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Thanks for sharing this! I went to med school for two years in my home country, married to a doctor who is in her residency training in the US and couldn't agree more.

If you look at my HN comment history, you'll see that I've tried to mention that part of the problem of exorbitant healthcare expenses in the US is the artificial scarcity of doctors. It starts with this inflated/unnecessary requirement to have a bachelor's degree before going to med school. Other nations in the world (e.g., India) do fine with training their doctors for five years (even that, I think is too much; the first year of med school training in my country is pretty much an extended high school curriculum not essential to medicine).

An internal medicine (generalist) doctor in the US can earn $250K right after finishing the residency. Elsewhere in the world (e.g., in the UK), the doctors earn about $90-150K.

I also have to agree with you that contrary to the popular belief in the US, doctors can be fairly un-intellectual. The main requirement to do well in their career is to rely on rote memorization (go check out on YouTube how Anki is so important/popular among med school people).

> contrary to the popular belief in the US, doctors can be fairly un-intellectual. The main requirement to do well in their career is to rely on rote memorization (go check out on YouTube how Anki is so important/popular among med school people).

I agree with everything in your comment, but this is one of the most important ones. This is actually the basis upon which my cocky little 17-year-old self decided he wanted to study math instead of medicine, contrary to the pressure my family was exerting: the idea of turning my brain into a file drawer was somewhere between horrifying and nauseating. I point-blank asked my brother-in-law at one point (he was around ~30 at the time) how someone as intelligent as him was satisfied with going into a field as unchallenging as medicine, and he was on exactly the same page as me: over the course of his medical education (started the same year as my sister), he also got an MBA and has started on a PhD, because being a GP would be immensely dissatisfying to his intellect. If you have a sense of yourself as fairly intelligent, it is _absolutely crucial_ for your health as a patient interacting with the healthcare world that you internalize that doctors aren't necessarily that smart (though of course, some are!).

This isn't an insult! Most professions are filled with people that aren't that smart. But putting yourself blindly in the hands of an imagined omniscient without being an informed and opinionated advocate for yourself as a patient is foolhardy and dangerous, and you'll quickly discover the costs, if you're self-aware enough. If you have a doctor who buys into the God Complex and scoffs at the notion of a patient having an opinion, then you're double-fucked, and should definitely get a new doctor.

This can be a delicate balance, and the doctors I know are quite fairly annoyed at the patient who does his own research (often poorly) and argues with them on the basics. "Knowing what you don't know" is an important part of being informed. Just 1) find a doctor who understands his limits and 2) approach the conversation as a meeting of mutually-interested peers logically discussing a problem (your health): one who has substantial headstart on the intimate, sometimes-inarticulable details of the problem, and one who has a substantial headstart on general research that's relevant to the problem.

> over the course of his medical education...he also got an MBA and has started on a PhD, because being a GP would be immensely dissatisfying to his intellect

To put it charitably, it seems unlikely that while in medical school someone can also complete a full-time two-year business program and start a doctorate. But taking the comment at face value...

There are plenty of specialties much more challenging than family med (which is what 99.999% of GPs do for residency). It's one of the least competitive and least well-paid specialties. This is why most of the med students who don't match end up scrambling into family med, because those are the (toxic) programs that have unmatched slots. If you don't own the practice you'll be lucky to break $200k cash comp without a post-residency fellowship. Infectious disease, pathology, and radiology are much more challenging intellectually and any surgical residency, including ones that you don't typically think of surgical like OB/GYN are similarly challenging. Hell, if you're in it for the money gynocologic ongcology and neurosurgery both have median cash comps well over half a million a year.

> Just 1) find a doctor who understands his limits and 2) approach the conversation as a meeting of mutually-interested peers logically discussing a problem (your health): one who has substantial headstart on the intimate, sometimes-inarticulable details of the problem, and one who has a substantial headstart on general research that's relevant to the problem.

I'm not a "peer" with my doctor because whether it's rote memorization or not, they've got at least 7 years of training I don't, and much more if they're a specialist and not a GP. You do not have a "substantial headstart" on any research relevant to your problem unless you've had it for years and are seeing a new GP just to get a referral to a new specialist. In which case, honestly, your old specialist can probably just refer you somewhere else.

