Talking to your doctor isn’t about medicine

On average, patients get about 11 seconds to explain the reasons for their visit before they are interrupted by their doctors. Also, only one in three doctors provides their patients with adequate opportunity to describe their situation…

In just over one third of the time (36 per cent), patients were able to put their agendas first. But patients who did get the chance to list their ailments were still interrupted seven out of every ten times, on average within 11 seconds of them starting to speak. In this study, patients who were not interrupted completed their opening statements within about six seconds.

Here is the story, here is the underlying research.  Via the excellent Charles Klingman.

Now solve for the telemedicine equilibrium.


frankly, we are pissed and not in the pleasant/british way
the conclusion headline "talking to your doctor is not about medicine"
does not match the data drapes of the study.
the sumbody who did the study forgot define "interruption"
is an interruption, a pertinent question related to the history, an affirmation, or a dismissal of the statement
or empathy.
all these things could be easily quantified in the 112 patient encounters
in the study
but they weren't
why not?
not a good headline for the journey/narrative? whatever they are
calling it this week.
thanks to the sociology dept.
patient centered care depends on getting an accurate diagnosis/treatment in a framework of 3-4 patients an hour.

They do assess whether the doctor understood the patient's agenda, which is probably the most pertinent measure of the nature of the interruptions in this context.

They also cite supporting research evidence that understanding the patient's agenda leads to more efficient communication--this is not about chasing a quixotic goal of "patient-centered care" without regard to realities of medical practice.

I agree that the headline doesn't seem supported by the study. I'm not sure what Tyler is getting at there.

Well, one could assume he wants those commenters at the higher ends of intelligence to solve for the telemedicine equilibrium.

Instead, as is becoming more common, commenters at the lower ends of intelligence keep pointing out that what Prof. Cowen has been recently highlighting (think Margaret Thatcher and the size of government or mice treat sunk costs as real) is less than reliably accurate.

Without even having to waltz Strauss into the discussion.

good point!
ban strauss not straws
we intuit that you like knockknock jokes;
knock knock
patient- I m having chest pain
biology dept- how many seconds are we supposed to wait now
until we are all0wd to say - tell me about the chest pain?

harvard linguist - aren't there a lotta appropriate responses that
that cannot accurately be redefined as interruptions

frankly, not all interjections, questions, sympathi/empathizations exclamations, affirmations, etc qualiy as interruptions.

if you create a meme of interruption and
a metric of 7 seconds without defining clearly
what that metric means you could end up eating another

Yeah, yeah, we get it, it's not your fault the patient died due to an excess of arrogance on the part of his physician. At least you didn't put leeches on him- which would be totally defensible by the way.

sketchy metrics leading to sketchy narratives is what has harmed
a lot of patients

good point!!
but it looks like the narrative journey/study was constructed in such a way
as to produce a headline/meme like on drudge right now
that says d"octors stop listening after 11 seconds" when the study
doesn't support what the headline states.

Righto. It's 8:30AM Saturday and I'm procrastinating starting the wash.

Hillary is so 2016. Now it's Alexandria Ocasio-Cortez, Biden, Sanders. Not as stupid as Hillary, but it's all I got. Alexandria (tell her Einstein parents that's a city in VA) recently told Kansans she would turn Kansas "red." Her little red book was showing. Still smarter than Hillary.

None of my doctors voted for Hillary.

And someone should tell Dick it is also a city in Egypt, named after one of the most famous and successful conquerors in human history, with just a bit more importance and history than the place I was born.

At least her parents did not name her Sasha, the Russian feminine variant of the name derived from Alexander. Probably another strike against her these days, to be honest.

I party like its 2016, the year Hillary lost the election.

Go to Thailand. Doctors will listen to you happily and charge you 1/100th of the American equivalent. They use the same damn machines anyways!

Operator, give me Thailand. T-Y....and so on.

Mexico is closer. The USA Amish use Mexican MD's.

As long as Hillary stays away from Thailand, I'm down for some pad thai and ladyboys.

What about the common refrain "talk to your doctor before starting any exercise program". How many millions has this piece of advice killed?

Exercise, any exercise is almost universally healthy. There may be a few weird corner cases, but even post heart attack survivors do better with regular exercise. In contrast millions will stay sedentary to avoid the additional hassle.

It is a strange refrain. I could understand it if it was meant to protect from lawsuits like "talk to your doctor before taking aspirin a day". But no one owns exercise. Do action movies have to warn you "don't run around unless you talk to your doctor first"?

But then car commercials warn you that even driving down the street at 30 mph is done by a 'professional driver'.

Anyone want a $28 epipen? That's twice what I pay for them. I would sell them at cost, but I want to be compensated for all the trouble I went through in developing an allergy to bee stings.

Are you complaining about a $14 prescription? What price would be acceptable to you?

I pay significantly more for my son’s epipen. It’s not ideal and I’m still happy to pay considering the benefits.

Normally I'd complain since there is only about 2 cents worth of adrenaline in one of them. But if I can sell them for $300 a pop, which is the going rate in the US, I promise not to complain about the $13 deadweight loss imposed by my country's shoddy health delivery system in getting epipens into the hands of black marketeers.

I have a really bad case of Hillary Derangement Syndrome. How much are the pills for that?

