HN comments for: Why doctors in America earn so much

There is absolutely a shortage of doctors. AMA is unwilling to fix this and instead rely on a system that drives many to suicide.

My wife is a doctor. I’m a software engineer. While she now makes more than I do, it took nearly 10 years. That whole time, we were racking up tuition/debt on tuition. Residency was demanding and severely underpaid.

Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.

In other word, medical training had a huge opportunity cost. Even if you solve the bottleneck of residency placement, salaries need to offset the insane burden of training.

Similarly, my husband is a commercial pilot and is now starting to make more money than me in tech after his 10+ years of underpaid work and a high student loan debt load.

But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.

I imagine your wife will be seen the same way. She can comfortably work until retirement age, in an profession that sees experience as a positive thing, while you might be a pariah before you know it.

Yes, we make good money when we're young in tech. But we age out much more quickly due to the bias common in our industry.

If you were bringing in a competitive salary in tech for the last 20 years you don't even need to work anymore. So there is that..

BLS says US median programmer salary in the US was just under $100,000 last year.

20 years of a normal US tech salary won't let you retire. A top-few-percent one, maybe.

First, Computer Programmer is a strange occupation. According to BLS there are just 147K positions in the US.

Instead I'd suggest looking at Software Developers (1.5M positions) with median income at $127K.

Second, by definition median is not a competitive salary. I'd think top 25% of devs are getting competitive salary. Which is $161K [1]

20 years of savings at 30% of income will get you $2M. Which is not a fat retirement, but still doable.

[1] https://www.bls.gov/oes/current/oes151252.htm#nat

> Second, by definition median is not a competitive salary.

Yes, it is. For the field as a whole? Yes, it absolutely is. For specific segments of it? No. Some of those are higher. And others are lower.

> 20 years of savings at 30% of income will get you $2M. Which is not a fat retirement, but still doable.

Healthcare complicates early retirement badly in the US. Retire at (say) 45 with only $2m in the bank and you are... gambling. To put it mildly. Even if you live reasonably frugally.

I do not agree. If someone said "bringing regular salary in tech" I'd agree that median should be used. "Competitive" means we are talking about higher percentile within the field.

> Healthcare complicates early retirement

You don't have to stay in the US when retired. With 4% SWR one will be getting $80K/year. Which is more than median household income in the US and majority of the other countries. I am not advocating retiring at 45 with $2M, I am just saying it is not that crazy.

I've always considered "competitive" to be a signal of "as close as possible to our average competitor". It doesn't mean good or high. When a job offer says "competitive salary", it's not a good sign. I assume they mean around average, maybe a little bit below average. If the job offer was offering a significantly great salary, the company would boast about it as more than "competitive."

Yes, absolutely - though it's a difference from colloquial English, where it does normally mean "good"/"better than average". Businesses just use it as a weasel-word.

"Competitive" is job listing filler IMO. Everybody is "competitive". I've seen "competitive" salaries wanting me to take a >30% pay cut.

It is also not going to be the easiest, emigrating to a country with a robust healthcare and social safety net as a retiree in your 40s.

A lot of cheap countries provide good healthcare for a fraction of american costs. Also, not sure why one need a safety net when they already have a stable income which is multiple of what any such net can provide.

Very true. This is a very big reason I left the US in my 40s, while I'm still working and can acquire permanent residency and later citizenship by having a job with a local company. I didn't want to be stuck in the US when I'm at retirement age and healthcare costs are unaffordable even with a decent nest egg, where a major procedure could wipe out all my savings.

> "Competitive" means we are talking about higher percentile within the field.

This is not a standard usage of the term in this context.

[EDIT] If you don't believe me, I'd encourage searching "competitive salary definition"

> Healthcare complicates early retirement badly in the US. Retire at (say) 45 with only $2m in the bank and you are... gambling. To put it mildly. Even if you live reasonably frugally.

100% this. I'm almost 50, and as I look towards retirement, I think I should try to find a cushy job that'll last me to 65 without causing too much stress, because until you qualify for Medicare it's really hard to afford health insurance premiums unless you're fashionably wealthy.

Really, what is a good ballpark for a family of 4? Is it like 5k a month?

> Healthcare complicates early retirement badly in the US. Retire at (say) 45 with only $2m in the bank and you are... gambling.

Uhh... Why? A very good health insurance is about $10k a year (PSA: the open enrollment period for 2024 has started today).

Even if you are unlucky to get a chronic condition that needs expensive care, that's still capped at around $6k a year by the out-of-pocket maximum.

So that's $16k a year per person maximum, over 20 years (until Medicare eligibility) that's $320k. If you want to include family, that's going to be around $500k. And that's the worst case.

It's going to be a huge chunk of the expense, but not insurmountable.

Heathcare could [again] get twice as expensive in the next 20 years: https://ourworldindata.org/grapher/price-changes-consumer-go...

As a retiree, you can probably arrange to qualify for a free silver plan under the ACA. There are no asset tests, only income. This is true for other subsidies too. If you've mostly accumulated assets in excluded locations, you can also qualify for college tuition subsidies.

Heh. I worked at a startup, and they were sponsoring a Green Card for me.

They had to raise my salary to $165k because this was the _minimal_ allowed competitive salary for my position ("Senior Software Developer"), and the USCIS doesn't take stock grants into account. This was 2 years ago.

The median income is ~$30,000. That means you have ~$70,000 to invest each year. If we assume a 5% rate of return, you'll have ~$2MM after 20 years. At the same rate, that will continue to provide you $100,000 each year in retirement. Bad luck can happen, but generally speaking retirement should have been quite easy with that kind of income.

Median topped $40k in 2022.

The (just under) $100k is pre-tax.

You won't get much social security when you hit "retirement age" if you retire after only 20 years of working at that level of income, so you'll need more savings at that age than others do.

$100k/yr is a 5% withdrawal rate on $2 million, which might be a "safe" rate at normal retirement age (debatable) but is risky as hell if you start doing it at 45 and don't plan to die in your 60s.

If you've been saving that aggressively (as cash/investments), you won't own your own house, or at least, you definitely won't be anywhere near paying it off. That significantly raises your costs in retirement.

You have significant risk from healthcare costs until you hit medicare age (and even then...). You're probably looking at $5k-10k a year in premiums (individual) at age 45+, and still five figures of annual risk exposure despite already paying that much.

Retiring on $2m at 45 would be very likely to end in failure, even as an individual supporting only yourself.

> $100k/yr is a 5% withdrawal rate on $2 million

Yes, that's what the previous comment said. Of course, you don't need anywhere close to $100k, so you would still be reinvesting the bulk of it, just as you did throughout your career. That will see your returns continue to increase as you grow older.

> you won't own your own house, or at least, you definitely won't be anywhere near paying it off.

You'd have no trouble buying a home on a $30k income 20 years ago. They could barely give houses away back then.

> You have significant risk from healthcare costs

You still have $70k to play with each year. If you have to miss a year of reinvestment it won't hamstring you that much. As before, bad luck happens. It is possible you are the unlucky one. But generally speaking the money is there.

> You'd have no trouble buying a home on a $30k income 20 years ago. They could barely give houses away back then.

I made a bit more than that 20 years ago and can guarantee you it wasn't anywhere near enough money to buy a house. Finding affordable apartments to rent on that salary was difficult enough. I lived in New Orleans, which wasn't a high cost of living city at the time. Maybe if you lived in the middle of nowhere that would be doable, but almost certainly not in a city.

their username is randomdata, not accuratedata.

my experience agrees with yours.

> You'd have no trouble buying a home on a $30k income 20 years ago.

You're absolutely right - the banks would give you a loan you couldn't actually afford. I seem to recall this leading to some sort of financial problem in 2008, unfortunately.

I love your optimism. Some may be able to live off software at 30k/yr making 100/yr "somewhere", but not most places. My rent started at around 40% of my take home and adding taxes alone, my pay rate was well under this 70% fantasy which doesn't even begin to address any other "incidental" living expenses like food, transport, children, elderly, school loans, etc......

> My rent started at around 40% of my take home

You were paying ~$3,000 per month for rent 20 years ago? I remember renting a place 22 years ago for $250 per month.

Maybe you were in some super insane cost of living area, but if that's the case, why would you accept just an average developer salary? Average salaries are for average places.

What's the distribution of experience though? In a fast growing field, most will be early in career, which will push this metric down relative to established fields with little growth.

The question's whether 20 years of a "competitive" tech salary is enough money to retire.

I think one must have a very-skewed, bubble-bound definition of "competitive" for that to be plausibly true. Programming jobs don't pay enough to grant easy-mode early retirement for most of our field—even in the US.

That was a competitive salary when I started in 2005.

Well, it'd also represent a raise for about 50% of programmers in 2022.

[EDIT] Further:

"The lowest 10 percent earned less than $54,310, and the highest 10 percent earned more than $157,690." (in 2022, still).

The ones who can retire in 20 years are making (ballpark) top-5%-of-field wages most or all of that time.

[EDIT EDIT] I didn't pick the best category for this, but the numbers only skew up 25ish % for the most-relevant one. Not a single BLS computer job category has a median particularly close to "retire in 20 years at this income" money. FAANG, finance, and a small segment of the startup market that's in that same category—yeah. Almost all the rest? No.

They classified people we don't think of as programmers as programmers. Classic job stats mistake.

Ok, sure, that's one category and some of the others do have a higher median. Some of what we think of as "programmers" or "developers" will actually land in other categories, and also some we don't, will too.

https://www.bls.gov/ooh/computer-and-information-technology/...

But still, even the top-median category, "Computer and Information Research Scientists", doesn't have "retire in 20 years" median wages.

What is a competitive salary? Do you mean the small fraction of programmers that work for FAANG companies? Or do you mean the more normal salaries the vast majority of programmers make at non-FAANG companies?

I’ve worked for the past 20 years and am as far from not needing to work anymore as my first day. Well, that isn’t strictly true, but my 401k only has about 33-50% of what it needs for me to retire. I have no savings beyond that.

I didn't realize anyone could go to medical school.

Maybe a little overly sarcastic, but there's a real point there:

Not everyone can get into med school (~5% acceptance rate?), but even more disturbingly some people get out of med school with tons of debt, and then either fail their step 2 or don't pass quickly enough to get a residency. Or fail boards after residency. Then you're in a really shitty position, with hundreds of thousands of debt but no ability to practice medicine.

Thing is which med school you’ll go will determine your debt load. Not all med schools charge the same rate.

And also your board exams success rate!

That depends exclusively on your savings rate (which dictates your years-needed-to-retire): https://www.mrmoneymustache.com/2012/01/13/the-shockingly-si...

Most people aren't saving ~43% of their take-home pay, no matter how much they earn.

Maybe I am naïve but I don't get this age vibe really. I do backend java distributed system stuff for a large company. A lot of my peers and managers are "older" 40s and 50s with kids. A lot of the work is high collaborative and design focused. Maybe I am just in a bubble of an aging tech stack but it does seem like we are always using "new" (at least different) databases, caching, and network layers to stay somewhat current.

Its hard to imagine that 5,10,15 years of distributed systems and system design experience and knowledge along with domain knowledge and social skills will be all of a sudden be so irrelevant that it is worth phasing all of us "old guys" out for someone who happened to learn the newest programming language straight out of school.

We are constantly expected to learn the new stuff and will just a project assigned with a mandate "okay this is to be done in spring boot, using this DB, this HTTP layer, etc...

It’s the bubble of very online people and start up culture who think tech people age out at 40. I know plenty of devs in theirs 50s, after that they just take early retirement since they’ve earned enough.

Most devs aren’t terminally online, they treat coding as a job not a lifestyle and for them it’s just like any other industry - so you don’t hear from them.

Also, some devs retire into SQL and DBA like work since you can basically make yourself unfireable if you want to coast out the last decade of your career.

> ... to coast out the last decade of your career.

Here right now the age vibe is coming from ;) It's not like a doctor can coast it out (or maybe I'm also naive).

(I'm an employer as of now)

I would argue that a coasting grey beard could easily be better than a mid level dev with maybe 5 years experience.

I run a contract shop and all my best DB guys are greybeards... coasting. It doesn't matter, after so many years with postgres & MySQL they are amazing.

