Hire people who aren’t proven

Conversely, I found it really hard to establish myself as a solid contributor and even a technical leader when I joined a team as a (relatively) newly minted developer.

No matter how far I progressed, or how competent (even excellent) I became, I was still perceived as the "kid", even though my colleagues are only a few years older. I think I've mostly overcome this, but TBH I'm still not certain and I've been here for ~3.5 years in this role, and have been promoted to senior developer. None of that matters to my coworkers.

Moving teams is a much easier way to shed that "newbie" reputation (a path I decided not to take). Is it possible someone is creating this culture at your work that locks people into their role when they join the team?

It just seems like false dichotomy to me. The idea that you must project passion the right way else you don't care. I think it did not worked that way on 90ties either.

Also, people who stayed in this industry long do care generally.

There is also something good to he said about people who understand importance of boring tasks and negotiation and planning and process and do those boring tasks.

The thing is, the salient bits of being a doctor have to do with the thought process going on in their head, the stresses of responsibility and decision-making, and all the considerations they weigh with each patient. It's just not an "observable" thing. Docs don't really start sharing their internal processes with you until you're in the second half of med school, and even then not commonly. From the outside, it just looks like... guy in a white coat, often at a computer, making pronouncements. And then doing paperwork, which largely consists of documentation to prove to the government and insurers you did everything they decided should have been done for that patient and if not, why not. The combination of accountability and lack of autonomy is a leading cause of physician burnout and, again, is all internal.

The other part it leaves out is the hours. "What do I do with this patient?" is a very different thought process at hours one, eleven, and eighteen respectively, of what should have been a twelve hour shift. One hospital I know of has its trauma/SICU surgeons do 5 days on and 5 days off where they pull 12 hour shifts daily, and they're on call every night. But trauma/SICU doesn't really sleep, so these folks are making critical care decisions at hour one-hundred-and-twenty, of which maybe eight hours involved sleep.

All of these things occur in the internal landscape. Shadowing is ... not effective.

Most med students have done clinical research, shadowed doctors, volunteered in hospitals, etc. Back in the day, I did hospital volunteerism, clinical research, hospital QI, and I worked in health insurance. I'd seen medicine from pretty much every vantage point before I second-careered into being a physician. And every senior med student and resident and physician will tell you, "holy shit, I had absolutely no idea what it would be like." Even the occasional nurse that decides to go to med school, who most commonly think they're halfway to being docs already, will say "omg, I had no idea how much I didn't know, and how much you guys have to do." We had two in my med school class back in the day. When we were in didactics, they were shocked by how much docs had to know. When we got to clerkships (the second half of med school, where you work in hospitals) they were floored by how much was involved in being a physician that simply wasn't visible to nurses. And that's... you know, nurses. Folks who work in our vicinity on a daily basis.

Hint: most of them are not contracting because they particularly like the contractor's life. They're contracting because they can be paid more. I think in London the reality is that, if your company is using a new and hot tech stack (say Spark or Kubernetes), then the contractor's rate IS the market salary, as most people how know this stuff are doing contracts. You can find them as full-timers with regular FT salary (60-90k GBP ?) too, but that's more of an exception and a lucky catch I guess. Also, once they figure out how easy it is for them to make more doing the same work, they might leave anyway.

I don't know, to be honest. I know a lot of docs blame insurance for this, but I've worked in health policy and insurance - the problems are bigger than that.

A lot of the documentation is an attempt to create "quality standards". I like that in theory, and it's independent of what kind of payment mechanism is used, but ... docs will have a riot if we're held accountable for final outcomes ("This guy has had 30 docs in 20 years, smokes like a chimney despite my repeatedly trying to get him to stop, and I'm getting my wallet drained because he had a heart attack?").

Alternatively, process measures ("Did you put everyone with high cholesterol on a statin?") kill autonomy, require documentation, destroy nuance (there's a good reason I don't want this patient on a statin) and also calcify medicine (advances in medical knowledge occur faster than Medicare updates its performance metrics).

Unfortunately, "quality care" is also a PR move to cut costs. Create enough metrics over enough things docs have no control over, and a documentation slip-up becomes a good reason to ding us our reimbursement. This documentation is also a way to cut government and insurance budgets: they want the information for their programs, but don't want to pay for anyone to convert unstructured medical notes into structured data. Therefore, it becomes an unfunded mandate plopped onto physician's heads. That's not going to go away, unless all insurance - public and private - go away.

All-cash payment removes documentation because there's no one to be accountable to. There's no central party trying to track your outcomes. But... I like the idea of tracking performance. I like the idea of encouraging quality care. I wouldn't mind if we could divorce quality metrics from centralized payors, and put the cost burden of data entry onto the party using and benefiting from that data rather than physicians.

Some of the paperwork headache won't go away regardless. Primary Care docs spend most of their time doing bullshit paperwork tasks. As often comes up on HN, an employer won't let you bring your own chair to work - unless you get a doctor's note. Family med guys write stupid notes every single day, and it occupies a significant percentage of their workday. It's disheartening, and it's not going anywhere.

Another big thing that's happened is social work. Every issue that society doesn't want to deal with rolls down to healthcare: the homeless, the mentally ill, the uninsured, eventually land in an emergency room. That means we're the central clearing house for social services. Psychiatry - especially ER psychiatry - spend probably as much of their time (or more) networking with social work and the state trying to secure Medicaid and housing for patients than they do addressing their mental health needs. It's work that needs doing, but man is it heartbreaking to train to be a physician just to spend your day trying to arrange housing.

Lastly, even a single payer system has incentives to deny services. That's still a cost borne by the system. Accordingly, docs will still find themselves fighting paperwork battles with the insurer to justify a course of treatment - they'll just be doing it against a single bureaucracy instead of several.