limit hospital system monopolies that given them too much leverage in price negotiation (though have to be careful not to give insurers too much negotiating power, delicate balance)

5. Cap out of pocket expenses, though I'm not sure how.

6. Standardize and simplify billing codes across the US, with more public visibility into them. Medical billing is currently an art, it should be a science.

7. Offer loan forgiveness to medical practitioners that serve for 10 years post-advanced training in a low-healthcare access communities. For what it's worth, I'd also place income-to-debt ratio restrictions on doctors' eligibility for public service loan forgiveness as well.

8. Sadly, if we won't let immigrant trainees stay and obtain citizenship in the US after training, we should stop allocating training spots to them.

9. Increase use of mobile clinics and/or transportation services. This would almost necessarily need to be government funded.

10. Reform malpractice insurance and litigation in a way that doesn't remove physician accountability but doesn't require such high overhead to be paid by everyone down the line.

The above would help, but I don't know how much.

During last 20 years, the # of US physicians has increased 60% with a corresponding improvement in the ratio of physicians per person. Where are the price cuts that should come with more doctors and nurses adding to care capacity by practicing like MDs? Perhaps the health care market is more complex than can be explained by simple economic theory.

In the last 20 years the US population has increased by 15%. And that population has also grown older and sicker, so demand is way up.

Healthcare supply and pricing is heavily controlled so you're correct that simple market based economic theories don't explain much about how it operates.

Weird I wouldn’t have known, I got a crazy wait for my physician and quality seems to have gone down

And then when you finally get an appointment, they can only spend 10 minutes with you and then rush to the next patient.

Docs are the face of the broken system and take the brunt of patient frustration over many flaws they have no control over. Try telehealth to get the access and responsiveness you need if your local medical facilities don't attract enough docs and nurses.

Afaik AMA lobbied congress to raise the amount of residencies.

> Before his confirmation hearing, RFK Jr was thinking of attacking the lucrative AMA revenue stream. As the Financial Times reported, “Kennedy’s team has discussed how the CPT process could be done in-house by the Centers for Medicare and Medicaid Services, according to three people briefed on the matter.”

Congratulations, the author managed to find the one thing where RFK Jr actually makes a good point.

The "economic termites" problem also applies to other parts of the economy. Software patents like Amazon's for "1 click purchases", the hot mess that is mobile phone standards where a wanna-be startup has to negotiate with a bunch of different patent pools (which is why you don't see new players other than Qualcomm, Apple/Intel, Samsung and MediaTek (who probably got started by just shitting on IP laws - if going by bunnie's old "gongkai" post, at least the people using their stuff in the old days certainly did), video/audio codecs that have the same situation, even ham radio has its issues - DMR for example is an ETSI standard, but the most commonly used voice codec theoretically has a patent that (IIRC) runs through end of the year, and Yaesu's C4FM is fully proprietary.

> 1. Liability Insurance: From what I understand, this cost has gone up faster than inflation.

The problem is, if you fuck up say a child's life during birth by noticing too late the child is running out of oxygen... two decades ago, the child would probably be dead by age 10 or even earlier. With modern medicine, it is manageable to keep that shell of a human alive until it dies at age 80 - that cost has to be paid for by liability insurance if it can be shown that the cause was a mistreatment. We have that problem with midwifes in Germany, who are dropping out in droves because insurance prices exploded [1][2][3].

[1] https://www.bundestag.de/webarchiv/textarchiv/2014/49932222_...

[2] https://www.zeit.de/gesellschaft/2015-07/hebammen-elternprot...

[3] https://www.br.de/nachricht/hebammen-mangel-bayern-102.html

>Software patents like Amazon's for "1 click purchases"

I'm not sure why this is mentioned, it's hardly a drain on other retailers to have a second click in their process.

>We have that problem with midwifes in Germany, who are dropping out in droves because insurance prices exploded [1][2][3].

I'm not convinced that's a bad thing, especially in Germany where there seems to be a lot of woo based practice masquerading as actual medicine. If the insurance prices are exploding due to actual malpractice, the profession probably should clean up their act which necessitates people leaving the profession. Sure you probably lose some of the good with the bad, but maybe they should have cleaned house a little earlier.

"I'm not sure why this is mentioned, it's hardly a drain on other retailers to have a second click in their process."

