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Will Truman

Will Truman is the Editor-in-Chief of Ordinary Times. He is also on Twitter.

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  1. Avatar Murali
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    says:

    Privately run clinics in Singapore charge $25 for a consultation. No appointment necessary. Government run polyclinics charge half of that, but have twice the waiting time.Report

  2. Avatar Brandon Berg
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    says:

    Paying by the hour rather than by the procedure seems like a good idea, but driving down doctor’s incomes generally is likely a false economy. People like to talk about the top 1% because it’s easy to generate resentment against a small minority, but the American economy is also characterized by unusually high wages for the top 10-20%. Which means that if you drive down wages for doctors, the next generation will have plenty of opportunities to make money in other fields, and many who might have become doctors will do just that.Report

    • Avatar Brandon Berg in reply to Brandon Berg
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      says:

      Actually, paying per hour might not be such a great idea, either. Seems like it would give doctors an incentive to drag things out.Report

      • Avatar Kim in reply to Brandon Berg
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        says:

        Consider how many patients leave their PCP office not knowing what they’ve just been told, or still having questions.

        Yeah, at least for PCPs, paying by the hour makes sense.Report

      • Avatar Patrick in reply to Brandon Berg
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        says:

        Only if the available queue length is so short that their inability to appear busy changes the domain approach to hiring. Otherwise, there’s always another patient, or some paperwork, etc., to do.

        Physicians might still draw an individual appointment out, but that will be an avoidance thing more than anything else.Report

      • Avatar Will Truman in reply to Brandon Berg
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        says:

        Brandon is actually on to something here, though not for the reason he might think. Doctors can often set their own hours, so if they want more money they can just work more. So it’s not a matter similar to the situation with our packer/movers, who would individually wrap a dead lizard because it meant more pay.

        However, PCP’s often would often like to see fewer patience. The economics favors seeing a lot of patients quickly. If they were paid by the hour, they could scale back the number of patients they see. Taking longer on each one. They wouldn’t “drag things out” but they would take longer than is absolutely necessary.

        (Clancy chose her previous job precisely because they let her take longer, per-patient, than other clinics would allow.)Report

    • Avatar Patrick in reply to Brandon Berg
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      says:

      I’m not sure that people who don’t really want to be doctors make good doctors anyway, Brandon.Report

      • Avatar kenB in reply to Patrick
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        says:

        people who don’t really want to be doctors

        It’s not a matter of people who don’t want to be doctors, it’s the talented people who are deciding what they want to be and have a number of options in front of them.Report

      • Avatar Will Truman in reply to Patrick
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        says:

        Despite the nice pay, I would honestly be happier if Clancy chose to be an engineer. Doctors are notoriously unhappy with their work. Which, given their levels of compensation, is saying something. Take away that compensation, and the calculus changes.Report

      • Avatar Kim in reply to Patrick
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        says:

        Depends. A doctor doing radtech stuff doesn’t even need to talk to a patient half the time, just analyze photos. That plus the pay would fit a lot of programmer-type folks (yes, I’m stereotyping here, sorry!)Report

      • Avatar morat20 in reply to Patrick
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        says:

        That sounds suspiciously like the argument used about teacher’s complaining about low wages. “Aren’t you in it for the kids?”

        My wife made more (once benefits were factored in) as an administrative assistant at an aerospace firm than a teacher. It wasn’t until we married and used MY health insurance that teaching actually brought home slightly more money.

        Which is a sad statement about Texas, right there, as she works in one of the better school districts. (Which is why all the teacher’s union bashing just makes me laugh. She technically has a union. All it does is mostly try to get the state Leg to actually fund the pension plan properly, and not raid it when the budget is short. No tenure, no strikes, no walk-outs, no collective bargaining. All that with a job most people think as slightly more advanced babysitting and think she’s overpaid for).Report

      • Avatar Kazzy in reply to Patrick
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        says:

        @morat20

        I mentioned this on the Monster.com post, but that line of thinking is often used against teachers during salary negotiations. It is really, really frustrating.Report

  3. Avatar Murali
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    says:

    Normally if you visit a private clinic in the middle of the day, you wait for about 20 min (considerable variation on either side) and spend anywhere between 10-15 min. 20 min tops. Usually tends towards 10 min.Report

    • Avatar Murali in reply to Murali
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      says:

      this was a reply to @brandon-bergReport

    • Avatar Brandon Berg in reply to Murali
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      says:

      So about $100 per hour for doctor time, from which support staff, rent, and other expenses have to be paid…how much do doctors in Singapore make?

