What would a better doctor education system look like?

A reader of “Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school,” asks, though not quite in this way, what a better doctor education system would look like. It’s surprising that it’s taken so long and so many readers for someone to ask, but before I answer, let me say that, while the question is important, I don’t expect to see improvement. That’s because current, credentialed doctors are highly invested in the system and want to keep barriers to entry high—which in turn helps keep salaries up. In addition, there are still many people trying to enter med school, so the supply of prospective applicants props the system up. Meanwhile, people who notice high wages in medicine but who also notice how crazy the med school system is can turn to PA or NP school as reasonable alternatives. With so little pressure on the system and so many stakeholders invested, why change?

That being said, the question is intellectually interesting if useless in practice, so let’s list some possibilities:

1. Roll med school into undergrad. Do two years of gen eds, then start med school. Even assuming med school needs to be four years (it probably doesn’t), that would slice two years of high-cost education off the total bill.

2. Allow med students, or for that matter anyone, to “challenge the test.” If you learn anatomy on your own and with Youtube, take the test and then you don’t have take three to six (expensive) weeks of mind-numbing lecture courses. Telling students, “You can spent $4,000 on courses or learn it yourself and then take a $150 test” will likely have… unusual outcomes, compared to what professors claim students need.

3. Align curriculums with what doctors actually do. Biochem is a great subject that few specialties actually use. Require those specialties to know biochem. Don’t mandate biochem for family docs, ER, etc.

4. Allow competition among residencies—that is, allow residents to switch on, say, a month-by-month basis, like a real job market.

There are probably others, but these are some of the lowest-hanging fruit. We’re also not likely to see many of these changes for the reason mentioned above—lots of people have a financial stake in the status quo—but also because so much of school is about signaling, not learning. The system works sub-optimally, but it also works “well enough.” Since the present system is good enough and the current medical cartel likes things as they are, it’s up to uncredentialed outsiders like me to observe possible changes that’ll never be implemented by insiders.

I wrote “Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school” five years ago and in that time we’ve seen zero changes at the macro level. Some individuals have likely not screwed up their lives via med school, and some of them have left comments or sent me emails saying as much, and that’s great. But it’s not been sufficient to generate systems change.

Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school

Many if not most people who go to medical school are making a huge mistake—one they won’t realize they’ve made until it’s too late to undo.

So many medical students, residents, and doctors say they wish they could go back in time and tell themselves to do something—anything—else. Their stories are so similar that they’ve inspired me to explain, in detail, the underappreciated yet essential problems with medical school and residency. Potential doctors also don’t realize becoming a nurse or physicians assistant (PA) provides many of the job security advantages of medical school without binding those who start to at least a decade, and probably a lifetime, of finance-induced servitude.

The big reasons to be a doctor are a) lifetime earning potential, b) the limited number of doctors who are credentialed annually, which implies that doctors can restrict supply and thus will always have jobs available, c) higher perceived social status, and d) a desire to “help people” (there will be much more on the dubious value of that last one below).

These reasons come with numerous problems: a) it takes a long time for doctors to make that money, b) it’s almost impossible to gauge whether you’ll actually like a profession or the process of joining that profession until you’re already done, c) most people underestimate opportunity costs, and d) you have to be able to help yourself before you can help other people (and the culture of medicine and medical education is toxic).

Straight talk about doctors and money.

You’re reading this because you tell your friends and maybe yourself that you “want to help people,” but let’s start with the cash. Although many doctors will eventually make a lot of money, they take a long time to get there. Nurses can start making real salaries of around $50,000 when they’re 22. Doctors can’t start making real money until they’re at least 29, and often not until they’re much older.

Keep that in mind when you read the following numbers.

Student Doctor reports that family docs make about $130 – $200K on average, which sounds high compared to what I’ve heard on the street (Student Doctor’s numbers also don’t discuss hours worked). The Bureau of Labor Statistics—a more reliable source—reports that primary care physicians make an average of $186,044 per year. Notice, however, that’s an average, and it also doesn’t take into account overhead. Notice too that the table showing that BLS data indicates more than 40% of doctors are in primary care specialties. Family and general practice doctors make a career median annual wage of $163,510.

