We're killing people, say over-worked doctors

Courrier Mail ^ | 9/6/09 | Matthew Fynes-Clinton and Michael Crutch

[Nachum]

EXHAUSTED doctors have confessed to killing and harming patients, falling asleep during surgery and crashing their cars because of marathon shifts.

The public hospital medicos claim to be so tired on the job that they are working "like drunks".

More than 100 doctors vented guilt and anger in a confidential Queensland survey. Almost 60 per cent admitted to fatigue-induced errors while performing procedures.

[AzaleaCity5691]

They’re overworked because there are not enough of them. They need to just accept a pay cut (as do medical schools) and allow the number of slots in medical schools to increase so that there can be more doctors and stronger competition.

[Forgiven_Sinner]

Here’s the problem: “The Queensland Government wants to push through a new pay and conditions deal for doctors that offers only limited respite. “

The government has no business setting wages or working conditions. This should be all private sector.

What you’re seeing is rationing—reducing the cost of health care, which reduces the wages for doctors, which reduces the number of doctors, leading to shortages, longer working hours, and lower quality.

[Forgiven_Sinner]

Here’s the problem: “The Queensland Government wants to push through a new pay and conditions deal for doctors that offers only limited respite. “

The government has no business setting wages or working conditions. This should be all private sector.

What you’re seeing is rationing—reducing the cost of health care, which reduces the wages for doctors, which reduces the number of doctors, leading to shortages, longer working hours, and lower quality.

[jimtorr]

Overpay obviously is not the problem. Lack of incentive to practice medicine is the real problem behind a doctor shortage in the modern world.

Greater incentive, ie, higher pay, is the way to increase the number of doctors.

The USA is actually paying medical schools to hold down the number of slots in their schools. Is Australia doing the same?

[Nachum]

They need to just accept a pay cut (as do medical schools) and allow the number of slots in medical schools to increase so that there can be more doctors and stronger competition.

Excuse me? Are you joking?

[Blood of Tyrants]

But, but, but, it’s FREEEEEEE!

[GnuHere]

You forgot the sarcasm alert. If the pancake house waitress could be a doctor, she probably has already checked that out.

[ransomnote]

This is Australia’s ‘public option’ workforce. Note the article refers to their public status “The public hospital medicos ...”
In 1978, I attended a lecture given by a speaker from Australia. He said things rather gently, fearing he would offend us, about how the US medical and housing system compared unfavorably to that of the Australian. He said very cautiously, “I have toured the US and I hate to say it but...there...are...some places I would not not want to live.” I almost laughed, I could think of places I would not want to live in the US. As his talk wore on - here was his point. In Australia (circa 1978) the government sees to it that if you are willing to work (e.g. street sweeper, dog groomer, bar tender - any fully employed person) then the government guarantees you housing and medical insurance. He pondered the idea of Americans without medical insurance saying “It’s as if some people don’t admit they are human...” He was baffled by housing and medical access inequity and said Australia guarantees nice housing (He agreed there was still disparity among the rich and poor but said none of it was at all objectionable) and full medical care. 30 years later, it looks like Australia’s ‘public option’ medical system in in collapse. Too few want to become a heavily monitored, underpaid physician so they have a doctor shortage. I recall horrible stories coming out of AU about a year ago listing extreme shortages of basics (one of which was aspirin) among the public option facilities - with one medical person lamenting conditions they likened to 3rd world countries. You can’t force someone to go to medical school to partake in this kind of system.

[AzaleaCity5691]

It’s not sarcasm. It’s basic economics. The medical school system in our country is not operating in sync with economic demand. They have limited the number of medical school slots far below what our country’s physician needs are. This limits the supply of doctors in the market thereby increasing the per unit demand for each one and therefore their price (salary). The green doctor right out of medical school, once their residency is done is guaranteed a pretty standard salary from the time they finish to the time they retire.

Because this salary is high enough it also puts them in a position to pay back exorbitant loans and so medical schools charge more than is economically necessary because they can get away with it and because it also serves as a barrier to entry.