You need a Bex and a good lie down. Unfortunately Bex has been banned by do gooders merely because it destroys kidney function. However, my friend Pigdog can get you a similar white powder from Vietnam for a very competitive price. It's even better than Ozzy Bex.

"Agendas"? Patients have agendas when they meet with their doctors? If not about medicine, then why do patients wish to talk to their doctors? One can read this blog post in any number of ways, the most Straussian is that patients (and readers of this blog) don't visit the doctor (and readers don't visit this blog) to learn but to push their own "agendas". The reference to telemedicine, however, throws me off. Does telemedicine (i.e., the patient and doctor not being physically present in the same place at the same time) reduce interruptions by the doctor so the patient can push her agenda? Terri Gross enjoys a reputation as an excellent interviewer. She revealed in an interview of her that she is rarely physically present in the same room with the person she is interviewing. She says she prefers it that way because there are fewer distractions, which makes her a better listener: to be a good interviewer, one has to be a good listener. I can appreciate that because I am not a multi-tasker: for that reason, I prefer telephone conferences - fewer distractions. With medicine, best practices (or is it custom?) requires hands-on, literally (i.e., the doctor must physically put her hands on the patient). That's not easy via telemedicine, and a reason why telemedicine hasn't been widely accepted. Indeed, the law follows the custom: telemedicine is considered the practice of medicine, which means that the doctor must be licensed in the state where the patient is located and that the patient must have a physical exam before the doctor may prescribe medication for the patient. That's not very Straussian, though. An aside (or is it?), Cowen, a well-known speed reader, is a speed responder to questions when he is interviewed. Most people pause to gather their thoughts before responding to a question, but not Cowen. It's as though he has already considered every question any interviewer could ask him. That's his explanation for his speed-reading: he has read so many books on so many subjects that it's rare to read a book that offers anything new; and if it does, he can quickly spot it by scanning. My observation is that the best teachers are also the best listeners. Is Cowen a good listener? Is your doctor a good listener? Is your spouse a good listener? Too many distractions, I suppose.

wont the medical equilibrium for telemedicine depend mostly on how well trained the fella/o is on the other end of the blower. not on the equipment.
the meme zombies will try and use it to expand care and save money
they will probably do it in a way that underrates the limitations of the
medium and that will have some negative consequences that they
will be reluctant to talk about. but it may be good for the goat herders
in rural areas .

===> "We performed a secondary analysis of a random sample of 112 clinical encounters recorded during trials testing the efficacy of shared decision-making tools."

... no way a 112-person 'sample' can be statistically representative of the general population in this doctor/patient study. And it's impossible for this to have been a random sample. You can not draw accurate conclusions about the general population from such very shoddy research on a tiny convenience-sample.

This is absolute 'Junk Social Science'

Hopefully TC is just baiting us with this cr@p, but fear he may well be suckered in by it ... since he routinely posts so much of this type of phony "research".

@clockwork_: "Instead, as is becoming more common, commenters at the lower ends of intelligence keep pointing out that what Prof. Cowen has been recently highlighting ... is less than reliably accurate."

...well, one would expect a high level professional educator would excel at clearly communicating his points/ideas to even a diverse audience.
Why play rhetorical games that require his audience to guess at his meanings ?

'Why play rhetorical games that require his audience to guess at his meanings?'

How new are you here? Prof. Cowen is a true devotee of Strauss, or is a Straussian, or is a leading practitioner of Straussianism.

Basically, it seems to hinge on the art of plausible deniability when discussing anything controversial. Here is a reddit discussion on the topic, actually -

Most of the time, Prof. Cowen's brand of Straussian writing could be more accurately described using this definition of mealy-mouthed - ' avoiding the use of direct and plain language, as from timidity, excessive delicacy, or hypocrisy; inclined to mince words; insincere, devious, or compromising.' This has been particularly notable regarding his writing about Trump in the last couple of years.

If Hillary is for this, then I am against it. Yes, I am supposedly a grown ass man.

msgkings, it's Saturday. Take a day off trolling and go out and get some fresh air.

I took your advice and got some fresh air but I still keep thinking about Hillary and socialism. Is there something wrong with me?

When I go to the doctor I can pretty much say what I want to say within an 11 second spiel - it’s actually quite a long time if you try.

Eleven seconds is plenty long enough to describe something.

Plus, the great majority of visits are for things that doctors have seen hundreds of times.

Funny thing is, they say the people who completed their "opening statements" and were not interrupted were able to do it in 6 seconds. If patients are interrupted within 11 seconds on average but they can complete their opening statements in 6 seconds, is the average patient just staring into Dr. McDreamy's eyes for 5 seconds?

Think harder. The average of those who are NOT interrupted is 6 seconds. If it takes you 6 seconds you won't get interrupted. If it takes you 20 seconds you will.

When doctors have 15 minutes to see patients, I imagine the last thing they want to hear is irrelevant information. Doctors often complain about not having enough time to see patients, so blame corporate medicine if you just. Doctors are just pawns in the scheme.

First, I don't think it is 'corporate' medicine. Many small practices I've been too have docs take 10 minutes or so with patients.

Second, let's say we move from 15 minutes per patient to 30. We have to double the # of doctors since by definition you're talking about cutting productivity in half.

Third, what about health output? Here I things falter on two levels.

