Tuesday, May 12, 2009

Where have all the doctors gone?

Rob Sanchez, in his most recent Job Destruction Newsletter, writes about a new Senate bill that would effectively lift the H-1B caps on the importation of foreign doctors. As Rob points out:
In conclusion, the Conrad "improvement" program is a backdoor attempt to raise the H-1B cap. That's because if more foreign medical students can get a Conrad waiver there will be more H-1B visas left over for programmers and engineers. We can expect more bills like this that whittle away at the H-1B cap without having to actually raise it.
This is likely true, and brings up a larger point that I'll probably get around to writing about tomorrow, but I wanted to pick up on one statement in the press release from the senator who's sponsoring this change:
The physician shortage in America is a growing crisis. By 2020, some projections show the nation may fall short by as many as 200,000 doctors. This shortage will be felt hardest in rural areas in North Dakota -- and across the nation.

The Conrad State 30 Program has brought more than 100 doctors to North Dakota communities that otherwise would have experienced a lack of physician coverage.
Need I talk about this again? I guess so. This is the same argument that we hear about the need to increase H-1B visas, that we simply cannot find all the qualified people we require to do...whatever it is the speaker thinks needs to be done.

Let me help the rural areas of North Dakota -- and across the nation -- with their problem. Fill a briefcase with cash, let's say a million dollars worth. Go to the Minot International Airport, catch a flight to Minneapolis, then on to Milwaukee, and finish in Boston, it takes less than a day. Go walk around a medical center, offering the briefcase to any doctor who's willing to commit to two years. I bet you'll find someone who will come.

[Actually, to go up even earlier in the quote, I'm not sure what it means to have a shortage of 200,000 doctors. We could make more simply by letting more into our medical schools, and immigration policy wouldn't have to enter into it at all.]

This is yet another in a long list of assertions that ignore how markets work. Any such statement should be followed by, "at the price we're willing to pay." You can get doctors to North Dakota or anywhere else, just as you can attract students into certain fields of study, just as you can compete with the industry leader in a certain technology - if you're willing to pay for it.

Now I'm not contending that that isn't hard sometimes. Finding a million dollars for two years of a doctor may seem like an intractable problem, just as wresting someone away from Google's search team might present a real challenge to Microsoft's recruiters.

But those are options, and they shouldn't be removed from the discussion just because someone sees a more expedient route if they can just push (lobby? pay?) to have laws changed. Immigration has increasingly become the solution of first resort, when it should only be part of the mix as one possibility. I've written before that there may be times when certain markets have a short-term shortage that requires importation of labor, but, if that happens, any relaxation of visa quotas should be accompanied by a longer-term strategy to alleviate that shortage. Clearly, that second part never actually happens; instead, we change our policies yet again to make the relaxation permanent.

I'm all for attracting the "best and the brightest" to our shores, but I know too many talented developers who are unemployed or underemployed or underpaid to believe that magical people from overseas are going to upgrade the profession, especially when a large number of companies aren't seeking out the best and the brightest, just the cheapest and most easily exploited. Sure, it's easy just to churn out the visas and give American companies and governments what they want, and it's a lot harder to look at the long-term implications of our decisions and be rational about it. But being hard shouldn't serve as a dterrent to doing what is right.


Anonymous said...

No, you are seriously mistaken. To accomplish your objectives, you will need to lower standards. "simply by letting more into our mesical schools" - smarm and ignorance! only possible by lowering standards. poaching doctors from other nations hurts other nations, and that makes me unhappy, but refusing their labor and insisting on locals makes me much more unhappy. states are currently lowering standards for nurses, and it's not clear how you're advocating anything less for doctors, while driving prices higher.

you may remember my political engagement with the nursing shortage. indeed, you've agreed in principle that importing nurses may be part of the solution. at one point during my involvement i got a deeply disturbing series of emails from a woman who was enraged that foreigners even attend american schools. she believed as you might that such an event deprives an American from the schooling opportunity. in reality we're all better off when schools can choose the most promising candidates. she's ready to march to national socialism and that should not surprise me.

an ageing populace will not be served by a locals-only policy, making shortages commonplace, costing substantial additional expense as well as reduced labor quality standards. the average nurse age is like 45, and retirement will be a freaking tidal wave of unmet demand in the next decade. i don't know if this holds for doctors, but the demographic shift of an ageing populace will not be solved with local labor, unless it's acceptable to let service costs soar, lower standards, and accept understaffing resulting in death. these conclusions are widely held and widely substantiated. again, i don't know about doctors, but i'd like to learn more. i don't think you've taught me anything more on the matter, regrettably.

the last bill regarding nurses did allocate imported labor while also funding our country's training facilities, which are also viciously poached of labor as industry compensation continues to experience lack of supply and soaring demand.

i think among doctors demand will soar for the different reason that people come to have insurance through government involvement. this is what happened in massachusettes and it makes sense to me. mandate/require/provide insurance... suddenly there's a huge deficit of primary care physicians. and that demand poaches academia of its capacity to teach! what a mess, where importing labor is a system-saving measure.

the talented developers i know all make large bank and cannot be called unemployed or underemployed. so our divergent experiences in this world continue to inform the chasm between our views. it's red oak's cue to belittle and berate my own experience now. yet your views are shaped by your experience just as much... all those talented developers you know and carrie hangs out with, crying over tea about how hard it is to make world-changing software anymore, what with all these foreigners in the game. it's bizarre to see such a chasm of perception but maybe we define talent differently. talented developers i know get $200k/yr, including h1-b's, and i've seen their paystubs. i do hope your talented developers get unemployment checks. you bet that's a chasm that would bring us to such vastly disparate conclusions. i don't see a clear connection between conrad and h1-b in any case. maybe some hysterical newsletter internet talking head does.