Much research shows that many people will leave one site for another for the tiniest delay or inconvenience. They've long competed on this. Why do you think Amazon patented saving a click or two in the first place?

Also, patents like this force most sites to be inconvenient for customers to avoid getting sued. Increasing patents like this increases odds that a site owner is sued for their optimizations. Also, patents don't allow for independent creation like copyright does. Every patent takes that method away from everyone else for 20 years even when they independently invented it.

I dont like patents at all. Even if we have a system, we shouldn't allow patents for software because they're only a hindrance to most software developers. We virtually never use or benefit from them. People who such money from developers using patents rarely contributed anything of value. Usually just filed a piece of paper.

> I'm not sure why this is mentioned, it's hardly a drain on other retailers to have a second click in their process.

it's a drain on any startup company doing anything with the web to search for trivial patents. Thankfully, Europeans don't have to do this.

> If the insurance prices are exploding due to actual malpractice, the profession probably should clean up their act which necessitates people leaving the profession. Sure you probably lose some of the good with the bad, but maybe they should have cleaned house a little earlier.

This is not about homeopathy crap, this is about actual errors that can happen, people aren't infallible after all - just that the financial impact to liability insurances in such cases used to be waaaay lower even 20 years ago than it is now.

> just that the financial impact to liability insurances in such cases used to be waaaay lower even 20 years ago than it is now.

Sure but everyone mostly accepted that malpractice just happened and lived with the results back then, things are better now.

If you're on Medicare and trying to figure out whether something is covered, CPT codes are the glue in a rat trap, the pin sticking bug to a board, you get the idea.

Everything is done by CPT codes. But you can't go and reference them yourself, even on the Medicare web site (no, really you can't). Doctors will tell you something is covered, then you have to demand the CPT code from them and call Medicare to find out if it's covered. Or, you can trust the doctor... who will be correct until they aren't. Sometimes doctors don't even know what CPT code they'll use until they see you.

I’m a doctor — and I’ll say it proudly: the AMA deserves every royalty they collect, and probably more. They’ve done more to protect the integrity of American medicine than any other institution. Without them, we’d be working 80 hours a week and still struggling to afford a one-bedroom apartment — just like doctors in France, where a cardiologist makes less than a dental hygienist in Ohio.

People don’t realize how bad it is out there. In some countries, doctors are taking public buses to work, skipping lunch to see 50 patients before noon, and retiring with the same savings as a schoolteacher. Meanwhile, patients complain that a 15-minute consultation in the U.S. costs $300. You’re not paying for the time — you’re paying for the privilege of certainty, of safety, of knowing your doctor passed through the most rigorous, exclusive system in the world.

And who built that system? The AMA.

They’ve helped ensure that American medical training remains second to none. Not just in quality, but in difficulty. The years of unpaid labor, the crushing debt, the endless exams — it’s not a flaw, it’s a filter. Without those standards, the profession would lose its weight, its dignity. If becoming a doctor were simply a matter of competence and compassion, we’d all be wearing name tags and making $60,000 a year.

But thanks to the AMA, we’ve maintained the sanctity of the white coat. We’ve ensured that when a patient walks into an American clinic, they know they’re not seeing someone who just slipped through the cracks. They’re seeing someone who’s been tested, refined, and yes — financially punished enough to demand respect.

Let’s not pretend this work is trivial, either. Just last week I diagnosed a UTI, prescribed a $4 antibiotic, and quite literally saved someone’s life — that’s a bargain at $500. If I’d been compensated based on the value of that outcome, I’d be driving home in a McLaren, not a Lexus.

And let’s be clear: this system doesn’t just benefit doctors. Everyone in medicine — from PAs to NPs to specialists — benefits from the professional ecosystem the AMA has helped shape. We’re not just providers. We’re institutions.

So yes, I’ll keep paying my AMA royalties. I’m paying to be part of something that still means something. I’m paying for the architecture that keeps American medicine elite, untouchable, and worth every penny.

And if someone wants to pay $100 for a doctor visit? There are countries for that. You just might have to bring your own stethoscope.

I just went to the doctor yesterday and had a 3 hour wait for them to tell me I need to see a specialist that won't see me for 4 months and in that time I'm waiting I could suffer serious consequences. At least the white coats maintained their sanctity though.

