Security Updates Not Needed - <AUTHOR> https://blog.gerv.net/2016/10/security-updates-not-needed/ <comment><USER2> That's the right way to have any computers, but it's clearly non-technical people who don't realize what their devices are doing or what risks they're posing to others.

As far as they know there is no risk/pain to them.</comment>


Keybase Exploding Messages - <AUTHOR> https://keybase.io/blog/keybase-exploding-messages <comment><USER3> Author here. I'm seeing the same comment in 4 different places on here, worded with various amounts of hostility. I now wish I had addressed this in the FAQ on the post.

There's the suggestion that an exploding feature is worthless, given your partner can just take a screenshot or video of what you sent.

This suggestion is missing (1) that your relationship with a partner is disproportionately okay at the time you sent something (i.e., you trust them THEN) and (2) there's a whole different class of adversary who compromises your or your partners' devices in the future.

SnapChat, as far as I know, has none of the cryptographic implementation of Keybase. And yet it has likely protected hundreds of thousands of kids from severe bullying. Consider the teen girl who sends the goofy sexy pic to her boyfriend. Before the advent of exploding messages, he might've iMessaged or emailed that to a friend, just one friend, his best friend, out of pride. And that friend sent it to a few more, and so on. Not out of malice, but suddenly the whole school has seen her pic of god knows what and she literally wants to die. But with Snapchat, taking a screenshot is knowingly violating a social agreement. It's also violating the trust of his current girlfriend - <USER2> knows it's not okay to screenshot that shit. And the number of people who would do that is much tinier. Second, consider the far worse scenario: she dumps him a month later and until then he has been NiceGuy. But then he becomes r/niceguy, the guy who will look through the old pictures and spread them around.

Finally, let's not forget that your device can be compromised by loss, theft, or hackers, at any time. Exploding messages are gone when that happens.

People can be tricked, compelled, coerced, blackmailed, and hacked. Or just turn evil. All in the _future._ Which is what a timed message protects against. This is why Keybase is doing this. Paired with encryption it's quite powerful.

<comment><USER4> > _SnapChat, as far as I know, has none of the cryptographic implementation of > Keybase. And yet it has likely protected hundreds of thousands of kids from > severe bullying._

Is this true? (Asking with no implication of criticism or being a leading question - I just genuinely don't know the answer)

I can believe both that these teens were going to sext each other anyway and Snapchat is keeping them safer, or that they _weren 't_ going to and Snapchat has convinced them that it can be done more safely than it can actually be done.

Has anyone done studies on this? (Is it even possible to do studies? I suppose you'd either need information from Snapchat itself on how often they detect screenshots, or from high schools on bullying cases over time and whether Snapchat is involved + hope that bullying cases that get escalated to adults at high schools is a meaningful proxy for actual bullying.)

I'm inclined to buy your argument that because of the implementation making stored pictures not the default, and the social pressure not to take screenshots, _probably_ Snapchat's disappearing messages are better than iMessage. But this seems like the sort of thing that's dangerous enough (in either direction! if the technology works and we refuse to deploy it, that's bad too) that hard data would be useful.

<comment><USER5> There's a theory about this: [https://en.wikipedia.org/wiki/Risk_compensation](https://en.wikipedia.org/wiki/Risk_compensation)

> "Risk compensation is a theory which suggests that people typically adjust > their behavior in response to the perceived level of risk, becoming more > careful where they sense greater risk and less careful if they feel more > protected. Although usually small in comparison to the fundamental benefits > of safety interventions, it may result in a lower net benefit than > expected."

There's a book too, with a special emphasis on on financial crises. [https://www.theguardian.com/books/2015/oct/12/foolproof- greg...](https://www.theguardian.com/books/2015/oct/12/foolproof-greg-ip- review-biggest-risk-is-safety)

> "In the run-up to the crash, consumers and even policymakers had come to > believe that smart regulators and forward-thinking bankers had made the > world of money a much safer place.

> "The fundamental insight of Ip's new book, Foolproof, is that this very > belief was a key factor in the lead up to the crash. When people believe > they are safe, they take more risks – they drive faster, in motoring terms – > and "speed makes everything worse". Or as the economist Hyman Minsky, whose > work Ip revisits, put it: "Stability is destabilising."

There are applications in our field too:

\- safety features for users might make them behave less safely (e.g. exploding messages)

\- better reliability of systems might lead us to put more trust in them, leading to even bigger outages when they occur (e.g. centralising trust in cloud providers)

It's interesting to see things like Chaos Engineering ([https://principlesofchaos.org/](https://principlesofchaos.org/)) introducing intentional "danger" into a system in order to improve system-wide stability. Of course, maybe Chaos Engineering will give us more trust in our systems which may lead us to take even bigger risks...

<comment><USER4> Yup, that's basically what I'm getting at, thanks for the links!

So, I'm okay with risk compensation if people are _net_ doing better. I don't think that "if even one person is hurt by this, that's too much" is a meaningful basis for decisions, especially when there's a risk that even one person will be hurt by _not_ doing the thing. So at the risk of reducing people to numbers, if, say, 100 teenagers send sexts when they otherwise wouldn't have and get screenshotted, but 1,000 teenagers send sexts when they otherwise _would_ have sent them to a non-disappearing-by-default client, and now their photos _don 't_ get copied because of social pressure / high-but- not-impossible technical barriers, that still seems like a clear win.

That's the sort of data that I think would be very interesting to inform good engineering decisions, and also pretty impossible to get.

</comment></comment></comment></comment><comment><USER6> I used to be against this style of 'DRM' \-- either analog hole (screenshot or physical camera) or client subversion (client logs all messages out of band forever); but I think I misunderstood the use case. This is about changing behaviours to be more ephemeral; An expectation that your messages are not there forever. In a world of "unlock your phone or arrest" these features are very important. Thanks for rolling this out KB

</comment><comment><USER7> Nice, succinct response in the FAQ to those who don't care about privacy:

 _" I have nothing to hide"

Because no one is trying to hurt you_

<comment><USER8> ... currently.

<comment><USER9> ... to your knowledge.

</comment></comment></comment><comment><USER10> As I understand, Keybase chat is open-source? ([https://github.com/keybase/client](https://github.com/keybase/client))

I don't have time to read through the code right now, but I'd love to hear how they implemented exploding messages with untrustworthy clients.

I've thought about it a few times before, and it seems one of the few places that closed software has an advantage - You can't easily force third-party clients to delete messages.

If they've solved that, I'm really interested to learn how it works!!

<comment><USER11> It is impossible to implement this feature "safely" even with trusted clients -- worst case I take a screenshot or even a photograph of the device displaying the message before it explodes.

If you don't trust the person at the other end, this is never going to work. It's more useful for "we both agree that we don't want a paper trail" kind of thing.

<comment><USER12> A dead simple way to thwart the "screenshot" attack is to release a tool for accurately falsifying a screenshot. I've never seen this employed in practice though.

<comment><USER13> How is any bitmap editor not such a tool?

<comment><USER14> I think they're talking more along the lines of those online meme editors. Yea i could download the lion king and clip the frame with simba and then pull it into photo shop and then add text and then upload it to imgur. Or I could go one of those online meme editors in click the photo and enter my text and then get a link to the meme I made.

The whole point is to totally lower the bar for anyone to make a passable copy, thus removing all confidence that any screen shot is genuine.

</comment></comment></comment></comment></comment><comment><USER15> If you haven't done so already, try clicking on any of the text of the blog post.

<comment><USER16> Nice touch.

</comment></comment><comment><USER17> You might be surprised, but for some people this feature can be life or death. My team has been actually waiting for Keybase to have this. We work in countries where some of us are regularly taken aside by the local police or armed forces and our phones are being checked to see if we have anything against the current government. We have to constantly make sure our communication has no traces. We'll be moving to Keybase very soon. Thank you for this!

<comment><USER18> Why don't you just use a client that deletes messages? Why would you wait for keybase to implement this?

<comment><USER17> We've been waiting for Keybase, it doesn't mean we've been waiting with no solution meanwhile. We want to use Keybase because many of its other features.

</comment></comment></comment><comment><USER19> As a security layperson my initial reaction was "how can cryptography help with expiring messages, once it's decrypted it's decrypted, that doesn't sound right", but I'm curious if I'm understanding correctly that this is actually two separate features: 1) clients voluntarily respecting "please delete this message at X time" and 2) forward secrecy. And Keybase has tied them together for UX reasons since people tend to not have an intuitive understanding of when they might want to use forward secrecy, but they always want it in the case of exploding messages.

<comment><USER20> This is not functionality meant to make sure the other party will not have access to the massage after X time anymore, it's just convenience opsec: If you don't want someone to know X after some time, you should never tell him in the first place (he doesn't need to hijack the keybase client, he can simply "remember" the message). Instead this makes it easy to limit paper trace using a nice UX.

</comment></comment><comment><USER21> Of course this is not to address the case where the recipient would take a screenshot. I still find disappearing messages useful to reduce attack surface if say, the phone gets taken away and unlocked by someone else, or a backup of it is found and restored on something else, or if the phone gets compromised at some point at least not all previous messages are exposed, etc. A useful feature, not meant to address scenarios or malicious recipients or previous compromised devices.

</comment><comment><USER22> I had to stop using Keybase after this issue [1] cropped up: when you re- install your OS, you lose access to the "device" and have to provision a new one, even though the machine is the same, and even in possession of an uncompromised private key.

Apparently this happens a lot [2-7... probably more]. Unfortunately, this renders Keybase unusable for me because, even though I still have my private key, I cannot access my laptop's Keybase when I install it.

