There should be a glut of nurses.

Jan 15 JDN 2459960

It will not be news to most of you that there is a worldwide shortage of healthcare staff, especially nurses and emergency medical technicians (EMTs). I would like you to stop and think about the utterly terrible policy failure this represents. Maybe if enough people do, we can figure out a way to fix it.

It goes without saying—yet bears repeating—that people die when you don’t have enough nurses and EMTs. Indeed, surely a large proportion of the 2.6 million (!) deaths each year from medical errors are attributable to this. It is likely that at least one million lives per year could be saved by fixing this problem worldwide. In the US alone, over 250,000 deaths per year are caused by medical errors; so we’re looking at something like 100,000 lives we could safe each year by removing staffing shortages.

Precisely because these jobs have such high stakes, the mere fact that we would ever see the word “shortage” beside “nurse” or “EMT” was already clear evidence of dramatic policy failure.

This is not like other jobs. A shortage of accountants or baristas or even teachers, while a bad thing, is something that market forces can be expected to correct in time, and it wouldn’t be unreasonable to simply let them do so—meaning, let wages rise on their own until the market is restored to equilibrium. A “shortage” of stockbrokers or corporate lawyers would in fact be a boon to our civilization. But a shortage of nurses or EMTs or firefighters (yes, there are those too!) is a disaster.

Partly this is due to the COVID pandemic, which has been longer and more severe than any but the most pessimistic analysts predicted. But there shortages of nurses before COVID. There should not have been. There should have been a massive glut.

Even if there hadn’t been a shortage of healthcare staff before the pandemic, the fact that there wasn’t a glut was already a problem.

This is what a properly-functioning healthcare policy would look like: Most nurses are bored most of the time. They are widely regarded as overpaid. People go into nursing because it’s a comfortable, easy career with very high pay and usually not very much work. Hospitals spend most of their time with half their beds empty and half of their ambulances parked while the drivers and EMTs sit around drinking coffee and watching football games.

Why? Because healthcare, especially emergency care, involves risk, and the stakes couldn’t be higher. If the number of severely sick people doubles—as in, say, a pandemic—a hospital that usually runs at 98% capacity won’t be able to deal with them. But a hospital that usually runs at 50% capacity will.

COVID exposed to the world what a careful analysis would already have shown: There was not nearly enough redundancy in our healthcare system. We had been optimizing for a narrow-minded, short-sighted notion of “efficiency” over what we really needed, which was resiliency and robustness.

I’d like to compare this to two other types of jobs.

The first is stockbrokers.Set aside for a moment the fact that most of what they do is worthless is not actively detrimental to human society. Suppose that their most adamant boosters are correct and what they do is actually really important and beneficial.

Their experience is almost like what I just said nurses ought to be. They are widely regarded (correctly) as very overpaid. There is never any shortage of them; there are people lining up to be hired. People go into the work not because they care about it or even because they are particularly good at it, but because they know it’s an easy way to make a lot of money.

The one thing that seems to be different from my image may not be as different as it seems. Stockbrokers work long hours, but nobody can really explain why. Frankly most of what they do can be—and has been—successfully automated. Since there simply isn’t that much work for them to do, my guess is that most of the time they spend “working” 60-80 hour weeks is actually not actually working, but sitting around pretending to work. Since most financial forecasters are outperformed by a simple diversified portfolio, the most profitable action for most stock analysts to take most of the time would be nothing.

It may also be that stockbrokers work hard at sales—trying to convince people to buy and sell for bad reasons in order to earn sales commissions. This would at least explain why they work so many hours, though it would make it even harder to believe that what they do benefits society. So if we imagine our “ideal” stockbroker who makes the world a better place, I think they mostly just use a simple algorithm and maybe adjust it every month or two. They make better returns than their peers, but spend 38 hours a week goofing off.

There is a massive glut of stockbrokers. This is what it looks like when a civilization is really optimized to be good at something.

