The planning of U.S. physician shortages (2020) | Hacker News Reader

The planning of U.S. physician shortages (2020)

niskanencenter.org

216 pointsflummox358 comments

Being a physician is a horrible career move right now. As a former Math/CS major turned eye surgeon, I can't help but think about how much easier my life would be had I stuck with tech. It's hard to understand exactly how hard the job is until you've lived it. I saw 40 patient's in clinic today in 8 hours without lunch or any kind of downtime and then spent 2 hours at the hospital because a patient needed an emergent procedure. They might go blind despite my efforts and I have to live with that. I also may get sued, if they're feeling spicy, despite going to heroic lengths to help this person. My son was asleep before I got home.

There's just no reason to do the job when you can get the same compensation working remotely in tech. Looking through the "Who's Hiring" thread is soul-crushing. Physician salaries are the only ones that do not grow relative to inflation and have decreased year-on-year relative to inflation for decades.

I do believe that the rigorous training model leads to a higher quality of care and much deeper understanding of the disease process. But, why would anyone want to do the job? It's just not worth the liability anymore. That said, is anyone hiring an ophthalmologist with CS and Math degrees?

> That said, is anyone hiring an ophthalmologist with CS and Math degrees?

I’m surprised you can’t leverage this into a product role or a consulting role for startups in the medical space. You know shit about med systems!!

It can be really hard to leverage this combination of skills, the demand for cross-discipline talents is usually much lower than for a single skill set, but also much deeper when the demand exists, it's going to take some serious searching to find a match but likely it's worth it. There was HN post about working with radiologists when building a AI diagnosis company:

https://news.ycombinator.com/item?id=36111596

May be try talk to some similar AI companies is a good idea, at this time the pay can be really good.

In the US medical device companies usually have a board of practitioners to give advice about the state of the art and the challenges with existing practice in the field. You can also start building your own device or system and plan to sell it, but you should find someone to consult on how to lobby the FDA and CMS as early as possible, because some devices get stuck in De Novo or PMA for years, and that’s a big risk to take. You’ll also need to have a long term plan for how the company will grow as you get closer to regulatory approval. A “product role” in these companies is very heavy on managing regulatory approval and making sure the company doesn’t get sued.

We’re hiring founding engineers at Develop Health! https://jobs.lever.co/develophealth.io?utm_source=hackernews...

Yes! The prior authorization process is so broken! I've been battling Blie Shield for months in a effort to fix theirs

The biggest complaint I always hear from people in the medical field is the long hours. It sure sounds to me like that (and thus any knock-on problems) could be solved by more practitioners, spreading the work around. I can't speak for you, but personally, a proper work-life balance in comparison to these horror stories is surely worth a possible salary cut?

> It sure sounds to me like that (and thus any knock-on problems) could be solved by more practitioners, spreading the work around.

Sort of. The equipment is so expensive that the actual solution is usually to work the rooms and equipment harder. Night shifts, early starts and evening work are actually shit.

That makes no sense, if the capital is expensive then you should hire more labor.

That is literally what I'm saying. Staff are worked harder as shifts are introduced. It is not a nice way to work. Sure, it helps reduce the number of patients, but it destroys work/life balance and that is what the OP was raising as an issue.

It is also hard to get patients to agree to having tests done at 5am or 9pm, so it's a case of diminishing returns. The staff penal rates go up too, so the squeeze comes from all sorts of directions.

> It is also hard to get patients to agree to having tests done at 5am or 9pm, so it's a case of diminishing returns.

In the US? With health care prices as they are? There are people that travel to entirely other countries for access to health. I'm plenty sure lots wouldn't mind at all to have an exam at 9pm if it meant it was way cheaper.

New Zealand. The issue is that the reimbursement is the same whenever the scan is done, but staffing costs more at night (so scans kind of need to cost more at night).

Reading what an MRI costs in the US, I do wonder if a trip to NZ for the scan would actually be cheaper.

I only know 1-2 NZ radiologists but I understand the system there is egregiously underpaid.

Medicare/insurance reimbursement rates for MRI (the professional fee component) are less than Canada (a system I know).

We scan outpatients near 24/7 on some of our magnets in Canada, the ones we don’t are because we don’t have MRI technologists to staff the shifts (the more expensive part as they have unions with labour laws, radiologists can be worked like dogs with no benefits/protections as contractors).

I haven’t heard radiologists complain about their pay here, they seem pretty well paid. The techs are paid nicely too, though that will depend on the employer.

I’m surely misunderstanding you - you aren’t saying techs cost more than radiologists in Canada are you?

Doing those hours with outpatients is very impressive, though I hope to never be involved in such things. Weekends are bad enough!

Just for clarity I don't mean to suggest at all that radiologists aren't paid well-enough (other than in private equity sweatshops but I feel like that's the case for any industry they buy into).

> I’m surely misunderstanding you - you aren’t saying techs cost more than radiologists in Canada are you?

Individually not at all but in aggregate yes. Disbursements to nursing/techs/allied health (who are also the majority of employees to be fair) are somewhere around 60% of hospital expenditures in Ontario (noting physicians are not included in this budget).

It will vary from institution to institution (and union) but probably similar in most places, for MRI my last institution required 3 technologists per magnet (or 5 for 2 magnets) considering break rules, techs also got an after-hours premium so it worked out to something like $90/tech/hour. You'd also have to hire more as techs are employees so they get work-hour limits and time-off requirements (i.e. can't just offer "extra evening shifts" for those who want it, have to grow the pool) so add whatever employee overhead is (30%?).

The radiologist fee depends on the study type and duration but to keep it simple I'd expect to bill $150-300 for an hour worth of MRI scans on average. These get reported the next business day so there's no extra cost from the radiologist perspective and we can tolerate the added volumes so no need to hire (an average radiologist working hard can cover 2-3 magnets worth of cases in realtime).

For other modalities like ultrasound it's an even bigger gap, I'd expect to bill $30-60/technologist-hour worth of work.

Thanks for this explanation.

My day job is staffing magnets, and the staffing levels you mention exactly match what I do.

The radiologists struggle to keep up with our output when we do MSK work or horrendous post treatment livers - I think we need you over here.

I think you meant to say [beautiful] post treatment livers! They're one of my favourite study types to read although everyone else seems to hate them.

MSK joint studies are definitely higher throughput but those are fun too. We would try and schedule "overnight MSK blitzes" q10min to minimize contrast reaction disruptions for the residents on call which would substantially change the financials I quoted. Ontario still has an add-on code for "3D sequence" if you can believe that so knees/shoulders pay a lot for how little effort they take to read.

> The radiologists struggle to keep up with our output

I noticed during fellowship that US radiologists seem to have lower volumes on average. Canadian radiologists are very overworked in my opinion (90+ CTs in an 8 hour shift, daytime MR seat of 40-50 cases is pretty common) which is largely why I left (also weather).

> I think we need you over here.

If you're in a metro with > 1 million people that's above freezing temperature > 6 months of the year and hiring I'm currently in the job market!

Auckland, population 1.6 million and it never dips below freezing.

Housing is way overpriced and the cost of living is high, but with the negatives out the way, the rest is pretty good.

All equipment is brand new, mostly Siemens.

If you are interested, we are hiring and my contact details are in my profile.

The question is what you are angling for. If your goal is, sincerely, to provide better service, then you won't get it. Keep in mind that with so many patients nowadays being eligible for Medicare, the money will come in anyway. Nursing homes got the brunt of the attention for their quality of care, but with hospitals facing the same population the same management techniques come too.

I work as a nurse on nights and everything said above has been quite accurate. A textbook understanding of... well anything really, does not serve someone well now.

EDIT: Also these companies now often run pharmacies, investment systems, healthcare programs... patient care is by no means the biggest earner.

> EDIT: Also these companies now often run pharmacies, investment systems, healthcare programs... patient care is by no means the biggest earner.

Are you referring to companies like Optum in the US?

They own entire medical systems(Everett Clinic in Washington), an insurance company(United Healthcare), and a pharmacy(Optum Rx) as subsidiaries so if there’s a problem everyone can point fingers and nothing gets done. This seems to be the new model for healthcare in the US.

Optum is an extreme example, but it's all of them. The non-profits run the same as the for-profits, and have converged more and more since 2000 or so.

UK: there was a proposal to introduce weekend surgery to make better use of operating theatres. The problem is staffing the facilities. Lead times on training people are long. And in UK the training process is not cheap and has significant up-front costs for the people being trained. Nurses as well as surgeons.

We used to have bursaries to cover the cost of training for nurses, but, austerity and all.

That seems backwards, unless you also need to be preforming more surgeries and thus need more people. Instead reduce the number of operating theaters while keeping a similar number of people. Net result same amount of operations, but lower capital expenditure.

Of course you now need to pay people more to be working in the weekends, but that’s a different question.

Yes, the UK needs more surgery capacity.

In that case it needs more workers independent of doing weekend surgery.

If you are unable to supply enough surgeons for the surgeries people actually need, something has gone terribly wrong with your price signaling mechanism.

Perhaps this is a problem with the UK system.

> Perhaps this is a problem with the UK system.

It’s a problem everywhere isn’t it? There aren’t enough surgeons and the price is too high.

Think that is the point. If their is expense equipment, high capital. Then companies will try to maximize the current labor first, grind them down, before taking the leap to hire more labor. Like running 2, 10 hour shifts, with few hours downtime, will be better than running 3, 8 hour shifts, at 24 hour uptime. The incentive is to stretch labor head count out, before adding more.

The expensive labor isn’t physicians and infrastructure/capital expenditures aren’t the barrier either.

It’s nursing costs and bed counts.

Look at Canada for an example, we have unemployed surgeons and interventional radiologists/cardiologists with surgical backlogs > 1 year.

We have the rooms, the hospital I trained at had 90 operating rooms but only 4 are funded for after-hours and on weekends, the rest run 8am-4am but no nursing money for the OR, recovery room, or patient wards.

Research indicates the "unemployed surgeon" problem in Canada is more folklore than reality. [0] AFAICT, Canada has a shortage of physicians. [1] That unemployed people exist at all is not evidence that there is no labor crunch.

[0]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866140/ [1]: https://www.cbc.ca/news/politics/canada-turning-away-home-gr...

That you are not running these rooms as much as possible indicates some failure in pricing/profit seeking, but I have no idea how the Canadian medical system works.

From the Royal College (our specialty accreditation society)[0]:

> 11-18% of newly certified specialists cannot find work at the time of their certification.

> 75% of those who are continuing training do so because they think this will make them more employable.

[0] https://www.royalcollege.ca/ca/en/health-policy/building-med...

From your first reference:

> Traditional unemployment is rare; underemployment is not.

> Eleven per cent of the cohort described themselves as primarily locum surgeons. When asked why they did locums, the most common responses were “waiting for a job to open up at locum site” (46%) followed by “could not get the staff job that I wanted” (23%).

It's not unemployment in the traditional sense, in the medical community it looks like a liver surgeon (2 years of extra training) doing appendectomies in a small town or a neurosurgeon forced into only doing spine work (both need monitored beds +/- ICU). Or doing multiple fellowships until you find something.

Sure you can work as a locum (temp) or go to [very undesirable location doing general work] if you're in a specialty like general surgery that allows for that kind of practice environment. Tough luck if you're a cardiac surgeon/interventional cardiologist or oncologic subspecialist of any kind that needs high nursing support, inpatient beds and expensive instruments.

Note that these training positions are mostly all funded by the government in Canada and allocated based on their needs assessment (so it's not people choosing some unemployable niche by choice per se).

> AFAICT, Canada has a shortage of physicians.

We have a shortage of primary care physicians (because no one wants to do it), we have enough specialists by body count but no jobs/rooms for them (see underemployment points and how many go to the US).

> I have no idea how the Canadian medical system works.

Hospitals are run by the provincial governments. Physician compensation also comes from the same ministry but not out of the hospital's budget with "fixed professional fees" set by the single payer.

> That you are not running these rooms as much as possible indicates some failure in pricing/profit seeking

This has truth to it, the hospital's incentive is to prioritize their budget and they have little incentive to maximize throughput.

Due to funding nuances they're essentially incentivized to prioritize acute/emergent care (which gets some extra $) and have less throughput for things with consumables (like procedures) that come out of the hospital's budget.

It's pretty common for Canadian surgeons to admit someone to facilitate a surgery so we can use an "emergency OR room" even though they don't need the bed. Entirely wasteful but from the hospital's perspective the bed is paid for (we're constantly at capacity, there's no reality where a bed is unused) and a broken bone admitted unnecessarily doesn't cost anything extra as they don't particularly need nursing or have nearly as many consumable costs like a person hospitalized for acute illness.

> more practitioners

His other complaint was about the stagnant wages. More doctors will only compound that problem.

I dropped out of an MD/PhD program after I passed Step 1, it’s hard to articulate exactly how it felt staring down the barrel of a career in medicine but this is sort of what I feared.

Since I’ve been in tech I’ve been laid off several times, and it’s not clear that compensation or demand will always be as hot as it is right now. I’m not complaining but if you take any satisfaction in actually helping people, there’s a real possibility you won’t find that anymore.

That said, you have options. If you’re willing to work at a junior or mid-level role, companies probably won’t care much what you did before. Maybe wait til the next boom in hiring happens, jump on the hype train. With your technical skills there’s probably some very unique research roles you could fill if you’re interested in that lifestyle — although the compensation is not super appealing. If it doesn’t work out, I feel like you could go back to surgery right?

> it’s hard to articulate exactly how it felt staring down the barrel of a career in medicine

Yeah. I used to enjoy this blog, written by a person who hated US medical school:

https://web.archive.org/web/20101218031844/http://www.medsch...

I know an eye surgeon who wrote a piece of software that streamlined the referral process for cataract surgery.

It’s a seriously big deal in his world.

When domain experts write make their own tools, the results are so much better than when an outsider does it for them.

Curious if you have a link

Thanks for sharing. A couple of questions if I may:

For a typical surgeon in the US, how common are lawsuits from patients?

Do you have plans to run your own clinic (if not already doing so)? If so, would this address some of your current issues (work hours, compensation) at the risk of having to operate your own business?

> For a typical surgeon in the US, how common are lawsuits from patients?

Not very common. Pretty much everyone gets sued at some point in their career, but it's rare to break through the malpractice insurance ceiling. That said, it's always in the back of your mind and when it happens it messes with you psychologically.

>Do you have plans to run your own clinic (if not already doing so)? If so, >would this address some of your current issues (work hours, compensation) at the >risk of having to operate your own business?

It's complicated. While being your own boss has a lot of perks, the path to ownership is not straightforward anymore in the current era of private equity. Some of the things that suck are not related to the financial aspects.

> Pretty much everyone gets sued at some point in their career, but it's rare to break through the malpractice insurance ceiling.

Attorneys don't want to ruin a doctor's career by going above the limit of their malpractice into personal funds. They target the policy as their bogey and work from there.