[1]: [https://github.com/keybase/client/issues/3460#issuecomment-2...](https://github.com/keybase/client/issues/3460#issuecomment-278486140)

[2]: [https://github.com/keybase/client/issues/3559](https://github.com/keybase/client/issues/3559)

[3]: [https://github.com/keybase/keybase- issues/issues/1952](https://github.com/keybase/keybase-issues/issues/1952)

[4]: [https://github.com/keybase/keybase- issues/issues/1985](https://github.com/keybase/keybase-issues/issues/1985)

[5]: [https://github.com/keybase/client/issues/4260](https://github.com/keybase/client/issues/4260)

[6]: [https://github.com/keybase/client/issues/2357](https://github.com/keybase/client/issues/2357)

[7]: [https://github.com/keybase/client/issues/2675](https://github.com/keybase/client/issues/2675)

<comment><USER23> I'm not entirely sure what your issue is here. Why not reprovision (either with a different provisioned device or your paper key) and give it a new name?

<comment><USER22> Because it's the same device as before. I only have one name for it.

<comment><USER23> Just call it device2?

<comment><USER22> That makes it impossible to recover my original device.

<comment><USER23> You don't need to reuse the original device name, just append a number to it. Think of it as device incarnation 2.

</comment></comment></comment></comment></comment></comment><comment><USER24> > corporate messages

In this day and age, I do not advise this. Check with your company's compliance officer or corporate council before doing anything that is designed to remove evidence of communication.

</comment><comment><USER25> Consider this:

      I send an exploding message, set for 1 day, to Bob.

      Bob checks his chat a week from now.

      Does Bob get the message? Or has it already exploded?

I guess I'm asking when the actual explosion timer starts - when the message is sent, or when it is read? For group messages, do all parties need to read it before the timer starts?

<comment><USER11> From the FAQ:

Does the timer begin when the message is sent or received?

Sent.

This seems like the only sensible answer for group chats. And we can't have a different answer for 1-on-1 chats and group chats. That would confuse people. Not the kind of person who reads an FAQ such as yourself, of course.

So our answer is simple: you set a timer and the message is gone after that time.

<comment><USER26> >And we can't have a different answer for 1-on-1 chats and group chats.

What might be the reasoning here that Keybase won't do it yet Signal messenger does start the timer on the "receive" end?

<comment><USER27> It narrows the attack window. It's not hard to imagine a scenario where something happens to the receiver and as the sender you didn't realize this until you sent a few messages but the third party who got the receiver won't be able to access the device for some time. Hopefully by the time they get in they have self destroyed.

<comment><USER26> A valid point! Thanks for postulating!

</comment></comment></comment></comment></comment><comment><USER23> This is like snapchat, they're offering something that they can't actually guarantee. Of course keybase users are going to be generally more knowledgeable than snapchat users and most will understand the limitations.

<comment><USER28> It's still better to delete the message than to leave it there "because you can't guarantee it 100% either way". Defense in depth.

<comment><USER29> I quote this far too much on security but "Perfect is the enemy of good." Meaning, people often dismiss improvements because they're technically imperfect.

And it isn't just random forum discussions, major technologies like secure DNS, secure email, etc were held back years because nobody could agree on compromises needed to make improvements.

</comment></comment></comment><comment><USER30> This very article shows you the problem with "features" like this.

You see that video demonstrating the feature? Notice how you can read the content of the message which was supposedly deleted?

<comment><USER27> If you don't trust the receiver you should not be sending them anything sensitive to begin with.

This feature just eliminates the messages in case something happens to the recipent or their device if either become compromised.

Let's say I work IT and user Bob forgot their password again and needs a temporary reset. I can message him his temporary password that expires in 3 minutes so that they can login and set a new one.

<comment><USER31> I trust the receiver.

I don't trust future bad actors who get hold of the device, including the receiver should they turn.

</comment></comment></comment><comment><USER32> I want _all_ my data on the internet to explode after N days.

I keep asking for this. Google, Facebook, where is that feature?

</comment><comment><USER33> click on some text in the article, it "explodes" :)

<comment><USER34> Did you see the hidden message? I'm not sure what it means. (Treasure at the root of esabyeK)

<comment><USER35> [https://keybase.io/esabyeK](https://keybase.io/esabyeK) which is keybase backwards

</comment></comment></comment><comment><USER36> Can someone explain the FAQ item around "My team uses Telegram and I'm scared shitless."? I musta missed the joke

</comment><comment><USER37> How does this differ from the existing "Message deletion/retention" feature that was present before this? Did the existing feature delete messages, but not keys? Is the old feature and the new feature combined, or are they still separate?

</comment><comment><USER38> anyone care to expand on the practical applications/implications/threat model where this makes sense?

<comment><USER39> It's for when you trust someone but don't want to risk either your or their device being compromised in the future. For instance:

\- if your or their phone gets taken at a border crossing

\- if your or their phone gets taken by the FBI (which is how they recovered encrypted WhatsApp/Signal chats from Michael Cohen's phone)

\- etc

<comment><USER40> Or in a much simpler and common case: you trust someone right now to run a non-modified client and not to take screenshots, for example based on a corporate policy.

Months later the relationship turns sour, and they are fired or denied a promotion. They can't _then_ go through the archives any more to take the screenshots.

</comment></comment></comment><comment><USER41> now that their is a exploding feature, can i finally explode this annoying notification about not providing my full name and description.

</comment><comment><USER42> Heard about this last week from a friend on the keybase team, happy to see it launch on time :) congrats!

</comment><comment><USER43> Seriously, do we need a stupid animation and a silly-looking "ka-boom" image? It just comes across as trying too hard to be cute and ends up looking childish and stupid.

<comment><USER44> Metaphors like this help people understand what's happening. If the message just vanishes that could be for any number of reasons. But with this animation it's clear that the message is being erased. Keep in kind not everyone is a hackernews-reading computer expert.

<comment><USER45> Though I am not personally a fan of cute stuff like that, if it helps in making secure messaging usable for everyone from IT experts to their grandmothers who have never touched a computer I am all for it.</comment></comment></comment>


A Forth implementation and programming environment for ATmega microcontrollers - <AUTHOR> https://mywebspace.wisc.edu/lnmaurer/web/FloatingAway/FloatingAway.html <comment><USER2> There are also chips that have a Forth as their instruction set:

[http://www.greenarraychips.com/](http://www.greenarraychips.com/)

Gotta love having 144 Forth machines in a $20 chip.

</comment><comment><USER3> FlasForth is another fun Forth for AVR and PIC microcontrollers. You can even try it out over telnet... :-)

[http://flashforth.sourceforge.net/](http://flashforth.sourceforge.net/)

</comment><comment><USER4> I love the AVRs, they are nice and simple Harvard architecture 8-bit microcontrollers, but I think, for any new project the ARM Cortex series (M0, M3, M4) are just a better option, they are 32-bit, are faster, have more RAM, more Flash, you can get DSP and other nice features, and they are cheap.

<comment><USER5> _Any_ new project? I just made a product for a client that had to fit inside a shoe and be as physically unobtrusive as possible while stealing power from another device.

It only needed one bit of input and one bit of output and the code fit into an 8-pin Tiny AVR and was probably just about a kilobyte of compiled C. The chip cost less than $1 in single units.

ARMs are nice and everything, but orders of magnitude overkill for the thousands of small devices like this.

<comment><USER6> The "any new project" generality is getting closer to an absolute truth every day. Many Cortex chips use _much_ less power than an AtMega or AtTiny in sleep modes, and use very little power in active modes. All are fast enough that they can spend the majority of their time in deep sleep modes. NXP is making significant inroads in producing low pin-count devices, and there are many chips available for under $2.50 in single quantities.

I mean, at the end of the day, the tool you know is the tool you should use, but it's more difficult to quibble about the technicalities of it all the time.

I would argue that the biggest barrier to Cortex M0/M3/M4 adoption in the hobbyist/maker/startup community is the lack of coherent open tool chains. Many of the cheap programmers will only program a subset of chips, many pre- canned compilers don't include various features (Many lack support for the M0+, or the FPU on the M4F chips), it's almost impossible to get code working on a chip without delving into a vicious hellscape of linker scripts, and many manufacturers license their peripheral libraries under onerous non-free/non- open licenses.

I could program an AVR with one hand tied behind my back using an entirely open toolchain. Until I can do that with even a single manufacturer's Cortex Mx offerings, the AtTinys and AtMegas will be sticking around. I want to work on my project damn it, not debugging my toolchain.

</comment></comment></comment><comment><USER7> This brings back some memories. :)

</comment><comment><USER8> Here's an aside on Forth-like languages: how much academic interest/research has there been in them? I've seen some people say that Forth is like Lisp in that it is its equal when it comes to high-level abstractions, but at the same time that it fits like a glow for low-level tasks. Some researchers must have been curious about this paradigm, at least enough to find out if that claim might hold some weight.

<comment><USER9> As the author of jonesforth[1], I found Forth to be a great hack and enormous fun to write. However as an actual language to implement things, not so good. It's terribly difficult to write correct code when you've got no bounds checking, only primitive memory management, no types, and having to manage the stack. (Modern Forths fix these problems to some extent.)

It's my understanding that most language research is on safety features, type systems and so on, so I don't know how interesting Forth would be.

[1] [http://git.annexia.org/?p=jonesforth.git;a=summary](http://git.annexia.org/?p=jonesforth.git;a=summary)

<comment><USER10> Hi! Thanks for jonesforth; I found it very enlightening when first learning about stack languages. I typically explain Forth as somewhere between assembly and C—a Forth implementation is minimal enough that it's practically a structuring technique for assembly programs, and (like types in C) more for convenience than correctness.</comment></comment></comment>


DNA test 'could predict most effective diet - <AUTHOR> http://news.bbc.co.uk/2/hi/health/8550091.stm <comment><USER2> "According to your DNA test, you need to eat less and exercise more. That'll be $5,000, please."

</comment><comment><USER3> What control? Anybody taking part in a big important Stanford research project may be 2-3 times more likely to stick to their diet.

