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Why you should not go to medical school (law.harvard.edu)
351 points by known on Sept 24, 2011 | hide | past | favorite | 173 comments

So, surprisingly, this rant is more or less accurate, imo. (I went to med school, residency, fellowship)

I mean some things stronger than others, but it hits on the major negatives as you go through training. I know a lot of these rants tend to romanticize how hard people's own professions are in a "no one else has it this hard" type stance. We see similar "how hard it is to be a programmer" type rants as well. But, I'll pull out the one aspect that I've always felt I lost.

"3) You will spend the best years of your life as a sleep-deprived, underpaid slave."

I do feel like I missed being young (20s) and just having a regular job, enjoying life with my friends. 4 years of medical school, and 3 years of residency pretty much wipe out age 22-29. So I do regret that.

I had a different experience. Medical school was easy, I was single and went out drinking / partying two or three nights a week. Not to be crass, but I did well with the ladies. Luckily I can get by on four hours of sleep or less. So, I don't feel like I missed out on much of the early twenties experience. Most of my non-medical friends had jobs and I didn't, but that was the only real difference.

Things got a little more serious my intern year, but I still managed to go out twice a week, and the nurses were much more responsive to my advances now that I was doctor.

At the start of my residency I got serious with a girl from my medical school. Her training was in Psychiatry and I was in Radiology. We worked a minimum of 80 hours a week, but we always had time for each other. We got married during third year.

Now I'm a partner in a successful practice, and she's taking a few years off to raise the kids. I make over 800k a year, and take 14 weeks of vacation. I don't deal with patients. I have the ultimate job security. And, I am a tremendous resource for my family. I'm sure you know how easy it is to get screwed by the medical system. That won't happen to me or mine.

I'm not a risk taker, so what else could I be doing with the security and benefits of my current job? Lawyer, maybe.

Lesson learned: If you do fine without sleep, and manage to wind up in the most lucrative specialty^, medicine may just be for you!

Speaking as the son of a psychiatrist who didn't marry a radiologist: you got lucky, and your wife got luckier. Good for you guys, but that's not what a student should expect from med school any more than a CS student should expect a $10mm exit.

^Barring, what, the specialized surgeries?

Many surgical specialties earn more than I do, like Urology, Neurosurgery, Orthopedics, etc.

> I make over 800k a year, and take 14 weeks of vacation.

I, for one, am disheartened by this gross misallocation of resources, but good work on the vacation time.

The median salary for experienced radiologists is $300k-400k. And increasingly radiology has been outsourced overseas with mostly technicians required stateside (scan during the day, radiologist in India examines at night, results available the next morning).

But roentgen claims to be a businessman as well as a radiologist. If so, most of his income would be from several radiology businesses. In that case the 800k/year number would not be surprising.

Always remember

- "On the Internet no one knows you're a dog." and

- "Don't believe everything you read."




That radiologists make 100K more than cardiologists and 200k (!!!) more than neurologists absolutely screams market manipulation. Radiology seems literally one generation of Intel processors away from being automated into oblivion. God speed that it is.

I'm not sure if you've ever seen a CT stroke study, which typically includes 4,000 images. If you think a computer can accurately interpret one of these any time soon, I would say you are poorly informed.

See my response below, and look into "CAD" and mammography.

Hmm, how exactly does the number of images affect predictive algorithms? If anything, more data is better. No offense, but as a radiologist you're not exactly familiar with the state of the art in A.I. image processing. I'd say that both of us are unqualified to state the degree of effectiveness of computational geometry and computer vision in radiology.

You might not see it because it's such an inconvenient thing to see; afterall your income is tied to it. The main factor keeping your income so high is the AMA and its regulatory allies.

With rising costs and increasing pressure to save money in healthcare, you better believe that one day a computer will do your job.

PS You might want to re-read The Innovator's Dilemma and The Innovator's Solution.

My income's not tied to it, so I'll say it.

Computers reliably interpreting films as the final word is not going to happen in the near future (within this guy's career). Reading films is as much an art as it is a science. I'm sure a lot of advances can be made on it, and we might see nice proofs of concept. But to the point that it actually replaces radiologists?

Even if you assume the technology can be perfected, there are too many non-technological hurdles for that to happen. Liability, trust, etc...

Machine EKG interpretation has been around for a while, but it's not even close to perfect and no one relies on it, and it's a much much much simpler problem.

This guy gets it. Many replies in this thread are asking about computers interpreting scans, assuming I know nothing about the underlying technology, or am blinded by some form of bias.

I have been programming computers since I was 5 years old. I have a MS in neuroscience, and I am a board certified radiologist, so I think I'm qualified to understand the problem.

Believe it or not, nothing would make me happier than a magical black box that could spit out accurate radiology reports. Someday I'm going to get sick, and I would benefit from the technology.

If my job was replaced tomorrow I would be OK. I'm smart and hard working, and I'm good at almost everything I try, eventually. Also, I'm saving every last penny I earn, so I can keep things up for a few more years I should be financially secure.

Having said all that, I still think the problem is not solvable. On any given day I read xrays, CT scans, MRIs, ultrasounds, PET scans, mammograms, nuclear medicine studies, or live flouroscopic studies, and using CT or ultrasound guidance I can get a needle into just about any part of your body to take a biopsy. Doctors talk to me and our discussion influences the differential diagnosis, and the interventions planned. I am not just matching patterns, I am thinking and using my hard worn judgement.

Wishful thinking aside, computers cannot do this now, if ever. And if / when we reach the point that computers can do this, my guess is every other job will have fallen, with the exception of plumbing.

The day computers can do your job, they can do every job.

But never underestimate the ability of programmers to oversimplify every other job while proclaiming a computer can do it.

Computers are tools to aid doctors, they are not doctors. It's like a blacksmiths claiming the horseshoes can get you somewhere without a horse. It's just not going to happen.

First, a radiologist made a judgement call and saved my mom's life. I've got a lot of respect for what you do.

Second, there must some set of scans that are easy. It's not hard to imagine a device that says, "yes" or "see a real radiologist". Perhaps later revisions can even say "No". an example might be a mammogram analyzer. I think even 10% getting an immediate answer would save a lot of money.

I think it's the normal progression of technology. Generally, you don't need a Phd in math or physics to program computers like was required in the 60's. The net effect will be the average case you look at is much more challenging.

> an example might be a mammogram analyzer.

These exist, google for "mammogram computer aided detection". While the data on their efficacy is equivocal at best, I well tell you that they are useless. I do get to bill more for reading a mammogram if I run it through a CAD machine, which my group owns, so of course I do it.

Strangely enough, patients are reassured when the learn that the computer didn't detect any problems. And, more importantly, ignorant juries can be swayed by this piece of information. "The computer didn't detect anything? Then there is no way the radiologist should be held liable for missing that little tumor!" I'm not joking.

Little do they know.

Do you use Thermography, I've read it to be safer?

It's naturally for humans, especially ones who've invested years of effort into something and get paid a lot for it to continue, to claim that something is "more of an art than a science." They are wrong. Do they collect data on how they make decisions and what the outcomes are, and then check that they are improving?

For contrast, look at http://www.lifeclinic.com/fullpage.aspx?prid=508121&type... There they decided to stop gathering lots of information and making a judgement and instead use a few simple rules to make a decision on whether someone was having a heart attack and how bad. It was more accurate.

I don't know much about reading films, but I do know something about AI, and this kind of direct data->solution problem with an enormous existing data set is just about as easy as AI problems get. I wouldn't be surprised at all if we are already at the point where its a trust/liability issue rather than a technological one.

I disagree with all your points. I think the main reason for differences in salary is that it is easy to measure what a radiologist does. It is also relatively easy to measure what a cardiologist does, particularly if they are doing procedures such as angiograms.

Mostly a neurologist diagnoses stuff and manages chronic disease, and how do you measure that? Arguably, the neurologist does the most difficult and complicated job. They get paid based on consultations per time, which is clearly a pretty hopeless measure.

Also, the notion that radiology is going to be automated by increased processor power is a bit ridiculous.

We are talking about a task where lives are at stake, communication and DISCUSSION with real people is required frequently, and there are large variations in the quality and modality of scanning.

