Open threads at the Open Thread tab every Sunday and Wednesday

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.


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.

This entry was posted in Uncategorized. Bookmark the permalink.

51 Responses to Annuntio vobis gaudium magnum: habemus officium!

  1. gwern says:

    > There’s this old Zen Buddhist parable about a family in ancient China who lived on a farm and owned only one horse.

    * Taoist; it’s in the _Lieh-tzu_.

    • Scott Alexander says:

      Huh. This was my source’s fault and not mine, but you seem to be right. Edited.

    • BeoShaffer says:

      I’ve a very similar story quoted as Zen by Charlie Wilson’s War, which is obviously a reliable source. That said its quite possible that the Zen Buddhists appropriated and modified it.

      • Kevin says:

        THANK YOU for remembering it was in Charlie Wilson’s War! I knew Sorkin had used it somewhere, but I thought it was in the West Wing and was going nuts trying to figure out which episode.

  2. Angie says:

    Congrats on matching. We’ll have to hangout sometime.

  3. sixes_and_sevens says:

    Having followed your adventures for a while now, it’s really nice to see this happen. I wish you all the best with it.

  4. ari says:

    Goongrats etc.. Although I’m feeling very, very slightly disappointed that I can’t reasonably expect to get to teach you programming now 🙁

  5. jsalvatier says:

    Brian Caplan claims that the number of new M.D.s has been flat for a long time (so the number per person keeps dropping). Is this new increase a super recent thing?

    Good luck!

  6. JJJ says:

    Will Alicorn follow you to Michigan?

  7. Deiseach says:

    Many congratulations on finding not just a job, but a job that you wanted!

    I have to ask, though: you could have gone to the Caribbean but you picked Ireland? Now, I love my little green island as much as the next patriotic soul who will be listening to mournful ballads about dying from starvation and weeping into our alcoholic beverages on Sunday, but what the hell, son?

  8. Berry says:

    You’re the best. This post made me the happiest I’ve felt in a while 🙂

  9. Joe says:

    Congrats!! This post makes me happy I read your blog. Your a good man and I wish you all the best!!

  10. Moshe Zadka says:

    You are superawesome, and I, for one, hope that you come back to the Bay area so that one day I can see you in person! When are you living for Michigan?

    • Scott Alexander says:

      You know I’m in the Bay Area now, right?

      I’m leaving for Michigan probably in June.

  11. Paul Torek says:

    Welcome to Michigan! It’s not too awfully cold here, unless you’re in the U.P. Here in southeast Michigan it’s only about 5 F colder than the Washington DC area, where I grew up. And global warming has probably given 1 or 2 of those back to me by now 🙂

    Chalk up another successful Prediction Book entry for me! And a gutsy confidence level, too.

  12. Erin says:

    Just wanted to say congratulations!

  13. Avantika says:

    Your happiness is really bursting through in every line of this post 🙂 Congratulations!

  14. nemryn says:


  15. Fnord says:

    Yay! Congratulations!

  16. estelendur says:

    I haven’t commented before but I’ve read this whole blog and am will be in Michigan this summer! 😛


  17. erratio says:

    Yay! (nothing substantive to add, but this post made me genuinely happy)

  18. Elissa says:

    Congratulations! I never doubted you’d land on your feet one way or another.

  19. Julia says:

    Very happy about this. I’m glad that you will be a psychiatrist.

    I spent a happy summer working on a farm in Ann Arbor. Real seasons can be nice. (Admittedly, tomatoes and crickets may be easier to love than ice storms.)

    One of my favorite bloggers writes about moving from San Francisco back home to Detroit and how much he loves living in Michigan:

    • Scott Alexander says:

      Thank you. That’s really helpful. We Californians have a bad tendency to think of the rest of the country as unbearably horrible in comparison, and since that’s the area where I’ll be it’s good to know people like it.

      I really tried to end up in Boston, but it just didn’t work out 🙁

  20. Pleeppleep says:

    Congratulations Scott! I’m really, really happy things worked out for you!

  21. Luke says:


  22. Sniffnoy says:


    I’m another person in Michigan (specifically another person in Ann Arbor), and I can say that the most recent few winters here have not been horrible.

  23. No one special says:

    Just the other day, I was saying, “I’ve been following this guy’s postings — he’s really interesting. It’s a good thing he lives in California, because if he lived here in Michigan, I would waste all my time talking philosophy with him.”

    Not that i know you or have ever spoken to you, mind you. Just another iLurker. But, for the hell of it, I live in Kalamazoo, and work in Holland (soon.)

    My ex-wife works at Holland Hospital, so if you’re working there, give he the cold shoulder for me. Or hell, maybe it would be useful to know her in some way, but I doubt it.

  24. A guy whose OKCupid profile made you muse that, if both our preferences were otherwise, you'd definitely give it a shot says:

    You deserved this. Even given the problems you’ve pointed out on LW with the concept of “deserving.” And despite the fundamentally deterministic nature of the universe, good luck!

  25. anon says:

    Congratulations! (maybe (99%) )

  26. Alex says:

    Wow congratulations! I know a family friend from outside the US who applied to residency programs in the US for several years before getting in (from Trinidad and Tobago, which is I suppose considerably less prestigious than Ireland).

    I’m curious, what made you decide to do medicine? I wouldn’t have guessed it from reading your writings here and on Lesswrong.

    • Alex says:

      Well, I suppose you do write a bit about public health which is sort of tangentially related to medicine, but still – why medicine?