Compare the medical school process to the process for getting an JD or an MBA and you’ll understand what I am talking about. We need to increase the number of medical school slots, increase the number of doctors and force them to actually compete with patients on the basis of service price and service quality rather than just opening an office and being guaranteed a full waiting room because there are so few doctors on the market.

[AzaleaCity5691]

But the thing is current U.S. physician pay is due to a market that is dealing with an artifical labor ceiling. If we were to quadruple the number of doctors medical costs would come down but so would the salary of the average physician and you would find that medical service providers would have to compete through price competition, something that they don’t have to do right now.

[Nachum]

I want to be sure what your point of view was before commenting.

It’s basic economics.

Yes. it is indeed basic economics.

Wage and price controls fail 100% of the time. One cannot "create" more medical schools to "create" more doctors. The only reason why there is a shortage of doctors in Australia is because there is absolutely no incentive to be a doctor. The state dictates an unattractive wage. There is no incentive to build medical schools because the state dictates the cost of tuition and the kind of payments to the school. You are experiencing what every single socialized system of medicine in the world experiences. If you want more doctors, establish a privatized market. Let the schools charge as much as they think they can get. Let the marketplace provide the incentive and let individuals have the freedom to choose. Then, even if your own schools do not create enough doctors, you will attract people from outside your country to practice medicine to fill the need.

[krb]

How hard is it to see that we don’t allow enough doctors to train?

[AzaleaCity5691]

See. I don’t know about Australia, I was referring to America. However, one actual can create medical school slots. It is called, one day, the medical school makes a decision and says “we are doubling the number of slots in our medical school. Send your applications in now”

The problem in the U.S. is that there are so few slots and many people who would make very doctors are never given the opportunity because of one bad grade or because they miffed a test and it doesn’t work that way for most professional schools. Business school, law school, most graduate programs all do admissions on a sliding scale between GPA, scores and other factors.

Not so for med school. If you don’t dot every I and cross every T you don’t get in and while there are alternatives with domestic schools overseas which are cheaper and which do admit Americans the med schools in this country have basically tried to shut them out of residency and out of the market to keep their wages artifically high.

Maybe I can explain this another way. If tommorow all the law schools got together and cut the number of law school slots by two thirds within a decade average attorney salary would be higher than average doctor salary and there would be no more “starving lawyers”. The same can be said for MBAs, MPAs, and hell, for undergraduate degrees itself. One reason that undergraduate degree has become worthless is because of how many people now have them. Apply the same reverse principle to med school enrollment and you would increase health care quality while lowering the cost.

This is nothing the government can do though, at least not directly, because there are no federal universities. However, a state government would be empowered to double the slots at their state run medical schools and that could have a positive impact on the situation.

[Jim Noble]

The medical school system in our country is not operating in sync with economic demand. They have limited the number of medical school slots far below what our country’s physician needs are

I've taught medical students for 34 years. About 1/3 of them shouldn't be allowed to graduate.

We went from 8800 in 1967 to 17 000 in 1977, and we relaxed standards so much to get to the higher figure that we've had problems with the output ever since.

If we can't get 17 000/year that have the stuff to become doctors (and, BTW, this has gotten much worse in the past ten years), where are you going to find all these extra doctors?

[AzaleaCity5691]

The problem is med schools do admission based on UGPA and the MCAT scores, neither of which have anything to do with being a doctor. A UGPA is only a reflection of how responsible you were as a 21 year old and the MCAT score is only a reflection of how well you test. Neither has anything to do with medicine and yet that’s how you determine admission and so many intelligent people who would be great doctors never get a chance because of their GPA or MCAT.

The other problem with med school admissions is that there are no second chances for applicants if they’re white or Asian. If they don’t have the numbers the day they finish undergrad, unless God smiles upon them they are almost always shut out of even having the chance to go, even if they would make far better doctors than those who do have the numbers but who, in your words, “shouldn’t be allowed to graduate”

[ArmstedFragg]

Let’s remember that in recent years, a sizable portion of the third world has moved to Australia.