Also, any data driven approach is very limited... what happens when a new MRI sequence is developed? We have to wait 15 years for real radiologists to do enough reporting so we can get a proper dataset?

If you read my other comments, I state that I make twice the average salary, because I read twice as many films.

> increasingly radiology has been outsourced overseas with mostly technicians required stateside (scan during the day, radiologist in India examines at night, results available the next morning).

This is not true. Some "preliminary reads" are read overseas at night, but the doctors reading the studies are trained and certified in the USA. "Final reads", the CT scan report that counts, cannot be read elsewhere.

> "Final reads", the CT scan report that counts, cannot be read elsewhere.

Why not?

I have sort of answered this question below.

Final interpretations must be performed by a radiologist residency trained in the USA, licensed in the state there are reading from, and credentialed for the facility and the insurance company.

Why? Well, I guess it's supposed to be to ensure quality. In general, it is probably good that every hospital in the USA has an independent credentialing process. You could debate the fact that doctors in the USA are better trained, but in fact that has overwhelmingly been my experience.

Cynically, I believe that the lawyers need someone to sue. Like I said, most doctors complain about malpractice, but not me. The trial lawyers can't sue doctors overseas, but they can sue me. So, in a sense they are my ally, they ensure that no one else ( except people they can sue ) can read the studies.

That being said, there are companies that take USA trained radiologists and station them overseas. Australia and Geneva are both popular. They take advantage of the time difference to read hospital cases that occur overnight, when I am home in bed. They usually provide a preliminary read, something like "no appendicitis." The next day I do a final read, look for mistakes in the preliminary read, and in general do a more thorough job. Sure, there's no appendicitis, but the preliminary read didn't mention the small tumor in your left kidney that kind of looks like a cyst, but isn't.

FYI - overseas reads by USA trained radiologists tend to be more expensive, not less.

Anyway, thanks for jquery.

He's running a business; what's not to get? He sits higher up on the ladder with a bigger net than most doctors. The doctor that reads your x-ray at the local community hospital and this guy are in two different positions. One is an employee, the other is a business founder. The amount of money that you and the insurance companies pay to both are no different.

Ok, so everyone agrees that doctors are underpaid and overworked, and when someone isn't underpaid or overworked it's a misallocation?

Trust me, a good radiologist is easily worth that much and more. They make hundreds to thousands of decisions a day and produce data which is scrutinized carefully. Many radiology mistakes also eventually come to light through time or autopsy, so they are also accountable.

People in other jobs are paid more to do far less and be far less accountable, the finance industry being the number one example. (Thanks for your good work lately.)

One final point is that medical training in other countries isn't like this. In Australia, we don't work ridiculous hours most of the time and remuneration is reasonable. As well as making actual healthcare inefficient and needlessly expensive, the US has managed to do the same to medical training.

Thank you for your honesty.

May I ask, what exactly do you do that you feel justifies your 800k per year? It seems to me that your career is ripe for disruption.

Generally, rare goods - and skills - are valuable. So going to school for a long time to learn an unusual skill well means that your services are more valuable.

Also, providing a large amount of value in a small amount of time (like accurately interpreting the results of a scan) leads to providing huge amounts of value over the course of a year. Part of the explanation is the sheer volume of individuals he can give a reasonable amount of value to.

Wouldn't radiological and physician services, in general, be less "rare" if medical schools started to train more physicians (admit more students)? I have read studies that suggest that in certain markets and certain practice specialties we are and will face shortages of physicians in part because medical schools are training too few physicians. When I ask academic physicians they seem to think admitting more students would erode the quality of students. In other words, scarcity is a public good in this case as it helps to ensure that the "most talented" will ultimately become practitioners. I don't know how this view squares with the large number of foreign-trained residents in some residency programs.

The Planet Money podcast covered this topic once. In proper markets, increasing the supply of a good or service decreases its cost. However, in the US, the more doctors we train, the more we spend on healthcare.

A reason this is the case is because the average healthcare consumer is totally removed from the cost of healthcare and the doctor has a perverse incentive to make work for him or herself and other specialists.

Right idea, but wrong bottleneck. Admitting more students to medical school would enlarge the pool of applicants to Rads residency, but it would by no means force Rads programs to admit more applicants.

So going to school for a long time to learn an unusual skill well means that your services are more valuable.

It's only a rare skill because of licensing/board requirements. I'm fairly certain if you told other people they could make $250k as a radiologist, they could self-teach.

The same thing could be said of programming if the only people that could practice had to be certified.

I'm going to respectfully disagree.

This may be possible in some medical fields (I doubt it), but not radiology. There is simply too much to learn. I completed 4 years of medical school followed by a 5 year residency. Some radiologists go through additional sub-specialty training. I've been practicing for 5+ years, and I'm still learning everyday.

I am a doctor's doctor, meaning my customers are doctors from every specialty, who order studies and read my reports looking for answers they can't answer clinically. I can talk to Orthopedic surgeons in their language, Neurologists in theirs, and Gastroenterologists in theirs. I'm familiar with the radiological manifestation of most pathological processes a human can experience.

The notion that someone could self-teach what I know seems impossible.

There are licensing and board requirements, but conspiracy theories aside they are not designed to create artificial scarcity, they're supposed to keep dangerously ignorant doctors from practicing.

This may be possible in some medical fields (I doubt it), but not radiology. There is simply too much to learn. I completed 4 years of medical school followed by a 5 year residency. Some radiologists go through additional sub-specialty training. I've been practicing for 5+ years, and I'm still learning everyday.

But what can you say that about? I did 4 years undergrad in CS, followed by 5 years for a PhD. Followed by more than a decade in industry. And I still learn everyday too.

The notion that someone could self-teach what I know seems impossible.

I should be clear, as the term is ambiguous, they'd likely learn from experts, but not by going to a board approved medical school. But through things like online schools, programs, books, etc... It wouldn't be someone trying to recreate a curriculum from scratch.

There are licensing and board requirements, but conspiracy theories aside they are not designed to create artificial scarcity, they're supposed to keep dangerously ignorant doctors from practicing.

Given the lack of policing after becoming a doctor I'm skeptical of this claim. At the college level I'd like to see a wider swath let in to medical school, and then a more rigorous approach to filterning, based on not only medical proficiency, but ethics. The big problem I see with doctors isn't in expertise or proficiency, but in ethics.

And given the data on sleep deprivation and learning, I think loosening the requirements even a tad would result in less scarcity and better prepared doctors on average.

We see things differently.

Radiology is a very difficult field to get into after medical school, something like 2/3 of American grads who apply get turned away. Additionally, for those who get in, up to 1/3 never pass all the board exams. It almost seems like you want to lower the bar, and I'm telling you it needs to be raised.

My guess is that if your system was developed and worked, the intelligence and drive required to complete it, the time spent studying and working to become competent in radiology would end up being no different than the current system. There are no short cuts.

"Radiology is a very difficult field to get into after medical school, something like 2/3 of American grads who apply get turned away."

I don't agree with kenjackson that the field can be self-taught, but saying that most people don't get into Radiology residencies tells me only that there aren't enough Radiology residencies to go around. The 1/3 board failure rate notwithstanding, my intuition is that there are far more people capable of practicing radiology than are currently allowed to try to get into the field. The intelligence level of medical students does not exceed that of PhD students in engineering, math, chemistry, etc., but the medical profession puts up much, much higher economic barriers to entry.

If the government decided to tax radiology providers and use the profits to increase the number of radiology residencies by 10 or 100-fold, I find it hard to believe that the lucrative profit margins of your industry wouldn't decline. Medicare reimbursement rates would go down as the number of providers increased.

Radiology is a very difficult field to get into after medical school, something like 2/3 of American grads who apply get turned away. Additionally, for those who get in, up to 1/3 never pass all the board exams. It almost seems like you want to lower the bar, and I'm telling you it needs to be raised.

All you've said is that some tests aren't being passed. Can you correlate them with improved medical care? Again, in my alternate world, I can construct a CS test that 90% of those w/ undergrad CS degrees would fail. That's not hard to do. The question is "does my ability to pass such a test correlate with my ability to do a website?"

