Is There a Future for the Professions? | Hacker News Reader

Is There a Future for the Professions?

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72 pointskawera58 comments

I think it's a question of barriers. You can't charge tens of thousands (often totaling hundreds of thousands) of dollars and many years for a professional degree and expect folks to buy it over other options that cost far less time and far less money.

I'm not saying coding bootcamps are panacean, but hiring does occur at such places and their cost (again, in terms of time & money) is a fraction of the cost of traditional professional education.

Professional education will need to adapt. I've heard of disaster-prone areas producing doctors in a matter of weeks. I don't want to be treated by a doctor who only has 8 weeks of training, but I don't think it's a bad start to a more, immersive, apprenticeship-based program that allows candidates to earn decent money while learning the full profession.

Do you have links for the 8 week doctors? Thanks in advance.

While I have no idea if OP was being hyperbolic, EMS level 3 could be shoved into 8 weeks if you were motivated, its only like 20 credit hours plus practical field work.

Not intentionally. I can't find the source right now, but I recall an article mentioning medical practitioners being trained for massive natural disasters (e.g., Haiti) in a matter of weeks.

Obviously these people were trained to perform a very narrow range of tasks, not unlike a coding bootcamp student would learn Rails and be virtually ineffective with just about anything else.

Even the article conceded these practitioners weren't ready to be full-time doctors, but the point was that they could do something in the field without years and years of formal education..

In more common terms, they'd be medics. That's a bit broad, as some medics are far more capable than others, but for those who are primarily intended to provide first aid (rather than long term care or surgery or diagnostics), they're typically called medics. And 8 weeks is enough time to train someone in the basics of that field (especially 8 weeks of full-time training).

Just drop into some country with Ebola.

>I don't want to be treated by a doctor who only has 8 weeks of training, but I don't think it's a bad start to a more, immersive, apprenticeship-based program that allows candidates to earn decent money while learning the full profession.

I think we need multiple grades of doctor. Even something as simple as being able to stitch up a wound is useful and could lead to positive health outcomes for those who couldn't otherwise afford a trip to the doctor. Better to get some healthcare than have all doctors be the best possible, but inaccessible to the masses.

I'd liken it to gas stations that also have small garages that can change your oil and top off your fluids. You'd probably never want to have them replace your transmission, but oil changes alone are in high enough demand that I'm sure they make up a good portion of all visits to mechanics.

I'm guessing that a similar situation exists with doctors; physicals, vaccines, and a handful of common diseases (like colds) probably make up a sizable percentage of visits. There's a market for someone who can just handle these cases and pass them off to the higher grade doctor when the need arises.

To an extent we have this in the form of various grades of nurses and the dazzling array of specialists that now exist, but it's not quite there yet.

I think we need multiple grades of doctor.

Isn't that where nurses come in?

It's pretty much impossible to just book an appointment with a nurse right now in the US.

I booked an appointment with a doctor for basic allergies (Houston), and ended up seeing some version of nurse instead. It worked well, and I didn't have to wait weeks and weeks for the appointment.

Then I think I see a pretty simple fix...

Legally, many levels of nurses can't write prescriptions. They also can't take appointments directly--I'm not sure if that's a legal requirement also--even if the work entailed would have been entirely done by them.

> I think we need multiple grades of doctor.

Don't we have that already?

Doctor / Physician

Physician Assistant

Nurse Practitioner

Registered Nurse

Nursing Aid / Nurse Assistant

You can't book an appointment with most of these directly, and not all of them can write prescriptions legally. For instance, I can't just book an appointment with a nurse to take a look at a cut to see if it needs stitches. The nurse might be the one to actually do the work, but I can't cut out the middleman legally.

> You can't book an appointment with most of these directly, and not all of them can write prescriptions legally.

You can with many nurse practitioners (and maybe physician assistants, but I've had no experience with them) at places like minute clinic (http://www.cvs.com/minuteclinic/).

I've gone to a similar place that's in my office for some minor routine things, and it's been cheaper and easier to schedule than a proper doctor visit.

Nurse practitioners are special in that they can do roughly 80-90% of what doctors can do, including writing prescriptions. In some cases they can act as specialists, such as handling mental health needs that your standard GP wouldn't handle.

