[syki]

I have a hard time rectifying the claim that you are a health economist with the fact that you don’t appear to understand that the bottleneck for increasing the supply of doctors is the number of residency slots. Foreign medical school certifications are largely accepted at face value but graduating a foreign residency program largely is not. I think it’s pretty much universal that each country wants doctors to go through their own version of residency.

My wife is a physician. She needs a large salary to pay off her large medical debt. When the medical debt is paid off her salary will still be large. A much more sensible system would to make medical school free so that the salaries don’t have to start off so high. There are people with hundreds of thousands in med school debt who didn’t match. We should feel sorry for those people.

[allcentury]

The limit of residency slots is in the article.

> A much more sensible system would to make medical school free so that the salaries don’t have to start off so high.

That's not how any labor market works. Your salary isn't determined by how much debt you rack up. Doctor's salary's are high because the supply of doctor's is so low (especially primary care).

The article covers all the points you're debating (much better than I).

[syki]

My response was about the claim that OP is a health economist while not understanding where the bottleneck in the supply for doctors comes from. I believe you are incorrect as it pertains to doctor salaries. Demand is high and supply relatively low. That is true but this isn’t the only factor that goes into determining pay. That’s an overly simplistic view of things. Supply/demand does not account for everything in this situation. If med students came out of med school with zero debt then the healthcare industry could make being a doctor sufficiently lucrative with salaries that are smaller than they currently are. Lowering the salary a bit in this scenario would not lower supply. You should read about David Carr’s work.

[vsskanth]

I don't agree the cost of university is driving the salaries here. It's all about how many doctors are available to meet demand. If there are less, it's going to drive up salaries. There are other countries where the cost of getting a degree in a certain specialty is very low due to state subsidies but the salaries are very high once they graduate since they are scarce.

[syki]

In countries with mostly free higher education doctor’s salaries are less on average than in the U.S. You really think having several hundred thousand dollars in student loans doesn’t in any way affect salaries?

[huitzitziltzin]

There are important differences in most of those countries including (importantly!) direct government regulation of prices, including salaries in the medical market.

British doctors, for example, work under a contract negotiated between a British version of the AMA and the British government. The government and the providers both have leverage, but the British government is the primary purchaser of services in that country. Salaries are lower since the government exerts pressure on them, as they are paid for out of direct taxation.

I understand that you feel very strongly that student debt for doctors is unjustifiable or too high or something. Student debt is not the main driver (or even a driver) of high salaries among US doctors. The level of their student debt is a completely separate topic.

[syki]

There are private doctors in Canada and the UK and they don’t make as much as their American counterparts.

Anecdotal evidence. My wife has $400,000 in med school debt. She needs a $300,000 salary to afford paying that debt off whilst also maintaining a “good” lifestyle. Med school, residency, etc. were hard and sacrifices were made to go through them. It would not be worth it to go through that without a reasonably high salary.

She’d gladly have gone through the process for a $200,000 a year job. It is certainly the case that highly motivated, highly intelligent people take into account the ability to service med school debt when deciding to become a doctor vs. another going into another field. It is obvious that high med school debt has an effect on the salary needed to attract talent.

David Carr won the Nobel Prize in part for his work questioning the traditional supply/demand view of labor economics. Here is a link to an interesting (to me) paper.

https://www.jstor.org/stable/24695058

[ChrisLomont]

In almost every country professional salaries are much lower, so looking only at doctors and thinking your argument is unique to them is flawed.

And no, debt does not affect salaries. It's the other way around - with the potential to make a lot more income, one is willing to get more debt to reach that goal. Higher salaries people cause more demand, and so prices go up.

If debt affected salaries, you'd expect your claim to play out on all fields, which it does not. Higher paying undergrad salaries don't correlate to more debt, for example.

[syki]

I made no claims about uniqueness so I don’t understand your first paragraph.

If debt affected salaries, you'd expect your claim to play out on all fields, which it does not.

This is very much wrong! All fields are not equal. No one should expect motivations, forces at a play in one field to necessarily apply to all fields.

Do you think highly intelligent, highly motivated people would take on hundreds of thousands dollars of student loan debt without an expectation of a high enough salary to service that debt while maintaining a good lifestyle? We are talking about people who could go into just about any field. To be able to attract the talent the salaries need to be high enough to service the debt. Without the debt the salary needed to attract that talent would go down.

My wife’s med school debt is $400,000. She needs the $300,000 salary she has to service this debt while living a good lifestyle. That high salary will last the rest of her life and not just for the few years it takes to pay off her debt. If she had no debt the she’d be able to live the same lifestyle making $225,000 per year.

Personally I think it’s naive to think that the debt level doesn’t come into play when determining the salary needed to attract the labor of highly intelligent, highly motivated people. You really think that in the alternate world where the U.S. had free med school and all else was the same that salaries would be the same?

https://www.jstor.org/stable/24695058

[kbelder]

It's mostly the other way around. Because of demand, doctor's salaries are high, and so the cost of education increases because new doctors can absorb the high loan payments.