[ransomnote]

Yes - I worked with someone from Monterey, California who also moved to Australia in the early 1990’s. One of the reasons he went was government subsidized medical and housing.

[Polybius]

It’s not sarcasm. It’s basic economics. The medical school system in our country is not operating in sync with economic demand. They have limited the number of medical school slots far below what our country’s physician needs are ....

You can always increase quantity by lowering quality. That is what Cuba does. Cuba cranks out "doctors" like Keebler cranks out cookies.

Guyana’s Cuban trained doctors – the tragedy of mediocrity – Walter Ramsahoye ...... There are no individuals who would qualify for recognition at the centres named above so we have a situation where the unqualified are training the unqualified. We will at the end of the day have numbers without quality and the majority of Guyanese are being put at risk. Another troublesome aspect is that these unaccomplished individuals behave as if a piece of paper makes them the reincarnation of Hippocrates. Their arrogance knows no bounds. They know not what they do not know. It is the tragedy of mediocrity. ....... Not a single Guyanese has achieved that qualification and this explains why Cuban “specialists” do not measure up to specialists trained in North America or the United Kingdom. [worth reading again!] Our unsuspecting public believes the holders are specialists when all they have is an entrance qualification for further training.

The green doctor right out of medical school, once their residency is done is guaranteed a pretty standard salary from the time they finish to the time they retire.

Ummmm .... "Once their residency is done" usually means 6 years AFTER they graduated from medical school. What other profession requires you to have 6 years of intensive experience BEFORE you are even hired?

The doctor "just out of residency" is often the doctor in the group with the latest training in the latest advances in medicine.

Then again, you can always cut that experience down and take your chances.

Maybe we can save money by having Physician's Assistants do your your total prostatectomy.

Because this salary is high enough it also puts them in a position to pay back exorbitant loans and so medical schools charge more than is economically necessary

Harvard Medical School charges about $42,000 in tuition. That's right in the ballpark with my daughter's private undergraduate college tuition.

Harvard Medical School Tuition

Compare the medical school process to the process for getting an JD or an MBA and you’ll understand what I am talking about.

What's the very worst that a JD or an MBA can do?

With a mistake, the JD can lose a case (in which his client gets a Mulligan in the form of an appeal). With a mistake the MBA can blow a business deal.

With a mistake, the MD can kill you or cripple you for life. (Sorry. No Mulligans. Mother Nature is a nasty mother.)

When what you do really does not matter all that much, you can roll the dice and take your chances three years after undergraduate graduation, like a JD, or two years after undergraduate education, like an MBA.

You know what you call a future surgeon three years after undergraduate graduation?

You call him a medical student.

We need to increase the number of medical school slots, increase the number of doctors and force them to actually compete with patients on the basis of service price and service quality rather than just opening an office and being guaranteed a full waiting room because there are so few doctors on the market.

"I graduated as a surgeon from a residency program where every surgery professor trained 5 residents at a time during each case. I never got very much "hands on" experience but I will do your surgery for HALF PRICE!"

[SaraJohnson]

Maybe they are killing people but the major question is whether they are killing the right people and are they reducing health care costs! /s/

[Jim Noble]

so many intelligent people who would be great doctors never get a chance because of their GPA or MCAT

Popular theory.

Totally false, but popular.

[Nachum]

How hard is it to see that we don’t allow enough doctors to train?

We have high standards. It is expensive to train a doctor and many with the intellect will choose other professions if there is too little reward. One cannot "manufacture" medical talent. It has to be encouraged, nurtured, and rewarded.

[Nachum]

However, a state government would be empowered to double the slots at their state run medical schools and that could have a positive impact on the situation.

If you increase the "slots" you will reduce quality. Whenever government imposes a change in standards as you suggest it will affect the outcome.

