Why are you guys choosing third tier trash medical schools?

[IMG69]

I have seen docs from the UK and Canada come here, bag on America's healthcare but I always wonder if they think it's so bad why don't they just go home?

We bag on your healthcare from a patient perspective not a physician perspective. When your charged $2000 for just an ambulance ride (even when you have insurance, idk if this right but the point still applies) don't you think that's reason enough to bag on your own healthcare system? I had Myocarditis when I was 23 which required several days stay in hospital; how much would that have cost me and how long would it take me to pay it off?

After I received the investigations/treatment for my Myocarditis I simply walked out of the hospital with some free meds, there was no bill, no receipt.

Correct me again if i'm wrong but isn't it like 5-10k to have a baby in the USA?

This video comes to mind, ignore the women that are obviously ignorant:


Now from the Physician point of view (keep in mind i'm M3) the UK health system is basically in volume overload and this is due to the fact such as others have mentioned, extremely poor pay, extremely long training paths - it could be 10 years for Gen surg. In fact the pay is so poor that a PA in America makes more than a 20+ year consultant in the UK. Something like 20% or so of UK graduates go overseas, mainly NZ/AUS because it's US pay with a social healthcare system essentially, so it's the best for both parties. There is a gigantic shortage of physicians which is in part why we have something like a 99.7% match rate and this is why you see articles of nurses doing colonoscopies etc because there is literally nobody else available, it's not a scope creep issue in the UK.

Edit: This isn't a which system is better argument, both systems are what they are.

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[Kardio]

Two consults for the price of one #WMSOM #SaveMoney

 

[MaximusD]

I graduated med school in 2008 so I'm a little older and crankier and don't understand what you guys are doing.

For those of you not aware, the term "third tier trash" used to apply to law schools, because they were opening up like McDonalds.

I hate to say this, but it now applies to med schools too.

Consider that in the last 20 years, there have been over 80 new medical schools (DO and MD). The prior 20 years before that, there were only 7 new medical schools.

Now we have Walmart opening medical schools in podunk Bentonville with a population of 50k -- Walmart heir's nonprofit to start new integrative medical school in Arkansas

We have for-profit med schools opening everywhere too.

I'm sorry but Walmart is a third tier trash med school
So are all the for-profit schools
So are all the schools opened in small towns that nobody has ever heard of before
So are all the schools opened in towns that dont even have a real hospital and force all their graduates to go off site for the entire 3rd and 4th year

Those things would have been UNTHINKABLE 20 years ago and now they are commonplace.

Medical school used to be something you could be proud of -- now it's a vocational tech program and nothing more.

If this trend continues, expect that just like law school, the name of the med school you go to will dictate everything.

No more dermatology matches from low tier schools, just like a white-shoe law firm won't touch a law grad from Dayton even if they are #1 rank in their class with a 4.0 GPA

There's a reckoning coming and it has nothing to do with socialized medicine or politics.

Anybody who attends Walmart Medical School should be embarassed and ashamed of themselves.

Did I miss the ceremony where you became King of the Medical Community?

 

[Lem0nz]

@Matthew9Thirtyfive I’m thoroughly enjoying this thread but how this hasn’t gotten locked is magical. How much gasoline can we throw on this fire?

 

[Goro]

Did I miss the ceremony where you became King of the Medical Community?

You rule the Internet today!!!!!

 

[Lawpy]

@Matthew9Thirtyfive I’m thoroughly enjoying this thread but how this hasn’t gotten locked is magical. How much gasoline can we throw on this fire?

We need to add thousands of residency spots in every specialty to keep up with the growing pace of med schools.

runs away as i get flooded with a huge sea of wows, sads, angrys, okays and dislikes

 

[VincentAdultman]

Lol so glad i needed approval from this guy to have attended/graduated from my trash med school.

lol

Last I checked that “third tier trash med school” had a 5-10 percent acceptance rate.

 

[LondonVibes]

The truth is even out of schools on the no apply list, the vast majority of them become practicing physicians. That’s quite a far cry from the law school fiasco. Even with law schools, you can largely avoid much of the trouble with a solid LSAT and GPA.

 

[LondonVibes]

I’m just a OM-0 but I predict that mainly the Carribean will be hardly hit. Even then, that’s also because of Step going P/F and I wouldn’t expect the Big 4 Carib’s match rate to go below 65% or so for a while.

 

[deleted1103055]

Where’s the empathy, the compassion, for those who might have chosen to pursue a career in medicine despite whatever obstacles they might have faced and maybe had no choice, for whatever reason to attend any school that accepted them?

this was a brilliant observation.

i worked in the 1990s with cardiothoracic surgeons at a state university as a clinical perfusionist. Most of the CT surgeons trained at big league centers: Texas Heart, Duke, Mayo. The most junior CT surgeon trained at a no-name university at the time. This surgeon knew he was from a “lesser“ institution, perhaps what OP would have termed third tier, but no matter, the junior CT surgeon handled himself with humility, grace and steadfast diligence. His clamp to clamp time was the longest, his approach intraoperatively was that of Job, patient, calm, never to get riled up, his composure during an ascending AAA repair case was unlike any other surgeon. Thus it came as a major accomplishment for him and hence the university, that this surgeon performed the first lung transplant in our state. His face was everywhere in the news, his demeanor still steady and unwavering, but he conducted himself with such humility that it spoke volumes. Later he went across town to work as CT chief at the VA Hospital, where he helped countless injured and sick vets and eventually retired. All this from a humble man who trained at a no-name university.

it isn't the university that makes the physician but their hunger to excel.