You're pointing to scarcity and arguing that this is proof that we require scarcity. I'm saying that if you dropped the bar on these tests, but increased other policing practices that yielded a net increase in the number of doctors, I think you'd see an increase in medical care. My thesis is purely speculative, I grant you that.

I suspect we're likely to find out if this does work out in non-US countries once as medical information and training becomes more prevalent on the web.

You make some good points.

Of course, I cannot prove that the tests insure quality. In fact, this is not what the radiology board exam does.

The board exam is designed to weed out dangerous doctors, which is probably the best we can hope for. So, I guess you can take my word for it or not, but dropping the bar at all would let dangerous people practice, which I see as a mistake. The people that I know who failed the exam should not be working in Radiology.

>There are licensing and board requirements, but conspiracy theories aside they are not designed to create artificial scarcity, they're supposed to keep dangerously ignorant doctors from practicing.

Thanks for the comments in this thread, they've been very informative.

I'm happy there are certifications, and I believe you that the bar should be raised, but given the huge demand for doctors, why aren't we increasing the number of medical schools?

If we have a supply problem, and we don't want to lower the bar, it seems like the answer is to let more people in at the front end, and let the filter do its job.

Just wanted to point out that while it may seem intuitive that increased supply = cheaper prices, thats not how it works with doctors

Doctors have the ability and incentive to increase demand, and I remember seeing data that this is what actually happens historically when you increase doctor supply.

How do these ability manifest? I suspect what you might be seeing is latest demand. There are a lot of people that would see the doctor more often, but often don't due to prices. Once access and prices become more reasonable they seek out medical services they normally wouldn't have.

Or doctors see their profit-margins / wages declining, and lower the threshold level for various kinds of specialised testing. So, you complain about a mole or a lump, and instead of a quick diagnostic poke and an "It's probably fine", it's off for an invasive biopsy, "Hmm, the results were inconclusive, better safe than sorry" surgical removal, and maybe a few extra scans for follow-up.

I'm sure that there a many areas where a GP would like to schedule a follow-up, but can't justify it on the current evidence, and lets it slide.

Because there's this level of subjectivity in medicine, any increase in supply can easily be countered by the suppliers pumping up demand, keeping D/S exactly the same.

(I'm not a doctor, although I'm friends with a few)

I'd argue this happens today at almost the maximal level they can extract. In fact this was my point earlier. The problem with doctor's is less proficiency, but more ethics. I honestly have more faith in my car mechanic than virtually any doctor I've worked with. I'm not sure how increasing supply can make an already worst problem worse -- except to expose more people to it.

BINGO. You win the thread. The Clintons learned this the hard way, but most people don't understand how this could be true.

I really, really don't think that's true. Most people are not able to do this, and most of those few who could don't want to put themselves through it.

And then separately, how many people would trust a self-taught diagnostician?

Most people are not able to do this, and most of those few who could don't want to put themselves through it.

Most people don't have to be able to do it, just more than are allowed to do it now, but a factor of say 10.

Furthermore, I don't think people would necessarily need to go through med school and residency.

It's like building a website. There's probably some parallel universe where programming requires certification and only a handful of schools have it. It requires doing MITs SICP as the intro course. Requires compiler construction courses, algorithms, theory of computation and complexity, etc... And then a 4 year apprenticeship with other programmers. And then you can start building webpages, if that's what you want to do.

But we live in a world where it is open and so there's instruction available at many different levels. Would you let someone without a PhD in CS build your website? Of course you would.

And then separately, how many people would trust a self-taught diagnostician?

I trust my car mechanics diagnosis despite the fact I have no idea what level of education he has. But I'm fairly certain he's not an ME from MIT or Berkeley. With good self-study tools, I think that one can self-teach in specialized areas and achieve good mastery rather efficiently. I could imagine Khan Academy for Radiology taught by JHU and Harvard professors to be quite good.

> I could imagine Khan Academy for Radiology taught by JHU and Harvard professors to be quite good.

You have got to be kidding me. How would this work for surgery? There are no short cuts to medical competency.

Sure, some of what I do is self-taught, I read books and articles, attend conferences, and complete Continuing Medical Education requirements. But I am able to do this because I attended medical school, then spent five years sitting less than a foot from experienced radiologists while they worked and answered every question I had.

Characterizing it as a "short cut" is disingenuous.

The argument here is that medical boards are too rigorous, and test things that do not matter practically.

To give a ridiculous example, if a medical school required you to climb Mount Everest before becoming a doctor that might result in only 1 person becoming a doctor per year. However that scarcity isn't proof that climbing Mount Everest is needed to become a doctor. Nor is it proof that cutting out that requirement will provide significantly worse doctors than previous.

Additionally, in many things we need quantity more than we need extreme compentancy. For example when cut, its better to have some kind of treatment (e.g. first aid, stitching) rather than waiting for a surgical specialist.

In fact, the medical licensing exams and board exams are too lenient. The general quality of people going to medical school in the US has been dropping for a generation. The standards are sliding, to our detriment.

I'd be quite interested to see evidence to support this assertion. Or is it just generally the case that everyone sees Osler's days as medicine's primetime, with a long slide since then?

I don't have any hard evidence, but I insist that it is true.

Bright and determined baby-boomers became doctors and lawyers and accountants. Today smart and determined people aren't even going to college. The HN demographic is a perfect example of this.

Intuitively, I think I get a different sense of the HN demographic. It's one thing to say that the brightest aren't going to medical school. It's another thing to say that the best and brightest aren't even going to college.

I might argue that going to college is no longer necessary for the purpose of learning, because the material is so widely available. Even though I think that's true (for some fields), I still wouldn't advise people not to go to college because of the signaling problem (which one then has to sidestep by starting their own business or by contributing impressively in open source, etc).

I get hyperbole for the purpose of making a point, but if you go too far, you come off sounding a bit incredible.

Have you seen a typical medical school class recently? The people getting in these days is almost shocking. I have a hard time believing that qualified people are being shut out of admission.

Yes? I mean, I am a medical student, and I'm routinely impressed by my peers. But I'm not trying to claim that my peers are better than their predecessors. I'm just doubting your assertion that medical students now are worse than before. The null hypothesis certainly is that things are the same as they always were.

Instead of writing out a long response, I'll just point out that to compare building websites with diagnosing life-threatening illness many times a day is pretty ridiculous.

Of course you don't need to have gone to MIT, etc to build a website. The room for error is just many many orders of magnitude different between that and radiology. There's a reason you don't generally hire self taught code monkeys to build software with real-time or life-ensuring requirements.

This only applies if those rare skills aren't rare simply because the need for them is rare. Supply and demand determines prices.

Demand isn't just about how many people want it (although a little competition is good), it's also about how much each person wants it. It seems like medical diagnosis could command a high price, even if only one person needed it.

Exactly, you stated it much better than I could.

The Health Care Finance Administration ( Medicare / Medicaid ) sets reimbursements rates, and most private insurance companies follow suit. So, I don't get to charge whatever I want to read an MRI. And, I don't order the studies that I read, other doctors do that.

The only thing I can control is the number of studies I read. If I work harder and read more, I make more. It just so happens that I am very fast, and I have surrounded myself with fast partners. On average we read two or three times what other radiologists read, so we make two or three times more.

As far as disruption is concerned, for now the law is on my side. Of course a doctor working in India could read studies cheaper than I could. Most doctors complain about malpractice, without understanding the benefits. Trial lawyers hold me liable for my reports, and rightly so. If I miss a small treatable cancer, it can turn into a large untreatable cancer. This liability also confers a monopoly. How can a lawyer sue a doctor in India? Consequently, in order to perform a 'final read' on a radiology study in the USA, you must have trained in USA, be credentialed in the USA, and liable in the USA. This makes it very hard to undercut on price.

So, I'm not sure if I deserve what I make. There aren't a lot of people that can do my job, or withstand the training. Anyway, I'm saving everything I earn, because I don't think it will last forever.

are you concerned that a computer program could eventually do your job?

I'm not sure if you're being serious or not, but I'll answer.

I happen to think real AI will not happen in my lifetime, if ever. This is not an uninformed opinion, I have MS in Neuroscience, and I'm a programmer. I'm sure others reading HN will disagree.

