From Dr. Michael Gottlieb’s “Mandatory Training Modules in Health Care—Time to Reassess” in JAMA:
The annual ritual of clicking through slides, answering perfunctory quiz questions, and electronically attesting to completion sends a subtle message that documentation is valued more than thoughtful learning.
He argues that 4 million physician hours are spent wasted every year.
One alternative to selling to private equity or the hospital? An employee stock ownership plan (ESOP), a type of tax-favored internal buyout where practice equity is sold to an employee trust and ownership is transferred over time as stock is allocated to employees.
From the excellent and illuminating Everything is Tuberculosis, written by YA author (e.g. The Fault in Our Stars) John Green:
I want to pause here to note a defining feature of humans, which is that we like to know why things happen, especially when really bad things happen. And if a reason is not immediately apparent, we will find one.
and
We all engage in the punitive act of giving a disease a meaning.
The ability to tell a convincing story is very different from the ability to be right. The narratives about TB that Green describes are both historically fascinating and unfortunately still very relevant today.
A reader asked me last year whether they should pursue applying to radiology as an intern because they felt like, in the end, clinical medicine wasn’t for them.
If Match Day results weren’t what you wanted, be aware: the mind is powerful. You will adjust, you will be happy, and you can find meaning in Plan B—hopefully so much so that, years in the future, you will look on this as the universe giving you what you needed over what you wanted.
Medical surveys are an easy way to make a few bucks at a good hourly rate (well, maybe at least for a resident), and there are multiple sites offering surveys to physicians. The caveat is that, of course, most survey sponsors are typically looking for board-certified physicians with multiple years of experience, particularly in sub-specialties. The less experience you have, the more you need to be prepared to get screened out of what seem like promising survey opportunities.
This article was originally posted way back on Feb 26, 2014 and last updated March 2026. This page contains referral/affiliate links (thank you for your support).
ENOS is a new healthcare panel with a novel premise: members are paid instantly via Venmo, Paypal, or paper check—no delays or redemption thresholds. ENOS always pays for your time: Even if you’re ineligible for a survey after completing screener questions, they still send you $5. Readers get a $25 sign-up bonus.
ZoomRx is also excellent and has a nice app and better/shorter-than-average surveys. $25 sign-up bonus for the following specialties: Hematology/Oncology, Cardiology, Neurology, Gastroenterology, Psychiatry, Nephrology, Rheumatology, Allergy/Immunology, Pulmonology, Dermatology, Urology, Endocrinology, Surgery. They even pay for attempts when you screen out.
One of the biggest survey sites is Sermo (also an online healthcare community), which is now offering my readers a $10 welcome bonus. The survey experience has been recently revamped, and once you maintain a balance of $100 in honoraria, you get preferentially invited to more surveys.
One of my very favorites is InCrowd, which has a slick mobile-friendly site and will send you survey opportunities by email or text message. These are always of the very short and painless variety (the fastest of all in my experience), so the payouts are small, but it’s good money for the time and basically effortless. You do have to respond quickly before surveys fill up, but you even get a buck when you get screened out. Being referred (like signing up through that link) will earn you a $10 bonus after you answer your first two microsurveys.
M3 now has three separate very active research companies under its umbrella: M3 Global Research, M-Panels, and All Global Circle. You can earn $25 for joining one panel, $40 for two, and $60 for joining all three (for the following specialties: Hematology-Oncology, Neurology, Gastroenterology, Nephrology, Cardiology, Urology, Surgery, Rheumatology, Obstetrics and Gynecology, Pulmonology, Allergy and Immunology, Family Medicine, Psychiatry, Dermatology, Ophthalmology, Endocrinology/Diabetes, and Pediatrics).
Curizon has been in the business a long time, but they recently completely revamped their website and platform. It’s a trusted site for well-paying healthcare surveys for physicians as well as other healthcare professionals. Every new registration is entered in a monthly drawing for $100.
At the resident level, one of my old favorites has been Brand Institute, which almost exclusively sends out short surveys about potential drug brand names. Payouts are always on the smaller side ($15), but each one is quick (about $1 per minute or more) and screen-outs are rare. So if you get invited to a survey, then you can generally complete it and get the honoraria. No BS. The main style/format is nearly always the same, so you pick up speed as you do more of them. And that honoraria size is also significantly larger than what one can generally pull as a non-physician (e.g. SurveySavvy, the biggest most popular survey site around, usually pays a measly $2 per survey). The website, however, is clunky and terrible. You’ve been warned.