<comment><USER4> Everyone in the study was on a diet, but they put some people on the "wrong" diet for their genome. They were the control. The 2-3 times more weight lost was comparing those two groups in the study, not comparing to people outside of the study.

</comment></comment><comment><USER5> Technology's all well and good, but couldn't trying both diets for a few weeks each lead to the same results for a lot less cost?

If this DNA test is going to be useful to you, you actually _do have to_ go on the diet at some point anyway!

</comment><comment><USER6> I wish I could recode my DNA to make pizza my ideal diet...

<comment><AUTHOR> While that is a good wish, I wish I could make Beer part of my ideal diet.

<comment><USER7> > I wish I could make Beer part of my ideal diet.

You could make the result of a beer diet your ideal.

</comment></comment></comment><comment><USER8> So, basically you should go paleo, but that varies depending on what's your ascendance

<comment><USER4> I wish they had gone into what genetic markers got assigned to which diet types, but that might be a bit too much for the BBC. A quick search of Google Scholar is not turning up a likely candidate for the paper.</comment></comment>


Physician burnout widespread, especially among those midcareer, report says - <AUTHOR> https://www.wsj.com/articles/physician-burnout-widespread-especially-among-those-midcareer-report-says-11579086008 <comment><USER2> Both of my parents are doctors. In high school I had real thoughts of going into medicine. They strongly discouraged me towards going into that field. In college I was pushed towards a MD/PhD program by my lab's PI. I thought about graduating at 28-30 and decided against it.

Jr year I interned at Amazon after that experience I knew I made the right decision. It is a really, really hard sell for this current generation to do another 5 years of school with residency and then specialization when you can quickly make 100k+ at a tech company. All of my friends who went into medical school are working hours like 6am-6pm or 8pm-8am. They get like two days off every two weeks. I think there are a bunch of possible solutions but the easiest one is making 5 year medical programs (2 years undergrad, 3 graduate) more common in the US.

<comment><USER3> Another solution is allow more doctors to be licensed so they don't need to be as overworked.

<comment><USER4> The medical cartel will never allow that. They have a complete stranglehold on both licensing and education.

<comment><USER5> By "medical cartel" are you referring to the US Congress? Because the actual bottleneck in physician production is in the shortage of residency training slots, and the vast majority of those are funded by the Federal government. The American Medical Association has been lobbying for more residency slots. Every year students graduate from medical schools but are unable to practice medicine because they can't get matched to a residency program.

[https://www.ama-assn.org/press-center/press-releases/ama- fun...](https://www.ama-assn.org/press-center/press-releases/ama-fund- graduate-medical-education-address-physician-shortages)

<comment><USER6> Why do we need the federal government to fund these slots at all? Hospitals work resident physicians to the bone and bill patients exorbitantly for it. Their hours are capped at 80 per week yet they receive no overtime pay[1]. Yes, the residents are "in training" but it's not like it's a burden for a hospital to take them on - they are the workhorses that handle a huge number of cases and drive hospital revenue.

[1] - [https://en.wikipedia.org/wiki/Medical_resident_work_hours](https://en.wikipedia.org/wiki/Medical_resident_work_hours)

<comment><USER7> Most hospitals operate at a loss.

The ones that don't nickel and dime their patients, or even engage in outright billing fraud.

Do you really want to move more hospitals to the latter form of doing business? Because they would be a huge net loss for everyone except the hospital CEOs.

<comment><USER8> Given the medical costs in the US, this really begs the question: why?

<comment><USER9> To receive federal and state funding as well as accept residents hospitals have to run an ER and accept patients regardless of payment ability. Some facilities will do their best to help a patient that will be unable to pay. Others will simply stabilize the patient until they're not going to die immediately and then kick them out. Since medical care is very expensive a single non-covered ED patient could EASILY cost the hospital 250k+ per visit. For example maybe a homeless person is found and brought in unconscious. They're then discovered to have untreated diabetes, rot in their feet, and psychiatric issues. They'll be in the hospital for at least a week, surgery to clean up any rotten tissue, and then maybe a stay in the psych ER or other facility. Every day wracking up huge charges which the hospital will never be compensated for..except by spreading the loss around to others.

<comment><USER8> This looks like a crude version of socialised healthcare to me. Other socialised healthcare systems around the world should in theory face the same problem, wouldn't they? But AFAIK they do not nearly have the same cost issues as the US, at least I'm not aware of this here in Germany.

One theory I've heard that sounds plausible is that

a) insurers do not pay anywhere near what hospitals bill to uncovered patients

b) hospitals do not even expect patients to pay the whole bill, but more like 20% of it, so it is always good to contest the bill

So the problem is that hospitals are cash-strapped for systemic reasons, but can't get it from insurers or the state because those have contracts in place. So hospitals try to squeeze uninsured patients as much as they can with inflated bills, with predictably horrifying consequences. Insurers don't mind because that makes the case for buying insurance even stronger.

So one solution might be to pay for poor/homeless care via state/federal budgets. This could cover poor people up to an income level that can afford insurance.

<comment><USER9> Most/many of the homeless that come in are eligible for Medicaid or other government benefits (veteran healthcare for instance). However figuring that out can be very difficult. Many of them are incapable or unwilling to give up their names or stay long enough for social workers to get their paperwork in order. Or they're afraid of being located (for example they have warrants out for their arrest). Then you have regular uninsured people who are simply incapable of paying that come in and give fake information.

Fun fact, if you're unable to pay the full amount most hospitals will do almost ANYTHING to stop from having to send your bill to collection. Even if you say 'I'll pay $50/month forever' thats way better than they'll get from the debt agency that buys your debt.

<comment><USER8> Thanks for the explanation. Hospitals shouldn't be left alone with this, I can't imagine forwarding the costs to Medicaid would be a worse solution than the accountability problems that arise when having patients with no names, like fraud.

</comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER10> Please lobby the AMA to not artificially limit the supply of doctors by creating regulations around residency. I personally know of many people with MDs from India who don't work here as physicians because they could not get a residency 'slot' in the Bay Area where their family lives. Relevant thread with links on StackExchange: [https://skeptics.stackexchange.com/questions/4561/does- the-a...](https://skeptics.stackexchange.com/questions/4561/does-the-ama- limit-the-number-of-doctors-to-increase-current-doctors-salaries)

<comment><USER5> The AMA isn't limiting the supply of doctors. The actual limit is in the number of residency program slots funded by the US Federal government. If you actually want to increase the supply of doctors then lobby Congress for higher residency funding.

[https://www.ama-assn.org/press-center/press-releases/ama- fun...](https://www.ama-assn.org/press-center/press-releases/ama-fund- graduate-medical-education-address-physician-shortages)

<comment><USER11> Apprenticeships in many (most?) fields are sponsored by the professional organization (akin to a guild) and paid for by laborers at lower-than-master wages. And yet, here is the AMA itself saying the problem lies with federal government funding. Curious. Seems like a convenient scapegoat.

<comment><USER12> I think you are significantly underestimating how much a medical residency costs.

Also, most apprentices end up working for/with the company/professional that trained them. I'm not sure there are many doctors who employ "apprentice/junior" doctors to work along side them the way a plumber/bricklayer/blacksmith/electrician would.

</comment></comment></comment></comment><comment><USER13> My wife just graduated medical school and started residency.

The burn-out affected both of us and we're just starting to get over it.

* Med school is a freaking grind. She was either at class, at rotations, or studying. Pretty much 80+ hours/week for 4 years.

* We had to move a lot, which has limited my social life. Ended up spending a lot of time just "working" while she'd study in the evenings.

* Major life impacting tests nearly every year. Low scores or failures on a single exam can kill any career aspirations.

* Insane debt load. We're looking at total payback costs around $310k. That was with no undergrad debt and my job paying for all living expenses. If you don't become an attending, you're fucked financially.

* Not enough residency spots for the number of medical schools. Less than 80% of candidates matched into a residency spot. Follow on matching is very low.

* That's right, pretty much 1 in 5 doctors will not go on to practice medicine because they cannot get a residency position.

* Residency salaries are complete shit. It's not unheard of for residents to have to take out loans to payback loans during residency.

* Resident have absolutely no leverage. They are literally slaves to the program they're "matched" to. Program director changes, hospital gets bought out, peers are insufferable - sucks to be you, you're stuck until you graduate.

* Financially being a doctor doesn't make any sense. Everyone looks at doctor's salaries, but completely forgets about the 8 to 10 years doctors (a) make nothing (b) pay for education (c) make pennies. Even with the "doctor salaries", it will take my wife well into our 50's to be financially ahead had simply pursued a career in her STEM field. There's a lot of life that can be live in 30 years that a "big house and a fancy car" doesn't make up for.

* Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives.

I could rant for hours about all of the bullshit my wife went through (and, lesser myself). If you're thinking of becoming a doctor, do yourself a favor and do something else.

If you really want to work in medicine, becoming an NP or PA is a looking like an increasingly attractive route.

<comment><USER14> Speaking as someone who quit after medical school and codes professionally (going on 10 years), I'd suggest temperance on the recommendation. Debt is high but so is salary, if they are in it for the long haul they'll be just fine. If you think you want to be a physician, shadow some. If you like what they do, you might like being a physician. I met many doctors who I think would be happier not being a physician, but also many that I think wouldn't be happy doing anything else. I'm happy with my decision overall but frankly i couldn't imagine going back as an NP, PA, Dentist... or anything in the field that wasn't an MD. Those all have much better work life balance, but you need to realistically understand what it means to do each if you want to be happy, and select the one that feels right. (And if it doesn't feel right, Dentistry has the absolute best work life balance, pay, and ability to help people who legitimately need it).

<comment><USER13> > Debt is high but so is salary, if they are in it for the long haul they'll > be just fine.

This is exactly why I recommend against medicine. You have to be in it for the long haul. If you find you hate medicine in your 3rd year (when rotations typically start), you're already $100k in debt.

