Annuntio vobis gaudium magnum: habemus officium!

I have accepted a job as a psychiatrist-in-training in a hospital in Michigan, starting in late June. I won’t be more specific publicly because I might want to blog in a very generic and confidentiality-maintaining way about my experiences, and the less identifiable my teachers, colleagues, and especially patients are, the better. I will say that I am not in inner-city Detroit (in case you were worried) and that if you live in Michigan you can email me and we should get in touch.

I did not spend my childhood dreaming of one day ending up in Michigan. But I am so happy. I was not kidding about the gaudium magnum bit. It is an incredible blessing to have a psychiatry residency at all.

As you may know, there is a serious doctor shortage in the United States, and an even more serious psychiatrist shortage. Medical schools have, depending on your level of cynicism, either “responded to this problem” or “taken advantage of this problem” by increasing class sizes. There are now more seniors graduating medical school than ever before.

But in order to go from “medical school graduate” to “real doctor”, one has to complete a residency, a (usually) four year apprenticeship in one’s chosen specialty. These are expensive for hospitals to sponsor because there are strict regulations requiring residents to learn many complicated skills in a variety of different settings, all of which must be taught by experienced doctors who charge a lot for their time. And the incentives are poorly-designed: Hospital X may spend mountains of money training a resident who, immediately upon being declared a Real Doctor, packs up and moves to more lucrative Hospital Y. The government tries to help, but as always it is pressed for cash. And every thousand doctors the government helps train means they have to give up another fighter jet which later turns out not to work.

As a result, although the number of patients and of medical school graduates keep growing, the number of residency slots hasn’t changed much since about the 1990s.

This is bad for patients in an indirect hard-to-notice way because there are fewer doctors around and the ones who exist can charge more for their services. But it’s bad for would-be doctors in a very direct glaringly obvious way, which is that every year, some people graduate from medical school, get inducted into this very insular culture where medicine becomes the most important thing in their lives, sacrifice four years of their youth and incur hundreds of thousands of dollars in debt – and then are told thanks but no thanks. And then have no idea what to do with themselves.

In the old days, when there were more than enough residencies to go around, American medical students got their pick of the best, and then international students came in to take the rest of them. These could be anyone from Indian or Pakistani doctors who noticed that they could get a much better salary in the US, to Americans who couldn’t (or didn’t want to) get into US medical schools and so went to schools abroad (usually in the Caribbean) set up explicitly for the purpose of transitioning back into the US medical system later. This latter group includes several thousand people and is itself a thriving industry.

Now this is starting to go wrong. International students applying to residencies are in a somewhat desperate situation, getting matched a little less than half the time. And even American students are starting to have a less than 100% success rate – the last statistics I can get show about 95%, but I’ve heard rumors this year was especially dismal.

I fell in the former category myself last year. I figured Irish medical schools were better than the ones in the Caribbean, that I had good test scores, and that I was probably a shoe-in. I was wrong. Last March 11, when I heard the news, was without exception the worst day of my life. I felt confused, betrayed, and just crushingly depressed. It wasn’t just not getting a job offer, it felt like a total rejection of my identity and life path. It was only thanks to my parents and to Alicorn that I came out of it remotely sane.

I told myself I would try one more year. I’d spend one more year doing endless interviews, writing up personal statements and begging for letters of recommendation, one more year doing thankless unpaid internships with doctors who never remembered my name and yelled at me if I got too close to a patient. And then I would figure out something else. As the old saying goes, “If at first you don’t succeed, try again. Then give up. No use being a fool about it.”

With the help of – well, once again, my parents and Alicorn – not to mention the people at MetaMed – I managed to make it a year without going broke or insane. And this year my luck changed, and after more rejections than I care to think about the nice people in Michigan – in a hospital whose name is an allusion to divine mercy – decided to offer me a residency.

And this is the bottleneck in the system. Obviously God smites anyone who says “it’ll all be smooth sailing from here on out”, so I won’t do that, but if I can get through this, I’ll be a Real Doctor and people will be begging me to work for them rather than vice versa.

I’ve been to this hospital in Michigan. It’s a nice hospital. It’s full of nice people who are very good at what they do. And I’m going to get to practice psychiatry, the career I’ve wanted ever since I was like ten. I am totally beyond caring how cold it is going to be.

…maybe

There’s this old Taoist parable about a family in ancient China who lived on a farm and owned only one horse. One day the horse ran away.

All the people of the village offered their condolences to the patriarch of the family, saying he must be heartbroken at such a great disaster.

The patriarch only answered “Maybe.”

A few days later, the horse returned with a herd of wild horses. The family was able to capture some of them, increasing their wealth by many times. All the villagers congratulated the patriarch on his good fortune.

The patriarch only answered “Maybe.”

In the process of taming the wild horses, the eldest son was thrown from the saddle and broke his leg. He was responsible for most of the work around the farm, and the villagers all consoled the patriarch on this new disaster.

The patriarch only answered “Maybe.”

A few days later, the emperor’s soldiers came through the village, drafting all able-bodied young men to go away and fight in a bloody war far away. Because the son was injured, he wasn’t eligible for military service. The villagers all told the patriarch how lucky he was that his son was still around when their own sons were off at war.

The patriarch only answered “Maybe.”

I think this story goes on for a few more iterations, but you get the idea.

Since the days of ancient China, we’ve advanced a lot. Like, instead of just saying “maybe”, we can put numbers to our probabilities! If our eldest son who does all the work around the farm breaks his leg, we can say things like “98% chance that, on net, this will decrease my utility, although of course there’s a 2% chance that it will help in some unexpected way.” This makes a less interesting parable.

But the Taoist teaching is still sound. We are consistently overconfident in our estimation of whether events will be good or bad for us in the long run.

As I said before, last year when I learned I didn’t match to a residency was the worst day of my life. I was about as dejected as you’ve ever seen anyone, and with good reason.

But as it turned out, it led to me moving to Berkeley. For the first time in my life, I got to live with a community of real-life friends who I really got along with. I started realizing what other people meant when they said that going out with their friends was more fun than staying home alone. I went from being terrible with girls and Forever Alone to being terrible with girls yet still mysteriously dating two brilliant and beautiful women whom I will miss immensely right up until the point where they give in to my incessant demands to come visit me. I learned all kinds of weird skills and expanded my mental horizon. I got to see a tiny bit of the San Francisco Bay Area, one of the most beautiful places on Earth, and I hope to see a little more of it before I go. I got to be of some small help to groups I really care about, like MIRI and CFAR, and to some people I really care about too.

So basically, my getting rejected from my dream job and having no idea what to do with myself led to me having the best year of my life, becoming a stronger and better person, and then getting accepted to said dream job a year later. I wouldn’t recommend suffering life-ruining disasters to everyone, I’m just saying it seems to have seriously worked for me.

I don’t like perverse incentives, so I’m trying not to go into this job with the mindset of “spend four years in exile getting a fancy piece of paper, then move back to the Bay Area so fast it leaves skid marks through the entire American Midwest”. I am going to give the Michiganers every chance in the world to convince me to stay around. Maybe there will be someone, somewhere in Michigan, who is as consistently awesome as the people I have come to know here.

But in deference to the ancient Chinese, I am going to carefully avoid attaching a probability estimate to that statement.

You are all wonderful. Please keep being wonderful. And one day I am going to be a fully-qualified psychiatrist, and then I can help people be wonderful myself.