      I assume you’re converting to US dollars?Report

      • Avatar Brandon Berg in reply to Brandon Berg
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        says:

        Or is this a consultation with a nurse?Report

      • Avatar Murali in reply to Brandon Berg
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        says:

        I’m not converting to US dollars. But given the current exchange rate, is the difference that significant? note also that this is just for the consultation. Consultation fees are usually waived if any further costs total up to more than $25 less the consultation fee. Private clinics don’t have nurses (or at least I can’t remember the last time I saw a nurse at a private clinic). But slightly more than $100 an hour sounds about right. Assuming a six day work week, a GP can easily earn $20 000 a month. That’s what a lot of specialists in government hospitals earn in the middle of their careers. They start off at about $5000 a month. Doctors here don’t earn as much as they do in the US. Not unless you work in a private hospital.Report

  4. Avatar DavidTC
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    says:

    If you want to have people wasting less of a GP’s time, might I suggest nurse practitioners in front of the doctors? Because something like half of what people want when they see a GP could be satisfied by a NP, or at the very least the 20% who have no business even seeing a doctor could be turned away.

    Or just having _more doctors_. Which is something we need seriously to do. By law, if needed, because the existing medical schools seem to enjoin constantly tightening their output, and having really stupid requirements. E.g., for the most idiotic example: ‘We will make medical students people work 36 hour shifts at hospitals, and if you can’t handle that, you flunk out, because of course you’re not fit to run a private GP practice in a small town.’

    The entire medical community, for decades, has been operating a…well, I hate to call it a ‘conspiracy’, but it is, where they are _deliberately_ restricting the amount of doctors that exist. (See also all the doctors from other countries that have showed up to fill in the gap.)

    I free this is going to cause rather serious problems when we get the dual hit of more people having insurance _and_ the population getting older.(1)

    However, speaking to the idea of small fees…what I’d like to actually see, if we really do somehow end up in a universe where the problem is _actually_ ‘wasting doctors’ time, is just a gatekeeper to doctors. It doesn’t even have to be a NP, or even someone with a medical degree. It just needs to be someone who says ‘So you have a cold? With perfectly normal cold symptoms? And you’ve have it for two days? Well, you have failed the checklist, you do not get to see a doctor. Come back if it has not cleared up in a week.’

    This is presuming a world _very different_ from America now.

    1) This is not, as idiots assert, some sort of _failure_ of the ACA. This is a failure of the _medical establishment_, who already didn’t have enough doctors, certainly didn’t have enough for the future, and now are even further away from enough now that entire swaths of the American people won’t choose to go without medical care because they can’t afford it.Report

    • Avatar Kim in reply to DavidTC
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      says:

      “The entire medical community, for decades, has been operating a…well, I hate to call it a ‘conspiracy’, but it is, where they are _deliberately_ restricting the amount of doctors that exist. (See also all the doctors from other countries that have showed up to fill in the gap.)”

      Since, oh, say, 1910 or so?
      *cackles*
      I’ve heard folks talk about what American Doctor Training used to be like.
      It wasn’t worth shit.Report

    • Avatar Kim in reply to DavidTC
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      says:

      Ayiyi.
      I dont give a jack about PCPs. They’re cheap, the whole way round.
      Let’s focus on costly things, shall we?
      ER visits:
      http://www.time.com/time/magazine/article/0,9171,2136864,00.html

      Unlike PCPs, we can quantify how many homeless jamokes show up,
      who don’t need more than a warm bed and some food.

      And there’s an easy fix, too. Take the cities (cause this is where homeless folk often live)
      and give them a “hot cot shop” where they can ship folks off to, if the nurse says “guy
      just needs sleep” (keep a nurse on standby for the unit, just in case someone does
      have a problem that ya missed).Report

    • Avatar Will Truman in reply to DavidTC
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      says:

      Medical schools aren’t the rate-limiter in producing doctors, and there is not a single coalition of medical schools – there are two. The AOA would love to have more schools pumping out DO’s. The problem is that medical schools are expensive. My alma mater has been wanting a medical school for the last two decades. The problem isn’t the medical establishment. It’s the state.