It will take nothing less than a full artificial intelligence to do what I do.

If you want to read more about early attempts, there is something called "Computer Aided Detection" that is used when reading mammograms. It is awful, and I'll let you in on a secret. Most places that CAD their mammograms do it so they can charge more, not because it helps.

You mentioned in an earlier comment about a CT scan being 6k+ images. I'm assuming these are cross-sectional slices or something similar?

I know a guy who's working for one of the big CT manufacturers (Toshiba, I think) working on 3D image-registration and partial analysis. In essence, lining up the features from different slides and sewing them into a 3D model.

One of the big features being looked at was automatic labelling of certain gross anatomical features - I seem to remember something about cardiac veins needing to be marked as part of a scan report? By mostly automating this, it saves time for the user so they can just check they're correct, maybe move them if not, rather than having to do all the work themselves.

I can see this sort of work being much more useful, and happening in a much shorter term than any sort of AI "You have cancer" system. I wonder how you feel about that sort of thing?

I use this software when we perform a CT scan looking at the coronary arteries. Under perfect conditions it can correctly idenitfy the coronary arteries, and subtract away the rib cage, heart, and lungs.

It sounds like you already understand what it does. It helps me read a study quicker by automatically processing the data, a step I used to do by hand. Many times the processing fails due to an artifact while scanning ( patient moves, ectopic heart beat, poor contrast injection timing, variation in anatomy), and I need to process it manually.

When it works well it is very helpful, but to be clear, it does not interpret the studies. I think many people replying in this thread don't understand the enormous complexity to accurate radiology reporting.

He makes that much as a partner of a practice, not as a doctor at a hospital. This is no different than being a founder of a successful small business.

It's also worth noting that radiology has been undergoing some significant transformations. Formerly, a practice would contract with one nearby hospital to read their cases. With the advent of teleradiology, though, it is no longer necessary for the practice to be all that close to the hospital. As a result, radiological practices are contracting with more hospitals. They are growing and sometimes putting smaller practices out of business. So I imagine there are some big winners and losers out there in the field of radiology.

I don't have first hand knowledge of this; I am a programmer. I hear about this from a family member who is a radiologist. roentgen may obviously speak with more authority about his situation.

My group does this, but not because we're evil. Larger groups often have fellowship trained radiologists who are experts in a certain sub-specialty, for example Neuroradiology. Smaller groups are usually all 'general' radiologists.

If we can read pediatric brain MRIs more accurately from across the country than the local small group, why shouldn't we?

One additional note. My 'customers' are not really the patients, my customers are the physicians who order the studies. Most hospitals and referring physicians demand that I be available to speak with face-to-face, so there are parts of radiology that cannot be performed remotely.

What protects you from outsourcing the reading of scans to foreign countries, such as India? Obviously some medical institutions will want to keep it all local, but won't this open up a market for cheaper, foreign competition resulting in a downward pressure on compensation?

See my other answers. "Final reads" must be performed my a physician who did a radiology residency in the USA, and credentialed in the USA. Note, you don't need to be located in the USA, but it doesn't matter, there is no competing on price.

See my other answers. For each scan or xray performed, two fees are billed. The reimbursements are generally set in stone, and non-negotiable. Additionally, "fee-splitting" is Medicaire fraud. Meaning, if you as an independent businessperson own an imaging center and I read cases for you, you cannot keep any of my "professional fee" for reading the case. So there is no way for another radiologist to compete on price with me, it is simply illegal to offer to read the cases for less.

Do you think this Medicare law is useful for protecting consumers?

Not really, no.

Trust. FMG (foreign medical graduates) have an extremely low reputation in the US. It's a component of defensive medicine.

Correct. When a CT scan is performed, there are two charges generated. A 'Technical Fee' for performing the study, and a 'Professional Fee' for reading it. The technical fee is almost always larger.

If you work for a hospital they keep the technical fee, and you get whatever professional fees you can collect. Insurance companies hate paying, so they will find any reason to deny. Collection rates range between 60% and 80%.

My partners and I own imaging centers, we collect both fees. So we are running a business, and I don't consider it small anymore.

Disruption is learning about and becoming healthy, or for example, one may spend their life savings on some supposed cancer treatment involving chemo, surgery and radiation.

If you are still in radiology, I'm not surprised by this. Radiology is one of the few times that you can be a doctor and expect to work something like a 9-5 day.

There are other ways to have a decently normal life as a doctor, but on average it's a pretty hard life.

True, but I knew about the lifestyle when I picked radiology, and it is a very hard residency to get. There are others with a similar lifestyle, like Dermatology, Ophthalmology, and Radiation Oncology. Guess what? They are the hardest residencies to get into when you finish medical school.

I should make clear why I'm replying in this thread. The world needs good doctors, and I want bright and ambitious readers of this site to know that there is a potential upside.

I know this is off-topic, but I figured I'd take the opportunity to ask:

As a medical student who aspires to enter radiology and ultimately own imaging centers, like you, what advice can you offer that'd help me and other HN-med students position ourselves to be appealing candidates for a radiology residency?

I don't know any secrets. It's hard to get a radiology residency. You need good grades. I don't think research experience matters. It also helps to be somewhat normal. The people interviewing you for residency have to be willing to sit next to you for four years, so if you're a "closet case" they might pass on you, even if you look good on paper.

"and ultimately own imaging centers"

Contact the MD here for advice:


A nice guy, he was glad to help when I was thinking of starting up an imaging center. (The upshot from the meeting is that you have to have a tie in with a hospital and be aware that the hospital could end up doing the same in house etc. He's a businessman and a MD and would have profited from the association so I believe the advice was honest. Of course it's only one data point out of many you will collect.)

Thanks, I appreciate it!

Meta-comment: how is it possible that 2 reasonable, informative comments from roentgen are being downvoted?

I didn't down vote it but I suspect that it's

"Medical school was easy"

"went out drinking"

"partying two or three nights a week"

"did well with the ladies"

"get by on four hours of sleep"

"nurses were much more responsive to my advances"

"busy but always had time for each other"

"make over 800k a year".

"ultimate job security"

"tremendous resource for my family"

"easy to get screwed by the medical system...won't happen to me or mine"

"not a risk taker".

Did I miss anything?

Sorry, but I wanted to be completely honest. There were a few guys like me in my medical school. There needs to be a counterpoint to the doom and gloom reports of "no life" and "living hell".

(Not a med student, but I double majored in two different engineerings so I had a pretty tough road)

Honestly I think people over rate how difficult school is.

I was definitely in the camp of 'it's so fucking hard, I have no life, it's horrible' etc etc etc. And I'm a smart guy. Guess what, when I actually went through and figured out how much time I was spending working, it wasn't that much. If you clear out the procrastination and bullshit and just sit down and work hard while you are working, it's not bad.

Then you actually have free time.

I struggled with this for years, but working at 50% effort for twice as many hours is a horrible way to go about things because you end up living a miserable life.

At my graduation they announced the valevictorian. It was one of my friends. We had no idea. He never talked about grades. He never bitched about work. He went out drinking nearly every day of the week. He spent a lot more time chasing women than chasing grades. But when he went to the library to work, he worked.

Remember, 6 hours a day of hard work is worth a lot more than 12 hours of half assed work, and thats what he did. That leaves 18 hours a day to enjoy yourself.

"but working at 50% effort for twice as many hours is a horrible way to go about things because you end up living a miserable life."

For how long? The years of college and graduate school?

Misery is not working hard enough and then ending up being one of those people unemployed in later years. (Which I agree can happen to anyone obviously.)

"6 hours a day of hard work is worth a lot more than 12 hours of half assed work"

True. But you will never be able to work as long and as hard as you can when you are young. The fun comes later. And once you have a family and kids all bets are off as far as how much you can work.

Look different things are important to different people.

But in life (as in entrepreneurship) you never know the thing that you do that will eventually benefit you. You have to learn and do as much as you can. I can trace things now that are of great benefit today that I did 15 years ago by foregoing a summer and actually summers of fun.

It's easy to look back (even roentgen at 800k) and say "look it all worked out for me and I was able to party". But we don't really have much data to support that strategy (an outlier as pointed out by verisimilitude) and in fact it doesn't really make sense that you can put in half the work and do AS WELL as putting in more of an effort without completely wearing yourself down.