Agree, with DBA or system administration it's possible. Not so with UI/frontend development, for some reason that's always a rush.

I would probably differentiate by work visibility: good work in DBA/sysadmin/security/accounting/quality is invisible, you only notice those folks when they have screwed up.

With product/UX/new features it's the other way around, coasting is not possible.

> With product/UX/new features it's the other way around, coasting is not possible.

That very much depends on the application. I maintain some enterprise solutions for customers. Clients get upset if UI has flow changes. Also, changes don't make me money unless they are required for a new customer. I will do it on request and invoice for the work but no one is interested in change for the most part. I think this is VERY common in enterprise software.

I take chill in-the-flow steady progress over hyper rah-rah-rah windmill attacks any day, week, and month.

Grey beard here. The last interview I had with a company was with the CEO (no beard) that could barely stay awake because he had been up all night (think Sam Altman with scurvy). I seriously doubt he remembered anything about me. That one experience let me know that I would not be doing the "coasting" being referred to in this thread. Instead I would be losing sleep repairing the mistakes from bad decisions and lack of experience which would ultimately lead to a dead startup. Thank you no.

There was a time when machismo was my middle name (much younger) and would have seen that as necessary for a successful startup. Now that I have several startups behind me I see it as simply bad management which decreases your chance for success which is stacked against you from the beginning anyway.

That was several years ago. I don't think that startup exist any longer.

I have often wondered if any VCs would allow a group of experienced devs to PE zombie startups, roll them up for pennies to see if any have an unexplored nugget of traction

You'd have to pay the experienced devs in real money.

Its the equity cramdown on the existing teams that would be harder

I meant nothing negative with my "retire into SQL" comment :-) some of the most fun I've had in my career is picking through a 25 year old SQL database understanding how it all works.

Since it is such a pervasive idea I will also drop a message to agree. I'm a mid 30s contractor and one of the youngest members of my team.

At 41 I’m the youngest member of my team across dev, QA, and management.

> It’s the bubble of very online people and start up culture who think tech people age out at 40

Shhh... please don't tell the tech bros that there is a world outside of the Silicon Valley bubble!

Where you can raise a family and make a good living working 9-5.

Where you are not constantly trying to ruin and exploit the lives of normal people to make a short term gain.

Where most of the actual work keeping the world afloat happens.

It is better for us working dinosaurs that way.

I've worked with plenty of folks that are well past 40 and are thriving!

Exactly, I work in enterprise and there are several guys past retirement age and they're the most productive and valuable guys we have. In other words, it probably makes sense to move away from startups as you age.

To be fair, you're comparing 55 year olds with 65 year olds. Every 55 year old in tech I've spoken with is talking about retiring "soon" (although soon always ends up being 2 years later every time they mention it). Every 55 year old doctor I know doesn't even have retirement on their radar and would probably work till they're 70+ if they could.

Ageism in tech starts at 50+ (probably even earlier). Ageism in healthcare probably starts at around 80 and at that point it's only because the doctor's not physically able to perform safely.

Thanks to compound interest, the money you can save early in life is exponentially more important than the money you can make later in life.

Many programmers started making money to invest in their teens, and save those who pursued other careers before pivoting, all were making money to invest by the time they are in their early 20s. Meanwhile, the doctors were racking up the debt until nearing 30. That decade plus is a huge setback – never mind the debt burden on top, and how the tax code greatly favours those who build up savings over a long period over receiving large lump sums in a single year.

In other words, 55 year old programmers are talking about retiring because they can. 55 year old doctors on the other hand, even with a higher income, need to work decades more to financially catch up.

50 years old here and still on the top of my game - but believe me - this is my last high $ gig - after this it will be challenging to find another job at this level given the rampant age discrimination

If you don’t mind asking - what is the order of magnitude for your perception of “high $ gig”? I’m asking because I’ve seen wildly different opinions on what people consider highly-paid (from $100k+ to $1.5M)

I don't think it's the case that experience is generally useless, but you need far fewer experienced people like this than you do cannon fodder to advance the front line a couple of centimetres.

There are people earning good scratch well into their "golden years" in the tech sector, but the demand for them is much weaker.

Isn’t that always the way? You need far more front line workers (whatever that means in your industry) than you need managers, and at most businesses advancement equals moving to management because there really isn’t far to grow technically..

It's still unfortunately common, because there are always young workers in the pipeline.

HP: https://news.ycombinator.com/item?id=38043552 ("It took seven years but over-40s fired by HP win $18M settlement")

IBM: https://www.diversityjobs.com/career-advice/team-building/ho... (Control-f "Sources")

https://features.propublica.org/ibm/ibm-age-discrimination-a... ("ProPublica: Cutting 'Old Heads' at IBM")

https://www.forbes.com/sites/jackkelly/2023/02/17/prior-agei... ("Prior Ageism Allegations At Google, Facebook And IBM Raise Concerns About Older Workers Being Targeted For Termination")

https://news.ycombinator.com/item?id=14932680 ("HN: Ageism is forcing many to look outside Silicon Valley")

https://www.orangecountyemploymentlawyersblog.com/dfeh-90-ag... ("DFEH: 90 Age Discrimination Complaints Filed Against Tech Firms Since 2012")

People overestimate ageism in tech because the number of tech jobs has grown so rapidly. That means there are a lot more young people in the industry than there are old people, and they wrongly interpret that to mean the "missing" old people were pushed out, when the reality is they mostly were never there in the first place.

You hit it in your first para:

It's not "age" it's current-ness.

Since most people aren't expected / empowered to learn what's next 'on the job', currentness decays, making age a stereotypical proxy for dinosaur.

Here at HN, by virtue of being here reading these comments, "this isn't you". You are making yourself aware of what's going on outside your backlog. The stereotype arises because most devs aren't here or anywhere besides chopping wood.

Until AI is flying planes...

I could not feel comfortable as a passenger on a commercial airliner without a human on board that could take over and fly the plane manually. There are all kinds of failure scenarios where a computer, AI or not, would get confused. Even just the specter of malware is enough for me to expect a human being, that values their own life, is able to take over.

> I could not feel comfortable as a passenger on a commercial airliner without a human on board that could take over and fly the plane manually. There are all kinds of failure scenarios where a computer, AI or not, would get confused.

"Person there just in case to take over in the rare case of emergencies" might not be as well paid as "person who's responsible for the plane at all times". Plus, if you're concerned about malware, you'll probably want a person still involved in vetting the code outputted by some hypothetical AI, so there would still be at least some engineering jobs.

The person to fly in case of an emergency will require the same kind of currency as a person flying all the time. The person flying all the time will be much more capable than the person watching the plane fly, and acquiring experience only in specific training.

> The person to fly in case of an emergency will require the same kind of currency as a person flying all the time.

Almost everyone requires the same "kind of currency", but that doesn't stop salaries from being different.

> The person flying all the time will be much more capable than the person watching the plane fly, and acquiring experience only in specific training.

If the plane can be piloted mostly automatically, that doesn't necessarily matter. What matters only is if the emergency person can handle the emergencies that do occur.

To be clear, I don't have any strong belief that human pilots will disappear any time soon; I just don't think the arguments people are making here are that compelling, because they seem to be assuming that the skill level of flying a plane is much too high for an automatic pilot. As someone who's been skeptical of fully automated driving for a long time now despite popular opinion seeming far more optimistic about it in the short term, it's kind of ironic to see "humans will always be better at flying" presented as axiomatic.

>Even just the specter of malware is enough for me to expect a human being, that values their own life, is able to take over.

I'd be more concerned abouta human going insane than malware.

I'd imagine they're mostly fly by wire anyway, so a virus could theoretically just disable the human input.

I assume / hope that there still exists manual hydraulic controls for the control surfaces. Maybe not in the cockpit, but somewhere accessible in flight in an emergency.

Modern U.S. submarines are also fly-by-wire, but hydraulic overrides are in the engine room in case of emergency.

Airbus designs are substantially fly by wire, although supposedly with an isolated control system. Boeing designs are isolated electro-hydraulic.

There's a big difference between isolating a single control link vs an entire control system comprising of, at least, a corpus database and all the supporting code that streams inputs and actuates outputs.

>There are all kinds of failure scenarios where a computer, AI or not, would get confused.

but there may also be enough kinds of failure—and routine—scenarios where computers do a better job, so on balance they could be much better, just killing a few people in the most absurd situations that would never fool a human. You can't guesstimate reason these things, need statistics.

also, if automated systems have a bright future for us, maybe we have to sacrifice a few people on the QA team in order to get there.

I'm infinitely more comfortable with an AI flown plane than a AI driven vehicle. The issues the plane has to deal with are going to be much more predictable than the issues a vehicle has to deal with.

Certainly things like the ghimli glider are better for having a human at the helm, but those sorts of things shouldn't happen.

I largely agree with you, however auto-pilot has existed for decades. I don't foresee AI taking over the cockpit anytime soon, but a compromise is likely. Perhaps it'll allow for copilots with less overall experience than copilots today.

Given how good ChatGPT is at coding, I'd bet on software development being radically disrupted before we're boarding planes with zero pilots.

I don't think we'll ever be at zero pilots. But one pilot instead of 2(or more) would nearly halve the pilot market, no?

Or a room of remote pilots that are signaled to take control in an emergency?

If a plane gets struck by lightning, the remote connection may cease functioning. So, too, might the onboard computer.

Regardless of what naive optimization might suggest, I doubt the airlines are going to risk the headline "217 Dead In Pilot-less Plane Crash" any time soon.

We're facing a really bad pilot shortage right now, even in the fun jobs like flying fighter jets for the Air Force. That change would allow more plains to fly, I doubt it'd hurt the market for pilots - salaries which are already depressed because the airlines have been able to get away with it.

The complaints I have heard from military pilots are that shortages are caused mainly by toxic leadership and unattractive career path options. Combat pilots don't appreciate taking orders from careerists or "shoe clerks". And they don't want to get stuck in staff or management assignments for years just because the service needs a warm body to fill a slot. Plus the day-to-day administrative workload is high even when they're not flying. So, a lot of them in the O-3 to O-5 range just get burnt out and quit. Air Force leadership could fix those retention problems if they actually wanted to, and it wouldn't even be very expensive.

"I apologize for the mistake in my previous response. The altitude is indeed 1,200 feet, not 12,000 feet. The correct action to take is to increase pitc"

The economics won't make sense any time in the foreseeable future. Pilots are a small fraction of the total cost of a flight, making the upfront cost to automate the extremely edge-case-laden final 10% of safety-critical operations they oversee a non-starter for now.

We'll have terrible Roomba boxes replacing flight attendants long before anything replaces pilots.

they're a pretty big fraction for shorter range flights/smaller planes (somewhere around 10%?), and more importantly they are a cause of cascading delays. often major delay problems happen because the flight before was delayed requiring the pilots to stop working and you now need to reschedule all your pilots leading to more problems. pilots are more of a problem than flight attendants because there are more attendants, so you can more easily have a few in reserve.

Pilots are more of a problem than flight attendants because not only are there fewer pilots, they need to be certified for the plane you have available. If your reserve pilot is certified on a CRJ-900 and you need to fly a 737, those folks aren't going anywhere.

>We'll have terrible Roomba boxes replacing flight attendants long before anything replaces pilots.

For American-run airlines (and many European ones too), terrible Roomba-like boxes would be a big improvement in service.

Not for Asian airlines, though.

Not sure about the replacements for flight attendants. I understand they have important tasks during emergencies.

Flying the airplane is the easy part. The hard bit is responding to equipment failures and other emergencies. There is no way to predict all of the possible failure modes, nor do we have AI that can figure out how to manage unexpected problems in real time. That technology is likely at least several decades away.

There is also a sensing issue. If aircraft sensors fail then they might feed the AI faulty data. And sensor redundancy or fault detection logic can't necessarily cope with that. Whereas experienced human pilots have a pretty good record of using their organic senses to handle such failures safely.

I’m 41 and I totally understand this sentiment. A silver lining is that the tech industry is just so much larger now than it was when we started, a trend I think will continue, and there are now tons of jobs where it’s really helpful to also be a developer. Some examples:

Developer and marketer/technical writer - selling to other devs is a giant business now and it often takes devs to make that content.