</comment></comment></comment><comment><USER15> I was interested in medicine in high school. I was able to shadow a few physicians and talk about career options. At the time I was shocked that most of the physicians I talked to said they would take a different career path if they could do it over again.

The common theme was that they felt it used to be a respected profession but now they're broadly just cogs in a healthcare system that given them little freedom for professional discretion and lots of paperwork.

I ultimately didn't pursue medicine.

</comment><comment><USER16> I would like to see the data sliced by employed vs independent physicians.

Independents (a majority of physicians) need to deal with all the billing and insurance headaches that now come with the industry, and have to deal with setting up their own EHR to deal with it.

Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient.

Would be good to see if there is a correlation there.

<comment><USER17> >Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient.

"Employed" physicians no longer deal with patients, they are called customers. Helps to keep customers happy and physicians focused on the profit motive.

<comment><USER18> Wouldn't the profit motive be stronger for an independent physician since they actually directly profit, rather than facing indirect pressure based on your employer's profit motive?

<comment><USER17> Independent physicians are free to act as they see fit, some are very profit motivated, some aren't.

Employed physicians are pushed to be as profit motivated as their employer wants them to be, or they get canned.

</comment></comment></comment></comment><comment><USER19> Here's the full report: [https://www.medscape.com/slideshow/2020-lifestyle- burnout-60...](https://www.medscape.com/slideshow/2020-lifestyle- burnout-6012460?faf=1)

Strangely, this "report" is a set of slides. It would have been useful if there was more information about how the Medscape authors conducted this study. On slide 28, it says the sampling size was "15,181 physicians across 29+ specialties met the screening criteria and completed the survey". What was the screening criteria and how many physicians did Medscape initially reach out?

I wish the WSJ asked these types of questions.

</comment><comment><USER20> I'm sure this isn't the case for every doctor, but what I've observed is that scale seems to be killing everything. When you have 10 minutes with a patient, have no long-term relationship, ship them off to a specialist that has even less context of their overall health, and ultimately just prescribe them meds to treat a symptom, that person does not get healthier. Over thousands of patients that starts to challenge any sense of moral obligation you originally had when entering the field. Then you become disillusioned and burn out.

The irony is the part about everyone becoming less healthy. That creates more demand for medical services. Rinse, repeat. We truly have the worst system imaginable in the US. It evolved over time. It's nobody's fault. It's everybody's fault. It needs to be burned down and rebuilt. It seemed like we had a chance with the ACA but it was pretty clear early on that it wouldn't fix the root causes and it hasn't.

<comment><USER21> There's a few doctors in my city who charge a $50 a month fee for a 30-39 year old and you can call and see them whenever. Insurance doesn't cover it at all. I'd also imagine if you tried to really abuse the relationship and show up constantly for no reason the doctor might fire you. I feel like it'd encourage a relationship of respect both ways.

I interviewed a couple of them and one talked to me for an hour about health and diet and exercise, just a friendly chat to see if I wanted to use him. He said he was getting ready to retire from medicine after years of ER work when his doctor friend encouraged him to try direct primary care. It was so different than the regular medical system, cutting out all the middle men.

<comment><USER22> Is this in the US? I would think that US malpractice laws, and the corresponding malpractice insurance costs, make this impractical.

<comment><USER23> I have a friend here in U.S. who runs their practice like this. They don't make any money at all at this kind of price. They should be charing each patient more like USD 200 per month.

</comment></comment></comment></comment><comment><USER24> Physician practices get absorbed by large national corporations and patient care gets reduced to metrics that administrators can tweak to extract more revenue and profit. The benefits get paid to administrators as bonuses, while physicians see their salaries stagnate.

The corporitization of physician practices is destroying the profession.

<comment><USER25> The country also wants more supply of healthcare, at lower prices, while the supply of doctors remains constrained via the restriction on number of residency training spots each year. This is the root cause, insufficient supply in the face of demand, and it is manifesting itself in these various side effects.

<comment><USER24> This is incorrect. There is no supply/demand relationship for pricing services. Doubling the number of trained physicians will not decrease healthcare costs, it will simply drive down physician annual income.

The main driver of inflated healthcare costs is administrative waste: hospital management, insurance management, government management.

</comment></comment></comment><comment><USER26> Does this indicate that more physicians are needed in the market, or that current system/workflow is unsustainable?

<comment><USER27> Remember the AMA successfully lobbied to reduce the number of residencies and thus the number of doctors in the 90s.

We need to open up the medical profession to competition and allow the # of doctors to meet the demand.

<comment><USER28> I think this is the key, so much of of the problems physicians face were created by physician and their own lobbying. American Physicians are paid more then other countries by a lot [1] in large part because of high educational requirements that were supported by physicians. Resident burn out is awful, but the people pushing them to work insane hours aren't the hospital administrators, but older physicians who have the attitude that they went through it too. It's really hard for a physician from another country to immigrate to the US and practice, restrictions supported by, you guessed it, physicians!

If you really want to lower physician burn out and decrease health costs we need to increase the supply of physicians in this country, and you'll have to fight the existing physicians to do it.

[1] [https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010....](https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.0204)

<comment><USER29> American software developers also get paid multiples of their non-us counterparts. Same with many other professions.

<comment><USER25> Except there is no organization limiting the number of software developers. In fact, I can't think of another field out there with so many free resources for one to educate and prove themselves a capable programmer.

<comment><USER29> Nurses make more in the us, then most doctors outside the us. There is a shortage of people in general in the usa, and we have the INS artificially limiting immigration for everyone.

</comment></comment></comment></comment></comment></comment><comment><USER30> What is the baseline of burnout for all mid-career professionals? I'm a mid- career guy and most of my friends/peers are a little burnt out no matter what they are doing. Balancing any serious career with kids on one side and aging parents on the other is tough.

</comment><comment><USER31> Anecdotal but my gen prac warned me on this 10 years ago, that obgyns were being driven out by high malpractice insurance. He suspected this would ultimately lead to consolidation of doctors under health organizations to limit personal liability.

Sure enough you have conglomerate health services corporations absorbing small practices, cheaper prices for consumers with added bureaucratic noise & volume thresholds for practitioners.

<comment><USER32> I've seen this with my own doctor. They said another reason besides the insurance was the increased demand for paperwork and electronic backups or something like that. So it's much easier and cheaper to have a single team manage the digital side for 20 doctors instead of just 1 or 2 doctors.

From the consumer end I like this more because their new group has a wide variety of specialties so you don't need to keep filling out the same paperwork and they also can afford to maintain an electronic system so you receive text notifications for appointments and can make appointments online and such.

<comment><USER33> As a consumer, I'm coming to dislike it. In theory, that consolidation of redundant efforts should improve my care and reduce my costs.

In practice, I've seen the opposite happen. My local health care market has consolidated down into a single large corporate entity that, like any good monopoly, has every reason to reduce quality of service while increasing prices.

I guess I fill out less paperwork, but that isn't saving me enough time to justify all the little routine visits that used to cost me $50 out of pocket suddenly costing $300 out of pocket.

</comment></comment></comment><comment><USER34> I can see the burnout starting in medical school and I would not be surprised if this trend continues to get worse.

<comment><USER35> The physicians that I know talk about this a lot. From what I gather, part of the problem is that medical school is _really_ expensive, so they take these really massive loans to get through school, which is generally on top of their debt from their bachelors and masters. Then, many of them discover that they're not in love with the field as much as they originally thought. The problem is that it's very difficult to back out at this point; they're hundreds of thousands of dollars in debt and dropping out leaves many of them with a degree that will not allow them to pay this debt down. As such, they power through. Then, they enter a profession were the hours are truly and utterly terrible. People don't get sick on a 9-5 schedule and unless you're working in something like dermatology, you're going to work nights and you're probably going to work shifts that range from 14-24 hours even as an attending. Yes, this depends on specialty, but hospitalists, emergency medicine, any surgical specialty, and most people doing procedures will end up with long night shifts at least a few times a month. And, this must be done for several years even after residency in order to clear the debt even if you just want to quit the profession entirely. Every physician I know of talks about an exit plan as soon as they enter the profession, which is generally not a good sign. Though, probably a smart one.

Now, does this differ from any other profession where we take on debt to get a degree in a profession that we don't like just to work that profession to pay off the loan? For the most part, no. I think the distinguishing feature for physicians is the debt is higher and it takes more years to get into a position to pay off that debt, so the exit point is farther away. I do think physician hours suck far more than most professions. I also think the profession is far more abusive than most white collar professions, but that's debatable.

</comment></comment><comment><USER36> The Doctor's guild does this to themselves by restricting supply to obtain their grotesque salaries. Zero sympathy.

</comment><comment><USER37> There are a lot of misconceptions and misinformation coming out in this thread. I'm going to try and shed some light on them. (HN says my post is too big, so I'll have to split up a bit).

There are four major groups of physicians:

-Residents. These are the folks that just completed medical school, and are doing four-plus years of training in a hospital setting to become independently practicing physicians. In year one they are called interns. By year three or four they have various amounts of independence: in internal medicine, family medicine, etc. they are basically practicing as full physicians, with some light supervision (the heavy supervision is years one and two). They are one of the hospitals most valuable employees: taking into account supervision costs, they are producing about 80-90% of the revenue of a "real" physician, for less than 1/4 the cost. These are the guys who work 80+ hours per week without exception, do all the scut, etc. These are _not_ "mid career physicians". This is where "old physicians had to go through it, so young physicians have to go through it."

\--Resident Training: the AMA has been pushing to expand resident training spots for years. The funding is part of Medicare legislation, and _no one_ has been willing to back expanding medicare spending in the name of training physicians. I know the AMA has been backing this because _I 've attended the Region 7 and national meetings where the resolution to push for it has been passed, repeatedly_. Literally, hit DDG and enter "AMA restricted residency training funding" and your entire page of results is the opposite. They may have done so _more than a generation ago_ , but... let's move onto things that were done by, and affect, people not currently retired, eh?