Thank you. However, statistical outliers (you) don't make strong counterpoints.

I'd describe you as a possessing several traits that make you well suited for a career in medicine.

Hypomanic personality. Characterized by low need for sleep, excessive energy.

High IQ/ general intelligence.

Low tolerance for risk.

You are probably making less money than you could as entrepreneur or in finance but that's consistent with your risk tolerance.

The professional medical career path is almost ideal for you and the author of the original post would probably acknowledge this. This is probably less true for many of the individuals who are steered into medicine by the elite educational system.

You have accurately described me.

In terms of job security, I heard that many hospitals are outsourcing radiology to India, ie. sending the X-rays, etc, over the internet and getting them diagnosed in India, by equally competent Indian doctors.

Is this true, and if so, do you think this might jeopardize at least radiology in the US?

> I make over 800k a year

Does it bother you that you are profiting handsomely from sick people?

Not at all. I'm very good at my job, and I worked very hard to get where I am. Sick people should be happy that I'm reading their CT scans. If the pay wasn't good I would have chosen a different field, and somebody else would be doing my job, less well.

For reference, before medical school I worked in IT, and at the age of 23 ( 15 years ago ) I was making six figures. I left that to go back to school, partly because I knew I would be financially rewarded.

Again, see my response below. I don't order the studies I read, and I don't set the reimbursement rates. Additionally, it is Medicare fraud for me to read a study and not charge for it. In short, I have very little say over what I earn.

Do you worry about being replaced by computer software? You said you make $800k a year, and for that amount of money you could higher 2-3 PhDs in machine learning and computer vision for each radiologist. Do that maybe 5 times over and give them 5-10 years and productivity and costs for CT scan analysis will probably go way down.

After all a radiologist armed with software that prescans each CT scan looking for interesting areas could work way faster then otherwise.

There's a small army of PhDs doing this right now, NIH-funded and in commercial research shops.

A radiologist still must look at every single slice for liability reasons for the foreseeable future. That's the real time cost.

I work for a neurosurgeon in image-guided surgical planning research. One of the challenges is segmentation (labeling) of target areas to use in navigation. (radiologists generally don't do this, for various reasons). I've used some of the best commercial software, and seen some of the top research algorithms. With these, for the `easiest` tumors, we still have to semi-manually choose the region on every 3rd or 4th slice. The best algorithms will interpolate the other slices based on essentially fitting along a levelset. For a typical tumor, it can take 20-40 minutes to do this task - using the best available software!

This is `not` radiology, it's image labeling. It's orders of magnitude simpler than radiology.

There are some promising techniques to, for example, automate detection of changes in volume of some radiographically questionable area (after manual labeling for the first scan). At best, this will add information with no extra time cost.

I can assure that there are already an awful lot of PhDs in machine learning and computer vision working on the problem of automatically analyzing medical images, and there's been lots of progress over the last few years. There's a really long way to go, however- it's one of those areas where the problem is a lot harder than it seems.

Working in the field has convinced me that radiologists earn every penny, and that there are good reasons for the lengthy residencies and stringent board exams.

> it's one of those areas where the problem is a lot harder than it seems.

Yes, exactly. To computer savvy people unfamiliar with radiology it looks like something a computer might be good at, but I suspect the best we can hope for is a computer to aid me in my work, not replace me.

I've sort of answered this problem above. I happen to think the problem is not solvable any time soon. If you or someone you know would like to prove me wrong, I will invest in your venture.

What type of work were you doing in IT? What was educational background at that time?

More importantly, does it bother him that they are sick in the first place, or is he happy?

Well, people aren't going to stop being sick anytime soon, so I guess I'm happy that I'm around to help them get well again.

keep going.. with time, money, knowledge and youth, I bet you could be doing more.

I sometimes wish I had gone to medical school - now is an amazing time to be in healthcare. Technology has the potential to have a huge impact.

Here's the problem: most intelligent driven people are not going to be satisfied with "having a regular job, enjoying life, etc" Sorry, it's just not built into us. Sure, we want those things, but we also want that sense of achievement or of making a valuable contribution to something bigger than our immediate concerns (e.g. a big impact startup, saving the world, or cure someone's illness). The key to health is not losing sight of the "regular things" in life while still pursuing our ambitions.

In medicine it's sometimes hard to see the positive impact you're having. Or maybe you don't think you are having a positive impact. If that's the case then figure out what the problem is and hack it.

One thing that won't fly is pining away for a "regular life" - If you were really going to be satisfied with that you would have taken that route a long time ago.

Believe me, there are people with regular lives who are wishing they went to medical school....

I up voted you, because I agree with some of your points. But I don't agree with the rest of it.

There are those, especially who visit this site, who are smart, have a lot of motivation, and want to do something great. Enterpreneurship is a hard life as well. Running a startup will suck much your life as much as residency or medical school might.

As you say though the key to health is not losing sight of the "regular things". The problem with medical school and residency is that you have little control over that. You will lose sight of the regular things. You won't be enjoying your life. And here's the big catch... you won't be changing the world, either. Being a doctor is not glamorous, if you think it is, re-read the rant because he touches on much of it.

And, very few people have an actual "passion" for medicine. I don't think I've met one person. Someone who would be doing medicine even if they didn't have to. Maybe your startup won't change the world either, but at least you might have a personal passion for it or the process.

My point is that for those with regular lives who wish they went to medical school... What's the reason? Read the rant. It's the wrong reason. (he even spells out that there is only one good reason to go into medicine)

I'm dental myself (waay easier than med in my opinion), but I do have friends in med. (Well, people I used to spend time with before they got socked with residency). So, I'm curious: were you _relieved_ to be able to take a different path than working as a doctor?

It's the sort of thing you aren't fully aware of while you are in it. After I quit practicing, it really felt like an enormous weight had been lifted. Just due to the responsibilities involved.

People ask me if I miss it. I do not. That said, I don't want to make it sound like it was terrible. There was a fair amount of job satisfaction and rewards as well, like most things, and at the time I felt like I enjoyed it.

arn, thanks for sharing, truly. I'm a general medical officer in the Navy (Navy still puts docs to work after internship, applying for residency later. The work is mainly fast-track or urgent care style triaging and treating).

I'm currently facing the choice of extending my current tour a year then going back to residency or taking a another two-year tour with the Marines and going to Afghanistan. I'm married with kids in California, so I could conceivably do either without moving the kids. Clearly, we have different paths, but why did you opt for the web over practicing? Along those lines, what was your fellowship? Where are you now? (Read: if you are in SoCal, I will take you to dinner of your choice in exchange for the conversation).

Fellowship in nephrology. Now in Virginia. Financially, it became an easy decision. I was making enough that I didn't have to keep working in medicine. Beyond that, I had my first child around that time, and didn't want to lose that time.

Feel free to email me if you have any further questions (email in profile).


The article is also missing something vital: medicine shuts down so many options. By the time you're down, you're so indebted that residency is the only thing that makes sense. Penelope Trunk gets this: http://blog.penelopetrunk.com/2011/08/30/the-best-alternativ... , but few others do.

I'm dating a newly minted resident, and she's inspired me to start my own essay and why not to be a doctor. Her, and a lot of the freshmen I teach who say they want to be doctor.

If you want to work in medicine, be a nurse instead. If you're the sort of person who'd like to see a draft, send an e-mail to seligerj [AT] gmail ((dot)) com .

... pretty much. I'm doing med school now, and it's been fun. How does one balance this stuff with hackery and such? "You don't" is the answer I've been getting, but I suspect/hope that it takes some clever time management.

I started MacRumors.com in my 4th year of medical school, which is a very light year. And it grew in the following years. I quit in 2008 to do it (and other sites) full time.

Assuming you grew up with Asian parents (disclaimer: I did), how'd breaking the news to your parents go when you decided to leave school and run a website full-time?

I grew up with Asian parents (who are doctors themselves, no less). Before I went off to med school, they were actually pretty open to other career choices. We spent quite a bit of time making sure that medicine was the way to go before confirming my enrollment. But after that, they've been committed to preventing me from giving up ;p

parents took it surprisingly well. don't think they would have taken it well if I had tried to quit years earlier. the site had grown pretty big/successful, and they mellowed over the years.