Look at medical device and pharma companies with a strong optha pipeline.

I work with maybe 2 dozen retinal surgeons, and it seems like a pretty cushy gig. High 6 figure salary, mostly working from home, providing input for clinical trials and product development. Some do it part time and still maintain private practices.

https://www.gene.com/scientists/ophthalmology

> Looking through the "Who's Hiring" thread is soul-crushing.

I know how you feel. I gave up on tech as a teenager and I still wonder what would've happened if I had stuck with it. Feels like it's impossible to switch careers now.

Where I live practicing medicine used to be a respectable profession but that's completely changed for the worse in the last 20 years. The communists currently running my country are literally quoted saying "we must create a new generation of leftist doctors who accept working for less". They flooded the job market with doctors.

> They flooded the job market with doctors.

US doctors have to put in long hours because there aren't enough of them. Are things different in your country?

Yes. Same hours but nosediving pay because we now have an infinite amount of deeply indebted doctors fresh off medical school competing for the same jobs. Wages are literally decreasing year upon year for the average brazilian medic. Workload is also increasing because healthcare managers are starting to interfere more and more in patient care. They want 10 minute consults.

So hours are long, and the number of Drs in the market are increasing. Are the number of patients increasing, or the time consumed by each increasing, or unemployment among Drs increasing?

> Are the number of patients increasing

The number of patients is literally never ending. It's a property of the decentralized public health system. If you have resources to spare, patients will be sent to you. No matter how much time and money you pour into healthcare, it's never enough. It's as if demand instantly scaled to exceed capacity.

> or the time consumed by each increasing

On the contrary, it's reducing. Cheap fast consults in popular clinics are now the norm. Doctors are doing more in less time for less money. The numbers are embarrassing, especially when converted to USD. The only consolation is it's still pretty good due to our low cost of living.

Brazilian software developers working for american companies for a salary that would be inhumane to an american put doctors here to shame. I'm talking 2-4x, depending on the company and exchange rate. It wasn't like this before.

> unemployment among Drs increasing?

A few years ago I saw someone joke about doctors driving Ubers for the first time. It's looking more and more likely each year. I'm also seeing doctors simply abandon the profession straight up.

Thank you for explaining.

> Brazilian software developers working for american companies for a salary that would be inhumane to an american put doctors here to shame. I'm talking 2-4x, depending on the company and exchange rate. It wasn't like this before.

It sounds to me that this is really the root cause of your unhappiness, rather than more doctors entering the market. We had a similar situation in India too, but over time the wealth gets spread around. The software engineers will too, after all, need healthcare and they will be willing to spend more on it given their higher disposable incomes.

> It sounds to me that this is really the root cause of your unhappiness

I know it sounds that way but the truth is I'm doing pretty good myself. I too make 2-4x more than those doctors. I just talked to one on Instagram about it. When I calculate the value per hour, I'm actually outcompeting those full time software developers. I make good money and have lots of free time.

Still, it's a bleak picture. In a few decades, medicine went from an elite profession, essentially guaranteed prosperity, to basically a normal job. Soon it looks like the liabilities will exceed the returns. Too much responsibility for too little pay. People here love suing doctors just like in the US. Why would anyone want to put up with that if they're not making a fortune?

The best option right now is to use medicine to raise some quick capital, start a business then quit medicine.

Just as an aside, I imagine there would be cool medical device startups working on smart glasses / artificial eyes.

They probably wouldn’t even advertise for an ophthalmologist/ CS / Math person, because I think there’s probably only the one of you!

With the rise of AR/VR this guy could probably make bank in the coming years.

> Physician salaries are the only ones that do not grow relative to inflation

Same has been happening to software engineers for the last 10 years at least. Salaries go up but not as fast as inflation.

I’ve gotten higher titles and more responsibility over the years but inflation is still winning compared to 5+ years ago.

> That said, is anyone hiring an ophthalmologist with CS and Math degrees?

As soon as the job market recovers I think you’ll have no problem finding a job in software.

Same has been happening to all labour. At least in Aus I think labour’s share has been going down since the 80s

Last 10 years? You must be joking. Software engineer salaries have done much better than inflation over the past ten years. If yours personally hasn't, you should have been asking for a raise or looking for a new job.

Over the past one year, they've probably done worse.

Do you have some statistics for this? Also, most of the inflationary damage was done in the last 3 years.

Unless 10 years ago you started at a very low salary I don’t think they’ve gone up significantly after inflation. If you were already a senior engineer 10 years ago for example.

Use BLS. Compensation for the average employee profile of "Software Developer" has far exceeded inflation.

I can't remember the exact timeframe, but roughly 2016 - 2022, salary for the profile of Developer has gone from ~$86k to ~$130k mean. I think that beats inflation quite significantly.

Ok, so that fits with what I'm noticing among my peers. The lower and middle salary range of developers is continuing to increase, but not a lot ($86k in 2016 is equivalent to $110k now), whereas the high end is not increasing very much or is losing to inflation slightly (people who were already earning $150-200k or more base salary in 2016, the start of the reference range you mentioned).

> That said, is anyone hiring an ophthalmologist with CS and Math degrees?

As someone who recently transitioned to a tech role, I'd urge you to focus on applying to companies related to your existing fields (ophthalmology, medicine, surgery, and their derivatives) who happen to be seeking SWE's, rather than general tech companies. Especially Series A, B, C startups. Look up all the companies that make your equipment or the software that you use, and go to their jobs pages. See anything that is tech or tech adjacent: swe, swe test, qa engineer, automation engineer, data engineer, anything mentioning python or javascript. The job market is the worst in 20 years and so the only companies that gave me the light of day were the ones in my previous field (energy and mechanical engineering).

This. This is best advice. I can't imagine there isn't some software company that could use a doctor-SWE combo. Usually SWE struggle not knowing the subject matter they are coding about. It is the subject matter experts that they need.

Even large corporations, Matt Lungren is a notable radiologist with a tech background and was hired at AWS and is now CMIO at Microsoft + Nuance.

This, I work with these people all day. There are tons of medical device and medtech companies that need people with both medical and technical backgrounds.

Companies in the healthcare technology space typically prefer to hire physicians as product managers rather than engineers. There's a shortage of product managers who understand clinical workflows. Lots of job openings.

> soul-crushing tech salaries

No one really gets those (statistically). I never did, despite being great at what I do. Basically a lottery system where the one lucky person who did the same exact problem two days ago wins.

I've found it's really about your negotiation and your confidence to ask for it. I've hired software engineers and frequently talk with others who do hiring, and I can confirm there's plenty of people who are making $120-140k who could've come in at $160-180k+ just by asking for it.

Sure, but doc is most likely talking about the $300k folks with 500k TCO at BigTech. Not the ones slaving away at Initrode.

> There's just no reason to do the job when you can get the same compensation working remotely in tech. Looking through the "Who's Hiring" thread is soul-crushing. Physician salaries are the only ones that do not grow relative to inflation and have decreased year-on-year relative to inflation for decades.

What ? Most U.S physicians make 300K + after residency with job security set for life. The real bright ones, the "faang" doctors make close to a million. Show me anyone in tech who can have that guaranteed for him. You're basically guaranteed to join the millionaire club if you decide to work enough years even as a mediocre doctor. Yes its an extremely difficult job I have no argument there, but there's no comparison to tech in terms of compensation or job security.

The job security issue is huge. Many of my tech and finance friends in their early 50's are getting pushed out of their jobs, while my physician friends in their 60's can keep their career as long as they want. A family member recently visited a dr. in his late 70's.

Difference is that in tech you can retire with 50. Few people who still work at 70 do so by choice.

So can many physicians. Furthermore, I'm willing to bet that most doctors in the 50–70 age group that continue to work do so not because they cannot retire, but rather because they do not want to retire because they find their practice fulfilling.

Not true, some do (stereotypically the surgeon with 4 ex wives and children that don’t know them) but it really depends on your country/practice pattern.

On one extreme Canadian physicians are (generally) ineligible for pension/retirement benefits. Many US private practice jobs are the same. Academic US jobs usually have some form of retirement support.

Add in the opportunity cost of not earning income until you’re 30+ as well as loans and I don’t think it’s a fair characterization to say “most physicians in the 50-70 age range want to work”, especially full time and considering burnout rates of ~50-60%.

Can’t speak about Europe which has very different compensation structure and debt burden.

> Many US private practice jobs are the same.

Where are you getting this from? The vast majority of doctors have access to the same kinds of fixed benefit retirement plans as people in other industries have.

Very few people in private industry have access to fixed benefit plans (other than social security). Most everyone has fixed contribution plans: 401(k) [or 403(b) for education/non-profit].

Sorry I invented the term fixed benefit to be in opposition to defined benefit. What I meant was defined contribution.

Which was my point physicians generally have access to the same plans as other industries.

"Fixed" and "defined" would be roughly synonyms in this usage, which is why no one understood you.

Defined contribution everyone would have understood to be in opposition of defined benefit.

From my job search as a physician. Literally no private practice job I’ve interviewed at or heard of provides defined-benefit retirement, if you know one let me know. Similarly I don’t know of many non-medicine jobs that still offer this either, but they do offer defined-contribution plans and GlassDoor suggests Google matches 7%.

The super high income (radiology) jobs people are alluding to here (500k-1m) are structured as partnerships that don’t offer employer contributions (depending if you own your own facilities you can potentially exit for a lump-sum at retirement, if you are just part of a hospital based group you don’t have any assets other than the contract so it’s like a 1-200k exit similar to the buy-in).

My surgeon friends in that income bracket are also all fee-for-service/eat what you kill rats that also don’t get employer retirement contributions/benefits or equity. A lot of us don’t even get paid sick days.

The jobs that offer you defined-benefit or employer contributions for retirement are academia or HMOs which is like 250-350k in radiology.

In Canada we’re technically corporations (for tax deferral) and consequently don’t even have RRSP (401k/IRA equivalent) contribution room (unless you pay yourself in salary). But there’s no employer matching/contribution in either case.

“ The super high income (radiology) jobs people are alluding to here (500k-1m) are structured as partnerships that don’t offer employer contributions”

Am I reading correctly that having no 401k match would be a concern for someone making $500k-$1m annually?

You’re reading incorrectly and I also wasn’t very clear.

It’s not a concern and I’m not saying we’re not well-compensated but 7% is something to consider when comparing total compensation across industries (and is one of the easiest line-items to objectively discuss).

A larger part of that physician’s income has to go towards planning retirement and inflation (and self managing that) than is being posited here. In addition to health benefits, sick leave and vacation. Someone making 400k at a place matching 7% with a good benefits package isn’t making less than a radiologist at 500k in private practice.

As an example a colleague of mine recently changed jobs and went to ~350k in an academic environment from ~520k PP and after calculating all of the benefits and reduced hours (less evenings/weekends, so assumed he would sign up for extra shifts) came out financially ahead. I haven’t worked an engineering job in over a decade but my gut/recollection is that similar base comp numbers would probably pan out the same especially as there is a significant opportunity cost.

It’s the difference between any independent contractor vs employee, regardless of if that’s medicine, construction or freelance SWE so when comparing the “high income physician” job it should be compared like you would a freelancer to FAANG employee @ 10 years of experience.

FWIW the median in private practice radiology is ~500k. As our compensation is literally per work-unit the only way to go higher is to work more hours, so the equivalent of FAANG engineer doing freelance work on the side.

> You’re reading incorrectly and I also wasn’t very clear.

There's nothing in your 3-4 posts that is applicable to physicians that also isn't applicable to any other white collar job.

> Someone making 400k at a place matching 7% with a good benefits package isn’t making less than a radiologist at 500k in private practice.

Sure, but what does it have to do with the discussion at hand? People need to do their due diligence about compensation when accepting a position, any position. This isn't unique to 1 profession, 1 field or 1 geographical area.

> It’s the difference between any independent contractor vs employee, regardless of if that’s medicine, construction or freelance SWE so when comparing the “high income physician” job it should be compared like you would a freelancer to FAANG employee @ 10 years of experience.

Sure, but the original point was, people making 400k + 7% or 500k can both easily retire at 50. The rest is pointless bike shedding.

> There's nothing in your 3-4 posts that is applicable to physicians that also isn't applicable to any other white collar job.

Disagree in that most other white collar jobs don’t treat their employees as independent contractors/self-employed.

Point of my comments was to compare the total compensation of the highest income physicians (which we are selecting in this hypothetical) with other high-income white collar professions as the pure dollar amount is misleading.

> Sure, but the original point was, people making 400k + 7% or 500k can both easily retire at 50. The rest is pointless bike shedding.

I mean retirement age in general is mostly a spending calculation.

To the original point, my argument is that if you’ve been making interest only payments on ~300k of debt and are starting to earn $350k at 32+ (a similar lifestyle/benefits job to FAANG, but specialist average income is $382k in 2023) it’s not nearly as easy to retire in your 50s as someone who has been making 100k+ from 22 without the debt and a similar # of earning years at 300+.

In other comments people were quoting 500k+ compensation so I apologize I was off-topic addressing that in this thread but was offering perspective on this very small subset of physicians.

The defined-contribution matching is not actually that significant. Google and Facebook e.g. match half of what one contributes up to 7%, so they’re paying at most 3.5%. More importantly, employees can only contribute up to the annual 401(k) max; that’s $22,500 in 2023. Thus, the matching is worth at most $11,250, even for execs with a seven-figure base salary.

Do Google and Facebook really only match half of 401(k) contributions up to 7%?

I thought employers competing on benefits were moving towards dollar for dollar or better matching. This is especially important for high income earners who'd be maxing out, because the 401(k) contribution limit for 2023 is $22,500 for employee contributions but $66,000 for combined employee and employer contributions.

Each is slightly different but it amounts to $10,250 worth of match if you max it out and then you can hit the $66,000 limit through the mega backdoor roth.

Right, and the mega backdoor you can fund yourself. So there’s not much point in cos juicing the match versus just paying people more, which big tech is not afraid to do.

Sort of. The employee + employer match can go into regular 401k or roth 401k whereas the mega backdoor roth is only roth.

Thus you can put ~33,000-66,000 into roth ones and only 0-33,000 into pre-tax ones whereas if the employer match got you up to the full 66,000, you could fully customize it to pre or post tax however you like.

Thanks for sharing, I'm still learning how retirement works in the US and was unaware of that detail.

I also wasn't sure how to value benefits (at least health/dental + disability if that's included) and PTO (including sick days and mat/pat leave which are unpaid for this subset of physicians), do you have a ballpark on what that is worth for accounting purposes?

Overall I think the biggest hidden line item in any physician's income is still opportunity cost of 10 years +/- loans but my main point is there are hidden costs behind that 500k which are fairly significant.

I agree benefits are hard to measure. Honestly, as a tech employee I think I value the free and convenient meals quite a bit more than paid sick days. I suppose one could try to put a dollar amount on it, but it’s really just a nice quality-of-life perk. One less thing I have to think about.