 

[Gastrapathy]

I guess we just ignore the fact that Caribbean med schools were going strong 20 years ago

 

[ohmanwaddup]

I guess we just ignore the fact that Caribbean med schools were going strong 20 years ago

are they still not going strong?

 

[Redpancreas]

I guess we just ignore the fact that Caribbean med schools were going strong 20 years ago

They were...In the last decade or so, DO schools stock has risen and Carribbean has fallen likely due to increased admissions standards at DO schools and more recently the merger. I think on the horizon, we're going to see programs requiring Step 2 CK from IMGs in general. AMGs should have it too but many may get away with not having it.

From my vantage point (haven't bother to dive into the NMRP stuff) I feel like this cycle was competitive but the AMGs who fell ended up displacing IMGs from spots they traditionally held. May be wrong though.

 

[efle]

They were...In the last decade or so, DO schools stock has risen and Carribbean has fallen likely due to increased admissions standards at DO schools and more recently the merger. I think on the horizon, we're going to see programs requiring Step 2 CK from IMGs in general. AMGs should have it too but many may get away with not having it.

From my vantage point (haven't bother to dive into the NMRP stuff) I feel like this cycle was competitive but the AMGs who fell ended up displacing IMGs from spots they traditionally held. May be wrong though.

I cant imagine US students applying with only a Pass on Step 1 and no CK score. Their peers are overwhelmingly going to have scores and that would be a huge red flag/disadvantage.

 

[Redpancreas]

I cant imagine US students applying with only a Pass on Step 1 and no CK score. Their peers are overwhelmingly going to have scores and that would be a huge red flag/disadvantage.

I was thinking uncompetitive programs that would love to have a US MD. Step 2 CK is definitely going to be needed in almost every case and be a big disadvantage not to have. I imagine it's going to be mandatory prior to ranking.

 

[YCAGA]

I just want to thank OP for an extremely entertaining hot take. I think some people are taking this a little too personally, but I am loving every one else who is enjoying the show and grabbing popcorn.

Also, before freaking out at OP, you have to realize that what he is saying about law school is entirely correct and could happen in medicine. The missing piece is that currently 11-12k residency spots are filled by IMG's, so we theoretically have a lot of room to add medical schools before we have entirely flooded the job market with domestic medical graduates. The other thing to realize is that, for now, adding medical students doesn't directly flood the physician job market. Adding residency spots is what floods the attending job market.

Now if we want to put on our tin foil hats, this is the chain of events that I would be worried about:

1. 50 medical schools get added in 10 years, 10,000 more domestic medical students graduate per year
2. With competitive IMG's still applying, domestic match rates fall to the mid 80s
3. BREAKING NEWS on CNN-Bezos-Walmart-DaddyMusk News Network: Thousands of young doctors unemployed!
4. Due to unmatched Americans, there is finally political pressure to dramatically increase residency spots to address a doctor shortage that doesn't exist
5. Physician job market gets flooded
6. ???
7. Bankruptcy

Step 0 is a gross oversupply of mid-levels so they are willing to work for half of their current pay and are even cheaper than physicians. Step 0 has already arrived.

If none of this scares you, just remember that most Western countries pay their physicians at the hourly rate of a US registered nurse, not even an NP or PA, and that is adjusted for cost of living/currency conversions. And no country has any problem attracting medical students. In fact, medicine is by far the most competitive university program in every country in the world (except North Korea because no one knows what goes on there).

 

[Redpancreas]

I just want to thank OP for an extremely entertaining hot take. I think some people are taking this a little too personally, but I am loving every one else who is enjoying the show and grabbing popcorn.

Also, before freaking out at OP, you have to realize that what he is saying about law school is entirely correct and could happen in medicine. The missing piece is that currently 11-12k residency spots are filled by IMG's, so we theoretically have a lot of room to add medical schools before we have entirely flooded the job market with domestic medical graduates. The other thing to realize is that, for now, adding medical students doesn't directly flood the physician job market. Adding residency spots is what floods the attending job market.

Now if we want to put on our tin foil hats, this is the chain of events that I would be worried about:

1. 50 medical schools get added in 20 years, 10,000 more domestic medical students graduate per year
2. With competitive IMG's still applying, domestic match rates fall to the mid 80s
3. BREAKING NEWS on CNN-Bezos-Walmart-DaddyMusk News Network: Thousands of young doctors unemployed!
4. Due to unmatched Americans, there is finally political pressure to dramatically increase residency spots to address a doctor shortage that doesn't exist
5. Physician job market gets flooded
6. ???
7. Bankruptcy

Step 0 is a gross oversupply of mid-levels so they are willing to work for half of their current pay and are even cheaper than physicians. Step 0 has already arrived.

If none of this scares you, just remember that most Western countries pay their physicians at the hourly rate of a US registered nurse, not even an NP or PA, and that is adjusted for cost of living/currency conversions. And no country has any problem attracting medical students. In fact, medicine is by far the most competitive university program in every country in the world (except North Korea because no one knows what goes on there).

Pretty thoughtful analysis. I agree that it's a hot take, but thought-provoking (username checks out) nonetheless. I think what will happen though is that with P/F Step 1, virtual interviews, the US medical students will push out the IMGs. I believe, but don't have the evidence or birds-eye view to confirm it, that US MDs matched where traditionally IMGs relied on.

I think there's a lose-lose here. Expand residency spots and we push out midlevels but create an #oversupply. If we don't expand, NPs/PAs will and #encroachment!

 

[ohmanwaddup]

I just want to thank OP for an extremely entertaining hot take. I think some people are taking this a little too personally, but I am loving every one else who is enjoying the show and grabbing popcorn.