The second is soldiers. Say what you will about them, no one can dispute that their job has stakes of life and death. A lot of people seem to think that the world would be better off without them, but that’s at best only true if everyone got rid of them; if you don’t have soldiers but other countries do, you’re going to be in big trouble. (“We’ll beat our swords into liverwurst / Down by the East Riverside; / But no one wants to be the first!”) So unless and until we can solve that mother of all coordination problems, we need to have soldiers around.

What is life like for a soldier? Well, they don’t seem overpaid; if anything, underpaid. (Maybe some of the officers are overpaid, but clearly not most of the enlisted personnel. Part of the problem there is that “pay grade” is nearly synonymous with “rank”—it’s a primate hierarchy, not a rational wage structure. Then again, so are most industries; the military just makes it more explicit.) But there do seem to be enough of them. Military officials may lament of “shortages” of soldiers, but they never actually seem to want for troops to deploy when they really need them. And if a major war really did start that required all available manpower, the draft could be reinstated and then suddenly they’d have it—the authority to coerce compliance is precisely how you can avoid having a shortage while keeping your workers underpaid. (Russia’s soldier shortage is genuine—something about being utterly outclassed by your enemy’s technological superiority in an obviously pointless imperialistic war seems to hurt your recruiting numbers.)

What is life like for a typical soldier? The answer may surprise you. The overwhelming answer in surveys and interviews (which also fits with the experiences I’ve heard about from friends and family in the military) is that life as a soldier is boring. All you do is wake up in the morning and push rubbish around camp.” Bosnia was scary for about 3 months. After that it was boring. That is pretty much day to day life in the military. You are bored.”

This isn’t new, nor even an artifact of not being in any major wars: Union soldiers in the US Civil War had the same complaint. Even in World War I, a typical soldier spent only half the time on the front, and when on the front only saw combat 1/5 of the time. War is boring.

In other words, there is a massive glut of soldiers. Most of them don’t even know what to do with themselves most of the time.

This makes perfect sense. Why? Because an army needs to be resilient. And to be resilient, you must be redundant. If you only had exactly enough soldiers to deploy in a typical engagement, you’d never have enough for a really severe engagement. If on average you had enough, that means you’d spend half the time with too few. And the costs of having too few soldiers are utterly catastrophic.

This is probably an evolutionary outcome, in fact; civilizations may have tried to have “leaner” militaries that didn’t have so much redundancy, and those civilizations were conquered by other civilizations that were more profligate. (This is not to say that we couldn’t afford to cut military spending at all; it’s one thing to have the largest military in the world—I support that, actually—but quite another to have more than the next 10 combined.)

What’s the policy solution here? It’s actually pretty simple.

Pay nurses and EMTs more. A lot more. Whatever it takes to get to the point where we not only have enough, but have so many people lining up to join we don’t even know what to do with them all. If private healthcare firms won’t do it, force them to—or, all the more reason to nationalize healthcare. The stakes are far too high to leave things as they are.

Would this be expensive? Sure.

Removing the shortage of EMTs wouldn’t even be that expensive. There are only about 260,000 EMTs in the US, and they get paid the apallingly low median salary of $36,000. That means we’re currently spending only about $9 billion per year on EMTs. We could double their salaries and double their numbers for only an extra $27 billion—about 0.1% of US GDP.

Nurses would cost more. There are about 5 million nurses in the US, with an average salary of about $78,000, so we’re currently spending about $390 billion a year on nurses. We probably can’t afford to double both salary and staffing. But maybe we could increase both by 20%, costing about an extra $170 billion per year.

Altogether that would cost about $200 billion per year. To save one hundred thousand lives.

That’s $2 million per life saved, or about $40,000 per QALY. The usual estimate for the value of a statistical life is about $10 million, and the usual threshold for a cost-effective medical intervention is $50,000-$100,000 per QALY; so we’re well under both. This isn’t as efficient as buying malaria nets in Africa, but it’s more efficient than plenty of other things we’re spending on. And this isn’t even counting additional benefits of better care that go beyond lives saved.