-Hospitalists. These guys have completed their residency training, and elected to work for a hospital, doing in-hospital medicine. Their specialty is "hospital medicine." They have no private clinic, no private patients, and are paid a salary by the hospital. Whether this is an integrated system like Kaiser, or ... _every_ other hospital in the market, they're very common. Their practice patterns are heavily dictated by the hospital, which is heavily dictated by the Centers for Medicare/Medicaid Services and the major insurers. Their work is increasingly focused strictly on documentation, since documentation is the way that CMS and insurers (a) find excuses to refuse reimbursement, and (b) the way that CMS and insurers outsource collection of "quality" information, by forcing docs to structure their input in very discrete ways. These physicians don't have to deal with billing directly, but they are constantly being pulled into trainings for the ways documentation requirements are constantly evolving, the ways in which payors want them order tests and in what order, etc. They constantly get phone calls from "helpful billing people" raking them over the coals whenever there's a mistake. THe hospital keeps running tallies and reports on doctors' mistakes in this arena, aiming for public pillorying and, ultimately, withheld wages. (Docs don't generally get bonuses, they get withheld wages - except for high-revenue services like procedures, where they may get a bonus for very high productivity.) These are "mid career physicians." They tend to work an official 10-12 hour day, ten days on, ten days off. In reality, due to documentation requirements, and the fact that they get more patients than anyone could ever see and document in 10-12 hours, they tend to work 14+.

-Private Practice. These guys completed their residency and either opened their own private practice (almost no one can do that these days, with the complexity of the documentation and EMRs required by CMS and insurers, and attendant overhead costs) or have become employed by such a practice with the medium-term goal of buying in as a partner. They are likewise having their arms heavily twisted by insurers and CMS, without any sort of leverage to fight back and negotiate better terms. These guys are going out of business left and right. These are "mid career physicians." Hours worked here are highly variable, depending on the specific practice pattern, number of employees and partners, etc.

-"Private Practice." Because of the complexities and overhead that are now required to stay open, many practices... can't. They sell to a local hospital - often at cost - and become hospital employees. The hospital offers solid salaries for the first couple of years, and then drives them out, replacing them with younger employees. Many of the "private practices" you go to are thus actually practices run by the hospital, with an employee acting as the physician. These are "mid career physicians." These tend to work 9-5 with one evening hour a week, or none. The spread of this is why no one can find a doctor to see in the evenings anymore.

Key to Understanding Medical Reimbursement:

This is not a free market. It is fee for service. You get a patient visit, it is coded as a particular service (usually a Level 3 Evaluation & Management), and a fixed amount of reimbursed, assuming you meet various documentation requirements. If you do not, the amount is decreased or denied altogether. Private insurers peg their fee schedules to CMS, so CMS - directly or indirectly - drives all physician reimbursement. If you own a geographic area (such as part of a sweeping hospital network), that network will negotiate better reimbursement (e.g., "112% of Medicare"), but that is not passed along to employee physicians. Total revenue for a physician is amount of work-time per year divided by time-per-average-service, times reimbursement-per-average- service.

That's it; that's your cap.

Thus, most services patients want are strictly cost centers. The sort of things that other businesses compete on - e.g., ambiance, good front desk staff - are problematic for physicians, because you can't pass that along to patients in moderately higher prices. The only way you can compete on service, and be free to set your prices accordingly, is to refuse all insurance and only take cash patients. There are vanishingly few such patients, largely due to a cultural expectation that insurance = healthcare. Actually paying cash for a primary care physician, at least, isn't that expensive, but since that doesn't cover all of your other healthcare costs, who can afford to pay that extra premium? Only upper-middle-class and up.

<comment><USER37> This has been manipulated since roughly the eighties to increase HMO profit. There was a thesis that most physicians are not trying to maximize revenue, but trying to hit a target upper middle class lifestyle. If you cut FFS reimbursement down by 20%, they'd increase the amount of patients they pack into a waiting room by 20% (rather than taking a 20% pay-cut by seeing the same number of patients, or saying "fuck you" and no longer accepting patients from that insurer). And that's precisely what happened. That has driven the ongoing trend since in which revenue falls, number of patients per hour increases, and the result is physician income that hasn't kept up with cost in education or changes in purchasing power. You, too, would be very upset if you were being asked to work more and make less.

This also makes physicians a target for every spending adjustment measure. Physicians are not the primary driver of cost growth in america: new procedures and changes in drug prices are (when was the last time an internist raised his prices 5000%? Never, because his reimbursement is set by Medicare). But they do write the prescriptions and orders and referrals. This means that the entire system converges on controlling physician activity.

This plays directly into government willingness to expand on training positions. The government has a budget to hit; in fact, CMS is required to do studies showing that any changes they make will ultimately be budget-neutral, because they're legally obligated to protect the Medicare Trust Fund. As you see above, healthcare costs for the nation scale linearly with the number of physicians: if a doctor's total revenue for the year is capped at available time * service unit revenue/time, well, CMS' costs are that plus the cost of whatever service or drug he prescribes in that unit time. Double the docs, you double manpower costs, and double the opportunities for prescribing, in the context of trying to minimize healthcare cost.

So why are physicians burning out? Why are fewer and fewer "best and brightest" applying to medical school?

\- Increased accountability with decreased authority. As the centerpoint for changes in documentation and prescription patterns, everyone is twisting physicians' arms to act in very precise ways, whether or not those ways are what the physician believe is good for the patient. Physicians get the scoldings, the pay decreases, the public scrutiny -"why don't doctors X?!" "why are doctors doing Y?!" \- and none of the power to actually decide any of this.

\- Decreased authority in the hospital. Hospitals are suffering the invasion of the MBAs (and MPHs, and MHAs), and have more and more people with zero clinical knowledge setting policy. The big trend has been in nurses getting MBAs (and MHAs and MPHs) and going into administration, combining "I saw what doctors do from the side, I must totally know what's going on in their heads, right?" with MBA acumen. It's deeply problematic. "This patient has depression, and you didn't give them an SSRI! Malpractice! What's wrong with you?"

"This patient has multiple comorbidities that are more serious than their depression. I have them on medications for those comorbidities, and those drugs are all second-line therapies for depression. Time has shown that this combination has been effective for controlling their depression, and as a bonus, I avoided risking the side-effects of putting this patient on a third medication."

You cannot imagine the absolute pleasure of being regularly second-guessed by someone with a tiny fraction of your training. I imagine it's rather like a senior engineer having their code regularly criticized by someone that just finished "learn python in one week!". And they will then go to the EMR folks and have them add an alert, so that I can never place an order w/o SSRIs for a patient w/ depression without going through a whole Alert! rigamarole. There are so, so many alerts that alert fatigue is ubiquitous.

Additionally, in (fair) response to bad behavior of physicians in the past, nursing and other auxiliary services have moved into parallel reporting structures.

So, when patients are mad at something that has happened in the hospital, they call the doctor and yell at them! How could the hospital have done such a thing! I have no authority over the nurses that did it, or the nurse MBAs that made the policy, but I will get to take the scolding, the risk of malpractice suit (because patients don't sue over errors - they don't know enough medicine to identify errors - they sue over breakdowns in relationships with physicians), have zero authority to change or fix anything, and if I say a word, it's outside of my operational stovepipe and I will be both ignored and ultimately ignored by nurses. The latter means that my future care orders will be ignored or given low priority, and I can rely on that ultimately affecting my patients. So I have to keep my mouth shut over anything less than egregious problems.

\- Increased time doing things unrelated to patient care. There's a myth that somehow all this new documentation is meant to improve patient care. It does not. The three major reasons have absolutely nothing to do with patient care:

\---Many of the increases in documentation have to do with increasing specificity that strictly increases opportunities for error, and thus reimbursement denials.

\---CMS wants increasing information on practice patterns, and wants to extract this from EMRs. Because they can't spend any money to collect this information (as I said above, they are required to be budget neutral), they shift this cost onto hospitals, which shift it onto physicians (it's worthwhile for hospitals to comply, because otherwise CMS brings out the reimbursement stick.)

\---EMRs make billing more reliable, and reporting data to CMS more easy, and are required now as part of the ACA. EMRs are slow as fuck, because the end- user is not the customer. Their UIs are just fucking atrocious. There aren't words enough to relate how bad they are. Most can't even present lab results in a decent way.

The result is more documentation, done more slowly, for reasons unrelated to taking care of the patient in front of me - but that none the less take time away from _seeing the patient in front of me._

And there is a constant media barrage about how terrible physicians are, which studiously ignores that 99% of the things they are describing and criticizing are systems-level issues physicians have no control over.

On top of all this, I have only rarely met a physician without a real sense of professional pride. That we are ordering tests we don't want to order, creating delays we don't want to create, hiring shitty front desk staff we don't want to hire, creating massively packed waiting rooms we'd rather not have, while patients are being bled dry by their pharmaceutical companies, all while working our asses off, getting scolded for it, and having trouble paying off our ever-growing student loans is... it's fucking heart-breaking.

It's heart breaking.

You have no idea what a tide of idealism enters medical school, and what a shambling army of heart-broken zombies is left by "mid-career." If anyone was willing to pay me my current salary to see a dozen patients a day rather than thirty, to give every single one of them the extended visit to collect a rigorous history and give them the scrutiny they deserve, I'd take it in a heartbeat.

You want me to be that doctor. I want to be that doctor. The delta between that, and what the system allows me to be, hurts us both.

<comment><USER38> Because your post is quite far down, I'm not sure it'll get many views/replies. Just wanted to say that I read it all and it's both informative, interesting, and (regrettably) demoralizing.