Nurses, by contrast, make about $70K a year. They also have a lot of market power—especially skilled nurses who might otherwise be doctors. Christine Mackey-Ross describes these economic dynamics in “The New Face of Health Care: Why Nurses Are in Such High Demand.” Nurses are gaining market power because medical costs are rising and residency programs have a stranglehold on the doctor supply. More providers must come from somewhere. As we know from econ 101, when you limit supply in the face of rising demand, prices rise.

The limit on the number of doctors is pretty sweet if you’re already a doctor, because it means you have very little competition and, if you choose a sufficiently demanding specialty, you can make a lot of money. But it’s bad for the healthcare system as a whole because too many patients chase too few doctors. Consequently, the system is lurching in the direction of finding ways to provide healthcare at lower costs. Like, say, through nurses and PAs.

Those nurses and PAs are going to end up competing with primary care docs. Look at one example, from the New York Times’s U.S. Moves to Cut Back Regulations on Hospitals:”

Under the proposals, issued with a view to “impending physician shortages,” it would be easier for hospitals to use “advanced practice nurse practitioners and physician assistants in lieu of higher-paid physicians.” This change alone “could provide immediate savings to hospitals,” the administration said.

Primary care docs are increasingly going to see pressure on their wages from nurse practitioners for as long as health care costs outstrip inflation. Consider “Yes, the P.A. Will See You Now:”

Ever since he was a hospital volunteer in high school, Adam Kelly was interested in a medical career. What he wasn’t interested in was the lifestyle attached to the M.D. degree. “I wanted to treat patients, but I wanted free time for myself, too,” he said. “I didn’t want to be 30 or 35 before I got on my feet — and then still have a lot of loans to pay back.”

To recap: nurses start making money when they’re 22, not 29, and they are eating into the market for primary care docs. Quality of care is a concern, but the evidence thus far shows no difference between nurse practitioners who act as primary-care providers and MDs who do.

Calls to lower doctor pay, like the one found in Matt Ygleasias’s “We pay our doctors way too much,” are likely to grow louder. Note that I’m not taking a moral or economic stance on whether physician pay should be higher or lower: I’m arguing that the pressure on doctors’ pay is likely to increase because of fundamental forces on healthcare.

To belabor the point about money, The Atlantic recently published “The average female primary-care physician would have been financially better off becoming a physician assistant.” Notice: “Interestingly, while the PA field started out all male, the majority of graduates today are female. The PA training program is generally 2 years, shorter than that for doctors. Unsurprisingly, subsequent hourly earnings of PAs are lower than subsequent hourly earnings of doctors.”

Although the following sentence doesn’t use the word “opportunity costs,” it should: “Even though both male and female doctors both earn higher wages than their PA counterparts, most female doctors don’t work enough hours at those wages to financially justify the costs of becoming a doctor.” I’m not arguing that women shouldn’t become doctors. But I am arguing that women and men both underestimate the opportunity costs of med school. If they understood those costs, fewer would go.

Plus, if you get a nursing degree, you can still go to medical school (as long as you have the pre-requisite courses; hell, you can major in English and go to med school as long as you take the biology, math, physics, and chemistry courses that med schools require). Apparently some medical schools will sniff at nurses who want to become doctors because of the nursing shortage and, I suspect, because med schools want to maintain a clear class / status hierarchy with doctors at top. Med schools are run by doctors invested in the dotor mystique. But the reality is simpler: medical schools want people with good MCAT scores and GPAs. Got a 4.0 and whatever a high MCAT score is? A med school will defect and take you.

One medical resident friend read a draft of this essay and simply said that she “didn’t realize that I was looking for nursing.” Or being a PA. She hated her third year of medical school, as most med students do, and got shafted in her residency—which she effectively can’t leave. Adam Kelly is right: more people should realize what “the lifestyle attached to an M.D. degree” means.

They should also understand “The Bullying Culture of Medical School” and residency, which is pervasive and pernicious—and it contributes to the relationship failures that notoriously plague the medical world. Yet med schools and residencies can get away with this because they have students and residents by the loans.