Also, before freaking out at OP, you have to realize that what he is saying about law school is entirely correct and could happen in medicine. The missing piece is that currently 11-12k residency spots are filled by IMG's, so we theoretically have a lot of room to add medical schools before we have entirely flooded the job market with domestic medical graduates. The other thing to realize is that, for now, adding medical students doesn't directly flood the physician job market. Adding residency spots is what floods the attending job market.

Now if we want to put on our tin foil hats, this is the chain of events that I would be worried about:

1. 50 medical schools get added in 20 years, 10,000 more domestic medical students graduate per year
2. With competitive IMG's still applying, domestic match rates fall to the mid 80s
3. BREAKING NEWS on CNN-Bezos-Walmart-DaddyMusk News Network: Thousands of young doctors unemployed!
4. Due to unmatched Americans, there is finally political pressure to dramatically increase residency spots to address a doctor shortage that doesn't exist
5. Physician job market gets flooded
6. ???
7. Bankruptcy

Step 0 is a gross oversupply of mid-levels so they are willing to work for half of their current pay and are even cheaper than physicians. Step 0 has already arrived.

If none of this scares you, just remember that most Western countries pay their physicians at the hourly rate of a US registered nurse, not even an NP or PA, and that is adjusted for cost of living/currency conversions. And no country has any problem attracting medical students. In fact, medicine is by far the most competitive university program in every country in the world (except North Korea because no one knows what goes on there).

I'm surprised i've never thought of this, but what are nurses paid in countries with some form of socialized medicine? The mantra I always here is that nurses are not paid enough, and I cant imagine their union would go along with a decrease of wages.

Just seems unlikely that hospitals would be able to pull off paying Docs and nurses the same amount, or even within 25k of each other

 

[YCAGA]

I think there's a lose-lose here. Expand residency spots and we push out midlevels but create an #oversupply. If we don't expand, NPs/PAs will and #encroachment!

Hit the nail on the head. The sad thing is is that some MBA probably figured this out decades ago and big healthcare has been lobbying for this outcome ever since. The reason physicians’ jobs are more secure in Europe is 1) they make around as much as our midlevels in terms of salary (lower hourly because docs still work 50-60 hours internationally, whereas I have yet to meet a midlevel who goes over 40-45hrs/week) 2) they actually have respect for medicine/science/experts and other silly stuff like that.

There is actually a funny story from Portugal…a nurse advocating for independent nurse practice/midlevels and a physician had a debate on national TV and the doctor asked the nurse to define hypertension…she couldn’t 🤡 pretty much ended that debate for the Portuguese

 

[hohxil_fr]

I just want to thank OP for an extremely entertaining hot take. I think some people are taking this a little too personally, but I am loving every one else who is enjoying the show and grabbing popcorn.

Also, before freaking out at OP, you have to realize that what he is saying about law school is entirely correct and could happen in medicine. The missing piece is that currently 11-12k residency spots are filled by IMG's, so we theoretically have a lot of room to add medical schools before we have entirely flooded the job market with domestic medical graduates. The other thing to realize is that, for now, adding medical students doesn't directly flood the physician job market. Adding residency spots is what floods the attending job market.

Now if we want to put on our tin foil hats, this is the chain of events that I would be worried about:

1. 50 medical schools get added in 10 years, 10,000 more domestic medical students graduate per year
2. With competitive IMG's still applying, domestic match rates fall to the mid 80s
3. BREAKING NEWS on CNN-Bezos-Walmart-DaddyMusk News Network: Thousands of young doctors unemployed!
4. Due to unmatched Americans, there is finally political pressure to dramatically increase residency spots to address a doctor shortage that doesn't exist
5. Physician job market gets flooded
6. ???
7. Bankruptcy

Step 0 is a gross oversupply of mid-levels so they are willing to work for half of their current pay and are even cheaper than physicians. Step 0 has already arrived.

If none of this scares you, just remember that most Western countries pay their physicians at the hourly rate of a US registered nurse, not even an NP or PA, and that is adjusted for cost of living/currency conversions. And no country has any problem attracting medical students. In fact, medicine is by far the most competitive university program in every country in the world (except North Korea because no one knows what goes on there).

Seriously, in my home country (I'm an international student), medical schools having been struggling to attract fine students because doctors earn little money, and there's negative sentiment against doctors. As I remember, among all classmates through my K12 education, not a single one I know wants to be a doctor. K12 teachers, on the contrary, are much much more popular and respected.

 

[YCAGA]

I'm surprised i've never thought of this, but what are nurses paid in countries with some form of socialized medicine? The mantra I always here is that nurses are not paid enough, and I cant imagine their union would go along with a decrease of wages.

Just seems unlikely that hospitals would be able to pull off paying Docs and nurses the same amount, or even within 25k of each other

This is a great question! I also didn’t ask myself for a long time. The short answer is that it doctors are making €30-100k/yr…nurses are making a lot less

I will use Germany as an example because I am familiar with it and the salaries are on the higher side internationally. $1.2 USD = €1 for reference. Residents make around €50-60k/Yr and up to €70-80k if their hospital pays overtime and they are working 60hr/week. Attendings make €85-120k/yr based on experience and leadership roles. Private practice can be €150-200k/yr but that is reserved mainly to things thay can be done outpatient and private practice licenses are restricted by the state to a certain number of X speciality per capita. I.e. there are no private practice cardiac surgeons like there are on the US and Berlin has a waiting list for primary care PP. Taxes will be about 35% on the low end to close to 50% if you are making €200k.

Nurses in Germany earn €24-40k depending on experience and leadership. Taxes will be lower but still around 32% on €30k/yr.

Edit: oh also a Chefarzt or Chief doctor can make €275k/yr but low single digit percentage of attendings ever make it to that level.

source: Krankenschwester Gehalt: was verdient eine Krankenschwester?