They certainly do have an important role to play, but we need a lower level medical professional that can accept appointments and perhaps write a limited set of prescriptions and handle treatment of basic ailments.

One shouldn't need a masters for the 'oil change' of medicine, just as one needn't be a registered engineer to change an air filter.

PAs fill much of that role. Yes, they do require physician supervision, but at many practices you can make appointments directly with them, never seeing an MD.

The last time I needed a basic physical, I saw the PA. She ordered blood-work and reviewed the results with me. I'm sure one of the physicians signed off on everything, but as far as I know, she did the work.

Likewise, the last time I had the flu, I made an appointment with one of the PAs. She did everything, with the physician just signing off on the prescription at the end.

Post-surgery, my follow-ups were with PAs or NPs, not the physician. He did drop in to say "Hi." but that was about it.

> You can't book an appointment with most of these directly, and not all of them can write prescriptions legally.

So I think that varies from state to state.

[Anecdote warning] When I was in grad school, at least, I was able to directly book appointments at the student health center with PAs, MDs and DOs (perhaps a university-run health center is different, somehow?). I also don't recall ever facing difficulty having a prescription written.

My understanding is that a PAs can't open their own practice, but that several PAs can function more or less independently under the supervision of one MD/DO principal.

Nurse practitioners are doctors. None of the others listed can legally diagnose illnesses or prescribe treatment. That's the point. If nurses could open up their own practice and prescribe meds, that would be more like what the OP is proposing.

PAs have prescribing power

Nurse practitioners might have a doctorate in nursing, but calling them doctors is extremely misleading. They function is a very similar capacity to PAs, although PAs often have more capabilities.

All of the levels mentioned here have their places, but calling any of them "doctors" who don't have an MBBS, MD, DO, or equivalent physician-level degree is inappropriate.

They do not require a doctorate in nursing -- it's a masters degree. ("MSN-NP")

Yeah, hence the "might"; some programs are doctorate degrees

Yes, but all those professions require the oversight of a MD. A doctor, or group of doctors who deeply care about profits. I'm not knocking profits. I know it's all about money. It's just when you can't increase competition, you have no control over prices. The amount of time, and political BS, a doctor has to go through just to get through medical school is rediculious. Then there's the residency--that's the apprentiship. When they get out--know wonder they want a lot of money for what they went through.

I don't have a simple answer, but I would like to see more government built medical schools; increasing the supply.

I would further like to see most drugs available over the counter, with the exception of antibiotics, and very strong pain killers.

I would like to see a society, where a patient who is on a long term medication, only has to see a doctor once a year, or if the patient needs a higher dose. (Right now most patients only need to see a doctor once a year, in order to get refills, but very few doctors are willing to authorize a year's worth of refills. They want to bill for those office visits. I understand it in some situations. In other situations, I don't understand dragging in patients, especially those patients with lousy insurance, or no insurance.)

I don't have a simple answer. I'm on medications--I can't just stop. I've felt hostage to the system for too many years.

I am greatful to the Health Care Act though. I know, you guys all hate it. Yes, it has faults, the Insurance/Pharmaceutical companies took advantage of, but let's see what the system looks like when the next Republician president vetoes it?

Dentistry has true to introduce an assistant level which can do basic dentistry, but so far as I recall this movement has only been successful I Minnesota? New Hampshire wants to try it out too, but generally dentists fear the profession will suffer from a perception of "dentistry light" and impact their business.

I can't imagine letting anyone take a drill to my teeth but the most skilled DMD I can afford to pay. I'm surprised others don't feel that way (but hey, whatever floats your boat).

This is a good point. Sometimes the market has already approximated grades-of-doctors - for example, it's possible to spend a lot of time and money with a podiatrist, and still end up not solving stance/arch/ankle problems with your feet. But a competent ski bootfitter will do a better job of sorting you out, for less money and without waiting rooms, for most non-surgical issues.

   I'm guessing that a similar situation exists with
   doctors; physicals, vaccines, and a handful of common
   diseases (like colds) probably make up a sizable
   percentage of visits. There's a market for someone who
   can just handle these cases and pass them off to the
   higher grade doctor when the need arises.

Those are called GPs up in Canada. They do more than just deal with colds, but the system is set up so you first go through a GP and then are referred up.

In the US we have general practitioners. They are full blown doctors with all of the 8 years of training that that entails.