Why would my friend have realized that she wanted to be a nurse? Our culture doesn’t glorify nursing the way it does doctoring (except, maybe, on Halloween and in adult cinema). High academic achievers think being a doctor is the optimal road to success in the medical world. They see eye-popping surgeon salary numbers and rhetoric about helping people without realizing that nurses help people too, or that their desire to help people is likely to be pounded out of them by a cold, uncaring system that uses the rhetoric of helping to sucker undergrads into mortgaging their souls to student loans. Through the magic of student loans, schools are steadily siphoning off more of doctors’ lifetime earnings. Given constraints and barriers to entry into medicine, I suspect med schools and residencies will be able to continue doing so for the foreseeable future. The logical response for individuals is exit the market because they have so little control over it.

Sure, $160K/year probably sounds like a lot to a random 21-year-old college student, because it is, but after taking into account the investment value of money, student loans for undergrad, student loans for med school, how much nurses make, and residents’ salaries, most doctors’ earnings probably fail to outstrip nurses’ earnings until well after the age of 40. Dollars per hour worked probably don’t outstrip nurses’ earnings until even later.

To some extent, you’re trading happiness, security, dignity, and your sex life in your 20s, and possibly early 30s, for a financial opportunity that might not pay off until your 50s.

Social status is nice, but not nearly as nice when you’re exhausted at 3 a.m. as a third-year, or exhausted at 3 a.m. as a first-year resident, or exhausted at 3 a.m. as a third-year resident and you’re 30 and you just want a quasi-normal life, damnit, and maybe some time to be an artist. Or when you’re exhausted at 3 a.m. as an attending on-call physician because the senior doctors at the HMO know how to stiff the newbies by forcing them to “pay their dues.”

This is where prospective medical students protest, “I’m not going to be a family medicine doc.” Which is okay: maybe you won’t be. Have fun in five or seven years of residency instead of three. But don’t confuse the salaries of superstar specialties like neurosurgery and cardiology with the average experience; more likely than not you’re average. There’s this social ideal of doctors being rich. Not all are, even with barriers to entry in place.

The underrated miseries of residency

As one resident friend said, “You can see why doctors turn into the kind of people they do.” He meant that the system itself lets patients abuse doctors, doctors abuse residents, and for people to generally treat each other not like people, but like cogs. At least nurses who discover they hate nursing can quit, since they will have a portable undergrad degree and won’t have obscene graduate school student loans. They can probably go back to school and get a second degree in twelve to twenty-four months. (Someone with a standard bachelor’s degree can probably enter nursing in the same time period.)

In normal jobs, a worker who learns about a better opportunity in another company or industry can pursue it. Students sufficiently dissatisfied with their university can transfer.[1] Many academic grad schools make quitting easy. Residencies don’t. The residency market is tightly controlled by residency programs that want to restrict residents’ autonomy—and thus their wages and bargaining power. Once you’re in a residency, it’s very hard to leave, and you can only do so at particular in the gap between each residency year.

This is a recipe for exploitation; many of the labor battles during the first half of the twentieth century were fought to prevent employers from wielding this kind of power. For medical residents, however, employers have absolute power enshrined in law—though employers cloak their power in the specious word “education.”

Once a residency program has you, they can do almost anything they want to you, and you have little leverage. You don’t want to be in situations where you have no leverage, yet that’s precisely what happens the moment you enter the “match.”

Let’s explain the match, since almost no potential med students understand it. The match occurs in the second half of the fourth year of medical school. Students apply to residencies in the first half of their fourth year, interview at potential hospitals, and then list the residencies they’re interested in. Residency program directors then rank the students, and the National Residency Match Program “matches” students to programs using a hazily described algorithm.

Students are then obligated to attend that residency program. They can’t privately negotiate with other programs, as students can for, say, undergrad admissions, or med school admissions—or almost any other normal employment situation. Let me repeat and bold: Residents can’t negotiate. They can’t say, “How about another five grand?” or “Can I modify my contract to give me fewer days?” If a resident refuses to accept her “match,” then she’s blackballed from re-entering for the next three years.

Residency programs have formed a cartel designed to control cost and reduce employee autonomy, and hence salaries. I only went to law school for a year, by accident, but even I know enough law and history to recognize a very clear situation of the sort that anti-trust laws are supposed to address in order to protect workers. When my friend entered the match process like a mouse into a snake’s mouth, I became curious, because the system’s cruelty, exploitation, and unfairness to residents is an obvious example of employers banding together to harm employees. Lawyers often get a bad rap—sometimes for good reasons—but the match looked ripe for lawyers to me.