A. I think you get more if a doctor sees 4 patients in an hour rather than 2 patients but spends twice as long chatting with them. Most of the time, critical stuff happens in the first few minutes (you need to lose weight, change your insulin, start taking a BP pill) and less important stuff happens in the last 15 minutes. A doc who sees 4 patients in an hour may make 4 critical diagnosis's. A doc who sees 2 patients may make 2 critical ones and at best maybe one or two minor ones (ok maybe you need a pill to help you sleep too)

B. Personal experience I knew an old doctor who had decades of experience as a private oncologist. He spent plenty of time with each patient each visit. You could wait in the exam room forever because he was always backed up. I also have experience with an oncologist who is somewhat younger but has an office running like a machine. He has teams of people work on the patients at each level, taking vitals, taking blood (which an onsite lab tests immediately), nurse practitioner handling medications and then finally doctor consultation.

I hate to say it but I think the 2nd doctor is better in the long run. A doctor who sees 5 patients per hour sees double or triple the patients a slower doctor sees. The value of the doctor is in building up a lifetime of experience treating patients and that includes seeing things that only happen rarely and making subconscious connections between cause and effect. To work well you need a huge amount of experience with a huge number of patients.

The average office visit is a follow-up. New diagnoses are relatively rare (maybe 1 in 10 visits). Further most diagnoses are not terribly important. I diagnose you with influenza, at best I can shave a couple days off the symptoms. I diagnose you with pancreatic cancer, I might buy you a few more months of life.

Longer visits are not about diagnosing more conditions, they are, for primary care, about increasing compliance. Diet, exercise, medication compliance, smoking cessation are all vastly more effective if the doc has time to use all those persuasion skills they teach in med school. Getting a patient to quit smoking by finding a motivation that works for them (e.g. children, money, scare of future illness) is worth basically everything else you will ever do for him. But that is idiosyncratic and requires time to build a relationship.

Even if we doubled the amount of primary care docs and the time they spent with patients, the US would STILL be below the OECD average for time spent with patients.

Why do we do things this way? Because that is how we pay docs. Long ago docs visited the number of patients they thought reasonable for the length they thought reasonable and billed first the patient and then later the insurance companies what they could pay. HMOs arose and rewarded docs with flat fees per visit far lower than average. This made sense because HMOs tried to skim the healthy patients; they should be cheaper. Now Medicare, Medicaid, and everyone else is unwilling to pay higher reimbursements for fear of breaking the bank. The AMA has made this worse by not keeping the supply of docs matched to the increases in population, population aging, survival rates, and increased depth of care.

Correctly diagnosing arcane things like Prader Willi or ackee poisoning are so miniscule that for all but a small handful of specialists docs should forget they exist if they can convince a single patient to quit smoking who they otherwise cannot.

Most of mine are quarterlt or annual check-ins so the doc will re-up my meds.

Diet, exercise, medication compliance, smoking cessation are all vastly more effective if the doc has time to use all those persuasion skills they teach in med school.

Why couldn't a nurse practitioner or medical assistant take on some of these coaching duties?

I have been surprised on more than one occasion at how quickly a doctor can correctly diagnose a problem. Eleven seconds might be all they need, but it seems short because of perspective. We don't deal with medical problems very often, so they seem challenging, and when we do there is an emotional aspect to it. People with chronic illness can usually diagnose themselves fairly quickly, as well.


It's easy to criticize research that are run on smaller clinical numbers but all research is open to criticize from some direction. Merely open an undergraduate research textbook and run your finger down the lists of threats to internal and external validity. Research on clinical populations is difficult to conduct, and N = 112 is plenty sufficient for statistical power if nothing else, and dismissing the generalizability of the finding out of hand due *simply to the size of the N* isn't justifiable.

Patients actually may or may not have agendas when coming in. Patients with lower cognitive function may either A. Just know something isn't right or B. Have been referred for something they don't understand/don't understand why or to what they have been referred. Also, a referring provider may misunderstand the situation, provide either A. Bad information in the referral or B. Refer to the wrong provider. Understanding the patient's perspective is critical regardless of referring information. There's incredible variance in provider diagnostic and interpersonal skills, and deficiencies are exacerbated by shortened visit time. With the time crunch it's even more important that doctors make sure they understand the problem they must treat or refer out for.

+1 Good comment. See my response to Sure for two books on this and related subjects.

Like Alex says in "Managing Incentives", we get what we pay for. And we pay for a visit.

The incentive point is a good one but I think more accurately we get what the insurance company pays for since in the US few people really pay directly for medical services & it is far from clear exactly what the insurance company is paying for.

There are many difficulties here:

Like many things in life, your typical patient is not who the visit is designed around. Giving a nice, normal average patient enough time to talk through their full problem list tends not to be a problem. However about 10-20% of patients cannot manage this. They may be lonely and the doctor is the only one they have time to talk with. They may be hypochondriacs or have some amount of psychosis such that they cannot finish their complaint. The problem comes that we stack patients tightly into the schedule these days with very little margin. One problem patient can lead to all the following patients being late. Not being able to tell who will be a problem patient, means we have to treat them all like they could be. Which means you have maintain some control over the conversation; which is actually for most people who are not gifted conversationalists so they interrupt.