In fact if we nationalized US healthcare we could get more than these amounts in savings from not wasting our money on profits for insurance and drug companies—simply making the US healthcare system as cost-effective as Canada’s would save $6,000 per American per year, or a whopping $1.9 trillion. At that point we could double the number of nurses and their salaries and still be spending less.

No, it’s not because nurses and doctors are paid much less in Canada than the US. That’s true in some countries, but not Canada. The median salary for nurses in Canada is about $95,500 CAD, which is $71,000 US at current exchange rates. Doctors in Canada can make anywhere from $80,000 to $400,000 CAD, which is $60,000 to $300,000 US. Nor are healthcare outcomes in Canada worse than the US; if anything, they’re better, as Canadians live an average of four years longer than Americans. No, the radical difference in cost—a factor of 2 to 1—between Canada and the US comes from privatization. Privatization is supposed to make things more efficient and lower costs, but it has absolutely not done that in US healthcare.

And if our choice is between spending more money and letting hundreds of thousands or millions of people die every year, that’s no choice at all.

How can we fix medical residency?

Nov 21 JDN 459540

Most medical residents work 60 or more hours per week, and nearly 20% work 80 or more hours. 66% of medical residents report sleeping 6 hours or less each night, and 20% report sleeping 5 hours or less.

It’s not as if sleep deprivation is a minor thing: Worldwide, across all jobs, nearly 750,000 deaths annually are attributable to long working hours, most of these due to sleep deprivation.

By some estimates, medical errors account for as many as 250,000 deaths per year in the US alone. Even the most conservative estimates say that at least 25,000 deaths per year in the US are attributable to medical errors. It seems quite likely that long working hours increase the rate of dangerous errors (though it has been difficult to determine precisely how much).

Indeed, the more we study stress and sleep deprivation, the more we learn how incredibly damaging they are to health and well-being. Yet we seem to have set up a system almost intentionally designed to maximize the stress and sleep deprivation of our medical professionals. Some of them simply burn out and leave the profession (about 18% of surgical residents quit); surely an even larger number of people never enter medicine in the first place because they know they would burn out.

Even once a doctor makes it through residency and has learned to cope with absurd hours, this most likely distorts their whole attitude toward stress and sleep deprivation. They are likely to not consider them “real problems”, because they were able to “tough it out”—and they are likely to assume that their patients can do the same. One of the primary functions of a doctor is to reduce pain and suffering, and by putting doctors through unnecessary pain and suffering as part of their training, we are teaching them that pain and suffering aren’t really so bad and you should just grin and bear it.

We are also systematically selecting against doctors who have disabilities that would make it difficult to work these double-time hours—which means that the doctors who are most likely to sympathize with disabled patients are being systematically excluded from the profession.

There have been some attempts to regulate the working hours of residents, but they have generally not been effective. I think this is for three reasons:

1. They weren’t actually trying hard enough. A cap of 80 hours per week is still 40 hours too high, and looks to me like you are trying to get better PR without fixing the actual problem.

2. Their enforcement mechanisms left too much opportunity to cheat the system, and in fact most medical residents simply became pressured to continue over-working and under-report their hours.

3. They don’t seem to have considered how to effect the transition in a way that won’t reduce the total number of resident-hours, and so residents got less training and hospitals were less served.

The solution to problem 1 is obvious: The cap needs to be lower. Much lower.

The solution to problem 2 is trickier: What sort of enforcement mechanism would prevent hospitals from gaming the system?

I believe the answer is very steep overtime pay requirements, coupled with regular and intensive auditing. Every hour a medical resident goes over their cap, they should have to be paid triple time. Audits should be performed frequently, randomly and without notice. And if a hospital is caught falsifying their records, they should be required to pay all missing hours to all medical residents at quintuple time. And Medicare and Medicaid should not be allowed to reimburse these additional payments—they must come directly out of the hospital’s budget.