- mcfnord

Androcass said...

I think it's slightly more complicated than you're stating here with respect to doctor training. One has to ask, is there some kind of innate "doctorness" that is uncovered by the admissions process, something immutable and necessary to being a good doctor, or is the training sufficient to make a good doctor? Keep in mind we're not talking about a cutting-edge researcher, but a GP whose practice is relatively straightforward. Our medical schools would like you to believe both, but both cannot be true.

And, yes, we may have to lower standards somewhat. That is the natural consequence of meeting increased demand, and it's true whether we admit more Americans to med school or get doctors from somewhere else. If we demand more doctors for the reasons you've cited or others, and the rest of the world has a higher standard of living, overall demand will increase and we'll all have to get those doctors from some place, and we'll have to pay more to get them, which is all I was saying in the first place.

As for your other comments, I will leave them alone for now, except to point out that it's unsubstantiated that "we're all better off when schools can choose the most promising candidates" - I think the issue is far more involved than such a blanket statement implies, especially when you've failed to define "better off" and "most promising"; at the same time, your correspondent's rage is quite misplaced, but unsurprising given that the U.S. does seem to have some problems with conserving its wealth.

Anonymous said...

if you want to gather software developers or doctors, you'll have better luck from a global pool of candidates. it's just the way aptitude and interest are distributed. and i think it's very helpful to think of some careers that way. good developers (the underemployed ones you talk with, perhaps) can build a search tool, but the globally great can build a Google. as for doctors, i don't want a reduction in quality! the difference between engineering products that work globally, and medical care that is still largely localized to the provider, makes the labor debates pretty different, but it's not surprising that parties opposed to all immigrant labor sources would paint a similar picture. destroy America's leadership in tech, and reduce the quality of its medical services while raising prices. it's a grand plan! - mcf

Androcass said...

I respectfully request that you read the things I've written before you lump me in with the most ardent anti-immigration forces. What I have consistently written is that some immigration is desirable - there are H-1Bs who I would want on my team, my company, my country - but that it is clear that many of the people making use of it are not motivated by a desire to find the best and the brightest, just the cheapest and most compliant.

That I cite people who are more anti-immigration that I am is because the mainstream press has pretty well bought into the self-serving hoo-ha of the corporateers who put short-term profits ahead of long-term quality (and I'm not saying that they "should" do anything else, just that we should recognize self-interest when it comes along).

I have also written, several times, that I am not opposed to the H-1B program, just that the numbers involved are almost completely arbitrary, instead of being based on logic and conditions. Of course I want the best and the brightest here instead of elsewhere; I simply question whether we're doing enough to identify those people. I've worked with H-1Bs who had no business turning on a computer, much less programming one, and the program does nothing to differentiate between those and the ones who are truly excellent.

As for the quality issue, it's a sad fact that, whatever the field, if demand rises quickly the quality of the supply will fall, at least in the immediate term. We saw it in the late '90s tech boom. If global demand for medical professionals is really on the rise, either supply will not keep pace (in which case the price will rise) or it will (in which case the quality will fall). I'm not real pleased about that either, but our displeasure won't change that. The U.S. needs to develop a strategy - something more than "we'll import all we need" - to increase supply and maintain quality. I'm not real hopeful about that.

Anonymous said...

Is H-1B even immigration? They all have to go home. It's a labor program.

The last bill before Congress about the nursing shortage allocated imported nurses AND increased funding for training at home. That sounds pretty strategic to me. The demographics require importing. Longer-term, as the President has said, importing is not the whole fix.

In the end you seem to want to do scholarly research on the "right numbers" and I think that's more useful than the nature of typical political debate, which boils down to caricatured extremes fighting. So get started: I'm aghast that you refer to the medical shortage speculatively, as if it might not really exist. In nursing and the GP doctor gap is well-documented in medical journals. Have you examined this research? Mainstream media whitewash? People will die, from underservice in the system and pricing barriers keeping them out. It's unethical to allow it. It's quite a different debate from H-1B or the tech boom. I made serious money as labor in the tech boom (or bubble). Wasn't unethical at all. Meanwhile nurses still enjoy the most rapidly advancing wages as anyone, even through the importing which continued through 2006.

Did you query the incapable H-1B's about their compensation? Did they create any value? How does a company operate on incompetents, at any wage? (Rehash Idiocracy Theory!)

Perhaps parties should back their H1-B applicants with cash. Perhaps the government should accept the higher offers within bands, or perhaps the government should sell all these visas to the highest corporate bidders overall. These seem like approaches to help assure quality. I've still seen a lot more good H1-Bs than bad, though.

I'll do a lot to protect America's commerce leadership position in the world. I'll back my assertion that the best-and-brightest need to be attracted, allowed, and retained. The only downside I see is the impact on the country we loot of its great labor. That's my only ethical qualm. I am very appreciative of the rest of the impact, both as an American, as a human being (who gets to interact with people from other cultures), as an investor, and as a software professional.

- mcfnord

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