Another thing that makes this challenging is that we have started to part out the medical visit between staff in a way that culture has not caught up with. Typically an MA now does the vital signs, gets the initial complaint (often in full, directly in the patient's words), and does a lot of the basic tasks. This means that the doc comes into the room with a bunch of knowledge from the chart and feels they already understand the patient. This does not actually work, but we live in a system where doctor's wages have been flat or negative after inflation for decades and where billing makes it highly uneconomical to do the old fashioned model of have a real full length talk with your patient.

Physicians today have a lot more things to manage with the patient. Back in the day you told your patient to eat better, exercise, and take these meds. Your work was done. Now, particularly with pay for performance, you have to figure out how to effectively get your patient to change these habits. On top of that we also have to spend time managing more aggressive smoking cessation efforts, illicit drug use counselling, and a plethora of more medical options.

It was easy to counsel Hep C patients when there was nothing we could do - you basically ignored it until it created problems. Now we have to figure out risk so we can see if they should get (another) titer and then proceed to treatment options. Similarly, we have massively more patients who are double and triple survivors. Managing "back pain" is easy when the patient is otherwise healthy. When they are a cancer survivor we need to screen for mets and ectopic hormone production. When they have survived a STEMI we need to now thing about strokes, cardiac infarcts, and other embolic pathology; we also need to consider aortic pathology; and and we may even have to run down other things like lung dysfunction or kidney dysfunction.

We not only have more diseases in play, we also have more treatments for each. Oh I think you might have cancer? Which test should I order - because I can make a case for multiple workups that did not exist 15 years ago. I want to treat your asthma? Well we have enough drugs that insurance companies get to be picky so I need to make sure we go with the one that is covered.

Worse still, the social support networks of our patients are cratering. In the old days if you wanted to say use medications that prohibited driving patients could typically manage to have a spouse, neighbor, fellow parishioner, or coworker manage much of that for them. These days I can have a patient come to the ED with horrific enough back pain that they are willing to come see me for a huge cost, but tell me they cannot take a couple days of muscle relaxants as they cannot drive to work and might lose their job. Uber is great, but unfortunately few people have a hundred bucks to splurge each day on 40 minute rides. Even worse, we now have to make calls about who can be in home providing very basic care (e.g. take it easy for a few days, take these pills, an you call me if he becomes delusional or has seizures).

The old days are gone, along with the skinny average American. Between reimbursement rates, increased care choices, declining patient health, and abysmal social support your doc is doing more with less to just tread water. Of course the less obvious parts of the visit are going to suffer; everything is metricated and those which aren't tend to give.

but we live in a system where doctor's wages have been flat or negative after inflation for decades

They haven't been.

According to the BLS the median family medicine doc in 2018 makes $208,560. In 1998 they made $138,277. According the BLS's CPI calculator that comes out to be $215,777 today. We can do similar numbers for other specialties and from other periods of time, but the long and short of it is that physician compensation was relatively much higher in past decades.

On the other side of this, the cost of medical school has done something like doubling over the time period.

Doctors are not poorly paid, but they do things like have 15 minute patient sessions, part out their work to MAs, RNs, PAs, etc., and rely heavily on their charts in order to maintain compensation with what was expected 20 or 40 years ago.

You wrote that family doctors make 3% more than they did 20 years ago but then added "but the long and short of it is that physician compensation was relatively much higher in past decades."

Looks like a contradiction.

I suggest you try reading that again. In 1998 family med doctors made 3% more than they make currently with inflation adjusted dollars.

1998 is NOT the high water mark for family medicine. 1998 was after HMOs reduced their compensation. The "golden age" of medicine reimbursement was the 70s and 80s. So yes, docs used to earn significantly more purchasing power.

But beyond that since 1998 real GDP growth has averaged around 2% per annum. Compared to the economy as a whole, doctor's income is around 50% lower it used to be. They are in a boat with many other is this respect but by and large doctors have fallen from being in the top 2-5% of incomes down to the top 5-10%.

In short, we have been reducing the amount of the economy going to pay doctors for about 30 years. Shockingly it has not even registered on healthcare costs. Doctors have responded to lower compensation per patient visit by increasing the number of visits.

Suggesting that we respond to compressed visitation schedule by doubling down on the incentive structure that got us here ... well that just seems a bit silly.

"Compared to the economy as a whole, doctor's income is around 50% lower it used to be... doctors have fallen from being in the top 2-5% of incomes down to the top 5-10%. "

Absolutely absurd. Doctors make up at least a plurality if not majority of the top 1%.

According to the IRS, the top 1% earned $465,626 in a year.

Specialties with average salaries that high are are your non-general surgeons (neuro, thoracic, ortho, vascular, plastic), cardiology, and maybe radiation oncology.

These are very small numbers of physicians and some of the smallest disciplines. They are also the elite level specialties that require very long training times.

Family med, Peds, Medical genetics, and the like make literally less than half the big shots. 1/3rd of docs practice one of the four largest specialties: Internal Med, Family Med, Peds, and Ob/Gyn. These are all among the lowest paying specialties.

And of course all of this is on a distribution. Places like Charlotte, NC have average salaries that are over $100K higher than Durham, NC. Women make less than men in the same specialty (and also tend to work less). Academic medicine pays much less.

Your average doc is no longer a member of the 1%. That died as we stopped having docs in independent practices. You were right ... decades ago. But physician pay has not grown with the economy and the vast bulk of physicians are not earning top 1% incomes.