What I'm proposing is an intermediate step between doctors and nurses (or perhaps buffing up the powers of higher level nurses so they could operate standalone) so that one doesn't always need to make an appointment with someone with 8 years of specialized training to be stuck with a tetanus booster shot.

GP := General Practitioner.

As a patient I don't want this to happen. I'm ok with nurses administering the shot, but by having an MD giving his approval first (or a "Super nurse"). At what point do you draw the line and say "this is enough knowledge, get to work"? What happens when things go wrong? How do you make sure things won't go wrong? It's not like in a lot of technological settings where if the system doesn't boot you can just buy a new one (caricature). You're dealing with the life and quality of life of a human being. Stakes are different.

> What I'm proposing is an intermediate step between doctors and nurses (or perhaps buffing up the powers of higher level nurses so they could operate standalone)

We have categories matching that description in the US now, most notably Physician Assistants [0] and Nurse Practitioners [1].

[0] https://en.wikipedia.org/wiki/Physician_assistant

[1] https://en.wikipedia.org/wiki/Nurse_practitioner

1) Start a major world war.

2) Find out the (new) standards the military sets for someone to fill the functional role of a full-fledged doctor.

Boom, there's your "MVP doctor" program.

I'm joking, but there almost certainly a ton of fat that can be trimmed from the training we expect out of that title, and it's probably just a matter of motivation. There shouldn't be that big a difference between our current standard for "doctor" vs the one the military comes up with in that example.

The problem I see is that these jobs already exist (e.g. paralegals, nurse practitioners, dental hygienists), but are baked into the total practice. My primary care physician costs the same whether I see him or the nurse practitioner, and they are performing the same tasks, so why am I wasting my doctor's time for rudimentary work and simultaneously paying much more for an NP when I don't need to?

Interestingly, if you see a nurse practitioner in-office while a physician is not present in the office (I don't think they need to stop in), insurance companies (maybe only Medicare, can't remember) only have to pay 85% of the bill charged by the doctor's office.

My brother and I started a "member/concierge" primary care network for uninsured/under-insured patients. Members pay $20/month (individuals) or $15/month (business plans) and the patients can set appointments to see an ARNP/PA for $10 copay or the MD for $25 copay. Most primary practices can't take this issue into consideration because your copay is set by your insurance policy.

Consumers in the West are choosing between pyramidal corporations vs independent professionals in many industries. While the former are often less expensive to the end user, they drain money out of the local economy towards fiscal havens. On the other hand, the latter often exploit their local connections to supercharge clients. For the health of my local environment, I tend to pay some more to keep the money within my community.

> But bits can never yield singular values; like any tool, they can be used to promote harmony or discord, greed or selflessness. [...] Valid values require constant human construction, surveillance, critique, reflection, rebuilding, and a commons in which we all have a stake, over which we all care, or, to put it more sharply, we all should care.

One thing I don't get from this argument is: does he consider programming a profession? It seems like his argument is that, replacing professionals with a strong code of ethics by automated systems might lead to some sort of societal decay. But that's only true if the people building those systems are inherently less ethical or perhaps less aware of the issues than the original professionals. Otherwise, the systems can be build to bias towards a very high ethical standard, even as they crowdsource some of their functions (there might be an ethics vs economics trade-off for some systems, but if the trade-off is approached in an informed manner by ethical people, then a 'reasonable' compromise should be often found).

Perhaps his argument for the eroding effect of technology is tied to his argument about the eroding effect of markets: because programmers are employed by large corporations which have strong incentives to increase profits[1] at the cost of much everything else they will eventually be led to bend any professional codes of ethics if market forces act against those. This could very well be true, but I am not sure that's what the article says.

The article seems to imply than a doctor or a lawyer is likely a more moral person than a programmer or at least than the system the programmer can build. I am not sure I understand why it would be so.

[1] Long-term profits, being generous. But still.

> One thing I don't get from this argument is: does he consider programming a profession?

If an engineer that programs, probably. But not likely programming by itself. When I worked at an integration company (industry contractor), we had to be careful about the language we used on timesheets. We were strictly forbidden from using "engineer" (verb) since we were not an engineering firm.

Related article: "Algorithm writers need a code of conduct" (http://www.theguardian.com/commentisfree/2015/dec/06/algorit...)

