Threat from overseas

[txrad]

The threat from India and other countries supplying cheap physicians is closer to reality than you might think. Check this out:

http://www.ama-assn.org/sci-pubs/amnews/pick_03/prsb0630.htm

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[squeek]

The program you cited appears to be in place in order to provide Spanish-speaking physicians/dentists to underserved areas in the United States. Actually, it makes a lot of sense. And, in many ways, it simply increases the pool of physicians already in programs such as the NHSC. In addition, the license granted is for three years and "non-renewable," according to the article.

I do not view these physicians as "threats." Instead, they are providing much-needed services in areas that US physicians are unwilling (or unable, due to our national inability to speak more than one language proficiently) to serve.

If radiologists didn't expect to be reimbursed $250K and up, the overseas "threat" would be a non-issue (as long as residency programs put out enough radiologists to meet nationwide demands...another huge factor driving up radiology salaries). As for me, I'd be happy to be reimbursed at the same level as a family practitioner, in spite of longer training. The lifestyle alone, not to mention the neat things happening in this field, are compensation enough for me.

Just my opinion...

 

[txrad]

Originally posted by squeek
The program you cited appears to be in place in order to provide Spanish-speaking physicians/dentists to underserved areas in the United States. Actually, it makes a lot of sense. And, in many ways, it simply increases the pool of physicians already in programs such as the NHSC. In addition, the license granted is for three years and "non-renewable," according to the article.

Well, every journey begins with one step. One may argue that right now, there are a lot of "underserved ares" for radiology, and may license Indian radiologists for 3 yrs, non-renewable; then it may become 5 yrs or 10 yrs. And they don't even need to come to the US, thanks to telerad. And for that kind of program, they won't have a hard time finding a medical school that is willing to sell out the profession for sweet profits.....See other threads re: MGH/Harvard already in this business of running radiologist sweatshops. You can then forget 250k income. You will be lucky to see 75k, unless, of course, you also run one or more sweatshops.

 

[eddieberetta]

Note that the actual example cited has nothing to do with radiology. This whole issue affects all areas of medicine, not just radiology.

 

[MacGyver]

Originally posted by squeek
The program you cited appears to be in place in order to provide Spanish-speaking physicians/dentists to underserved areas in the United States. Actually, it makes a lot of sense. And, in many ways, it simply increases the pool of physicians already in programs such as the NHSC. In addition, the license granted is for three years and "non-renewable," according to the article.

This is just a pilot program. Trust me they are going to start pushing thru legislation to make it a permanent program soon.

You should be naive and jsut assume this is a one-time deal cause its not.

I do not view these physicians as "threats." Instead, they are providing much-needed services in areas that US physicians are unwilling (or unable, due to our national inability to speak more than one language proficiently) to serve.

So the US has to conform to Mexicans now? Why dont they conform to us?

If I voluntarily move to Mexico and dont speak a lick of Spanish, then I understand that I'm going to have some serious troubles communicating with healthcare workers.

Why does that logic not apply to the USA?

You talk about our national inability to speak 2 languages, but is 2 languages all we are talking about? What about Chinese, Vietnamese, Farsi, etc?

At any rate, what about the Mexicans inability to speak 2 languages?

Why should Americans have the burden of learning Spanish when its their voluntary CHOICE to move here?

I dont understand that logic.

If radiologists didn't expect to be reimbursed $250K and up, the overseas "threat" would be a non-issue

Oh please. Do you REALLY think that if rads made only 80k that outsourcing would not be an issue? You have got to be kidding me. Indian rads make around 12-15k per year.

(as long as residency programs put out enough radiologists to meet nationwide demands...another huge factor driving up radiology salaries).

We have more radiologists now than ever before, and salaries have gone UP, not down. Your analysis is too simplified.\

As for me, I'd be happy to be reimbursed at the same level as a family practitioner, in spite of longer training. The lifestyle alone, not to mention the neat things happening in this field, are compensation enough for me.

Fine, lets say you make 75k per year. Now please explain to us why that means foreign competition is no longer an issue. Even if you only make what an FP makes, foreign rads are willing to work for far less.

Unless you are willing to work for 12 or 15k per year, then outsourcing will still be an attractive option.

 

[MacGyver]

BTW, whoever said that doctors will sell out to make money is spot on.

Those businesses that are backing the hispanic coalition will poney up money until one of the med schools ****** themselves out and accepts the deal.

Ultimately, doctors are to blame for this mess. They are too apathetic about legislative issues and sell out for the almighty dollar.

Future generations of doctors will pay dearly for these fools lack of foresight and untempered greed.

 

[MacGyver]

Another thing, once these doctors get here, do you REALLY think they are just going to pack up and go back to Mexico after the 3 year lease is up?

No freaking way.

First off, the INS is so inept they couldn't deport them even if they wanted to.

If you offered to pay the Mexican docs only 5k per year, they would take that in a heartbeat--not because they are excited about the 5k but they KNOW that once they are inside US borders they have basically a free pass to living forever in the US.

Sure they might have to settle for 5k temporarily, but after that they can start making 70 or 80k per year, which is four or five times what a Mexican doc would normally make.

 

[LovingItAll]

Hi everyone. I've been lurking for a while, having posted only one other message a long time ago...I thought I'd post to get some clarity on the discussion.

What's the issue here?

1) Why is it a "threat" to increase the supply of physicians in the marketplace?
2) Doesn't basic economics tell us that an increase in supply yields a decrease in cost? Why is decreasing the cost of medical care a bad thing?

I get the impression that this dicussion of a "threat" is that of competition. More specifically, of being paid less that we otherwise would for all our years of hard work in school and residency.

My feeling is that competition is a *good* thing. It increases quality (which I like) and decreases costs (which I like even more). As for doctors being paid less than they otherwise would, I say: tough - the benefit to society in general outweighs the loss to doctors.

Having said that, the REAL threat from foreign docs is that of poorer quality. No way should we license them to do anything unless they can pass our rigorous examinations and demonstrate minimum proficiency.

If (and I know some people see this as a big "if") - if foreign docs, even foreign radiologists, can perform the same service that domestic docs can, at the same level of competence/quality (i.e. they can pass our board certification exams), then why not let them come in and increase competition in the marketplace? Is this increase in competition what McGyver is calling "selling out the profession"? Wouldn't restricting the level of supply for the benefit of our wallet's constitute "selling out the public"?

I'm curious to read your responses, because I believe that if we talked it through we'd be able to get the core of the foreign doctors issue. I'm thinking strongly about radiology, and I never think twice about the foreign doctor issue except when I come on here and read these posts.

 

[txrad]

Originally posted by eddieberetta
Note that the actual example cited has nothing to do with radiology. This whole issue affects all areas of medicine, not just radiology.

True, but radiology is most susceptble because of telerad.

 

[MacGyver]

Lovingitall,

its all about degree.

How far are you wiling to take your logic? What if 150,000 doctors worldwide passed our medical boards and became licensed? Should we let ALL of them in?

What if its 200k, or even 500k? Should we let everybody in who wants to come?

I guarantee you there are at least a good 30k-40k foreign docs PER YEAR that could probably pass the boards and would love to come to the US.

Keep in mind that there are only 16k US medical grads (MD) per year.

 

[LovingItAll]

Originally posted by MacGyver
Lovingitall,

its all about degree.

How far are you wiling to take your logic? What if 150,000 doctors worldwide passed our medical boards and became licensed? Should we let ALL of them in?

What if its 200k, or even 500k? Should we let everybody in who wants to come?

I guarantee you there are at least a good 30k-40k foreign docs PER YEAR that could probably pass the boards and would love to come to the US.

Keep in mind that there are only 16k US medical grads (MD) per year.

Well, I dunno - that's why I'm interested in exploring the issue. If I'm John Q Public, I'll take the 500K extra providers, because that'll cut my medical costs with no sacrifice in quality. If I'm a US doctor, I'd rather not have any more competition.

Question is: who's interest should previal (and more importantly, why?)

 

[GeddyLee]

Well I must say this is the kind of crap that I love about med students. Sometimes the world can't be driven by the idealism of which you speak. First of all, if those thousands of foreign docs come to the USA to set up shop, won't that create gaps in health care in the countries from which they emigrated? Secondly, what makes you think competition will drive down medical costs? Do you honestly believe the doctor's salary is the major factor in medical cost? I wonder what percentage of money spent on health care go to doctor fees, and how that compares to hospital, medication, transportation, supplies, etc.
ANd what of all the american trained physicians, who won't be able to find work so they can pay off their six figure student loans? Thank you very much for all of your sacrifice, but we were able to hire this foreign doc for a quarter of the price. Is that what you think you deserve?
If you are looking to decrease medical costs, don't look to cutting doctor fees. I think medicare pays like 20 dollars for an established patient visit, which probably takes 10 to 15 minutes. I dunno, but many docs are having a hard time just meeting the overhead costs of renting their office, paying their employees and expenses, supplies, etc. Not to mention the great salary of maybe 120K they get, if they are lucky. That's for primary care, i mean.
Maybe we should close all US med schools and open the borders to foreign trained docs, that way we would save even more money that usually goes to subsidizing loans and paying for residency training.

Geddy

 

[LovingItAll]

Originally posted by GeddyLee
Well I must say this is the kind of crap that I love about med students.

Yeah darn crazy med students - always asking questions and trying to analyze issues. Geesh, I got some nerve, huh?

Sometimes the world can't be driven by the idealism of which you speak.

Well, I'm not looking to drive the word, I'm trying to figure out what exactly is the nature of the "threat" posed by overseas doctors...particularly in "shortage" areas such as rads and primary care in rural areas.

First of all, if those thousands of foreign docs come to the USA to set up shop, won't that create gaps in health care in the countries from which they emigrated?

Perhaps it may. Assuming that it would, what's your point? Again, I'm looking for the "threat" that this thread is premised on. Are you saying that as a matter of policy, allowing foreign docs poses a threat because it it'll create gaps in health care in other countries? How is a shortage in docs in another country a threat to us here in the US? Something tells me that's not what the original poster had in mind.

Secondly, what makes you think competition will drive down medical costs?

Simple economic analysis makes me think it - when supply increases (aka competition), then price decreases. Its how markets work.

I know you know that. So, I'll turn the question back on you: what makes you think competition will NOT drive down medical costs?

Do you honestly believe the doctor's salary is the major factor in medical cost?

I never said I believed that. Whether its a major factor or a minor factor, its still a factor. Cutting the costs of any factor, even a relatively small one, will still cut the costs of the overall bill.

I wonder what percentage of money spent on health care go to doctor fees, and how that compares to hospital, medication, transportation, supplies, etc.

Although I think the percentage off-point (see my response to the previous question), I'll answer with the following statistics published by HHS at:
http://cms.hhs.gov/statistics/nhe/default.asp

For the latest year they have, 2001, HHS reports:
1,424,541 million in total health care expenditures
313,649 million (22%) was for "Physician and Clinical Services"
451,220 million (32%) was for "Hospital Care"
140,574 million (10%) was for "Prescription Drugs"
The other categories were dental care, other professional services, home health care, durable and non-durable medical products, etc.