      Besides, even if we pumped out more and more medical schools, it wouldn’t by itself produce more doctors. The result would be that we’d be keeping out foreign doctors and graduates of foreign medical schools Why? That is the bottleneck. Residency slots. Residencies are also expensive (dirt cheap troop labor notwithstanding). PPACA actually improves this, but not by enough. But the solution is in, more than anyone else’s, the federal government’s hands.

      With regard to mid-level providers, I think the ultimate solution to the shortage is going to lean heavily on them. A problem we have with that, though, is that most people don’t want to see MLP’s. They pay their $20-40 and they feel entitled to see a bona fide doctor. This is where it would be helpful to incentivize seeing an MLP. (A visit to an MLP is free, a doctor is $20, something like that.)Report

      • Avatar Kim in reply to Will Truman
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        says:

        Man, I would totally dig that. I tend to show up to the doctors knowing what I need already
        (this isn’t hard for acute problems most of the time).

        For the times I don’t (or seriously need an in person doublecheck), then I’d go to the doctor.

        And the nurse WILL pull the doctor in if there’s a real issue (liability issues).Report

      • Avatar Will Truman in reply to Will Truman
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        says:

        My only experience with an MLP was not a particularly positive one. I knew what I needed but she declined. It wasn’t terrible – my last visit with a urologist was worse – but enough that I use my connections to see a doctor. Thus, I am a part of the problem.Report

      • Avatar DavidTC in reply to Will Truman
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        says:

        See, you stand there and explain exactly what the problem is…and failed to notice the people _requiring_ those residencies are, in fact, the medical community. Requirements for doctors were not handed down by God.

        The entire residency system is completely insane.

        We’re talking about the free market elsewhere. Ask yourself _exactly_ how we can be maintaining multi-decade long shortages in something that takes ten years to produce?

        It is because the industry has enacted barriers to entry.

        And this is about the point where the medical community starts talking about ‘quality’, but the simple fact is that the medical community is often _horrifically bad_ at maintaining quality, so I’m not entirely sure the idea that making people work horrible hours, shitty pay, and often poorly supervised for a supposed training position increases ‘quality’ is one we should put much weight in.

        It really just looks they want free labor, combined with a system that ends up filtering out a huge percentage of competent people that either cannot afford it, or literally can’t find somewhere to do a residency.

        Deliberate barriers to entry. The medical community can try to spin it however they want, but there it is.Report

      • Avatar Will Truman in reply to Will Truman
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        says:

        If you want to argue that the problem here is government intervention, David, far be it for me to complain. Because it’s governments (or government agencies, to be precise) that require residency training. And it’s the federal government that isn’t sufficiently expanding the number of residency slots available where the most doctors are needed.

        I would actually agree with you that we presently have too few doctors because we are not making enough effort to create more doctors. The nature of the problem, though, isn’t what you are saying it is. Not understanding where the bottleneck lies is only the start.

        In case you missed it, I’ve been watching this problem evolve from viewing distance, more or less. My wife has been prevented from doing things she has the experience and (in any sane universe) qualifications to do. At her last job, she had months of 20+ days of call due to an inability of her employer to recruit doctors. She had the licensure process in one state drag on for over a year despite being well qualified and already licensed in another state, until she finally gave up. (Indeed, she is giving up on primary care altogether.)

        This stuff matters to me beyond an ideological or theoretical discussion on the Internet. What you’re talking about less so, because you’re not really describing the situation on the ground. Would that the “medical establishment” were so singular and competent, because then we could at least get doctors in the subfields where everyone agrees more doctors are wanted and needed.Report

      • Avatar DavidTC in reply to Will Truman
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        says:

        Reposted in the right place. I hate this idiotic forum software:

        The GP shortage vs. specialists is mostly due to stupid insurance stuff causing vastly different income levels, from what I understand.

        However, I’m going to ask this carefully because I have absolutely no idea how the rules are actually set:

        Are you asserting that the Federal government is actually _setting residency requirements_ without the input of the medical community? That the medical community is saying ‘We don’t want residency requirements?’ and the government is refusing to change them?