 

[YCAGA]

Seriously, in my home country (I'm an international student), medical schools having been struggled to attract fine students because doctors earn little money, and there's negative sentiment against doctors. As I remember, among all classmates through my K12 education, not a single one I know wants to be a doctor. K12 teachers, on the contrary, are much much more popular and respected.

Do you mind sharing what country?

 

[ohmanwaddup]

This is a great question! I also didn’t ask myself for a long time. The short answer is that it doctors are making €30-100k/yr…nurses are making a lot less

I will use Germany as an example because I am familiar with it and the salaries are on the higher side internationally. $1.2 USD = €1 for reference. Residents make around €50-60k/Yr and up to €70-80k if their hospital pays overtime and they are working 60hr/week. Attendings make €85-120k/yr based on experience and leadership roles. Private practice can be €150-200k/yr but that is reserved mainly to things thay can be done outpatient and private practice licenses are restricted by the state to a certain number of X speciality per capita. I.e. there are no private practice cardiac surgeons like there are on the US and Berlin has a waiting list for primary care PP. Taxes will be about 35% on the low end to close to 50% if you are making €200k.

Nurses in Germany earn €24-40k depending on experience and leadership. Taxes will be lower but still around 32% on €30k/yr.

Edit: oh also a Chefarzt or Chief doctor can make €275k/yr but low single digit percentage of attendings ever make it to that level.

source: Krankenschwester Gehalt: was verdient eine Krankenschwester?

Ironically it seems like it may be the nursing lobbies that save us? can't imagine they would be ok with 36 grand a year

 

[hohxil_fr]

Do you mind sharing what country?

It's in Asia. If you look at surveys like "the most respected professions in the world" you'll find some countries have low respect to medical doctors -- yes among those ones. If someone from America visit these Asian countries, they'll be shocked how disrespectfully they'll be treated. I can tell you I forwent a seat at one of the world's top medical school when I graduated from college. Seriously not a lot of students want to be a doctor.

 

[efle]

Hot take: there wouldnt be that much brain drain to other fields if docs all made 200k. Theres plenty of bright folks in science professor positions, engineering, compsci making that and less. Youd still be rejecting a lot of med school applicants every year who would've been fine doctors.

It would radically change which residencies were competitive though. I remember abroad they thought it was really funny that derm was hypercompetitive over here because it's not popular at all there.

 

[sslarso1]

Tell the Admissions of Directors of the Non Third Tier Trash Medical Schools, to change their metrics for evaluating applicants. Maybe if they had a little more IQ points they would stop using Direct Metrics to automatically screen out applicants, and actually extend interviews to a more diverse pool of applicants. The Third Tier Trash Medical Schools give students who are automatically screened out a chance to enter the Medical Profession, and as such they want to make a profit for this opportunity.

 

[sslarso1]

Tell the Admissions of Directors of the Non Third Tier Trash Medical Schools, to change their metrics for evaluating applicants. Maybe if they had a little more IQ points they would stop using Direct Metrics to automatically screen out applicants, and actually extend interviews to a more diverse pool of applicants. The Third Tier Trash Medical Schools give students who are automatically screened out a chance to enter the Medical Profession, and as such they want to make a profit for this opportunity.

 

[YCAGA]

It's in Asia. If you look at surveys like "the most respected professions in the world" you'll find some countries have low respect to medical doctors -- yes among those ones. If someone from America visit these Asian countries, they'll be shocked how disrespectfully they'll be treated. I can tell you I forwent a seat at one of the world's top medical school when I graduated from college. Seriously not a lot of students want to be a doctor.

Gotcha. that sucks. My knowledge is pretty much limited to US, EU, and Latin America, so that’s depressing to learn. So are you saying medicine doesn’t have the highest entrance exam/GPA requirement in your home country? Because that’s definitely not the case in Europe, LA, or the Indian subcontinent.

 

[hohxil_fr]

Hot take: there wouldnt be that much brain drain to other fields if docs all made 200k. Theres plenty of bright folks in science professor positions, engineering, compsci making that and less. Youd still be rejecting a lot of med school applicants every year who would've been fine doctors.

It would radically change which residencies were competitive though. I remember abroad they thought it was really funny that derm was hypercompetitive over here because it's not popular at all there.

I can attest the funny derm thing. It's used to be the quacks' field in my home country. I remember they posted their ads all over the utility poles when I was a pupil, claiming they had the secret formula for all skin diseases.

 

[YCAGA]

Ironically it seems like it may be the nursing lobbies that save us? can't imagine they would be ok with 36 grand a year

Unfortunately those are the union rates, the private hospitals pay even lower in Germany. Part of the reason for the low pay is that it would be weird for a nurse to get paid as much as a resident who is a physician (duh haha). Residency is more of a job in Germany not indentured servitude like here, and there are more residency spots than applicants, so that means they can’t get away with the salaries they pay US residents.

Resident salary is actually an interesting aspect of Europe. Residents make as much or more in Germany, Scandinavia, Switzerland, etc than American residents, it’s just the attending salaries that are much lower (on average/median).

 

[Lem0nz]

This is a great question! I also didn’t ask myself for a long time. The short answer is that it doctors are making €30-100k/yr…nurses are making a lot less

I will use Germany as an example because I am familiar with it and the salaries are on the higher side internationally. $1.2 USD = €1 for reference. Residents make around €50-60k/Yr and up to €70-80k if their hospital pays overtime and they are working 60hr/week. Attendings make €85-120k/yr based on experience and leadership roles. Private practice can be €150-200k/yr but that is reserved mainly to things thay can be done outpatient and private practice licenses are restricted by the state to a certain number of X speciality per capita. I.e. there are no private practice cardiac surgeons like there are on the US and Berlin has a waiting list for primary care PP. Taxes will be about 35% on the low end to close to 50% if you are making €200k.