So docs make up 22% of the bill, assuming I'm interpreting their data correctly (which I may not be - I invite someone with more knowledge to correct me if I'm not. I downloaded the file nhe01.zip on the above-listed hhs website).

ANd what of all the american trained physicians, who won't be able to find work so they can pay off their six figure student loans? Thank you very much for all of your sacrifice, but we were able to hire this foreign doc for a quarter of the price. Is that what you think you deserve?

Increasing competition will no doubt lower physician salaries, and that will no doubt make repaying student loans tougher. You've done a good job identifying a countervailing interest. But this still doesn't answer the question of *WHY* that interest should outweigh the interest the public has in lower medical costs: Why should our laws artificially depress the supply of physicians (via restrictions on foreign docs), which gives them a greater ability to repay their loans, when doing so costs the consuming public more in costs?

You asked me if I think US med grads "deserve" being undercut by competition from foreign docs. I think anybody that provides a service in the marketplace "deserves" competition from any comparable provider of services. I'll again turn the question back on you: do you think they deserve protective laws just because they've taken out a bunch of student loans?

If you are looking to decrease medical costs, don't look to cutting doctor fees. I think medicare pays like 20 dollars for an established patient visit, which probably takes 10 to 15 minutes. I dunno, but many docs are having a hard time just meeting the overhead costs of renting their office, paying their employees and expenses, supplies, etc. Not to mention the great salary of maybe 120K they get, if they are lucky. That's for primary care, i mean.

Well, what I'm really looking for is a clear articulation of the "threat" posed by foreign docs. You're right, some specialities like PC specialties do have a relatively low profit margin. 120K is still plenty of money to live comfortably and pay off school loans...which is why there are still med grads each year who go into FP/Peds/etc. I understand that 120K is relatively low among medical specialties, but its nothing to turn your nose up at. 120K is better than damn near most other jobs in the country.

Maybe we should close all US med schools and open the borders to foreign trained docs, that way we would save even more money that usually goes to subsidizing loans and paying for residency training.

Ahhhh sarcasm - how clever. Please don't let sarcasm get in the way of the discussion. I know you can contribute more than that.

I'll go ahead and respond to help you better focus, should you decide to post a reply. Closing all US med schools would do the same thing that restrictions on foreign docs do: it would decrease the supply of physicians, thereby decreasing competition and increasing costs. The increase in costs would heavily outweigh the costs saved in loan subsidies and residency training. Therefore, I would have the same questions about such a proposal that I have now about the so-called "threat" posed by overseas docs.

 

[GeddyLee]

I still think the premise that increasing physician supply will decrease cost is wrong. Physician payments don't follow the typical supply/demand rule. If it did, wouldn't you assume that the cost of a doctor visit in a major city would be much cheaper than the cost in an underserved area? I'm not sure about this, but I think medicare and most insurance companies have a set payment they pay for a service, regardless of where the service was rendered. Again, I'm not certain about that, but I believe that is true. And, say if the foreign docs build high enough numbers in the USA to to cause significant competition, where would the competition be? I think it would take huge numbers to cause enough real competition in rural areas such that fees for service would actually decrease. However, who's to say these docs would lower their fees? There are plenty of areas that are saturated with physicians in certain specialties, yet they tend to charge roughly the same fee, even if they don't accept medicare reimbursements.

Teleradiology poses a somewhat different threat by sending studies outside of US borders, where the work may be done cheaper. I assume where this is being done, it is through an elaborate setup where ABR certified radiologists sign off on the foreign read studies. This certainly has the possibility to drastically decrease costs, and increase the necessary supply of radiologists. Thats fine...I think 800 dollars for a CT scan is a bit high. Here again, though, I think your idea of competition driving costs down significantly is wrong. How much was a CT scan when the technology was fairly new? Now most towns have multiple locations where a scan can be done, yet costs are not that much lower.

As for the USA absorbing foreign docs and creating deficiencies in other nations, maybe it would be real and maybe it wouldn't. And i guess your are right when you say that it poses no threat to the USA, but on a global public health scale, maybe it could.

Furthermore, I think that decreasing physician salaries has the potential to drive down quality of care. Doctors may decide to work longer hours and see higher numbers of patients in order to keep there salaries at the present level. This would at least decrease the amount of time per patient visit. At least, that's what I've seen on my rotations....ailing practices that cannot meet their expenses double booking appointments. And one could theorize that the competition to receive medical training would decrease, and thus the quality of applicants could decrease, as no one wants to work that hard for falling incomes and uncertaintity about there employability.

Just my thoughts, maybe I'm totally wrong, but I would hate to see the day when US medical graduates can't find jobs. Maybe its a selfish viewpoint, but I think flooding the market with foreign trained docs for the possibility of lowering medical costs is not the answer.

Geddy

 

[MacGyver]

Originally posted by LovingItAll

Increasing competition will no doubt lower physician salaries, and that will no doubt make repaying student loans tougher. You've done a good job identifying a countervailing interest. But this still doesn't answer the question of *WHY* that interest should outweigh the interest the public has in lower medical costs: Why should our laws artificially depress the supply of physicians (via restrictions on foreign docs), which gives them a greater ability to repay their loans, when doing so costs the consuming public more in costs?

Show me ONE industrialized country that lets in doctors from all countries with no restrictions.

The USA takes in more foreign docs than all other industrialized countries COMBINED.

You need to address that critique to places like Japan or Europe.

You asked me if I think US med grads "deserve" being undercut by competition from foreign docs. I think anybody that provides a service in the marketplace "deserves" competition from any comparable provider of services. I'll again turn the question back on you: do you think they deserve protective laws just because they've taken out a bunch of student loans?

You dont really believe that.

Because if you did, you'd be willing to work for 10k per year. Trust me there are plenty of foreign docs that would jump at that opportunity.

I dont care how altruistic you claim to be, you are a hypocrite.

You assume that doctors would only make 80k instead of 150k. You want unlimited competition with no restrictions whatsoever on foreign competition.

Now, what I want you to do is make a claim that you are WILLING to work for only 10k per year. That way we can all laught at you and call you a liar.

If you are NOT willing to work for 10k, then like I said above, you dont really believe what you just said.

120K is still plenty of money to live comfortably and pay off school loans...which is why there are still med grads each year who go into FP/Peds/etc. I understand that 120K is relatively low among medical specialties, but its nothing to turn your nose up at. 120K is better than damn near most other jobs in the country.

Are you clueless or what? Do you REALLY think that if we flooded this country with 500k new docs that FP/IM docs would still make 120k? Try more like 30k.

Again, like I said, you dont REALLY support the notion of opening up the US medical market to foreign competition with no restrictions.

 

[Caffeinated]

Originally posted by LovingItAll
Simple economic analysis makes me think it - when supply increases (aka competition), then price decreases. Its how markets work.

I know you know that. So, I'll turn the question back on you: what makes you think competition will NOT drive down medical costs?

Increased competition (in the form of increased foreign docs) will NOT drive costs down in the US medical economy. Supply and demand economics do NOT work in all markets. The reality is that they only work in capitalist markets. The US medical economy is anything but capitalist. Who actually pays for their own medical care? Answer: almost nobody. Sure, they may pay their insurance premium (directly or indirectly), or medical care may be paid out of taxpayer dollars. Until people start actually paying for their own care with their own money, supply-demand economics cannot be applied.

So what will happen if their is a flood of foreign docs? That's hard to predict. But I'll give you my best guess. Foreign docs will realize that nobody pays for their own care (heck, people whine about a $15 copay). So they too will be on insurance panels and Medicare. But if they indeed work for less, then this will drive down the local averages for reimbursement. Medicare will pick up on these trends, and the reimbursement from Medicare will plummet. The insurance companies will follow suit (as they all follow the reimbursement tables created annually by CMS), and they too will drop their reimbursements.

Now, it looks like this is a good situation at first: cost of reimbursements are going DOWN. So the government is spending less, and insurance plans are spending less. Will this translate into cost savings for the the public or the medical community? No. The plummetting reimbursements will make it harder for docs to keep their doors open. Insurance companies will get fatter and richer (because they will NEVER lower the premiums even though there is less money going out the door), and the government will spend the Medicare savings on some other federal entitlement program.

 

[sdntran]

It's more than just competition. Being boarded in radiology in this country (after some 26 years of schooling and extensive cost) should earn you a distinct privilege that foreign MDs shouldnot be given. I can train my teen age son to do a breast biopsy after one or two days. And I can train him to read a brain CT in about a week. Being able to do some thing well doesnot grant a person a right/privilege to practice it. Passing written boards doesnot meant possessing equal skill and knowledge (in the movie Catch Me If You Can, the protagonist passed the BAR without even going to school). Granting foreigners with equal right to practice medicine without having to go through our residency programs would undermine our educational system. By the way, I know several friends whose children are unable to get into medical schools in the this country. They have to send their kids back to the phillipine or ireland where medical schools are much easier to get into and the training is not as vigorous. Those kids then take the STEPs and eventually became physicians. But do you really want them as your personal physicians?

 

[pitman]

Originally posted by sdntran
It's more than just competition. Being boarded in radiology in this country (after some 26 years of schooling and extensive cost) should earn you a distinct privilege that foreign MDs shouldnot be given.

So you're referring to FMGs? The privilege arises from being American? I thought it was about truth and knowledge (er, competency and quality of care)?

What about (US) IMGs who may have had better training than you? Where's the cutoff and how's it determined, if not by something standardized like STEPs.. something more arbitrary (or nationalistic/protectionist)?

Granting foreigners with equal right to practice medicine without having to go through our residency programs would undermine our educational system.

I don't think anyone's advocating this, and the status quo is pretty much that FMGs must do US residency along with everyone else to help ensure acceptable levels of competency (along with desired levels of slave labor, as demanded by the Industry itself).

...Those kids then take the STEPs and eventually became physicians. But do you really want them as your personal physicians?

So you're referring to IMGs, and not FMGs?

Yes, they will need to take standardized tests, as all AMGs will shortly be doing, then if they pass will need to complete US residency training, as everyone else. How are you (as a scientist?) concluding superiority-by-school-location if not by any standardized means?

My state-side physician, chosen for her qualities, has a S. African med degree. Screw her? Or screw me?

-pitman

 

[pitman]

Originally posted by Caffeinated
Increased competition (in the form of increased foreign docs) will NOT drive costs down in the US medical economy. Supply and demand economics do NOT work in all markets. The reality is that they only work in capitalist markets.

It's more (but still not wholly) accurate to say that supply and demand pressures will apply to the degree to which markets are capitalist (and free).

Until people start actually paying for their own care with their own money, supply-demand economics cannot be applied.

Sure it can, just not as simply as is drawn on the board in ECON 101 -- it's a componentwise continuum, here with the means of production and distribution (of services) largely privately held, the insurance industry privately held w/ fees paid *largely* via the free market (either by individuals or corporations).