        The medical community invented residencies. The medical community started requiring them, and that got coded into law. Hell, they’re the ones who invented medical licenses in the first place and got _that_ into the law. The medical community is the one who has basically put up _every_ barrier of entry into practicing medicine, by asking the government to install it.

        And now, somehow, it’s not their fault that no one can get in. It’s that horrible government…which does _exactly_ what the medical community wants on medical licensing, on deciding who a doctor is.

        Now, yes, the government doesn’t like paying for residencies…and that’s because they are a con to start with. They are a way to rip off the government. But the medical community doesn’t get to invent a nonsensical method of training, aka, free labor, at the Federal government’s expense, demand the Federal government require it by law, and then whine when the Federal government is reluctant to fund it.Report

      • Avatar Will Truman in reply to Will Truman
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        says:

        David, I never said anything about “without input from the medical community.” What I meant was that ultimately, the decision to require residency is a product of government agencies. I believe that is actually at the state, rather than federal level. State medical boards will not give licensure to people who did not complete residency. Yes, this is very much supported by doctors. But it’s the government that makes the ultimate decision, either by setting requirements or endorsing a medical board to do the same. They could end residency, and there wouldn’t be anything physicians could do about it. The buck stops with the government.

        I should add that even doctors who desperately want their to be more doctors support the residency requirement. It seems to be a pretty universally held belief. I’ve brought it up a couple times, and the thought of waiving residency is not something they would consider. It’s not how they believe that the gap should be closed. I don’t know if they’re right or not – I’d have to think that there be some other way that doctors get the additional training they need – but it’s pretty sincerely held for reasons other than self-interest.

        Whether residency is a “crock” or not depends on what you mean. I have been convinced that post-med school training is needed. I’d like to think that there is more than one way of going about it. I don’t like the way that residencies operate. I used to think it was indentured-servitude-for-profit. But what I have since discovered is that residency programs lose money (primary care ones do, at least). Which is why they usually needed to be funded by the federal government. Otherwise, they wouldn’t be able to operate. They’re not money-makers. If they were, more places would be starting them – or trying to start them – without help from the feds.Report

    • Avatar Dave in reply to DavidTC
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      says:

      If you want to have people wasting less of a GP’s time, might I suggest nurse practitioners in front of the doctors? Because something like half of what people want when they see a GP could be satisfied by a NP, or at the very least the 20% who have no business even seeing a doctor could be turned away.

      This is what most physician practices I deal with do already and have been doing for a number of years.

      The entire medical community, for decades, has been operating a…well, I hate to call it a ‘conspiracy’, but it is, where they are _deliberately_ restricting the amount of doctors that exist. (See also all the doctors from other countries that have showed up to fill in the gap.)

      A labor shortage does not mean said labor shortage is caused by a conspiracy. In fact, I’m pretty sure that conspiracy has nothing to do with it. In fact, I can assure you that the hospitals and health systems do not want to be in a position where they don’t have enough medical professionals to serve their patients. To suggest that the “medical community” (whatever the fish that is) has actively played a role in it is absurd.

      It just needs to be someone who says ‘So you have a cold?

      I don’t think this would fly given licensing and insurance requirements. That’s a medical malpractice suit waiting to happen.

      This is not, as idiots assert, some sort of _failure_ of the ACA. This is a failure of the _medical establishment_, who already didn’t have enough doctors, certainly didn’t have enough for the future, and now are even further away from enough now that entire swaths of the American people won’t choose to go without medical care because they can’t afford it.

      The supply of medical professionals has nothing to do with a centralized medical establishment. I have no idea where you come up with this.Report

      • Avatar Will Truman in reply to Dave
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        says:

        I have no idea where you come up with this.

        It’s surprisingly common. One of these days I am going to finish my post on the American Medical Association and how it’s not the organization people think it is*. DavidTC didn’t blame the AMA, for which I am glad. But you’re right that we’re talking about a lot of moving parts. The AHA would love for their to be more doctors because they’re the ones that can’t find doctors. Rural primary care physicians would like there to be more PCP’s because then they wouldn’t have call every other night. But other segments are just fine with there being a shortage. And, to be honest, the shortage does make it broadly easier for physicians to block reforms they feel would be bad for doctors and patients.