Ah, a three-hour wait followed by a four-month delay to see a specialist — I understand your frustration. But please try to appreciate what that delay represents: you are being granted access to a system so refined, so in demand, that even suffering must wait its turn. That’s not failure. That’s prestige.

In many countries, you could see a doctor same-day — perhaps even speak to them casually at a pharmacy window. But here, in the U.S., your care is being prepared with intention. Like a reservation at a five-star restaurant, your health is being considered by professionals with the rare luxury of selectivity. It takes time to deliver care at this level. You wouldn’t expect to walk into the Louvre and demand a private tour on the spot, would you?

And let’s not forget: you’re not just being seen by a person. You’re being seen by someone who survived organic chemistry, board exams, 80-hour work weeks, and a system designed to crush the spirit of all but the most committed. You’re being evaluated by individuals whose very presence in the room adds measurable value to the atmosphere.

Yes, it might feel like you’re waiting. But behind the scenes, the machinery of excellence is turning slowly, beautifully. It’s not just about treating illness. It’s about upholding the dignity of care — care that has been pre-aged, curated, and rationed for maximum significance.

And this message — this small moment of clarity — is my gift to you. Normally, it would be bundled with a billing code, perhaps tied to a 99213 modifier and sent through three layers of insurance review. But today, I offer it freely. You’re welcome.

This satire is too good to be detectable at a glance, I can only hope it doesn't get greyed out of existence.

It's AI slop and it's a satire of their own position, in service of giggling at someone fearing for their long-term health. Seems rushed, ill-considered, ill-tempered, and smug in its lack of concern for anyone outside themself. So, just my $0.02, but i won't go out of my way to encourage it.

Thank God AI hasn’t figured out proper use of em/en dashes yet, so we still have a shibboleth.

Funnily enough that's one of the commonly claimed AI tells, em-dashes -- but near-universally when I see it, it looks like someone is just mad because they're being talked down to.

I'm leaning toward this being top-notch satire, but I can't be entirely sure---and that's a good thing.

> Without those standards, the profession would lose its weight, its dignity. If becoming a doctor were simply a matter of competence and compassion, we’d all be wearing name tags and making $60,000 a year.

Sufficiently advanced satire is indistinguishable from fundamentalist ravings, so says Poe.

But this comment has me solidly believing it's satire: https://news.ycombinator.com/item?id=43495692. Not that I can't believe someone would really think that way, just that the odds of them being an actual psychopath who doesn't see what they're saying seem lower than the odds of a non-psychopathic person taking the opportunity to make a joke.

Yeah they're definitely trolling us.

Let's take what you said apart a bit;

- Doctors take busses to work: I lived in NYC and regularly saw doctors take public transportation. I also saw lawyers take public transportation, and many other professionals do the same. Why not doctors?

- "in France where a cardiologist makes less than a dental hygienist in Ohio."

As someone who lived briefly in France, and who grew up with a French parent, this is either untrue, or requires a lot of context in this apples to kiwis comparison. Show me data, and also don't forget to count all the income streams a physician in France has, and the fact that they don't carry the same debt as an American doctor, and compare their income to a dental hygienist in the same region of France.

- Meanwhile, patients complain that a 15-minute consultation in the U.S. costs $300. You’re not paying for the time — you’re paying for the privilege of certainty, of safety, of knowing your doctor passed through the most rigorous, exclusive system in the world.

Between my wife and myself, we've lived in five countries. The skill of doctors in the US is not any better than doctors of the non-US countries we've lived. The idea that US doctors are "the best in the world" is just nationalistic.

I worked in the US medical billing industry, and the idea that the US system is efficient or even fair is completely bizare to me.

I current reside in Canada, where I regularly argue the health care system is broken, but compared to the US, it's still heads and tails better for the vast majority of Canadians. The Canadian system needs major reform to bring it to the level of eg a European nation, but the US is cruel. It's cruel to patients, who are regularly prevented from getting care due to financial issues. It's cruel to require patients pay so much in fees, and risk bankruptcy due to their health. It's cruel to doctors too, to force them to work with the sword of Damocles over their heads of crippling debt, an inhumane insurance system, endless amounts of paperwork, stressful schedules, etc.

The cause of this miserable state in the US is clear, and has been for at fifty years.

Oh and I saw the doctor earlier this week for a followup. I didn't bring my own stethoscope. I also didn't bring a credit card.