[AzaleaCity5691]

Ok then. Say we have the case of prospective medical student, who is white so no affirmative action, who has a 2.6 GPA because they drank a bit too much in undergrad and they get a 33 on the MCAT. My contention is that this person will never get their chance to go to medical school (in the continental U.S.) even though they may make the greatest doctor in the world simply because they were irresponsible as an 18-22 year old.

So tell me if this is a false conception, how does this student get into medical school. And this would also be a student with no extracirrics and who did not have any jobs in college other than maybe an internship and campus jobs.

Tell me because if you had a similar situation with a prospective law student or MBA student (with the LSAT and GMAT and equivalent type scores) then they would be able to get in somewhere and probably could talk there way into one of the better ones.

[AzaleaCity5691]

How a person is at age 19 is no reflection upon how they are going to be in their professional career. Most 19 year olds are concerned primarily with scoring booze and scoring period. They are totally irresponsible. The idea that so many professional opportunities revolve around how people carried themselves at Age 19 is simply asinine.

There is also the fact that not everyone develops that academic work ethic until later in their academic career. I went to college with more than a few people who had lousy GPAs because we all did the Greek thing. However, when they got into their professional school and weren’t distracted with parties and football all of the sudden they pulled out averages in excess of 3.75 and were ranked among the top of their class.

Undergraduate GPA is perhaps the worst thing to judge an applicant on because there are differences between institutions and because it is that time of life where you really aren’t taking anything seriously. Now, a test score is a better measure but it is still highly arbitrary (especially when they have courses teaching you how to game it). The GPA doesn’t measure aptitude at all and the various tests are only a so-so indicator.

[Jim Noble]

even though they may make the greatest doctor in the world simply because they were irresponsible as an 18-22 year old

No sale.

18 is an adult. Irresponsible is irresponsible.

Reject.

[AzaleaCity5691]

18 can’t buy a pistol in many states, can’t buy alcohol in all states and can’t buy tobacco in Alabama. Try again.

Why shouldn’t people get a second chance, especially if they have the test scores that with a better GPA would get them in? Especially when they do this in every other professional schools.

More importantly, is anyone here who is criticizing my idea a medical doctor and therefore someone with a vested interested in keeping the system as it is and who might not like my criticism of them?

I have offered a market oriented solution for lowering the cost of health care and this would also be accompanied by strict tort reform. I have offered a plan for health care that we could use as a direct counterpoint to ObamaCare and yet I and the idea get attacked.

Why should we deny someone who wants to be a doctor the chance to be one if they are competent to do it based on a few mistakes? If they turn out to be an incompetent doctor then it will be found out and they’ll lose their license.

However, if they turn out to be worth more than their UGPA suggests then we’ve added an extra medical care provider into the market thereby forcing the doctors there to have to compete more rather than getting away with practices that in any other business would get them put out of business simply do the the short supply of service providers?

[krb]

If you increase the "slots" you will reduce quality.

That is not true. I think you are operating under the (understandable) assumption that the American medical establishment allows 100% of the qualified applicants to purchase medical education. It is understandable to assume that because a) it would seem logical to allow as many good people into the profession as we can, and b) other professional fields work that way.

But not the physician profession. As an example I will paraphrase my girlfriend's letter of acceptance to med school: Congratulations, out of 6000 applicants for the incoming class of the year 20xx, 600 were deemed qualified. Out of those 600, we selected 150 for the class...

Even though that's a paraphrase, the numbers are correct, and the story is basically the same at all medical schools in the country.

You see, while your gut is right that a majority of applicants are unqualified (90% in this case), they still deny 75% of the folks who are qualified from purchasing the training. That is, there is absolutely no reason to expect that if we randomly picked a completely different block of 150 people out of those 600 qualified candidates we will get any better or worse care.

[Nachum]

You see, while your gut is right that a majority of applicants are unqualified (90% in this case), they still deny 75% of the folks who are qualified from purchasing the training. That is, there is absolutely no reason to expect that if we randomly picked a completely different block of 150 people out of those 600 qualified candidates we will get any better or worse care.