Developer and SRE - we live in the world of huge scaled our saas businesses where there are always support issues too advanced to be handled by non-devs

Developer and project manager - everybody has worked with non-dev project managers and it’s usually terrible.

Developer and people manager - there are so many more eng manager roles than there used to be, and moving to the management side is a well worn path now.

Developer and product manager - you have to develop a lot of new skills but in this role a past life as a developer can give you super powers.

That said, I moved first into people management and then into running a small software company which sort of demands a little bit of all of those skills

> Developer and SRE

I'd say these are pretty interchangeable in one's career if they wanted to. The others not so much.

If you're 20+ years experience and not any good as at least a project manager, I think your core skills are also pretty suspect.

You mean your core tech skills will be suspect if you aren't a decent project manager? Well that's a depressing thought. Though in my experience so far we have dedicated project managers. But maybe you are right.

I think dedicated project managers are a good idea to keep people focused, but I also think if you've been buildings things for 20 years you should have absorbed enough of the process to be at least basically capable at it. That's not really true of people management (an entirely different skillset) or technical writing (though it's a bit closer) or even product management (but if you code mostly customer-facing features, probably you should have picked up a lot of this too).

If you've just been a "turn the crank" developer implementing someone else's sprint-scoped tickets for 20 years, you probably topped out after around five years. (Or you're doing all the interesting stuff outside work, in which case... you definitely have project management skills.)

Interesting about the tech writing too. I'm not good at this. I've seen this mentioned on hacker news

https://www.amazon.com/Docs-Developers-Engineers-Technical-W...

I'm think I could do with reading that. As could the team I'm on.

completely agree but I think it's more general than that.

A strong senior should be able to do any of the roles all the way up and down the chain, including "product manager", "business analyst", etc. It's an issue of time and scope rather than skill.

note: I'm aware that most business analysts are domain experts, my point there is that a senior can both analyze a problem and create a solution and can interface with domain experts where needed.

Given the number of devs I’ve worked with who stare blankly when you say “cgroup” or “IOPS” I’m going to say no, Dev —> SRE is not an easy switch.

For a good dev it's an easy switch, the issue is that a lot of developers WANT to be treated like line workers. monkey grab task, monkey implement task.

I honestly find it shocking, but there it is.

> > Developer and SRE

> I'd say these are pretty interchangeable in one's career if they wanted to. The others not so much.

They are? Now I'm pretty new to this (despite my age) but my impression has always been, with the former you mostly focus on one project and maybe even just a small part of it, with the latter you are keeping an eye on half a dozen systems, have to know their ins and outs to babysit them, and occasionally firefight when something breaks in production.

If you can get one of these jobs, you can get the other, although not necessarily at the same level. You can certainly switch careers between these two, especially early career.

I don’t know about anybody else, but I would see experience in both as a plus on a resume. I think it’s a good idea for SREs in particular to get a dev job on their resume since the person hiring you is going to be a developer a massive amount of the time so it never hurts.

… they should be, but some people just seem markedly incapable of debugging.

(But I'd agree with you: you should be supporting, in the form of debugging & problem solving, the thing you're writing. Separate SREs are an anti-pattern in my book … somewhat comically since I'm basically an SRE at the moment…)

> I’m 41 and I totally understand this sentiment. A silver lining is that the tech industry is just so much larger now than it was when we started

I'd also point out that if people forget the growth-aspect, they will overestimate the problem of ageism in the industry.

Yes, there aren't that many grizzled 60-year-old programmers today... but much of that is because 40 years ago there were only a handful of 20-year-old programmers to start with.

Even if advancing age turned people into happy rockstars, they'd still be outnumbered today just because there are more jobs.

And a good chunk of them probably hit it big at some point and retired early. I know so many software engineers my age (40s) that are effectively retired already.

Yep. Most of my friends work as software engineers and we're in our 40s. And most of them have/could retire if they wanted to.

One was working at Google and got shit for taking time off when he planned it 6 months out. He quit and decided to retire early instead of putting up with it. He's 42.

I don't, but then again I didn't focus on maintaining job application loops against multiple giganto companies every single year...

> much of that is because 40 years ago there were only a handful of 20-year-old programmers to start with.

Which also explains that the more youth you see competing for the gigs helps crowd out those of us elderly tech folk who are left.

As a 63 year old programmer, I can confirm the industry used to be much smaller.

A lot of people my age also retired because they had too much money to work :)

Managers have to be youthful as well these days.

I'm almost 40, never made good money... this makes me sad

A case of the keeping up with the Joneses syndrome?

Recent figures are not readily available, but as of 10 years ago a yearly income of $32,000 was enough to put you in the global top 1%. Adjusted for inflation, that is around $42,000 today. Interestingly, the median income in the USA is $41,535, so it is likely that half of all Americans are in the top 1%.

Although I would think that "good money" would cast a larger net than just the top 1%. Surely at least a 75th percentile income would be considered "good" by most? As such, it is likely that a $20-30,000 income is "good money".

If you have not even made that much at some point over the past 25 or so years that you have been of working age, how can you afford to be here?

it's a bit disingenuous to compare US citizens to 3rd world countries.

yes, it's technically true, but no one with a 3rd world income would ever be able to afford to live in the US, they'd be homeless. its apples and oranges.

Not at all. The topic is money made. That is independent of expenditures. We could go down the road of retained money (i.e. net income), but then clearly money made is no longer relevant. The guy who made $20,000 and spent $10,000 of it is the one who retained good money, not the guy who made $1,000,000 and spent $999,999.

right, and someone living paycheck to paycheck in NYC is somehow richer than someone living in a LCOL area with more buying power.

There's a reason why discussions of salary have to happen around the area the salary is made in.

Again, the topic is money made. x made is x made.

One may need to spend more x to live in a certain location, sure, but that's a completely different topic. One where the money made is not relevant, for reasons already stated. As we are talking about money made, you know we are not talking about that.

this is clearly false.

10k USD/year is "good money" for many people in other countries but no one would ever describe that as "good money" for someone living IN the US.

and yet, the poster YOU chose to respond to said this:

> I'm almost 40, never made good money... this makes me sad

> the poster YOU chose to respond to said this:

Yes, as you can clearly see, he added the operative word "made". A word you conveniently left out from your message in your ongoing quest to change the subject. Had you included it like in the original comment, it would completely change your message.

I have to conclude you're either under the influence of a mind altering substance or trolling.

either way I'm done with this conversation. Come back to this when you're sober and read my post more closely.

Interesting that this has turned to be about me and not the content in play. Logically, they are independent of each other.

While I am not sure what you think you can be done with given that you have not yet joined the conversation that we were having before you arrived, no amount of drug use is going to give me interest in your off-topic tangent.

I get it. You misunderstood what was written earlier and now you are grasping at logical errors in order to avoid having to come back now and ask questions for clarification to save your pride. But, why are you letting your emotions drive you like that? Who cares if you made a mistake? I certainly don't. I don't care about you at all.

So troll then.

For anyone reading this, you can clearly see where the word 'made' is in the quote given, yet this person decided to claim I left it out on purpose. The implication being that I cherry-picked a quote when I quoted the _entirety_ of the post in question.

You included the post, but failed to speak to it, instead forcing your off-topic direction in the rest of the comment.

If it is me who misunderstands you, go on. You have already been given the floor for quite some time to explain yourself and reason for interjecting in a rational manner instead of spouting nonsensical logical errors, but I'm generous enough to give you another chance.

If I, in wintery Canada, made what is considered by most to be a good car and then put it on a boat to ship it to the hot African desert, does it magically become a bad car? The car hasn't changed. It is still the exact same car.

Join the club. I did good money once with tiny startup exit. Salary is just enough to pay for food, mortgage and vacations.

I am almost 50, and my partner (ophthalmologist) always made more than me as developer, and architect. But to be fair, I only worked for small startups in the Bay, and startups that did not make big. Not complaining, but a bit worried for the next decade though. Especially as I am super busy at work, so much that I cannot spend time on programming anymore.

> he's basically going to make top dollar until he's 65

There's no such guarantee in any of the professions.

True but it's likely, unless fully-autonomous commercial airliners are developed. There's a shortage of pilots as well, and unlike most other careers, they have to retire at 65 (or maybe younger?).

Even if autonomous aircraft are developed, will the "old" planes be converted? Could they be converted without tons of changes? Sounds unlikely.

Planes are typically in service for decades but if they could eliminate the pilots, that could very well change the calculus.

But, public mistrust of a pilotless plane might very well put the kibosh on that for a long time. People have trouble trusting air travel as it is, doesn't matter if it's irrational, and they usually know that it is.

Imagine a lottery where instead of winning, you die in a terrifying way.

That's flying. You enter into an aluminium can, and from that point you are completely helpless, whatever happens. The only thing you can do if something goes wrong is assume the fetal position and hope.

And yes, life is pretty much like that. You could get cancer or get hit by a car or a meteorite for that matter, but even these things feel more controlled. I can pay attention to my surroundings to avoid getting hit by a car. I can potentially treat cancer. I could probably not do much against a meteorite or gamma ray burst or whatever cosmic thing might happen but that stuff feels less real anyway.

I agree that the fear of flying is somewhat irrational, but at the same time I think it's a valid fear especially in light of things like Russia shooting down passenger planes, the whole Boeing Max 8 thing etc.

Doesn't necessarily matter when its rich countries (or their carriers) that buy the new planes and out of a sudden, pilots have the choice of flying for an indonesian island hopper or not at all.

They're one failed First Class Medical exam away from losing it.

Especially with machine learning engineers automating lines of work away :)

There is by necessity, nuance, and specialization.

But if someone wanted to be rich by capturing more of the value they could produce, it's highly unlikely as someone else's employee.

> But we age out much more quickly due to the bias common in our industry.

Just prove you lost a job or weren't hired due to age, and you'll have a lawsuit that results in a large enough settlement you will once again be paid more than your spouse and won't even need to work.

And how exactly would one do that?

Same way as any age discrimination lawsuit.

If you have reason to believe you were terminated or not hired because of age, meet with a lawyer. If a lawsuit it filed, discovery is a powerful tool in litigation to help gather evidence that is generally required to prove the claim. Often this will be data about the other employees they have let go or in the case you weren't hired the age of the person ultimately hired and those that were interviewed but not hired.

There are about 10,000-15,000 a year, like all areas of law probably about 90% settle pre-trial.

My point is that I don’t think it’s that easy to prove unless it’s blatantly obvious from an outside perspective and most lawyers wouldn’t take a case on contingency unless it was blatantly obvious to them that it was a winner.

So do you pursue it paying some lawyer an hourly rate to sift through a thousand emails just to find that the company hired a younger but still fully qualified candidate? If you are a person at the sunset of your career and still need a job it’s likely that you will not bankroll the effort…so you just move on.

I mean, mathematically speaking, having your high-income years happen earlier in life is significantly better because of the way compound interest works.

What do you do when 'high-earning' last decade is somewhat laughable to this one? Was compounding worth it when inflation just gobbled up all of the effort you out into those earnings faster than interest could compound?

It's been a rough couple of decades afterall.

Some napkin paper math. I googled "largest index fund" and got these 3 results:

Vanguard 500: 3x return over last 10 years

Vanguard total stock market index fund: 2x over last 10 years

SWPPX: 3x over last 10 years.

Google is telling me inflation from 2013 to 2023 is 41%.

So even with inflation accounted for you're looking at a 50-150% ROI over 10 years. Maybe I just got incredibly lucky picking index funds, so I googled the total market capitalization of US domestic companies and that grew from about 15 to 30 trillion. This stat seems to be wonkier, other estimates claim 45 trillion (probably a more inclusive estimate counting smaller companies).

But TL;DR: No, inflation did not gobble up the returns on investments

It depends on how you measure "inflation".

The standard way is to measure the amount of stuff money can buy, where "stuff" is daily necessities and so on. But prices are just relative. It can be argued that such daily necessities like food, clothes, etc. have actually gotten "cheaper", and the increases in stock and other asset prices are a function of how much money is printed by central banks. (There's a strong correlation there, at least.)

It's not the standard narrative, but it's something to think about in such cases where these numbers are absolutely crucial to your life plans.