        * – Which is not to say that I am a fan of the AMA. I’m not, and could write a separate post on that! Though it would ultimately come down to “The AMA represents some doctors at the expense of other doctors.” (And, from a selfish standpoint, my wife is among the doctors to whom they give the shaft in their policy recommendations and wage-interference.)Report

      • Avatar Kim in reply to Dave
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        says:

        Dave,
        I’m pretty sure that the scientific/medical community had something to do with closing down loads of incompetent “doctor/apprentice” relationships, circa 1910 or so, when they did a comprehensive survey and discovered how much they suck. (the ones that stayed around were connected to a uni of some kind, by and large)Report

      • Avatar DavidTC in reply to Dave
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        says:

        This is what most physician practices I deal with do already and have been doing for a number of years.

        Really? The nurse can turn away patients without even having a doctor look at them?

        I mean, that’s great if that’s how it works, but I’ve never heard of it.

        (‘When you need to see a doctor’ is one of those basic life skills we really need to teach in high school. In both directions, because people often don’t bother a doctor for stuff that doesn’t bother them but is actually an indication of a serious medical problem.)

        A labor shortage does not mean said labor shortage is caused by a conspiracy.

        *sounds the ‘Person does not believe in the free market’ alarm*

        Yes, long-term shortages just exist by _magic_. Magic I say! Markets can just randomly fail to provide things in this country that somehow exist in other countries.

        It’s not like there are a lot of people who want to be doctors who can’t manage the insane rules the medical community has set up, like being required to work for several years for almost free.

        And the medical industry has absolutely no bearing on how much medical school costs. It’s not like medical colleges employ medical doctors, or are associated with medical establishments. Educational prices are a magical thing the medical community can do nothing about.

        I don’t think this would fly given licensing and insurance requirements. That’s a medical malpractice suit waiting to happen.

        Doctors are not required to see every patient that walks up. They’re not even technically required to even see patients in life-threatening danger unless it’s at an ER.

        It might be a malpractice suit if the non-medical professional said ‘You do not need to see a doctor’, So it probably needs to be worded as ‘Dr. Smith will not see you because you meet the checklist of having just a common cold and nothing else, and Dr. Smith does not treat the common cold. Dr. Smith will see you only if these other symptoms develop. If you wish to see a doctor before that, you will have to find a different one.’.Report

      • Avatar Kim in reply to Dave
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        says:

        Dave,
        “This is what most physician practices I deal with do already and have been doing for a number of years.

        Really? The nurse can turn away patients without even having a doctor look at them?”

        Yes. In Gynecologist offices, nurses are often the only person one sees.Report

      • Avatar DavidTC in reply to Dave
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        says:

        No, Kim, I know that. Nurses can do that.

        We were talking about non-medical people doing that. Like a receptionist or something.

        I’m not really sure if that’s needed or not, but I suggested it, and Dave said it was already happening.

        Of course, we really should just have enough nurses to do that anyway, then we wouldn’t have to worry. (The nurse shortage is something else entirely from the doctor shortage.)Report

      • Avatar DavidTC in reply to Dave
        Ignored
        says:

        The GP shortage vs. specialists is mostly due to stupid insurance stuff causing vastly different income levels, from what I understand.

        However, I’m going to ask this carefully because I have absolutely no idea how the rules are actually set:

        Are you asserting that the Federal government is actually _setting residency requirements_ without the input of the medical community? That the medical community is saying ‘We don’t want residency requirements?’ and the government is refusing to change them?

        The medical community invented residencies. The medical community started requiring them, and that got coded into law. Hell, they’re the ones who invented medical licenses in the first place and got _that_ into the law. The medical community is the one who has basically put up _every_ barrier of entry into practicing medicine, by asking the government to install it.

        And now, somehow, it’s not their fault that no one can get in. It’s that horrible government…which does _exactly_ what the medical community wants on medical licensing, on deciding who a doctor is.

        Now, yes, the government doesn’t like paying for residencies…and that’s because they are a con to start with. They are a way to rip off the government. But the medical community doesn’t get to invent a nonsensical method of training, aka, free labor, at the Federal government’s expense, demand the Federal government require it by law, and then whine when the Federal government is reluctant to fund it.Report

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