In my first year of college I wanted to be a doctor and landed an absurd position - in hindsight - over my freshman summer where I was in the operating room with my surgeon nearly everyday (he led the residents). I tagged along through all the rounds, operations, and (of course) the tedious paperwork and billings.

By the end of the summer I was entirely jaded and switched programs. I still often think about whether or not I should have stuck it out.

However, what I ultimately saw (as you mentioned) were residents at this top, well-funded hospital who deeply loved medicine when they began medical school fall into a deeply jaded, pessimistic state. They made no money (while living in a high CoL city), were consistently overworked, and riddled with anxiety about where they would actually get a job post-residency.

Becoming a doctor - a surgeon in particular - struck me as a dozen year journey of constant make-or-break tests, quasi-lotteries with regards to residencies/fellowships, and then complete ambiguity as to where you would actually work when it was all done and you hit your mid-thirties. It also seemed increasingly devoid of any kind of professional autonomy and, most surprising to me, was how ungrateful and mean-spirited many patients were. Their lives would be saved, but they would yell at the surgeons over cosmetic concerns about the scars.

I often wonder whether my experience was not representative or simply too much to absorb as an 18-year-old at the time. However, the only folks I've talked to who seem to be truly satisfied and content with their careers are family doctors operating (largely) on their own terms and making 200-300k a year.

EDIT: I should say, I wish you the best moving forward and hope you find a level of contentment and happiness in a bruising - to put it mildly - system.

<comment><USER37> > I often wonder whether my experience was not representative

Everything you described is concordant with what I saw on my surgery rotations in medical school, and everything I've seen of surgeons in the hospital since then. Especially the mean-spirited and ungrateful patients. The ones that hurt, though, are the ones that come into the hospital hostile and confrontational from the outset.

"I know exactly what I need, and exactly what you need to do, and you're going to do it, or I'm going to have your balls!" I mean, that might be true. Sometimes it is. Sometimes it isn't. But nothing about talking to me like a rabid dog is going to make the process any better. And honestly, if you know your health, that's great - that will be very helpful. But ignoring other things it can be that masquerade as what you've got would be tragically irresponsible, so please don't bite my head off when I address the other conditions on my differential. I'm not ignoring you, I'm just trying not to be negligent.

Some patients will understand that, if we're given time to talk to them like human beings. But we basically never are, which makes things terrible for everyone.

The constant make-or-break tests and quasi-lotteries are a particularly apt description of medical school, and why - IIRC - the most recent stats put medical student rates of anxiety disorders at almost 50% of med students, and depression at approximately 30%. We absolutely destroy young physicians right at the outset. Studies of physician compassion have found that med students' compassion drives into the ground somewhere in third year - not with their first "your entire career relies on this" exam, but with their first exposure of what medicine has become, and how patients will be treating them.

</comment></comment></comment></comment><comment> trey-jones While I was having a vasectomy late last year I had a conversation with the doctor performing the surgery. It started with a quip about "It's not your first time, right?" or something to that effect, and went into the general process of developing new techniques which he claims is non-existent in the US right now, what with liability and the threat of malpractice squashing any incentive for innovation.

He gave a specific Urological example of a technique that was developed at MIT and took 6 hours, impractical for all purposes. European doctors have since come over and trained US doctors on a means of the same outcome that takes 1 hour.

My first thought was that the stagnancy of the field would contribute to burnout, but thinking about it more, I think just living under the imminent threat of malpractice lawsuits is probably enough.

</comment><comment><USER39> Mandated electronic medical records is the problem, not some constrained supply of doctors. (Not the concept of electronic records, but the implementation. Scanned paper records probably would have been fine. Epic and competing software solutions are not.) It means the same supply of doctors has less time for the same (or increased) demand.

Forcing doctors into a workflow dictated by software is what's causing 12 hour days to turn into 16-18 hour days, with no additional pay, and no reduced hours to compensate.

Also results in doctors focusing on the computer instead of the patient.

You didn't see burnout levels increase until electronic charts were forced.

</comment><comment><USER40> Stuff like this make me question how those in the medical field can put up with this stuff. All that hard work, all that debt, all that lost time, and for what? Meanwhile there's a bunch of people in a handful of cities who make comparable if not greater salaries for writing software to freaking deliver ads to sell people shit they don't need (I'm exaggerating a little). And all while living a much more comfortable life! Time ain't free.

</comment><comment><USER41> I cannot find the studies now, but I have seen multiple times numbers to the effect that medical interventions/treatments are responsible for 10% of health outcomes. The remaining 90% is determined by diet, exercise, and genetics.

Genetics is out of everyone's control. But the fact that 1/6 of the American economy is focused on that 10% is mind blowing.

The best ways to improve your health are to eat less, eat better, and exercise more.

</comment><comment><USER42> I have seen this happen as a chronically ill patient for the past 30 years. There is a wave of poorly understood chronic illness and doctors are powerless to treat it. It must be exhausting to tell so many people that there is nothing they can do. I say this with 100% sincerity. It must be a nightmare to work so hard without the reward and satisfaction of significantly improving people's lives.

</comment><comment><USER43> I think specialization is making labor markets more exploitative.

If the market expects you to do things that aren't worth the wage, but you spend a decade and half a million dollars on training and switching to something comparable would take a ton more time and money, well, then you probably won't switch careers. And if too few people switch then there's little market pressure to adapt.

</comment><comment><USER44> It's even worse in Pediatric ICU. They're one of the lowest paid doctors due to ICU not being profitable. They have the mental/emotional stress of really sick and dead kids. They have to work 24+ hour calls with little to no sleep. I know one who worked 36 hours last weekend and got 2 hours of sleep. That can't be good for outcomes, but they can't hire more because again, the ICU loses money. They don't get big salaries from drugs like anesthesiologists.

It's almost like healthcare shouldn't be run like a normal capitalistic business.

I imagine burnout is much lower around the world and would love to see the data on that.

<comment><USER25> The root cause is the people receiving the healthcare in a pediatric ICU don't have the ability to pay for it, and based on the lack of votes for taxpayer funded healthcare, voters also don't want to pay for it.

Notice how people 65 and over have no issues getting their healthcare paid for. That group of voters has a very high voter participation rate.

</comment></comment><comment><USER45> hasn't this always been widely known? same with big law lawyers

</comment><comment><USER46> I went back to undergrad to finish med school prereqs, after the mcat I decided to go back to coding and am so thankful that I did. I did it because of the earning potential, not passion, and I don't think it's possible to be happy in that career path if you're just trying to get money out of it

</comment><comment><USER47> [http://archive.md/HZOmv](http://archive.md/HZOmv)

</comment><comment><USER48> Medicine burned me to the ground

</comment><comment><USER49> Wouldn't a good solution be to pay doctors less and train more doctors? We pay our doctors really well by international standards, but we are also really good at burning them out.

</comment><comment><USER50> We need doctors. This is a serious problem.

I wonder how this compares to countries with nationalized healthcare.

<comment><USER51> It seems reported healthcare quality is highly correlated with physicians per capita, in developed countries. Notable exceptions are Japan and Singapore, but these countries tend to have more efficient infrastructure and populations with predilections toward above average health. Socialized healthcare countries like the UK and Canada, known for their absurd wait times, have comparable physicians per capita to the US [0]. Most of the other European countries with touted healthcare systems also tend to have significantly more doctors than the US.

[0] [https://data.worldbank.org/indicator/SH.MED.PHYS.ZS](https://data.worldbank.org/indicator/SH.MED.PHYS.ZS)

</comment></comment><comment><USER52> It's not so much the profession itself, but not finding one's true "Ikigai". Too many smart people getting medicine for the money and prestige. Unless you truely enjoy helping sick people, you will get burned out at some point..

</comment><comment><USER53> There's burnout in every field because capitalism places a higher reward on burning people out and finding fresh replacements instead of keeping your existing employees happy and balanced in their lives. The structural market forces inevitably lead to this outcome in the insatiable quest for efficiency and profits. You can't fix burnout without fixing the underlying structural cause.

</comment><comment><USER54> Paywall-free URL?

<comment><USER55> [https://github.com/iamadamdev/bypass-paywalls- firefox](https://github.com/iamadamdev/bypass-paywalls-firefox)

[https://github.com/iamadamdev/bypass-paywalls- chrome](https://github.com/iamadamdev/bypass-paywalls-chrome)

</comment></comment><comment><USER56> Physicians spend hundreds of millions of dollars making competing with them illegal.

Now they can't handle the demand.

But hey physicians make 300k/yr...

</comment><comment><USER57> Well well, I think most people have financial problems nowadays, it's not a secret that the human world is on the descending slope.

</comment><comment><USER58> Almost all burnout in the medical profession stems from state intervention and the extremely complex lobby relationships between different actors in the market. Classical liberal policies would change everything in the market.

In particular, there are a few things that crush doctors:

Problem: Cost of education: You require licenses per-state, and a license can be gotten only after a very grueling and expensive educational process in the half a million dollars range or more in student debt.

Solution: Make it legal to practice medicine with foreign education licenses. Doctors can study in countries where the education is free or nearly-free.

\----

Problem: Too few people go into the medical profession per-capita in the US. Currently a 20-year in practice specialist doctor from any other country has to go through a lowly paid residency in the US to be able to exercise, plus compete in the very narrow H1B visa space.

Solution: Make a special purpose visa for medical professionals (Nurses & Doctors) and allow them to practice medicine.

\----

Problem: Malpractice insurance is extremely expensive due to the high levels of litigation in the medical profession, that far outstrip the typical responsibility of a professional. Some specializations require insurance of thousands of dollars a month!

Solution: Allow for malpractice waivers that let doctors practice at a cheaper rate, and let patients decide what kind of risk they are willing to get or not.