It turns out that I’m not a legal genius and that real lawyers have noticed this obvious anti-trust violation; an anti-trust lawsuit was filed in the early 2000s. Read about it in the NYTimes, including a grimly hilarious line about how “The defendants say the Match is intended to help students and performs a valuable service.” Ha! A valuable service to employers, since employees effectively can’t quit or negotiate with individual employers. Curtailing employee power by distorting markets is a valuable service. The article also notes regulatory capture:

Meanwhile, the medical establishment, growing increasingly concerned about the legal fees and the potential liability for hundreds of millions of dollars in damages, turned to Congress for help. They hired lobbyists to request legislation that would exempt the residency program from the accusations. A rider, sponsored by Senators Edward M. Kennedy, Democrat of Massachusetts, and Judd Gregg, Republican of New Hampshire, was attached to a pension act, which President Bush signed into law in April.

In other words, employers bought Congress and President Bush in order to screw residents.[2] If you attend med school, you’re agreeing to be screwed for three to eight years after you’ve incurred hundreds of thousands of dollars of debt, and you have few if any legal rights to attack the exploitative system you’ve entered.

(One question I have for knowledgeable readers: do you know of any comprehensive discussion of residents and unions? Residents can apparently unionize—which, if I were a medical resident, would be my first order of business—but the only extended treatment of the issue I’ve found so far is here, which deals with a single institution. Given how poorly  residents are treated, I’m surprised there haven’t been more unionization efforts, especially in union-friendly, resident-heavy states like California and New York. One reason might be simple: people fear being blackballed at their ultimate jobs, and a lot of residents seem to have Stockholm Syndrome.)

Self-interested residency program directors will no doubt argue that residency is set up the way it is because the residency experience is educational. So will doctors. Doctors argue for residency being essential because they have a stake in the process. Residency directors and other administrators make money off residents who work longer hours and don’t have alternatives. We shouldn’t be surprised that they seek other legal means of restricting competition—so much of the fight around medicine isn’t about patient care; it’s about regulatory environments and legislative initiatives. For one recent but very small example of the problems, see “When the Nurse Wants to Be Called ‘Doctor’,” concerning nursing doctorates.

I don’t buy their arguments for more than ad hominem reasons. The education at many residency programs is tenuous at best. One friend, for example, is in a program that requires residents to attend “conference,” where residents are supposed to learn. But “conference” usually degenerates into someone nattering and most of the residents reading or checking their phones. Conference is mandatory, regardless of its utility. Residents aren’t 10 year olds, yet they’re treated as such.

These problems are well-known (“What other profession routinely kicks out a third of its seasoned work force and replaces it with brand new interns every year?”). But there’s no political impetus to act: doctors like limiting their competition, and people are still fighting to get into medical school.

Soldiers usually make four-year commitments to the military. Even ROTC only demands a four- to five-year commitment after college graduation—at which point officers can choose to quit and do something else. Medicine is, in effect, at least a ten-year commitment: four of medical school, at least three of residency, and at least another three to pay off med school loans. At which point a smiling twenty-two-year-old graduate will be a glum thirty-two-year-old doctor who doesn’t entirely get how she got to be a doctor anyway, and might tell her earlier self the things that earlier self didn’t know.

Contrast this experience with nursing, which requires only a four-year degree, or PAs, who have two to three years of additional school. As John Goodman points out in “Why Not A Nurse?“, nursing is much less heavily or uniformly regulated than doctoring. Nurses can move to Oregon:

Take JoEllen Wynne. When she lived in Oregon, she had her own practice. As a nurse practitioner, she could draw blood, prescribe medication (including narcotics) and even admit patients to the hospital. She operated like a primary care physician and without any supervision from a doctor. But, JoEllen moved to Texas to be closer to family in 2006. She says, “I would have loved to open a practice here, but due to the restrictions, it is difficult to even volunteer.” She now works as an advocate at the American Academy of Nurse Practitioners.

and, based on the article, avoid Texas. Over time, we’ll see more articles like “Why Nurses Need More Authority: Allowing nurses to act as primary-care providers will increase coverage and lower health-care costs. So why is there so much opposition from physicians?” Doctors will oppose this, because it’s in their economic self-interest to avoid more competition.