Further, to the extent that the government acts as an agent among many bartering/negotiating for services, it is essentially acting as a corporation and not inhibiting free market.

So what will happen if their is a flood of foreign docs? That's hard to predict. ...But if they indeed work for less, then this will drive down the local averages for reimbursement. Medicare will pick up on these trends, and the reimbursement from Medicare will plummet. The insurance companies will follow suit (as they all follow the reimbursement tables created annually by CMS), and they too will drop their reimbursements.

And this will have no positive affect on cost of medicine?? So there's no competition among HMOs?

It's a pretty simple deduction -- increased freedom for foreign doctors to come will result in increase in supply of doctors will result in decrease in salary demands (many more doctors from outside the US think less of their salary, and many have much lower debt due to publicly better-assisted schooling).

Ceteris paribus competitive insurance industry will drop medical cost accordingly.

-pitman

 

[redshifteffect]

Originally posted by sdntran
It's more than just competition. Being boarded in radiology in this country (after some 26 years of schooling and extensive cost) should earn you a distinct privilege that foreign MDs shouldnot be given. I can train my teen age son to do a breast biopsy after one or two days. And I can train him to read a brain CT in about a week. Being able to do some thing well doesnot grant a person a right/privilege to practice it. Passing written boards doesnot meant possessing equal skill and knowledge (in the movie Catch Me If You Can, the protagonist passed the BAR without even going to school). Granting foreigners with equal right to practice medicine without having to go through our residency programs would undermine our educational system. By the way, I know several friends whose children are unable to get into medical schools in the this country. They have to send their kids back to the phillipine or ireland where medical schools are much easier to get into and the training is not as vigorous. Those kids then take the STEPs and eventually became physicians. But do you really want them as your personal physicians?

Hey sdntran perhaps this is the vigorous training you perfer...or maybe you would like this kind of personal physician?

http://www.usmle.org/news/cse/csefaqs2503.htm

Don't medical schools already require clinical skills for graduation?

Medical schools vary in the ways they teach clinical skills and the standards they use to evaluate them. The clinical skills exam will establish a national standard that all students will need to meet before they practice medicine. Some US students still graduate without ever being observed in clinical settings. During recent field trials, 20 percent of the fourth-year students who completed a survey said they had been observed interacting with a patient by a faculty member two or fewer times. One in 25 said they had never been observed by a faculty member.

Oh and by the way how come countries such as Australia/NZ/UK/Ireland train their graduates for 2-3 years longer than US Grads??

 

[driedcaribou]

Restrictions are necessary but not for the reasons sdntran has stated.

Originally posted by sdntran
It's more than just competition. Being boarded in radiology in this country (after some 26 years of schooling and extensive cost) should earn you a distinct privilege that foreign MDs shouldnot be given.

Your logic is basically, 'I've been here longer so I deserve more- I had to go through the system, I put my time in, it is my right to have an advantage based purely on my seniority regardless of what my skills are'.

I can train my teen age son to do a breast biopsy after one or two days. And I can train him to read a brain CT in about a week. Being able to do some thing well doesnot grant a person a right/privilege to practice it.

You're belittling your own profession here.
If any teenager with a high school education can do breast biopsyses in two days, why are we taking so much time to put doctors through the system and why are we paying them so much money when we can make this a 2 day course. We'd have a larger number of skilled people to screen the population and we'd be healthier as a result.

Passing written boards doesnot meant possessing equal skill and knowledge (in the movie Catch Me If You Can, the protagonist passed the BAR without even going to school).

This is a hypocritical statement. You yourself had to write exams as well. What makes you different?


'Catch Me If You Can' was based on a con man's true story in the 60s.... the exams back then were different. So were the exams for medicine.

When did you graduate? If you've been in for 26 years, things have changed a lot in the school system as well as medical knowledge and technology. Did you possess the same amount of knowledge when you graduated than a current graduate?
My point is, the system keeps changing.
It is important that as long as standards can be met, you shouldn't be so aversive of foreigners joining your member's only club.

Granting foreigners with equal right to practice medicine without having to go through our residency programs would undermine our educational system.

Although I do think it is a good idea to put foreigners through some sort of residency program in the country they intend to practice, I do not think that by skipping it, it would undermine your educational system if they come from a country with a reputable school.

By the way, I know several friends whose children are unable to get into medical schools in the this country. They have to send their kids back to the phillipine or ireland where medical schools are much easier to get into and the training is not as vigorous. Those kids then take the STEPs and eventually became physicians. But do you really want them as your personal physicians?

I can't comment about the amount of training in medical schools in the Phillipines but I certainly do not think Ireland has an inferior medical education.

For one thing, the basic sciences are universal- they don't change just because you live in a different part of the world.

Also, everybody is different. There are many doctors in the US that are book smart but have horrible bedside manner.
How are they screened out of the system? They aren't. You deal with them all the time. I only care if my physician is knowledgable and is willing to put the time to help me.
I don't care if my physician graduated from some really prestigious school and spent 20 more years under my country's medical system. Time does not equate to quality.
He/she could be a ****ty practicioner for 20 years.

True professions self-regulate themselves. If a foreign doctor is ****ty, then by all means, take away his license.
It isn't your right to be a doctor; don't you dare make it sound that way.


Being a doctor is also about the ability to learn quickly and change.

Your arrogance and lack of empathy makes me wonder why you ever became a doctor to begin with.
You sound threatened by competition and threatened by those you perceive to take that 'back door' to medicine not because their training is not as vigorous, but more because they didn't have to do what you had to do to get into medicine.

In my mind, a FMG has the advantage of life experience in another country as well as the drive to actually go the distance to risk going overseas learn.

If you want to make sure they're qualifed, then just test them more vigorously.
Don't turn them away because they're not your kind.

 

[MacGyver]

caribou,

its a question of principle.

The United States already has the easiest system for foreign docs in the world, among industrialized nations.

I tell you what.

When Europe and other first world nations drop their restrictions on foreign docs, then the US should do the same.

I know that your next comment is going to be something along the lines of "the US leads the world, sets an example, blah blah blah"

The job of the US government is to protect US citizens FIRST and everybody else second.

 

[LovingItAll]

Originally posted by MacGyver

The job of the US government is to protect US citizens FIRST and everybody else second.

Yeah, thing is - unfortunately, thanks to the organized medicine lobby, the US government protects doctor's wallets/egos first, and cheaper healthcare/access to healthcare SECOND.

Its telling how afraid you all seem to be of competition.

Enjoy your $240K and up salaries.

Sincerely,
the ripped off public

 

[redshifteffect]

Originally posted by MacGyver
caribou,

its a question of principle.

The United States already has the easiest system for foreign docs in the world, among industrialized nations.

I tell you what.

When Europe and other first world nations drop their restrictions on foreign docs, then the US should do the same.

I know that your next comment is going to be something along the lines of "the US leads the world, sets an example, blah blah blah"

The job of the US government is to protect US citizens FIRST and everybody else second.

MacGyver,

It's more than that. The US has tried to shut down all the extra residency positions but have been unable to do so... that's why in every single thread you will see "Us to shut down extra positions blah blah blah....but it never happens, and the reason is that the PD's start an outcry...

The truth is that the US needs the IMGs because if they weren't doing the training where would they get the doctors that they need for those hospitals??? I doubt USMGs would take the positions, and even if they would there's not enough of them to go around.

Don't think the US is doing this to set an example...their only doing it so they can have labour. cheap labour.

Do you know how many really good doctors are being sucked away from other countries? South Africa in particular is appealing to the rest of the world to stop the drainage of some of their best docs....because now they have a huge doctor shortage.

So it's not like you are getting the worst...quite the opposite you are draining the best from each country.

Finally think about this, a lot of other countries do open the doors to doctors. For example in some provinces in Canada almost 60-80% of doctors are trained overseas...but unlike the US (as usual) they will accept post grad training from some countries...so the US is the only country that makes every single doctor redo their residency over again... so I doubt it's the "easiest" system.

 

[colforbinMD]

The reason this is such an issue with can we let in FMGs/IMGs. How many should we let in and what should we do to assure they are qualified. Stems mostly from the fact that the AMA who controls the supply of doctors coming from US med schools has greatly limited it for years while the population has grown and medicine has changed and become more and more specialized. Instead of really tracking doctor supply and need closely and trying to keep up they have for years kept it stable and watched the changes in population growth and medicine with a big smile and dolllar signs gleaming in their eyes. Every year thousands of QUALITY applicants do not get into the US medical system and a good percentage of that are so dedicated to their desire to practice medicine they go to non LCME schools and then try to come back. If the AMA had not been so greedy and kept pase with US needs then many of these could have received the COVETED US training you claim qualfies you for more then their foreign schools did.
Nobody here is going to argue that no USMGs should not be subject to standardized quality screening and nobody here is going to argue differently for IMGs. Thankfully now it with the CSE it will trully be standardized.
The truth is your issue about foreign docs is the same that sent many US citizens to become foreign trained. GREED. You see a threat to your job and it may very well be a real threat I don't know. Time will tell but if it is you and your AMA brought it on yourself by being greedy and not keeping up with your patients needs for doctors. As long as the us had underserved areas they have to be filled by docs from somewhere.

 

[pitman]

Um.. AMA resolutions are largely non-binding. For example, it's been trying to get equal treatment for IMGs for YEARS, but res programs (independent ACGME) have largely ignored its resolutions. It's also been one of the loudest advocates of USMLE for ALL. Not sure how you've decided AMA is "greedy", but you should do more research on this and come up with specific greedy acts.

If you're referring more specifically to med school accreditation (via the LCME, jointly founded by the AMA and the independent AAMC, and which also cooperatively accredits Canadian med schools), then I'd like to hear a cogent argument for how the accreditation/review process (via published standards) has effectively been hijacked by greedy AMA conspiracists trying to restrict the number of domestic med students (and which explains, e.g., recent accreditation given to Florida State University).

-pitman

 

[colforbinMD]

If it's not solely the AMA that funds the LCME then I was wrong. However wrong I may be on the exact villain limiting the number of doctors educated by USMS the fact that it is still the main problem does not change. Nor does the reason the problem exists (greed) change.
Simple question. Are there enough US doctors to serve us public. Answer no.
Are there even CLOSE to enough US doctors to serve US public. Still no. Are US medical school class sizes and overall number of medical schools being allowed to expand to meet this problem. NO. Or shall we say AT THE VERY LEAST no where near enough.

 

[pitman]

Let's assume for the moment that there are not enough US-trained doctors (I'd actually disagree with this, while agreeing with the very different claim that there are not enough US-trained doctors to independently fill all US needs..which is precisely why IMGs are necessary).

Where's the link between this and your argument that therefore "greed" is the cause? Who is restricting the number of US grads, how, and why? Wouldn't such restrictions be obviously self-defeating given that IMGs currently supplement the supply?

For example, I'd think that if greed were policy's driving force here, the ACGME would have to be in on a conspiracy (restricting residency slots, which have never successfully been restricted), with the LCME (1/2 AMA, 1/2 AAMC) increasing accreditations, both policies working to effectively rid the need for IMGs (US docs the only definable group of greed I can think of), despite these organizations' public disagreements on IMG policy.