Thanks for assuring me that it is at least possible. I guess I'm still one of those idealistic greenhorns... thinking that I'd be more useful to the medical community if I were also a computer hacker.

The reason why it is so hard to become a doctor is because the AMA restricts the number of applicants and schools that can create doctors so wages can remain artificially high.



Does anyone have any idea if this would be similar to becoming a doctor in Canada? My girlfriend is doing her undergrad and plans to do med school, I'm not sure if I should show her this article or not... If this really only pertains to becoming a doctor in the USA, then there isn't a point in shower her this. Any advice/info is appreciated :)

That post should go straight to the top.

This is also why residents have to suffer ridiculous hours. With the severe limitations on the number of people who can become doctors, the profession is characterized by an extreme workload.

It's seriously wrong. I, for one, would not want to be operated on by a surgeon who'd been working for 21 hours straight. Commercial pilots are limited to 40 flight hours per month, and what they do is a lot less complex than what doctors have to do.

There are commercial pilots and there are commercial pilots.

The senior staff can pretty freely pick the longest and easiest flights with the most turnover time, and thus they can enjoy eating and sleeping, and probably some shopping or exercising as well. On the other hand, if you're a young co-pilot you are likely to get the shittiest flights and the worst possible schedule, and you will probably find yourself in situations where you've flown more than your fair share of hours straight and you still have to haul one last plane home. And wake up next morning at 6am to begin a new shift.

I must say that planes have autopilot but operations don't. That might not be of much consolence, however.

So, effectively pilots are only working 1/4th of the time that I work? Or is there non-flight-time work that eats up 120 more hours a month?

There's a fair amount of non-flight work. It'd say that it averages 120 hours of work time total per month. Less than we work, but with worse hours.

If you fly international with the majors, you're in good shape. Those guys make $200k easily, but those jobs are essentially inaccessible because the people who get them never retire. The rest make very little, and work a lot harder.

What sort of non-flight work do they do? I'm honestly curious, and I don't know any professional pilots. I imagine there's paperwork to fill out before and after every flight, and maybe mandatory training...

Walking around airports, going through customs, switching planes, waiting for matinee, paperwork, hotels, etc.

I'm married to a resident and this article is a very accurate portrayal of a resident's life. Her work schedule is insane. It's not just the amount of hours but the fact that these hours are packed and spent with difficult people and life or death situations. After a day of work she often mentions she didn't have time to eat or pee during the day. She has had some call shifts that lasted 40h strait (more than 3 days) where she got only 3 to 4 hours sleep breaks per night plus a few eating breaks here and there because it was busy the whole time. That meant no time for a shower in those three days, only superficial cleanups and quick change of scrubs when things got too bloody/amniotic.

I'm dating a resident.

Also, anyone thinking about medicine should realize how little autonomy they have. When my girlfriend explained how residency works, I was shocked: it sounded like a circumstance ripe for an anti-trust lawsuit. Turns out it was the subject of a lawsuit: http://www.nytimes.com/2004/08/14/us/antitrust-lawsuit-over-... , but one that Congress and President Bush granted an anti-trust exemption. So residents can't even negotiate outside the match. The legal barriers to medicine help explain why it's so miserable.

Great article and on point.

A former flatmate of mine committed suicide about 1.5 years after I left the flat, which I did due to his erratic and hostile behavior toward me, which I think was due to a number of factors, but mainly his stress from an intense hospital residency while he also did further study simultaneously.

There's an article mentioning him here: http://vitualis.files.wordpress.com/2006/09/action_vow.pdf

The danger zone for med students is when they sacrifice themselves and tolerate all the reasons that the Harvard article states why not to go to med school, because of the idealistic notion that:

"You have only ever envisioned yourself as a doctor and can only derive professional fulfillment in life by taking care of sick people."

As such, these smart and ambitious med students shoot for the moon, and due to the reasons in the article, realize that they won't make the moon (ie earn that fellowship, obtain that degree, receive that certification, get that promotion) and then they feel that their life is a failure, or won't have any further meaning the way they wanted it to, and then they kill themselves, because they have no exit strategy (or plan B) and are ill themselves.

There's nothing noble about the suicide of med students and interns, but I've seen how it happens right up close. I have further thoughts on the matter but that's the core of my experience regarding the negatives of this career path.

There is not a doubt in my mind that this schedule ensures that they learn less and perform their jobs in much worse ways than compared to when they would be able to get more sleep and less stress. There's zounds of experiments that back me up on this.

As far people saying it's cheap labor: when residents make mistakes and the hospital gets sued, the labor suddenly isn't so cheap anymore. Again, there is not a doubt in my mind that this practice leads to a lot of damage and death, with the associated financial fallout.

That hospital management doesn't try to change this shows how blind they are to the consequences of entrenched practices. I wonder whether the health care market could be disrupted merely by creating hospitals that actually try to get their employees to perform optimally.

I personally have been very happy with my decision to go into medicine (specifically, interventional radiology). I have a few comments about this discussion:

1. The average radiologist gets paid about $40 (after expenses) to read a CT scan. So you have to read a LOT of scans to make as much as roentgen. Many scans contain hundreds of images, and the diagnosis can depend on just a few pixels. Partly based on the radiologist's diagnosis, the patient may need to go to surgery (at least $25,000) or need another round of chemotherapy ($50,000), etc. When viewed in this context, I think $40 is a great value for getting an expert opinion. (As a side note, there is a lot of regional variation in salaries. They are probably lowest in New York City. Contrast that to law or finance, where the highest salaries are probably in New York City. I think the difference is due to the fact that medicine (even radiology) is practiced locally, and thus depends on local supply and demand, and does not have the kind of network effects that you see in law or finance.)

2. In terms of disruptive technologies in radiology, I don't think that computers will be able to replace radiologists any time soon, but there are lots of ways that computers could help radiologists be more productive or accurate. Much of the advances in consumer technology from the past decade are not yet available in radiology. Images are usually transferred to another hospital by mailing a CD. Reports are transferred using a fax machine. We're lucky if we can get 10 frames per second when scrolling through a large study. Computer systems are not linked -- ie, we have to type the patient's name into both the radiology system and the medical records system. For various reasons, many of these problems will have to be solved by big companies and not startups. But there are other opportunities for startups. If you're interested, check out my startup http://www.revisionrads.com.

Some of the comments on that page are even better than the main article/rant:

"Last note, what bullshit is it that your plumber can charge whatever he wants to unclog your drain, but if I replace both knees the insurance companies automatically take 50% off the second. What am I, fucking Payless?"

That's not a great analogy. The insurance companies have negotiated a fixed rate with the hospital, and so if you work for the hospital, of course you must honor it. Same as if you were a plumber working for a large plumbing corporation, which had a contract with its clients. In that case, if you unclogged the drains at BigCorp, you would not be able to charge whatever you want, but only the rate BigCorp had negotiated with your employer.

So I owe HN a blog post. Here is something of a stopgap.

I am (still) a medical student at Johns Hopkins, and I love the place very much. I have for the past 6+ years.

After my third year, essentially on a whim (my sponsor, I think, knows this) I pursued a research fellowship in cardiovascular genetics. I loved it a lot, and stayed on a second year (spontaneously; thank you, Stanley and Lola J. Sarnoff).

After my fifth year in medical school, my second year of CV genetics up at MGH and the Broad Institute, I got the opportunity to pursue the startup dream for a year. I'm midway through and absolutely loving it.

But yet, I miss medicine. And I think that the grass is always greener, so I think I will miss whatever I'm not doing. Next year, in medical school for the first time in three years, I will miss research. Or I will miss the startup life. Something. I know it, because right now, I miss the hospital.

I miss working 80 hours a week while paying $50,000 a year for the privilege. I miss having a best answer (and if you think there are better answers in software than there are in medicine, please email me so I can hire you).

But I know that soon, I will miss the freedom of working at a startup. There is no right answer for everyone. And for many of us who were drawn to medicine, I think there can be no possible right answer, ever.