Regardless, executives make up 31% of the top 1%. Medical (which includes docs and certain members of the hospital admin) make up 15%. Finance make up 14%. Back in the "golden age" of medical billing in the 80s, docs made up around a quarter of the top 1%.

The average physician is now somewhere in the top 5-10%. This is not a an uncomfortable place to be. But the days when medicine was a fast ticket to the truly elite levels of income are long gone. Medicine will make you comfortable, but is a worse career for wealth accrual than tech, law, or finance. Between the time, the debt, and the training pay medicine is not a profit maximizing endeavor.


Import enough doctors and nurses until the prevailing wage is on par with ...some average of the EU and Japan? Maybe 65,000 a year for GP, 40,000 for nurses. Ballpark.

Eliminate residency requirement for Mds if they’ve done the equivalent in their country.

Free market baby. That should free up some schedule time for docs.

And because why not:

Only allow pro bono malpractice suits. Don’t let lawyers profit by jacking up paperwork, liability, and stupidity. That should save more time.

Make a federal formulary for generics. No public money for brand drugs unless it’s life or limb.

The US suffers from a high labor cost disease. Finance and technology bid up the price of high end labor. If you drive down compensation of docs to a European average you will see doctors leave practice or not enter practice in the first place to go work for tech or finance.

Of course if we import enough docs to actually move wages that is going to suck down most of the skilled immigration slots for years. This, in turn, will bid up the price of technology workers higher. Of course importing a bunch of people who do well on standardized tests and with education is going to temp many of them to leave practice, get educated in something more lucrative, and then we go back to a doctor shortage.

If you want to have enough immigration to lower all the high skill wages you basically have to either go full Trump (point system that only accepts high skill labor) and exclude all other immigrants or massively increase the immigration rate; quite likely you would need to do both.

We could try retooling the system to be a middle skill labor setup ... but that is what all the PAs, MAs, RNs, etc. are already doing. Doc salaries are about 15% of all medical costs currently. If we just enslaved them all, that buys us maybe 5 years before medical inflation eats all those cost savings.

Ultimately the problem is that we are using healthcare to make up for other deficiencies in our lives. If Americans doubled their rate of church attendance and religious observance, according to the literature that would be associated with ~15% reduction in all-cause mortality.

This is comparable to curing cancer.

And the costs are trivial in many cases. Even going with a full tithe and 8 hours a week of religious observance would be cheaper per QALY than most medical interventions.

Or consider having a spouse. Being married is a 10-15% reduction in mortality. Record low numbers of Americans are married. If we had maintained 1950s rates of coupledom we could save more health than curing asthma. And being married is cheap. Aside from some idiotic policy choices, being couple decreases the per person cost of everything.

Or perhaps we should look at parenthood. Having children gives us 1.5 years of additional life expectancy for all comers. Worse, being a single parent has a much higher all-cause mortality for parents. Single moms have a 50% increase in all-cause mortality over partnered mothers while single dads have a 200% all-cause mortality increase over partnered dads.

But let's not stay on the traditionalist bent. Being socially connected through a trade union or civic group is also associated with better health. Too bad all of these groups are rapidly declining.

And all of that is before we get to the effects of diet, exercise, obesity, and stress (where the average high schooler is now more likely to meet DSM criteria for stress related issues than the average WWII GI).

Medicine is expensive because it is a fail safe. If you want to live longer - go to church, get married, have kids, and cut stress. Then improve your diet and exercise. Then see me about meds.

Healthcare is where we are willing to spend time, money, and effort on people. It basically soaks up all the work once done by churches, spouses, children, neighborhoods, and civic organizations. It will only get more expensive as society atomizes further.

We're talking about time constraints and spending. It is none of my business if people go to church or have kids. Also I'm not only talking about doctor salaries.

But sure, cut SNAP to only healthy foods and obesity will go down. Saves me money. Throw in a high federal soda and alcohol tax and do a 1 to 1 reduction in payroll taxes.

Labor costs in hospitals and health systems are 60%. We regularly pay nurses and doctors 1.5-2x as much as other countries. Obviously this is where the money is.

Show me the difference in productivity between a US doc and a EU doc. I'll be waiting.

Yes, make a special visa for nurses and doctors and set the quantity where the equilibrium is defined as the median salary equivalence in PPP as the EU + Japan + SK + Taiwan.

That's 30% of the damn spending already.

You take brand drugs off of all government formularies unless there is literally no generic equivalent. That cuts another few %.

There is no doctor shortage when there is a disequilibrium in wages.

Free trade is good for the construction workers and meat packers, but this whole concept only works if the working class wages don't get sucked up in rents for doctors, lawyers, and the university administrators.

Throw in tort reform and you cut another few %.

'Show me the difference in productivity between a US doc and a EU doc.'

Not the EU, but a German doctor spends essentially zero time and employs basically no one to deal with various insurance companies. Of course their productivity is higher since they are not wasting time on the sorts of things that an American doctor probably considers inevitable when practicing medicine. On the other hand, that German doctor will probably be taking several weeks vacation a year - might make an impact on the other side of the productivity balance.

Oh please. US teachers have a median income of $58,000. OECD average is $28,523. Firefighters earn a 50% premium for being in the US. Postal workers likewise earn a premium. Engineers, programmers, and every other possible is more lucrative in the US.