We have no idea if what the acceptance letter says is true or not. And I would disagree with the conclusion that if we picked at random there would be better or worse care. I also reject the notion that education of this sort can be quantified in this sort of statistical way. If you play havoc with the admissions process and reduce to being administrated by a political committee or some authority it is a slippery slope that certainly will reduce quality.

I have experience with relatives and friends from foreign countries who experienced this sort of thing and ran from it. It is a recipe for failure.

[krb]

It is expensive to train a doctor and many with the intellect will choose other professions if there is too little reward. One cannot "manufacture" medical talent. It has to be encouraged, nurtured, and rewarded.

I agree 100%. My only disagreement is that it's a fact that the desk quota at med schools is not optimized for "best." Not by a long shot. First of all, there's all the hokey stuff they have to play with trying to engineer race and gender outcomes:

http://www.aamc.org/data/facts/2008/mcatgparaceeth08.htm

Second, given the chronic shortage of various types of providers in many areas it is clear that the MDs who get to decide how many more MDs to train have done a poor job in making sure we have enough people in the pipeline.

[Kozak]

Here’s a dirty little secret of the doctor shortage in the US.

More then HALF of med school classes are women. Women practice less hours, and have on average much shorter careers. So each female graduate equals about 60% of a male graduate in terms of productivity over the lifetime of a medical career.

Of course this is a verboten topic.

[Richard Kimball]

Maybe I can explain this another way. If tommorow all the law schools got together and cut the number of law school slots by two thirds within a decade average attorney salary would be higher than average doctor salary and there would be no more “starving lawyers”.

Yeah, but we'd have to shorten the season and start tagging them. Catch and release, have to throw back any lawyer you catch that's under five feet, you know the story.

[Kozak]

Do I get to set my rates too? Can I refuse to see people for free? See right now I am forced BY LAW to see anyone who walks crawls or rides to my ED. 1/3rd pay me zero, zip, nada, nothing. Another 1/3rd “pay” via Medicare or Medicaid next to nothing. I’d LOVE to a real market for my services where I could set what I charge and get paid.

[krb]

I’d LOVE to a real market for my services where I could set what I charge and get paid.

Me too. There's a new doc in my area that actually has a price list posted for all of the stuff they do, if you don't want to pay via insurance. And I don't mean posted like some shame thing like they may grudgingly have available at other places. You are free to check the prices and go elsewhere if you want.

Unfortunately, though, Kozak, we aren't going to see anything like that on a widespread scale until we wrestle the med school desk gate from the hands of entrenched MDs who are successfully fooling the populace into thinking that they have our best interests at heart.

[Revolting cat!]

Dude, I have a minor surgery scheduled for the 28th (removal of a pimple on my ass, if you have to know!) Are they gonna kill me?

[meyer]

...removal of a pimple on my ass, if you have to know!

Ahhhh, an Obamectomy. Might be painful for a few days, but it must be removed before the infection spreads.

[Revolting cat!]

Yes, but will there be a Prayers Going Up thread for me and my ass here on that fateful day?

[Nachum]

It depends...

If you see the doctor take out the saw... or the drill :)

[philetus]

They need to just accept a pay cut”

I think I heard the medical schools are doing OK schooling foreigners on our dime.

[krb]

They need to just accept a pay cut (as do medical schools) and allow the number of slots in medical schools to increase so that there can be more doctors and stronger competition.

You know, there doesn't have to be a pay cut just by increasing the number of practitioners. If we also reduce a lot of the regulatory BS they have to manage and maybe even throw in some tort reform, we can still afford to pay them really really well, while at the same time taking away their keys to the med school gate.

But who am I fooling? Too many intelligent things need to happen for anything good to come out of our system. None of them (tort reform, training more docs as we increase the demand for their services) are going to happen, so why bother even worrying about it.