Married to a final year surgery resident and unfortunately this article rings very true. I'm not sure if the profession changed at some point, but if we were advising my kid now on future professions, doctor would not be on that list. I remember the idealism that my wife went into the profession with and that is completely gone now. I find that very sad.

Well said.

After four years of gearing up to go to medical school, I dropped that goal and went into software engineering. I wrote about this choice pretty extensively, as it was not an excruciating decision [0]. In spite of how much I really wanted med school, I also wanted a life. I tried to maintain a life while applying to med school, full of all the hobbies that make my life fun, but balancing those two wasn't actually possible. So I chose to reclaim my life.

Reading this piece is refreshing--I haven't seen enough people talk about the trade-offs of a physician. A lot of people in software think "I would have a meaningful life if I were in medicine"--and they probably have the smarts to be in medicine--but I think we should combat the idea that moving in that direction makes for a life that's any more fulfilling than engineering.

[0]: http://wit.io/posts/pivot-my-journey-from-medicine-into-tech...

They should be treated as Flight controllors. My friend is one and ,it being a high-risk job like being a doctor, they have 8hr workdays with 2 hours of working and 2 hours of resting, and their salaries are sky-high. So sad all those smart,kind and hard-working people are being so used.

(plus, so glad I didn't end up in med school, I almost did :)

Do you know how they settled on the 2 hours on/2 hours off deal? I'm interested in alternative working hours to improve productivity and would be interested in knowing more about their schedules.

I started the med school track late in life (27 when I started taking premed classes), and while I haven't finished, I have to say that all of the complaining I hear from fellow students and doctors is ridiculous. All careers take up lots of your life. All careers end up dominating your social circles. All careers leave you feeling underpaid, including the people I know in finance who makes tons of money and work 12 hours a day 7 days a week minimum. Life is hard. I'm glad I took a lot of my 20's to experience that in other ways, so now that I've come to the medicine path, it really feels great. I agree that the decision to do this is not one that an 18 year old starting undergrad should make. But nonetheless, medicine is no worse than anything else.

Did you read the article?

No of course not I'm studying to be a doctor.

Kinda explains.

Was it always this bad? Was the process of becoming a doctor more sane in the past?

What would be the picture of perfect 22-29 span? Being born with a silver spoon in a mouth? Partying every day?

I'm a CS grad student, married to med student. While our schedules are different, there isn't much difference in time. I'm mostly occupied with reading papers, grading papers, doing homework, grading homework and generally providing very cheap labor in a form of research assistantship and teaching assistantship to university.

To me, the experience of every point the author mentions is the sole reason for existence between 20-30 years of age.

The most telling part of this article is point #8 (which basically says you will end up blaming and then eventually disliking the patients for your sad lot as a modern day doctor). What I find amusing here (and so comically characteristic of a Doctor's absurd notion of self-importance) is that the author so completely lacks the capacity for self-introspection that he doesn't even realize the truth of who is to blame.

To all the doctors out there that feel the same way as this author does I have one message for you. The only person to fucking blame is YOU!!!

Guess what? You're the one who made the decision to go into medicine and so you're the person at fault for the sad state of affairs in the modern medical profession. It's your fault for failing to do your due diligence on the demands and rewards of the profession. Why didn't you do your due diligence? You probably had some romantic notion of what it would be like as a Doc. Or possibly you went into medicine to make your parents happy? Or you thought it was a respected profession, or you simply wanted to help folks in need because it's an altruistic pursuit.

Well, sorry buddy, but all those things aren't an excuse for not doing your due diligence. It get's worse though...

At the macro level it's a self-reinforcing cycle. The lack of due diligence happens so frequently and by so many aspiring docs, it has repercussions on the profession as a whole. At the aggregate level, it causes wages to fall and working conditions to get worse for docs and interns (since the demand for medical school entrance remains strong regardless of conditions or wages).

You think just because you got good grades and got into med school that makes you smart? Ummm...no. And that is why Doctors get paid less than - and have more difficult working conditions than - Investment bankers. The type of person who goes into I-banking is smart enough and introspective enough to do their due diligence. The type of person who goes into medicine isn't.

As a complete aside, the Piecework article by Atul Gawande linked from the story has now been archived, and they broke the original URL.

Working version at http://www.newyorker.com/archive/2005/04/04/050404fa_fact

wait, so, in the US a programmer earns double what a doctor earns?

No, not at all the average doctor's salary is more than twice the average programmers salary.

The article lists $45,000 per year for doctors. Programmer polls on HN showed that $100,000 is little.

What am I missing? :-)

$45/year for residents. At that point you're still basically an apprentice doctor.

Right. Turns out I completely misunderstood every sentence that contains "resident" in that article, then :-)

Thanks for pointing it all out. Does make his argument about the bad money bogus though. Nearly every other job is worse money than being a doctor (which is why he compared to investment bankers and the likes)

Well, the things is that if you include resident medecine studies are really long. So: * You'd have to average for a life time of work * You need to make sure you subtract the cost of studies (although in US pretty much any study costs a ridiculous amount of money) * You may also want to take into account that you start making a good salary late in your life, at a time you'd need some (like when you want to buy your first house)

Anyway, I don't know about US but in France doctors are not that bad. They have pretty competitive studies and they also have a few resident years, but they don't have to pay for study (as for any student) and pretty soon they get their well paid job. They also don't have as many stupid trials as in US.

Does make his argument about the bad money bogus though. Nearly every other job is worse money than being a doctor

If you worked those other jobs for 80 hours a week, I think you'd start catching up pretty quickly ;-)

Yeah, but in medicine, by the time you're making the big money you're working much less. Or on whatever schedule you like.

At the age of 29: $45,000 for eighty hours a week.

At the age of 49: $600,000 for forty hours a week.

HN readers are not average programmers and are not likely to be junior.

Or people lie.

I understand that $45k is about average for residents. Fellows make a bit more, and so on.

Then, if you think of work as the process of converting time/life into money, I'd say private practice is a bit more efficient than hospital work. Because you work for yourself, you get to extract as much life as you want in exchange for money. I suppose it is very similar for entrepreneurs.

I think it's implied after 8 years of experience.. Still seems a little sketch, but I think it would be on par in say the Bay Area (though the programmer would have no debt)

I practice, but most of this article rings true for me as well, and I think most of my colleagues would consider me pretty idealistic.

Residency training is mostly cheap labor for hospitals. Working 36 hours straight every third or fourth night (common when I was a resident) saves teaching hospitals from hiring night floats or other coverage. Trying to make any kind of important decision for another human's medical care after you've been up for 24 hours is like trying to do so after several shots of alcohol. Such a schedule does not teach efficiently, endangers patients, and stresses the mental and physical health of physicians. There have been new work rules supposedly limiting residents to 80 hour work weeks, but they are routinely ignored.

Physicians spend most of their time trying to bring order to chaos. Regardless of a physician's specialty, I daresay each was shocked to learn how much time he/she spends basically just trying to simply coax new behaviors in patients - as such, performing at some level as psychiatrists (who I respect greatly - tough work). That's the challenge; everything else is pretty much plumbing. Either you find that work interesting (and it can be) or you soon get pretty burned out dealing with humans as they are, and they are obviously at their (usually temporary) worst much of the time when they need medical care.

My own colleagues are the best people I know - I still see the driving compassion there on a daily basis, and I think that's true for the great majority of docs. On the other hand, I've met a few physicians who would be happiest in concentration camps performing medical experiments on the inmates.

It's ironic that it doesn't have to be this way at all. It's counter productive other than it makes someone richer. Doctors want to keep their high prices with artificial barriers such as these and the glamor keeps the supply relatively high.

The long hours and over working is more a factor of a hospital trying to save money than having anything to do with supposed 'price controls' being purposefully set up by doctors. The price comes mostly as a factor of the extremely expensive education (both in cost and time) that is necessary. If you want talented people in any field, especially one with such a laboring path of entry, you have to pay them well.

If the kids had choices, they would not choose hospitals where shifts are 40 hours long and only sleep of 6 hours out of those 40 every thing else being equal. They don't, because of the power that the hospitals have over residents in granting their licence and the cultural ubiquity in practice.