> super high income (radiology) jobs

Weren't these replaced by outsourcing imaging reading to third world doctors?

Mostly no. Foreign doctors can't legally practice medicine on US patients. Those third-world doctors are mostly used for things like insurance case review. Some radiologists also perform interventional procedures, which requires being physically present (at least until teleoperated surgical robots become common).

Aside from procedures:

We have multidisciplinary case conferences every day which can't be outsourced and perhaps most importantly you also want to know who your radiologist is.

Reporting of anything remotely complex (e.g. oncological studies, inflammatory bowel disease, interstitial lung disease) isn't black/white and is adjusted to local practice environments/treatments options with feedback from clinicians continuously adjusting how we report.

Every center I've worked at in US & Canada won't even accept an outside report from another North American academic institution for oncological studies and will request a formal second opinion even if the scan and report came from MGH/Mayo/Hopkins.

Some of this is medicolegal risk but it's apparently backed up by research/quality improvement studies although I'm not familiar with the literature.

The stuff that's outsourced to licensed physicians (within continental US or abroad) is the easy stuff like ER/acute care.

private office physicians, and General Practitioner physicians, effectively were eliminated in rounds of consolidation and changes in insurance practices, by the early 2000s here in California. Second, large areas of low population density have zero local MDs.

Sorry I invented the term fixed benefit to be in opposition to defined benefit. What I meant was defined contribution.

My wife is a physician, as are many of our close friends. They nearly all work for private groups, and they mostly have some kind of employer matched plan. My wife’s group just directly contributes up to 13% of her salary to her retirement plan through profit sharing.

I know a far higher percentage of non physicians without employee contributions to retirement.

My wife doesn’t get paid vacation, but she only needs to work 12 shifts per month to maintain full time status and she makes more than I do (working only 12 shifts) as a principal engineer.

> My wife is a physician, as are many of our close friends. They nearly all work for private groups, and they mostly have some kind of employer matched plan. My wife’s group just directly contributes up to 13% of her salary to her retirement plan through profit sharing.

Knowing that your wife is in PEM now I expect she's not in the 500k-1M category (if she is kudos again but I definitely made a career mistake) and presumably a large/whole-hospital billing group?

In this setting there tends to be more benefits because the group is so large the costs are diluted and you need to retain certain lower-billing specialties to maintain coverage requirements (peds EM being a good example) but overall compensation tends to be on the lower end, kind of like an academic-lite environment but less non-clinical work hours so comp is better but I really can't imagine the average specialist in a paediatrics or hospital-based group is taking home 500k-1M while providing benefits.

The majority of physicians billing >500k purely for clinical work (especially as you go up) will be 'high income specialties' (proceduralists/surgeons) where the setting is much smaller specialty-based partnerships, or billing as single-individuals, where benefits don't exist as they more directly come out of your pocket and you don't need to 'subsidize' a specialty to keep them employed/eating and your contract in place.

I’m not sure where we only started talking about physicians making >500k. Very very few software engineers are making that despite what you’d think from reading HN. The vast majority who are making anywhere near $1M are no longer really ICs, so they aren’t comparable to a physician who only does clinical work.

My wife doesn’t make $500k, but if she decided she wanted to work 40-50 hours a week instead of 25-30 she could get close.

Her group, and from what she says most hospitals in the country, are basically always struggling to find enough PEMs to maintain coverage.

The incentives to work more than 15 shifts and more than 4 overnights are very generous—the alternative is to bring people in from the next city over. And if she really wanted to she could pick up extra responsibilities and work towards becoming a partner.

But virtually no one is making $500k-1M in base compensation in any industry, so percentage based benefits are such a small part of it.

Look at Google for example, you’re at senior staff before your base reaches $250k, so percentage based contributions are based on a much smaller chunk of your total compensation.

Just curious are aware how little CPP pays? Why is that even a consideration,I don’t understand.

The vast majority of tech jobs offer no RRSP match as well

Also consider how few faang jobs exist ( especially now) vs physician

Many of the doctors at the VA I go to are retired then took the VA job. They see 8 to 10 patients a day and spend between 20 to 30 minutes with each. They work 8am to 4pm and go home. On the other hand surgeons and their support staff have crazy schedules.

That is BS, a big load of BS. There are a ton of people in tech that struggle, and reach 50 just to be nearly living on the street. This thread must have a lot of top FAANG's managers posting this morning.

An above average eye surgeon in the US with a few years of experience is the rough equivalent of a middle manager in terms of age and could be in terms of rarity.

> There are a ton of people in tech that struggle, and reach 50 just to be nearly living on the street.

In the literal sense I doubt that. If they are "nearly living on the street" then they seem to have issues handling money. Literally everybody else around then is making less and is not in the street either. Or are you saying that the lady behind the Walmart cashier or the pizza place guy or the girl moving the office lawn all make more than the tech guy? Hardly.

In the figurative sense, sure, some of them may not have a big detached single-family house with two big BMWs in front, but if anything below that is considered "nearly living on the street" then it's your perspective that needs some adjusting, not mine.

Perhaps I was over-stating. But it is true, that tech people retiring at 50 and living comfortably is a real small minority, not some common occurrence like everyone in tech is swimming in gold. Living on street was hyperbole, but I do see a lot of tech people working long hours, on -call 24-7, dealing with bad bosses, all because of the 'fear' of living on the street. So maybe they aren't close to the street. And if over 50, that fear drives the 'do-whatever-it-takes-even-if-pulling-another-weekend'. It isn't some golden retirement, that is so bogus. Its like there is some assumption that everyone in tech got stock options at google.

A more nuanced discussion would perhaps help. You are just jumping between extremes.

Obviously the average tech person can't retire with 50 while living in a golden castle. Nobody claimed that. If you retire that early then you lifestyle needs to match your wallet. I'm not even 50, I'm just below 40, but I could retire tomorrow despite not having worked at Google or similar. Obviously I couldn't own a 1500sqft condo in downtown SF, drive a big car and go on a yacht vacation in Monacco every year. But I could afford a nice place in the countryside and continue with the hobbies I have, none of them demanding big financial resources. It's about lifestyle choices, no matter how much money you have.

That was the claim, I was replying to : "Difference is that in tech you can retire with 50. Few people who still work at 70 do so by choice.".

Saying you can retire at 50 if you choose too, and working is a choice, is completely bogus. You are not being nuanced, you are being misleading.

Nobody is retiring at 50 that isn't very well off. Even with a small house, remember, there is covering health insurance, taxes, food. It is well beyond a large percentage of people.

Spinning it as lifestyle choice is not what was being alluded too. Yes, I could choose to live in a small apartment and live on rice, and thus 'retire'. Do you really think that is what the original post was implying.

"Nice place in the countryside and continue with the hobbies ". I just can't believe the levels of disconnection here. It almost comes full circle, I could 'retire' if I would just choose to live on the street, it's totally a lifestyle choice.

> Saying you can retire at 50 if you choose too, and working is a choice, is completely bogus. You are not being nuanced, you are being misleading.

Perhaps read again what I wrote. I explicitly stated that those who still work at 70 rarely do this by choice. More concretely, the lady behind the counter at Walmart is 75, and she definitely does not do that job because she loves it so much.

This was to contrast with the comfortable situation that we in tech are in. We can choose to retire early, even if it comes with lifestyle impacts. Not everybody desires a penthouse in downtown. And not living there does not mean you are living on the street.

OK. Guess I read it opposite. Your wording of choice, seemed to imply there was a choice. I missed a negative, so you are saying, a lot of people do NOT have a choice.

I guess then, I agree. A lot of people have very limited choices, and in tech we have slightly more choices. I'd just disagree with the degree of choice. In Tech we have more choice, I'd say that isn't much more. If there is some arbitrary scale of choice, from 0-100, and most people have 10% of choice, and in tech we have 20%, that is still at the bottom. When you get outside of SF, there is a vast world of tech, where tech people are not rich, and they are slugging away making ends meat like everyone else. Generally better off, but I'd say a really long way from being able to make a choice to retire early.

It's kind of like the scene in Game of Thrones where they are arguing about slaves having a choice, and Tyrion is saying slaves have a choice, meaning that they can commit suicide. So yes, we all have a choice.

> In Tech we have more choice, I'd say that isn't much more.

Ok. Then our main disagreement is whether a household income of $400k grants significantly more freedom than a household income of $150k. I'd argue that it indeed does.

See that is the disconnect. Who in tech has a household income of 400K except for the rarefied top people at a FAANG. I'm saying that is like <5% of total Tech workforce. The argument isn't between 400K and 150K, it is between 150K and 70K. There are a vast number of people in tech at <100K$. So who making 100K can retire at 50. It is possible with the right choices to live very minimally to the point where you could argue it isn't really a choice. The real misunderstanding is the number of people that think Tech=400K.

That’s not true at all.

If you got on the FANG train around the time they dropped the standards and kept the comp going.

Tech is boom/bust. Ask a grandpa who worked for DEC in the 80s how that worked out for him.

A 50 year old physician or lawyer, if they are good, is at the absolute top of their profession and can 90% expect work another ten or twenty or more years still earning top dollar.

A 50 year old non-management programmer? Look forward to having 23 year olds asking if you know what an array is for the rest of your work life.

I don't agree about lawyers actually. If you haven't made it into something close to partner level or have extremely valuable knowledge and skillset you'll be seen as a liability. There's plenty of people in their late 20s to early 40s who will be preferred over you. Same goes for most jobs actually, doctors are the outliers. For now...wait till A.I makes progress in medical circles.

One fact I can add to your knowledge is that at my firm, the lawyers who have been practicing longest have the highest billable rate.

One more is that I very, very rarely ask any 29 year old lawyers at my firm any questions, although I love them dearly. When I need someone to review my work or answer a ticklish question, I seek out 72 year olds and ask them. I'm not sure who clients prefer but when it comes to legal problems I prefer elder lawyers.

Yes they are partner level. How many 50 year old lawyers has your firm hired recently? Ones who haven't advanced to partner?

To be clear I'm not saying this never happens (hiring of mid level 50 year olds), I'm just saying it's just as rare as in tech. I don't think I'm imagining this, it's a pretty well established statistic that after 50 job participation rates begin to fall.

I perceive the lateral market for 50 year-old non-partners to be robust and I believe the market for first year lawyers is vastly more challenging. I myself would vastly prefer age and experience in a lawyer to the billable hour vigor of youth.

Do you participate in either or both of those markets? Let’s put it this way: I intentionally left the old tech guy market and I can tell you the old law guy market had no problem supporting me. I am not a partner and (if you believe my boss) I’m not very skilled.

> Do you participate in either or both of those markets?

My wife is a big 4 consultant (international tax). She has worked in almost all of them - E.Y, KPMG etc. Same structure everywhere - a couple of 35-45ish (sometimes 50ish) partners and a bunch of young managers and seniors who do all the work. My wife is now an old 36 manager there. So it seems like you either move up or move out in big 4.

> I myself would vastly prefer age and experience in a lawyer to the billable hour vigor of youth.

I have no argument with you there. I also tend to prefer older devs but it's a personal preference. Anyway we should try to move from an anecdotal discussion.

"According to the SRA, only 8% working at larger law firms are aged 55 to 64, and while the current war for talent has meant law firms have focused on attracting and retaining lawyers early on in their careers, we rarely hear about efforts to recruit and retain older lawyers."

https://www.law.com/international-edition/2022/09/28/silver-...

I’m going to chalk this up to micro markets, I think. I get recruited harder now than I did as computer.guy and I’m that many years older thanks to taking a break for law school. My passing familiarity with Accenture means I understand what you’re saying about the big four. One factor I wonder if you’re taking into account is that there aren’t a lot of law firms as big as the big four accounting firms. Maybe the situation you (and that law.com article ) are detailing is how it is in big law right now, where I am not?

It's definitely possible different smaller law offices have different vibes yes, just like not all tech companies are the same. I think the trend I'm describing IS accurate though. Anyway I'm happy for you it's not affecting you!

> A 50 year old non-management programmer? Look forward to having 23 year olds asking if you know what an array is for the rest of your work life.

Fuck. That made anxious. I am close to that age.

Also, my middle manager friends are having much harder time finding a job than programmer types. Don't know if its just them or if its a trend.

A.I is gonna change the job market so deeply I wouldn't worry much. It's futile to worry, we simply don't know what's coming we only know it will change everything.

Quoting ('someone's on the Internet' (-) Messages I read in the last days...):

"And, because the bosses don't want to raise wages?

This is why AI hype is big right now. There's a lot of companies hoping to hawk a snake-oil 'solution' to lower productivity that doesn't require raising wages.

Given that most government accounting is single entry and most macro (-economic-solution) does not really recognise the role of money in the economy, this is in itself quite revolutionary stuff

It's pretty sickening to see how much money is allocated in developed Capitalist economies to (disturbing-kick people-) scams like AI.

On June 15 a session titled 'The New World Economy — Not Global, But Interconnected' will take place as part of the business program on the St. Petersburg International Economic Forum 2023

'It is about an authoritarian communist regime that gave up communist economic policy, but not in other segments. But... It's still a communist country'

> They were told they were building a castle, but instead they built a prison.

The industry term is 'golden handcuffs.'"

...maybe and i hope so there is something to learn from regards...

No need to. If your experience is solid, there's plenty of work for consultants. Not those types, who walk in and get told to create a CRUD app, but those who can advise on tech, its implications on the business, the risks, etc.

Any resources for finding these opportunities?

Don’t be anxious.

The best programmers I’ve ever worked with and deeply respect are the ones in their late 50s, early 60s. They’re unflappable when it comes to outages. They’ve seen it all. They work more sustainably and methodically to get stuff done.

It's interesting that places value seniority and experience so much more in medicine vs tech. Things change daily in both fields--new procedures, new findings--yet tech seems to have far more ageism. Why is an older doctor so much more valuable than an older developer?

I wouldn't say they're valued, the compensation is (with some nuance) based on a work-unit/fee-code which is the same for all of us. The academic component goes up for relevant physicians like it does for any professor-type role.

Doctors work longer mostly because you can't fire them unless they're negligent/incompetent (for various reasons including that most are self-employed/contractors either individually or as a group).

The only value the hospital places on seniority is that you know the local practice patterns so there's less of a learning curve as compared to someone ewer.

> Things change daily in both fields--new procedures, new findings--yet tech seems to have far more ageism.

We have continuing medical education requirements but the reality is most of medicine is designed to be easy and guideline based. Weird and wonderful stuff benefits from experience.

> Why is an older doctor so much more valuable than an older developer?

A 60 year old surgeon is still taking out an appendix, just with newer tools than when they were 30, for the same amount of money as a newer one. I would imagine an older developer would want to be more well-compensated and have career growth focusing on things like architecture or having a team but I defer to practicing developers for their input on why they're not valued.