"One could say that, in theory, these needs and roles could be satisfied in a completely marketized society—but we have seen that they are not. Indeed, as amply documented in 2001 (following the collapse of Enron) and 2008 (following the collapse of Lehman Brothers), the avowedly marketized society does not even prevent economic disaster; we need to regulate markets firmly and fairly."

The author jumps to a conclusion fairly quickly: that free-market capitalism caused Enron and Lehman Brothers (and not perverse incentives wholly separate from free-market ideology). This isn't the place to debate that, but rather it's illustrative of a larger point about academic professionals: they spend most of their effort engaged in very deep speciality, but occasionally they come up for air and assert broad knowledge, usually about politically charged topics.

In those cases, there's a palpable anxiety based on the knowledge that they do not make as much money as their intellectual inferiors who went off to work in business, or even worse, to use their professional credentials in the service of business (as a side note, for proof of this dynamic go read university professors' blogs about Mark Zuckerberg and his billions -- in the hierarchy of "deserves their money," tech nerds rank last, because they're simultaneously capitalists and social inferiors). This must be explained, internally and then externally -- their life choices are admirable, others' are not, and something must be done so that elites in the university and in government institutions can reign in the parasites.

I agree professional certification is important for healthcare and law -- when my life or liberty is at stake, I want to be sure my chosen expert actually has expertise. But the author is arguing that some sort of quality of life and cultural recognition should be automatically granted in exchange for completing training and passing tests -- something I don't think is worth caring about too much.

This is a fantastically presented and well-written essay. It's too bad the author stops short of providing any clear, actionable steps towards the reinvigoration of the professions:

> It’s high time for those of us who continue to value the professions to reinvigorate and, as necessary, reinvent the professions. We need to acknowledge our complicity in the current undesirable situation, embody the principles and values that have enabled professional practice at its best, and work to ensure that they will be strengthened, not undermined, by the technologies to come, and insofar as possible, in harmony with the ever unpredictable winds of history and culture.

This is about as close as he gets to an actual suggestion:

> we need to regulate markets firmly and fairly

Who is "we"? How do "we" do that? Perhaps Prof. Gardner should have had a word with Larry Summers over a pint at the 2001 Harvard faculty Xmas party when Prof. Summers returned as the university's president, having helped repeal Glass-Steagall a few years prior.

More seriously, Prof. Gardner is in a position of power within an institution that does more to shape the future of the world than any other. He should have one of the best vantage points in the world to suggest changes, given his access to the students and faculty that go on to make many of the governing decisions within the country. It would have been interesting to read more about how the culture of a pivotal institution such as Harvard has changed over the past 30 years, and whether that has been in response to, or the cause of the decline in profession.

> a profession consists of individuals who have undergone a standard form of training, culminating in some kind of recognized title and degree.

So the professions were pillars of society when the world changed little and education was scarce. Now most people complete college and "the professions" are a quaint old-timey thing.

It would have been nice if the author weren't such a meandering windbag, but maybe he has trouble getting to the point because he can't bring himself to say he just wishes they professions were still considered "elite".

>> a profession consists of individuals who have undergone a standard form of training, culminating in some kind of recognized title and degree.

Yes, and basically ending there, except for being able to teach it to the next generation. The professions were things like philosophy, geometry, theology, etc.

As I understand it, the title "doctor" was used by scholars, e.g., PhDs, long before medicine even existed as a respectable field, and physicians started calling themselves "doctor" to assume an air of respectability.

The trades may have been respected, but were a couple of notches below the nobility and the clergy. The idea of achieving a high social status for actually doing something is a newfangled concept.

> contemporary professions are failing economically, technologically, psychologically, morally, and qualitatively, and by virtue of their inscrutability (p. 33). Or, as they put it colloquially, “We cannot afford them, they are often antiquated, the expertise of the best is enjoyed only by a few, and their workings are not transparent. For these and other reasons, we believe today’s professions should and will be replaced by feasible alternatives”

Anyone retain an attorney for a will lately versus downloading Legal Zoom?

For professions to be viable, there has to be a large dip between people starting out and people who had mastered it already. Otherwise there is no real incentive for people to start out in the first place; noone will pay a lot of money and invest years of their time if anyone with a few weeks of education can do essentially 99% of what they can.