Additional legitimate additional survey sites, many of which are significantly less active, are below:
Preparing for standardized tests by yourself using high-quality resources is both effective and a little bit soulless. There’s a reason why much of medical education could be streamlined in both time and cost to what amounts to an old-time correspondence course—that’s because it’s long been sold as an information problem, and the core question for schools has been how to best transmit the holy information to the student.
This was probably historically at least partially true, but in the 21st century, this conception misses the point: information is no longer the core skill that needs cultivation. It is social intelligence, human skills, and the bringing of information to bear for problem-solving. It’s critical thinking, and doing it while working with people. And yes, the information is important (it really, really is!)—but the information is not where very expensive medical schools really shine. With the advent of better qBanks, Anki decks, and commercial lecture products, we are increasingly choosing a factory schooling model over one that prioritizes a social experience of working with caring teachers, motivated peers that are important to you, and patients with meaningful tasks to provide motivation and centering.
The schools and students spend lots of money on pieces of paper and question banks and other forms of curated video content, and these are all wonderful things. My point is not to suggest that using better lectures and better questions is a bad thing for education—it’s certainly not. It’s that those things do not preclude the need for the other part—not in some token problem-based learning format or anything so prescriptive—but real, meaningful, non-tedious, in-person work.
Whatever it once was, it is no longer mainly an information problem. As the cliche goes, you can lead a horse to water, but you can’t make it drink. We need to encourage people to be motivated (or find motivated people), and we need to help curate and support sustaining that curiosity—that people can do and internalize the need to continue doing that type-2 fun of hard work. The fact that students would rather be at home studying instead of working in the hospital shows the fruits of our system: the triviality of many students’ clinical experiences (the clerkship as performance art) combined with the pressure of Shelf exams as the defining feature of their grades.
The world is full of heavy objects, and yet most people are not ripped. We are the limiting factor, and we need systems to help us and support us to be our best selves. Burnout is a system that snuffs out our soul’s flickering flame.
There was a time in my radiology training where people were encouraged to incorporate multiple-choice questions with audience response into their lectures instead of taking hot-seat cases where people were put on the spot. That is more comfortable, to be sure, but I can tell you the fear and anxiety of wanting to perform for your colleagues and mentors was much more inspiring. Not every time you’re wrong in public is unfair pimping/humiliation.
An ability to take those hits on the chin when you flub a case is also important. Psychological safety doesn’t mean never being challenged—it means being supported enough that you can bounce back from your inevitable failures. We have forgotten how important resiliency is, and we’ve allowed undergraduate medical education to remain dominated by the factory information paradigm while neutering the chance for more students to become respected members of the care team more of the time.
I would posit that good healthcare is more analogous to a restaurant than most large corporations. From Michael E. Porter’s Competitive Strategy: Techniques for Analyzing Industries and Competitors:
If close local control and supervision of operations is essential to success the small firm may have an edge. In some industries, particularly services like nightclubs and eating places, an intense amount of close, personal supervision seems to be required. Absentee management works less effectively in such businesses, as a general rule, than an owner-manager who maintains close control over a relatively small operation. Smaller firms are often more efficient where personal service is the key to the business. The quality of personal service and the customer’s perception that individualized, responsive service is being provided often seem to decline with the size of the firm once a threshold is reached. This factor seems to lead to fragmentation in such industries as beauty care and consulting.
Healthcare has seen those fragmentation factors dissolve since the 1990s and especially since the ACA.
In Redefining Health Care: Creating Value-based Competition on Results, Porter then argues:
Competition has taken place at the wrong levels, and on the wrong things. It has gravitated to a zero-sum competition, in which the gains of one system participant come at the expense of others. Participants compete to shift costs to one another, accumulate bargaining power, and limit services. This kind of competition does not create value for patients, but erodes quality, fosters inefficiency, creates excess capacity, and drives up administrative costs, among other nefarious effects.
Over the years since I returned to the area, the local university medical center has progressively moved away from individualized service into a predictably depressing corporate marketshare grab. If this is “The Future of Medicine Today,” the future is bleak.
If policymakers want to improve US healthcare, the easiest lever to pull first is to enable physician ownership and make it feasible to stay small without needing to opt out of the system entirely by going direct pay.