[Polybius]

How a person is at age 19 is no reflection upon how they are going to be in their professional career. Most 19 year olds are concerned primarily with scoring booze and scoring period. They are totally irresponsible. The idea that so many professional opportunities revolve around how people carried themselves at Age 19 is simply asinine.

What are you talking about? When you are 19, you are a sophomore in Pre-Med along with, at least back in my day, what seemed to be half of the campus.

Oh, I get it.

Were you or your kid a Pre-Med and, in freshman and sophomore years, "concerned primarily with scoring booze and scoring period"? So, you bombed out of the first adult weeding process of your life? And you wanted a Mulligan? Right off the bat without ever showing that you had what it took to persevere?

Well, sorry to tell you that ALL 19 year ols or even 18 year olds are not "totally irresponsible".

There is also the fact that not everyone develops that academic work ethic until later in their academic career. I went to college with more than a few people who had lousy GPAs because we all did the Greek thing. However, when they got into their professional school and weren’t distracted with parties and football all of the sudden they pulled out averages in excess of 3.75 and were ranked among the top of their class.

So, you make the case for people with a high I.Q., a high hedonism score and a poor, undisciplined work ethic. They are the ones that will get going when the going gets tough during surgery residency and later, in private practice, when the 2:00 AM phone call summons them back to the hospital to perform at a level that will, literally, mean the difference between life and death?

Actually, things have gone in that direction with the newer generation of primary care doctors. They want "quality of life" which means that they only want to work 4 days per week. Hospital work is too stressful and 2:00 AM phone calls are too bothersome so they give up their hospital privileges and hospital call and have "Hospitalists", (those who decide that somebody has to tough it out at the hospital) take care of their patients that need hospitalization.

So, you have more and more primary care doctors doing less and less until they are shocked, shocked, I tell ya, to discover that what they actually do can also be done by much cheaper Physician's Assistants and they, themselves, are paid accordingly.

Undergraduate GPA is perhaps the worst thing to judge an applicant on because there are differences between institutions and because it is that time of life where you really aren’t taking anything seriously.

You are not judged solely on your GPA. You are judged as a package. You are judged on your work ethic. You are judged on your character. You are judged on your maturity. And, yes, you are judged on how seriously you have taken things.

I did not have a great GPA during my freshman year in Pre-Med. My father died when I was 16. Money was so short, we lost our house and my siblings and I were farmed out among our aunts and uncles until my stepmother was able to afford an apartment.

During Pre-Med, I did not have enough money to afford lunch at the University cafeteria. I could not afford to live on campus in the dorms or afford a car so I had to commute from one end of Miami to the other on two public buses to get to campus and then squeeze in time to work at the University Bookstore.

So, with 5 hours of time per day wasted in commuting and working, I had to compete with the rich Pre-Meds living in the dorms or driving to campus in their fancy new cars, all expenses paid for by Daddy.

After first year, something obviously had to change so I decide that all work needed to be done in the summertime, not during the school year, and I bought a 1961 Chevy Impala that could barely get me from home to the campus and back without falling apart. I did not have to worry about "scoring booze and scoring period" since I did not have enough money left over to even score lunch at the cafeteria.

With those five hours available for study, the GPA turned around. In my junior year, I scored a perfect 4.0 and I smoked the MDCAT.

When it came time to apply for medical school, my essay included an explanation of why I had a poor GPA my freshman year.

I got accepted to medical school. My rich friend that drove his fancy car to campus every day did not.

Even if you completely blow your chance to show your work ethic and desire in Pre-Med, there are lots of second acts. In my medical school class there were many who first went into nursing or something else, went back and took the Pre-Med requirements again, showed that they had what it took and then got accepted.

Now, a test score is a better measure but it is still highly arbitrary (especially when they have courses teaching you how to game it). The GPA doesn’t measure aptitude at all and the various tests are only a so-so indicator

Which is why admission is not based on test scores and GPA's alone.