There's also the element of the US stock market basically outperforming everyone else in the past decade. (And it's mostly because of tech.) If you pick a couple non-US indices the numbers look much more shaky.

> But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.

Errr, I'm 64, generally get a title like "senior programmer", and have switched jobs a few times recently and didn't have a day out of work. I expect to be going for a few years yet - in fact I expect your husband will be forced into retirement, whereas I will chose my time.

Moreover, I have quite a few software engineering friends or about the same age. It's the same for them. Some are still working, some not. But in every case it's been their choice, they weren't forced into it by the industry.

Thanks for posting. It's something that concerns me as I head into my 40's, so it's really nice to read anecdotes from folks showing there are opportunities for those getting up there in age.

I'm 45 and have often wondered if I'm just lucky, based upon your post my experience isn't nearly as unique as many seem to think.

I wonder if it's more about skill level (certainly I'd like to think so :])

I hope you’re correct but the very realistic possibility of SPO (single Pilot Operations) is what pushed myself - and many others like me - away from the career. The current pilot shortage was by design, as the airlines were well aware of the issue and had many ways to avoid it. I’m still of the mind the current shortage (and short term plans to mitigate it) are just to hold them over long enough to end the current 2-pilot system and bring the standard to single pilot operations

Wouldn't that require FAA complicity? And do you think pilot unions would allow it? Do they have power to stop it?

I think the biggest obstacle will be public acceptance of a single pilot at the helm. It would take some serious backup tech assurances and maybe a generation's worth of time before it happens.

I think the ageism thing is not as big of an issue anymore. Yes, you will see it in startups that are run by 20somethings but I'm in my early 50s and haven't had any problem staying employed or getting offers.

If you stagnate skills wise or stop trying to grow/evolve your abilities then you definitely will have issues but that's true in many industries, not just ours.

As someone whose done a lot of hiring (at several companies), senior devs with a lot of (applicable) experience can always find work even if they’re “old” (40/50/60+).

But career changers will have a rough time - e.g. I remember a social worker who went back to school in his late 30s looking for an internship(as a developer), he had a much harder time getting hired than someone in the same position in their early 20s.

>But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.

People used to believe this, but it's not true at all in my experience.

> I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.

Can confirm, but it’s more like around 50. That is why you tend to not see a lot of senior folks wanting to bounce gigs every three years like the younger folk do. I hope to ride out another 7 years at my current gig and retire. Hopefully they won’t have other plans because at that point I’ll likely have to shift to WalMart greeter.

It's not a matter of the goodness of the deal that a doctor has versus that of a software engineer. It's that the deal doctors get is emotionally scaring to them and it produces horrific social dysfunction.

Not to sound like a naive optimist, but the average age of somebody working in tech is going up over time, and that is likely going to make tech less exceptional in its ageism.

Tech is also slowing down in how much it is changing, which makes it easier to do the work while older, which again takes the edge off of ageism.

> But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.

My grandfather made good money fixing systems for y2k in the 1990s and retired shortly after.

There's plenty of work for dinosaurs. Plenty of systems quickly hacked together today will be around for much longer than planned for.

"he's basically going to make top dollar until he's 65" ...unless he fails the flight physical.

Your husband is also in the position where any mental issue and a lot of physical health issues will force an early retirement.

And if he wants to make the big bucks, there are not that many companies to work for (~10 mainline carriers in the US at the moment), and the seniority rules suck.

> Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.

I disagree. Go to some technical meetups.

At practically all of them I have seen people offering jobs to both juniors and greybeards. The biggest problem everybody is having right now is connecting. The garbage in the middle is clogging everything up. So, everybody is going back to the old tried and true, the weak social network of in-person acquaintances.

Yeah, you have to not suck and you have to keep your skills up-to-date. But, that's true whether you are 20 or 60.

Here's the thing. There won't be "tech work" or any kind of work in 5 years due to AGI.

In fact any long term plans at this point seem silly. AI is going to make all human labor irrelevant.

> Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all

My dad is in his 60s and is still doing cutting edge work on Kubernetes, Golang, eBPF, etc in a big tech company in the Bay Area. It honestly isn't that hard to keep yourself up to date with technology looking at his experience.

If you can't get yourself interested in upskilling or learning the next new paradigm you're in the wrong field.

I question the aging out aspect of software dev on a career level. Yes you might get agism at trendy companies started by and heavily employing young people, but there are many software companies out there with many industries now employing software divisions, and the heavy demand I always see is for senior developers with experience.

One “problem” in software: it’s really difficult to coast for a long period of time without training up new skills. You can certainly do it, but eventually the industry shifts underneath you. So the cushy senior Java dev position in a particular service might be able to last you for a decade or more at some companies, but I think most developers agree that if you want to keep getting better salaries you need to stay on top of trends and keep reeducating yourself.

And I don’t really see this as a problem as much as a feature of tech, but if you’re looking for predictability in a career I think it’s a tough thing to get in tech.

I wouldnt be so sure. aviation is ripe for automation (and planes can even land on its own now.). I can see airline companies pushing for only 1 pilot in the cockpit.

I think if you actually take the time to talk to some older dev people you will find that you are wrong, and when you actually get older you will find out how wrong. We are doing great - financially and professionally, despite having to face a small number of people with this attitude.

> Yes, we make good money when we're young in tech. But we age out much more quickly due to the bias common in our industry.

52. Gimme 10 more years, I won't care. I don't want to be working any job after that even though I love programming and it's all I ever wanted to do (for a living).

> Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.

I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.

Compare a doctor to almost anything beside an engineer - and it won't seem so terrible.

Most people that have been in engineering for >10 years got into it because it's what they liked doing - and then it just so happened to be ridiculously lucrative and not require you to go into hundreds of thousands of debt to get trained to do the job (medical, lawyer, etc).

Even most trades (electrical, plumping, beauty, the taxi medallion system, etc) are designed similar to the medical industry - and require ever more schooling (debt, opportunity cost) to get the job - to artificially reduce the work force to benefit current workers at the cost of future workers and everybody who uses those services.

I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.

We're all gonna need medical help some day...

Maybe we can do our own plumping and cut our own hair and be good law abiding citizens and not need a lawyer. But we're all going to have severe medical problems at some point.

Your last point isn't correct.

While that is the result I think emphasizing that it isn't made easier is important.

Electricians need to install high voltage wires that are safe in the home for untrained individuals for potentially a century.

Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)

Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation.

Lawyers need to know a phenomenal amount of information to meaningfully know what o research when it comes to prepping for court cases.

All of these jobs are hard to prepare for and their is value to everyone else that you can prove you actually prepared.

The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.

But it isn't made up boundaries just to benefit existing members.

I don’t think you can reasonably draw a comparison from medicine to home electrics and plumbing.

My dad was a plumber and I’m preparing to pass the certification that permits me to work on home electrics. They are, to be blunt, easy. An average person can pick up most of it in a couple of months. Electrics and gas plumbing carry a certification requirement because an error can kill someone, but it’s easier than passing a driving test.

Obviously, there are higher tiers of those trades that require a lot more training, but even those aren’t really comparable to the level of knowledge and study needed to become a qualified doctor, let alone a consultant.

In the UK, shortages of tradespeople are less to do with the difficulty of training, or lack of course capacity, and more to do with people really just not wanting to do the job, for various reasons.

Medicine has more barriers to entry at least partly because we’ve decided to erect them. Doctors learn all kinds of things outside their direct specialty that they don’t really need to know, but nobody inside the system has an incentive to streamline medical education or to encourage more and earlier specialization.

For example, we force most doctors to take a 4 year degree before medicine (sometimes pre-med, but often an arts or non-biological science degree). Wasting 4 years of a future doctor’s prime career on an expensive and often irrelevant screening program is extremely wasteful for society as a whole.

> Wasting 4 years of a future doctor’s prime career on an expensive and often irrelevant screening program is extremely wasteful for society as a whole

I have a cousin who's doing his residency right now and he has an interesting take on this.

You don't want to have a 21 year old in a cancer ward directly treating patients. They may lack the personal skills and life experience needed to convey empathy. In addition, they will not be taken seriously by patients due to their youth.

He is speaking from experience as someone who is doing his residency at a slightly younger age than average.

> You don't want to have a 21 year old in a cancer ward directly treating patients. They may lack the personal skills and life experience needed to convey empathy. In addition, they will not be taken seriously by patients due to their youth.

I just don't buy this take.

You don't let the junior engineer wild in production. You place guardrails around them until they learn and prove themselves as capable. The exact same thing can be done in medicine.

> You don't let the junior engineer wild in production. You place guardrails around them until they learn and prove themselves as capable. The exact same thing can be done in medicine.

You mean like a residency?

A residency is direct care of a patient. MDs already have internships and shadowing during their degree.

Residents provide direct care under supervision and have many guardrails, as the comment I was replying to stated.

Clinical clerkship is not an internship, interns are first year residents. Shadowing does not teach you medicine.

Residency is one form of that. A form with extreme labor restrictions and no ability to move jobs.

Yes, the system as designed by a cocaine addict[1] is broken. Residency is still necessary in principle. In a specialty program one only starts to become competent in PGY4.

It's a difficult problem to fix, I finished my residency training in Canada where we don't have ACGME protections in place and while it was far more abusive than US programs (where I currently work) it certainly made us very competent at the end, better than I am seeing in the average US trainee I supervise.

I'm not sure what the solution is to be honest. Competency is almost entirely driven by clinical volumes and exposure, you don't train to handle the 90% of normal cases but the 9% that are challenging and the 1% that's incredibly complex. If you're not working long hours (or spending many more years in training) chances are you won't get that exposure.

With that said one could argue with the current expectation that everyone does 1-2 fellowships we're already training longer.

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

There isn't enough staff to manage teaching AND medical care at hospitals.

Shadowing/Interning is already done in your MD program.

In Engineering, you will generally have 1 engineer paired with 1 intern/NCG. In a hospital setting that is an unrealistic ratio given the relative lack of staffing.

Add to that liability related issues because unlike CS, you as a medical professional can be held legally liable. This of course leads to high malpractice insurance rates subsidized by the hospital, who then in turn also need to show insurers that they are doing the needful.

> There isn't enough staff to manage teaching AND medical care at hospitals.

The complaint "we can't spend the time to train new employees" isn't specific to the medical field, but the solution is the same: they can't afford NOT to, and the lack of staff is proof of it.

The last plan ended in the failure we're at now (no staff available to train new staff). The best time for staff to start training more staff was before they ran out of staff. The next best time is now.

The rub is that lack of staff isn't what prevents this, nor is even lack of staff time. It's a conscious, short-term-focused decision by hospitals to focus efforts outwards on making more money, rather than inwards on training or changing the status quo. And honestly, the long-term herculean task of changing the existing resident system seems, in my opinion, out of scope and fantastical for the average hospital.

Residency positions are not paid for by hospitals. They're paid for and allocated by the federal government.

That is also correct, the task of changing the system just seems out of scope for any given hospital.

Maybe if a sufficient number of hospital systems were sufficiently motivated to sufficiently lobby the government for change. I don't know what that would take.

Residents unionizing is a good start.

Practically the whole world educates doctors with a 6-year program straight out of high school, out of which 6 years are relevant to medical education, instead of the 8 years in the US, out of which 4 are barely relevant to medical education.

"Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation."

From my experience they don't. If you have any problem off the beaten path you may spend years and multiple doctors to figure out what's going on.

I agree that happens, my point is about the intersection of speciality and expected.

Aka it doesn't always happen but that is the goal.

Honestly disease diagnosis is the one area I could see AI being super helpful in which might lower this burden from extreme memorization to facilitating collecting data for analysis and being a guard on false positives.

Agree about AI. It would be way more patient and take its time to talk to the patient than doctors have these days.

AI has had the opposite effect on false positives. Statistically, most patients aren't (that) sick and don't have zebras.

Taking radiology as an example (because that's my specialty) ~90% of studies are normal and some types (e.g. CT for pulmonary embolism, CT for transient ischemic attack/vertigo) are closer to 98-99% normal.

Every diagnostic AI application I've seen implemented as of 2023 that merely replicates the work of a human has done nothing but increase false positives.

The extreme class imbalance makes this a non-trivial problem.