Agreed. Much like the vast majority of people that boldly claim "X Country" has the greatest Y in the world, it's unlikely this person has lived (for any significant duration) in any other country besides X.

Having spent many years in Taiwan along with standard doctor appointments and even surgery, I found the medical care in Taipei to be just as comparable as any of the doctors I've seen in the west.

I can literally drive to a CVS, spend $10 on a test, and self-diagnose a UTI by peeing on a stick. And if I go to urgent care there is a 0% chance I’ll actually see an MD for an UTI. I couldn’t think of a worse example of how your supposed eliteness is valuable.

> I can literally drive to a CVS, spend $10 on a test, and self-diagnose a UTI by peeing on a stick

It's knowing to do that in a case that isn't obvious that's the hard bit. Once you've decided to check for UTI, yes, it's an easy self-test.

Trust me, if you have female anatomy after the first or second UTI it’s patently obvious when you are getting another one. That’s my point- I can’t think of an easier condition to recognize and self-diagnose than a UTI in a healthy adult.

But what if it's not presenting normally, or it's the first one? Or it's not female anatomy? Given not all experiences are the same, why are you assuming that your experience is relevant to this other experience? Or have I misread and it is definitely the same?

Any LLM could have told me to do that.

And yes, LLMs are frequently wrong. Do you really want to go there, Doctor...?

I'm not a doctor. LLMs might be frequently wrong, but they don't hallucinate that badly.

Yeah, I'm not disagreeing with you. Just pre-emptively putting that out there to answer the inevitable "B...b...b...but unlike people, AI sometimes makes stuff up!" response from nervous gatekeepers.

> Just pre-emptively putting that out there to answer the inevitable "B...b...b...but unlike people, AI sometimes makes stuff up!" response from nervous gatekeepers.

You're misusing the word gatekeeper, if there is even a good use for it. Requiring a driving test isn't gatekeeping. Or rather it is, but gatekeeping is an obtuse complaint.

I'm not even sure any of the urgent cares around here are staffed by MDs. All of the NPs are theoretically overseen by an MD but I don't know that they are onsite at all.

Yeah except for the fact I have to wait 3 months to see you to even pay that $300 for that 15 mins.

Certainly there’s a middle ground where there are enough doctors to meet demand while not having them below the salary of school teachers.

The situation in the UK is currently considered pretty bad by the public, but you can get free on-the-day appointments with qualified doctors who are paid roughly the equivalent of headteachers. Privatisation, middle-men, and private monopolies create a lot of inefficiency.

Then you should support the AMA's lobbying efforts to remove the bottleneck in residency programs.

https://savegme.org/about

My sibling is a MS3 so know my question is not meant to be as antagonistic as it sounds.

What is the lesser evil - poor working conditions and financial outcomes for the healthcare system or prohibitively expensive treatments for patients? Are patient outcomes of French healthcare that much worse than the United States (and other public health systems such as that in the UK)? Are the wait times as egregious as the headlines make them out to be?

I believe the data supports your points, and there is a lot of data. But I also think the AMA and other institutions need a huge amount of improvement that will likely be very painful to implement - hopefully opioids won't be overprescribed for that pain management.

Thank you for your comment and for bringing expertise and meaningful experience to this discussion.

And yet they do nothing for the auxiliary staff that the medical industry demands to provide the unskilled labor that often play a critical role in patient outcome.

Please do me a favor (yes, me, the stranger on the internet) and look up how much a CNA makes at your local hospital, and compare that to the cost of living for your area. Now check how much your facilities staff makes.

I know you’re talking about the AMA, and I know my grievances are not necessarily well directed at that organization, but I’m at a loss as to where change for these critical workers will come from if not the physicians who hold the most leverage against the bean counters.

Turning patients to prevent bed sores, emptying catheters, providing the most basic of care all falls down to the CNA in a modern clinical setting, who in my wife’s firsthand experience makes less than a barista at Starbucks. Literally, she left her CNA job doing all of the above and more, to make more as a Barista. Your auxiliary staff is critical in preventing hospital acquired infections, and ensuring adequate care is provided for vulnerable patients who cannot assist themselves.

If you get the opportunity, go to your nearest oncology ward and interview some of the CNA staff about their experience as a CNA. Ask them how often a nurse is available to assist with turning a bariatric patient. There is a world of exploitative labor below you, supporting the high profit margins of the American medical system.