[syki]

I believe there is a dance between these various quantities. Overall, my claim is that large med school debt does play a role in high doctor salaries. I don’t claim it is the only factor but just that it is a factor. I further claim that if med school was free them doctor salaries wouldn’t have to be quite as high as they are. That is, the same number of people would be aspire to be doctors with med school being free but doctor’s salaries being x% lower.

[maxerickson]

If it has any effect it is much less than the regulatory bottlenecks imposed on the number of doctors.

[CogitoCogito]

I believe you have it backwards. The high salaries increase the levels of debt potential doctors consider acceptable.

[N1H1L]

> That's not how any labor market works. Your salary isn't determined by how much debt you rack up.

True, or else college dropouts from a private school will have higher incomes than a state school undergrad, which is not the case at all.

[lupire]

Primary care is a low paying job because nurses and PAs can provide primary care.

[strikelaserclaw]

To be perfectly honest, i have found primary care doctors pretty useless in the last 5 - 10 years, not only did i find that their answers were things i could easily find on google, i also noticed that most of them didn't actually care about patient well being. It seems like most doctors these days are only in it for the money, which is fine if they are actually providing a valuable service, but low level doctors are nothing more than glorified drug dealers at this point.

[namelessoracle]

This is sadly true.

There is basically no value in a general medicine doctor that i can see. General health issues can be handled by a nurse practitioner, they can see if you have an ear infection, are sick with the flu, and proscribe you the antibiotics, or other controlled medicines just fine. They could easily switch to a model where the General Medicine doctor acts as like the staff engineer over the senior devs, and just does a quick plus one on their results and makes sure no mistakes were made. (this is how most doctors visits play out anyways)

When there IS something seriously wrong, they almost always send you to a specialist who can actually treat your specific issue. Have a really bad ear infection / something is lodged in your ear? Here is the ENT referral! Pay me for telling you to go see the ear doctor when you had ear problems.

[kashunstva]

Former general internist here. I obviously have opinions about the assertion that generalists provide no incremental value. The model you posit, wherein a generalist oversees a panel of NP’s and PA’s is already common. Many primary care problems can be handled in this way. No disagreement. But there is a host of multi-systemic disorders that most mid-level practitioners would never recognize. And do you think most subspecialists are interested, aside from the occasional rheumatologist, in comprehensive management of the protean manifestations of most of these types of disorders. This coordination of care for complex disorders has to be done by someone. And for the sake of the patient I hope it’s someone with a solid command of pathology, physiology, pharmacology and so forth. And maybe someone with the time and empathy to talk to actual humans. If you think coordination of care is handing out referrals, that’s a massively reductionist view.

[namelessoracle]

What you are talking about is ideal state. My experience is literally its always "here's the referal" if i talk about anything specific and the standard host of anti biotics and standard z pac style medicines dont clear it up. Always.

Now my view might be biased because i have been given Kaiser as my provider and i know they have incentives in their system that arent the norm. But its always a specialist referral. Ear problems that the anti biotic didnt solve? ENT referral! (the ENT laughed and said the general medicine doctor made the problem actively worse with the multiple types of anti biotics proscribed sense it was a fungal infection in the ears). Skin issue? Here's the dermatologist referral! Shortness of breath after working out? Here's the pulmonology referal if you want it. Your knee hurts? Here's the rheumatology referral.

I am legit curious what medical service the doctor would provide. You mention "multi-systemic disorders that most mid-level practitioners would never recognize" do you have an example of that?

[thfuran]

A doctor in it for the money is pretty unlikely to go into primary care.

[strikelaserclaw]

They usually set up their own clinic and rake it in, tons of primary care doctors i know did this.

[huitzitziltzin]

> I have a hard rectifying the claim that you are a health economist with the fact that you don’t appear to understand ...

Don't tell my PhD thesis adviser, I guess? He could have sworn he approved a dissertation about health economics but you've uncovered my secret, or something? (And what was I working on for all that time then? It was years of my life! Apparently nothing?!?)

> the bottleneck for increasing the supply of doctors is the number of residency slots.

No, _you_ are misunderstanding what change I want. There is no reason at all for a German, Mexican, British, etc. practicing doctor to have to do a US residency at all after they finish whatever training qualifies them to be a doctor in their home countries.

Read the article again. US medical education takes much longer than medical education almost anywhere else in the world, yet our outcomes are almost always worse along nearly any measurable dimension.

You will say: "yeah, but that's the result of many factors!" Great - I agree. But in that case it really isn't obvious that the extra years of medical education in the US do a lot for patient outcomes.

In fact, not only do I want more residency slots in the US, I want to reconsider that whole residency system, especially for doctors trained abroad.

> I think it’s pretty much universal that each country wants doctors to go through their own version of residency.

Why? That's a big part of the problem. There is literally no reason in the world for a German doctor who has been practicing there for a few years to have to come here and do a residency again. It makes no sense. You wouldn't do it for a C programmer, right?

Example: "Sorry - you learned C in Germany. If you want to program here, you'll have to get a four-year degree in CS again."