The next problem with becoming a doctor involves what economists call “information asymmetry.” Most undergraduates making life choices don’t realize the economic problems I’ve described above, let alone some of the other problems I’m going to describe here. When I lay out the facts about becoming a doctor to my freshmen writing students, many of those who want to be doctors look at me suspiciously, like I’m offering them a miracle weight-loss drug or have grown horns and a tail.

“No,” I can see them thinking, “this can’t be true because it contradicts so much of what I’ve been implicitly told by society.” They don’t want to believe. Which is great—right up to the point they have to live their lives, and see how their how those are lives are being shaped by forces that no one told them about. Just like no one told them about opportunity costs or what residencies are really like.

Medical students and doctors have complained to me about how no one told them how bad it is. No one really told them, that is. I’m not sure how much of this I should believe, but, at the very least, if you’re reading this essay you’ve been told. I suspect a lot of now-doctors were told or had an inkling of what it’s really like, but they failed to imagine the nasty reality of 24- or 30-hour call.

They, like most people, ignore information that conflicts with their current belief system about the glamor of medicine to avoid cognitive dissonance (as we all do: this is part of what Jonathan Haidt points out in The Righteous Mind, as does Daniel Kahneman in Thinking, Fast and Slow). Many now-doctors, even if they were aware, probably ignored that awareness and now complain—in other words, even if they had better information, they’d have ignored it and continued on their current path. They pay attention to status and money instead of happiness.

For example, Penelope Trunk cites Daniel Gilert’s Stumbling on Happiness and says:

Unfortunately, people are not good at picking a job that will make them happy. Gilbert found that people are ill equipped to imagine what their life would be like in a given job, and the advice they get from other people is bad, (typified by some version of “You should do what I did.”)

Let’s examine some other vital takeaways from Stumbling on Happiness: [3]

* Making more than about $40,000/year does little to improve happiness (this should probably be greater in, say, NYC, but the main point stands: people think money and happiness show a linear correlation when they really don’t).

* Most people value friends, family, and social connections more than additional money, at least once their income reaches about $40K/year. If you’re trading time with friends and family for money, or, worse, for commuting, you’re making a tremendous, doctor-like mistake.

* Your sex life probably matters more than your job, and many people mis-optimize in this area. I’ve heard many residents and med students say they’re too busy to develop relationships or have sex with their significant others, if they manage to retain one or more, and this probably makes them really miserable.

* Making your work meaningful is important.

Attend med school without reading Gilbert at your own peril. No one in high school or college warns you of the dangers of seeking jobs that harm your sex life, because high schools are too busy trying to convince you not to have one. So I’m going issue the warning: if you take a job that makes you too tired to have sex or too tired to engage in contemporary mate-seeking behaviors, you’re probably making a mistake.

The sex-life issue might be overblown, because people who really want to have one find a way to have one; some med students and residents are just offering the kinds of generic romantic complaints that everyone stupidly offers, and which mean nothing more than discussion about the weather. You can tell what a person really wants by observing what they do, rather than what they say.

But med students and residents have shown enough agony over trade-offs and time costs to make me believe that med school does generate a genuine pall over romantic lives. There is a correlation-is-not-causation problem—maybe med school attracts the romantically inept—but I’m willing to assume for now that it doesn’t.

The title of Trunk’s post is “How much money do you need to be happy? Hint: Your sex life matters more.” If you’re in an industry that consistently makes you too tired for sex, you’re doing things wrong and need to re-prioritize. Nurses can work three twelves a week, or thirty-six total hours, and be okay. But, as described above, being a doctor doesn’t let employees re-prioritize.

Proto-doctors screw up their 20s and 30s, sexually speaking, because they’ve committed to a job that’s so cruel to its occupants that, if doctors were equally cruel to patients, those doctors would be sued for malpractice. And the student loans mean that med students effectively can’t quit. They’ve traded sex for money and gotten a raw deal. They’ll be surrounded by people who are miserable and uptight—and who have also mis-prioritized.