Daniel Cook on Mixing Games and Applications:
Why do games have such a radically different learning curve than advanced applications? It turns out that games are carefully tuned machines that hack into human beings’ most fundamental learning processes. Games are exercises in applied psychology at a level far more nuanced than your typical application. Implicit in this description of interactivity is the fact that users change. More importantly, the feedback loops we, as designers, build into our games, directly change the user’s mind… The person that starts using a game is not the same person that finishes the game. Games and the scaffold of skills atoms describes in minute detail how and what change occurs.
This is a pretty big philosophical shift from how application design is usually approached. We tend to imagine that users are static creatures who live an independent and unchanging existence outside of our applications. We merely need to give them a static set of pragmatic tools and all will be good. Games state that our job is to teach, educate and change our users. We lead them on an explicitly designed journey that leaves them with functioning skills that they could not have imagined before they started using our application. Our games start off simple and slowly add complexity. Our apps must adapt along the user’s journey to reflect their changing mental models and advanced skills. Failure to do so results in a mismatch that results in frustration, boredom and burnout.
Interesting applications to enterprise software including EHRs, PACS, etc, where there is a distinct lack of gamification. This dovetails nicely with Jason Fried’s point about software design between making features obvious, easy, and possible.
In many practices and especially in academia, important but burdensome tasks are either treated like hot potatoes or flow downhill to the most junior faculty. There are several strategies for distributing important but non-measurable or non-promotable tasks:
Avoid asking for volunteers in some situations, particularly for tasks that have little upward mobility, little chance to shine, and where performance is perhaps less important or easy to measure. Otherwise, you get the same people-pleasers doing everything and burning out. Even if they’re not burning out, their time is taken up (perhaps by doing the wrong activities as acts of service).
Alternatively, if a task is important enough to get done, consider ways in which it can be part of someone’s job description. This may be more practical when something undesirable is paired with something desirable, like remote schedules with a more challenging case mix.
Another possibility is putting your money where your mouth is. My practice has a small component of bonus compensation tied to accumulating enough brownie points for doing various tasks like tumor boards, recruiting activities, etc. The reality in our group is that we are large enough and the tasks varied enough that the minimum threshold to qualify is laughably small, and there aren’t measurable benefits to accumulating more than you need. It ensures a floor, probably relying more on the principle loss aversion than the actual money at stake.
You can give people effort RVUs for doing those tasks, but in this market, anything that gives you credit towards a full day’s work that detracts from reading cases can also contribute to overall staffing problems. In other clinical fields, it just pushes more work into the evening/weekends (and eats up precious academic/admin time if in the mix). In small groups where such activities may be distributed evenly, nothing may need to happen. In larger practices where most members will do nothing except interpret scans, stipends are an option, particularly for larger tasks like division directorship.
Bean counting is fine to an extent, and some activities like multidisciplinary conferences are easy to count. But many important tasks are challenging to quantify and may even backfire when attempted. The classic daycare fine experiment added a financial penalty when parents arrived late to pick up their infants, which replaced a powerful social norm with a market norm (swapping guilt for a few dollars). Sometimes, something people would do for free is devalued when a sticker price is put on it that is laughably small.
Consider preventing excess accumulation/consolidation: if someone is going to do something more, the default should be for that person to do something less as well. It’s not just for their benefit. Our institutions are fragile when they rely on individuals too much for any reason.
(On a related note, documentation is key for onboarding and transferring. Truly useful internal documents that are up to date are exceedingly rare.)
Distinguish between areas where someone is specifically important—where the specific representation matters—versus when someone is a warm body. Not all extra work is the same, and not all additional roles are interchangeable or easy to replace. The ones that leave a real hole need to be valued more, even if that comes mostly in the form of consistent gratitude.
If you think someone special knows just how much they are respected and appreciated, they don’t. I promise.
Mike Swanson’s “Backseat Software” perfectly describes one of the many modern software problems that also happen to plague the Epic EHR:
So the problem isn’t that software ever teaches, asks, or informs. The problem is that once a company builds the machinery to do it, that machinery becomes cheap to reuse, and the incentives gradually pull it away from “help the user succeed” toward “move the metric.”
What starts as an occasional heads-up becomes a permanent layer of UI exhaust.
And then:
So why does it keep happening? Because inside companies, the incentives are clear and the measurements are easy. You can measure clicks and track whether they led to a “completion.” You can measure whether a nudge led to the next step in the funnel.
You cannot easily measure the resentment. Or the rage clicks when they smash a button to dismiss another “did you know” pop-up. You cannot easily chart the moment a user thinks, “I used to like this product, and now it feels needy.” You cannot easily quantify the slow erosion of trust.
I have been dismissing the same feature tour prompt at every login for 5 years.