The Washington Post has a story today about the fact that medical providers are now required to make test results accessible to patients as soon as they're available (generally via phone or online portal). This is a very popular rule, but it can cause problems if the results are (or seem) scary and it takes days before you can talk to your doctor about them.
All true. But why does it take days for doctors to call and let you know what the tests mean? And why is it all but impossible to call a doctor yourself?
I'm here to tell you the answer. But first, a reminder that here in the US we spend more—way more—on health care than any other rich country in the world:
And what do we get for all this money? Not a lot of doctors:
This explains why doctors don't get back to us quickly: we don't have very many and they're overworked. We're nearly 30% below the average of rich countries. But it's actually even worse than that. Check this out:
Among primary care physicians, the US is dead last by a considerable margin. We are more than 70% lower than the average of rich countries. And believe it or not, it's even worse than that:
Not only do we have a minuscule number of primary care doctors, but the number has been essentially flat for more than 20 years while other countries have been steadily adding primary care doctors.
So what do we spend all our money on? The answer is:
- We pay doctors and nurses more than other countries.
- We pay specialists fantastically more than other countries.
- We pay more for pharmaceuticals than other countries.
- We pay more for machines than other countries.
- We pay a cut to insurance companies.
As a result of all this we can't afford to have a lot of doctors—and the ones we do have all want to become specialists because the pay isn't just better, it's massively better.
And that's why it takes a long time for your doctor to call you back.
POSTSCRIPT: In case you're wondering, even with the enormous salaries we pay specialists we're below average on per capita numbers even there. But only by about 4%, which means that specialists don't really seem to have a workload excuse for not calling back quickly.
Give or take a bit, primary care physicians in the US see 20 patients per day while specialists see 2.5 patients per day. Specialists spend a lot of their time doing procedures, of course, but with a patient workload like that you'd still think they could be a little more available. I'm not sure what their problem is.
Reminds me of some videos by "Dr. Glaucomflecken" (who is an ophthalmologist and comedian), such as ...
https://www.youtube.com/watch?v=awVKh5RsGCg
Dr Hibbert: “Mr Simpson, you only have 24 hours to live. 22 actually. Sorry about the wait.”
I don’t know… my doctor has always responded same day to blood test results. And they weren’t even all that important.
Medical boards set the number of slots available at medical schools. And they really don't want too much competition.
In the schools, the students compete for slots for specialities. And what smart person would want to be a GP in the US???
Correct on both items. And based on my undergraduate experience as a PhD-track biology major competing with pre-med students, very few of them appeared to be especially bright or altruistic. Most of them admittedly just wanted a lucrative profession. I don't know what fraction of them became MDs, but presumably a substantial fraction of them.
The medical students are also a brutally competitive bunch of assholes. Here (University of Minnesota), they had to create a separate intramural basketball program just for them, because no one else would play them. Even the law students.
At 8 p.m. Friday night, I got my test results and diagnosis from Labcorp:
"R/O melanoma."
I appreciate having the quick test results, and I know I'll have to wait until Monday for the official word, but Google tells me that R/O probably means "rule out." Would have been nice to have a doctor to explain that in a timely fashion, though.
"Give or take a bit, primary care physicians in the US see 20 patients per day while specialists see 2.5 patients per day."
I see nothing but specialists, and they are definitely seeing more than 2.5 patients a day *when they see patients*. The difference is that some of their days are spent in surgery or procedures, which you note, but I very much doubt they are even *averaging* as few as 2.5 a day. They wouldn't be building a clientele on which to make all that money.
So I call bullshit on that stat. I also get very quick turnaround on tests and while there are many times when my specialist isn't available for months, I just ask to see their PA, which gets me great care and the knowledge that if something serious is going on, it will get back to the specialist.
It's an average, which means there are specialists taking more than a day on some patients.
The cost of specialist treatment allows them to see relatively few patients.
While you may doubt that the current state of US healthcare could possibly the true....IT IS.
Good post by Kevin as I think that most people are a bit unaware of these facts. They do seem hard to believe, but.....this is what we have chosen.