You probably also don’t realize how ill-equipped you are to what your life would be like as a doctor because a lot of doctors sugarcoat their jobs, or because you don’t know any actual doctors. So you extrapolate from people who say, “That’s great” when you say you want to be a doctor. If you say you’re going to stay upwind and see what happens, they don’t say, “That’s great,” because they simply think you’re another flaky college student. But saying “I want to go to med school” or “I want to go to law school” isn’t a good way to seem level-headed (though I took the latter route; fortunately, I had the foresight to quit). Those routes, if they once led to relative success and happiness, don’t any more, at least for most people, who can’t imagine what life is like on the other end of the process. With law, at least the process is three years, not seven or more.

No one tells you this because there’s still a social and cultural meme about how smart doctors are. Some are. Lots more are very good memorizers and otherwise a bit dull. And you know what? That’s okay. Average doctors seeing average patients for average complaints are fixing routine problems. They’re directing traffic when it comes to problems they can’t solve. Medicine doesn’t select for being well-rounded, innovative, or interesting; if anything, it selects against those traits through its relentless focus on test scores, which don’t appear to correlate strongly with being interesting or intellectual.

Doctors aren’t necessarily associating with the great minds of your generation by going to medical school. Doctors may not even really be associating with great minds. They might just be associating with excellent memorizers. I didn’t realize this until I met lots of of doctors, had repeated stabs at real conversations with them, and eventually realized that many aren’t intellectually curious and imaginative. There are, of course, plenty of smart, intellectually curious doctors, but given the meme about the intelligence of doctors, there are fewer than imagined and plenty who see themselves as skilled technicians and little more.

A lot of doctors are the smartest stupid people you’ve met. Smart, because they’ve survived the academic grind. Stupid, because they signed up for med school, which is effectively signing away extraordinarily valuable options. Life isn’t a videogame. There is no reset button, no do-over. Once your 20s are gone, they’re gone forever.

Maybe your 20s are supposed to be confusing. Although I’m still in that decade, I’m inclined to believe this idea. Medical school offers a trade-off: your professional life isn’t confusing and you have a clear path to a job and paycheck. If you take that path, your main job is to jump through hoops. But the path and the hoops offer  clarity of professional purpose at great cost in terms of hours worked, debt assumed, and, perhaps worst of all, flexibility. Many doctors would be better off with the standard confusion, but those doctors take the clear, well-lit path out of fear—which is the same thing that drives so many bright but unfocused liberal grads into law schools.

I’ve already mentioned prestige and money as two big reasons people go to med school. Here’s another: fear of the unknown. Bright students start med school because it’s a clearly defined, well-lit path. Such paths are becoming increasingly crowded. Uncertainty is scary. You can fight the crowd, or you can find another way. Most people are scared of the other way. They shouldn’t be, and they wouldn’t be if they knew what graduate school paths are like.

For yet another perspective on the issue of not going to med school, see Ali Binazir’s “Why you should not go to medical school — a gleefully biased rant,” which has more than 200 comments as of this writing. Binazir correctly says there’s only one thing that should drive you to med school: “You have only ever envisioned yourself as a doctor and can only derive professional fulfillment in life by taking care of sick people.”

If you can only derive professional fulfillment in life by taking care of sick people, however, you should remember that you can do so by being a nurse or a physicians assistant. And notice the words Binazir chooses: he doesn’t say, “help people”—he says “taking care of sick people.” The path from this feeling to actually taking care of sick people is a long, miserable one. And you should work hard at envisioning yourself as something else before you sign up for med school.

You can help people in all kinds of ways; the most obvious ones are by having specialized, very unusual skills that lots of people value. Alternately, think of a scientist like Norman Borlaug (I only know about him through Tyler Cowen’s book The Great Stagnation; in it, Cowen also observes that “When it comes to motivating human beings, status often matters at least as much as money.” I suspect that a lot of people going to medical school are really doing it for the status).