This is why US GDP/per capita is $57,591 while OECD $42,158. We should prima facie expect salaries in the US to be about 35% higher. But it gets worse. If your product has to compete on the global market (e.g. manfacturing) then your wages are likely to be close to both the OECD and global averages. Occupations which compete less then should be expected to be higher still.

But what about immigration? About 1/4th of the physician workforce is already foreign born and that number is increasing. But why do they immigrate? Because it is astoundingly lucrative. If you want to push the MD salaries down you are talking about truly massive waves of immigration. Each $10K you lop off compensation drops the pool of potential immigrants by a lot. Getting it down down mid-range labor prices is going to mean drastically retooling the workforce.

" US teachers have a median income of $58,000. OECD average is $28,523. Firefighters earn a 50% premium for being in the US. Postal workers likewise earn a premium. Engineers, programmers, and every other possible is more lucrative in the US."

Much of the difference between the U.S. GDP per capita and the rest of the OECD countries is the salaries of doctors, lawyers and CEOs.

Physicians, like everyone else suffer from fat tails in the distribution. The median physician income is less than fifth of the top 10% of physician incomes. Many of the highest paid physicians own property (e.g. hospitals, clinics) that actually make the money for them. Even for the ones who work for their pay, the differential between primary care (the docs where this stuff matters) and specialists is already a factor of three.

Primary care docs simply are not paid what specialists make. Their pay is much more in line with international norms. Further, only the US actually uses nurse practitioners. If you want an apples to apples comparison of health costs we should compare primary care salaries in other countries to those of Family Medicine physicians and nurse practitioners.

Regardless, physician pay is not a significant driver of healthcare costs. It has fallen in real terms most years and is at best flat for decades.

'If you drive down compensation of docs to a European average you will see doctors leave practice or not enter practice in the first place to go work for tech or finance.'

You mean entitled American doctors will get to feel the effect of the free market? Dean Baker has been pointing that out for years, that certain groups seem to be very well protected from the free market, most particularly doctors.

'Of course if we import enough docs to actually move wages that is going to suck down most of the skilled immigration slots for years.'

Of course, the idea of creating a new category of visa - call it medical professional MP1 - and then having those allowed in the U.S. using it have no connection to existing quotas would clearly be utterly, totally unimaginable.

'Doc salaries are about 15% of all medical costs currently.'

Which would mean an easy 5% saving of all medical costs in a short period of time (if we used EU levels of doctor compensation 7.5% is realistic, but we are talking about the American health care system).

Getting to $65,000 a year for physician salary is not viable with immigrants barring wholesale mass immigration on larger scales than any ever seen in the course of modern human history.

First consider how much that limits the pool of potential immigrants. European average physician salary is $117,00. Going below that will mean we start losing docs to Europe. In fact, we can reasonably expect of those economic physician migrants who come to the US, a sizeable percentage will relocate again. After all average physician salary in Canada is around $150,000 and so heading north after 5 years of work would be highly lucrative. We would basically be pulling only physicians from the poorest countries.

But these are not human chattel, so back home docs make on average something like twice to thrice the median wage in their country. This suggests that if they quit medicine in this country they could make easily 1.5x median wage. Which means that we should expect many of those immigrants to scoff at $65,000 after a few years and try their hands at software, project management, sales, finance, or whatever. Skilled labor is going to be fungible. You are not paying someone the cost of being a doctor alone, you are also paying the cost of him not becoming something else.

Conservatively you would need the US to take in tens of millions of workers to bring down the wages of not just doctors, but also all the careers they might slip away to instead.

Right now it takes about 10 years of training to become a doc and you carrying $200,000 debt at 5% interest. Cutting wages is either going to need to cut med school cost (which in turn means pay cuts for lots of other people) or we basically have no viable MD graduates.

Frankly it amazes me that people make this level of ignorant comparisons. US docs are trained more heavily and are literally able to do more than other countries. We can do this because we have nurse practitioners and others who take on roles that lower paid MDs do in other countries.

If you really want to lower physician costs, then do something to make being a physician less onerous:

Eliminate the bachelor requirement and start med school right after high school like many other countries manage.

Eliminate the surgical requirements for all docs, like many other countries. Train only for things you will actually do or need to understand. Instead we spend a huge amount of time learning skills for specialties that we will seldom if ever need.

Pay for schooling out of public funds (or even pay students for attending) so they are not forced to defer milestones (home purchase, having children) due to debt and interest.

Reduce the BS compliance. Why exactly do I have to take boards every 10 years? Virtually no one fails and by the time you actually fail due to senility or negligence someone in the ecosystem has reported you to the state medical board regardless. Why do I have to make "meaningful use" of an EMR? Why am I paid based on Press Ganey scores? Why do I have to routinely work with idiots about if it is my MA or me who activates a macro in the EMR?

Immigration? Sure, I am all for more docs immigrating. But it is not going to move the needle hardly at all. The social drivers of costs are going to obliterate any savings in short order. Having any sort of action on those will of course be forever ignored.

But this is clearly nonsense.

By importing doctors we get wage parity, but this INCLUDES all the bs about medical debt. We let Germany and France pay for medical school and we steal their doctors.