My roommate in medical school was rejected THREE TIMES before he was accepted. He was married with a child and therefore had other constraints on his time but he did what he had to do to show that he had the character and perseverance to succeed.

The rate limiting step in producing quality doctors is not the medical school classroom. One professor can lecture 10 students, 100 students, 300 students or, with a video hook-up, lecture 50,000 students on the giant video screen of an NFL football stadium. The rate limiting step in producing quality doctors are the limited number of grey-haired clinical professors in teaching hospitals that have to teach the future internist or future surgeon with real, live patients, one on one, case by case, individual patient by individual patient. Unless you are willing to sacrifice teaching hospital patients by the bus full, you cannot teach that to 50,000 residents at a time on a video screen without drastically degrading quality.

So, each teaching hospital can only handle a certain number students and residents and still provide a quality education.

So, decisions need to be made as to who will take up those slots.

So, with literally hundreds of thousands of high I.Q. students who can get a high GPA in the US ( when they are not "concerned primarily with scoring booze and scoring period" ), you have to have some sort of criteria for deciding who gets those limited spots.

Two students with identical GPA's and test scores apply to medical school:

STUDENT NUMBER 1: "I was responsible from Day One. These life difficulties affected my GPA. This is what I did to overcome the difficulties. These are the results. I did poorly the first year and smoked the last three years."

STUDENT NUMBER 2: "I didn't get a fantastic average GPA but it's still pretty good. I could have done better but, you know, with girls and cars and my Dad's motor boat, I didn't feel like studying a lot of the time. But, things will be different in the future. I promise."

Student Number 1 will get accepted. Student Number 2 will not.

Then there's Student Number 3.

"I was concerned primarily with scoring booze and scoring period. I was totally irresponsible. Most 19 year olds are like that, you know. You need to take that into account."

That student's application is not going to make it past the first cut.

[Polybius]

If you increase the "slots" you will reduce quality.

That is not true. I think you are operating under the (understandable) assumption that the American medical establishment allows 100% of the qualified applicants to purchase medical education.

I addressed that issue in part of my Post 42, pasted below.

The rate limiting step in medical education is the carrying capacity of a teaching hospital, not the capacity of a lecture hall at the "medical school".

You can teach 50,000 medical students biochemistry at one time with one biochemistry professor by putting those 50,000 medical students in the New Orleans Super Dome and putting the biochemistry professor on the stadium Jumbotron.

You cannot teach 50,000 medical students why their work up of the patient they worked up last night was flawed in such a way.

You certainly cannot teach a surgery resident that he is about to cut the wrong thing that way.

Think of it in terms of a flying school. Let us say that the three of us on this post are going to Top Notch Flying School and our instructor will be this guy:

I've heard he's pretty good.

Can he teach the three of us to fly in one year?

It's a pretty good bet that he can.

How about 10 qualified students, just as qualified as the three of us are?

How about 100 qualified students?

How about 300 qualified students?

How about 1,000qualified students?

How about 3,000 qualified students?

Captain Sully can teach aerodynamics to 50,000 of us at one time by talking to a video camera.

He can only teach one of us at a time when "stick time" comes into play.

THAT is the rate limiting step.

**************

The rate limiting step in producing quality doctors is not the medical school classroom. One professor can lecture 10 students, 100 students, 300 students or, with a video hook-up, lecture 50,000 students on the giant video screen of an NFL football stadium. The rate limiting step in producing quality doctors are the limited number of grey-haired clinical professors in teaching hospitals that have to teach the future internist or future surgeon with real, live patients, one on one, case by case, individual patient by individual patient. Unless you are willing to sacrifice teaching hospital patients by the bus full, you cannot teach that to 50,000 residents at a time on a video screen without drastically degrading quality.

So, each teaching hospital can only handle a certain number students and residents and still provide a quality education.

So, decisions need to be made as to who will take up those slots.

[Nachum]

So, decisions need to be made as to who will take up those slots.

As long as some politician or their appointee aren't making that decision.