Bourlag saved millions of lives through developing hardier seeds and through other work as an agronomist. I don’t want to say something overwrought and possibly wrong like, “Bourlag has done more to help people than the vast majority of doctors,” since that raises all kinds of questions about what “more” and “help” and “vast majority” mean, but it’s fair to use him as an example of how to help people outside of being a doctor. Programmers, too, write software that can be instantly disseminated to billions of people, and yet those who want to “help” seldom think of it as a helping profession, even though it is.

For a lot of the people who say they want to be a doctor so they can help people, greater intellectual honesty would lead them to acknowledge mixed motives in which helping people is only one and perhaps not the most powerful. On the other hand, if you really want to spend your professional life taking care of sick people, Binazir is right. But I’m not sure you can really know that before making the decision to go to medical school, and, worse, even if all you want to do is take care of sick people, you’re going to find a system stacked against you in that respect.

You’re not taking the best care of people at 3 a.m. on a 12- to 24-hour shift in which your supervisors have been screaming at you and your program has been jerking your schedule around like a marionette all month, leaving your sleep schedule out of whack. Yeah, someone has to do it, but it doesn’t have to be you, and if fewer people were struggling to become doctors, the system itself would have to change to entice more people into medical school.

One other, minor point: you should get an MD and maybe a PhD if you really, really want to do medical research. But that’s a really hard thing for an 18 – 22 year old to know, and most doctors aren’t researchers. Nonetheless, nurses (usually) aren’t involved in the same kind of research as research MDs. I don’t think this point changes the main thrust of my argument. Superstar researchers are tremendously valuable. If you think you’ve got the tenacity and curiosity and skills to be a superstar researcher, this essay doesn’t apply to you.

Very few people will tell you this, or tell even if you ask; Paul Graham even writes about a doctor friend in his essay “How to do What You Love:”

A friend of mine who is a quite successful doctor complains constantly about her job. When people applying to medical school ask her for advice, she wants to shake them and yell “Don’t do it!” (But she never does.) How did she get into this fix? In high school she already wanted to be a doctor. And she is so ambitious and determined that she overcame every obstacle along the way—including, unfortunately, not liking it.

Now she has a life chosen for her by a high-school kid.

When you’re young, you’re given the impression that you’ll get enough information to make each choice before you need to make it. But this is certainly not so with work. When you’re deciding what to do, you have to operate on ridiculously incomplete information. Even in college you get little idea what various types of work are like. At best you may have a couple internships, but not all jobs offer internships, and those that do don’t teach you much more about the work than being a batboy teaches you about playing baseball.

Having a life chosen for you by a 19-year-old college student or 23-year-old wondering what to do is only marginally better.

I’m not the first person to notice that people don’t always understand what they’ll be like when they’re older; in “Aged Wisdom,” Robin Hanson says:

You might look inside yourself and think you know yourself, but over many decades you can change in ways you won’t see ahead of time. Don’t assume you know who you will become. This applies all the more to folks around you. You may know who they are now, but not who they will become.

This doesn’t surprise me anymore. Now I acknowledge that I’m very unlikely to be able to gauge what I’ll want in the future.

Contemplate too the psychological makeup of many med students. They’re good rule-followers and test-takers; they tend to be very good on tracks but perhaps not so good outside of tracks. Prestige is very important, as is listening to one’s elders (who may or may not understand the ways the world is changing in fundamental ways). They may find the real world large and scary, while the academic world is small, highly directed, and sufficiently confined to prevent intellectual or monetary agoraphobia.

These issues are addressed well in two books: Excellent Sheep by William Deresiewicz and Zero to One by Peter Thiel and Blake Masters. I won’t endorse everything in either book, but pay special attention to their discussions of the psychology of elite students and especially the weaknesses that tend to appear in that psychology.

It is not easy for anyone to accept criticism, but that may be particularly true of potential med students, who have been endlessly told how “smart” they are, or supposedly are. Being smart in the sense of passing classes and acing tests may not necessarily lead you towards the right life, and, moreover, graduate schools and consulting have evolved to prey on your need for accomplishment, positive feedback, and clear metrics. You are the food they need to swallow and digest. Think long and hard about that.

If you don’t want to read Excellent Sheep and Zero to One, or think you’re “too busy,” I’m going to marvel: you’re willing to spend hundreds of thousands of dollars and years of your life to a field that you’re not wiling to spend $30 and half a day to understanding better? That’s a dangerous yet astonishingly common level of willful ignorance.