Agreed, medical school in addition to a bachelor's is absurd. Let students enroll at age 18. Increase the slots for residency to anyone who passes the tests. But this will be a result of open immigration. They will be forced to adapt to compete.

They formed a guild and try their damnedest to restrict entry. Open the gates and see where it shakes out. They can always advertise their premiere education, if anyone cares. Just like everyone else.

We have Europe, Japan, South Korea, Taiwan, and if that's not enough we open the gates to India given certification parity. The constraint is artificial. I seriously doubt software engineers score lower on IQ tests than MDs. In fact I would bet a large amount of money this is not true.

They are over-trained in accordance with the guild requirements, and use political leverage to limit residency slots to not have to compete. Bullshit, we don't accept this for any other aspect of the labor market.

And it's not just doctors, it's nurses and techs. Open the floodgates till they reach a reasonable wage and then we can talk. Worst case scenario the rest of the world subsidizes our medical education. Awesome!

Next up a law that says brand drug pricing has to be a developed country global price or patents are not recognized. If Europe wants Hep C cures then they pay the same rate as American cash pricing.

Unlimited doc immigration without residency requirements and we'll see if it moves the needle!

Good luck with that.

Europe's average physician pay is over $110,00. Japan is also over $110,000. South Korea is over $100,000. Taiwan makes around $60,000 ... except cost of living is much lower in Taiwan so only idiots would move.

That leaves India. There are 10 million doctors in the whole country. The US employs around a million docs. Given purchasing power in India and the need to deal with the hemorrhage of Indian docs into more lucrative careers once you give them a visa ... you need somewhere around half the physicians in the country to come.

Again 25% of US docs are already foreign trained.

As far as forcing other nations to subsidize us ... good luck. They will just place conditional loans on their docs that come due if they leave their home country. They will simply nationalize the intellectual property behind drug patents. Governments in those nations will literally fall if we start siphoning off enough docs to actually impact wages. I mean heck I would fully expect the NHS to start conscripting physicians if they actually started losing too many doctors.

This ain't some consumer product we are talking. This is "people's lives" so I fully expect governments (ours and theirs) to freak out in all manner of fun and interesting ways.

And for what is all this being done? So we can save, at best maybe 5% on overall healthcare costs? Get real. Tamper around the edges, sure. But the gains you seek are simply not there.

It may be an affront against good government. It may be regulatory capture. It may be the upper class protecting themselves ... but none of that makes what you seek plausible.

Also I would like to add. We already have everything you ask within the US. Alaska, for instance, has some of the easiest credentials to get in the country. Their median pay for a primary care physician is around $330,000. That is about 50% higher than the lowest paying states. Somehow physicians are already leaving over $100,000 dollars lying on the table ... but somehow you expect margins that are half that large to induce doctors not to move from one state to another where travel is just a plane ticket away ... but to leave behind their culture, their family, and their continent.

If the market clearing forces are so strong, why don't physician wages equalize between the states?

All of this is subterfuge. Just end the AMA monopoly and everything will sort itself out and we can see for ourselves what the market clearing rate is. Not $65k but something comparable to other countries.

Not really.

As noted the market within the US does not "clear". There is a huge premium for working in Alaska. When we include cost of living in calculations, there are utterly massive imbalances that makes places in the hinterlands pay astoundingly better (e.g. 100% premium).

Likewise, the much of the EU has reciprocal recognition of medical licensing. They still have not cleared the market (I think it is something like a factor of 4 between top and bottom countries).

Yes, driving a stake through the heart of the blood suckers at the AMA cartel would lower physician salary. But it would not fall much below $150,000 in any achievable world. Much lower than that removes the entire premium from practicing in the US compared to the rest of the OECD when you account for purchasing power. Likewise, dropping the salaries too low and you will have people quit practice and you will start to see empty seats in medical schools.

Forgoing income for ten years, taking on $200,000 debt, and having atrocious training ours (legally limited to 80 hours a week with rampant violations) is not going to be attractive at some point. This means med schools will have to adapt ... and the AAMC lobby is just as strong as the AMA (medical schools are the largest employers in at least dozens of congressional districts).

At the end of the day, physicians are going to get paid something comparable to what they could earn doing something else. If you go lower the profession will need wholescale reworking to not be a high end labor profession. Maybe that is doable, but it will take truly radical change.

+1 to you.

A very thoughtful comment, particularly when you are discussing doctor patient interaction regarding habit changing and compliance.

If you are interested in understanding how behavioral economics applies to healthcare, including doctor patient interaction, awareness and compliance, I would strongly recommend two books: 1) Irrationality in Healthcare: What Behavioral Economics Reveals About What We Do and Why by Doug Hough; and 2) Nudging Health: Behavioral Economics and Health Law by Cohen (ed.).

How long your doctor talks to you with or without interruption

Won't matter soon because IBM Watson is often performing better at diagnosis than your internal medicine doctor:

This message brought to you by Watson AI.

Still enamored with that 2011 episode of 'Jeopardy'?

'What is technonaivete?'


The medical version of Watson gives a correct diagnosis of a heart disease 80% more often than cardiologists in a trial a coupl of years ago.

Then there is this statement on radiology by deep learning expert Geoff Hinton in 2016:

They should stop training radiologists now. It’s just completely obvious within five years that deep learning is going to do better than radiologists. It might take ten years, but we’ve got plenty of radiologists already. I said this at a hospital, and it didn’t go down to well.”