When it comes to value, when my wife interviews for a job (she’s a physician) they fly her out and spend a day taking her to see the sights, so they convince here how great the city is. Then they take her out to a fancy dinner and woo her some more.

When I interview at a new job as a very senior engineer (and relatively well known I in my area), I get to jump through 7 rounds of interviews where someone asks me the equivalent of medschool exam questions.

If I’m lucky my connections might let me whittle the interview rounds down to 5.

There may be 20 people in any given tech stack/industry who are valued the way my wife is by employers.

> When it comes to value, when my wife interviews for a job (she’s a physician) they fly her out and spend a day taking her to see the sights, so they convince here how great the city is. Then they take her out to a fancy dinner and woo her some more.

Interesting, are these in underserved areas? I just went through interviewing for a new job and despite being in an in-demand subspecialty with desperate employers the most I got was a dinner after the 2nd round interview but no one covered my travel. Do you mind if I ask what kind of physician she is? I clearly picked incorrectly.

> When I interview at a new job as a very senior engineer (and relatively well known I in my area), I get to jump through 7 rounds of interviews where someone asks me the equivalent of medschool exam questions.

> If I’m lucky my connections might let me whittle the interview rounds down to 5.

Why do you think that's the case? Is it a compensation issue or is there age-ism/an assumption that only a 25 y/o engineer can be "10x". I periodically see posts about the challenges facing older developers on HN but I didn't last long enough in tech to understand it.

In the corporate world it's routine for employers to cover travel expenses for job applicants coming to interviews that farther than driving distance. Did you ask about that? Sometimes if you don't ask, you don't get.

> Did you ask about that? Sometimes if you don't ask, you don't get.

I did not. I think I'm so conditioned to being treated poorly by hospitals I just assume I'm going to be taken advantage of but you're probably right and I should have asked.

>Interesting, are these in underserved areas? I just went through interviewing for a new job and despite being in an in-demand subspecialty with desperate employers the most I got was a dinner after the 2nd round interview but no one covered my travel. Do you mind if I ask what kind of physician she is? I clearly picked incorrectly.

Pediatric Emergency Medicine. All in cities large enough to have a children’s hospital, so basically minimum metro populations of 500k or so.

>is there age-ism

I’m sure there is, but not really at the principal engineer level from what I’ve seen. Mostly there’s an assumption that staff plus engineers will skew a good bit older.

I think the issue is that everyone cargo cults FAANG interviews. They get so many applicants that they can afford to treat very senior people like new grads, and that attitude trickles down to most other companies.

From what I observed early in my career, there was definitely a time when higher level engineers escaped the FAANG style hazing process. But slowly more and more companies have started putting everyone through the whole thing.

I’ve been at companies where leadership tried to force very well known engineers with decades of experience, hugely popular open source projects, multiple famous talks/blogs/podcasts etc… to do weed out take home assignments.

> Pediatric Emergency Medicine. All in cities large enough to have a children’s hospital, so basically minimum metro populations of 500k or so.

Interesting, pediatrics is so underfunded and poorly respected in Canada that I'm genuinely shocked (and pleasantly surprised) to read about a paediatrician not being treated like refuse.

Kudos to your wife though, that's a very challenging field and anecdotally my interactions with peds ER physicians have been overwhelmingly positive. They all seem to have a very well-developed sixth sense about when something is "off" despite many of their patients not being able to talk.

> They get so many applicants that they can afford to treat very senior people like new grads, and that attitude trickles down to most other companies.

Is it just during the interview process or do you find bias against older engineers in hiring decisions and the work environment as well?

Curious if you could add some color to the switch from tech to medicine

Because technology has no educational pathway. Sure, you can go to a college and study algorithms or math for a while, but plenty of people with "good degrees" can't code. Plenty of people with no degree can.

It's also kind of challenging to tell an eye surgeon whom you are interviewing to do an eye surgery if you're really not sure he knows how to do it or not.

> Why is an older doctor so much more valuable than an older developer?

The lower barrier to entry that the developer has?

I've heard of the "tech bro" stereotype (and seen it many times first hand), but struggle to recall a "doc bro" or equivalent one. I've also never heard of the term "culture fit" when discussing a potential hire in the medical industry like I do tech, software specifically. I wonder if the majority of the types of people who go into tech are different than the majority that go into medicine.

> It's interesting that places value seniority and experience so much more in medicine vs tech

I don't think the tech world devalues seniority as much as they despise people older than them and not of the same generation(ish).

All big generalities and of course don't fit every situation/company/person.

Stereotypically, surgeons are the doc bros.

I, too, watched the early 2000s medical sitcom Scrubs, featuring the beloved Dr. Todd.

And orthopedics specifically are the broiest of the doc bros

“When you hear hoof beats think of horses – not zebras”. Old doctors won't catastophize and scare you as much but are in my opinion more likely to misdiagnose a rare disease.

> Why is an older doctor so much more valuable than an older developer?

which would you take with you on a one way trip to a desert island?

that’s a meaningless question, it assumes their jobs are their siloed experience, and that nothing outside of job is real.

training. licensing. you can’t just go become a doctor. yes, there can be new doctors, cheaper, maybe better, maybe not. but the funnel is finite.

got a computer? or a smartphone? device with screen and input? with a little work, you’re gonna be writing code in no time. call yourself an engineer and mostly nobody gets mad that you have no license, no certification, possibly no degree. because none of that matters.

no, that isn’t capturing nuance, context, or detail. just the macro. it’s enough.

> which would you take with you on a one way trip to a desert island?

How long are we going to be there?

well, given that it is a one way trip, that’s largely up to you and your travel companion.

> Things change daily in both fields-

This is not true ?

As someone in the midst of a difficult career pivot from tech to medicine, I confirm that this is the primary motivation for making the switch at this stage of my life.

Even now 300k TC is pretty easy to get for any competent engineer wanting to work for a publicly traded company that can get comp in RSUs.

It's also very easy to get a 200k+ remote eng job, even now, that will allow you to spend as much time with your family as you like, rarely have you working past 5pm, and working in predictable, relatively low stress (potentially fun!) problems all day.

The job security is a good point, but job security isn't as meaningful for extremely high stress jobs since the risk of burnout is much higher. Doesn't matter if it's easy to get work if you find that work destroying your personal life.

Your circle of 2/300k engineers does not represent average people. 99% of Americans should not be able to get a faang job even if the exact park was laid in front of them before college.

I have never worked for a FAANG company, or anything close, and can usually not get in the front door at any "prestigious" company.

In my last round of interviews nearly all startups/small companies I talked to where offering 200k+ for remote senior engineers. It's not hard to break 200k remote as a software engineer.

If you're not there I highly recommend you start looking around, even in this market, rather than simply dismissing this comp as "prestigious faang only". Personally I think the 500k+ TCs are going to disappear for all but the rarest of cases (this is closer to what FAANG engs that I know make), but 200k+ is likely to be the baseline for the foreseeable future for experienced software engineers.

Do you make 300k? You said it was “easy to get” so surely you’re above that?

Yes and so do all of my teammates and every senior engineer at a publicly traded company you've likely never heard of.

Again it's pretty standard anywhere in tech right now, startup or otherwise, to get 200k base + equity. Technically most startups I've chatted with also offer 300k+ TC... but that assumes the equity component eventually becomes liquid.

Around 200k base is very easy to get anywhere right now, and getting larger than that is a factor of how liquid your equity is. If you join a publicly traded company you should easily be able to get 200k base + 100k/year of RSUs

And to be clear: I'm talking about Senior Engineer level in the US. Most of these roles I've looked at are remote so the NY/SV part is not necessary.

edit: your profile says you work at a FAANG so this should be old news for you.

I make well above 300k. It wasn’t an “easy” interview by any means.

You can go look at levels.fyi and see that there are plenty of F500 companies that don’t pay 300k for L5. Just spot checked for Ford, Disney, AT&T, Verizon, Target, and more.

I do hiring for small companies, no one is paying that much. 130-150k is base for seniors. Also seeing a decrease in US based developer jobs, lots of offshoring happening. I'm halfway considering moving to Costa Rica and running a firm down there.

They must be very small because I don't know of anyone hiring senior devs in that range. Even those smaller, early stage companies I know are offering at least 150-190k base, and they struggle to hire.

However if you're dealing with dev roles that are being actively outsourced I suspect you're dealing with an entirely different class of software jobs.

Where are you finding these jobs?

To be fair, I think op was referring to engineers specifically. You don't need Faang to make 200k as a sr. Look at non tech focused fortune 500 companies. 200k is available to sr engineers, even remote if US based

FWIW, 200-300k is not that uncommon far outside of FAANG or the usual tech cities for experienced senior engineers with current skills. We are not even talking startups necessarily but boring industrials and other companies no one thinks of as tech companies. Every large business is being forced to be much tech savvier and this reality has diffused high-paying tech jobs among a much wider range of companies and locales.

You are correct on one point: most Americans don't have the skills for these jobs. That is why these jobs pay so well, almost definitionally.

It is trivial, in the US, for someone to work at the older large tech companies and get over $300k just by staying in the job. Your typical SWEIII is making $220k base with a 20% bonus and gets roughly 50k/3 RSU grants each year. After 3 years, that's $50k annual due to stacking. This for relatively easy big company roles, and not even lead.

> What ? Most U.S physicians make 300K + after residency

Most US physicians also pay for a lot of work-related expenses out-of-pocket (insurance, continuing ed, etc), and due to the nature of tax codes, most that often is not actually deductible in practice (particularly since they'll usually end up paying AMT).

There's a lot of variance depending on which specialty you choose and where you work, but as a point of reference: most new attending physicians in metro areas are actually netting less than an engineer in the same area who has been working since graduating college[0]. (And that's before you factor in any student debt, or the opportunity cost of forgoing ~10 years of gainful employment).

> with job security set for life.

May have been true 40 years ago, but definitely not true today, especially for certain fields.

[0] If two people graduate college at the same time, and one goes into medicine and the other goes to work as an engineer, the engineer will easily reach career level (senior) by the time the other person is done with their residency.

All true, but the unemployment rate for licensed physicians is virtually zero. They can always find some kind of job, although they might have to move somewhere undesirable.

Exactly. Longevity is much greater outside of tech.

I've got friends and family that are physicians and they also work a lot. They're in the EU so at least the "getting sued" part is close to non-existent (there's still a risk but typically only if there's a real fuckup). At least one of them also complain that the job isn't paid well enough and that the job kinda lost some of its luster.

But...

> There's just no reason to do the job when you can get the same compensation working remotely in tech.

Compared to serving ads and/or engaging in surveillance capitalism, at least there's a lot of comfort in that they're doing (and you 're doing) a useful job.

So I know it's not much but thanks a huge lot for what you're doing.

Your income is relatively insane (multiple 100k), you have ultimate job security even in old age, opening a private practice makes your income essentially open ended depending on how much hard work you put in, you can help your loved ones and yourself to better navigate health care, will always receive priority treatment and probably have the job with the highest social standing that exists.

I don‘t know what it is with doctors world wide having zero awareness of their maximum privilege and zero perspective on how their average and median fellow citizens do.

Yes it‘s hard, but so are many, many other jobs you don‘t hear much about.

Like farmers

This viewpoint is just plain crazy. If you worked in tech you'd be totally disposable, just like all the rest of us programming drones. Hit 40-50 and boom, unless you've transitioned into management, suddenly no one wants to hire you, or if they do its half of what you were making before.

Your MD degree and the AMA literally writing laws on your behalf limits labor supply competition like nothing in tech. You may have noted 250K+ tech layoffs in last year or so. Many of those people could probably code circles around you. Where are the physician layoffs? There aren't any.

If you want fewer hours, work fewer hours. What are they going to do, fire you? They can't. There is a shortage as this notes.

This needs explanation. If there is such an extreme shortage of talent, why can't doctors demand better terms, e.g. shorter hours?

Sometimes they do, look at the UK strike for an example although the environment here is no where near as toxic.

One of the shortage issues is that it takes 9-12 years to train a specialty physician. For example we need more radiologists today but we can’t fix that until we increase residency spots which won’t impact the job market for 6 years so until then I’m reading more than I want to, even though I’d gladly work less for less total compensation.

Someone has to do the work though and I can’t just say “not me” and leave the studies unreported. There is a human on the other end who needs care.

They can, just not alone. If they were to unionize in sufficient numbers, there would be nothing to do but meet the demands. But “unions are bad” is the prevailing belief in the US, not to mention the huge amount of efforts that companies and the government go through to suppress them.

Many physicians still work in sole proprietorships or partnerships. From an employment perspective they are management, not labor.

Some physicians working as employees of large provider organizations are unionized. The government doesn't do anything to suppress this. Rather the opposite.

https://jamanetwork.com/journals/jama/article-abstract/27949...

This is what I don't get, if there was such an extreme shortage then the average visit to a family doctor should cost hundreds of dollars.

Physicians are disposable too, look at what happened with primary care, nephrology, anesthesia and is starting in radiology where private equity firms move in and outsource physician care to allied health professions and create an “eat what you kill environment”.

In other countries like Canada it’s also near impossible to get a job in a surgical specialty (and until 2 years ago other ones like radiology), especially in a desirable city despite huge shortages and backlogs because our jobs use a lot of expensive resources.

> If you want fewer hours, work fewer hours. What are they going to do, fire you? They can't.

They can, many jobs set a minimum FTE you can work.

They also reduce fee codes (with a system known as relative value units/RVUs) so you have to work harder to make the same money. We’re at the mercy of payers in US/Can.

My specialty (radiology) has had work-unit compensation periodically slashed over the last 10 years (20-30%) that’s been offset by reading more cases (and to a lesser extent technological advances making reading faster although studies have gotten far more complicated to read with modern treatments).

There’s also the increasing clinical demand and generally caring about the humans on the other end. I don’t want to read 50-90 CT scans on a ER shift but I have to because the studies are being ordered, the patients need their reports, and we don’t have enough radiologists.

The grass is always greener. Most Canadian software engineers are getting paid much less for the same work as across the border. Currently there are layoffs, hiring freezes and pay increase freezes. Canadian software engineers make less than doctors. FAANG salaries are a thing but you have to be willing to move to the US in order to attempt to achieve that.

Yes, if you consider non NYC/SV salaries physicians come out ahead in the vast majority of cases, we earn more or less the same no matter where we live.

I’m happy with my compensation but I’m also happy with my job/not optimizing solely for it. My point is that if I was I would have chosen a different career.

I also left Canada to make less in the US as a physician because I wanted more work/life balance and not to be working in a system constantly on the brink of collapse. The hospital I trained at was on “life or limb critical capacity” so often I had to set up an e-mail filter to send it to my junk.

Speaking of hiring freezes, from 2010-2020 the only jobs for radiologists were in small towns or undesirable locations, it’s better now for rads. Most surgeons and proceduralists (cardiology being a horrible one) still can’t find jobs in major metros without 2+ fellowships and at least one somewhere prestigious. It’s still hard with that.