 

[driedcaribou]

Originally posted by MacGyver
caribou,

its a question of principle.

The United States already has the easiest system for foreign docs in the world, among industrialized nations.

I tell you what.

When Europe and other first world nations drop their restrictions on foreign docs, then the US should do the same.

I know that your next comment is going to be something along the lines of "the US leads the world, sets an example, blah blah blah"

The job of the US government is to protect US citizens FIRST and everybody else second.

I do not think the restrictions that other countries have on foreign docs are 'right' nor was I going to say that the 'US leads the world and should set an example' because those topics would be irrelevant. If you want to change the topic go ahead because I can go there too.

What is the principle? By bringing up the argument that 'the US is already the easiest country for foreignn doctors to come in' as well as the 'if they don't make it easier why should we' makes it sound more like an argument based out of bitterness and pride.
What a political statement and what righteous values to stand up by. I guess that's how you justify not signing the Geneva convention. Our enemies didn't, why should we? We'll still use chemical weapons and landminds because our enemies do too.

Oh right, the job of the US government is to protect US citizens FIRST and everybody else second.

Well of course it is. I never once said the US government was wrong for placing restrictions on international doctors. I even said in my reply that I agree with restrictions.

The principle I am arguing is that sdtran had horrible reasons for why he thought international doctors should not practice.

You bring up a principle of 'fairness'.

This was something implicit in sdtran's argument which I disagree with.

It is arrogance for a doctor or for anyone in any profession in the world to think he/she has a 'right' to have his/her job. When you are dealing with people and you are regulated, it is a privilege for you to work. You are accountable for your actions.

Place more regulations on foreign doctors, sure.
But don't judge them soley based on the fact that the US goverment has to protect US trained doctors. Oh no, God forbid that US doctors lose there jobs but they won't because legislation (as in keeping out foreign doctors) keeps them working because the government has to protect their jobs.

Here, let me put this in all caps so you can skim my reply again and get my point:

IF THE DOCTORS ARE COMPETENT AND GOOD AT THEIR JOB, WHY ARE THEY AFRAID THAT SOME INTERNATIONAL MEDICAL DOCTOR, WHO THEY FEEL HAS SUBSTANDARD TRAINING, WILL THREATEN THEIR LIVELIHOOD?

If you look at sdtran's reasoning, he makes Radiology sound so easy that perhaps he's just overpaid for the work he does so it's an attitude based on greed.

If you want to protect citizens, why not argue that you need more regulations?

And what protects the US citizens from bad doctors graduating from within the system?

 

[LovingItAll]

Originally posted by pitman

For example, I'd think that if greed were policy's driving force here, the ACGME would have to be in on a conspiracy (restricting residency slots, which have never successfully been restricted), with the LCME (1/2 AMA, 1/2 AAMC) increasing accreditations, both policies working to effectively rid the need for IMGs (US docs the only definable group of greed I can think of), despite these organizations' public disagreements on IMG policy.

How is the LCME increasing accreditations? Mercer was the last med school that was accredited, and that was in 1985. Almost 20 years ago. If our country needs more docs (which is does, because our population has grown considerably in the past 2 decades, and more importantly, our population has grown older over the past 2 decades), then why the hell haven't more med schools popped up?

As for ACGME - they have hardly been responsive to physician shortages:

2000-2001: 97352 filled residency positions
2003-2004: 99705 filled residency positions
- so over that three year period, all the ACGME manages to churn out is an extra 2500 more positions?

Even more telling:
2000-2001: 502 family practice programs, 10146 spots filled
2003-2004: 478 family practice programs, 9962 spots filled
(see: http://www.acgme.org/adspublic/)

Huh? Is this how organized medicine responds to the lack of access problem in the US? By reducing the number of FP training programs?

Moreover, if *any* of those programs have unfilled positions, then shame on organized medicine. We don't have enough docs to do primary care and work in rural america, and yet we have unused FP residency slots?

If the AMA/ACGME/AAMC really cared about improving access to healthcare, they'd increase the supply of doctors: more med schools, more IMGs into residencies, etc.

But, look out! Here comes the AACOM - osteopathic schools have been popping up like wildfire, and existing ones have been upping their class sizes. They can do this, of course, because the AMA doesn't control them. More DOs will help ease the doctor shortage, particularly since many DO grads go into FP, but its a shame the AMA doesn't get behind the idea of increase the number of doctors in America.

OK - so the greed thing - protecting member paychecks seems to be the most obvious answer to me. How does the AMA/AAMC not start up a new med school in almost 20 years, limit the number of foreign docs, treat IMGs like 2nd class citizens, etc....all while while our population continues to get larger, and our mean age gets older?

My answer: AMA, which is a powerful political lobby, is afraid of seeing its members' salaries drop even further then they have because of managed care and medicrap. By contrast, the AOA, not under the thumb of the AMA and mainstream organized medicine, has seized the opportunity to enter the marketplace for the good of everyone.

Furthermore, since the AMA hasn't eased the shortage, we're seeing the rise of the allied health professions: PAs, NPs... and even, gulp, chiropractors.

That's how I explain what's going on - but I may be wrong...enlighten me - how do you explain it?

 

[redshifteffect]

Originally posted by LovingItAll
How is the LCME increasing accreditations? Mercer was the last med school that was accredited, and that was in 1985. Almost 20 years ago. If our country needs more docs (which is does, because our population has grown considerably in the past 2 decades, and more importantly, our population has grown older over the past 2 decades), then why the hell haven't more med schools popped up?...

Actually I think you have a good point there, it's not only the AMA that is worried about creating too many doctors but a lot of medical organisations around the world. The AMA (Australian), BMA etc...all of these countries have shortages and yet they are still imposing very strict rules on IMGs that in some cases their own graduates do not have to jump through. (Though not as strict as the USA)

The AMA (Australia) even went so far as to publicly argue that letting in foreign doctors lower the already *low* pay cheque of doctors, and that there has to be a little bit of a shortage ...

But the ironic thing is that doctors in rural areas make way more money than doctors in urban areas (and the rural areas are were the problem is anyway), and the logic is simple; too much supply in the urban areas, not enough demand. Most USMGs would probably prefer to work in urban areas anyway....

So if there are any 'restrictions' that should be placed on IMGs it should be to limit them (at least for a number of years) to these areas, which would mean no competition for USMGs and a benefit to the patients.

 

[pitman]

Geez, pplz. Do your research before spoutin', or at least form some valid arguments.

Originally posted by LovingItAll
How is the LCME increasing accreditations?

Look more closely at my argument -- it says that IF greed were the driving force behind policy for doctor levels, THEN I would think there'd have to be a conspiracy (between ACGME and LCME), with (significant) increase in accreditations... Granted, there are other ways there could be greed-driven policy, but this argument was made to show some contradictions inherent to the one it was addressing.

Mercer was the last med school that was accredited, and that was in 1985.
Almost 20 years ago.

Wrong -- as stated above, Florida State University was recently accredited. Just a token increase?

If our country needs more docs (which is does, because our population has grown considerably in the past 2 decades, and more importantly, our population has grown older over the past 2 decades), then why the hell haven't more med schools popped up?

Maybe because more and more IMGs fill residency openings.

But your logic here is: population has increased and residency slots have not, therefore there must be a shortage. Doesn't such simplistic reasoning require a lower physician per capita? On the contrary, there is a higher per capita forecasted out to 2010, even out to 2020:

http://www.ama-assn.org/amednews/2002/01/21/prl20121.htm

As for ACGME - they have hardly been responsive to physician shortages:

2000-2001: 97352 filled residency positions
2003-2004: 99705 filled residency positions
- so over that three year period, all the ACGME manages to churn out is an extra 2500 more positions?

This is some of the weirdest logic I've heard in a while -- your prima facie analysis of demographics tells you not only that more physicians (in general) are needed, but that 2500 in three years couldn't possibly be enough to cover the (qualitative) need that you perceive?

First, most studies since the 80's have forecast physician surpluses. These are studies by independent entities, such as med schools, business schools, think tanks, etc. None of them conclude that there is currently a general physician shortage. Recently, there was a study projecting a physician shortage down the road, but neither does that one support your assertion of current shortages (see URL above). And there's no consensus on this latest projection (e.g., Wharton researchers don't believe it will happen anytime soon). Are the study investigators part of the vast greed conspiracy? Or at any rate, your perceptions of demographics outweigh the only science on the matter?

Many studies do indeed show current shortages in particular regions (certain rural areas, for example), or for particular specialties (not GPs, however -- albeit the analysis is a tad bit more complicated). This has always been a problem, but will always be, since changing demographics and specialty & domicile preferences cannot be perfectly anticipated, and at best attempts to address mis-projections take many years (lag). Take general surgery for example, where impending shortages if not addressed immediately will take, um, 5+ years to rectify:

http://www.ama-assn.org/amednews/2002/04/08/prsc0408.htm

The decrease in interest in general surgery is the result of the AMA greed conspiracy?

Even more telling:
2000-2001: 502 family practice programs, 10146 spots filled
2003-2004: 478 family practice programs, 9962 spots filled
(see: http://www.acgme.org/adspublic/)

Huh? Is this how organized medicine responds to the lack of access problem in the US? By reducing the number of FP training programs?

More telling of what?? Yes, filled FP slots have decreased about 2% in your sample of two. Guess what, this may be because projections (from the 80's) saw shortages of generalists, resulting in increases in generalists throughout the 90's. Now researchers generally believe that there are/will be too many generalists and not enough of some specialists, and as a result, generalist slots should decrease. Would you prefer that the ACGME ignore the independent studies and their projections, instead reacting only when a problem is realized? Such is how a health care crisis occurs.

Moreover, if *any* of those programs have unfilled positions, then shame on organized medicine. We don't have enough docs to do primary care and work in rural america, and yet we have unused FP residency slots?

Since you can't force US docs to practice in under-represented rural areas, you can't just wave a magic wand and increase GP residencies, ignoring the problems of general surplus (or freedom, or lag), until all such rural residencies get filled. The economics is just a bit more complicated. Another factor: FMGs who are more likely to bend over and fill such needs used to be able to stay in the US if they practiced rural medicine, but since 9/11 this incentive has largely been removed:

http://www.ama-assn.org/amednews/2002/04/22/prsc0422.htm

So now Bush/Ashcroft are part of the AMA greed conspiracy?
Or maybe it's the AMA's fault that there aren't huge publicly funded initiatives to pump physicians out to where no wants to practice?

...But, look out! Here comes the AACOM - osteopathic schools have been popping up like wildfire, and existing ones have been upping their class sizes. They can do this, of course, because the AMA doesn't control them. More DOs will help ease the doctor shortage, particularly since many DO grads go into FP, but its a shame the AMA doesn't get behind the idea of increase the number of doctors in America.

Ooo, look out, DOs will save the day from the evil AMA.