Hey, its Todd K!

"The medical version of Watson gives a correct diagnosis of a heart disease 80% more often than cardiologists in a trial a coupl of years ago"

Dealing with your mind numbingly stupid comments never gets any easier.

Citation? Reference[s]? Link? Anything, for Christ's sake?

Ladies & gentlemen, Marginal Revolution's most striking entrant in the Dunning Kruger Effect Sweepstakes!

If you want more time to jabber at your doc, get a Concierge doc. They specifically allow more time for you to jabber.

Such is life in America.

Such is death in America.


Such is Hillary in America.

I'm a C U C K!! At least, that's what she said.

News flash! Doctors are pressed for time and ask questions!

It's funny how two posts this morning are related, but no one (other than bill, who is not me) has seen the relationship, and there is some humor in this.

First, this post is measuring the amount of input (time spent with the doctor) and not the output (results), decrying the amount of time spent is sort of like saying from the previous post: the bigger we dig the hole (input) the better, regardless of outcome. Compare this post with the one on the involving incentives and the Army Corps of Engineers contract.

Second, outputs (results) matter, not inputs (amount of time spent). The study on doctor time spent on listening would have been better if it had measure outputs. Also, the study may be a mispectification of inputs: I often talk more to the nurse than the doctor, who comes prepared after having read the comments and observations from the nurse's interview.

Third, there is another very important economic principal or issue here that is not discussed: doctors ALONE do not determine the healthcare product; doctors and patients actually produce together the healthcare come. In economics or marketing co-production (manufacturer and dealer) co-produce the outcome (a sale or customer satisfaction). Same with healthcare.

Finally, if there is co-production, the glaring failure of doctors is that they do not know behavioral economics--the failure of persons to act rationally--and are unaware of nudging, default options, habit creation and destruction techniques that are so often used in marketing household goods.

The failure of the doctor is not how long he spends with the patient: it's the quality and effectiveness of the interaction and the doctors understanding of behavioral economics and marketing.

See the books I recommended to Sure in this comment section.

Is anyone asserting that doctors are failing (other than you)?

I read the study and the definitions, a few comments.

First, to those who are merely irritated because the study seems to take down high-status individuals and support "snowflake" complaint language, get over yourselves.

Second, this is an interesting and useful study that should generate follow-up research to build a better picture. It has flaws but it isn't the joint effort of the sociology and English lit departments, as some of you seem to think.

Some things that are unclear to me from reading:
- It sounds like "agenda elicitation" had to happen at the start of the appointment. To me it makes sense that this would happen a lot less in specialist settings. In primary care the reason for the visit could be anything. In a specialist setting, you may be following up with the patient for a very specific issue, and it makes sense (is good practice) for the MD to start off with a review of recent blood work and drug levels, the results from an MRI, an inquiry into specific symptoms, etc. They may have elicited an agenda later, but I'm not sure that would have met criteria in the study. It reads as though it wouldn't have. In fact, certain patients will be desperately awaiting test results at the start of the appointment, and will become extremely anxious if this information is delayed by a "Hey wassup?" opening.

Many people do not know how to prepare for a medical appointment, or are stressed when they attend, somewhat disorganized, etc. Even if an agenda was elicited, a patient might mention a cough then veer off into a rash. The MD might say, "Wait, before you go on about that rash, I want to hear more about that cough." That would have qualified as an interruption, but is good practice.

Certain patients need to be interrupted, otherwise the MD can't get a picture of things.

Certain people don't respond well to very broad questions like "How can I help you?" They need a bit of coaxing, and from the definitions I can see that some coaxing language would qualify as interruptive.

So the study has limitations, boo-hoo. It's still interesting groundwork. Now we can all ignore the hysterical headlines as it shows up in media coverage. And by the way, I too have no idea what the evocative "solve for" coda suggests either.

If a doctor doesn't listen to me, I find another doctor.

have you ever required medical attention in another country where you can't say anything beyond good morning and thanks?

I had the very bad luck to require an emergency surgery under these circumstances. everything went perfect. perhaps a talking patient is overrated.

so, if you are really sick, in pain, disoriented or even unconscious, words are useless.

MD's are really just more useful forms of college professors. The likelihood that you will encounter one that is arrogant is about the same.

The US medical system is geared for one purpose. Money. But this isn’t a reflection on the doctors, it’s a reflection of medical schools that are sponsored by food companies, medical device and drug manufacturers. It’s a system that is incentivized to provide procedures and write prescriptions for profit. It’s a system in which doctors are required to deliver profit to the industry bottom line instead of patient health and well being.

Only 25% of doctors receive any training in in nutrition which is the primary means of preventing chronic disease. Those who do receive this training take one course designed by the food and drug industries that are incentivized to treat illness, not healthy people. So, doctors lack even a remote knowledge of the best way to treat and reverse chronic disease.

Your best approach to deal with this situation is to avoid doctors and hospitals by maintaining a whole food plant-based lifestyle. Whether they know it or not, doctors do not have the best interests of the patient at heart.

What do you do if you need life saving surgery or medical care? Not all conditions can be prevented or cured with nutrition.

By the way, neither I, a doc of 40 years nor my daughter of 3 years were funded by food companies, medical device or drug manufacturers.

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