That makes more sense. I interpreted the "catch" quote to mean that doctors are expected to literally come down with any contagious disease within their specialty.

I've heard a quip from my wife, "When you hear hoofbeats behind you, don't expect to see a zebra." Essentially, you need to know that booth horses and zebras make hoofbeats, but zebras are rare (in the US). It'd be foolish to look for a zebra until you've ruled out the possibility of a horse.

In fact, it even has a wikipedia page: https://en.wikipedia.org/wiki/Zebra_(medicine)

> Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)

There is no shortage whatsoever of licensed plumbers who will do incompetent work. Fortunately there is a decent collection of companies making excellent plumbing products that are quite robust.

Current personal favorite failure modes:

Use of inappropriate water-insoluble flux. This usually doesn’t cause a leak, at least not quickly. It is, however, disgusting (petroleum crud and not-very-good salts being released slowly over months to years in cold water pipes) and is a code violation.

Use of copper in boiler condensate pipes.

Use of essentially arbitrary mixes of pipe tape and pipe dope.

Overtightening of plastic threaded connections.

Incorrect combinations of tapered threaded fittings and gasketed straight threaded fittings.

I once moved into a house and had a plumber come out to connect the fridge to the water (there was some custom work that needed to be done).

There was a plastic line there already and that line hadn't been used in atleast a year (previous tenants kept their fridge in the garage). I remember asking the plumber if we should replace that plastic line and he said no, I even told him it hadn't been used in over a year.

A week or so after he did this work I'm walking through my living room and my socks are getting wet. At first I couldn't figure out what was going on until I realized that line had split (as I expected it to) and was leaking, said leak having moved into the living room where it was making the wood floors damp.

To this day I don't understand why that plumber thought that would be ok when I, as a complete layman, understood what happens to plastic lines that go unused for that long (they dry and crack).

What kind of plastic line? I've used a decent amount of name brand LLDPE tubing, and I've never seen it fail or even appear to degrade.

I have had issues with compression connectors at the ends (they don't like to be too loose or too tight), and I've seen plenty of failures of the really crappy washers that get used in "female compression" connectors.

I'm not a plumber so I couldn't say, but clearly it did degrade :)

>The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.

>But it isn't made up boundaries just to benefit existing members.

I would argue that it largely is just made up boundaries to benefit existing members. That is to say, regulatory capture has increased the barriers so far that any benefit from additional quality of service is far outweighed by the increased scarcity.

It doesn't matter if you have the best doctors and electricians in the world, if they are so few and expensive that the public does not have access to them.

The fundamental problem is that is both easy and popular to error on the side of "caution", creating increasingly stringent licensing requirements. These benefit established interests and sound attractive to the public.

I don't disagree but I like to distinguish between "there shouldn't be barriers" and "there should be fewer barriers" and the verbiage I responded to felt like the former.

> We're all gonna need medical help some day...

95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.

I wonder how much doctoring is due to negligence of a healthy lifestyle, or perhaps chronic choices (addictive substances like alcohol, shift-work).

> But we're all going to have severe medical problems at some point.

Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.

I had rectal cancer at age 40. There were no indications that my lifestyle caused or contributed to it. I rarely drank, didn't do drugs, etc etc. I might have had a genetic predisposition, but who knows, cancer is a complex thing. If I didn't have insurance, my medical bills would have easily been over $800K. So enough with your BS statistics that you pulled out of your ass.

Obviously many people get critically ill for no reason, totally without apparent casualty.

https://bowelcancernz.org.nz/about-bowel-cancer/early-detect... says about prevention: While no cancer is completely preventable, a healthy diet and regular exercise can lower your risk of bowel cancer. Numerous studies have indicated that a diet too rich in red meat and processed foods can heighten the risk of bowel cancer. However I would guess the percentage amount you can lower your risk by is below 1%. Across all health outcomes, healthy food choices and a daily walk can have a large effect overall.

It seems to me a hell of a lot of our healthcare funding goes towards people that make no preventative effort towards health. I have friends and acquittances with chronic conditions due to alcohol (diabetes, excessive obesity, gout, Korsikov's, accidents), smoking (emphysema, cancers), severely damaged joints (impact sports, car accidents), drugs (hepC, OD, teeth, accidents and worse).

Personally I eat "risky" foods , occasionally I drink excessively, I heartily enjoy high risk sports and activities, and I definitely don't exercise enough. I am not trying to preach: my point is many close their eyes to known risks.

I certainly am not blaming your cancer on your lifestyle. I sincerely hope the best for remission.

> I didn't have insurance, $800k

I'm in New Zealand and our taxes pay for reasonable quality cancer care for all - probably not $800k worth often. The sticker price for the US insurance system is often grossly[1] overstated (for reasons). I've seen our healthcare system mostly work (and I've seen some failures too).

[1] e.g. Hospital billed $100K, insurance negotiated to about $20K. The actual doctor only got $2-3K. https://news.ycombinator.com/item?id=37977337

> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.

You're young, aren't you?

The percentage is significant, but nowhere near 95%.

I'm middle-aged.

I might be over-estimating the percentage. I might also be over-estimating how much we can affect diabetes, weight, fitness, addiction.

I can say that the chronic health problems of my peer-group often appear to be self-inflicted.

Of my dead acquantances there are maybe a few groups: (1) health problems caused by childhoods of poverty, (2) health problems that we haven't solved yet which the medical system helps little, (3) suicides, (4) crashes/accidents, and (5) health problems caused by smoking, drinking and drugs (e.g. HepC).

Also acquaintances with chronic conditions often don't follow medical advice anyway e.g. diabetic friends that abuse their bodies. Or people told to quit drinking or smoking that do not stop.

I'm not saying it is easy. I am saying I know plenty of acquantances that have made difficult choices to improve their lifestyle choices (presuming cause not correlation), and others that have not made positive changes.

Context: I'm in New Zealand, so healthcare is mostly free and of reasonable quality. We have lots of immigrants so I have some exposure to people from other (often adjacent) cultures.

I have multiple problems with this comment

> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.

This is a statistic pulled out of nowhere.

>> But we're all going to have severe medical problems at some point.

>Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.

Again this is pulled out of nowhere. All types of joint replacement, stents and heart surgery are major procedures which are common and not prophylactic. Prostate cancer surgery has an 85% success rate in eradication where I live, and no, I didn't get it from bad lifestyle choices.

> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.

Maybe 70%? Genetics play a huge role. You will likely need a doctor if your family has a long history of cancer.

There can be more schooling and training in engineering.

After undergrad, master’s, PhD, a postdoc or two, one would still make low income. After that, there is a never ending path where one has to constantly chase ever changing technologies. The older you get, the harder it will be to keep up and remain employed.

In medical science, you finish the residency (roughly equivalent to 1-2 postdoc in engineering), and you start to practice. Already, income is OK in residency. The older you get, the better!

The income is most assuredly not okay in residency, or for that matter, fellowship. Most U.S. residencies and fellowships range from $60-$70K a year, basically the U.S. median income, and on a per hour basis is terrible.

To make it worse many of the big name institutions one would aspire to train in (e.g. 10 of the US News top 20 hospitals) are in expensive metros where you don't cross the "low-income line" until the third year of residency.

All the while spending 60-80 hours a week on clinical service and 5-10 hours on research and education so you can maybe get a job somewhere not remote when you're done.

Problems are doctors are unlikely to "help" with, and are highly likely to make matters much, much worse.

Also, contrary to popular opinion, there's little stigma or awareness of "bad doctoring", for a number of systemic reasons.

So you have someone who doesn't give a fuck about anything, certainly not your situation, not listening to you, and trying to prevent you from receiving medical treatment.

This doesn't look so necessary to me. I know there will still be medical experts and surgeons and so forth, but much of this medical infrastructure doesn't benefit the average citizen (I know there's an argument that it does or for a change in perspective, but that's a whole different can of worms.

Similar to policing, if you think of the typical way you interact with the medical system, you start to realize there's very little in there to help you. 99.99% of the infrastructure is built to benefit powerful people with tons of money; helping you is an after thought.

What happens when you're a victim of crime? Turns out there's very little in place to help. Oh, someone is actively trying to murder you? well give us a call after it happens and maybe we'll investigate.

How many of us have experienced something like this? I'm not saying there's no reason for the arrangement, but we should stop trying to pretend these people are looking out for the public.

I know people may be tempted to chime in regarding some situation a police officer or doctor helped you. I'm not saying you're wrong, just explaining why some people are asking questions; if you honestly think about it, your naive assumptions about safety and health will be shattered.

A doctor, in many ways, arguably has a patients WORST interests at heart, in a similar manor to a police officer, in it's interaction with the public. They have, as their most important responsibilities, to detect certain things, and take actions to hurt the person.

This is priority #1, virtually everything else comes after. This is an important observation, is not obvious, and should cause us to reconsider these institutions.

Perhaps a more diplomatic to phrase what I perceive as your thought there is that a good doctor or policeman is actually in some respects often acting that way regardless of the system -- they would've tried to help people as much as they could anyway. Meanwhile a bad or apathetic doctor, policeman, etc. will tend to receive little friction for it while you have to fight uphill to get basic care, all while being milked of as much of your money as possible and still having to wait unbearably long for useful treatment.

Likewise, there's such a range of outcomes, and when it's involving chronic diseases combined with an apathetic or bad doctor, you can be stuck realizing you've wasted months with no resolution (not even getting into any potential costs) only to now have to start all over again potentially several more times just for a sliver of hope that you'll find a doctor who's caring and competent enough to finally help you out. So sitting on the receiving end feels like being bled dry by people who couldn't care less about your suffering or if you die, so long as you keep paying them, with little realistic recourse other than accepting that you got burned and moving on.

In any case, just my two cents from what I think seems like a somewhat related view but with a different "spin".

The point is that the "bad or apathetic" doctor doesn't exist; It's not distinct. This is just default.

People are treated based on convenience to the doctor and their moral judgements. EVERYTHING in medicine works the opposite from the propaganda. I've been convinced it's part of a trope.

Any time a profession tries to convince you it's not something (eg. do know harm, treat regardless of morality, ect.), it is ALWAYS because they were doing exactly that, people correctly detected it, and now they're doing damage control.

>to artificially reduce the work force to benefit current workers at the cost of future workers

is that really the purpose? or is it that an entire industry has been built on top of the trades, and that industry does whatever to continue to grow?

> I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.

I don't disagree. However, I certainly am not a top earner in the industry. Much of my career has been remote. My income is not out of line with most STEM fields. The main benefit for me was the ability to work remotely, moving with my wife to various small towns/cities.

Keep in mind, my wife had almost 10 years of med school and residency to start her career. I was making income the whole time. That's essentially a $1M difference 10 years into careers. It takes a while to overcome that gap.

-----

> I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.

Yep. There's also a huge personal burden of carrying that non-dischargable debt. If residency doesn't work out for some reason, you're in a huge hole.

We know many physicians who say they wouldn't do it again if they had know how shitty the journey would be.

Why are you expecting the AMA to fix this? The primary bottleneck on producing more physicians today is lack of residency program slots. Every year some doctors graduate from medical school but are unable to practice medicine because they can't get matched to a residency program. The AMA has been lobbying Congress to increase Medicare funding for those programs.

https://savegme.org/

Why on earth would medicare have anything to do with residency spots to start with? Why wouldn't the hospitals use this as an apprenticeship program and pay the residents and charge appropriately for their services?

Because hospitals generally don't have the funding (in the case of rural or urban trauma barely balancing the books) or inclination (in the case if wealthy suburb, managed facilities trying to maximize profit by running minimal staff) to do this.

Ergo, like education in general, it's funded from the federal government.

If hospitals don't have the revenue, they should charge the cost of services to balance their books.

I think government involvement in the residency program is problematic distortion, causing hospitals to chase a scarce resource instead of working to expand the supply pipeline.

This is not a free market and you won't accomplish anything by telling hospitals what they "should" do. Prices are largely fixed by Medicare/Medicaid reimbursement rates. Whenever prices are fixed, shortages are pretty much inevitable.

Relying on Medicare to pay for residency programs isn't an ideal situation. But the reality is that there are no other major players in the system with both the money and incentive to cover those costs. That won't change without a complete restructuring of the entire system, and achieving the political consensus to do that will be extremely difficult.