Another friend asked what I wanted to accomplish with this essay. The small answer: help people understand things they didn’t understand before. The larger answer—something like “change medical education”—isn’t very plausible because the forces encouraging people to be doctors are so much larger than me. The power of delusion and prestige is so vast that I doubt I can make a difference through writing alone. Almost no writer can: the best one can hope for is changes at the margin over time.

Some med school stakeholders are starting to recognize the issues discussed in this essay: for example, The New York Times has reported that New York University’s med school may be able to shorten its duration from four years to three, and “Administrators at N.Y.U. say they can make the change without compromising quality, by eliminating redundancies in their science curriculum, getting students into clinical training more quickly and adding some extra class time in the summer.” This may be a short-lived effort. But it may also be an indicator that word about the perils of med school is spreading.

I don’t expect this essay to have much impact. It would require people to a) find it, which most probably won’t do, b) read it, which most probably won’t do, c) understand it, which most of those who read it won’t or can’t do, and d) implement it. Most people don’t seem to give their own futures much real consideration. I know a staggering number of people who go to law or med or b-school because it “seems like a good idea.” Never mind the problem with following obvious paths, or the question of opportunity costs, or the difficulty in knowing what life is like on the other side.

People just don’t think that far ahead. I’m already imagining people on the Internet who are thinking about going to med school and who see the length of this essay and decide it’s not worth it—as if they’d rather spend a decade of their lives gathering the knowledge they could read in an hour. They just don’t understand the low quality of life medicine entails for many if not most doctors.

Despite the above, I will make one positive point about med school: if you go, if you jump through all the hoops, if you make it to the other side, you will have a remunerative job for life, as long as you don’t do anything grossly awful. Job demand and pay are important. Law school doesn’t offer either anymore. Many forms of academic grad schools are cruel pyramid schemes propagated by professors and universities. But medicine does in fact have a robust job market on the far end. That is a real consideration. You’re still probably better off being a nurse or PA—nurses are so in-demand that nursing schools can’t grow fast enough, at least as of 2015—but I don’t want to pretend that the job security of being a doctor doesn’t exist.

I’m not telling you what to do. I rarely tell anyone what to do. I’m describing trade-offs and asking if you understand them. It appears that few people do. Have you read this essay carefully? If not, read it again. Then at least you won’t be one of the many doctors who hate what you do, warn others about how doctors are sick of their profession, and wish you’d been wise enough to take a different course.

If you enjoyed this essay, you should also read my novel, Asking Anna. It’s a lot of fun for not a lot of money!

[0] Here’s another anti-doctor article: “Why I Gave Up Practicing Medicine.” Scott Alexander’s “Medicine As Not Seen On TV” is also good. The anti-med-school lit is available to those who seek it. Most potential med students don’t seem to. Read the literature and understand the perils. If after learning you still want to go anyway, great.

Here is too intelligent commenter ktswan, who qualifies the rest of the article. She went from nursing to med school and writes, “I am much happier in medicine than lots of my colleagues, I think in many ways because I knew exactly what I was getting into, what I was sacrificing, and what I wanted to gain from it.”

[1] One could argue that many of the problems in American K – 12 education stem from a captive audience whose presence or absence in a school is based on geography and geographical accidents rather than the school’s merit.

[2] You can read more about the match lawsuit here. Europe doesn’t have a match-like system; there, the equivalent of medical residency is much more like a job.

[3] Stumbling on Happiness did more to change my life and perspective than almost any other book. I’ve read thousands of books. Maybe tens of thousands. Yet this one influences my day-to-day decisions and practices by clarifying how a lot of what people say they value they don’t, and how a lot of us make poor life choices based on perceived status that end up screwing us. Which is another way of saying we end up screwing ourselves. Which is what a lot of medical students, doctors, and residents have done. No one holds the proverbial gun to your head and orders you into med school (unless you have exceptionally fanatical parents). When you’re doing life, at least in industrialized Western countries, you mostly have yourself to blame for your poor choices, made without enough knowledge to know the right choices.

Thanks to Derek Huang, Catherine Fiona MacPherson, and Bess Stillman for reading this essay.

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