> In some countries, doctors are taking public buses to work

I am programmer who earns quite a lot and takes public bus to work, because why wouldn't I?

> The years of unpaid labor, the crushing debt, the endless exams — it’s not a flaw, it’s a filter. Without those standards, the profession would lose its weight, its dignity.

That is ridiculous argument. I would be fine with idea that they learn better if this or that, but this here would make me think you are being sarcastic if you was not serious in the rest of the post.

I can't put it better than this comment: doctors will love the AMA, no matter what it does.

Their software vendor charging an $18/month is a pittance.

It dictates school credentials and # of seats, keeping doctors supply-constrained.

This works out from a doctor's perspective. It guarantees $400K/year or whatever you want to negotiate (ex. $280K/year for working 2 weeks on 2 weeks off, or $500/hour for 4 days for 2 weeks so the other 2 weeks, you can pick up locums shifts 2 hours away for $700/hr).

They also keep doctors informed that without this, they'd be conscripted to work 80 hour weeks for $70K.

(all of this is also why there's a long-term secular shift towards nurses, the second thing my doctor friends will do after being defensive about pay is complain about the low standards of education in nursing)

average schoolteacher salary according to Google

>> they'd be forced to work 80 hour weeks for $70K. (average schoolteacher salary).

That’s crazy and a terrible reason for the AMA. The correct way to solve this problem, for both schoolteachers and doctors, is with a union.

FWIW I agree, I'm being dry with that.

It's easier to disagree these days by presenting a simulacrum of agreeing, and explicitly point out what was said that I am agreeing with, rather than trying to disprove a hypothetical or claim hysteria

Also, you make an interesting layered point, took me a few minutes to realize the layer of irony that this broad claim of forced, dystopian, working conditions is set in democracies that retain a seat for workers / unions, unlike the US. ex. NHS strikes are a semi regular concern.

The AMA keeps the quacks out, to say the least. I know this is not a popular stance on HN.

> The AMA keeps the quacks out, to say the least.

I'm sure it does! That's a very important function I am grateful.

> I know this is not a popular stance on HN.

You think so? I think keeping quacks out of medicine is popular. shrugs

No, the AMA, though not perfect, is an excellent organization that benefits our healthcare.

Locums shifts for $500-$700/hr? Really?

Claimed, yeah, anesthetist in SW US in small small town. (Wouldn't shock me to hear they're exaggerating btw, my experience is people are puerile, and it's absolutely possible they're telling tall tales to brag while I don't have a job)

I really hope this is a troll. If not it at least showcases the attitude that’s wrong with much of the American medical system.

Ah yes, the American dignity of a fat paycheck based on gate keeping.

> Let’s not pretend this work is trivial, either. Just last week I diagnosed a UTI, prescribed a $4 antibiotic, and quite literally saved someone’s life — that’s a bargain at $500.

Let’s be fair, a nurse can do that too. Really ChatGPT probably could do that now. ChatGPT deserves a McLauren now!

Actually Alexander Fleming, Howard Florey, and Ernst Chain deserve more credit for discovering and then mass producing the first antibiotic penicillin. Which btw they didn’t patent because they believed it should help people.

That’s precisely why ChatGPT must be banned immediately and without exception. It’s not just about automation—it’s about preservation of the divine art of diagnosing strep throat with an air of sanctified superiority. You see, in America, we don’t just let anyone wield a stethoscope. No, we demand a decade of gladiatorial combat through organic chemistry, physics, and at least three near-death experiences in med school. Because how else can we be absolutely certain that someone’s IQ is sufficiently astronomical to distinguish between a cold and an alien parasite invasion?

In some other countries, you can become a doctor without even crying during an MCAT. Without even seeing a benzene ring! How, pray tell, can you trust a person to perform heart surgery if they’ve never solved a Schrödinger equation while sleep-deprived?

In America, we value Quality—capital Q, trademark pending. Misdiagnosis? Impossible. Our doctors are forged in the fires of molecular orbital theory and 700-page biochemistry textbooks. And yet… ChatGPT dares to show up, diagnose your flu, and not order a $12,000 MRI just for fun? It’s an affront to civilization itself. Give it a McLaren? Nay. Give it a muzzle.