As in all things, it really depends what you want in life. But if you have the aptitude to reach the highest levels of physician income and have mobility you’re probably skilled enough to have done the same in other professions (e.g. finance, software) with an easier (physically speaking) path and less opportunity cost.

Any reading on these PE driven radiology changes?

Curious, are there any other fields with laws built to limit competition. Lawyers?

> Physician salaries are the only ones that do not grow relative to inflation

Spoken with the true conviction of a position of privilege, and blinded by the very same. (No pun intended.)

Hint: The majority of U.S. citizens have it worse than you.

So what? Making a doctor’s life better doesn’t preclude making everyone else’s life better. I think we should buoy everyone who isn’t in the capital class. This crab bucket mentality has got to go.

Totally. The criticism was that the post responded to literally claimed that physicians have it worst of all since everybody elses compensation has been growing more than inflation. Which is just nonsense.

"I saw 40 patient's in clinic today in 8 hours without lunch or any kind of downtime"

You want to give better care to patients, which means more time per visit and at least three breaks per day (morning, lunch and afternoon). You want to have more coworkers so that you can have consistent on-call work. Increasing the quality of your life-work balance will improve the quality of your work.

As a resident, you likely did 24 hour shifts -- or worse. That was just hazing: nobody does their best work while sleep-deprived, and training in it doesn't improve things. You need reform throughout the system.

You need a union. And one of the things that union needs to focus on is getting more people into this line of work.

I know this probably won’t make you feel better because you know this, but you’re actually making a huge impact on the quality of people’s lives. I work in tech (though not at a FAANG company) and my wife decided to go back to school (now that the kids are relatively self-sufficient) and she is hospice nurse. She gets home exhausted from 13-14 hour shifts. Having said that she feels so much more satisfaction than I ever have writing code to update a value in a database.

I agree, I left a FAANG and startup to pursue medicine (not that finances were my motivation) and my co-founder who went back to a FAANG is earning more than most physicians now.

I’m far removed from this work environment now but at 10 years of SWE in a FAANG one seems to be making ~$350k-400k in total compensation? Not sure how many make it to L6 or higher, I defer to other commenters here.

If you consider the competitiveness of high earning jobs (especially in desirable markets, probably the top 20% of candidates), the opportunity cost during a decade of training I would imagine a similar %ile candidate in CS would be making more in major cities.

With that said physician income is relatively similar in metro vs cheaper COL areas so if you wanted to work in non-tech cities or smaller metros specialty physicians would probably make more.

With that said, with the hours and work intensity I put in now I could probably do 2 FTE SWE jobs (at least comparing to what it was like 10+ years ago).

But is that high paid era over?

Could be. Could also happen in medicine (many think the golden era for compensation is nearing its end)

A decade ago nephrologists in a dialysis unit were making high 6 figures until private-equity moved in and now they make 1-200k.

Most people cannot last 10 years in FAANG. It’s up or out.

It's a pretty reasonable expectation for the 95th percentile. IDK how that translates to surgeons, maybe 70th-80th percentile?

Hard to compare, the "high-income" specialties are either brutally intense (e.g. neurosurgery, cardiac surgery, vascular surgery), competitive (plastics, derm, radiology) or both (ortho).

The competitive ones are variable with ~50-80% match rates for US MD graduates. Generally hard to get employed in desirable markets (especially NYC, LA, SF, Boston) unless you trained around there so the "desirable" programs are harder to match to but numbers aren't released. Some residency programs are toxic dumpster fires.

Attrition is hard to gauge because once you're in you're kinda stuck due to loans, sunken cost etc. Completely made-up but I would consider any of the intense specialties to represent at least the top 10%ile of physicians for a combination of aptitude and work-ethic/masochism.

You’re on the wrong forum to complain about the medical field. These SWE think you’re a privileged complaining brat (ironic) who breezed through the 15 years of school and training and don’t deserve anything but disrespect. You’re part of the medical cartel and for the most part, they despise you. Your salary is deemed too high and you are expensive overhead that needs to be decreased - hence the outrage and popularity of these articles here.

You must know this? Have you not seen their comments on HN medical threads? So vocal and often horribly wrong it would be comical if it wasn’t so depressing.

I’m not going to one up you with my own sob story, but it’s like you say for all of us everywhere in the US - but you can really only complain to other MDs. Outsiders will demand you work more, get paid less, get sued more, and grovel. They hate us, so don’t complain to them. In the end they will get what they want - automated service by LLM combined with other diagnostic software and nursing. They will then complain for the return of the human physician. It’s so typical.

You are perfectly suited to giving them automated service. Just spitballing and probably wrong - have an optho specific app with an LLM and maybe a plug in smart phone device that has object detection/instance segmentation for diabetic retinopathy. Cataracts detection might be secondary? There’s plenty of products for retinopathy and looks like Inception networks do fine for cataracts. Other eye pathologies that are easily visually diagnosed are on the table too. Why see 40 patients when you could see 150 and the LLM/app have done the referral, initial screening questionnaire, and your nurses/MAs write your note/rx/orders etc. Ideally you should be like a dentist (they clearly figured this out already). You walk into the patient’s room do a quick eye exam, say what needs to happen, don’t answer any questions, and walk out. They hate you already anyways, might as well lean into it.

- Currently an imaging fellow in the cartel.

I remain optimistic that some people here are open to learning so I still try sometimes.

- Also a radiologist who gets told I’m egregiously overpaid when [insert immature AI tech] can definitely do my job better.

I am not optimistic here. This is the lion’s den - I’m here to see what the predators have in store for us. Back in early residency it exposed me to CNN and real time object detectors and a co-resident and I made a little proof of concept app that detects ICD/PM on CXR.

So I think there’s value to me here - just no value in proselytizing and apologetics. They don’t like us and are here to eliminate us.

I don’t view it as adversarial. I’ve had productive conversations on HN including some which gave me NLP approaches I hadn’t considered.

Engineers (including myself when I had a health-tech startup before my MD) tend to misunderstand the problem space (simply put they consider radiology a classification task and assume ground truth labels exist/are even possible like for object recognition) so it seems easy to them, but I don’t believe the intent is nefarious.

Perhaps it’s my naivety but I think most smart people at least partly care at improving society on some level (even if they want to make a lot of money doing it) and the physician-services budget is a large line-item that seems like an easy target rather than the ??? to improve inefficiencies and outcomes.

Without a doubt the AI-enabled radiologist will render the non-AI rad obsolete but it won’t replace our profession. I don’t believe anyone with the skillset and experience in the relevant AI tech believes that it will eliminate radiologists (other than maybe Hinton), certainly isn’t the attitude of the pure CS supervisors I’ve had in my training (or the folks I collaborate with now).

> They don’t like us and are here to eliminate us.

Don't take it personally. They're even trying to eliminate themselves [0].

[0] https://github.com/features/copilot

Cry me a river. How horrible it must be to have perfect job security, as close as you can get to tenure, unless you massively fuck up. Oh, and an automatic 1% salary.

> but you can really only complain to other MDs. Outsiders will demand you work more, get paid less, get sued more, and grovel.

Oh yes, this is exactly what I want. I don't care about anything my GP does, except whether they kiss my feet when I schedule an appointment. How do you know me so well?

Becoming a physician is a choice. Choosing your specialty is a choice as well (to an extent). Staying a physician is also a choice. And an immense privilege.

I have great respect for physicians I have worked with in IT for years. However I do not have patience for this sort of argument. You can always find another job if you'd like to, like everybody else. And unlike the majority of the population, you can set yourself up to have the financial freedom to do so.

No "sane" person "hates" doctors. They just don't pity them.

---

BTW, the tech FOMO is just FOMO. Grass is greener. Software engineering can be very exciting (just like medicine), but also very boring (just like medicine). Compensation is a really bad metric. If you value your time off, then don't become a physician. Sounds to me like some people just can't ever be fulfilled (usually the more privileged)!

In my experience, most of the outrage against the medical system is that it is so expensive, and has such variable outcomes. I don’t think overworking doctors (even more than they already are) is the solution, but I do feel something has to give. What do you think is the problem. What could be productively changed that would make access to healthcare more affordable?

The simplest thing we could do to make access to healthcare more affordable is that Congress could increase Medicare funding for residency program slots. That would boost the number of practicing physicians within a few years.

https://savegme.org/

The simplest thing they could do would be to get rid of insurance companies. They add no value to the system, but take plenty

Most devs are not earning anywhere near what a doctor is.

Is working for half time for half the salary an option?

Would you be willing to share your story of how you made the switch? CS major here considering going into medicine (despite your best efforts to convince otherwise :) ) but the general coursework wasn't something I targeted in school all those many years ago.

I've no doubt the stress of your work is immense and the constant threat of litigation (and the expense of the insurance to fight it) can be overwhelming. As a recipient of multiple eye surgeries (I had strabismus as a kid), I am grateful for competent professionals like you. But I think you buried the lede.

In the 2010s I owned a high-end bicycle and sporting good store. It was 7 days of 10+ hours a day most weeks. And it was very nearly non-profit or barely-profit for most of its run. If you know anyone that owns a bike shop, you should give them a hug. They need it.

Nearly every Friday afternoon, just after lunch, a few of my customers who were physicians or surgeons would pull up in their Model X or Cayenne to get service for their 10k road bike they were taking to their vacation home for the weekend. On more than one occasion, one of them would exasperatedly tell me how much they envied me and how lucky I was to be doing what I "loved". As I confronted my busy, work-filled weekend cemented to the shop to deal with the fickle and spoiled public, I had to chuckle as they drove away in their luxury vehicles to their luxury vacation home with a nicer bike than my own.

In retrospect, I've concluded that the real problem they faced is they'd built a life dependent on a physician or surgeon's income. They were told they were building a castle, but instead they built a prison. The fact is, you just can't spend enough money to truly escape the stresses of your work, but you can certainly spend enough money to become shackled to it.

> They were told they were building a castle, but instead they built a prison.

The industry term is "golden handcuffs".

The grass is always greener in another profession, and my problems are always uniquely bad :)

from over here it sure looks like mine are worse

I have to be honest and say working mostly in Security my pay is good enough and work is easy for me... Mostly I'm annoyed that my employer doesn't get enough projects for me...

I could be paid more, but I wonder would that be worth the extra effort.

> But I think you buried the lede.

> In retrospect, I've concluded that the real problem they faced is they'd built a life dependent on a physician or surgeon's income. They were told they were building a castle, but instead they built a prison. The fact is, you just can't spend enough money to truly escape the stresses of your work, but you can certainly spend enough money to become shackled to it.

I don't know why you're making the leap in assuming that, just because you knew some physicians and surgeons who seemed to be inflating their lifestyle to match a high income, that OP is necessarily doing the same. There's no indication in their post of any of that.

I made the leap because of what the parent plainly stated:

> There's just no reason to do the job when you can get the same compensation working remotely in tech.

Same compensation. That’s the unique qualifier that was chosen. That’s certainly not no indication.

I know doctors who live a modest lifestyle, so it can be done. The leader of a band that I play in was an ER doctor for a while, then got a job at a walk-in care clinic, and retired at a young enough age to enjoy his retirement. During this entire time, he lived in a modest house, and mostly rode his bike to work. He lived within his means like the rest of us.

There's no law that you have to live a rich lifestyle. Part of that may be feeling the need to maintain the class status that you were born into, and that you expect your kids to be born into. Case in point, my friend came from a working class background.

goodness gracious there is a lot to unpack here.

> As I confronted my busy, work-filled weekend cemented to the shop to deal with the fickle and spoiled public

> And it was very nearly non-profit or barely-profit for most of its run. If you know anyone that owns a bike shop, you should give them a hug. They need it.

some serious mental gymnastics to land this hypocrisy. someone else struggling differently? here’s an anecdote about how “their kind” are bad. incredible stuff.

read carefully, your comment suggests you don’t much like anyone other than bike shop owners.

maybe that’s why things felt so hard?

Well Dr. Freud, I was just pointing out anecdotally that perspective is important. That’s all.

yet your perspective seems to be that this doctor and all like them are inferior, your tone drips with it.

why do you think that is?

do you hate psychiatrists? your jump to using “Dr Freud” was rather interesting.

> In the 2010s...

I don't know how things are in the US, but here where I live in Brazil, my doctor friends always tell me how in medicine things aren't anymore as rosy as they were before. It seems like there has been a large increase in the supply of physicians by universities and the younger generations face way stiffer competition to move up the professional ladder than before.

This. All of a sudden you go from 70k/year as a senior resident to 400k/year+ as a specialist with no financial education. Add on a decade worth of burnout (especially in training but ~60% in attending physicians) and living in relative poverty (70k/year - interest on $200k in debt doesn't leave much) and you end up with a group of mostly financially illiterate people making up for lost time and depression by overspending on luxuries with their new found income.

If you can believe it I worked with people who made > 1m and started having anxiety that they couldn't cover their mortgages when covid slow-downs resulted in a 25% pay cut.

Physicians are well paid, and I don't mean to suggest otherwise, but it's a really shitty path to earn that paycheck if money is all you want out of the career considering what you give up to get there (e.g. all of your 20s and spending 5 years working 24 hour shifts every 3-4 days and 2/4 weekends) and how stressful the job can be.

Obviously this is a generalization, and no one is forcing them to overspend, but I strongly suspect an element of this spending pattern is driven by unhappiness/regrets based on interactions with colleagues. Medical training is a lot of (very) delayed gratification until you get to the end and realize it is no where near as fulfilling/satisfying as promised.

Tech is temporary, though. The reason salaries (and profits) are so high is because tech companies, when successful, displace whole industries and capture the revenue in a more labor-efficient way. But once the industry has been displaced, you don't need the software engineers anymore. Eventually the tech company becomes a dinosaur that the finance department milks for profits and share buybacks, and then gets replaced by a younger, hotter tech company.

If you ask 40+ year old software engineers, the biggest problem with the profession is the need to re-train every 5-10 years or face obsolescence. I'm in my early 40s, been doing this 20 years, and I've re-trained 4 times on new technology before finally switching into management. I just had an emergency medical procedure done. My surgeon graduated medical school in 1981, before I was born. He's able to learn one set of skills and then keep milking it for 40+ years.

This whole comment needs a big "citation required". It's all anecdotes and speculation.

Tech displaces industries, yes, but in the history of tech there has never been a company that stopped needing software engineers.

If you ask your surgeon he'll tell you how many times he feels he's retrained in his 40 year career. It's not going to be 0.

And don't your two paragraphs contradict each other? Isn't the need to retrain every 5-10 years a big sign that software engineers are not going anywhere?

I would agree with everything you wrote if it was prescriptive rather than normative. I would like software engineers to work themselves out of a job. And I'd like technology to be stable so we can focus on something besides the tech aspect of a company. But that seems poles apart from the world we live in.