If you have a few million dollars to spare then feel free to donate it to your local teaching hospital. They'll be happy to take your money to expand their residency program. There is an opportunity for philanthropists to do some real good in reducing the physician shortage.

I dont think I agree. Medicare/medicaid rates change constantly. The cost of retaining physicians is part of cost of providing healthcare, so there is no reason to carve it out. Hospitals have a natural incentive to have doctors on staff. The only reason they dont have incentive today is because there is someone else taking on the cost.

I would argue that it is easier and more realistic to simply include it in the price than expect congress accurately predict future demand, and continually pass legislation to that effect. We dont need a congressional act to subsidize hospital janitors- Somehow hospitals figure out how to include them in their operational expenses because they need them.

Furthermore, it wouldnt break the bank of most of these hospitals. Take one of the largest teaching hospitals in the world, Cleveland clinic, with 2000 residents. at typical resident grant of 100k, that is 200 million. The Cleavland clinic annual revenue is >13 Billion.

That is not a realistic or sensible proposal. Only a subset of hospitals do graduate medical education. If teaching hospitals raised their prices to cover the overhead of residency programs then that would put them at a competitive disadvantage relative to hospitals that don't train residents at all. In order to keep residency programs financially sustainable there has to be a separate revenue source.

Cleveland Clinic is a non-profit. Their total revenue is irrelevant. If you'd like them to spend an extra $200M on their residency program then they would have to spend less on other stuff. Take a look at their financial statements and then you can tell them exactly where they ought to cut back in order to fund your proposal. Please be specific.

https://my.clevelandclinic.org/about/overview/financial-info...

Of course their revenue is relevant? IF they can stack 2 billion per year onto their endowment every year, they could spend 200 million on residents.

That is my specific proposal. If they refuse to raise prices, then they should grow the endowment by 200 million less per year and provide the same services. It is bad enough that a non-profit charges 20% more than the cost of their services. They would be fine if they were only making 18% more than their costs.

It is basicity the same as if Harvard college claimed it cant afford to train teachers aids while charging students more than enough to cover expenses and sitting on a 50 billion endowment that grows ever larger each year.

> We dont need a congressional act to subsidize hospital janitors- Somehow hospitals figure out how to include them in their operational expenses because they need them.

Observation that the lead/training time for additional hospital janitors is a couple weeks.

An additional resident takes 4+4=8 years.

My point was with respect to billing, and the idea that hospitals couldn't use revenue to pay for residents and offset their cost. The idea that medicare costs are "fixed" and doesn't include residents is besides the point. Hence, medicare doesn't janitors, but hospitals figure out a way to pay them as an operational expense

They’ll take your money, and it will go straight to exec bonuses.

Among other laws, there's the EMTALA that prevents charging the cost of services.

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

You just need to look at an EoB statement to realize the sheer volume of revenues earned by Residents (thought not retained by residents). They are huge profit centers for the medical system with millions in earned revenue annually.

Medicare does not need to pay for residents, they are massively net positive revenue. The AMA boards create artificial scarcity and "medicare" is the boogeyman word.

But if those residents were paid by hospitals, they wouldn't be huge profit centers.

Or, to put it another way, if hospitals have difficulty balancing the books with free resident labor, adding additional paid residents wouldn't necessarily fix the financial problem in most hospitals.

>> But if those residents were paid by hospitals, they wouldn't be huge profit centers.

Paying residents is not the blocker here, Residents are already paid by hospitals. They are paid a fraction of revenues, which is normal for any profitable business.

https://www.ziprecruiter.com/Salaries/First-Year-Medical-Res...

Hospitals absolutely have the funding. Residents make a shit load of money for the hospitals they work for.

Some hospitals allow residents to moonlight (e.g. practice in off hours) and pay $300+/hour.

Residencies lose money, so they're reliant on federal subsidies.

> Residencies lose money,

Do they though? Or is that mostly creative accounting. I've heard claims in both directions but like anything in medical billing in the US, it's all pretty murky.

There are a lot of bizarre path dependence issues and misaligned financial incentives in the US healthcare system. Most teaching hospitals are non-profits, often run by university systems or governments. Those hospitals get much of their revenue from Medicare/Medicaid. Reimbursement rates are fixed and hospitals have no ability to raise prices to cover increased training expenses. So, the only solution has been to get separate GME funding from Medicare.

There are other GME funding sources such as private charitable foundations but still the majority of the money comes from Medicare.

Medicare pays for the residency spots.

https://www.cms.gov/medicare/payment/prospective-payment-sys...

https://crsreports.congress.gov/product/pdf/IF/IF10960

The general impression is that AMA is basically giving lip service to that goal. In public, that may be their goal. In private, it's certainly not happening.

Most states are begging for more qualified providers. Many are looking to mid-levels to fill the gaps. If the AMA were serious, they'd be working with all of these states to fill those gaps with physicians.

The primary bottleneck today is caused by lack of residency slots. The AMA isn't doing anything to prevent states from putting more money into residency programs. In fact they are actively encouraging it.

https://www.ama-assn.org/education/gme-funding

And if you think they're saying something else in private then let's see proof. This is not a place for baseless conspiracy theories.

> And if you think they're saying something else in private then let's see proof. This is not a place for baseless conspiracy theories.

With all due respect, not everything that lacks proof is a conspiracy theory. I've spent a bunch of time in discussions with physicians. There's a consensus that AMA is largely ineffective and it's implied that it's ineffectiveness is valuable for inflating physician salaries.

This is a great write up that highlight how the AMA created the situation to begin with: https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...

------

I did find a great example of AMA's double speak on this issue. A bunch of states have started looking for alternatives for providing care to their populations. Some states are now loosening regulation to allow mid-levels to practice. 6 states are now allowing physicians to practice (in certain fields) without completing residency.

That sounds great right? All of these groups have completed 3 to 4+ years of graduate medical education. They might not be as skilled as a physician, but they can certainly provide basic care. AMA doesn't think that's great.

> The AMA opposes enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state’s requirements for licensure to engage in the practice of medicine and surgery.

https://www.ama-assn.org/sites/ama-assn.org/files/corp/media...

The AMA doesn't actually want to engage in any of these solutions because it threatens their golden goose.

Not that long ago (through at least 1997), the AMA was doing the opposite. They were instrumental (but not alone) in creating the shortage.

Residency slots are the bottle neck because the AMA requires residency to be the bottleneck.

There is literally no path to becoming a physician other than the blessed med school + residency path. By contrast, you can become a lawyer simply by passing the bar exam.

Some states are starting to allow physicians to practice without residency and the AMA is vehemently against it.

America needs tuition-free state universities and trade schools. Full-stop. We're encountering endless problems, sending our entire economy (and living standards) out of whack, because we don't.

Who pays for tuition free universities and trade schools?

The same people that pay for tuition free primary education....

> The same people that pay for tuition free primary education....

Are you suggesting that people should be locked to the school in their district? Because that's the way primary education works.

They aren't locked in. That's the one provided for free. It doesn't seem to stop private schools and homeschooling at all.

Public universities are generally run by the state, not a local government so sure, free in state tuition sounds reasonable.

Public community colleges primarily attract and accept students from the local community and are usually supported by local tax revenue - from Wikipedia.

Local taxpayers/property owners?

That model doesn’t really work to fund higher education. The public won’t accept doubling or tripling their property tax.

> That model doesn’t really work to fund higher education. The public won’t accept doubling or tripling their property tax.

[citation needed]

And I can give you a citation against. In my local municipality the tax base is roughly $1.5 billion. The annual expenditures for the local vo-tech school for that municipality is $30 million. If all of the state and tuition funding for the vo-tech school suddenly vanished the property owners would see a rise of ... wait for it ... a grand total of 2%. Certainly a far cry from the doubling or tripling you suggested.

Amortizing the tuition across all public post-secondary institutions in the state via income and property tax bases of the entire state would likely be somewhere in the neighborhood of 1-2% total every year. Based on that analysis it seems monumentally stupid to NOT publicly fund post-secondary education.

Ditch the NCAA sports programs and it probably gets cheaper. The whole sales pitch for sports is that scholarships provide a pathway for some students to go to college that otherwise could not afford it. Get rid of tuition and suddenly that reason goes away, too.

Colleges/Universities absolutely do not need more money...they need more accountability.

I'm not arguing with your numbers, I guess my point is that I don't think taxpayers will accept a huge "freebie" for one group which results in their taxes going up. The optics are terrible.

In reality (and historically), it's the state taxes and not property taxes.

Still, if I had 2 kids, doubling my property tax would be cheaper for me than my paying for their tuition at current rates.

Who pays for them in Germany? In Germany, universities are free for everyone even foreigners.

Since GP says State Universities I would assume the State they were in would, through whatever tax policy they like.

In Germany, taxes are 39.5% of GDP. In the US, they are 26.6% of GDP. There’s no realistic proposal that has ever been advanced, not even from the Bernie/AOC/Warren types, on how to raise the extra $2.8 trillion annually that would be required. Elizabeth Warren’s proposed wealth tax wouldn’t even raise that much money over a decade, much less annually.

"extra $2.8 trillion" is incredibly dishonest. Nothing in any universal/single-payer healthcare proposal magically adds $2.8 trillion in actual medical expenses to the system. It's fundamentally an accounting change, akin to a married couple with a joint banking account deciding who'll pay the restaurant bill this time.

To be like Germany, you would have to take $2.8 trillion from the private sector and put it into the public sector by taxing and spending an extra $2.8 trillion. That’s not an accounting change—the government doesn’t have a joint bank account with the private sector.

> To be like Germany, you would have to take $2.8 trillion from the private sector and put it into the public sector by taxing and spending an extra $2.8 trillion.

And those taxes would replace the insurance premiums employers and individuals are currently paying out the ass for. It's a difference in who writes the checks, not how much actually goes out of individuals' pockets.

Claiming "$2.8B in new taxes" is like claiming "I Venmo you $5, you Venmo me $10" costs me five bucks.

> That’s not an accounting change—the government doesn’t have a joint bank account with the private sector.

That "joint account" is the GDP you're on about.

If they were free, more people would take advantage of them, potentially earning more, bumping them into higher tax brackets, where their taxes would be used to fund tuition free education, and the cycle would continue.

The money moves in a circle, thus creating the self-sustaining economy we’ve been looking for.

This question is important and needs to be asked because nobody's already solved this problem. We'd be moving into uncharted territory.

We literally had tuition free universities and trade schools for decades until desegregation. I'll let you figure out what happened after that.

This sounds like less accountability when fixing the problem requires more.

America needs to stop letting their University systems bloat everything unrelated to actual education and research.

Agreed. American universities need a two-pronged fix.

- Implement ACA-style budget efficiency minimums

This much of tuition must be spent on direct-teaching expenses. Only this much may be spent on everything else. Otherwise the university in ineligible for any federal educational assistance grant/loan.

- Increase funding via increased state contributions to public universities (returning to historical averages), to lower tuition costs

Full-stop? Hardly. Who would gatekeep so that universities and trade schools aren't just continuing the babysitting in high school?

Sounds like the system is basically set up to enrich loan companies, and to a lesser degree universities.

Who is lobbying for this system to be improved? Because almost certainly loan companies and universities are lobbying against that.

Medical schools absolutely want to expand, they make tons of money and have many applicants who are qualified and willing to pay. The problem is there aren't enough residency seats. If there were more med school grads without expanding residences many competent graduates would go unmatched.

In the us, there are almost 3 residency spots for every 2 us medical students.

Source?

https://www.nrmp.org/about/news/2023/05/nrmp-releases-the-20...

This is overall not per speciality and doesn’t include overall people who did not apply, the article even says itself it’s a all time match high.

Look no further: https://www.nrmp.org/wp-content/uploads/2023/03/Match-Rates-...

The person i was responding to said that residency spots are the bottle neck, and not medical school spots. While residency spots have not kept pace with population growth also, the medical student spots are a much worse bottle neck. Specialties have their own periodic undersupply and oversupply, but that was not the topic of discussion in the post i was responding to.