Nurses in Germany earn €24-40k depending on experience and leadership. Taxes will be lower but still around 32% on €30k/yr.

Edit: oh also a Chefarzt or Chief doctor can make €275k/yr but low single digit percentage of attendings ever make it to that level.

source: Krankenschwester Gehalt: was verdient eine Krankenschwester?

To be fair - taxes and government services extremely relevant to this discussion and comparison. Taxes are sky high but what is provided from taxes is also amazing comparatively to the US if I recall.

 

[hohxil_fr]

Gotcha. that sucks. My knowledge is pretty much limited to US, EU, and Latin America, so that’s depressing to learn. So are you saying medicine doesn’t have the highest entrance exam/GPA requirement in your home country? Because that’s definitely not the case in Europe, LA, or the Indian subcontinent.

Pretty much the thing. Engineering and finance are the most competitive fields. I was a bio major in college. Bio is a mid-tier major in terms of entrance exam and other merit metrics. Medicine, agriculture, environmental sciences are the lowest when I attended the college (there are two paths in medicine in my home country: either direct admission after high school or a US-style 4+4 path). As a bio major student, we will have guaranteed seats in medical school after my college graduation. Among about 30-40 of my bio major classmates, maybe 3 took that seats. All top GPA students came to the US to do PhD, or transfer to CS and become engineers in the Bay Area.

 

[YCAGA]

To be fair - taxes and government services extremely relevant to this discussion and comparison. Taxes are sky high but what is provided from taxes is also amazing comparatively to the US if I recall.

In the salary range of physicians over there, I agree. But an FM doctor making $250k in Florida or Tennessee is going to come out ahead even though they will pay for their kids’ college, family health insurance, etc out of pocket instead of in taxes. Part of the reason their taxes seem to go so far is wages are lower across the entire economy. So it costs less to run a big bureaucracy and supply a lot of social benefits when $60k is a very respectable salary for a single person in Germany, when that is nothing to write home about in the US.

 

[Lem0nz]

In the salary range of physicians over there, I agree. But an FM doctor making $250k in Florida or Tennessee is going to come out ahead even though they will pay for their kids’ college, family health insurance, etc out of pocket instead of in taxes. Part of the reason their taxes seem to go so far is wages are lower across the entire economy. So it costs less to run a big bureaucracy and supply a lot of social benefits when $60k is a very respectable salary for a single person in Germany, when that is nothing to write home about in the US.

Right. But this adds a ton more context - not necessarily to the physician side, but to the nurse side.

 

[hohxil_fr]

Hot take: there wouldnt be that much brain drain to other fields if docs all made 200k. Theres plenty of bright folks in science professor positions, engineering, compsci making that and less. Youd still be rejecting a lot of med school applicants every year who would've been fine doctors.

It would radically change which residencies were competitive though. I remember abroad they thought it was really funny that derm was hypercompetitive over here because it's not popular at all there.

There're reasons why we see a lot of international students come to the US to do PhD and post-doc. Working as a university professor in some countries is very lucrative, conformable, and respected.

 

[NY_Med]

I just want to thank OP for an extremely entertaining hot take. I think some people are taking this a little too personally, but I am loving every one else who is enjoying the show and grabbing popcorn.

Also, before freaking out at OP, you have to realize that what he is saying about law school is entirely correct and could happen in medicine. The missing piece is that currently 11-12k residency spots are filled by IMG's, so we theoretically have a lot of room to add medical schools before we have entirely flooded the job market with domestic medical graduates. The other thing to realize is that, for now, adding medical students doesn't directly flood the physician job market. Adding residency spots is what floods the attending job market.

Now if we want to put on our tin foil hats, this is the chain of events that I would be worried about:

1. 50 medical schools get added in 10 years, 10,000 more domestic medical students graduate per year
2. With competitive IMG's still applying, domestic match rates fall to the mid 80s
3. BREAKING NEWS on CNN-Bezos-Walmart-DaddyMusk News Network: Thousands of young doctors unemployed!
4. Due to unmatched Americans, there is finally political pressure to dramatically increase residency spots to address a doctor shortage that doesn't exist
5. Physician job market gets flooded
6. ???
7. Bankruptcy

Step 0 is a gross oversupply of mid-levels so they are willing to work for half of their current pay and are even cheaper than physicians. Step 0 has already arrived.

If none of this scares you, just remember that most Western countries pay their physicians at the hourly rate of a US registered nurse, not even an NP or PA, and that is adjusted for cost of living/currency conversions. And no country has any problem attracting medical students. In fact, medicine is by far the most competitive university program in every country in the world (except North Korea because no one knows what goes on there).

To be fair, in most other countries medical students also don't get put in crippling debt to get their education like in the US. I wouldn't mind getting paid less if I didn't have 300k+ in loans I would have to pay back. So personally, I think the US would have trouble attracting students if they didn't reform medical school costs.

 

[YCAGA]

To be fair, in most other countries medical students also don't get put in crippling debt to get their education like in the US. I wouldn't mind getting paid less if I didn't have 300k+ in loans I would have to pay back. So personally, I think the US would have trouble attracting students if they didn't reform medical school costs.

The debt burden is a big difference and important to acknowledge. But I disagree that medical schools would have any trouble attracting students if physician salaries were slashed but tuition costs remained high. Some applicants would deterred from medicine, but there is such a surplus of qualified applicants compared to domestic medical school spots that I don’t think there would be issues attracting students.