Most people, including my doctor, think that doctors' salaries are the biggest part of US healthcare cost. 10% though, is a number you see thrown around the internet. When I went looking I found reports from a couple of US government agencies. One put it at 6% and the other 8%.
We don't have enough doctors because we decided back in the 1970s that rising healthcare costs correlated with the number of doctors. We were going to hold down the costs by keeping the supply from growing. That worked well didn't it?
My understanding is that the limiting factor is the availability of residencies and that these are mostly funded by Medicare. Medicare could fund more of them...why don't they?
The biggest driver of increased healthcare costs in the US is the private medical insurance business. It's direct costs are enormous, but it also drives even larger administrative costs by the providers trying to get paid. The Canadian healthcare system is not at all best in the world when it comes to efficiency. However, in 2017 Canadians spent about $550 per capita for healthcare admin costs vs about $2500 per capita in the US.
An article about it:
https://www.americanprogress.org/article/excess-administrative-costs-burden-u-s-health-care-system/
The last time I looked (quite a while ago), it cost $1M to educate a doctor through medical school and residency. Part of that is paid by the student, part by the federal government and the rest by the state. For some reason, states are reluctant to build more expensive medical schools which is why about 25% of new residents are imported from other countries. It’s cheaper to let India pay for our doctors' medical school.
We're not even good at that.
I have a friend who's an American citizen (born here) but he got his medical training in the EU. He's tried multiple times to get certified in the states and each attempt ends when one end or another decides the time limit jas expired before the other has replied with the proper paperwork.
Part of the problem is RBRVS, the Medicare system that was used to set the fee scale 40 years ago. It tries to set reimbursement rates based on some evaluation of resource use so specialists get way overpaid and GP's get way underpaid.
The charts suggest Australia is much more fortunate with regard to what we call "general practitioners", but if so, it's only because we rely so much on recruiting GPs (and nurses) from less developed countries which need their skills much more than we do. For reasons nobody seems capable of explaining, we suffer a chronic shortage of locally-trained doctors even though medicine is the most highly sought-after university placement for high school graduates.
When I was a boy, it was normal for GPs to spend half their day consulting in their surgeries and the other half "doing their rounds" - i.e. making house calls. Good luck finding a GP who does house calls these days.
As a MD PhD trained in a relatively obscure speciality, (medical geneticist) I thought I would provide some data to keep the conversation going and then make a few comments.
Here’s more info than you probably wanted regarding average US physician incomes (data are for 2023):
1. Neurosurgery: $763,908
2. Thoracic surgery: $720,634
3. Orthopedic surgery: $654,815
4. Plastic surgery: $619,812
5. Oral and maxillofacial surgery: $603,623
6. Radiation oncology: $569,170
7. Cardiology: $565,485
8. Vascular surgery: $556,070
9. Radiology: $531,983
10. Urology: $529,140
11. Gastroenterology: $514,208
12. Otolaryngology: $502,543
13. Anesthesiology: $494,522
14. Dermatology: $493,659
15. Oncology: $479,754
16. Ophthalmology: $468,581
17. General surgery: $464,071
18. Colon and rectal surgery: $455,282
19. Pulmonology: $410,905
20. Emergency medicine: $398,990
21. Occupational medicine: $317,610
22. Infectious disease: $314,626
23. Internal medicine: $312,526
24. Pediatric emergency medicine: $309,124
25. Rheumatology: $305,502
26. Family medicine: $300,813
27. Endocrinology: $291,481
28. Geriatrics: $289,201
29. Pediatric gastroenterology: $286,307
30. Preventive medicine: $282,011
31. Child neurology: $279,790
32. Pediatric pulmonology: $276,480
33. Medicine/pediatrics: $273,472
34. Pediatrics: $259,579
35. Pediatric hematology and oncology: $251,483
36. Medical genetics: $244,517
37. Pediatric infectious disease: $236,235
38. Pediatric rheumatology: $233,491
39. Pediatric nephrology: $227,450
40. Pediatric endocrinology: $217,875
Several comments.
