Links: Short stories, cheating, Anthem, Jacques Barzun, Tuition, and more

* “[postsecret] What It’s Like To Cheat.”

* “Why Does the Short Story Survive?” notice this:

As the title suggests, this book has an instructive function and can be read like a manual for aspiring prosers. Each author introduces his or her selection, and the results are frequently thrilling. Imagine taking a ten-minute master class with Dave Eggers or Amy Hempel or Lydia Davis, whose erudite prologue to Jane Bowles’s “Emmy Moore’s Journal” shows how to nail an opening hook. Publisher’s Weekly has called Object Lessons “an MFA between two covers,” and there are valuable craft takeaways for those who seek them. But the book’s variousness should also remind writers that short fiction’s formal conventions are far from set in stone.

* An unusual reading of Ayn Rand’s Anthem. (HT Marginal Revolution.)

* Jacques Barzun dies. I’ve only read From Dawn To Decadence, and liked it, except for the last 100 pages.

* It was only a matter of time: Tuition by Major.

* The European Left and Its Trouble With Jews.

* Socialized Medicine Can Kill, with Caroline Cassin as a specific example.

* Amusing search query of the week: “how much do band guys get laid.” Probably depends on the band and the guy. Someone else found this blog by searching for “why do europeans have more class than americans?”, which is also pretty amusing. For an answer, ask Henry James.

* Why We Can’t Solve Big Problems.

Thoughts on possible and perceived income inequality

Someone in my family sent me “Standard of Living Is in the Shadows as Election Issue,” which is about how we allegedly need to break “out of a decade of income stagnation that has afflicted the middle class and the poor and exacerbated inequality.” But measuring standard of living solely through income has a couple of major problems. One is that a lot of people are getting life improvements through non-income-based measures (surfing the Internet is an obvious example). It also appears that the average basket of goods consumption is changing. Anyone who has to or chooses to consume health care or education is really hurting. Anyone who isn’t is arguably benefiting from the major drop in prices for virtually all manufactured goods.

I’m not convinced that income inequality has changed as much as the media believes it has. Robert J. Gordon wrote “Has the Rise in American Inequality Been Exaggerated?,” which argues that the indices used to measure inequality are flawed, that a lot of income is now needlessly spent on housing (primarily because so many cities restrict housing supply through various means, including arbitrary parking requirements and height limits), and that behavioral choices and changes may have changed perceived inequality. I don’t want to argue the merits of Gordon’s paper. His explanations are at least plausible, and that the more one tries to measure these kinds of changes, the harder it is to really know if what one is measuring is real or evidence of statistical artifacts or measurement biases. Standard of living arguments face the same issues.

I mentioned the kinds of goods we consume in the first paragraph. We have large incentive problems built into healthcare, education, and government, all of which are growing faster than inflation and have been for decades. Tyler Cowen’s The Great Stagnation: How America Ate All The Low-Hanging Fruit of Modern History, Got Sick, and Will (Eventually) Feel Better discusses these issues. Cowen also says:

More and more, ‘production’—that word my fellow economists have been using for generations—has become interior to the human mind rather than set on a factory floor. Maybe a tweet doesn’t look like much, but its value lies in the mental dimension. We use Twitter, Facebook, MySpace, and other Web services to construct a complex meld of stories, images, and feelings in our minds. No single bit from the Web seems so weighty on its own, but the resulting blend is rich in joy, emotion, and suspense.

This might be overly utopian: consider the arguments of Sherry Turkle’s Together Alone or Nicholas Carr’s The Shallows, neither of which may be fully persuasive but which still give me pause about the Internet as a “resulting blend. . . rich in joy, emotion, and suspense.”

At least “Standard of Living Is in the Shadows” understands this: “The causes of income stagnation are varied and lack the political simplicity of calls to bring down the deficit or avert another Wall Street meltdown.” The Wall Street meltdown is also a symptom, not a cause, of underlying problems. This is also probably true:

Maybe the biggest reason for optimism is that there is still a strong argument that both globalization and automation help the economy in the long run. This argument remains popular with economists: Trade allows countries to specialize in what they do best, while technology creates opportunities to extend and improve life that never before existed.

Previous periods of rapid economic change also created problems that seemed to be permanent but were not. Neither the cotton gin nor the steam engine nor the automobile created mass unemployment.