OK - so the greed thing - protecting member paychecks seems to be the most obvious answer to me. How does the AMA/AAMC not start up a new med school in almost 20 years,

Empirically denied (Florida State). Further, as asked previously, what makes you think that the LCME is somehow preventing US med schools from forming? Merely because they haven't formed?? How/why are they doing this, i.e., how many US schools do you know about that failed accreditation, and for what (conspiratorial) reasons?

..limit the number of foreign docs, treat IMGs like 2nd class citizens, etc....all while while our population continues to get larger, and our mean age gets older?

1) House of cards -- until you show (despite the best data) definitively that there is currently a physician shortage, the rest of your argument falls apart.
2) AMA, AAMC and LCME really don't have much to do with how IMGs are treated. ACGME also does not, since individual residency programs make their own residency decisions..unless you are arguing that the ACGME is culpable since it doesn't FORCE residency programs to put IMG applicants on the same level as USMG applicants (which parity is precisely what the [supposedly greedy] AMA has been calling for, for years!!)

My answer: AMA, which is a powerful political lobby, is afraid of seeing its members' salaries drop even further then they have because of managed care and medicrap. By contrast, the AOA, not under the thumb of the AMA and mainstream organized medicine, has seized the opportunity to enter the marketplace for the good of everyone.

Silly aspersions & wishful thinking. Read the research papers, read the industry reactions and resolutions, then try to tell everyone that the AMA has an interest in creating a health care crisis via shortages.

Furthermore, since the AMA hasn't eased the shortage, we're seeing the rise of the allied health professions: PAs, NPs... and even, gulp, chiropractors.

There's no rise of "the allied health professions" as a group -- there are critical shortages of RNs, HHAs, PTs, technicians, and others, increasing burden on the rest of the industry:

http://www.ama-assn.org/amednews/2001/10/01/edca1001.htm

That's how I explain what's going on - but I may be wrong...enlighten me - how do you explain it?

Explain what? I haven't heard a valid argument defining any particular problem yet.

-pitman

 

[LovingItAll]

Originally posted by pitman
Geez, pplz. Do your research before spoutin', or at least form some valid arguments.

"Geez" dude - get over yourself. We're all so lucky we have someone as smart as you to critique our ability to research and form arguments.

Look more closely at my argument -- it says that IF greed were the driving force behind policy for doctor levels, THEN I would think there'd have to be a conspiracy (between ACGME and LCME), with (significant) increase in accreditations... Now, there are other ways there could be greed-driven policy, but this argument was made to show some contradictions inherent to the one it was addressing.

Well then you'd think wrong. Just because doctors want to protect their paychecks doesn't mean there has to be a "conspiracy." All it means is that they'd be resistent to allowing competition -- and since its doctors who man licensing boards, and doctors who advise policymakers (predominately via the AMA's political activities), they certainly have the ability to control the supply of physicians.

Wrong -- as stated above, Florida State University was recently accredited. Just a token increase?

Yeah, I stand corrected, 15 years between accreditations. That proves that the medical community has accommodating the market's ability to control doctor supply?

Because more and more IMGs fill residency slots. But your logic here is: population has increased and residency slots have not, therefore there must be a shortage. Doesn't such simplistic logic require a lower physician per capita? On the contrary, there is a higher per capita forecasted out to 2010, even out to 2020:

http://www.ama-assn.org/amednews/2002/01/21/prl20121.htm

Well, you seemed to have missed my "simplistic logic." I said population increase *and* the fact that its getting older, indicates that we need more doctors.

Did you even read the article you provided a link for? They are predicting SHORTAGES in physicians despite an increase in doctors per capita. Besides, doctors per capita isn't the only metric for determining physician shortages. If I can't get into to see my family doctor for another 3 weeks, and when people wait hours and hours to see a doctor, that tells me there's not enough of 'em.

Moreover, there are significant areas in the country that are underserved. But then again, you probably don't believe that either.

This is some of the weirdest logic I've heard in a while -- your prima facie analysis of demographics tells you not only that more physicians (in general) are needed, but that 2500 in three years couldn't possibly be enough to cover the (qualitative) need that you perceive?

First, most studies since the 80's have forecast physician surpluses. These are studies by independent entities, such as med schools, think tanks, etc. None of them conclude that there is currently a general physician shortage. Recently, there was a study projecting a physician shortage down the road, but neither does that one support your assertion of current shortages (see URL above). And there's no consensus on this latest projection (e.g., Wharton researchers don't believe it will happen anytime soon). Are the study investigators part of the vast AMA conspiracy? Or at any rate, your perceptions of demographics outweigh the only science on the matter?

Haha. Sorry pal, you just seem to love attacking a straw man, don't you?
My point with the 2500 was that it indicates how little the number of physicians being trained is increasing.

And second - I'd love to know what a physician "surplus" is. "Oh no - there's too many doctors! There's too much access to healthcare! Doctors fees are too low!"? Come on.

The article you posted, http://www.ama-assn.org/amednews/2002/01/21/prl20121.htm, even went so far as to associate perceptions of shortages/surpluses with the rate of new med schools -- which is exactly what I've been saying. Did you even read this article, or did you just skip to the bottom to read the per capita stuff?

Many studies do indeed show current shortages in particular regions (certain rural areas, for example), or for particular specialties (not GPs, however -- albeit the analysis is a tad bit more complicated).

Uh huh. That's what I thought. I knew you knew there are shortages in this country. Thanks for admitting it.

This has always been a problem, but will always be, since changing demographics and specialty & domicile preferences cannot be perfectly anticipated, and at best attempts to address mis-projections take many years (lag). Take general surgery for example, where impending shortages if not addressed immediately will take, um, 5+ years to rectify:
http://www.ama-assn.org/amednews/2002/04/08/prsc0408.htm

Well, now you're the one using befuddling logic. Regional and specialty shortages will always be a problem, and addressing them would take too long to rectify...so what are you saying..."why bother?"

Since when does the market require monitoring and help? We need more docs in certain specialties and in certain areas...but docs aren't going there because the locations usually suck. They are opting for other available jobs near big cities (which wouldn't be available if they were already filled by other doctors), even if its slightly less money.

Well, if we had a higher supply of doctors, there would come a point were compensation would simply be too low in the nicer locations, and doctors would say "screw it, its not worth it" and then they'd go somewhere where it is worth it. Invariably, some docs would make it to areas where there are no doctors.
It's even starting to happen in Cali:
http://www.ama-assn.org/amednews/2001/08/06/prsd0806.htm

The decrease in interest in general surgery is the result of the AMA greed conspiracy?

Huh? You talking to me? I never said anything about specialty preferences.

More telling of what?? Yes, filled FP slots have decreased about 2% in your sample of two. Guess what, this may be because projections (from the 80's) saw shortages of generalists, resulting in increases in generalists throughout the 90's. Now researchers generally believe that there are/will be too many generalists and not enough specialists, and as a result, generalist slots should decrease. Would you prefer that the ACGME ignore the independent studies and their projections, instead reacting only when a problem is realized? Such is how a health care crisis occurs.

I would prefer that the marketplace not be interfered with by the government, the medical community, etc.

We saw how well the ACGME reacted to their "surplus" of physicians they were previously predicting. Interference with the health care markets - "Such is how a health care crisis occurs."

Since you can't force US docs to practice in under-represented rural areas, you can't just wave a magic wand and increase GP residencies, ignoring the problems of surplus, until all such rural residencies get filled. The economics is just a bit more complicated.

Who needs a magic wand? Train more doctors - that'll put more doctors into the resident pool, and then you are bound to have more grads available to fill residency spots. Guess that's just a bit "too complicated." The AOA didn't seem to think so.

The "problems of surplus?" This I'd love to hear.

Another factor: FMGs who are more likely to bend over and fill such needs used to be able to stay in the US if they practiced rural medicine, but since 9/11 this incentive has largely been removed:

http://www.ama-assn.org/amednews/2002/04/22/prsc0422.htm

So now Bush/Ashcroft are part of the AMA greed conspiracy?
Or maybe it's the AMA's fault that there aren't huge publicly funded initiatives to pump physicians out to where no wants to practice?

Haha. I hate to break it to ya buddy, but every public med school is a "huge publicly funded initiative" to churn out doctors.

Ooo, look out, DOs will save the day from the evil AMA.

Ah yes, sarcasm. Nice counter. Is that your example of how to "form valid arguments?"

Empirically denied (Florida). Further, as I asked earlier, what makes you think that the LCME is somehow preventing US med schools from forming? Merely because they haven't formed?? How are they doing this, i.e., how many US schools do you know about that failed accreditation, and for what (conspiratorial) reasons?

Come on man, think outside the box. What prompts the creation of new med schools (answer: recommendations by the AMA, etc).
Interestingly, while doing a bit of my substandard research, I found that the following article that reported that the AMA and the AAMC (as well as existing FL med schools) voted against the creation of FSU's med school because they thought there were enough physicians already. Why I am not surprised?

http://www.sptimes.com/2002/02/08/State/FSU_med_school_not_ac.shtml

1) House of cards -- until you show (despite the best data) definitively that there is currently a physician shortage, the rest of your arguments fall apart.

Head in sand - see above.

continued

 

[LovingItAll]

Silly aspersions. Read the research papers, read the industry reactions and resolutions, then try to tell everyone that the AMA has an interest in creating a health care crisis via shortages.

"Silly aspersions." Haha, nice argument again. Well, I'll give you credit: it sounded more fancy then what you really mean, which is: "nuh uh."

If you don't think doctors don't have an interest in protecting their paychecks, then I'm not sure what to tell you. Why did HMOs come into existence again?

There's no rise of "the allied health professions" as a group -- there are critical shortages of RNs, HHAs, PTs, technicians, and others, increasing burden on the rest of the industry:

http://www.ama-assn.org/amednews/2001/10/01/edca1001.htm

You can have a both a rise and a shortage. You really need me to explain that one to you?
PAs and nurse practioners are a relatively new creation. I've already spent waaay to much time responding to this thread, so I'll let you go look it up.

Explain what? I haven't heard a valid argument defining a particular problem yet.

I refer you to my original post earlier in the thread - explain the nature of the "threat" posed by teleradiology and IMGs.

Its financial (aka GREED)

 

[pitman]

Originally posted by LovingItAll
"Geez" dude - get over yourself. We're all so lucky we have someone as smart as you to critique our ability to research and form [valid] arguments.

In the absence of either..the shoe fits.

Your main arguments as presented were either logically flawed (invalid) and/or completely contradictory to readily-available evidence -- um, like the existence of shortages..which you claimed in the most general sense, later tried to claim you never did, yet all the while neglecting how half your arguments as presented depend on general shortages (go back to the original post if you don't think there's some argument shifting going on here).

So no, my statement has nothing to do with my high opinion of myself, since asking for one who asserts to be able to back up sensational claims with evidence or logically valid arguments from the start is not a flatteringly high bar to set, particularly in such a field of researchers and seekers of truth. Arguments are taken how they are presented, and the ones you presented were blatantly invalid and unsupportable. SO here's another attempt..let's see how much the argument has been shifted now..