This doesn't mean doctors know their limits, I've heard some absolutely boneheaded nonsense out of GPs who got out of their lane - my favorite was a 70 year old, borderline morbidly obese physician telling me not to do back squats below parallel because "it will destroy your knees," and he subsequently groaned when he stood out of the chair. But that's in the same vein as going into a GP because you've had bad headaches for the last two weeks and approaching it as a "meeting of mutually-interested peers."

> it seems unlikely that while in medical school someone can also complete a full-time two-year business program and start a doctorate.

If you're very ignorant about a topic, it's probably a good idea to do thirty seconds of Googling to make sure a claim is actually implausible before you accuse someone of lying.

MD/MBA programs exist that add 1-2 years to one's med school[1]. On top of that, "over the course of his medical education" quite explicitly doesn't simply mean "in med school", unless for some bizarre reason you don't consider one's residency (and possibly fellowship) years to be part of one's education. Lastly, and I can't believe I have to explain this, _starting_ a doctorate doesn't actually take any time. In the limit, it takes one Planck time[2].

> I'm not a "peer" with my doctor because whether it's rote memorization or not, they've got at least 7 years of training I don't, and much more if they're a specialist and not a GP. You do not have a "substantial headstart" on any research relevant to your problem unless you've had it for years and are seeing a new GP just to get a referral to a new specialist. In which case, honestly, your old specialist can probably just refer you somewhere else.

You've entirely missed the point of my comment. You seem to think that doctors are equipped with future-tech Neuralinks to personally feel the day-to-day manifestation of every one of your symptoms and Black Mirror-style grains to review your entire life history and extract the parts which may be relevant to your medical issue. I hate to be the bearer of bad news, but they're not: for any non-trivial medical issue, doctors have the difficult task of compressing the entirety of your life into the data that are relevant to your current condition, and doing so in a very short time. If you think that they're capable of doing this without active participation from you, then I pray you never have any medical issues, because you are going to have a very bad time in the healthcare system.

> There are plenty of specialties much more challenging than family med

Yes, obviously. Part of "know what you don't know" is realizing that the complexity of some medical issues means that the "general technical knowledge" side of the scale is weighted heavier than the "intimate insight into the specific problem" side of the scale. I'm not suggesting that one starts arguing with an oncologist about which course of chemo they should be on. But then, I'm pretty sure that was obvious to everyone reading my comment who _didn't_ write a response constructing a series of towering strawmen.

[1] https://freeman.tulane.edu/academics/graduate-programs/doubl...

[2] I'm not a physicist, this is an attempt at a lame joke, don't @ me

"Physicians are just human mechanics" - a disgruntled PhD

Or, as the late-great Christopher Hitchens said - “Picture all experts as if they were mammals.”

> the idea that an entire industry full of people are immune to incentives is an especially pants-on-head stupid model of the world

This is true of nearly every industry, though. Our real estate agent (who was otherwise pretty good) insisted that he was a fiduciary to us and would seek the best financial deal for us, but his advice on our bid was "I don't think that'll be enough to get the job done", and then we were the high bid. I'm a Google engineer, and from my perception, my job is to give people free services that they want, despite HN's perception of my employer. Investors will say that they "get paid for allocating capital and making the economy more efficient", lawyers are here to "help people enforce the rights granted to them by law", salesmen "make people aware of products that they really want to buy anyway", etc.

Of possible interest:

https://slatestarcodex.com/2017/10/02/different-worlds/

People's perceptions really do differ, and people see through their values and emotions. When people hold a self-perception of what they do that is wildly at odds with what you think they do, it's often because folks who actively believe they are doing bad for the world are often so bitter that nobody wants to be around them.

> This is true of nearly every industry, though.

Yes, I think this is implied by the portion of my comment that you quoted. The claim that _any_ industry is immune to incentives is what I describe as "pants-on-head stupid".

I've also read every Scott post shortly after its posting for probably the past 8 years, but I appreciate the share!

Sorry for the double-reply, but I realize I didn't address the meat of your comment.

> When people hold a self-perception of what they do that is wildly at odds with what you think they do, it's often because folks who actively believe they are doing bad for the world are often so bitter that nobody wants to be around them.