This brings me to the point of software development. Software development is aweful as a choice of a profession if you work for someone else, and not for yourself, due to constantly increasing competition (every kid needs to learn how to code). Most work doesn't need a real understanding of the subject matter (algorithms, protocols) and can be performed using frameworks and libraries that "encapsulate" those concepts. I foresee something alike the split of nurses and nurseaides happening to software developers. There'll be a few software developers capable of understanding computing from A to Z who will write the libraries and the tools, and everybody else will be a consumer of these tools writing apps for the end users.

The only real rewarding part of software development is being able to design your own product and bring it to life, and reap whatever rewards the market allows you.

> I foresee something alike the split of nurses and nurseaides happening to software developers. There'll be a few software developers capable of understanding computing from A to Z who will write the libraries and the tools, and everybody else will be a consumer of these tools writing apps for the end users.

I think that's already happened to some extent, as the proliferation of coding boot camps demonstrates.

On the other hand, a lot of the tools currently in use require a great deal of programming knowledge from users, e.g. Hadoop.

> There'll be a few software developers capable of understanding computing from A to Z who will write the libraries and the tools, and everybody else will be a consumer of these tools writing apps for the end users.

The problem is that all the money is in the end-user facing applications. If you publish a research paper in some CS journal explaining a brilliant new algorithm, that is not worth very much (if anything). When somebody packages that up into a product that they can sell to users, or charge for the use of, then they've captured most of the value.

In my experience, all the money is in writing the hardened, scalable infrastructure. But then my experience is in the database, microsoft, oracle, amazon, facebook worlds.

I beg to differ. I don't see constantly increasing competition, partly because the demand for (good) programmers is also increasing, and partly because (in my opinion) most programming work actually does need real understanding.

Besides, programming is a very rewarding activity in itself, due to the creative nature of it [1].

So I have the complete opposite view - software developer is a great career: http://henrikwarne.com/2014/12/08/5-reasons-why-software-dev...

[1] Why I Love Programming: http://henrikwarne.com/2012/06/02/why-i-love-coding/

The great thing about software is that each new piece of software that is written opens up more opportunities for writing new software than it closes off.

And the great thing about software writers is that each new writer creates more work opportunities for experienced code maintainers and rehabilitators than they could possibly create for themselves.

Combine those two great things, and you realize that as long as the software industry can grow wider faster than it can grow deeper, it must. The tide of crap software with huge technical debt that will eventually have to be fixed by someone with real experience will only abate when everyone with the aptitude for writing software has already been doing it for a while.

At that time, people will be able to distinguish between a software writer that can maintain an existing CRUD app and one that can write new business-infrastructure software that scales across the entire enterprise.

That last category will be able to demand high compensation well into the foreseeable future, simply because the type of personality that has competitive advantage there is relatively rare in the general population.

I think your points make sense but you are forgetting that the demand for a certain skill isn't constant. So, while it's true that there are many people who can code entering the workforce, it doesn't imply software development being a poor choice of a profession if the demand for them is also going up.

And from what everyone seems to be saying, the increase in supply has still not yet hit the demand.

You are pretty wrong about software development. The only problem there is too much bugging from recruiters all the time. I can switch jobs without any trouble. The only problem is the amount of work is so great, the opportunities too huge, its hard to make a decision. If one job has too much work, or has bad culture, then switch jobs. I got my degree from a southern school, I didn't go to MIT or anything, and I have endless opportunities. And I'm old, almost 50.

Given ready access to information and knowledge, and eventually cognitive enhancement, maybe the focus of professional education ought to be on core values and skills. Plus enough general background to know where to start with any particular project.

This is almost like a reverse Betteridge's Law of Headlines. So maybe the real law is, if the headline asks if there will be a huge change of the status quo, the answer is no. If the headline asks if the status quo will remain, the answer is yes.

Why are people even trying to formulate a consistent model out of Betteridge's law? It's puerile and missing the point. It's nothing but a sardonic aphorism that observes how tabloids tend to structure their headlines. It's absolutely trivial to subvert: "Did six million Jews really die in the Holocaust?".

Is there a law about people egregiously overestimating the applicability of Internet laws?

It's called a "joke."

AnimalMuppet seems to be trying to make something serious out of it, hence my response.

Alternatively "Whatever the question headline is suggesting is probably incorrect."

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