I don’t pretend to have answers to these questions, but both major political want to sell easy and probably wrong answers. A critical mass of voters haven’t revolted, or won’t revolt. I don’t see the end game. But we may also get self-driving cars, 3-D printing, and human genetic modification in the next decade. All three are big, transformative technologies that may alter the fabric of human life in major and unforeseeable ways. Remember that a huge number of technologies diffused through society incredibly quickly during the depression (radio being the best known). In my own case, for example, Amazon, Barnes & Noble, and Apple’s digital reading devices have made self-publishing pragmatic in a way that it wasn’t prior to about 2010 or so, and that’s a pretty big win for me, given my experience with literary agents.

There does, however, seem to be a pervasive societal sense over the last four years that something has gone wrong.

In an e-mail, one friend said this: “These days, I feel like much of society is living in some sort of shared delusion, where people want what they want but are blithely unaware of the effects of their desires” in the context of a link to Branford Marsalis’ take on students today. Marsalis says that he’s learned that “students today are completely full of shit. [. . .] Much like the generation before them, the only thing they’re really interested in is you telling them how right they are and how good they are.” I said to my friend:

I suspect people have always been “living in some sort of shared delusion, where people want what they want but are blithely unaware of the effects of their desires,” but wealth has enabled us to indulge these desires and shared delusions in new ways. And “shared delusion” as a small and relatively unimportant percentage of GDP / government spending is a cheap, affordable thrill. But shared delusion in an environment where economic growth is weak—I tend to buy the Tyler Cowen argument espoused in The Great Stagnation, along with Peter Thiel’s addendums, though I’m more than willing to consider alternate points of view—is much harder. A lot of people are clawing for a bigger slice of a limited pie, which is a more substantial problem than a lot of people clawing for a sliver of a growing pie. Most people don’t even understand the problems, or try to genuinely understand; it’s easier to fit small pieces of complex problems and phenomena into an existing social / political worldview than it is to try getting a handle on the problem domain and the forces in play (most of the political posts I’ve seen on Facebook look like mood affiliation and simple, Haidt-style posturing and mood affiliation than anything else). The delusion isn’t new, but the large climate /environment has changed. The scale of the delusion has changed too, and scale has qualities of its own.

But I still wonder about something real: when someone makes it really rich (Astors, Vanderbilts, or, today, Gates, Ellison), there’s a tendency for the wealth and the kinds of behaviors that led to the major wealth in the first place to be diluted over time and across generations (think of Paris Hilton as a salient media example). I wonder if that also happens to some extent at the level of countries, but over centuries instead of decades. Most of the time I tend to guess not—the wealthiest countries in 1800 are still mostly the wealthiest countries today, with a couple of notable exceptions (Argentina has gone down, South Korea up)—but it’s still something I ponder. Changing wealth distributions play into this too, although I’m not really sure how.

The preceding paragraphs might be overly pessimistic. Let’s take the long view: things are actually pretty good. The Soviets aren’t threatening us with total annihilation (and vice-versa: the news that Kennedy seriously considered a first strike in the 60s is really scary), we’re not in the Great Depression, there’s still lots of cool stuff happening, books are cheaper than ever, and virtually everyone has a magic box that lets them communicate with almost anyone, anywhere, any time. The minutia and stupidity of politics is being enabled in new ways, but I think the basic content isn’t so different from the past. By virtually every metric people are better off today than they were 30 or 40 years ago (psychologically speaking, I’m not so sure, but we’ll leave that to the side). Anyone who has had medical treatment that wouldn’t have been possible 40 years ago is aware of this.

As I said above, we may also get self-driving cars, 3-D printing, and human genetic modification in the next decade. These technologies might be overhyped or not pan out. But I still think:

Pretty neat!

People who are well-equipped to take advantage of modern nutrition and communication are in an especially good position. People who fall into the defaults—lots of simple sugars and fast foods, four or five hours of TV of dubious value every day—might not be. Simply being a consumer might be getting harder. So is following default paths. Certainly I derive a huge amount of benefit from being part of modern communication networks, but the kind of person who doesn’t care that much about writing or artistic production or whatever might not care or benefit.

In Name of the Rose Adso thinks: “As I lay on my pallet, I concluded that my father should not have sent me out into the world, which was more complicated than I had thought. I was learning too many things” (179). But we can’t avoid getting sent out into the world. All we can do is hope we have or can develop the strength and fortitude necessary to make a go of it. Maybe the very wealthy, who have inherited wealth, can avoid much of the world, but that will only last for a generation or two, and then it’s back against the hard rock face of reality, whether we’re ready for it or not.

School, incidentally, does a poor job of presenting the rock face, which is another issue for another, but I think it’s possible to present that rock face without being a jerk about it. I try to do so.

I also try to remember that life is hard. Even when it’s beautiful.

