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

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

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

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

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

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

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

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

(I'm an employer as of now)

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

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

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

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

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

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

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

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

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

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

It is better for us working dinosaurs that way.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I honestly find it shocking, but there it is.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I disagree. Go to some technical meetups.

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

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

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

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

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

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

It's been a rough couple of decades afterall.

Vanguard 500: 3x return over last 10 years

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

SWPPX: 3x over last 10 years.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

> Healthcare complicates early retirement

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

> You have significant risk from healthcare costs

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

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

my experience agrees with yours.

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

[EDIT] Further:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Not for Asian airlines, though.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I just don't buy this take.

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

Shadowing/Interning is already done in your MD program.

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

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

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

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

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

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

You mean like a residency?

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

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

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

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

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

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

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

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

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

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

Current personal favorite failure modes:

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

Use of copper in boiler condensate pipes.

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

Overtightening of plastic threaded connections.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

> I didn't have insurance, $800k

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

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

You're young, aren't you?

The percentage is significant, but nowhere near 95%.

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

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

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

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

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

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

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

This is a statistic pulled out of nowhere.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

do you believe this is the case now?

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

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

Can we please touch grass?

It is possible that everyone will become a programmer, like everyone has become an elevator operator, but unlike an elevator button press that takes milliseconds and you're done, does it behoove "the boss" to spend their day describing their ideas to GPT? I suspect, like today, they will still want to hire other humans to bridge that gap so that they can spend time doing more important things.

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

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

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

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

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

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

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

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

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

https://savegme.org/

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An additional resident takes 4+4=8 years.

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

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

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

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

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

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