It’s not just that the average income of American MDs is higher than physicians in Europe, the UK, and Australia, it’s the enormous differences in salary between some specialists and generalists in the US (e.g., compare neurosurgeons and pediatricians), as the range of incomes between different specialties in the rest of the world is much, much less.
Second, specialists don’t get by with 2.5 patients / day. In 2024, the vast majority of physicians are highly-paid wage slaves who work for the man (e.g., a health care system or a private practice owned by investors) with everyone pressuring doctors to speed up the line by seeing more patients while spending less time with each one. (And you don’t necessarily have their full attention during an in person visit - Does your doctor spend more time talking and interacting with you during a visit or staring at the computer screen while entering data?)
Third, some specialties are at risk because they don’t pay as much as general practice. Take my field, medical genetics, as an example. It’s an extra 3 years of training, yet the average income is $244K, $15K less than general pediatricians and $56K less than family practitioners. Medical students are now graduating with an average of ~$250K of student loans. So it’s hard to convince them (and their partners) that medical genetics is worth it. Consequently, we regularly fail to fill our residency slots, the average age of geneticists is over 60, and wait times to see one of us can exceed 12 months. By way of contrast, Europe and Canada don’t have this manpower shortage, as their medical geneticists are paid better and no one has the student loan burden faced by US med students.
I can’t help noticing that I got to #30 before seeing the word “Preventive.”
Computers* are going to take care of much of that - at least explaining test results - pretty soon.
I'm no techno-utopian, but, like Kevin, see machines taking over more complex tasks going forward.
* AI is gee-whiz terminology; try not to use it.
...And who is going to teach these computers, implement their diagnosis, and take the liability?
As it turns out, we are teaching the computers. One of my research projects is to develop ultra-rapid genome sequencing to diagnose critically ill babies in neonatal intensive care units. We use a machine-learning based software to identify which babies should be sequenced - software that was trained to mimic the decisions that medical geneticists make.
It behaves like a somewhat clever medical student - frequently right, but sometimes spectacularly, 180 degrees, wrong (It's AUC is 0.86, if you're interested).
" AI is gee-whiz terminology; try not to use it."
+1
Not only "gee-whiz", but also too wide meaning.
The right term is "machine learning".
Interpreting results is a hard problem for humans. Doctors get statistical measures from the test, but they have to interpret them for individual patients. Every patient is different, has different attitudes, a different variety of ailments and medications, a different family history and so on. Numbers and statistics only take one so far without the ability to do actual medical reasoning. LLMs can't actually reason since they have no ontological model. They rely on textual descriptions, and textual descriptions are sparse.
So the fields in shortest supply and who have the highest workload get paid the least. What's wrong with this picture?
Its designed for profit margins and taking advantage of the more serious and urgent nature of conditions that require specialist treatment.
Actual healthcare is not the primary concern.
"but with a patient workload like that you'd still think they could be a little more available. I'm not sure what their problem is."
All those golf balls aren't going to hit themselves.
What do doctors know? All you really need is the super secret medbed!
https://www.nytimes.com/2024/07/28/us/politics/far-right-miracle-cure-medbed.html
Miracle cure!
The videos claimed with no evidence that the U.S. military was already in possession of advanced, or possibly even alien, technology that could cure all disease and extend human life. There were said to be at least three types of medbeds already in existence in secret military tunnels.
There really is no way to coexist with these nut jobs.
But...at the end of the article, they guy said he felt better. So there you go.
Remember, doctors spend hours a day dealing with insurance companies. Pre-approval anyone?
Doctors don't. They just have YUGE staffs who do.
And, not infrequently, the doctor still has to step in. At least according to my father (a doctor), my cousin (a doctor), and my nephew (a doctor).
The caption said this is a street in Cairo and all the signs are for doctors,
https://i.redd.it/65rcodshz3fd1.jpeg
It's actually WORSE than that!
In other countries a Doctor works at being a Doctor
In the USA he/she must spend a fair amount of time "working with" Insurance companies
YES - clerical workers will do most of that - but the Doctor still has to do some of it