I’m not the only one to notice bad academic writing: B.R. Myers in The Atlantic

I’ve occasionally, and probably futilely, pointed out bad academic writing, but my audience is small and the war against cliche is a lonely one, fought mostly by guerrilla cranks, misfits, and writers, frequently all embodied in the same person, and often ten against the official and indifferent edifice of institutions that are nominally devoted to literary excellence. But I’m heartened that B.R. Myers has spotlighted the problem in his Atlantic review of Every Twelve Seconds: Industrialized Slaughter and the Politics of Sight:

The author also conforms to the current academic practice of laboriously redescribing the obvious. To say that people hide what they don’t want others or themselves to see is to make a commonsense point that a small child could grasp. It verges on tautology. Yet for all his access to a rarely described world, Pachirat keeps returning to this of all points, writing in revelatory tones of a “politics of sight,” of “distinctions between visible/invisible, plain/hidden, and open/confined that, in theory, keep repugnant activities hidden and therefore make them tolerable.” In a profession where success is judged by how often one gets quoted, the author has perhaps succeeded in creating a new catchphrase, something colleagues writing on other topics may feel compelled to invoke. As in, say: “The dictator’s effort to conceal the massacre was a prime example of what Timothy Pachirat calls ‘the politics of sight.’ ”

In academia, you don’t earn points for beauty or concision, but you might be docked for confusing a distracted or dense peer reviewer. So writers err on the side of the obvious, because that’s what their incentive structure rewards. The person who gives up reading because of bad writing isn’t considered.

Links: Back to Blood and James Wood, Amazon wipes Kindle account, school reform, computing, the female social matrix, and more

* “‘Back to Blood': Tom Wolfe forgot his own rules: Almost 25 years ago, the author made a case for the realist novel. His silly new book suggests he should reread it.” In other Wolfe news, James Wood doesn’t like it either, although “doesn’t like it” is a pretty stupid phrase, but I can’t find or fashion one better at the moment: Wood’s review is really about how free-indirect speech, registers, and personality function not just in this novel, but in The Novel.

* “A couple of days a go, my friend Linn sent me an e-mail, being very frustrated: Amazon just closed her account and wiped her Kindle. Without notice. Without explanation. This is DRM at it’s worst.” Until there are more robust legal or contractual guarantees on Kindle books, I’ll remain reluctant to buy them. On the other hand, as of this writing, it’s possible to strip the DRM from your ebooks. And it works!

* “Why school reform is impossible.” Maybe.

* “As we watch computing become a central part of the language of science, communication, and even the arts and humanities, we will realize that students need to learn to read and write code because — without that skill — they are left out of the future.

* The Female Social Matrix: An Introduction.

* This is the Era of Nuclear Rejections.

* “How American Health Care Killed My Father,” and what to do about it. Unfortunately, we haven’t done the things we should have done and should be doing, as discussed in the article.

* “Write My Essay, Please! These days, students can hire online companies to do all their coursework, from papers to final exams. Is this ethical, or even legal?” This supports Bryan Caplan’s theory that much of education is about signaling.

I think some women on OkCupid employ the same strategy:

“Mantises are large carnivorous insects. [. . .] they will attack almost anything that moves. When they mate, the male cautiously creeps up on the female, mounts her, and copulates. If the female gets the chance, she will eat him, beginning by biting his head off, either as the male is approaching, or immediately after he mounts, or after they separate. It might seem most sensible for her to wait until copulation is over before she starts to eat him. But the loss of the head does not seem to throw the rest of the male’s body off its sexual stride. Indeed, since the insect head is the seat of some inhibitory nerve centres, it is possible that the female improves the male’s sexual performance by eating his head. If so, this is an added benefit.”

—Richard Dawkins, The Selfish Gene, which is best read in its latest edition.

The problem with justifying college involves cost

In “Telling the Right Story,” Dean Dad notes that higher education has had a series of real or perceived crises, around hippies / protests, diversity / multiculturalism, and, as he says, the latest set are “about cost.” Though I would say they’re about cost and value, the basic point remains: skepticism regarding the utility of conventional colleges and universities is growing, as is skepticism about the idea that the “lifetime payoff” of college always justifies its costs for all people. Dean Dad ends his post by saying, “have you seen or heard a better story for demonstrating the value of public higher ed to the public?”

To me, the problem is simple: “the value of public higher ed” increasingly depends on the major that one picks and the amount of work that one does in college. Payscale.com’s salary data shows data for a bunch of majors, with things like art and social work clustered at the bottom while engineering and applied math at the top. (I find the relatively low salaries of business majors interesting.) Someone who majors in petroleum engineering (starting pay: $98,000; mid-career in the mid six figures) is basically living in a different world than someone majoring in sports management ($35,300 and $57,600, respectively). Lumping both into “college” makes only slightly more sense than lumping McDonald’s and dung beetles into the general category of “food” just because both happen to be edible.