There is no reason the federal government needs to pay resident salaries. There is no reason residents need to make $50k/yr in NYC. There is no reason medical school needs to cost $400,000 for someone to make $200k/yr as a family med doc.

Who gives a shit about the dignity of the profession? The AMA gate keeps medical schools and residency slots "to maintain the dignity of the profession" while people wait weeks or months to see a physician who hasn't cracked a journal open in 20 years and just refers them to a specialist anyway.

I'm not saying doctors shouldn't make a lot of money, they absolutely should. There should also be twice as many of you. Med school slots are not limited by how many qualified people want to be doctors, they're limited by bureaucratic bullshit. Plenty of people meet all your ridiculous requirements and more yet don't become doctors simply because the seats are full.

I hear what you’re saying, and of course, there’s always room to improve the system. But let’s not pretend economics doesn’t exist. If there were twice as many of us, we simply wouldn’t be worth as much. Not because we’d be less capable — but because value is determined not just by skill, but by rarity.

Flood the market with physicians, and suddenly, the decade I spent sacrificing my youth, relationships, and financial sanity becomes… just a long, expensive hobby. We didn’t endure that gauntlet so that healthcare could be as available as tap water.

Yes, med school is expensive. Yes, resident salaries are lean — especially in NYC. But that’s part of the process. It creates a kind of gravity around the profession. It filters out those unwilling to bear the cost of commitment. You say plenty of people are qualified. I don’t doubt that. But the profession is not merely about who can do it — it’s about who is willing to pay to do it, in every possible way.

And as for doctors who haven’t cracked open a journal in 20 years — well, isn’t that the beauty of the system? They don’t have to. The structure itself protects them. We’ve built an ecosystem where even if a physician isn’t on the cutting edge, the mere fact that they exist — credentialed, licensed, and allowed to operate within this curated bottleneck — means they remain valuable.

If the goal is universal access, then yes, by all means, widen the gates. But just know: the moment everyone can see a doctor anytime, anywhere, the profession stops being a calling — and starts being customer service. And I didn’t sign up to wear a headset.

So no — there shouldn’t be twice as many of us. There should be just enough that when you finally get an appointment, it means something.

> We didn’t endure that gauntlet so that healthcare could be as available as tap water.

"I worked really hard so it doesn't matter if people die for want of care if it means I will make $450k/yr instead of $500k/yr."

> let’s not pretend economics doesn’t exist

I would argue you're the one arguing against economics, or at least arguing for artificial barriers to a free market. Yes, if there are more physicians then physicians will make less. But if you make $500k/yr because a cartel is artificially limited who can compete with you, and making it harder than it needs to be to get your credentials, and making it artificially more expensive to get those credentials, you haven't earned $500k.

> And as for doctors who haven’t cracked open a journal in 20 years — well, isn’t that the beauty of the system? They don’t have to. The structure itself protects them. We’ve built an ecosystem where even if a physician isn’t on the cutting edge, the mere fact that they exist — credentialed, licensed, and allowed to operate within this curated bottleneck — means they remain valuable.

I've typed this word a few times and deleted it because I really don't want this to be an inflammatory comment, but this is an absolutely disgusting mindset.

The system that allows someone who got their medical degree when doctors had a preferred brand of cigarette to maintain a lucrative practice simply because they have a particular credential or license without requiring that they stay up-to-date cannot be called "beautiful" by any sane or ethical person.

I worry that you think I'm arguing for some system where doctors make $40k/yr and you can call a GP office at 2 PM and get an appointment for 2:15. That's not at all what I'm arguing.

I don't know your specialty but you can't make $400, 500, 900k/yr and pretend that letting people who are qualified to be doctors become doctors regardless of some arbitrary seat limit implemented by the AMA and artificial scarcity will mean you suddenly have to "wear a headset." You and I both know that's completely disingenuous framing and not even remotely what would happen.

What would actually happen, for the first 7 years at least, is nothing. And beyond that, private practices would be able to accept new patients, hospitals would be able to staff their positions, and people would be able to access health care without having to wait months for an appoint.

Your whole comment smacks of "I don't care if you need a wait 5 weeks for an MRI, and then another month for a radiologist to read it, I want to be able to buy my Lexus in cash instead of having to finance it."