For example, according to the medscape survey, which lowballs salary, primary care average is about $250k and speciality average is about $350k. If those got cut to $200k and $250k, medicine would still be by far the highest paying “mainstream” career with a set path. Law, finance, business, and tech don’t pay that much on average, not even close. There are of course a lot of jobs within those fields that pay that much, but there are approx. 1 million physicians in the US so you have to keep the scope of the professions in mind. Also, to get pay in those fields comparable to the hypothetically reduced salary numbers, it is very competitive and you have to go to a top school (usually). Outside of top cities, physicians aren’t competing for jobs like people compete for a job at Google or a big law firm in NYC.

Finally, medical school debt in this country is heavily weighted towards $0 debt and <$200k in debt as the most common debt burdens. This is because medical students overwhelmingly come from families in the top 5% and top 20% family income.

Source for debt Debt levels of recent med school grads - Infogram

Take aways: This includes premed debt...26% of medical students have NO debt from premed or medical school, another 42% have less than <$200k. So for many medical students, medicine would not be financial suicide even if salaries were cut by 30-50%.

 

[Redpancreas]

Hit the nail on the head. The sad thing is is that some MBA probably figured this out decades ago and big healthcare has been lobbying for this outcome ever since. The reason physicians’ jobs are more secure in Europe is 1) they make around as much as our midlevels in terms of salary (lower hourly because docs still work 50-60 hours internationally, whereas I have yet to meet a midlevel who goes over 40-45hrs/week) 2) they actually have respect for medicine/science/experts and other silly stuff like that.

There is actually a funny story from Portugal…a nurse advocating for independent nurse practice/midlevels and a physician had a debate on national TV and the doctor asked the nurse to define hypertension…she couldn’t 🤡 pretty much ended that debate for the Portuguese

I've written about it in so many places, but the American system is messed up in so many ways. The training has excess time (undergrad, some of medical school). If you're a fan of a well-rounded, liberal arts, & general science education get that done in high school (or allow us to sign off on it). I went to a fairly ambitious high school and graduated with the equivalent of 6 college courses in world lit, world history, calc, philosophy, biology, and chemistry. Students can do the effect of preclerkship courses after that and take a knowledge based assessment (USMLE Step 1) prior to getting into medical school which should really start with learning in the hospital. Then we're not taking out 4 years of student loans and losing so many years related to our international colleagues or even peers who choose other fields. If we could start at 24 as generalists and 28 as specialists, then I think a starting salary of 120K starts to look more palatable. If you say that's ridiculous and doctors need to look older, realize that the first 2 years of college are spent relearning things we already learnt (or should have learnt) in high school. For many, the next 2 years are spent in advanced level science courses that aren't even relevant or would be taught in med school anyways. The first two years of medical school could be condensed into one. That right there gets rid of 5 years of "training". What will we do with 5 years? We can add them to residency training or let physicians start practicing earlier less saddled with age and debt.

 

[YCAGA]

To be fair, in most other countries medical students also don't get put in crippling debt to get their education like in the US. I wouldn't mind getting paid less if I didn't have 300k+ in loans I would have to pay back. So personally, I think the US would have trouble attracting students if they didn't reform medical school costs.

Oh another thing you would probably still see is what I will call the "ortho phenomenon." Let's say specialty salaries were cut to a $250k average but ortho "only" got cut to $450k. You would have a lot of people applying to medical school with the plan of doing ortho, even if statistically they are much more likely to end up in general IM. Add in a few other specialties like nrsg, derm, and interventional cards that retain high compensation and you have enough carrots to attract the people who are more motivated by money than the average applicant. You see this phenomenon in law and computer science all the time. Many students at mediocre law schools and CS programs have the goal of working for a FAANG company or starting at a big law firm making $180k at 22 years old. Everyone thinks they will be above average in their field.

 

[Redpancreas]

The debt burden is a big difference and important to acknowledge. But I disagree that medical schools would have any trouble attracting students if physician salaries were slashed but tuition costs remained high. Some applicants would deterred from medicine, but there is such a surplus of qualified applicants compared to domestic medical school spots that I don’t think there would be issues attracting students.

For example, according to the medscape survey, which lowballs salary, primary care average is about $250k and speciality average is about $350k. If those got cut to $200k and $250k, medicine would still be by far the highest paying “mainstream” career with a set path. Law, finance, business, and tech don’t pay that much on average, not even close. There are of course a lot of jobs within those fields that pay that much, but there are approx. 1 million physicians in the US so you have to keep the scope of the professions in mind. Also, to get pay in those fields comparable to the hypothetically reduced salary numbers, it is very competitive and you have to go to a top school (usually). Outside of top cities, physicians aren’t competing for jobs like people compete for a job at Google or a big law firm in NYC.

Finally, medical school debt in this country is heavily weighted towards $0 debt and <$200k in debt as the most common debt burdens. This is because medical students overwhelmingly come from families in the top 5% and top 20% family income.

Source for debt Debt levels of recent med school grads - Infogram

View attachment 336918


Take aways: This includes premed debt...26% of medical students have NO debt from premed or medical school, another 42% have less than <$200k. So for many medical students, medicine would not be financial suicide even if salaries were cut by 30-50%.

I completely agree with this. The kicker is that do you think those with <200K in debt (64.6%) or <100K in debt (38.4%) or no debt (26.7%) would choose medicine if salaries went to midlevel level like in other countries (let's just say 120K?). Absolutely not. Most students with that low debt load have medical school paid for by their parents barring scholarships. Would those kids/parents shoot for medicine over other STEM/law/business fields if the salaries for physicians was 120K (similar to midlevels with maybe a small boost). I think parents would pocket their child's medical schools fees/subsidies and try another field that didn't make them start earning when they were 30. Medicine is full of (including myself) students from upper middle class incomes.