I understand your situation - it's all of our lives too. Nobody that works for a living has had a raise compared to inflation, all of us have less than we ought to.

Tech is a terrible place to be employed right now - at least you will still have a job for the foreseeable future.

Plus, if your income is around the average eye surgeon salaries in the US (250k-300k according to some random website) - your income places you in the 97th percentile.

I'm not saying you should suck it up and deal with it - not at all, this is wrong and you feel the way you do for a reason. It isn't your fault anymore than it's someone's fault for getting stuck at a dead end job.

We are all in the same boat... except for those in super yachts.

The truth is simply that most people are far worse off than you. Except for the billionaires, we are all poor.

> But, why would anyone want to do the job?

> I do believe that the rigorous training model leads to a higher quality of care and much deeper understanding of the disease process.

you somewhat answer your own question in the prior sentence. maybe not want, maybe called, or cared, maybe something else. not that it is binding or permanent, not that it should be.

but for all of the words spent about how it is a bad choice, how it has harmed you directly, how the money isn’t great, you’re bringing up positives, for patients.

you sound burned out. that’s not a criticism, nor should it be a badge of honor. maybe i have totally misjudged, but the career choice doesn’t sound like a purely financial decision for you.

even if not, even if i misjudge this, you, you did that ten hour plus death march. you gave your best efforts though that patient may go blind anyway, though they may feel punitive about it towards you.

you still did it. someone had to. by your own words, the patient NEEDED the procedure. you needed to go home, and be with family.

the patient got the procedure.

in case no one else has said it, or joining in with anyone that already has:

thank you, stranger.

>That said, is anyone hiring an ophthalmologist with CS and Math degrees?

I mean there's a bunch of AI stuff/hype now, you could probably find something if you want to leverage your MD? I imagine you'd have a lot of insight into what would actually work well in practice and improve outcomes.

I just skimmed your comment history, so you already know about AI diagnostics e.g. https://health.google/caregivers/arda/

And worldcoin probably needs an opthamologist who can help ensure the retina id scans are stable... there are also a lot of retina scan companies anyway for digital identification that probably need an opthamologist. It may be as simple as keeping a set of scans over time so you reauthenticate in person and get your token updated like when you get a passport renewed for example. But maybe there's other stuff like preventing adversarial attacks.

Or maybe robotic surgery? Or maybe start your own? You might be able to patent something even.

This being HN, the world is your oyster and all.

This might sound crude, but a man who becomes a physician (and especially a surgeon) gets his pick of the most attractive mates as well as a high social status for life. That's pretty strong motivation for many.

These people might:

https://www.arcscan.com/

I can make an intro if you're serious

Respectfully, the "reason to do the job" is that you help people see. That's pretty cool. I understand the rest of the experience is pretty poor, but you do have a pretty fair amount of "helping people" potential at work.

If you worked in tech, you could help people see... advertisements. That's potentially more lucrative but it's gotta be depressing after a life of that to reflect on one's life work.

Planning and predicting highly variable systems is hard. Long-range interventions are especially risky given the possibilities for unexpected consequences and also the long lead times in fixing the problems.

Central planning on resources has been especially rife with failed examples (the USSR being the all-in poster child.)

As the article points out, the concept of central planning is orthogonal to who is providing the service. With heath care there are a range of national strategies (from fully private to fully public), and the impact of central planning (or lack thereof) can be seen across the board.

So one should be careful of concluding that this is a party-political issue. It seems unrelated to left-right politics, and rather the result of central planning, predicting and modelling.

"Communist" Cuba has 64 physicians per 10K population, which is 2nd in the entire world for physicians per capita.

https://en.m.wikipedia.org/wiki/List_of_countries_and_depend...

During the pandemic, they were sending droves of doctors to Europe. They offered to assist in NYC but Trump turned them away as our population dwindled. Famously, when a British cruise ship with ill passengers aboard was denied by ports in Florida, Cuba took them in and saved many lives.

What’s with the scare quotes around communist? Sure they have a lot of doctors. And how many of those doctors are allowed to do business as a private practice? Or how many would be allowed to change careers if they wanted to? How many are allowed to spend their income at fancy places, where the currency they get paid in isn’t even accepted? Hate to break it to you, but “your” worldview is incredibly, laughably, misinformed.

I’m not a fan of communism, but your worldview about it is also misinformed. People are allowed to change careers under communism: source I was born in USSR, my mother had many careers in the 70s and 80s.

I’d give you the inability to work for a private practice, that is true, but I am not entirely convinced it’s all that beneficial to society.

Lastly, Cuba can have some things better than the US, it doesn’t necessarily mean communism is a superior type of system. It just means that even a broken clock can show the right time

According to a Marxist definition of communism (classless society) neither Cuba or the Soviet Union are or were communist.

Well, you're right but it's think that despite the definition Marx coined, or the government he imagined, Communism has evolved and so has the definition.

The countries that tried Communism did so differently but with many similarities and all still had/have social classes.

A classless society only works theoretically - those that have tried to implement such societal changes have been unable to realize that goal practically.

Practical application matters most.

It may not be so much that modern Communists have failed to implement Marxist government but rather that Marx failed by focusing so solely on social class.

Inequality is the problem - it eats away at a society and its people. True equality is impossible and honestly not even desirable. Absolute equality doesn't mesh well with individuality.

I don't need to own the same things that everyone else does, live in the same size house or drive comparable cars - it's OK that people have nicer things than I do. It's not OK that everyone I know works hard their entire lives and others don't have too.

It's not OK that I know several people that have died bc they were avoiding medical care they knew they needed due to the expense.

It's not OK that everyone I talk to under 25 all seem to want to skip college and go work wherever - they are not lazy, they are certain that our future is uncertain. Why have goals that can't be reached?

I'm fine with classes as long as all classes have the same MINIMUM quality of life. Society should never limit the individual but should rather empower them to live well, as such, the only limits on maximum wealth I would impose would come after several billions have been added to an account - it does the society that generated that wealth no good if it simply sits an account and gets bigger.

Gates, Zuck, Mush, Bezos and other super rich are examples of our societal failure to regulate OUR economy well enough to prevent the greediest of us all from taking all of OUR collective wealth.

This is what Marx missed. This is why his definition/ideology didn't work out - also why so many have failed.

There will always be owners and workers, rich and poor, good and bad people - this is why government exists. How can a government eliminate the reason it exists?

To be frank, it was kinda stupid to think that paying everyone the same, trying to treat everyone the same, taking away ownership and attempting to equalize access to possessions would transform society into a paradise.

tl;dr: The definition of Communism has changed since Marx because everyone that tried Marx failed miserably and had to make due - today Communism is what they are doing now and isn't at all like Marx proposed.

Again, it's best not to align planning to political methodologies. Cuba has success stories. That isn't a vote for communism.

Equally, another "communist" state (China) is doing very well and while there is a lot of planning there, there is also a lot of free-market. Again, not a vote for communism.

I use communist in quotes here because Chinese communism is different to communism as practiced in the USSR. Just like capitalism is different in the US compared to say Switzerland.

There are (literally) hundreds of political systems, and we find it helpful to lump them together under broad names, but that can lead to a misunderstanding of the actual system.

Incidentally some planning is necessary- but it remains hard.

Cuba planned for, and got, a fantastic heath system built around primary health care. Cuban doctors are well respected, and are exported all over the world.

Cuba also got a lot wrong, and saying they got something right is not an endorsement of all ideas Cuban.

Cuba actually has a terrible health system that lacks even basic medical supplies like aspirin and antibiotics[1]. The state department and in the past MSF have called their medical missions modern day slavery[2][3]. There are also a lot of questions about the quality of Cuban medical training[4].

[1]https://cuba.miami.edu/business-economy/a-close-look-at-cuba...

[2]https://www.reuters.com/article/us-usa-cuba-trafficking/u-s-...

[3] https://www.hrw.org/news/2020/07/23/cuba-repressive-rules-do...

[4] https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909...

The first three articles are various flavours of FUD and vague assertions of coercion of the usual kind of "flood the field" BS everyone is used to from MSM.

The fourth link you provided "asks questions" but then the actual conclusion is that their trainings fine and people are spouting FUD and they'll need some extra focus on country specific problems.

""" Results South African students trained in Cuba have had beneficial experiences which orientate them towards primary health care and prevention. Their subsequent training in South Africa is intended to fill skill gaps related to TB, HIV and major trauma. However this training is ad hoc and variable in duration and demoralizing for some students. Cuban-trained students have stronger aspirations than those trained in South Africa to work in rural and underserved communities from which many of them are drawn.

Conclusion Attempts to assimilate returning Cuban-trained students will require a reframing of the current negative narrative by focusing on positive aspects of their training, orientation towards primary care and public health, and their aspirations to work in rural and under-served urban areas. Cuban-trained doctors could be part of the solution to South Africa’s health workforce problems. """

Really because the Cuban state bio pharmaceutical industry items at least a 40% shortage in medical supplies[1](I hope you read Spanish). Here’s another from Univision[2]. I could dig through the state news and find where they say the same thing but I have limited patience for stalinist ramblings.

As for the training, I did only cite one study. But I know doctors who have worked along side Cuban doctors in Africa through MSF, and they’re according to multiple people I’ve spoken with very poorly trained. The medical missions are also as I pointed out basically slavery.

[1] https://diariodecuba.com/cuba/1658314405_41049.html

[2] https://www.univision.com/amp/local/miami-wltv/falta-medicam...

The shortage of medical supplies is a problem created by the US which is then recycled into evidence of medical failure which is quite a nice little Gordian knot.

>As for the training, I did only cite one study. But I know doctors who have worked along side Cuban doctors in Africa through MSF, and they’re according to multiple people I’ve spoken with very poorly trained. The medical missions are also as I pointed out basically slavery.

I'll be honest the corporate media has played so fast and loose with information the last few years so they don't get the benefit of the doubt and I'm aware of a fair few countries with various flavours of regimes to stop doctors and/or graduates emigrating instantly with their expensive training so I wouldnt know enough to judge on "slavery". I'd need more context and another viewpoint to form an opinion.

It is categorically not a problem created by the US. Cuba was a satrap of the USSR that never developed any local economic or agricultural capacity. This is despite receiving free oil, machinery, training and fertilizer from the USSR and later free oil from Venezuela. Cuba still has the lowest agricultural output in the Caribbean by miles, clearly this is a result of communist economic policies. One only needs to look to Deng’s agricultural reforms in 1980s China to see this.

The embargo is no excuse. Cuba’s largest trading partner is Spain and they could get any European good or equipment they wanted if they had anything worth exporting for foreign currency. Cuba receives nearly a billion dollars a year in remittances from Cubans in the US alone, yet they are unable to do anything to unlock the potential of that inflow because they’re hung up on broken stalinist policies.

I sent you several Spanish language articles on the topic published outside of the US, this isn’t a “corporate media” narrative. The Cuban government is just terrible. If you can’t read Spanish that isn’t my fault. I know tons of Cubans, including Cuban leftists, and I read Spanish. I’m pretty well informed here and not just buying a narrative.

Human Rights Watch calls the medical mission slavery. They don’t allow the doctors to communicate with family, take their passports, take their wages, often send them into conflict zones, threaten their families, and on and on.

I'm not sure how they could have assisted with anything, they basically have no medical supplies[1][2][3][4]. And before you bring it up, no medical supplies aren't covered by the embargo, they get a special exemption since the 90s.

[1] https://havanatimes.org/cuba/medicine-shortages-a-challenge-...

[2] https://www.reuters.com/world/americas/cuban-diaspora-sends-...

[3] https://www.sabcnews.com/sabcnews/south-african-medical-stud...

[4] https://cuba.miami.edu/business-economy/a-close-look-at-cuba...

There's a US law that says any ship that docks with Cuba can't dock with the US. Considering that modern shipping relies on big ships making many port calls, this law restricts Cuba's access to stuff like medical supplies.

You can still sell food and medicine[1]. There’s a regular liner service and DHL takes packages to Cuba.

[1] https://2001-2009.state.gov/p/wha/rls/fs/2001/fsjulydec/2612...

There was a time where supplies was the issue, and I doubt Cuba could help there. But there was also a time when medical labor was the issue, and Cuban doctors could have helped with that.

Probably not. They definitely wouldn’t have had training with modern medical equipment, which isn’t available in Cuba. Also we take a dim view here on slave labor which is the most accurate way to describe the Cuban medical mission.

The thing is, not all of those doctors work in Cuba. The government rents them to neighboring countries to make money.

This is definitely true, but enough work in Cuba to give them a higher life expectancy than the US.

Some of those physicians (mostly young and female) take second jobs as prostitutes, because their baseline pay makes it hard to survive.

What? I would like some evidence of that.

Here's a (part of) PhD thesis covering this subject:

https://nsuworks.nova.edu/cgi/viewcontent.cgi?article=1166&c...

It speaks about how, since most people in Cuba have roughly equal (equally low) salaries, prostitution is present in all strata of society. Example citation from the link; a prostitute speaking: "We're all on a survival plan, no matter who you are, if you're a doctor, a philosopher, a teacher, we are all pretty much the same, we make the same money, 20 or 30 cuc a month is not enough at all."

I feel like we are going too far. Central planning in presence of hostile adversaries unrestricted by any ethical systems failed. And by what measures has “free market” has proven itself as successful? You can come up with your measures of success and others will propose measures of shortcoming. Others will even dispute the claim the American-led west is anything different from a centrally planned set of cooperating economies.

What are those adversaries and why were they unrestricted ethically?

Central planning, in this context, is not the same as political philosophy. So be careful not to conflate the two.

Central planning does happen in free-market economies all the time, at various levels. An HOA for example is a hyper-local example of central planning. The larger the scale the stronger the lever, and hence the more variable the result.

The "free market" brings all kinds of its own oroblems of course - I'm not arguing for the elimination of planning - but long-range planning at national scales, is hard.

Haha, I love "Central Planning" is viewed as a bad thing by most normal Americans - like the commies are the only ones doing it.

It takes a huge amount of "Central Planning" for our economy to function - as its fundamentally based on the concept of delayed gratification.

Those concepts are very very similar. Any American that has worked and budgeted towards any financial goal should be able to see that for what it is... essentially the same thing.

Planning isn't the problem, planning to the point of forcing others is the problem.

USSR stooped so low as to plan vacations of its workers: where they could go and with whom they could go.

https://daily.jstor.org/workers-of-the-world-take-pto/

Not all central planning is the same. An American budgeting their finances is not the same as USSR deciding what the entire country should do during their vacations.

It's the same here - we just have more options and corporations tell us where to go and what to wear, watch and do.

The corporate world is much more efficient tho

Critics of mostly free market systems generally base their argument on a comparison of wealth levels in such systems. They implicitly assume (or don’t care) that in a planned system the total wealth would be the same, just distributed differently. There is little evidence to support this.