There's no reason the federal government needs to pay resident salaries — except that no other major player is willing to do it. Hospital cost accounting is always kind of squishy and confusing but on average it seems that teaching hospitals lose money on their residency programs, so they need some kind of subsidy to make up the difference. Most of these teaching hospitals are run by local governments or non-profit foundations. Where will the money come from? There are a small number of residency slots funded by other sources but those are only a fraction.

> You’re not paying for the time — you’re paying for the privilege of certainty, of safety, of knowing your doctor passed through the most rigorous, exclusive system in the world.

Certainly. But how many 9's do we actually need and why are we paying for so many more 9's than that?

Most of the time, I know when my kid needs antibiotics for an ear infection. I didn't go through any exclusive gamut for that single 9.

Thank you for sharing the perspective of some doctors. You'll likely get down votes because it comes across as condescending and elitist.

I didn't downvote because I think diverse perspective is important, but the OP's comment is condescending and elitist: it declares that US doctors and the system they operate within is superior to the doctors and medical systems of every other country. This is clearly false.

“ They’ve helped ensure that American medical training remains second to none. Not just in quality, but in difficulty. The years of unpaid labor, the crushing debt, the endless exams — it’s not a flaw, it’s a filter. Without those standards, the profession would lose its weight, its dignity. If becoming a doctor were simply a matter of competence and compassion, we’d all be wearing name tags and making $60,000 a year. But thanks to the AMA, we’ve maintained the sanctity of the white coat. We’ve ensured that when a patient walks into an American clinic, they know they’re not seeing someone who just slipped through the cracks. They’re seeing someone who’s been tested, refined, and yes — financially punished enough to demand respect.”

But somehow the system doesn’t manage to sort out doctors who are alcoholics, repeatedly injure patients and don’t listen to patients.

I like this paragraph too

“ If becoming a doctor were simply a matter of competence and compassion, we’d all be wearing name tags and making $60,000 a year.”

Competence and compassion should be the number one criteria for a doctor. Not having a chip on their shoulder because they survived an abusive system.

> Just last week I diagnosed a UTI, prescribed a $4 antibiotic, and quite literally saved someone’s life — that’s a bargain at $500.

Hmm.. would the patient not have been able to tell that they had a UTI without your intervention? As I understand it, with UTIs, time is of the essence. You want to get the patient treated very quickly before the infection can spread to the bladder. What if the patient developed symptoms on Friday at 3 pm and wasn't able to get a doctor until Monday morning? I know it's not that life threateningly urgent to treat, but $500 plus time in excruciating discomfort is not a bargain when the treatment is a simple $4 antibiotic. I guarantee that by Friday night the patient would have known what was wrong with them, as well as the standard treatment.

Is this a serious post? I can't tell.

> Meanwhile, patients complain that a 15-minute consultation in the U.S. costs $300. You’re not paying for the time — you’re paying for the privilege of certainty, of safety, of knowing your doctor passed through the most rigorous, exclusive system in the world.

> But thanks to the AMA, we’ve maintained the sanctity of the white coat. We’ve ensured that when a patient walks into an American clinic, they know they’re not seeing someone who just slipped through the cracks. They’re seeing someone who’s been tested, refined, and yes — financially punished enough to demand respect.

Nonsense. Then how do you explain why so many people complain about having visits that yield no diagnosis, no treatment plan, or outright gaslighting by physicians? All the publications in recent times of misdiagnosis and malpractice? The stories on this here on HN and the media have been countless; including my own experience where probably 9 out of 10 visits for me are effectively worthless, especially if they're within a specialty (neurology for example).

Are you suggesting that the quality of treatment depends on the conveyance the doctor used to get to work? Have you even been to France, to dig into just one example?

Gatekeepers going to gate keep. American doctors overprescribe EVERYTHING. From unnecessary tests to unnecessary surgeries & even unnecessary pharma (see Opiod crisis), a majority of MDs are looking out for their wallet first.

Of course you love the AMA. They artificially keep supply of doctors low so you can justify the exorbitant costs for a 15 minute consultation. It's no surprise that the state of tech in US Healthcare is also so poor. When you're so busy sitting on your high horse about your education, you dgaf about the actual experience for the patient.

You say the AMA keeps folks from seeing someone who just 'slipped through the cracks' but completely ignore the fact that many folks will complete their medical education training in the Carribbean and then do residency in the US. The worst part, post-residency, it's almost impossible to know where a physician went to medical school because they obfuscate and deflect to where they did their residency.