 

[alm414]

Law, finance, business, and tech don’t pay that much on average, not even close.

To be fair, (maybe law? I don't actually know anyone in law), finance, business, and tech don't require 7-12 years after college before you start getting paid well to work in your field.

 

[efle]

To be fair, (maybe law? I don't actually know anyone in law), finance, business, and tech don't require 7-12 years after college before you start getting paid well to work in your field.

The well paid big names in law, consulting, finance etc do work you crazy hard throughout your initial years too though. "Up or out" is a big part of their game. You get paid more than a resident in your 20s but many people burn out and leave, with no 500k light at the end of the tunnel like surgical subspecialty trainees are essentially guaranteed. Grass always greener, no free lunch for anybody

Plus the salary data from the brand names isn't as impressive as I expected. Places like Yale law and Wharton business are looking at high 100s coming out typically. Someone who picks medicine for the money and goes into ROAD isn't making as much of a mistake as SDN will lead you to believe. If you're trying to fatFIRE in your 40s-50s that's still ol' reliable

 

[YCAGA]

The well paid big names in law, consulting, finance etc do work you crazy hard throughout your initial years too though. "Up or out" is a big part of their game. You get paid more than a resident in your 20s but many people burn out and leave, with no 500k light at the end of the tunnel like surgical subspecialty trainees are essentially guaranteed. Grass always greener, no free lunch for anybody

Plus the salary data from the brand names isn't as impressive as I expected. Places like Yale law and Wharton business are looking at high 100s coming out typically. Someone who picks medicine for the money and goes into ROAD isn't making as much of a mistake as SDN will lead you to believe. If you're trying to fatFIRE in your 40s-50s that's still ol' reliable

Can I just copy and paste this when this discussion comes up in the future? Beautifully said.

 

[YCAGA]

To be fair, (maybe law? I don't actually know anyone in law), finance, business, and tech don't require 7-12 years after college before you start getting paid well to work in your field.

Many of my friends went to work at “top” finance companies out of undergrad. They made six-figures straight out, think $100-200k/yr depending on prestige, but 80hrs/week was a light week and 90-100hrs was typical. There are no work hour restrictions in the corporate world lol. The stakes in terms of human life are obviously much smaller, but it’s entirely possible to make a five or six figure mistake as a 20 something in big law or finance or tech, so there still is a lot of pressure.

Also the attrition in these jobs is insane, like @elfe astutely pointed out. You have to think of the corporate world as a pyramid scheme. Yes, some software engineers in FAANG/unicorns make $500-600k in SF and Seattle, but there are only so many middle managers a company can support. Compare that to medicine where, although there is a strict hierarchy, >90% of M1’s eventually become an attending.

 

[Spectreman]

@Matthew9Thirtyfive I’m thoroughly enjoying this thread but how this hasn’t gotten locked is magical. How much gasoline can we throw on this fire?

Think I know where the gas shortage is actually coming from lol. We throwing the whole supply on this thread.

 

[Socrates25]

There's so much anguish about NPs but in a private practice clinic based setting I don't worry about them too much because NPs are strictly shiftwork 9-5, "how soon can I go home" employees and that kind of "not my problem, I'm going home" attitude comes across to patients very often.

Every week I have new patients calling my clinic asking my staff if I'm a "real doctor" because we have NP clinics at the county health department who see patients for FREE.

Think about that for a moment -- patients can go to a FREE clinic right down the street and see an NP or they can pay $100 a visit to see me. Trust me I'm plenty busy and about to hire another doctor because I can't handle the volume on my own anymore.

Even in the states where NPs have "independence" they aren't very much of a threat to outpatient practice IF you show them the true value of an MD and build up strong relationships with your patient base. If you're a piker who walks at the bell, then yes you are going to have a problem with NPs, or anybody else for that matter, taking patients from you.

Inpatient/hospital based doctors have a lot more to worry about from NPs than I do despite the fact that I work in an "NP independence" state.

 

[Redpancreas]

Many of my friends went to work at “top” finance companies out of undergrad. They made six-figures straight out, think $100-200k/yr depending on prestige, but 80hrs/week was a light week and 90-100hrs was typical. There are no work hour restrictions in the corporate world lol. The stakes in terms of human life are obviously much smaller, but it’s entirely possible to make a five or six figure mistake as a 20 something in big law or finance or tech, so there still is a lot of pressure.

Also the attrition in these jobs is insane, like @elfe astutely pointed out. You have to think of the corporate world as a pyramid scheme. Yes, some software engineers in FAANG/unicorns make $500-600k in SF and Seattle, but there are only so many middle managers a company can support. Compare that to medicine where, although there is a strict hierarchy, >90% of M1’s eventually become an attending.

Meh, maybe we're spoilt then.

 

[Redpancreas]

There's so much anguish about NPs but in a private practice clinic based setting I don't worry about them too much because NPs are strictly shiftwork 9-5, "how soon can I go home" employees and that kind of "not my problem, I'm going home" attitude comes across to patients very often.

Every week I have new patients calling my clinic asking my staff if I'm a "real doctor" because we have NP clinics at the county health department who see patients for FREE.

Think about that for a moment -- patients can go to a FREE clinic right down the street and see an NP or they can pay $100 a visit to see me. Trust me I'm plenty busy and about to hire another doctor because I can't handle the volume on my own anymore.

Even in the states where NPs have "independence" they aren't very much of a threat to outpatient practice IF you show them the true value of an MD and build up strong relationships with your patient base. If you're a piker who walks at the bell, then yes you are going to have a problem with NPs, or anybody else for that matter, taking patients from you.