Under the current system, the “punishment” is usually a threat of losing accreditation, which is too extreme and too harmful to the residents. Precisely because this is such a drastic measure, it almost never happens. The punishment needs to be small enough that we will actually enforce it; and it needs to hurt the hospital, not the residents—overtime pay would do precisely that.

That brings me to problem 3: How can we ensure that we don’t reduce the total number of resident-hours?

This is important for two reasons: Each resident needs a certain number of hours of training to become a skilled doctor, and residents provide a significant proportion of hospital services. Of the roughly 1 million doctors in the US, about 140,000 are medical residents.

The answer is threefold:

1. Increase the number of residency slots (we have a global doctor shortage anyway).

2. Extend the duration of residency so that each resident gets the same number of total work hours.

3. Gradually phase in so that neither increase needs to be too fast.

Currently a typical residency is about 4 years. 4 years of 80-hour weeks is equivalent to 8 years of 40-hour weeks. The goal is for each resident to get 320 hour-years of training.

With 140,000 current residents averaging 4 years, a typical cohort is about 35,000. So the goal is to each year have at least (35,000 residents per cohort)(4 cohorts)(80 hours per week) = 11 million resident-hours per week.

In cohort 1, we reduce the cap to 70 hours, and increase the number of accepted residents to 40,000. Residents in cohort 1 will continue their residency for 4 years, 7 months. This gives each one 321 hour-years of training.

In cohort 2, we reduce the cap to 60 hours, and increase the number of accepted residents to 46,000.

Residents in cohort 2 will continue their residency for 5 years, 4 months. This gives each one 320 hour-years of training.

In cohort 3, we reduce the cap to 55 hours, and increase the number of accepted residents to 50,000.

Residents in cohort 3 will continue their residency for 6 years. This gives each one 330 hour-years of training.

In cohort 4, we reduce the cap to 50 hours, and increase the number of accepted residents to 56,000. Residents in cohort 4 will continue their residency for 6 years, 6 months. This gives each one 325 hour-years of training.

In cohort 5, we reduce the cap to 45 hours, and increase the number of accepted residents to 60,000. Residents in cohort 5 will continue their residency for 7 years, 2 months. This gives each one 322 hour-years of training.

In cohort 6, we reduce the cap to 40 hours, and increase the number of accepted residents to 65,000. Residents in cohort 6 will continue their residency for 8 years. This gives each one 320 hour-years of training.

In cohort 7, we keep the cap to 40 hours, and increase the number of accepted residents to 70,000. This is now the new standard, with 8-year residencies with 40 hour weeks.

I’ve made a graph here of what this does to the available number of resident-hours each year. There is a brief 5% dip in year 4, but by the time we reach year 14 we’ve actually doubled the total number of available resident-hours at any given time—without increasing the total amount of work each resident does, simply keeping them longer and working them less intensively each year. Given that quality of work is reduced by working longer hours, it’s likely that even this brief reduction in hours would not result in any reduced quality of care for patients.


I have thus managed to increase the number of available resident-hours, ensure that each resident gets the same amount of training as before, and still radically reduce the work hours from 80 per week to 40 per week. The additional recruitment each year is never more than 6,000 new residents or 15% of the current number of residents.

It takes several years to effect this transition. This is unavoidable if we are trying to avoid massive increases in recruitment, though if we were prepared to simply double the number of admitted residents each year we could immediately transition to 40-hour work weeks in a single cohort and the available resident-hours would then strictly increase every year.

This plan is likely not the optimal one; I don’t know enough about the details of how costly it would be to admit more residents, and it’s possible that some residents might actually prefer a briefer, more intense residency rather than a longer, less stressful one. (Though it’s worth noting that most people greatly underestimate the harms of stress and sleep deprivation, and doctors don’t seem to be any better in this regard.)

But this plan does prove one thing: There are solutions to this problem. It can be done. If our medical system isn’t solving this problem, it is not because solutions do not exist—it is because they are choosing not to take them.