Also the arrogance surrounding foreign medical professionals in this comment is astounding. Most doctors around the world want to focus on helping their patient actually heal. American doctors just treat symptoms.

It’s easy to paint with broad strokes, but sweeping generalizations rarely capture the full picture. Not all of us “gatekeep” or overprescribe, we follow evidence-based guidelines and clinical judgment. When a patient presents with nonspecific fatigue and unintended weight loss, for instance, ordering a CBC, CMP, TSH, and A1C isn’t "unnecessary" it’s standard of care to rule out anemia, metabolic derangements, thyroid dysfunction, or early diabetes. That’s not about revenue.. it’s about ruling out high-risk pathology before it escalates.

As for the AMA, it’s far from perfect, but it doesn’t define the ethos of every practicing clinician. Many of us—regardless of where we trained—are here because we care deeply about patient outcomes, not profit. I don’t dismiss international medical graduates; I’ve worked alongside phenomenal ones. What matters to me isn’t where someone studied, but how they think, how they treat, and whether they practice medicine with integrity.

Healthcare needs reform, no doubt—but assuming every U.S. physician is complicit in systemic issues is reductive. Most of us are doing the best we can within a deeply flawed system.

And yet actual health outcomes are worse than some of those other countries. Are you kidding here?

You Sir are at least the equal of Sacha Baron Cohen. Thank you.

It's impossibly hard to tell if this is satire or serious.

What? The AMA is not what it was. What are you, a PGY3?

Hard to tell if this is a troll or not. If it isn’t: we have to govern for the majority, not for the minority.

Thank you for sharing this side of the story so well. The truth is that the AMA keeps the quacks out and standards high.

Dr. Oz is a huge quack but also a very accomplished doctor, how did he get past the AMA?

https://pmc.ncbi.nlm.nih.gov/articles/PMC6167233/

I don't know if I would go that far. Every time my wife goes to a specialist, they just declare her a medical mystery and move on. Our primary care doctor is awesome though.

My wife spent years going to different doctors trying to figure out what was going on with her back. For years, different doctors would just tell her, "you must just be starting your period or something." 5 years of that, she finally found a doctor who actually looked at her and listened to her, did some testing and came back with an answer that she has some arthritis.

They probably screw the patients too.

The American Medical Association (AMA) was founded in 1847 to lobby for making competition to the Medical Doctors (M.D.) illegal. At the time, upstart approaches to medicine [0] did not believe bloodletting and calomel were effective medicine, and the doctors didn't like that their communities did not have faith in their omniscience.

Most states had AMA-approved licensing laws by the early 1900's. After outlawing competition, the Carnegie foundation (a proxy for the early pharmaceutical industry) financed the Flexner Report (1910) to help the M.D.s improve their standards for medical education. The report said, essentially, that all medical schools should be like John Hopkins.

The Doctors of Osteopathy (D.O.) was the only medical philosophy that was organized enough to secure equivalent licensing laws. Osteopathy founder A.T. Still required his students to at least be aware of pharmaceutical options as a 'last resort' for their patients. The modern D.O. license is legally equivalent to the M.D. license.

The AMA standardized on "allopathic medicine". While a lot of progess has been made at understanding and improvinghuman health, modern medicine still has sacred cows, which are quite profitable for the medical-industrial complex (Statin drugs, anti-dopamine drugs, overuse of steroids, etc).

At least modern doctors only bleed people when it's a useful treatment - for hemochromatosis (excess iron stores) and the use of leeches for limb reattachment, etc.

[0] "Herbal medicine, eclectic medicine, and homeopathic medicine were some of the pre-1850 approaches to health that, whatever faults they might have had, did not encourage practitioners to bleed their patients to death or poison them with mercury." - https://www.madinamerica.com/2024/07/theodoric-arizona/ 1444

[minor edits]

[edit 2] having finished the article, I think it’s a good take on the problems of American healthcare. Liked this quote towards the end: “There are two kinds of populist approaches to health care. [Bernie Sanders…] And the second is that of RFK Jr, who, to oversimplify, seems to think that expensive medicine itself is often a ruse by large corporations to keep Americans on an unhealthy sugar-and-seed-oil diet. Whether RFK Jr. is right or wrong is a less interesting question than why most of the powerful lobbyists in D.C. didn’t oppose him.”

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