Now, I don't know how you would ever include people who don't apply. I mean there are 5 million americans of age every year, so i guess that's a denominator.

what's a all time match high ? The number of spots and students ? Yeah, so ? The concern was that the number isn't high enough, and where the bottleneck is.

The real answer to why doctors in america earn so much, is that everyone in america earns so much. If you compare doctor to median salaries in the us, vs. doctor to median salaries in europe, maybe its not so different ?

> the medical student spots are a much worse bottle neck.

No, they are absolutely not. About 5% of medical school graduates do not placed into a residency program. There's a slew of Caribean medical schools that take only US based students. They have about a 20% non-placement rate.

Med schools have a lot more flexibility in slots. Once established, it's far easier to increase class size by 10% than it to get 10% more residency slots.

Right, but then half of all med students apply only to derm residency or other lucrative and competitive field with nice hours, leaving us in the situation we are in now where 18% of all emergency med department residencies went unmatched: https://www.aliem.com/mismatch-unfilled-emergency-medicine-r...

Emergency med has decent flexibility in terms of hours. The problem was Covid and remote work reduced infections and accidents and heart attacks, and they lost turf to physician assistants manning urgent care centers.

Not during residency, and I have not idea what the second part has to do with the match going underfilled. Are you saying med students saw this phenomena and decided emergency med was best left to PAs, and did not apply to match?

What I heard was emergency departments suffered brutally during covid, and that has had a chilling effect on anyone wanting to go into it. The med students matching now were all rotating through departments during covid.

yes, there are periodic oversupply and undersupply of various medical specialties (just like oil, labor, money, real estate agents), and medical students do react and choose accordingly. ER was hot for a while, and radiology was not so hot for a few years after 2008. Now surprisingly radiology has held up despite AI fears, because of baby boomers starting to get cancer, and ER is down, because private equity went nuts investing in urgent care centers before covid.

There was rampant expansion of emergency medicine residency spots in the prior years without an associated increase in demand for new EM docs. People noticed the market there and chose to go elsewhere. Also, the unfilled positions are also the low quality ones where your education would be questionable (linked article mentions corporate owned which imo is a red flag).

What “loan companies?” For more than a decade, medical school loans have been provided directly by the federal government.

> Sounds like the system is basically set up to enrich loan companies, and to a lesser degree universities.

It's pretty foolish to take out private loans for medical school. Most people avoid it unless they need to cover living costs.

Federal loans have the chance of being forgiven with PSLF.

Who knows if software engineers will be paid the same in the future but doctors will most likely have a strong "moat" till the day they die. Software engineers lucked out in this era not because they are smarter / harder working than people like mechanical engineers but they just chose a profession that naturally scales, and scaling is really how you can make a lot money.

eventually, the cost of a team of software engineers will be the monthly fee to chatGPT

Maybe, but how longs is eventually? I love GPT, use it every day but it is pretty flawed. 10 years?

who knew what chatGPT was 2 years ago? things are moving fast, and gaining speed. will they plateau before getting to being ubiquitously useful?

LLMs have been around since the 50s. Chomsky has plenty to say on them [1]. It's not half as rosy as the current hype cycle.

1. https://www.nytimes.com/2023/03/08/opinion/noam-chomsky-chat...

The machine building itself is end game. At that point you're suggesting singularity. I don't see how any profession survives that.

There's so much hype around AI right now, it's absolutely unhinged. Yes, we have semi-conversational AI. Yes, image detection is pretty good. It's all supervised.

Can we please touch grass?

At that point, the same will likely be true of most doctors, with DoctorGPTs making most of the cognitive decisions and a team of lower knowledge technicians and nurses doing most of the hands on work.

Other than surgeons, a ton of what we would traditionally think of as doctoring has already been abstracted away and work specialized and divvied up to technicians, with MDs pulling strings in the background.

I'm actually expecting doctor's moat to break in our life time. We're already seeing the beginnings of it.

Essentially, physicians have been so bottlenecked for so long that a bunch of states has simply said "screw it" and started paving the way for mid-levels (NPs and PAs) to operate in certain roles physicians have previously covered. The physician lobbies seem unwilling to address this, so I expect that mid-levels will continue to move up the chain. They know the market is desperate for a solution and physician interest groups are completely unwilling to provide that.

Midlevels don’t necessarily hurt doctor compensation, because they are supervised by the doctor, who gets a cut for managing them in private practice. In hospitals it frees up doctor to do more high value procedures instead of lower value follow up visits in clinic.

> they are supervised by the doctor

I think this is the part that's going to break.

IMO, a model where a doctor leads a group of mid-levels seems pretty much ideal. It's like the senior dev leading junior engineers.

Unfortunately, it seems AMA has been so resistant to any change that enough places are simply saying screw it to oversight and allowing mid-levels to practice independently (with limited scope). i

Midlevels are partly making up for the doctors who go part time / retire soon after finishing their training.

Yeah, rural areas that can’t support a full time doctor have no choice but to let midlevels practice medicine if they can even get a midlevel.

> [...] harder working than people like mechanical engineers but they just chose a profession that naturally scales

The product of mechanical engineering also naturally scales. Once you design a machine, you can build it an infinite number of times. However, in neither case does the labour scale. One engineer, whether their focus be on software or mechanical, can only do so much in a day.

Software engineers lucked out in this era because it is a new, relative to other industries, field that saw a rapid rise in demand for labour, with comparatively few people able to fulfill the need for that labour. By virtue of supply and demand, incomes had to run high to attract workers.

> and scaling is really how you can make a lot money.

That is true, but engineering doesn't scale. It is highly doubtful that engineers will continue to benefit into the long future. The owners of the software built by engineers will be able to continue to reap the benefits of scalability, but the labourer – who does not scale – will undoubtedly start to get squeezed as the industry matures and demand is no longer growing exponentially.

>e. Software engineers lucked out in this era not because they are smarter / harder working than people like mechanical engineers

do you believe this is the case now?

> they just chose a profession that naturally scales, and scaling is really how you can make a lot money.

They chose a profession that appears to scale to investors. When software _actually_ scales rather than being a subpar substitute for an existing mechanism is when the people involved were indeed smarter and worked much harder (typically).

There is a reason why most med schools have like a 5% acceptance rate. They have a much bigger moat than most software engineers. They are guaranteed a lot of money even if they aren't that good. They don't have to worry about leet code grinding and learning the newest random framework either.

Leet code grinding is maybe like USMLE and board grinding?

Life will always get you. There’s no way around work if you are a well paid professional. Maybe nepotism or fraud can get you there.

I’m not sure what leet code entails but these tests required a lot of preparation:

MCAT (hundreds of hours, thousands of questions, 10 practice exams)

USMLE Step 1 (hundreds of hours, 5,000 questions, 1 practice test)

USMLE Step 2 (maybe 40-60 hours, probably less than 2,000 questions)

USMLE Step 2 CS (4 hours a few dozen practice clinical scenarios. this thing doesn’t exist anymore)

USMLE Step 3 (30 hours, less than a 1,000 questions

Radiology CORE 1st board licensing exam (hundreds of hours, 5,000+questions)

Radiology Certifying 2nd board licensing exam (8 hours, 2,500 questions)

My next one is the CAQ and I haven’t started grinding for that yet. I do wake up every morning and do practice q’s though.

I still have a deeply negative networth and hate my job. Maybe others don’t, good for them.

The amount of studying described here may be what you did but is not a minimum requirement by any means.

I'm not even sure where you're getting 5000+ questions for the ABR Core.

-Another radiologist.

I actually did 3 months for Core, i think that’s pretty average.

Kevlar Radprimer Board vitals

Radprimer has probably more than 5,000 basic and intermediate questions by itself. Are you saying I lowballed it? I was pulling numbers out of my ass

RADPrimer isn't board prep and the question have little to no relevance for the ABR Core. Basic is designed to be completed in R1 and intermediate during R2-3.

The 5000 questions are how you're supposed to learn radiology, as an alternative to reading a textbook.

You trying to be abrasive or no? It seems like yes but I’ll respond.

Everyone I know from multiple residencies and in fellowship all reset radprimer and redid the questions for core. It’s not like people save it, they do it twice. Anyways, like I said, I was pretty average for prep. Also I forgot to add - everyone I know also used the Radiology Core Physics app, that’s like an additional 300 or 500 questions.

Ben White is pretty well known, he pretty much gives a road map that includes rad primer

https://www.benwhite.com/radiology/approaching-the-abr-core-...

“Looking back, in an ideal world: I would have read Core Radiology and started RadPrimer in the fall. Done CTC and physics Feb/March and then filled in the rest of the time with questions, probably primarily via the A Core Review Series. Qevlar is nice for the phone app with offline capabilities and probably would’ve made it in too. Most of the latter would have been important mostly for anxiolysis or possibly long-term retention, as passage wasn’t an issue.”

I felt like Radprimer and the physics app were the highest yield Then board vitals Last Kevlar

Highest yield book was War machine. Crack did OK. Essentials books were solid, especially nucs.

Later gator

Not being abrasive, I have written questions for RADPrimer. We’re not instructed to write board style questions and that roadmap is the officially stated guidance.

When I was in residency most of us just did BoardVitals, Crack the Core and War Machine or the physics app you mentioned. That’s sufficient to pass the exam hence why I said this may be what you did but not the minimum necessary.

Resetting RADPrimer is a good way to review all of radiology but as you may remember the intermediate questions are much harder than the exams, almost all image based, and generally have many image sets and long stems.

It’s a completely different style and aim than BV, ACR DXIT or ABR Core which are generally either quick hitters or don’t have images.

Most people don’t study for the cert exam which is considerably easier. ABR doesn’t give statistics but I’ve never heard of someone failing it.

Basic and intermediate RP “what is the diagnosis” with just images and no history are very similar to what’s on core - with basic being higher yield.

Crack the Core is now lower yield but War Machine is still go to for physics. Things could change in the future though. Board vitals gives way too much history and text without enough just image based questions, so it’s lower yield but still worth it I think. Maybe they changed qbank up since I used it. Qevlar was a waste - could be different now.

The certifying is easy diagnostically but the nucs/RISE/NIS documents need a read. Those don’t take a huge amount of time but they’re not 0 hours. If someone is confident in their ability to be passed by ABR then not looking at anything is a strategy I suppose.

Anyways, fun time over

> Basic and intermediate RP “what is the diagnosis” with just images and no history are very similar to what’s on core - with basic being higher yield.

Again, basic is intended for first year radiology residents not as board prep. You may have used it for this purpose, but it is neither a prerequisite to pass the ABR Core nor is it the most efficient way to prepare.

You can make the statement that a lot of work goes into becoming a radiologist without the inaccurate claim that the one exam requires 5000+ practice questions.

The official description:

"RADPrimer helps radiologists fine tune their diagnostic skills and enhance their knowledge:

Comprehensive radiology training for all levels

RADPrimer allow physicians to customize their educational path, focusing on the topics that matter most. RADPrimer allows radiologists to use their time efficiently as they work toward professional advancement. Topic-focused lessons present specific diagnoses, anatomy, differential diagnoses, and assessment questions related to the topic. RADPrimer provides over 5,300 case-based learning and traditional questions."

Here’s a secret: if you’re a good software engineer, you don’t have to worry about those things either.

> salaries need to offset the insane burden of training

A cycle here is that student loans rise with expected earnings and banks are fairly open ended about it, institutions happy to justify the use of the cash.

Salaries wouldn't need to be nearly as high if you didn't walk out of residency with 200k+ [medical school ] debt at a point that is effectively mid-career. As a society we'd probably be better off if the both the median salary and median debt was much lower. I've also seen the "guarantee" of a high salary later lead many young doctors and med students to be foolish with money, as "eh, what's a little more debt" is easy to fall into.

It's also part of the driver to overspecialization, more available GP's and fewer people reliant on emergency visits would obviously improve the system, but the economics and QOL for a general practice keep getting harder.

Residency bottleneck and the high barrier for foreign trained mid-career people are the two other areas for potentially major impact.

The question is, does it really cost 200k to train each doctor? Surely the main input is the student's own time and effort, which isn't even included.

It probably costs more than that.

As a baseline, university education in Finland costs about €10k/year on the average. Medical education is more expensive than the average, probably between €15k and €20k a year. Universities in the US are generally better funded than those in Finland, which allows them to provide more personal attention to the students. And university salaries are higher in the US than in Finland.