\----

Problem: US has the lowest level of Primary Care doctors per capita of developed nations in great part because they are the least protected specialization by the AMA which is mostly compromised by specialty doctors. One rule made here is that PCP's cannot collect 'kickbacks' or revenue by referring patients to a speciality doctor, and thus the PCP works for free to provide referrals to specialists.

Solution: Allow for transparent processes of verticalization and monetization, which will bring PCP's to a more natural rate count.

\----

Problem: The government subsidizes medical insurance by making it tax exempt. This makes it so everyone gets insurance through their employer which in turn makes it impossible for a doctor to compete with the insurance model that is tax exempt by being all-cash. The tax benefit allows insurance companies an oligopoly against small practices.

Solution: Eliminate insurance through employer and/or get rid of the tax exemption.

\----

Problem: The government pays a higher revenue rate if the medical practice is digitalized. This has pushed the entire industry into using electronic records to get that revenue boost long before its time, producing terrible technical solutions. (The biggest player in the space, Epic, collections millions of dollars a year per hospital and its made in Visual Basic)

Solution: Get rid of all electronic record requirement laws, subsidies, programs, etc.

\----

I can keep going. In the health industry market literally every single player has a legal advantage over every single other. Its everyone screwing everyone.

<comment><USER48> It is definitely not state intervention alone that explains the culture within the medical profession overemphasizing hierarchical relationships and deemphasizing direct patient care

<comment><USER58> You would be surprised! That is exacty the history of american medicine, depicted in the seminal work "the social transformation of rhe americam physician"

<comment><USER59> I believe the correct title is "The Social Transformation of American Medicine".

Dry as hell, but an insightful book.

<comment><USER58> Thats correct. One hand typing from memory XD</comment></comment></comment></comment></comment>


Turkish archaeologists say they have uncovered the tomb of St. Nicholas - <AUTHOR> https://www.washingtonpost.com/news/acts-of-faith/wp/2017/10/04/santa-dead-archaeologists-say/ <comment><USER2> Well, no need for the kids to be worried.

The Santa Claus as celebrated is so far removed from the christian saint St Nicholas, and from anything in the christian "universe" for that matter (heck, there's even a flying reindeer involved and little elf people) that it might as well be a totally different person.

Not to mention that he has nothing to do with the Christmas's eve (he has been traditionally celebrated for millennia on the 6th of December), or with extreme shopping.

</comment><comment><USER3> I'm Turkish and none of the local news say how they become sure that the tomb belongs to St. Nicholas.

</comment><comment><USER4> My parents got a (somewhat twisted) kick of taking me to the Church of St Nicholas in NYC when I was a kid so I could see several relics that were supposedly parts of the remains of Santa.

(sadly, the Church would be destroyed in the 9/11 attacks, and IIRC, the relics were never recovered.)

</comment><comment><USER5> Again? ;-)

<comment><USER6> At least it's not running with the cringe titles this article had on CNN: "Don't tell kids, Santa is dead!" I'm being serious.

<comment><USER7> Although it is in the article:

       The bad news: Santa Claus is definitely dead.

<comment><USER5> The good news: Santa is real.</comment></comment></comment></comment>


Ask YC: Are you more likely to use an online service if sign up is optional? - <AUTHOR>

If I had two versions of an online service - one with limited features that doesn't require signing up and one with <i>slightly</i> more features but requiring a sign up, which are you likely to opt for? The no-sign up service could be completed in under 30 seconds. With sign-up you are looking at the first transaction taking ~ 5 minutes with email confirmation etc <comment><USER2> Since I like to try out a ton of different services, I normally end up with a bunch of accounts and a bunch of passwords. I don't exactly like this. I'd much rather be able to try out the app and then decide later if I want to sign up. (This is one great advantage of OpenID, but you still have to leave information on the service)

This does two things in my opinion. It would save me from having to worry about information leaking (email address, etc) to services that I'm actually not interested in using. Two, it potentially saves the product developers from getting their hopes up when they see tons of users signing up at launch, only to realize that most of them never come back.

I really like the way jaanix.com takes care of this, or rather used to take care of this. They gave you an account like guestXXXX or something strange, that could then be converted into your real account, when you actually sign up.

<comment><USER3> Posterous does this and I think it's great.

<comment><USER2> The way posterous handles signups is indeed great. Actually, posterous as a product is pretty great, I don't know why I don't actually use it.

</comment></comment></comment><comment><USER4> No signup wins by a mile. Having to create accounts on every two-bit website is annoying, and I usually just go somewhere else.

</comment><comment><USER5> Almost certainly the no-sign up. Why go to the hassle if I'm not even sure I want to use it yet?</comment>


CD Baby, a Company for the Niche Musician - <AUTHOR> http://www.nytimes.com/2014/08/13/arts/music/cd-baby-a-company-for-the-niche-musician.html?src=dayp

<comment><USER2> I highly recommend Derek's book "Anything you want" [http://sivers.org/a](http://sivers.org/a) it's a great read. It's basically about the company he founded, CD Baby. After I read it I sent an email to Derek with a 'thank you' and he just replied the next day... He is great.

<comment><USER3> FYI, his Book, "Anything you want"[1], is free with Kindle Unlimited.

1\. [http://www.amazon.com/Anything-You-Want-Derek-Sivers- ebook/d...](http://www.amazon.com/Anything-You-Want-Derek-Sivers- ebook/dp/B00506NRBS/)

</comment></comment><comment><USER4> I like their founder's talks, Derek Sivers[1]. He's also got a good youtube channel[2].

[1][http://www.ted.com/talks/derek_sivers_weird_or_just_differen...](http://www.ted.com/talks/derek_sivers_weird_or_just_different) [2][https://www.youtube.com/user/dereksivers](https://www.youtube.com/user/dereksivers)

<comment><USER5> Derek is/was a regular here on HN.

<comment><USER6> is! - [https://news.ycombinator.com/user?id=sivers](https://news.ycombinator.com/user?id=sivers)

</comment></comment></comment><comment><USER7> Surprised the NYT article didn't mention [http://distrokid.com](http://distrokid.com) by [https://news.ycombinator.com/user?id=pud](https://news.ycombinator.com/user?id=pud)

<comment><USER8> I just started writing songs recently and gave DistroKid a try - it's so easy and low cost. One happy customer.

<comment><USER9> Glad to hear it.

\- DistroKid founder</comment></comment></comment>


Detecting voting rings using HyperLogLog counters (2013) - <AUTHOR> http://opensourceconnections.com/blog/2013/10/14/detecting-reddit-voting-rings-using-hyperloglog-counters/ <comment><USER2> > _Each post gets 2 HLL counters, one positive votes and one negative. When a > user upvotes or downvotes a post, their id is submitted to the corresponding > HLL counter._

Third, you wouldn't be able to undo your vote.

<comment><USER3> It shouldn't be an issue given that HLL is approximate and that relatively few votes are undone. You could also debounce the vote before recording it in the counter, at the cost of a small delay.

</comment></comment><comment><USER4> Nice idea, but it doesn't matter if this doesn't work in practice.

<comment><USER5> I don't think this would work for small-ish subs, would it? Most upvotes one gets _might_ actually come from the same group of people...

<comment><USER6> Yeah. This seems as likely to detect cohorts of similarly interested groups of people as it would a voting ring.

This might be useful though, in that things which trend towards _honest_ are actually trending toward _general interest_.

</comment></comment></comment><comment><USER7> Ye gods, what a waste of time. This is what you get when you let reddit brogrammers run away with their own pedestrian imaginations.

      To keep a count of uniques, you have
      to store every IP address that you
      ever see. And upon receiving a new IP
      address, you have to first check that
      the new IP address has not been run
      across before, and only then do you
      increment the site counter. Under the
      best of situations, the storage and
      the computation probably scale
      as O(log(n)).

Okay, guy. Scamper off back to your SEO click-bait advertising gif banner day job, and don't work on anything important.

The seas are boiling the foundations of the ecosystem in a stew of toxic waste and plastic. Species are going extinct. Governments are waging wars with robots, while starving countries are crushed, bought and sold wholesale, and spy satellites are enumerating all of us, as we walk to seven eleven for another pack of smokes, and here's an article about tracking unique users by... checking their... IP adresses...

What is this? 1998?

<comment><USER8> It looks like you stopped reading after the second paragraph; this caused you to _completely_ mischaracterize the OP.

In particular, the paragraph you quoted is the second in the OP; in it, the author is summarising the conventional technique _not_ the one they propose.

of course, this is a common device--ie, "here's the conventional way to do X; here's what we propose here"

in other words, to provide the appropriate context, the paragraph you copied above, should be prefaced with "here's the conventional way to do X"

and in fact, the next paragraph, begins like this: "With the HyperLogLog counter it's all different"

<comment><USER7> This is all just an over-engineered way of saying:

" _If a person 's lifetime tally of all unique fans (say: 150 different people, cumulative) consistently matches the typical number of unique fans per thread/article (say: ~135 on any particular post) then those fans are probably employees with vested interests_"

(in other words, it's the same people upvoting that guy every time, and they're all in a gang)

You don't need big O notation and hash tables to conflate that idea.

See: [https://en.wikipedia.org/wiki/HyperLogLog](https://en.wikipedia.org/wiki/HyperLogLog)

And: [https://en.wikipedia.org/wiki/Cardinality](https://en.wikipedia.org/wiki/Cardinality)

</comment></comment></comment><comment><USER9> There is no info on the accuracy of the HyperLogLog algorithm relative to the data set size. These algorithms are for big data application.

But I would test it if I was working at Reddit or At Hacker news.

<comment><USER10> Play with the Javascript implementation that the site links to. Even after trying it a couple times, the error bounds swing up to 20%.</comment></comment>


Researchers Who Exposed VW Gain Little Reward from Success - <AUTHOR> http://www.nytimes.com/2016/07/25/business/vw-wvu-diesel-volkswagen-west-virginia.html?src=me <comment><USER2> Society cuts off its own ways of monitoring corporations' behavior.</comment>


50 Skills Every Real Geek Should Have - <AUTHOR> http://www.maximumpc.com/article/features/50_skills_every_real_geek_should_have

<comment><USER2> Differentiate Between Dr. Pepper and Mr. Pibb?! Beat Quake in Under an Hour ?!