Similarly, there are very limited spaces to enter medical school and it's extremely difficult to enter. How many new orthodontists are trained in a year? Under a 100? In a country of 300 million people? On top of that, medical school is very expensive. On top of that, you have to go to university for 3-4 years before you can even enter med school.

Imagine if engineering degrees were like that, because they could of been. Similarly with accounting or finance. Maybe they're not because the math heavy nature is enough of a barrier, even the simple math of accounting. American medical schools (and doctor associations) could choose to structure their curriculums to be similar to an engineering degree, admit high school students and make the education be 5-6 years long, teach in the summer, whatever. I'm fairly sure the UK does that, and I'm not sure if they haze their residents too with 40 hour shifts. They can also release the spigot, hire more teachers and teach more students to increase the supply of doctors. The increased supply of doctors will lead in a decrease of overall doctor wages and decrease health care costs. That along with an FDA drug approval process that doesn't cost 200 million and more clearly defined and easy to avoid malpractice rules (as in it's not easy to commit malpractice by mistake) would lead to huge systemic decreases in US health care costs alone.

Don't tell me it's about wanting the best, because treating people with sleep deprived residents is negligent. That is no where near the best care for any sort of patient. The best will just walk away once they know that they can make more money doing less work in i-banking, tech, petroleum, engineering, or business in far nicer environments, and they do by droves.

Medical degrees are first degrees in the UK:


I believe traditionally junior doctors in the UK were also made to work extremely long hours - there have been efforts to change this recently.

Yeah, it does make the lawyers and insurance vendors richer...

(no offense intended; wealth is good!)

> You should become a doc because you always wanted to work for Medecins Sans Frontières and your life will be half-lived without that.

Everything else was just whiny bullshit.

We all hate people. It's because people have no common sense anymore. People don't respect the Earth anymore. It's all about greed... and greed is and has always been the seed of all Evil. Combine greed with a constant influx of media and interruption, you get zombies.

It's never going to change. We are left here on this lonely planet to our own devices - we were warned about greed, but greed has in fact taken over.

The 90's saw the most productive and the most lucrative period in the history of mankind. We take it for granted. The truth is - to live in the USA during the 90's was the pinnacle of human civilization and it will never be that way again. It was unsustainable.

We are in a death spiral, there will be casualties. Those that cannot adapt will be sacrificed. Gasoline has been replaced by the Internet and global marketing. Gasoline is obsolete.

Gasoline is obsolete. Because it's cheaper to hire foreign workers via the Internet than it is to make cubicles in the USA.

One could say the same for any given field from sports to programming to business to pet-sitting. It's a hard knock life for us all. None of these reasons should have stopped any decent doctor from taking the path. The single reason would be: Don't go into medical school if you care more about money and an easy-going life than the actual field and people involved. And the same applies to every single field.

> One could say the same goes for any given field

Please name a sport, business, or other profession that involves staying up 40 hours straight unshowered, unfed, on a routine basis, for years, trying to not die or get anyone killed.

I can think of only two: medicine and the military. I do both. They're roughly equal. Given the choice between residency and deployment, I would need more information.

edit: Actually, I'm facing that choice now: do I apply for residency or orders which will probably involve going to Afghanistan. I'm leaning toward Afghanistan.

Deep sea fishing? It certainly gets the very little sleep, unwashed and very dangerous aspects.

"... Please name a sport, business, or other profession that involves staying up 40 hours straight unshowered, unfed, on a routine basis, for years, trying to not die or get anyone killed. ..."


So... the military, just as the commenter you replied to already noted?

"None of these reasons should have stopped any decent doctor from taking the path. "

Here's part of the problem. You don't know what it's like to be a doctor, until you become a doctor. I think that's somewhat unique to the field. You can go into it with the right intentions, but it's not like people doctor as a hobby or as a passion and then decide to go into it. It's not like being a musician, or a programmer, sports or pet sitting.

You don't know what it's like to be a doctor, until you become a doctor. I think that's somewhat unique to the field.

No, it's like that in a lot of fields.

Obviously, many jobs have a much lower barrier to entry than "doctor" -- it takes years of work to reach the point where you can understand what doctoring is like first-hand -- but I've found most jobs fall into one of these categories:

A) The problems with the job don't always manifest until you're months or years into it, whether it's long-term boredom, lack of opportunity for advancement, chronic occupational injury, or rare but awful events. (Soldiering is a lot more fun before you're under fire than afterwards.)

B) It's not so hard to be a happy amateur, but the amateur experience is much different from the pro experience. Pros need to make money, consistently, and that is a big constraint, often to the point that it takes an entirely different skill set. (e.g. Being a freelance programmer or musician is as much about marketing and customer service as it is about code or music, and the stuff that's valuable to customers may be boring to the point of tears for you. Ask a classical musician to tell you how they feel about the inexplicably popular Pachelbel's Canon.)

C) And, of course, jobs with barriers to entry are hard to really understand until the barriers are down. Research has a whole series of barriers: Being a science major is not like being a grad student, being a grad student is not like being a postdoc, being a postdoc is not like being a junior prof.

Mind you, though you can never know what it is really like to do a job without doing it, you can interview people and get some big hints. And you'll find that medicine is actually pretty easy to research, as careers go. The OP's points are not hidden mysteries. They have been made before. There are a lot of doctors, both successful ones and burned-out ones, and they're happy to talk. The trick is to be able to listen to what they tell you, and unfortunately there are also a lot of teachers and parents who are happy to push you into medicine regardless of what the actual doctors are telling you.

I agree with you to an extent but this article is especially relevant to the medical profession. There is a tremendous commitment to entering it. You must go to undergrad, medical school and residency (with standardized exams throughout) whereas for programming, there is no "traditional" path that you must follow. Moreover, although there is a tremendous reward—financial, societal and perhaps even moral—at the end, that end only comes after 8+ years of extremely hard work. Compare that with programmers, athletes and businessmen who could make millions before they turn 30. I know this number is very tiny but such a prospect is virtually impossible for any med students.

I'm not disparaging the medical profession; I actually go to a school where most students (I'm guessing about 30%) are pre-med majors. If anything, this article makes me appreciate just how much sacrifice doctors and doctors-to-be make just to help people.

I'd argue that this sort of article applies mostly to the "glamourous" professions -- things that kids want to be when they grow up, jobs that will impress your nephews. Actor, musician, doctor, certain varieties of lawyer, physicist cough, athlete, artist, airline pilot.

These sorts of professions have a ready supply of suckers wanting in, which means that the competition is tough, the work is hard and the compensation is minimal at the lowest levels. For all of these professions, the advice is the same: there are definitely some cool bits to the job if you can reach the top, but it's a really tough slog, so don't go into it unless you just can't think of anything else you want to do with your life.

But then you've got the less glamourous professions. Accountant. Actuary. System administrator. Management consultant. Less glamourous varieties of law. Pet sitting. Running a lawnmowing business. And hundreds of other occupations which don't readily spring to mind because they don't impinge much on the public consciousness, but which exist and pay well and are good jobs for folks who can't think of anything else in particular that they'd like to be doing. Since there aren't huge masses of people clamouring to become actuaries, junior actuarial positions are actually well paid and generally reasonable jobs. On the downside, your nephews won't brag to their friends about their uncle the actuary.

Figuring out where programming jobs fit into this classification is left as an exercise for the reader.

Last I heard actuarial science is brutally competitive and quickly becoming a slog. Apparently all the asian math geniuses see it as their only way to please their grandparents without switching to medicine or law.

How depressing.

Actually the introductory salaries in law are quite high. They start in Canada at or above the average Canadian salary. First year lawyers make between $40-100k a year depending on who you work for (in Ontario). If you're willing to move there's also nearly guaranteed employment by going up north/rural areas.

Being a doctor doesn't take 8+ years of education just because it's a competitive field.

No, but the bit after you finish medical school and spend the next eight or twelve years as a sleep-deprived zombie working thirty-hour shifts for a crappy salary at a hospital you probably didn't choose is due to it being a competitive field.

"One could say the same for any given field"

Nah, it varies a lot. The nature of the work itself is different among various jobs and economic forces also create inequalities in working conditions in various industries.

I've been a programmer and a teacher. I've found being a programmer to be easy, and being a teacher to be difficult (but not as difficult as what was described in this blog post).

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