Well then you'd think wrong. Just because doctors want to protect their paychecks doesn't mean there has to be a "conspiracy." All it means is that they'd be resistent to allowing competition -- and since its doctors who man licensing boards, and doctors who advise policymakers (predominately via the AMA's political activities), they certainly have the ability to control the supply of physicians.

In the scenario I gave, it would indeed require a conspiracy (among and within groups -- do you want also to claim no consp. necessary within groups?). If you don't like the scenario, point out its flaws, but more importantly for your own argument's sake, since I am rebutting you, he who asserts, give a (policy) scenario without conspiracy (and not some over-simplified drivel like "people make up boards and people are selfish therefore policy is of greed"), which can honestly be evaluated. It's not that it's impossible, it's that it hasn't been done. See the point? More on this later.

Yeah, I stand corrected, 15 years between accreditations. That proves that the medical community has accommodating the market's ability to control doctor supply?

Nope, it doesn't, nor does it try to. Recent accreditation diminishes any argument that the AMA has prevented any new schools. I'm not the one who made the argument:

LovingItAll:
Mercer was the last med school that was accredited, and that was in 1985...[since] our country needs more docs...why the hell haven't more med schools popped up?

Ok, so you're now conceding my point, that your statement was wrong (and so were similar statements), so rephrase to say something else, like "why has there been only one school created in the past two decades..?". But that would diminish the strength/biasing effect of your above statement (since would show policy to increase docs), which above statement was used to support the theory that greed is policy is the reason (which is a circular argument to begin with). Further, to change the statement to be accurate would be to concede that you're shifting arguments.

While you're at it, retool your arguments while dropping the general shortage claim, and the arguments that are dependent on it, then see what's left -- did you in fact make the case that there are regional FP shortages? Have you made it obvious that simply increasing FP residencies results in sufficient FPs in those under-served areas? Have you shown what's preventing FP residencies alone from increasing? Do you have any policy examples..who's policy? What are the motives for the policy, and how do you know this? I'll address your shifted arguments on this down below..

Well, you seemed to have missed my "simplistic logic." I said population increase *and* the fact that its getting older, indicates that we need more doctors.

So if you weren't arguing general shortages, why mention population increase at all, why say that such an assertion "indicates that we need more doctors", and not a mere shift in distribution, or even just "more FPs"? It's all the same to you? The economics all just works itself out? Wow, glad there's such a simple one-size-fits-all solution, everyone studying HR economics can go home now.

Further, why refer to gross ACGME residency stats at all, exclaiming:

"..all the ACGME manages to churn out is an extra 2500 more positions?"

..if you were only referring to regional (FP?) shortages? (so the way to address regional shortages of an expensively-trained, highly specialized, non-fluidly-mobile, non-corporate-controlled, human commodity is just to flood the market? Read those same articles to see a glimpse of some of the varying -- i.e., not obvious -- expert viewpoints, or read up on HR macroeconomics, he who asserts...).

The only other references you make to shortages are when discussing FPs, which if taken alone, shifts your argument. Is the ultimate problem now with the AMA policy of greed that it restricts the FPs in rural areas? Make that argument (oops, too late -- we're onto a different debate now..), back it up coherently, and then it can be responded to intelligently.

In other words, concede on the old argument/statements, then make the new case that you're making below (rather than trying to make it sound as though your original argument, the one responded to, makes any sense). This will become more clear as we continue..

Did you even read the article you provided a link for?
They are predicting SHORTAGES in physicians despite an increase in doctors per capita.

Precisely. Did you even read my argument that you're currently addressing?

As I stated, the one study -- for which there is no consensus among the peer-reviewed experts -- that says anything about a general shortage is one that predicts a future one, not one that refers to any supposed current shortage. Your argument, as stated, relies on current shortages, not projected ones (i.e., known unstoppable shortages caused by past greedy behavior):

Wherever the (projected) shortages are still preventable, you haven't shown any policy of greed.

Where any supposed shortages occur because the ACGME or LCME listened to the peer-reviewed research (which you interestingly claim later in this post), however flawed the underlying reasoning, then you cannot use this to support your *AMA policy of greed* hypothesis.

Where there are no shortages, you cannot claim greed caused them. Where there are, you need to rephrase half your arguments to stop alluding to general shortages and explain how greed *policy* is the cause of regional shortages (this burden is on you, he who asserts.., not I).

But in your fantasy policy world (see below), such a projection of general shortages as this one would be ignored? But then again, it wouldn't be needed, because the system would be perfectly balanced in Feng Schwinnng... w/ zero lag in responsiveness, because if everyone would just let go of any control of physician supply, the free market would solve, by flooding the system with so many physicians that everyone's satiated with quality affordable medical services(?!) Wow.

So..in your next counter-post, will you be big enough to concede any of this, or even that I had clearly read the article when I first referenced it?

Besides, doctors per capita isn't the only metric for determining physician shortages. If I can't get into to see my family doctor for another 3 weeks, and when people wait hours and hours to see a doctor, that tells me there's not enough of 'em.

If anyone, it was you who was over-simplifying the "metrics" -- I'm not the one who made the argument that (in part) b.c. populations are increasing, yet residency numbers have not increased, there must be a shortage. For that argument to make any sense, or the follow-up, that the solution is to increase number of physicians, it'd be dependent on physicians per capita data. A counter-argument need only be as simplistic as the argument. A slightly more complicated argument, one not argued, would be to increase FPs while not increasing docs overall. Since this alternative isn't even addressed (could be dismissed outright, if you still claimed a general shortage ), your proposed solution (e.g., `..therefore general increase needed to solve regional problems`) does not follow. But if you'd like to shift in that direction, I will address it, too.

BTW if we had a truly "free market" (and one that is fluid enough to seep into deficient areas) of physicians, as you seem to advocate below, then there would sure as hell still be waiting lists to see the better doctors (as there are now in well-served areas -- this is typically seen in HR economics or economics of quality and is not simplistically caused by insufficient supply). Some people waiting does not support your argument. More on economics below.

Moreover, there are significant areas in the country that are underserved. But then again, you probably don't believe that either.

Uhm, that's addressed all over my post. Now that we both acknowledge (me from the start, you in your 2nd Affirmative) the only real shortages are regional, and now that regional shortages are the narrowed focus of your argument, I can respond to it in kind (below).

 

[pitman]

So we've established that there is no general doctor shortage. So now the question is whether regional shortages are caused by AMA greed, and whether a seemingly non-greedy proposal (flood the market with docs) will solve.

Originally posted by LovingItAll

Haha. Sorry pal, you just seem to love attacking a straw man, don't you?
My point with the 2500 was that it indicates how little the number of physicians being trained is increasing.

You claimed "more" physicians were needed, then used a recent increase in physicians to support your point that greed is restricting doctors? Why, because it's so obvious in the absence of any quantitative analysis that what's needed is a number greater than X? You don't see how this only diminishes your argument? Your point was obvious, its validity is in question.

And second - I'd love to know what a physician "surplus" is. "Oh no - there's too many doctors! There's too much access to healthcare! Doctors fees are too low!"? Come on.

Here's where you should start by reading those papers more closely to get an *idea* of the complexity of the issue. Yes, there can be too many doctors..

...some experts arguing it will result in an INCREASE in health care costs (this would be bad, indeed counter-productive) -- I'll let you figure out potential reasons why (it's not too hard, and it's a theory advocated by some of the best economists..but you know better, eh?).

...others arguing that it would lead to a reduction in salaries that radically reduces the quality and supply of doctors (not so ironically also bad) -- do you think it a coincidence that med apps go down a few years after the economy booms and up a few years after the start of a recession? Do you think med students don't consider cost of education + debt or at remuneration when deciding to devote 7+ years of training? Or those matters when deciding on a specialty? Keep pumping them in, 5x, 10x, until you get some "natural" equilibrium, e.g., from financial forces driving FPs down, volumes driving up the numbers, until no area has a shortage? How many MCAT 18's will need to be accepted?

...with most understanding the burden of the cost of training those extra doctors (via diminishing returns, effects on budget, net effect on economy, etc.) How many more are needed exactly to flood the plains and fill out all the under-served areas? Don't forget to plug this number into your handy quantitative analysis calculator to determine govt. outlays for residency..or is the requirement to do residency in the US also doing more harm than good (another part of the AMA greed policy? if not part of it, then AMA greed certainly can't be blamed for that barrier to the solution!)

But here's the interesting part of your argument: you know better, in fact you are so sure of yourself that the cost wouldn't be too much to bear, that projections don't do net good, and that adjusting to "market forces" is the smart way to handle health care delivery shortages, even if, depending on the nature of the shortage, it may take 3+ years (min res. length), 7+ years (min training length), or longer (time to change people's perceptions, career goals, etc.) to adjust to them, even if none of the researchers think it makes an economic sense (this isn't just an issue of salary, in case you missed something), even when in the status quo there are no general shortages or health care crisis. Hmm.

But even this is not enough for your argument to be valid! For you also need to show that the AMA is holding back the flood gates (with what policies, exactly? Oh, right...we don't need to show the mechanism, since this is all common sense, since people are selfish, I see...), not because that's what just about every sane economist is recommending, but they're really doing it in spite of the research...out of greed.

The article you posted, http://www.ama-assn.org/amednews/2002/01/21/prl20121.htm, even went so far as to associate perceptions of shortages/surpluses with the rate of new med schools -- which is exactly what I've been saying. Did you even read this article, or did you just skip to the bottom to read the per capita stuff?

No, you have not been saying that -- the article referenced someone who said that people's perceptions matter when determining doctor levels, not that LovingItAll's (or anyone's) intellectual musings of shortages should determine levels. An example they give is of looking at (statistics of) complaints, as one indicator of relative shortages. And none of those researchers argued that the solution is to stop controlling doctor levels!

Well, now you're the one using befuddling logic. Regional and specialty shortages will always be a problem, and addressing them would take too long to rectify...so what are you saying..."why bother?"

Wow, there's a stretch. Keep reading.

Since when does the market require monitoring and help? We need more docs in certain specialties and in certain areas...but docs aren't going there because the locations usually suck. They are opting for other available jobs near big cities (which wouldn't be available if they were already filled by other doctors), even if its slightly less money.

Here's your statement undermining projections b.c. you believe the market solves. It's addressed where relevant.

Well, if we had a higher supply of doctors, there would come a point were compensation would simply be too low in the nicer locations, and doctors would say "screw it, its not worth it" and then they'd go somewhere where it is worth it. Invariably, some docs would make it to areas where there are no doctors.
It's even starting to happen in Cali:
http://www.ama-assn.org/amednews/2001/08/06/prsd0806.htm

And this spread out over the US..is a good thing? Disruptions in care, mobile disgruntled doctors, these are good in health care? Doctors fleeing to states that pay higher wages, drawing health care quality with it? Creating effective health care pot-holes..since who's paying the most expensive docs who have been compensated enough to live, e.g., in rural Kansas, in this "free market" system..the poor living in rural Kansas? Or the US government? I guess the US govt. is ALSO part of the greed conspiracy (since if not, then surely the AMA can't be blamed when the US govt. skips out on the bill. Ooo, wait you say, the problem/solution is much too complicated to blame the govt? ..it's only complicated enough to blame AMA greed!).