This obviously makes no sense. C is (ideally) the same language wherever it is written. And yet, while you have the same number of kidneys as a German and the same nervous system as Russian ... are you seeing the point I'm trying to make? Why require years of extra training for a doctor from one of those countries to work here? That keeps them out of our market and keeps prices high.

> A much more sensible system would to make medical school free so that the salaries don’t have to start off so high.

Let me pull out my economist card again and say: "this is not how that works." Salaries are not high because medical school is expensive. Salaries are high because supply is restricted. That's how supply and demand work.

[syki]

There is no reason at all for a German, Mexican, British, etc. practicing doctor to have to do a US residency at all after they finish whatever training qualifies them to be a doctor in their home countries.

You should have stated it this way. In your original post you referenced medical school and that gave the impression that you aren’t aware of the credentialing process to becoming a licensed physician. You had written:

There is no reason why Mexican, Canadian, British, Indian, German, ... doctors should not be allowed to come and practice in the US with more than some cursory verification that they actually attended a medical school where they are from.

There is actually a valid reason to make it hard for doctors to move from one country to another. Training doctors is time consuming and expensive. There is a moral aspect to luring doctors trained in poor countries to rich countries.

David Carr would like a word with you regarding your belief that supply/demand alone accounts for the pay of doctors. The supply would not go down if med school was free but starting salaries were x% what they currently are. The experiments have been run. Countries with mostly free higher education have lower doctor pay than the U.S.

[huitzitziltzin]

> There is actually a valid reason to make it hard for doctors to move from one country to another.

When your goal is to increase supply in the US and drive down prices, then no, there is not a valid reason to do this.

> Training doctors is time consuming and expensive. There is a moral aspect to luring doctors trained in poor countries to rich countries.

FWIW I don't completely disagree with this. But that's kind of a crappy thing to say to a Turkish doctor who wants to flee the Erdogan Sultanate, or a Sudanese doctor who wants to make more than a pittance every month.

I'm not willing to condemn some poor Pakistani doctor to a life much less comfortable than he could enjoy here AND force US citizens to pay extremely high prices for medical care to protect the incomes of US doctors. If you are, cool.

Before you get indignant with me: you yourself could train as a nurse practitioner pretty quickly and cheaply (if you are in the US) and then go practice in Sudan or 100 other countries. They'd love to have you. If you only speak English, try India, Ghana, Nigeria, ...

You would be providing a great benefit to the Sudanese. Don't want to? Then why condemn some Sudanese doctor to the same just because he was born there instead of here?

> David Carr would like a word with you...

I don't know who this is.

> regarding your belief that supply/demand alone accounts for the pay of doctors.

I will happily believe this, both on my own authority as an actual informed expert in the field AND on the basis of the research of numerous colleagues of mine, who have in the aggregate devoted several hundred years of work to understanding this topic.

> The supply would not go down if med school was free but starting salaries were x% what they currently are.

This would be a notably interesting result in economics if it were true. It is not true. Doctors salaries are not responsive to the cost of medical school.

[syki]

I said there was a moral aspect to taking medical talent from poor countries. You say that you don’t completely disagree with this. So it sounds like you too believe there is a moral aspect to this issue. Great.

I'm not willing to condemn some poor Pakistani doctor to a life much less comfortable than he could enjoy here AND force US citizens to pay extremely high prices for medical care to protect the incomes of US doctors. If you are, cool.

You assume that I’m opposed to giving licensed doctors in other countries an exemption to going through a U.S. residency program in order to practice in the U.S. You are making assumptions that are not justified by what I have written. There are at times valid reasons to restrict medical talent from easily leaving one country to another and there are times where there aren’t really any valid reasons for doing this. I was responding to your statement, “there are no valid reasons….”

Your argument here is way too black/white given the complexity of the issues involved. Thinking that “…condemning Pakistani doctors…” and “…force U.S. citizens to pay more” are the only or are necessary outcomes to not allowing Pakistani doctors to practice medicine in the U.S. without going through a U.S. residency program is not correct.

https://www.jstor.org/stable/24695058

EDIT: Modified to be less vituperative.

[vsskanth]

> There is actually a valid reason to make it hard for doctors to move from one country to another. Training doctors is time consuming and expensive. There is a moral aspect to luring doctors trained in poor countries to rich countries.

There might be a reason for the home countries to not want their trained doctors to leave considering the money spent training them. Some of them do have agreements for the trained doctors to work for a few years in return for the subsidy. That's for the home country and the student to decide.

However the main economic argument here is there's no reason the US should force them through residency again to practice, instead of just directly allowing them to practice after some vetting (USMLE whatever) and reap the benefits of fulfilling pent up demand, lowering healthcare costs and improved access.

I have point out here that "We shouldn't steal talent from poor countries" as a moral argument is a common trope amongst those pushing for immigration restrictions to limit competition to themselves. People are considered free and aren't owned by their countries. Its an understandable argument but I wouldn't pass it on as beneficial to the US or the people (it's not).