As Megan McArdle wrote, “It’s very easy to spend four years majoring in English literature and beer pong and come out no more employable than you were before you went in.” People who aren’t developing important skills should be asking what they are doing; by now, it’s pretty clear that a lot of majors don’t require much effort. Colleges are happy to offer some majors that require learning and some that don’t. This isn’t purely anecdotal: as Academically Adrift demonstrates, a lot of students simply aren’t learning that much in many majors. In chemical engineering and computer science, students are presumably learning the kinds of skills they need to get paid a lot of money. Alternately, those majors weed out students who can’t or won’t learn the material.

If they students get out of college and end up in jobs that don’t require a college degree, then perhaps they shouldn’t have gone to college in the first place. Universal college isn’t a panacea, especially for people who enter without the skills, motivation, or inclination to succeed. Plus, not everyone does well sitting in a classroom and manipulating abstract symbols. Which is okay. But we’re pretending that everyone should sit quietly in classrooms and manipulate abstract symbols, and we’re subsidizing them through student loans to let them do so, and then we’re surprised when not everyone fits this profile.*

To be sure, there is more to life than money, but again, Academically Adrift shows that a lot of students don’t appear to be learning anything measurable. Maybe they’re growing as people. But $50,000 – $250,000 is an onerous payment for that growth, especially when the debt incurred for the growth can’t be discharged through bankruptcy.

To return to Dean Dad’s point, I don’t think he or anyone else will hear “a better story” than the one we have now (“We’ve used the ‘lifetime payoff’ argument for a long time, generally to good effect. But that argument gets less convincing when the cost to the student goes up and entry-level opportunities go down”) until we, collectively, acknowledge reality and look much more closely at how lifetime income varies by major.

Clever stories can’t hide hard truths.

I’ve written about this set of issues before. I’m sure I’ll write about them again.


* Arguably the worst-off students are the ones who attend for two or more years, incur the debt, and then don’t graduate. They don’t even have the piece of paper at the end.

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 of the medical students, residents, and doctors tell the same story that they’ve inspired me to explain, in detail, the underappreciated yet essential problems with medical school and residency. Furthermore, most people don’t realize that nursing provides many of the job security advantages of medical school without binding them 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). But there are numerous problems with these reasons: 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 do, c) most people underestimate opportunity costs, and d) you have to be able to help yourself before you can help other people.

Straight talk about doctors and money.

Although many doctors will eventually make a lot of money, they take a long time to get there. Nurses, by contrast, 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’re reading the following numbers.

Student Doctor reports that family docs made 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. The Bureau of Labor Statistics—a much 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 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.” There’s an obvious reason for nurses’ market power: medical costs are rising and residency programs have a stranglehold on the doctor supply.

This 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 pretty lousy for the healthcare system as a whole, which is lurching in the direction of finding ways to provide healthcare at lower costs. Like, say, through nurses.

Those nurses are going to end up competing with primary care docs. The New York Times recently published, “U.S. Moves to Cut Back Regulations on Hospitals,” which includes this:

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. For more on the subject, see “Yes, the P.A. Will See You Now,” which starts this way:

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. If you’re thinking about being an MD, you should study this issue carefully. You should also be aware that calls to lower doctor pay, like the one found in Matt Ygleasias’s “America’s Overpaid Doctors: We pay our doctors way too much,” are likely to grow louder. Note that I’m not taking a moral or economic stance about whether physician pay should be higher or lower: I’m arguing that the pressure on doctors’ pay is likely to increase, and Yglesias’s arguments are one form that pressure is likely to take.

One friend, who read this and who is a medical resident, simply said that she “didn’t realize that I was looking for nursing.” Or being a physicians assistant (P.A.). 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 contributes to the relationship failures that notoriously plague the medical world. Yet med schools and residencies can get away with this because they have you 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. So a lot of high achievers think being a doctor is the optimal road to success in the medical world. They pay attention to those eye-popping surgeon salary numbers and to the 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 thing for you, as an individual, to do is exit the market because you have so little control over it. Most prospective doctors who don’t exit the market live to regret it.

Sure, $160K 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.

The higher social status thing 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 a regular doctor who happens to be on-call because the senior doctors at the HMO know how to stiff the newbies.

This is where prospective medical students say, “I’m not going to be a family medicine doc.” Which is okay: maybe you won’t be (have fun in 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 of them are, even with barriers to entry in place.