I would prefer that the marketplace not be interfered with by the government, the medical community, etc.

Here's your free magic carpet market solves all argument, addressed elsewhere.

We saw how well the ACGME reacted to their "surplus" of physicians they were previously predicting. Interference with the health care markets - "Such is how a health care crisis occurs."

Yet there hasn't been a crisis, and if we take your assertion that the current projection is correct, then interference would be required (and will be made) precisely to prevent one.

More importantly, the ONLY WAY THIS ARGUMENT CAN EVEN BE MADE, THE ONLY WAY TO MAKE THE CLAIM "We saw how well..", is via recognizing the (validity) of current projections of shortages, which projections you are in the same argument condemning! Wow! Such blatant self-contradiction takes serious balls!

Haha. I hate to break it to ya buddy, but every public med school is a "huge publicly funded initiative" to churn out doctors.

I hate to break it to ya, you just supported several of my arguments above (unanalyzed increased cost of increasing docs, independent govt. ($) factor affecting current levels => AMA greed not to blame)

But I was referring to the lack of (sufficient) publicly funded initiatives needed to address the problem of regional shortages -- either the US govt. is part of the conspiracy for not pushing initiatives above and beyond what they made available before 9.11, or it alone is culpable for the lack of such initiatives (thus AMA greed policy could not strictly be to blame). See why "conspiracy" keeps coming back up? The alternative is that AMA Greed Theory is false.

 

[pitman]

Here's where there is an attempt made to link some (what?) AMA policy derived from greed to an assumed (how?) restriction of doctors (who?).

Originally posted by LovingItAll
Come on man, think outside the box. What prompts the creation of new med schools (answer: recommendations by the AMA, etc).

I like the "etc." bit -- so your only connection between doc levels and AMA policy is by mere assertion that new med schools are created upon recommendation by the AMA (citing "think outside the box" as your source)? Like when FSU got its accreditation despite AMA's resistance (which resistance you so willingly point out below when it suits some other faulty argument)??

So what stops someone from creating a med school that they want? Read down this time before responding.

Interestingly, while doing a bit of my substandard research, I found that the following article that reported that the AMA and the AAMC (as well as existing FL med schools) voted against the creation of FSU's med school because they thought there were enough physicians already. Why I am not surprised?

And as I said, LCME would have to be in on the conspiracy for the greed policy to be effective (i.e., would have to blatantly violate its own policies to lead to shortages via rejecting accreditations) .

I guess I should spell this out: for the negative effect (shortage as a result of greed), greed policy would have to be effective. You just gave me an example where accreditation succeeded (check the AMA site if you want an update) -- where supposedly the AMA, along with AAMC, supposedly out of greed, to cause a shortage, attempted to block accreditation, but failed due to the actions of the non-conspiring LCME(!??!??@#$@)

Yes, accreditation is no picnic -- should it be..should the magical "free market" determine med school standards?

Read this part a little more closely: the LCME is actually 1/2 AMA and 1/2 AAMC (reps come from both), the statements/votes from the parent boards non-binding policy positions, while those very same organizations, through their legislative branch (LCME being able to enforce policy here), voted to allow the school! Oh my god, the greedy selfish bastards! They tried so hard to screw the country with a shortage, but they were stopped just in time.. by themselves.

But OF COURSE if you start with the premise that there are not enough doctors, then any claims by boards, statesmen, and medical schools that there are enough doctors will invite all sorts of cynical responses. So what the hell is that supposed to say except that you've been rationalizing this whole time?

I'll ask this one again -- do all the independent researchers who tend to agree that there is no shortage (i.e., no significant drawback from current levels of physicians) necessarily belong to the greed conspiracy? Because if they don't, then AMA greed cannot be blamed for shortages whenever the research projections are listened to.

And what about the researchers who don't argue for opening the flood gates..they're likewise all wrong? And AMA, ignoring their recommendations, is really acting out of greed, pretending to agree with these researchers' reasoning, but secretly just agreeing with and acting on their policy recommendations, but for really selfish (greedy) reasons?

In sum:

You still have no line drawn from sound premises to your conclusion -- to show (AMA or any other) greed affecting policy, particularly policy leading to physician shortages. You're left with "greed exists" and "regional shortages exist", which no one would argue with, which is nice and all, but which says nothing, has no logical connection -- how, to what effect.. does greed lead to the uneven distribution of physicians? Come on! Make real connections, not "think outside the box" pleas that the reader fills in himself.. at least a workable scenario that can be evaluated, dammit!

Sure, I'm cynical and believe people are motivated out of self-interest, but that doesn't mean every cynical theory I (or you) could come up with that accounts for (or predicts) a negative is therefore correct.

I'll end by making more explicit one of my many implicit arguments that LovingItAll's causal chain (doctor shortage -> AMA greed) is overly simplistic:

pitman:
The decrease in interest in general surgery is the result of the AMA greed conspiracy?

LovingItAll:
Huh? You talking to me? I never said anything about specialty preferences.

Really? Wow, if you didn't, how come AMA greed theory doesn't explain it, but does explain regional physician shortages?

-pitman

 

[Gradient Echo]

There are 3 new MD schools:

1) Florida State
2) Cleveland Clinic
3) University of Hawaii (new campus)

In addition to that, the University of Texas is seriously thinking about opening up a new medical campus in Austin.

In addition to those 3 new MD schools, there have been 10 or 12 new DO schools opened up in the last 15 years.

The United States is already in the upper echelon of countries in terms of # of docs per capita. I dont see the need to increase this ratio even more.

 

[pitman]

Thanks for the pertinent info!

In fairness, the paper referenced above does (controversially) claim students amounting to about 10 new schools will be needed to head off its projected shortage, but if correct could be staved off by temporary (i.e., more flexible) increases in current schools' enrolments and/or IMGs (such is what Australia does, albeit via strict policy).

-pitman

 

[Gradient Echo]

pitman,

are those studies including NPs, PAs, and DOs? Its unclear to me whether they are referring to MDs only or not.

Do you have a link to a study that has a detailed breakdown on their methodology and all data sets?

 

[pitman]

Originally posted by Gradient Echo
pitman,

are those studies including NPs, PAs, and DOs? Its unclear to me whether they are referring to MDs only or not.

Do you have a link to a study that has a detailed breakdown on their methodology and all data sets?

Health Affairs, Jan/Feb.

That study is about MDs+DOs only, but commentary by others is where nurses, etc. as substitutes was brought up.

No link for paper -- was only using reference to it to show how even the one study showing (general) shortages was a mere projection and thus did not support original argument..but since you're close to a med library..

Article referencing original study, with commentary:
http://www.ama-assn.org/amednews/2002/01/21/prl20121.htm

Funny part about the adjustments the study made is the one for a 20% productivity reduction for women..I'm sure *somewhere* a review article's titled "Study claims women physicans are 20% less productive than their male counterparts!".

Commentary on state of allied health professionals:
http://www.ama-assn.org/amednews/2001/10/01/edca1001.htm

-pitman

 

[pitman]

BTW nice description of MRI in other thread..one part confused me tho:

http://forums.studentdoctor.net/showthread.php?s=&postid=929209#post929209

-pitman

 

[LovingItAll]

Originally posted by pitman

In sum:

You still have no line drawn from sound premises to your conclusion -- to show (AMA or any other) greed affecting policy, particularly policy leading to physician shortages. You're left with "greed exists" and "regional shortages exist", which no one would argue with, which is nice and all, but which says nothing, has no logical connection -- how, to what effect.. does greed lead to the uneven distribution of physicians? Come on! Make real connections, not "think outside the box" pleas that the reader fills in himself.. at least a workable scenario that can be evaluated, dammit!

Sure, I'm cynical and believe people are motivated out of self-interest, but that doesn't mean every cynical theory I (or you) could come up with that accounts for (or predicts) a negative is therefore correct.

You're quite the piece of work. Seriously.

First, I must admit for as "smart" as you are, you sure do make for some confusing reading. I had an easier time understanding the Architect's explanation for the Matrix. Since you started the idea of critiquing argument presentation, let me suggest two things to you: Less pronouns, more periods.

Putting that aside, I gotta applaud your tenacity. I love the way you purport to tell me what "my" argument is, but do so on your terms...and then ask me to justify my argument, as restated, with "cogent," "workable scenarios" that can't possibly follow from the way you've framed "my" argument.

For example, you want to get off this "conspiracy" thing? YOU are the only who brought up a conspiracy - in fact, conspiracy seems to be the only proof acceptable to you of AMA greed controlling physician supply. Yes, the AMA is a powerful lobby. NO, it isn't omnipotent. Sometimes things happen despite the AMA's best effort. The AMA's failed attempt to quash chiropractic medicine in the 70's is an example of how it is sometimes ineffective in achieving its goal. If you really think there'd have to be a "conspiracy" (a plan formulated in secret for an evil purpose), isn't it kind of silly to be demanding proof of it? Not exactly a secret plan if I can find it using a goggle search, is it?

Since you're so keen on how "complex" things are, I find it surprising that the only possibilities you seem to be open to are: 1) the AMA is in absolute control of this countries' medical education by way of a sensationalistic conspiracy or 2) the AMA is this inert, benevolent organization that sits around passing "non-binding" resolutions. Well, I happen to put it in between these two extremes, but much closer to #1 than #2. As I've said before, organized medicine is extremely politically powerful by virtue of stuff like the AMA lobby and physician control of state medical board licensure.

Second, along the same lines, Did I ever say that the AMA is trying to create shortages? No. But, if you want to continue to attack the straw man, please go right ahead.

Third, I really enjoyed how you tried to pull the rug out from under me on the issue of shortage. You (and your articles and statistics) don't even want to accept the notion of physician shortage. So, you are demanding that I prove the existence of a cause that has (in your mind) a non-existent effect.

Anyway, I still stick with my original point: the "increase" in accreditations does NOT preclude the idea that greed is a driving force in physician supply.

Why you decided to put the burden on me to show a "greed conspiracy" is escapes me. (What was that "he who asserts" stuff you were saying earlier?) At first, I thought I'd bicker because you just sounded to like too much of an d%ck with your "geez ppl" crap. But, the novelty worn off, and I'm thoroughly bored with this whole discussion. Let's face it, neither of us are going change the others' mind on this.

So, "um" - I guess you got me -- you exposed the "simplicity" of my "negative constructive" on this issue. Gee I wish I wuz smart likes you.

 

[pitman]

Originally posted by LovingItAll
Putting that aside, I gotta applaud your tenacity. I love the way you purport to tell me what "my" argument is, but do so on your terms...and then ask me to justify my argument, as restated, with "cogent," "workable scenarios" that can't possibly follow from the way you've framed "my" argument.