Really? Are these the skills you really need?

<comment><USER3> These are skills for nerds, not geeks.</comment></comment>


State of Text Rendering (2010) - <AUTHOR> http://behdad.org/text/ <comment><USER2> This is a great reference, but ten years out of date. Unfortunately there is no really good central place to get updated information on this.

For almost five years, I was tech lead of the text stack in Android. There are a few things about the architecture not to like, but overall it is a world- class implementation - it has refinements like hyphenation and Knuth-Plass style paragraph layout, and of course emoji. It also had the benefit of Roozbeh Pournader's work for much of that time, so it gets Unicode and locales right. Among other things, I claim it does one of the best jobs on the "CJK problem" of any stack out there, using both font selection and the locl OpenType feature to adapt rendering for the preferred language(s). It's open source of course, but does suffer from thin public documentation.

Another good source is Chromium, which tends to be a bit more open, with discussions in the bug tracker and published documents, such as [https://www.chromium.org/teams/layout-team/eliminating- simpl...](https://www.chromium.org/teams/layout-team/eliminating-simple-text)

I'm interested in building the next stack in Rust, and have done some work in this direction. I'd _love_ to see solid documentation as part of that effort, but of course writing takes time and effort, and the target audience is quite specialized.

<comment><USER3> > Among other things, I claim it does one of the best jobs on the "CJK > problem" of any stack out there, using both font selection and the locl > OpenType feature to adapt rendering for the preferred language(s).

What does Android infer the preference from? I'm using U.S. English as the UI language with input method set to combined Finnish and English (with Simplified Chinese, Traditional Chinese, Korean and Vietnamese also in my input method list) and using a Finnish SIM, and Android 9 seems to pick Simplified Chinese glyphs for me. (I'm not suggesting these signals should have another result. I'm just curious what signals are considered meaningful.)

<comment><USER2> The main signal is the locale setting, which can have a list of languages in it. For example, you could have Finnish as your primary language, with Hong Kong Chinese second. Then CJK will get rendered as zh-Hant-HK.

Apps can set locale explicitly to override that, but almost none do. Probably the motivating example is a translation app, which can then render both, say, Chinese and Japanese correctly.

Input methods are technically a separate setting from your locale list, which is maybe confusing but that's the way it is.

<comment><USER3> Thanks. I take it that Simplified Chinese is the default then, if none on the CJK languages are in the UI language list.

<comment><USER2> Yes. Just based on numbers :)

</comment></comment></comment></comment></comment><comment><USER4> .. reading the post, do we need to be reminded that text is rendered on more devices than an Android mobile phone? Is 'done' == 'dead' here?

A web browser and a desktop interface (windowing,menus,mouse) sharing core glyph engine components sounds important, at least. In other news, the state of font availability, rendering fidelity and directional support are always going to be changing across the entire world, no?

</comment><comment><USER5> From 2014: [https://news.ycombinator.com/item?id=8084880](https://news.ycombinator.com/item?id=8084880)

Discussed at the time: [https://news.ycombinator.com/item?id=1479870](https://news.ycombinator.com/item?id=1479870)</comment>


Running a start-up is great, growing a business is boring - <AUTHOR> http://jacquesmattheij.com/running+a+start-up+is+great%2C+growing+a+business+is+boring <comment><USER2> I suppose it depends on your personality, perspective and how you grow your company's culture.

I just finished reading Tony Hsieh's upcoming book, Delivering Happiness. He describes how LinkExchange, his first big company, became boring to grow because the company culture wasn't fun. But he still enjoys working at Zappos because he and his execs managed to keep the company culture fun and interesting. He doesn't know everyone there, but it has a great feel to it. Keeping his employees engaged, serving his customers, etc. are all great joys to him.

Note that I'm not saying Zappos still feels like a startup. I think from the book it's apparent that it doesn't have a startup culture at all. But it does have an "engaged" culture. Everyone enjoys what they do.

Side note: I don't recommend reading the book. There are about 10 pages in it I actually felt I could generalize to be useful.

<comment><AUTHOR> I think that that 'culture' thing is why the faster growing tech companies spend so much money on trying to maintain that 'start-up' look-and-feel.

If there is any kind of financial crunch though, those perks are the first to go, and 'efficiency' is suddenly the buzzword.

</comment></comment><comment><USER3> I disagree. The problem isn't that you need money to motivate you in the later stage of building your company. No, you're trying to be motivated by the wrong thing. You need to seek ulterior motivation. Passion, purpose, vision. I think that's how Steve Jobs, Bill Gates, Larry Ellison, Richard Branson and countless others built their companies. It wasn't money. It was vision. Vision to change the world.

<comment><USER4> You mean "intrinsic motivation" not "ulterior," which denotes something else entirely :)

<comment><USER3> Thanks =)

</comment></comment></comment><comment><USER5> > And even if plenty of the code behind [scaling search] must be very > interesting, the actual money is made in the adsense department, and though > at that scale there are some interesting challenges, keyword advertising, > statistics, reporting and so on are nowhere near as interesting as search.

If you don't think adsense is just as interesting as search in the core technical algorithms, you probably haven't really thought about it at all.

<comment><AUTHOR> Adsense at that scale has interesting challenges, but I don't think it compares in scope to indexing the web and making it accessible.

Agreed that it is a far from trivial problem, but the dataset is relatively limited in comparison the biggest hurdles are to get it to match up with a reasonable ad on first delivery within a given timespan, to track all the statistics and especially to combat click fraud in the network.

But in the end, without a search engine to display those ads on google would be just another advertising agency, and in many ways they are.

A better example of an interesting challenge would be to transform google news in such a way that it would show you only relevant news. There is a lot of room for improvement there and it would boost natural language processing a lot to have the tech to do that.

Any piece of tech has interesting components, but that's a relatively small part of the whole, and the money is made in the drudge-work, that was exactly the point.

From a start-up perspective, the 'core' engine of the product is probably relatively complete by launch day, but the infrastructure to make it scale, to market and monetize it, which is going to be a whole lot less sexy, is where the money eventually will come from.

<comment><USER2> I kind of think you're countering yourself here.

Just like only showing relevant news is an interesting challenge, so is only showing relevant ads. Advertisers don't want to show you ads you're not interested in; they want to show you ads you'll actually find useful. In many ways, that's a much more interesting challenge than showing relevant news.

Extending the advertising example, it's also a very interesting challenge to show people that highly-targeted ads can be a good thing. Just like it's an interesting challenge to convince advertisers to use your ad platform. Although they are not technical challenges, they are very interesting business challenges.

<comment><AUTHOR> Relevant ads with a chunk of text is matching two chunks of text based on a bunch of keywords.

Matching relevant news to a person is a completely different class of problem.

<comment><USER6> Why are you making a distinction where there isn't one? News? Ads? It's the same problem. Matching content to user.

</comment></comment></comment></comment></comment><comment><USER7> One of my favorite insights from Steve Blank is "you fail if you stay a startup." I strongly recommend watching his Startup Lessons Learned Conference presentation (link below). The differences between startups and established companies run deep and most entrepreneurs don't make the transition from the former to the latter.

[http://startup-marketing.com/steve-blanks-sll-keynote- its-a-...](http://startup-marketing.com/steve-blanks-sll-keynote-its-a-must- watch/)

<comment><AUTHOR> Neat, thanks for the pointer!

</comment></comment><comment><USER8> I'm just in the beginning stages of a start-up. I know that is exactly how I'll feel once the initial challenges are surmounted.

I love the initial challenges; dealing with the first customers. But staying at the head (or near head) of a company when it just becomes another corp? Never. Boring. :-)

</comment><comment><USER9> Counterpoint: Running a startup means working 18 hour days trying a bunch of stuff that probably won't work and if it does then you end up in a job you don't like. Growing a business means helping something along that will have lasting value. Just depends what type of person you are; making a blanket statement that growing a business is boring is actually pretty narrow minded.

(Disclaimer: I work at a startup, love it, and will probably work at or start another startup in the future)

<comment><AUTHOR> > I work at a startup, love it, and will probably work at or start another > startup in the future

Doesn't that sort of prove my point though? Why not stick around and grow it then?

Isn't the 'what kind of person you are' part the whole point of what I wrote ?

Some people are good at creation and the work that comes with that small team where you can wear a whole bunch of hats, they thrive in that environment, but they find that it is much harder to maintain that attitude in larger companies.

Suddenly there are procedures and forms to be filled out and all kinds of corporate stuff that will drag you down. You can only work on weekdays, you have to work between 9 and 5 (hey, I'm a night person), and so on.

I remember that when working for a large corporation (bank) early on in my career after I switched to the IT department someone came up to me and asked me not to work so hard because I made some of the others on the team look bad. They were actually trying to _slow me down_ , can you imagine that sort of thing in a start-up?

I'd work for any start-up that has a technically challenging idea, even without pay if the idea was worthwhile enough in my opinion, but I'd have a really hard time joining up with some 200 employee company that does the same thing, or hanging around if the idea was received well by the market and the company needed growing to that level.

Sooner or later your tech days are over and you'll find yourself to be a 'manager', and not everybody is cut out to be one. The choice then is to hang on to the start-up that you helped found and manage people or to hang on and be managed by some guy hired two years after you founded the thing.

I'd rather move on at that stage. In the past this has led to school friends of mine that had also gone in to programming to be hired by start-ups that I helped found, 20 years on and they're still working there.

I could have _never_ done that, compared to what I've seen in the last 20 years that sounds like being tied to the same disneyland ride for two decades.</comment></comment>