Inpatient/hospital based doctors have a lot more to worry about from NPs than I do despite the fact that I work in an "NP independence" state.

To the bolded, hospitals don't care about the extra stuff residents/attendings do. There are no metrics that track dedication. Overall, as a whole, I agree in your setting NPs may be less of a concern.

 

[Steve_Zissou]

There's so much anguish about NPs but in a private practice clinic based setting I don't worry about them too much because NPs are strictly shiftwork 9-5, "how soon can I go home" employees and that kind of "not my problem, I'm going home" attitude comes across to patients very often.

Every week I have new patients calling my clinic asking my staff if I'm a "real doctor" because we have NP clinics at the county health department who see patients for FREE.

Think about that for a moment -- patients can go to a FREE clinic right down the street and see an NP or they can pay $100 a visit to see me. Trust me I'm plenty busy and about to hire another doctor because I can't handle the volume on my own anymore.

Even in the states where NPs have "independence" they aren't very much of a threat to outpatient practice IF you show them the true value of an MD and build up strong relationships with your patient base. If you're a piker who walks at the bell, then yes you are going to have a problem with NPs, or anybody else for that matter, taking patients from you.

Inpatient/hospital based doctors have a lot more to worry about from NPs than I do despite the fact that I work in an "NP independence" state.

That’s a very long winded way to say “I got mine, I don’t care about anyone else.”

 

[YCAGA]

There's so much anguish about NPs but in a private practice clinic based setting I don't worry about them too much because NPs are strictly shiftwork 9-5, "how soon can I go home" employees and that kind of "not my problem, I'm going home" attitude comes across to patients very often.

Every week I have new patients calling my clinic asking my staff if I'm a "real doctor" because we have NP clinics at the county health department who see patients for FREE.

Think about that for a moment -- patients can go to a FREE clinic right down the street and see an NP or they can pay $100 a visit to see me. Trust me I'm plenty busy and about to hire another doctor because I can't handle the volume on my own anymore.

Even in the states where NPs have "independence" they aren't very much of a threat to outpatient practice IF you show them the true value of an MD and build up strong relationships with your patient base. If you're a piker who walks at the bell, then yes you are going to have a problem with NPs, or anybody else for that matter, taking patients from you.

Inpatient/hospital based doctors have a lot more to worry about from NPs than I do despite the fact that I work in an "NP independence" state.

The main worry with NP’s shouldn’t be replacing a doctor one for one. I have said this a thousand times but it is worth repeating, especially now that people are paying attention to what has happened in EM.

The worry with midlevels should be that one midlevel doing all the “easy” cases can end up replacing an entire physician worth of work. For example, say 25% of a community general surgery practice is “easy” hernia repairs and there are 4 surgeons in the practice/hospital. If you get an NP to do just hernias, they can replace one of the physicians for $150k/yr instead of $400k like the surgeon. The other 3 surgeons would actually get a pay bump because they now can replace the hernia 25% of their practice with higher billing stuff from the 4th surgeon who just got laid off. They also will get a piece of the midlevel supervision billing after the hospital takes their (size-able) cut.

This exact same concept can be applied to ANY field in medicine, from outpatient primary care to tertiary center CT surgery and neurosurgery.

So I wouldn’t feel too confident by the fact that one NP can’t replace my entire practice as a physician. All they have to do is replace 25% of the patients for 4 physicians, and now one of is out of a job, while the other 3 physicians get a pay bump. Start training midlevels in “residencies” and they will start saying they can do 30-40% of a physicians job. Even doing 10% of a physicians job is scary if you realize that could lead to a 10% physician unemployment rate, which is insane given the time and money put into this profession.

Now, you might say, a midlevel doing hernias can’t be that good at it. And that we all know that even “easy” operations like hernia repairs have great data saying experience significantly improves outcomes. Cool, but we aren’t making the decisions on this, so I would not fall back on that. Same with “tHeY wiLl GeT suEd!!!” Cool. Just bump up malpractice insurance some and lobby heavily for more tort reform in heavy litigation states. If midlevels were seriously costing hospitals so much money from lawsuits, they wouldn’t be so prolific already. Midlevels don’t have to be as good as physicians at the “easy” stuff, they just have to be good enough. They also don’t have to catch as many land mines hidden in easy cases as physicians, they just have to catch enough hidden disaster to not overcome the huge cost savings from their lower salaries.

And all of this is with 0 midlevel independence. That’s not even the major problem here. Another thing is the insane oversupply of midlevels predicted in the next 10 years, which we have already started to see. If you think midlevels are cheap now, wait until there is a 5,000 surplus of surgical NP/PA’s in the Northeast alone.

Finally, EM is an example of what I am talking about that has already started to play out. A significant number of ED visits can be muddled through by a midlevel. Whether we say that is 50% or 20% of visits, that argument only is relevant when we try to figure out how many physicians will get replaced by midlevels.

The possible solutions are:
1. Stop midlevel expansion with legislation (lolol we are more likely to invade Canada than this happening)
2. Physicians will have to take a big pay cut to remain competitive with midlevels. Physicians will earn more than midlevels because physicians (hopefully) will always be able to do more and can supervise more people safely.
3. Find a field with Hyper-specialization, high technical complexity, and extreme acuity so a huge chunk of your hours can’t be replaced by a midlevel. Think congenital cardiac surgery, not general cards. Midlevels can and already do do caths, they aren’t going to be doing open heart surgery on a 2-day old even in a worst case scenario. But fields like that make up like 0.1% of physicians so…buckle up buckaroos.

I think a combination of 2 and 3 are inevitable. It’s just a matter of timescale and magnitude of salary/job market changes.

Thanks for coming to my midlevel TED talk.