Explain how I mis-interpreted or mis-represented your argument -- I never said you claimed conspiracy, I brought up several examples of where your argument implied a conspiracy..such were examples of reductio ad absurdum.

For example, let's take my statement:

pitman said:
But I was referring to the lack of (sufficient) publicly funded initiatives needed to address the problem of regional shortages -- either the US govt. is part of the conspiracy for not pushing initiatives above and beyond what they made available before 9.11, or it alone is culpable for the lack of such initiatives (thus AMA greed policy could not strictly be to blame). See why "conspiracy" keeps coming back up? The alternative is that AMA Greed Theory is false.

If the statement isn't self-explanatory, then why not make an argument against (or inquiry into) it, rather than some anti-intellectual knee-jerk response that merely asserts you never said anything about a conpiracy?

Suppose for a moment that there is no conspiracy between AMA and the US govt. to restrict the number of docs in the US. The US govt. recently (post 9.11) cut way back on the number of docs being sent to under-served areas by rescinding its offer to allow FMGs stay in the US if they serve there. This means that AMA Greed Theory cannot explain this not-so-insignificant recent reduction in docs in under-served regions. This means that AMA Greed Theory (AMA greed is the cause of regional shortages) cannot be true, since it's the US govt. which rescinded the offer.

First, I don't care if you believe the AMA is powerful enough a lobby to be able to effect US policy like this, such would still not mean the blame lies with AMA when the US govt. decides to change policy (or, make the argument!), and you weren't originally claiming complacency.

Second, do you really think the recent policy change had anything to do with AMA politics? If you really thought this, then first, why did the opportunity exist before 9.11? Second, I would claim it would have to be the result of a conspiracy, an agreement among individuals to do a subversive act (and certainly not a secret one). Why would it be? Because it doesn't take a genius to know there are under-served regions, and it would take a *****ic AMA to apply its political pressure to have FMGs removed from those regions at a time when Ashcroft is considering national security issues (the reason for the change in policy). In other words, the AMA's motives would be so obvious to the policymakers, and vice versa, that the agreement would be implied.

Do you NOW see why I keep bringing up conspiracies? Or will you continue to miss the point and irrelevantly insist that you never claimed "conspiracy"?

For example, you want to get off this "conspiracy" thing? YOU are the only who brought up a conspiracy - in fact, conspiracy seems to be the only proof acceptable to you of AMA greed controlling physician supply.

Actually, I addressed every argument you made that supported AMA Greed Theory, and you continue to refuse to explain how your original argument survives. You can't claim general shortages, you can't claim schools have been limited, you haven't shown FP shortage an issue, you haven't explained how increasing res slots would solve any such supposed shortage, you haven't explained any AMA policy/action that is causing (what..regional FP shortages?) the supposed problem, nor how you know that greed must be their raison d'etre (oh yeah, aside from claiming that people are greedy). In other words, you have not given any reasons for anyone to believe the following inflammatory assertions:

If the AMA/ACGME/AAMC really cared about improving access to healthcare, they'd increase the supply of doctors: more med schools, more IMGs into residencies, etc.

...

OK - so the greed thing - protecting member paychecks seems to be the most obvious answer to me. How does the AMA/AAMC not start up a new med school in almost 20 years, limit the number of foreign docs, treat IMGs like 2nd class citizens, etc....all while while our population continues to get larger, and our mean age gets older?

My answer: AMA, which is a powerful political lobby, is afraid of seeing its members' salaries drop even further then they have because of managed care and medicrap...

Now I have to, what..disprove your general statements to show that your above AMA Greed Theory is false? No..this is the burden of he who asserts. My burden, of someone who disagrees, is to put holes into your above argument, which I certainly have, and to show how those holes render your conclusion unwarranted, which I have and to which you haven't responded!

Sorry if you don't like my writing style, or can't follow the connections between my arguments (which are generally made inline with yours), but that is not my issue. For I am not arguing with you in order to convince you that you are wrong. I am doing so for anyone else who is reading this thread, who is able to follow the arguments and assess your statements as they are revealed.

Yes, the AMA is a powerful lobby. NO, it isn't omnipotent. Sometimes things happen despite the AMA's best effort. The AMA's failed attempt to quash chiropractic medicine in the 70's is an example of how it is sometimes ineffective in achieving its goal.

And you'd still have to make SOME CONNECTION beyond claiming that people are self-interested, to make a valid claim that chiropractry was objected to by the AMA out of greed. It's an interesting NEW argument, and I'd reply to it..if you "told a story" -- explained why the objection existed back then, how you know this, what the mechanism was (e.g., policy), and how you know it's based in greed. But this is not what I have been arguing against -- you made the claim that supposed current shortages are being caused by AMA greed. So, uhm, make the argument.

If you really think there'd have to be a "conspiracy" (a plan formulated in secret for an evil purpose), isn't it kind of silly to be demanding proof of it? Not exactly a secret plan if I can find it using a goggle search, is it?

"It" referring to proof of conspiracy? Of the conspiracy that you agree doesn't exist? How'd you find that via google? Or do you mean "proof" of greed? I'm still waiting for you to show that magic of google.

But a conspiracy doesn't have to be secret, and the purpose doesn't have to be "evil". Can be illegal or subversive for example. 'Proof' of one could be lacking, but people can know about it and have EVIDENCE of it. Logic can imply one, or it can refute one. But all this is relevant..how?

If you're trying to say that I'm unfairly demanding evidence for a conspiracy for you to make your case while it's supposedly impossible for one to show a conspiracy, then first: it's not my fault if you make arguments with impossible/contradictory implications; second: conspiracies are shown pretty damn well in court all the time, so they're certainly demonstrable beyond a reasonable doubt; third: you haven't even tried to explain away the contradictions that concurrent beliefs in AMA Greed Theory and no conspiracies presents; fourth: the absense of evidence is not evidence of absence (or, why believe in something for which there is no evidence?).

Since you're so keen on how "complex" things are, I find it surprising that the only possibilities you seem to be open to are: 1) the AMA is in absolute control of this countries' medical education by way of a sensationalistic conspiracy or 2) the AMA is this inert, benevolent organization that sits around passing "non-binding" resolutions. Well, I happen to put it in between these two extremes, but much closer to #1 than #2. As I've said before, organized medicine is extremely politically powerful by virtue of stuff like the AMA lobby and physician control of state medical board licensure.

No, my argument is very simply that no semblance of a valid argument has been made that AMA greed is at fault for current (regional) shortages .

Second, along the same lines, Did I ever say that the AMA is trying to create shortages? No. But, if you want to continue to attack the straw man, please go right ahead.

Of course you have -- if the AMA is responsible for current shortages, out of greed, then they are responsible for creating the current shortages, and unless they have 0 self-reflection/self-awareness/intelligence/responsibility, they are "trying" to have these shortages. See your own quote directly above, or read your entire post.

 

[pitman]

Originally posted by LovingItAll

Third, I really enjoyed how you tried to pull the rug out from under me on the issue of shortage. You (and your articles and statistics) don't even want to accept the notion of physician shortage. So, you are demanding that I prove the existence of a cause that has (in your mind) a non-existent effect.

What the he*ll? "..prove the existence of a cause that has (in your mind) a non-existent effect" ?? You mean I've 1) asked for evidence that there is in fact a general shortage; and 2) am expecting that you have some evidence AMA greed is why the shortage exists? Holy **** what outrageous expectations I have!

So what you're really saying is that the studies (i.e., the only direct compilations of evidence) are all wrong, the economists and other researchers that study this particular issue..are all wrong, that you don't even need to explain them away, and you still maintain that there are general shortages, all b.c. you personally know better? I see..no need for further comment.

But all I've ever demanded is some evidence beyond "people are self-interested AMA is powerful therefore AMA is cause of (perceived) shortages".

Anyway, I still stick with my original point: the "increase" in accreditations does NOT preclude the idea that greed is a driving
force in physician supply.

Too bad it wasn't your point. But the increase in accreditations, (along with the existence of the LCME), takes out your argument that the AMA is restricting schools, leaving you with no mechanism for AMA greed to affect doc levels. The argument is an attack on your assertion, not a proof of the converse.

Why you decided to put the burden on me to show a "greed conspiracy" is escapes me. (What was that "he who asserts" stuff you were saying earlier?)

If you have to ask, then you shouldn't be engaging in argumentation -- those who follow this thread know that you have nothing credible remaining.

-pitman

 

[colforbinMD]

What he has credible remaining is something you seem not to have. The intelligence and maturity to recognize when an argument is a waste of his energy. You both have made your points and neither have disuaded the other from their points of view. My question for you before I leave this thread all togethor may come off as an insult and I really do not intend it to. It is a serious question that has popped up in my mind again and again reading your posts. My question is how did you miss your true calling as a litigator. Your argument style and shall we say tenacity (trying not to insult here) seems that of a great lawyer not a physician.

 

[pitman]

Originally posted by drkp
What he has credible remaining is something you seem not to have. The intelligence and maturity to recognize when an argument is a waste of his energy. You both have made your points and neither have disuaded the other from their points of view....My question is how did you miss your true calling as a litigator. Your argument style and shall we say tenacity (trying not to insult here) seems that of a great lawyer not a physician.

Interesting assessment, but not sure how you could make any distinction when there have been the same number of alternate responses (his original statement up to my final response).

Stating that one is done arguing while making arguments is not to "recognize when an argument is a waste of ... energy". I keep responding to the arguments presented to make sure there is no way to interpret the original inflammatory accusation (what I've coined AMA Greed Theory) as valid. To truly decide it's not worth it is to be silent (or to concede).

I apologize for not going into law, but a formal understanding of logic and argumentation is beneficial in (and to) any field.

Which is more "undoctor"-like: a tenacious commitment to valid reasoning, or anti-intellectual knee-jerk accusations of greed-driven industry policy?

-pitman

 

[driedcaribou]

Originally posted by drkp
My question is how did you miss your true calling as a litigator. Your argument style and shall we say tenacity (trying not to insult here) seems that of a great lawyer not a physician.

A doctor needs the ability to argue to defend his views in terms of his choice of treatment, for research, his rights and his patient's rights.

It takes all kinds.

 

[colforbinMD]

is the ability to simply communicat. A doctor most certainly does need to be able to argue but he/she needs to do so in a non condescending manner and to not talk around an issue and argue statements with questions. I am unsubscribing to this dead thread so please don't bother posting your response of.

"How did I not argue in a cohesive and cogent manner becoming of the traditions of and allopathic practitioner from an LCME accredited school of medicine. Please provide specific instances of where I failed to answer a statement with a statement and provide sources of how this is condescending"

 

[pitman]

Nice one. And just to rub it in, I'm responding.

1) This thread says nothing about the *ability* to communicate at your prescribed level. It does however reveal the ability to reason.

2) You have just demonstrated the very same anti-intellectual tactic of making an argument (and a characterization), then trying to have the last word by claiming it's beneath you to continue. Hmm.

Oh yeah, don't feel obligated to respond, but certainly do if you want another rebuttal (since I'm not a hypocrite).

-pitman