To belabor the point about money, The Atlantic recently published this: “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, and, if they did understand 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. After all, med schools are run by doctors. 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.

The underrated miseries of residency.

As one 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 if you get a nursing degree and hate nursing, you can quit without having taken completely obscene student loans. You can probably go back to school and get a second degree in twelve to twenty-four months.

In normal jobs, if you hear about a better opportunity in another company or industry, you can pursue it. If you’re sufficiently dissatisfied with your university, you 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 times, in the gap between each residency year.

This is a recipe for exploitation, and 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 over you enshrined in law. Most other fields don’t have this level of coercion.

Once a residency program has you, they can do almost anything they want to you, and you have very little leverage. In a normal employment situation, if an employer turns out to suck, you quit. You work for three months, realize it’s not for you, walk out. Residency programs don’t let you. You don’t want to be in situations where you have no leverage, but that’s precisely what happens the moment you enter the “match.”

The match occurs in the second half of your fourth year of medical school. You apply to residencies in the first half of your fourth year, interview at various places, and then list the residencies you’re interested in. Residency program directors then rank you, and the National Residency Match Program “matches” you to each other. You’re then obligated to attend that residency program. You can’t privately negotiate with other programs, as you can for, say, undergrad admissions, or med school admissions, or almost any other normal employment situation. You can’t say, “How about another 5 grand?” or “Can I modify my contract to give me fewer days?” If you refuse to accept your “match,” then you’re blackballed from re-entering for the next three years.

Once I realized how nasty the residency match process is and how fundamentally unfair the labor market for residents is, I was shocked: 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 in our society, and sometimes for good reasons, but a case like this looked ripe to me.

It turns out that I’m not a legal genius and that lawyers have noticed this anti-trust violation. So an anti-trust lawsuit was filed. You can 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. Yes, indeed, curtailing employee power by distorting markets is a valuable service. The article also noted this bit of 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 exploitive 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 many 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.)

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. There’s a very good reason they argue for residency being essential: 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. So we shouldn’t be surprised that they seek other legal means of restricting competition (indeed, 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 they 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 do anything about it: doctors like limiting their competition, and people are still fighting to get into medical school.

When you enter the military, you usually make a four-year commitment. Even ROTC only demands a four- to five-year commitment after graduation—at which point you can choose to 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. At the same time, 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, 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 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.”)

Here are 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.

Go to 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. Medical students are signing up for three to six years of this condition, which may explain why so many of them are miserable and unhappy; they’ve failed to optimize the things that probably would make them happy, like getting more action. They’ve made bad trade-offs without really realizing that they’ve made them.

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 are doing a job that consistently makes you too tired for sex, you are doing things wrong and need to re-prioritize. If you’re a nurse, you can work three twelves a week, or thirty-six total hours, and be okay. But, as described above, being a doctor doesn’t let you 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 you effectively can’t quit. You’ve traded sex for money and gotten a raw deal. You’ll also 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 flakey 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 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 and directing traffic when it comes to problems they can’t solve. Medicine, meanwhile, doesn’t select for being well-rounded, innovative, or interesting; if anything, it selects against those traits through its relentless focus on test scores and so forth, which don’t appear to correlate strongly with being interesting or intellectual.

You’re not necessarily associating with the great minds of your generation by going to medical school; you may not even really be associating with great minds. You might just be associating with excellent memorizers. I didn’t realize this until I met a fair number 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 I expected, and plenty who see themselves as skilled technicians and little more.

A lot of doctors are the smartest stupid people you’ve ever 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. You don’t get a reset button, a 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 it offers that clarity of professional purpose at great cost in terms of hours worked, debt assumed, and, perhaps worst of all, flexibility. Given that set of trade-offs, I think a lot of people who become doctors would be better off with the standard confusion, but they take the clear 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 of the big reasons people go to med school. Here’s another: fear of the unknown. I think a lot of people start med school because it’s a clearly defined, well-lit path. The problem is that such paths are becoming increasingly crowded. 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. As he 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 physician’s 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.

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.

By the way, I’m far from 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 (or “you,” if you prefer) are almost always 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 probably spent much of their lives being 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, and, even if they have knowledge like that contained in this essay, I’m not sure they’ll use it. 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.

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.” The anti-med-school lit is available, if you care to seek it. Most potential med students don’t seem to. If you read the literature and understand the perils and want to go anyway, great.

[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] You should read Stumbling on Happiness; it did more to change my life and perspective than almost any other book. And I’ve read thousands of books. Maybe tens of thousands. Yet this one probably does more than any other to influence 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 and Bess Stillman for reading this essay.

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