Correct. Moreover, if you shift the goalposts (wealth is no longer/can’t be primarily defined by a balance in a bank account) then society will adapt and create different wealth constructs to make up for it. So, you’ll have the government caste with nicer perks and opportunities, and then everyone else from there on down.

Haha, yeah but it will all different people getting the perks than those with perks now

Yes, we know how egalitarian the USSR was, they didn’t discriminate against Jews or Asian minorities at all… /s

> Central planning in presence of hostile adversaries unrestricted by any ethical systems failed.

This is what happens in any system that leans too much on central planning. What we’re witnessing is just entropy ie late stage capitalist society in decline due to too much power being centralized. It’s not exclusive to capitalist economies. Historically, it’s even worse in primarily socialist economies because there are much less divisions of power from the start, where as in capitalist systems this happens over time. For this reason, the same decline happens much faster in primarily socialist systems.

The main flaw in thinking that socialism is better than capitalism, despite the clear results in the 20th century, is missing the fact that corrupt sociopaths don’t just disappear just because you changed the economic and political system; they adapt.

I don't know for sure, but I feel like you're possibly conflating socialism with communism? They are really quite different political models, although I'll grant you that both have a spectrum of examples.

Equally capitalism, socialism and communism are all (somewhat) tangential to government organisation (single party, two party, multiparty, monarchy, dictator etc.)

And I understand here that I'm painting with a very broad brush here - grouping some very dissimilar things together under the same terms while disregarding a lot of nuance)

Communism is just late stage socialism. Besides even if they were two separate things, by design in socialism nearly everything is centrally planned. Corruption just spreads much faster in systems where you centralize power from the start ie you want the groups running the media, producing goods, and managing the laws to be separate entities

I think we'll gave to agree to disagree there. In my understanding socialism and communism are two very different animals.

Communism is about the absolute equality of all - no rich, no poor. Socialism is about caring for the poor, with no upper bound on the rich.

In other words one squeezes from the top down. The other pushes from the bottom up.

What you’ve just described are socialized safety net programs inside mixed capitalist economies. That’s not socialism. There is no private ownership in socialism. Consequently, there are no rich in that system. The “community” owns and produces everything.

>Central planning on resources has been especially rife with failed examples (the USSR being the all-in poster child.)

This assertion is greatly exaggerated. It's certainly true that the centrally planned economy of the USSR didn't grow as quickly as peer countries with similar levels of economic development. The typical contrast is the much faster growth of Japan versus the Soviet Union in the late twentieth century. (Even the computer knows the story; my phone's predictive text got the countries right!)

But the Soviet Union nonetheless grew. Its growth rate was similar to that of the United States, but starting from a lower level (missing out on catch-up growth). It was the contradiction between the government's insistence that the planned economy would outperform the West versus the reality of the situation that led to a death spiral of political dysfunction and "alternative facts".

Even though the system was not efficient, it wasn't disastrous by itself, only suboptimal. It's a standard prediction of economic theory that lower risk tolerance comes at the cost of some expected return. But in the case of fields like education and medicine, we might have a lower risk tolerance and be willing to tolerate lower growth to achieve it.

In this case, the government stopped subsidizing medical schools. That would seem like what the libertarians want, but the outcomes were not good. Blaming central planning per se doesn't seem like the answer.

Clearly there are multiple factors in play, and it is simplistic of me to pin all the failings of the USSR on central planning. (Which is the essence if my root post, planning is hard and only one small part of the political environment.)

Clearly geographical, climate, and population dynamics (Not to mention war damage) of the US , USSR and Japan post WW2 are enormously varied.

>> the government stopped subsidizing medical schools

That's part of it, yes. The other part and perhaps more damaging part, is the moratorium on creation of new schools, and the measures to actively reduce the ability of hospitals to offer residency positions.

Given a finite money supply the feds have to pick winners and losers for receiving money. However introducing policy, beyond money, has more impact on outcomes.

The libertarians would argue that the policies caused the shortage, not the lack of money. (As evidenced by the US citizens training outside the country.)

> But the Soviet Union nonetheless grew. Its growth rate was similar to that of the United States, but starting from a lower level (missing out on catch-up growth). ... Even though the system was not efficient, it wasn't disastrous by itself, only suboptimal.

I am sorry but it is total BS. I grew up in late USSR and can attest that its economy was in free fall. Central planning was one big demotivator and major contributor to the economic disastor. There were no incentives whatsoever to do your job well. Social mobility, career growth depended on factors outside of your direct control. Productivity was a fraction of what it was in the West. Bottom line -- any attempt on economic central planning first has to solve the problem of motivating productivity of human free agents. Otherwise it will fail in a similar way as Soviet Union did.

What you're describing sounds suboptimal rather than disastrous

> economy was in free fall

In the late 80s.. Before that there was some growth intertwined with stagnation.

> In the late 80s.. Before that there was some growth intertwined with stagnation.

In both 70th and 80th there was no growth. Maybe in 60th there was some but it was before my time. Anyway, it was depressing place. There were some great people there but it was despite the system not because of it.

It would have been worse as a peasant under the tsar. Communism brought modernity to Russia and made it a world power.

> It would have been worse as a peasant under the tsar. Communism brought modernity to Russia and made it a world power.

Big misconception. Russian Empire just before the WWI (1913) was a dynamic growing economy. It was behind Germany and UK but it was in the middle of the pack of European countries. Bolsheviks totally ruined the country. People paid enormous price for the "modernization" that was already underway during the tsar. Bolshevik revolution of 1917 was a single worst calamity that happened to Russia in 20th century, even worse that nazi invasion of 1941.

>I grew up in late USSR

Data is better than anecdotes:

https://commons.wikimedia.org/wiki/File:GDP_per_capita_devel...

These are data reconstructed by Western economists, not Soviet partisans. Only when the political system was in a meltdown by the end of the '80s did the USSR experience a sustained economic decline.

It is troubling that people trained similarly (to the people who made the forecasting blunder in the article) and given similar powers, are involved in forecasting in other significant domains: climate, war, inflation, etc.

The health care industry seems to be profiting off this by having more care provided by nurse practitioners and physician assistants but billing the insurers same as they would charge for M.D./D.Os.

Medicare and most insurance strictly control this.

But the industry benefits from a constrained supply of doctors because it means less competition; laws ultimately require doctors to be in charge of a practice. Some laws are now even restricting the number of PA/NP's that can be supervised, but it's not a strong effect.

Some states permit NP's to practice without a physician, but PA's all require a supervising physician.

Not all. Iowa: https://www.desmoinesregister.com/story/news/politics/2023/0...

“With this move, Iowa joins five states that have removed the legally mandated relationship between physician assistants and doctors, according to the American Academy of Physician Associates.”

PA's no longer require a supervising physician. Also why do people seem to think PAs and NPs are equivalent? PA's have 4x the clinical experience/ training that NPs have. 2000 hours vs 500 and MDs at 4000.

Depending on the specialty, 4000 hours is off by many multiples. And that’s on top of 2 extra years of classroom training.

This implies PAs are at half the level of an MD but the difference is astronomical. Those 4000 MD hours are training to be a physician, the 2000 are training to be a PA which is a much simpler role. If PA school went to 8000h doing what they do currently to train wouldn’t get you near an MD (not to mention the talent of the intake, rigour of exams and depth/ breadth of knowledge required).

They carefully maintain the scarcity of doctors, but import as many nurses as they possibly can, work them hard, and pay them the least they can get away with. It's only logical.

There is also planning of hospital bed shortages through certificates of need. https://en.wikipedia.org/wiki/Certificate_of_need

anti kickback laws are also a double edged sword. https://en.wikipedia.org/wiki/Stark_Law

But in the end, the usa has the healthcare system where doctors want to work and rich patients want to be treated given an option of any country.

The rich people I know in the US do have an option of getting their healthcare from any other country, and that is what they often do.

Yeah, rich people are "Global citizens" and utilize the entire work as we do the county we live in.

They have it backwards, rich people come to the US for their treatment. It's not a coincidence that places like Mayo/Hopkins/MD Anderson all have buildings named after a gulf country sheikh.

Top US institutions are definitely the best/most advanced in the world right now for cancer care and arguably overall, especially for weird and wonderful stuff.

Affordability and accessibility is a different question.

A similar phenomenon occurred in the UK, where under fears of "medical unemployment", the British Medical Association argued against increasing medical school places [0].

The attitude persists even today, where the BMA advocates that medical school entries should be limited to the number of specialty training places that follow basic training, so as to avoid the risk of doctors becoming unemployed or under-employed.

As a consequence the UK has a dearth of doctors, and those who are trained are over-worked. The government tries to alleviate the situation somewhat by recruiting from overseas.

[0] https://www.bmj.com/content/348/bmj.g2398

While this is a problem. The single largest issue that isn't properly being disscussed (especially during the strikes) is retention.

The NHS is a leaking bucket of highly skilled doctors and nurses.

Anecdotally, my wife is a doctor at a large tertiary hospital. Asking all the completing Foundation junior doctors what their career plans are, 80% of them have obtained either an Australian or New Zealand Visa and were securing jobs abroad.

No one skilled and smart enough wants to stay in the UK.

Completely true. Killer stats on this: 1 in 7 U.K. trained doctors work abroad The number of GP training places are up 2000 and number of qualified GPs hasn’t changed due to poor retention. I could go on and on. U.K. medicine is a shitshow of poor pay and poor retention. Even the cheap imported doctors are only staying a short time due to the chaos of the system and better ops back home once NHS training is on your CV

The main justifiable complaint by junior doctors is that of being over-worked. Unfortunately the OP and the link above suggest that this is a problem partly self-inflicted by the profession itself.

There isn't a great risk of emigration by UK-trained doctors, as evidenced by an over-subscription for training places. Further, OECD data show that when adjusted to average national salaries, the pay scales for clinicians in the UK are competitive with the main destinations, including Australia, Canada and NZ [0].

A large part of the solution would appear to be increasing undergraduate medical education and further professional training slots. This would need increased government funding as well as agreement from professional bodies.

[0] https-//www.oecd.org/health/recent-trends-in-international-migration-of-doctors-nurses

they better change how it works, or we're going to be out here doing minor surgeries on ourselves with scalpel in one hand and watching youtube tutorial on our phone in the other, with gpt on speaker

Multimodal ChatGPT is already capable of generating diagrams for a DIY appendectomy (in the style of LEGO instructions!).

Unfortunately, it completely hallucinates on the instructions on how to stitch oneself up afterwards, inevitably resulting in fatal internal bleeding. Thankfully it also forgot about anesthetic so I didn’t get that far.

I doubt US would be able to see a level of medical accessibility on par with many European countries. The medical education system has a perverse incentive to reduce the yearly graduates -- the less graduates there are, the more profits and prestiges each of the current members can garner (with arguably better trained graduates) -- and as shown in the article, they seem to have monopolistic capability for the throttling. And the incentive is only larger when people spend more disposable income for their healthcare, which has been the case. Maybe political powers may shift the direction a bit, but I do not see any evidence of a major course correction.

There already has been. The solution was to pump out physician assistants (PAs) and nurse practitioners (NPs) that require a fraction of the training of a doctor to get licensed, and then have them practice medicine under the “supervision” of a doctor.

Some states even went as far as giving people with no medical training the right to prescribe, such as naturopaths, whatever that means.

So it is up to each person now to figure out how qualified the person giving them healthcare is.

Also, doctors now have to contend with a handful of large payers. Their customers are mostly the federal/state government, or a handful of managed care organizations like UHC/Elevance/CVS/Cigna/Humana/etc.

I would say doctors’ golden years of having a favorable negotiating position are behind them.

Hospitals have regional monopolies are are being consolidated by private equity companies. The doctors have way more leverage with the hospitals.

That is not what I have read. Doctors are having to join as employees of larger doctor groups, that are owned and operated by older doctors or private equity. Or they can join the local hospital system as a W-2 employee. Either way, they are up against big payers, so they have to also join big employer groups themselves.

Or work in undesirable locations.

My experience with PAs and NPs have been mixed. I would still prefer MD doctors if I have a choice.

Now that there are many reasonably good medical education systems outside US, why doesn't US just open more to those international MDs? I would prefer those MDs to NPs or PAs. Maybe doctors' golden years have been passed, but I don't think that necessarily means more accessibility to quality cares.

Your are extremely optimistic to think the US will make immigration easier anytime soon.

We won't but we should.

We should take everyone that can get here - everytime. It's like tryouts - want to be an American? Get here.

A person that chooses to leave their country for the idea of another knowing full well the arduous journey ahead and the struggles all immigrants face everywhere - all so they can maybe have a life they like, deserves to be an American... if they can get here.

That's the test - or so it should be.

We are the descendants of those that said "f*ck this" - we should want everyone with that mentality to come here, always.

That mentality is what being an American is.

...plus China and India have a billion people MORE than us - 100 million immigrants wouldn't catch us up. Most people do have kids tho - even if your a Trumper you should understand that not all of the immigrant children will continue to require government assistance - most will go get jobs, go to school, start families and all of that creates wealth and prosperity.

Even if it takes 2 generations for the US to recoup the expenses incurred providing for the 1st generation of immigrants or refugees - the country still wins exponentially.

Nothing is more valuable than people.

Well: https://www.statnews.com/2023/05/18/doctors-trained-outside-...

I hate that this shift is being driven almost entirely by profit motives, but I also wonder if this is such a bad thing. I love my doctor; she's been my doctor for 25 years. However, I sometimes wonder what real value she provides. All she ever does is send me to a specialist. Couldn't a PA or NP do the same thing?

Your doctor has significantly more education and training than a PA or NP.

The additional cost of seeing a doctor would quickly be recouped by the reduction in unnecessary / inaccurate referrals that would come from a lesser-trained medical professional.

Yes. But PAs and NPs lack the training and will more likely give referral for the wrong things or provide worse clinical care.

Management did the same thing with offshoring engineering. It's akin to saying, "competent engineers who understand business requirements and good software engineering principles are expensive. Can't engineers from another country (who often cost less) do the same thing if all they do is write the same code?"

You're being disingenuous. PAs are required to have 2000 hours of clinical experience before they can sit for their licensing exam. NPs however only require 500 hours. MDs require 4000 hours.

Where are you getting this 4000 hrs number from?

I’m a MD and this isn’t even remotely correct and the number seems to be pulled out of thin air. Comparing a 2 year PA program with a 4 year MD program plus mandatory 2-7 year additional training is extremely disingenuous.

Where are you getting these numbers? 4000 hours for what specialty? Let’s take Pediatric Emergency Medicine as an example. 4 years of med school, 3 years of residency, then 3 years of fellowship.

That’s many times 4k hours. The difference in training time between a newly minted PA and MD working in a children’s ER is not 2x, it’s many times that.

Your numbers are way off, but even assuming they weren't, 1 hour of PA training is not the same as 1 hour of MD/DO training.