I don't agree with this, at least as applied to my comment. There's a wide, wide gulf of reasonableness between "what I do is unhelpfuly and unworthy" and "everyone in my industry is an omnibenevolent, maximally-selfless angel". I'm quite proud of the work I do without thinking this, and as I mentioned in my previous comment, if my sister had a possibly-irrational but not totally-unreasonable greater pride in her work, I wouldn't blame her at all. But doctors who consider themselves a separate moral species from human beings aren't just egomaniacs, they're _dangerous_ (as I said, my sister luckily grew out of this a little bit).

I think that people vary greatly in terms of their "set point" for how much they believe people in general are benevolent. HN is filled with skeptics and critics; our set point is pretty low. Most of the rest of the world considers that to be an unreasonable downer: if you go into a typical party saying "The AMA is a tax-exempt hedge fund and licensing corporation", best case you'll get smiles and nods and worst case you won't be invited back.

I don't know your sister, and you can judge a lot better than I whether her beliefs in the benevolence of her profession are "reasonable". I'm saying that it's pretty common for people to hold a positive emotional view of their work in particular and the world in general, because, well, positive emotions feel more positive.

Ask marginalized people - generally a subset of, but not limited to, people subject to generational poverty, people with prominent genetic ancestry in the Global South, LGBT/queer folk (especially the T), and those with visible, chronic physical (weight, height, mobility, etc.) or mental (developmental disorders, mental illness, etc.) "deviances" - and you'll learn just how effective and esteemed doctors really are. (Of course, people generally don't ask us, so...)

While I imagine that some people have already had a certain particular rage switch thrown in their brain wrt the preceding list, stay with me here. We're not just talking about intersectional pile-ups; go ask your fat friend about his last check-up.

> go ask your fat friend about his last check-up

The doctor probably told him to lose weight. And?

The complaint is usually that doctors are overly reductive towards overweight people, treating their weight as a hard-blocker to listening to any other problems that can potentially be treated (or palliated) in parallel.

I can't speak to its veracity, as I'm not privy to the medical history of anyone I know who's overweight.

Overweight people have more medical problems, and the more overweight you are, the more problems you will have and the more severe they will be (in aggregate, we can find exceptions to every rule).

I've heard this complaint as well but it's usually from people not doing much to lose the weight in the first place. If you've gone from 400 lbs to 300 lbs in 6 months and suddenly you have knee pain you never had before, I think most GPs would take an acute interest in that and not just chalk it up to being 300 lbs. But if you've gone from 250 lbs to 300 lbs and suddenly develop knee pain, you're going to have a hard time convincing anyone that it's not the obvious problem.

Sure, the fact that there's a plausible motivation on the doctor's side is the reason I don't have much of an opinion on the veracity of the claim. That doesn't preclude the possibility a trend exists within the medical system of worse care for the overweight due to treating weight as a hard blocker. I chose my framing of the claim I've heard pretty carefully, and what you're saying only supports it: as being overweight is upstream of so many health problems, it seems entirely plausible that doctors (given that they're human beings) would be prone to falling in the trap of not wanting to think about anything that can be done while the weight problem is still being worked on (or not). Again, this doesn't require assuming that doctors are horrible people; this kind of reductiveness is the way most people respond to everything.

> it's usually from people not doing much to lose the weight in the first place

This is far too arrogant an assumption for a doctor to be making about a patient. I don't know any overweight people, but I do know people who have had (theoretically solvable) drug problems and other bad health habits, and the blockers to fixing them are not always "just believe in yourself and have some willpower", especially when (even sub-clinical) mental health issues are involved. Hell, I used to smoke way too much weed and not eat particularly well (though never badly enough to get overweight) and it turns out I had an undiagnosed sleep disorder. If smoking weed happened to be associated with a bunch of health problems and I had a doctor who was narrowly focused on it and refused to help me with other incidental issues before I solved it, I'd be pretty upset too.

I think your comment is oversimplifying a little, and I'm generally not a fan of the "woke" take on most things (to the point that I'm glad HN has come around in the last couple of years...), but I admit I'm surprised to see this downvoted so heavily.

It seems trivially true that a relationship in which _techne_ is overesteemed relative to _metis_ is one in which those farther from society's average would suffer more, if only because _techne_ would be less representative of them.