Overall, I would estimate something like $20k/year for the undergraduate degree and $30k to $40k/year for the medical school, for a total of $200k to $240k. And that's just for the education, not including costs of living as a student.

Sounds great, but my wife’s state-funded public medical school cost $85k/yr usd before cost of living.

There are a handful of state medical schools near the $40k/r, but they are on the much cheaper end

I was estimating the costs of providing the education, not the prices of getting it. (The latter would be €0/year in Finland.) If a university can charge more, it can usually find a way to spend the extra money.

I wasn't wording things clearly. The 200k is just the median residual debt from medical school alone. People don't tend to pay it off much during residency years though, since residency pay is relatively low (50-70k). Lots of them acquire extra personal debt during residency. Doctors aren't typically considered "trained" until after residency.

My wife had $210k in debt from medical school. It's basically impossible to pay it off durning residency, so it just balloons.

All in, at the end of my wife's training, we would have been $1M ahead if she had simply worked a normal career. That's huge in your 20's and 30's when your trying to establish a house/family/etc.

I know a guy who accrued $400k+ of med school debt and dropped out last quarter. Insane system. I didn't even consider medicine, despite being a top science student, because of the stress.

And god forbid you think you can handle it at 18 years old and then being stuck on the medical track for... decades.

Why did he decide to do so, if I may ask?

I didn't know him well enough to ask

That’s a year of their salary. The salary/debt ratio in engineering is lower.

But it's not a year of salary for a med school dropout.

i dont get ageism in tech at all if anything i would hire the most experienced programmers tf would i hire a less experienced person.

Ageism in tech is based on the premise if you aren’t already a multimillionaire dabbling in angel investing by 30, you don’t have the “it” (ambition, skill, etc) to really contribute at a high level, and a young programmer can do similar work but be more familiar with latest tools and langs

While true, in my experience, many much more experienced developers can do a lot of things the less experienced ones think they can.

What about the people who did make a lot of money but like to work and create things?

The assumption would be if you are someone who likes to work and create you will be a founder or maybe work on some mission specific passion career.

People worry a lot about ageism here. I'm not seeing it be a problem in the real world.

At every company I've been at, the most senior people are the ones with the most pull, with the strongest direction and advice.

I've worked with a few people 60+ who suck. I bet they sucked at age 30, though.

Based on the workload of medical students and residents, I do not believe that even if the AMA relaxed the standards for entry that unless they relaxed the standards for exit we would have more doctors.

And by workload, I don't mean just hours on the job, I mean amount of material to learn. It is overwhelming to most

Is it all really necessary? As an outsider it looks like letting the perfect be the enemy of the good. That, or it's just tradition / an elaborate hazing ritual.

I don't see how the ability to work long hours is necessary to heal the sick. They don't train airline pilots like this, or nuclear plant operators. What's so special about doctors?

Residency certainly seems like an elaborate hazing ritual. I believe there is something to be said for errors made when handing off patients between doctors at the end of a shift, which is why you would want to train physicians to maintain good performance even over long shifts. But in general, modern residency was invented by a morphine- and cocaine-addicted surgeon who decided, hey, I want you to undergo a grueling residency for an arbitrary number of years and you'll be a doctor when I say you are: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/

Sleep deprivation in the service of error prevention always seemed a bit illogical. Other professions have shift handovers

Just want to expand on that "tuition/debt/time" bit.

TL;DR: Becoming a physician requires sacrificing an additional 6-10 years of your life to education and training beyond what you'd expect for most careers, and assuming something like $250K in additional debt. It'll take the average physician about 16-years out of college before they start to out-earn the average engineer.

Details:

Let's imagine that two smart people start college in the United States. One goes into engineering, the other into med school.

The day they graduate, on average the engineer will get job that pays them $74k their first year.

Year 4, the engineer is likely making $84k/yr, and they have earned a total of about $315k in their career.

Meanwhile, our doctor friend has so far accrued about $250k in debt. A delta of about $560k in just 4 years, but it's gonna' get worse before it gets better.

For the next ~3-5-years (for most specialties, there are outliers), our doctor friend is gonna make about $50k/yr . (Yay, positive cashflow!) We'll generously assume their debt doesn't accrue interest in this period.

Assuming our engineer friend assumes an average career path, he's gonna be up to $92k/yr at the end of this period, with a lifetime total earnings of $669k, while our doctor friend has clawed their lifetime earnings all the way back up to -$52k.

This is also the biggest delta between the two careers. At year 8, our engineer friend has out-earned our doctor friend by a delta of $720k.

Now, on average, our doctor friend starts making $202k/yr. Good money, right!

To make the math easy, we'll assume that their debt still doesn't accrue interest.

With all that, it's not until 16-years out of college that the average American physician will start to out-earn the average American engineer.

So if they both graduated at 23, our Engineer friend is gonna out-earn our doctor friend until they both hit just about 40.

Of course, if our doctor friend has to pay some interest on their med school debt, and our engineer friend is able to invest a chunk of their salary in those early years, the magic of compound interest will be on their side as well.

And that says nothing of the fact that our doctor friend probably had to sacrifice about 4-years of mandatory 80+ hour work weeks. It also assumes that our doctor friend doesn't drop out/fail out of med school and manages to match to and complete a residency. None of which are givens.

Which is a very long way of saying: physician compensation is wonky because it's a career where you sacrifice a ton and take a ton of career risk very early on, for the promise of higher compensation and quite high job security later on in your career.

Maybe I'm missing something but why does the engineer not have any educational debt and why does the doc in your example have no income?

Looks like he's starting a the end of a bachelor's degree. It's a sane simplification since it should be the same for both fields.

For medicine, undergrad debt is pretty tough since you really have no way to pay it off. It just accrues.

Yeah, exactly right. Whether you do pre-med or an engineering undergrad, you should have the same amount of debt/time. Though of course I simplified everything to not really account for interest.

Assumedly, an engineer would be able to pay off their undergrad debt much quicker than an MD.

Will you mind breaking out the typical educational costs and earnings potential.

I have a child I’m encouraging to become a doctor, and it’d be great to know some actual economics before I push too hard this profession.

It varies wildly depending on the medical school (state school in Texas is affordable for example), scholarships, program (MD/PhD programs, MD only, MD/JD programs), and terminal specialization.

On some quick googling the mean debt at graduation from medical school is about 250,000 (this includes undergrad). This number is trending upward. There is also the opportunity cost of 4 years additional school and 3-7 years of getting paid 60-70k.

Most doctors end up making between 265k and 382k per year, this varies wildly (from pediatrician on the low end to brain surgeon on the high end).

Here is a good article: https://www.whitecoatinvestor.com/how-much-do-doctors-make/

That would be helpful to me as well

My teenager wants to be a radiologist but I have no idea if it’s even possible to do that in a way that isn’t a path to depression and burnout

She has better job security than you, however.

And career longevity. A 40 year old developer is "old". At 50 you're ancient.

A 40 year old doctor is insanely young. A doctor in his late 60s can easily be in their prime, especially in some practice areas or research. Provided they are okay health-wise, even an 80 year old doctor can still be working, especially if they have a strong team. They'll probably be in a mentorship role or a more laid-back practice, but they'll still be earning a meaningful income and having a very real impact on their patients.

And generally speaking, doctors in the West live longer than the general population, so that longevity is better as well.

You are absolutely correct.

So far, that really hasn't been a factor for us. It is worth noting that job security becomes much less important as you build wealth. It's a lot easier to build wealth when you're not racking up debt and being underpaid in your 20's.

On the other hand, you want doctors to be well rewarded because it's a high stress, high work hours, high responsibility, high liability, high effort and high opportunity cost profession. If it doesn't pay well, very few people are going to bust ass in medical school and residency for 10 years to do it.

In my country the government flooded the market with doctors and the results weren't pretty to say the least.

I would prefer to see a reasonable paid, not stressed and not overbooked and not over worked doctor.

Most doctors I know would rather be overworked than underpaid.

I'd say that the law of one price applies here. Doctors need to be making this much to compensate for living in debt their whole youth and early adulthood. Also having money is probably more enjoyable when you're younger.

Not necessarily. The demand for doctors is generally greater than the supply. Because the profession gatekeeps.

The law of one price requires free market competition.

Hmm, are you turning both your wages into hourly rates and then comparing? My wife is a physician (me a SWE) and at face value she makes more but after considering hours worked it’s not even close.

She is regularly pulling 65-90 hrs/wk with little flexibility in her schedule.

Is your spouse still in residency?

I ask because I didn’t know 65-90 hrs/week (13 hr days / 7 days per week) was typical for non-residents.

I have no source for it, but I read once that (GP) doctors make less than software devs on average, simply because devs get that decade head-start with much less debt. It makes sense.

This is such a hard problem to fix. I doubt anyone is interested in hearing any solutions that involve worse-trained doctors, or longer training schedules, or massive pay increases for what are viewed as some of the highest-paid people in the nation. There is a lot of talk about opening up medical care for more people - which, naturally, means there will be a surge in demand. I can only imagine this would exacerbate the problem. It feels like we're running out of time to fix this.

GP is a pretty shit field right now. Pay is stagnating and mid-levels are starting to take over an increasing number of general practice roles.

Same here. I am a programmer with a wife who is a doctor. It took her about 12 years after she started her practice before her total earnings surpassed mine.

One thing that rarely discussed in this kind of conversation is taxes. A doctor spends 12 years earning next to nothing and going into debt for training costs. Then the second they start making a real doctor salary, the IRS thinks they are 'rich'. They are taxed at the highest tax bracket even though it might take them another 10 years to surpass someone who was earning barely a six-figure salary the whole time.

If you spend 9 years earning nothing and then make $1M in your tenth year, you will pay much more taxes than someone earning $100K for 10 years (even though both earned a total of $1M over those 10 years).

Not to mention that most retirement accounts have yearly maximums, if you where making 401k for 10 years at 100k you will have significantly lower effective taxes than a person who made nothing and then sees high earnings trying to put into retirement.

We don't have a shortage. We have too much regulation by AMA limiting number of doctors.

Just because the shortage is intentionally engineered doesn't make it not a shortage.

Yeah, for real, the whole residency/shifts they are submitted into are borderline abusive, and I don't think any other profession accepts their professionals going though this

It's basically a firm of hazing

Programmers face much more ageism than doctors. Actually they face the reverse ageism (against younger ones).

Yeah but doctors also get social cachet, and get to feel like they’re doing something positive.

> Residency was demanding and severely underpaid.

Wait, you're getting paid?

chad?

> Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.

This has quite frankly zero relevance to anything. The analysis depends on what you her husband does (I mean seriously how does that prove a point at all) and your choice and abilities (totally arbitrary based on a host of factors especially given the tech scene over the last decade.

I mean ROI? So someone makes a career decision by comparing to what their partner makes or what ROI is?

> AMA is unwilling to fix this

This has to do with residency slots and residency slots are determined by how many hospitals can accept residents. Now you can say AMA is a roadblock to that but there are a slew of other roadblocks in addition (if true not sure it is) to having more residency slots.

You can think idealistically that you can re-imagine the whole system but massive change in something entrenched like that (where lives matter) most likely is not practical.

Really helps to come from money so that you don't have that huge college debt to crawl out from under.

>Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.

Depending on if you're married or brought a home, her education and status already paid off with special rates for doctors/lawyers/high earners/professional mortgages:

https://www.studentloanplanner.com/professional-mortgage-loa...

socialism needs to offset the cost.

it's that simple.

And not to mention that doctors usually have no work life balance. I have many doctors in my family/friends here in the US and most of them have no time for anything including weeknights and weekends. It is crazy.

You’re making the comparison with software engineering in the US which is one of the biggest outliers in terms of income.

Most of my friends who became doctors have rich parents. The ones without rich parents funnily enough dated software engineers who were the main breadwinners during their med school/residency.

The difference being a doctor is a lifestyle business requiring performance of service while a software developer can potentially make passive income. There is, however, a lack of essentialism to being a software developer that AI can replace, whereas caregivers will be the last to be automated away. It is likely software development incomes have peaked and will decline long term.