The solution was to pump out physician assistants (PAs) and nurse practitioners (NPs) that require a fraction of the training of a doctor to get licensed, and then have them practice medicine under the “supervision” of a doctor.

This is my biggest concern about primary care. NP training significantly lacks rigor in clinical sciences and standardization. I would also say days of seeing competent primary care (even in urban settings) is behind for patients.

In Germany I can only see a specialist doctor if I 1) wait half a year, 2) am at the brink of dying or 3) give some cash. Most people have the illusion that the system works because 99% don’t have to deal with it and it’s a nice thing to believe if the yearly insurance fees are about $10k for public insurance (employee+employer). Whilst I agree that in Europe we do not have these outrageous costs for medication and intransparent and greedy billing - quality of healthcare is literally NIL. I have zero confidence this system would be able to help me beyond an ear infection or maybe removing an appendix.

You'll have a similar wait in the US for most specialties.

Most specialists in the US can see you in well under two months.

> Physician salaries are the only ones that do not grow relative to inflation and have decreased year-on-year relative to inflation for decades.

Medical insurance has been increasing faster than inflation for a while now. Are only insurance companies getting this extra money? Are at least some medical professionals getting a cut?

Doctor shortage, pilot shortage

Frustrating to see these problems of purely human design.

The doctor shortage is also specifically caused by doctors.

What is a nutshell explanation of how healthcare got to the overall shortage state? (For the USA, but curious about other countries.) In the past 20 years, costs have shot up, doctors are seeing many more patients, and quality of care seems to have generally declined. Where have the resources gone? In the 1990s my GP had time to shoot the breeze for 20 minutes or more. Now I get a 5-minute diagnosis on the run, after scheduling months in advance.

Grossly insufficient pay for the work concerned. This applies to everywhere, US and otherwise.

Unless you are a saint given existence upon this mortal plane instead of the high heavens, there are simply no objectively good reasons for ordinary men to pursue a career in medical.

I get how low wages could cause personnel shortages, but how does the tremendously rising cost of medical come out of this? I would expect the causation to be rising costs => stalled wages => personnel shortages.

Nursing, I agree. But as a doc in the USA? It's THE highest status you can achieve on title alone, and comes with a paycheck in the top 1-5% guaranteed for almost 100% of entrants.

>Where have the resources gone? In the 1990s my GP had time to shoot the breeze for 20 minutes or more. Now I get a 5-minute diagnosis on the run, after scheduling months in advance.

See the population pyramid getting older and the general decline of healthiness / increase in proportion of people with health problems.

It seems doctors want to intentionally keep their supply low so their pay remains high.

Physicians don’t control the supply of physicians. The federal govt funds residency slots so they indirectly controls the supply.

Shareholders.

I'm a physician as well (radiologist). I started practicing a few years ago, and I'm currently working part time and doing my masters in AI/data science. After a few years I hope to leave the field as well. It isn't because of lack of jobs (in fact, radiologist shortage is dire). It is because it is very stressful and demoralizing to be a physician in america, and the seemingly "high" pay does not make up for the downsides.

Can you explain how being a radiologist is stressful and demoralizing? Genuinely curious.

I do know some radiologists and they certainly don't appear stressed to me. At least one of them works from home pretty much full time; not sure about the others.

Medicine is a pretty high stakes career. You mess up and people can die. In radiology, we are expected to be near perfect (not miss important findings however subtle they might be) and make the right calls. This is difficult to do even with the training we have had. Part of it is just dealing with uncertainties. Did I make the right calls? Did I miss something subtle but important that might harm the patient - such as a subtle small nodule that 2 years later can become metastatic cancer? If so, am I going to get sued? You do that with every case, none which pay well at all. Medicare is the largest insurer in America and they pay around 4-5$ for a chest x ray or a wrist x ray or whatever joint x ray. A CT be it a cancer staging ct or trauma ct is valued at 40$. It can take a while to read if you really do your due diligence…meaning you compare to the past CTs to see how things have progressed, read history, take your time looking at the images. So it should take half an hour to read. Often times the prior imaging and clinical history isn’t even available. And if you work at big academic centers you are forced to read quickly.

No physicians want to do a bad job but we are just cogs in wheels in the medical industry complex.

Very easy solution, allow every 4-year state college to have MD programs. Flood the market.

Yup, increasing the supply is the obvious solution but one that the medical cartel has actively lobbied against.

I’m glad to see others calling it what it is, “medical cartel” is the most accurate description I’ve seen for our system

Perhaps designing a society around profit motives was a poor decision.

discriminatory MCATs, brutal STEPS, insane Pre-Med curriculum, and more nonsense designed to cater to white elites who gamed the educational system and less to those who are genuinely trying to help the disenfranchised, unremembered, diverse and more.

Hopefully one day, we'll make it as easy to become a doctor as it is to -- say -- become an Engineer.

I hope it’s not as easy to make a doctor as it is to make an engineer.

I am an engineer dating a surgical resident who has to go through so much training that an engineer would never even come close to an engineer. The room for error is quite small. If it was as easy to make a doctor as an engineer I would lose faith in the medical system and would never want such a doctor opening me up.

You're only referring to SWE, right? I've noticed that there are no bootcamps for becoming an aerospace engineer and getting a job at Boeing.

And actual engineering disciplines you can't do jack squat unless someone w/ a PE license signs off on it and becomes legally liable. Meanwhile Tesla deploys OTA at will... Oh yeah - and why be a medical doctor, or a Professional Engineer when you can make more money with less debt without the legal liable...

I agree we want medical personnel who are very well trained, certainly better than software engineers.

I'm less clear about which aspects of the current medical education system produce effective training and which are more of a hazing run selecting for the privilege and determination to survive it.

It’s not that medicine should be _easier_ or _as easy_ as engineering, it just needs to be easier than the status quo.

This is theoretically an easy change, since most complaints are about the unnecessary bureaucracy and not the pedagogy itself. Doesn’t matter how simple the solution is, it’s practically hard because the bureaucracy has so many incentives to make the process harder.

I'm a physician, pathologist specifically. But also did a surgical internship. My dad is an engineer, my undergrad is in Physics and I spent years on ships in engineering and weapons departments.

Yes, the room for error can be incredibly small. A surgeon might cut out a breast cancer that's 5 to 10 cm on a side. The margin, the distance between the cancer and the edge of the surgeon's incision, might be negative by 1 cell. The cancer might be 1 cell away from having been left in the patient's body. The room for error in medicine is in some ways disturbingly small, in others it is incredibly large. Factor of 10 errors are so common they are a standard outcome measure in trainee fatigue studies. Ask your SO about ACDF. Imagine driving screws essentially blindly, without tapped holes, a few millimeters away from a spinal nerve root, with an 8" torx driver. On 3 hours sleep, after standing on your feet for the last 7 hours. An engineer, hell, a carpenter, would have measured the system extensively, set up a jig, and spec'd the entire process, soup to nuts.

From that perspective the margins for error, in absolute terms can be, and often are, enormous. Which is what lets them run on 3 hours of sleep for months. In that setting, sleep-deprived, no exercise, terrible food, compounded by relentless moral injury, yes, it seems like the margins are miniscule. But a good cabinet maker, electrician, or pharmacist takes more care in many aspects of their work, in absolute terms.

If being a doctor is so incredibly hard then why are they allowed to practice after not sleeping for so long?

You're right. It's been noticed. There are regulatory initiatives (in the U.S.) to address that for doctors. Also for pilots of passenger aircraft.

No, it really hasn't. In 2016 the ACGME increased the consecutive hour limit from a bad 16 to a completely ridiculous 28. The difference between rest requirements for truckers and pilots compared to doctors is just absurd. And it is even worse because doctors should know better than most how sleep deprivation affects people.

Well it's not that hard, or that important, they're not truck drivers.

I’m married to a doctor. My opinion is training level generally needs to correlate to the level of acuity.

Surgeons will always need to be extremely highly trained because they do not have the ability to hesitate. Most of healthcare simply isn’t anywhere near the acuity level of surgery.

By far, the biggest need is primary care. The exact opposite of acute. The rigor, effort, and expense of medical school simply doesn’t match modern primary care. Either the system needs to change to accommodate that or physicians are in for a reckoning.

Physician lobbies have a golden opportunity to ensure even higher pay and better product by building better care models. Instead they simple say “fuck your I got mine”

Physician lobbies are notorious for not actually aligning with physicians' interests and, rather, being in the pockets of the hospital industry. The AMA is the worst for this. Most physicians feel that they do not have a voice anymore.

Medical school and residency are incredibly hard things. So you could make getting admitted to them easier sure but you’d be setting people up to fail if they can’t pull 80 hour weeks and manage information overload when they get there.

I think what parent was referencing are the “tricks” required to get into med school. Applications are incredibly competitive, and students have every incentive to do anything they can to make the cut. Easier classes, begging for grades, leaning on connections, charity work (dependent on financial resources), etc. Leet code grinding, med school edition. Perfectly good potential doctors are passed over because they are missing X.

I wanted to become a doctor. But I also wanted to study engineering. I didn’t want to do some relatively useless degree path like biology simply to fill all the required prerequisites for med school. And then I learned about all of this other stuff, like the MCAT, and how you essentially get abused during residency. I don’t think I’d be able to function on the sleep you’d get anyways.

It shouldn’t be easy to become a doctor, but man the bar right now is so high.

Too many white doctors? Have you been to a doctor in the last 15 years?

What’s discriminatory about MCATs?

If there are differences in outcomes between demographic groups some groups, like the SCOTUS, assume malice unless proven otherwise. See disparate impact or Griggs vs. Duke Power. Obviously the writers of the MCAT worked very hard to ensure Asians would get higher scores than any other group on them. The US is a country built in Asian supremacy.

> Obviously the writers of the MCAT worked very hard to ensure Asians would get higher scores than any other group on them.

I am not sure how you are coming to that conclusion. Look at the latest metrics on scoring. Sure, Asians overall tend to score higher on average on standardized exams (which really ought to be split into different sub-ethnic groups because there is a disparity there too) and I'm not seeing the average MCAT score for Asians being disparately higher than the average score of Black Americans that would warrant such a statement.

https://www.aamc.org/media/6066/download

MCAT scores range from 472-528. 514 is 88th percentile, and 505 is 61st percentile.

>... less to those who are genuinely trying to help the disenfranchised, unremembered, diverse and more.

There are many government and philanthropic institution-sponsored programs in the U.S. that repay 100% of medical school, dental school, or medical specialty tuition and expenses, in return for committing to five to 10 years of medical service, on site, to remote or under-served communities.

'Remote' can be rural communities in Appalachia. They can be 'under-served' and very remote, e.g. for American indigenous people who live on their sovereign nation's land.

Under-served communities can also be in economically devastated cities (usually due to offshoring of manufacturing) in the Midwest or East Coast where people of color and white people lack access to medical care that is within walking distance or public transport.

A physician shortage is not a good thing, but I'm closer to the nurses shortage; my wife is a nurse. Nurses get it from all sides: The healthcare administrators never put enough on duty, similarly they don't have enough CNAs helping them, and the patients and families can be pretty abusive.

It's really a game of numbers: You should have 1 nurse for every X patients, and Y CNAs for every nurse. But the common story is that there are always games being played with increasing the number of patients and decreasing the number of CNAs, leaving nurses having to do more things for more patients. This directly, negatively impacts patient outcome.

I would've been a CNA out of high school instead of working retail if it would have paid me more than retail. Fact is, you're wiping ass for minimum wage and obviously not a lot of people are going to want do that. I'd say start with wages if I was addressing the issue.

This article is based on reading (some) government reports, not on actual experience reports from medical schools, funding (which has increase), etc. Still, it's an important issue and set of data.

It's not unreasonable given the training investment to err on the side of avoiding wasted education, and fill gaps with less-trained people.

The physician/patient ratio is not a good measure of service availability. Some would say US doctors are more productive.

The alternative is not more doctors, but more "advanced practice" providers - Nurse Practitioners and Physician Assistants (or Associates). Their numbers have increased dramatically, and they have taken over anything routine and many ancillary functions of complex cases. PA schools in particular have proliferated, and produced an over-supply of PA's, who depend entirely on having a supervising physician. NP's by contrast benefit from the long history of unionization in nursing, have taken over management in many cases, and restrict the supply at the school level. Overall they top out at what doctors start at, even with decades of experience. It's good for young professionals, but there's not a lot of headroom.

As for dependence on foreign schools, the US has more foreign graduates in every field, and most have been hired into hospital systems as a way of combating medical practice groups.

The independent medical practice groups almost completely died out, as hospital systems refused to contract out to practices, and instead hired doctors as employees so they could control costs. Recently with private equity targeting specific local monopolies, you're getting specialty practices in radiology, anesthesiology, cardiology (mostly stenting) and now even GI, where the same private equity firm coordinates everyone in a geographical area (and pursues a number of dark-billing practices). There may be small internal practice in the hospital for poor people to get middling care, but the good doctors go into the practice groups.

Access to care comes down to logistics (terrible IT) and PCP's being used to reduce care. They hate it, which is why those who can avoid primary care.

The other side of supply is loss. Doctors are leaving the profession at a high rate because they're not really doing medicine (and they can afford to leave). They need better systems and adjuncts and more sensitive administration.

Most problems in a rich country like America are entirely created due to backwards, uneducated policies.

Are you by chance asking this so you have some places to escape to when the looming eternal September event ( triggered by the change in reddit's API policies July 1st) suddenly drives a bunch of, well, reddit-level traffic from there to here?

Imagine a world where computer use required a prescription from a limited number of licensed engineers. You have to pay to talk to them about your problem and they’ll set you up with an app to use for a week or two.

I'd take a giant stab in the dark suggesting there maybe a surplus of dermatologists but not enough oncologists, endocrinologists, or neurotolaryngological surgeons.

This is depressing. After recent medical scare that let me see the current level of medical treatment up close. I had though of leaving SWE to go into a medical field in order to help people. I'm in the US, and man, being in a hospital is really depressing, people are literally just dying for lack of help, being left behind. Or, maybe it's just more late stage capitalism, and I just happened to get a glimpse at how our society is choosing solve the problem of poor people, just put them down.

If it's any help...

It has been a lot of shit, a lot of brutality, but it is changing. It is difficult to sustain such an environment forever. Most of the mega-laws that got passed in the last few decades, if they ever were, have become unenforceable with how overloaded public services are in the... are we still calling them red states, cultural South, etc?.

You have people in Indonesia, Argentina, US, etc. all talking to each other. Where there isn't formal education, informal education can actually take a decent place. The young across the world are more like each other than anyone would really admit. People who come to the US aren't really forced to learn the language to an unrealistic degree anymore, and that's good, really. The standards have been too high for a century.

Things are so overloaded because turns out people do still need a law system, a health system. It shows a self-respect people didn't have 10 years ago. I could go on but, there is still hope.

Socialism or Barbarism.

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