The Medical Degree Lottery: Congratulations, You’ve Won Other People’s Money

Too many doctors and dentists treat their medical degree like a winning lottery ticket instead of a covenant with their patients. The letters after their name become a license to print money, not a reminder of why they went into medicine in the first place.

Working the System, Not Serving the Patient
Walk into far too many clinics and dental offices, and you can feel it: the quiet hum of a machine optimized for billing, not healing. The degree on the wall might say “Doctor of Medicine” or “Doctor of Dental Surgery,” but the workflow screams “Doctor of Maximizing Revenue Streams.”
The script is depressingly consistent. Something minor is framed as potentially catastrophic. “We wouldn’t want to miss something,” they say, right before ordering the full panel of bloodwork, the fancy imaging, and the procedure that conveniently bills at a higher level. In dentistry, there’s a whole literature now on overtreatment—x-rays, implants, orthodontics, cosmetic work—where the main risk factor isn’t your mouth; it’s your provider’s business model.

Too many clinicians confuse “what’s billable” with “what’s beneficial.” When your professional identity is tied to production numbers and RVUs, “doing more” starts to feel like “doing better”—even when the patient’s body and bank account would strongly disagree.

The White Coat as a Lottery Ticket
Here’s the uncomfortable truth: medicine and dentistry are among the few professions where the public still walks in assuming, “They must be acting in my best interest.” That’s an enormous amount of unearned trust. And where there’s blind trust plus opaque billing plus complex science, there is endless opportunity for quietly turning a degree into a lottery ticket.
If you design a system where people are paid more to do more stuff, you get more stuff done—whether or not it was needed. You don’t need an ethics committee to predict that; you just need a basic understanding of human behavior and incentives. In that kind of ecosystem, a medical degree becomes less a calling and more a credential that allows you to pull from the giant piñata of health-care spending. Hit it hard enough, and the money falls out.

And here’s the part nobody seems willing to say out loud: I promise, Doctor, you will still make plenty of money if you stop ordering the unnecessary tests and stop scheduling the “just-because” procedures. You will still pay your mortgage, still send your kids to college, and still go on vacation—but you might actually sleep better at night. I hope. Just do what’s right.

The worst part? Many clinicians convince themselves they’re doing the right thing. Defensive medicine, “patient expectations,” fear of missing something—all excellent justifications for padding a workup. Over time, the moral discomfort dulls. What once felt like overkill starts to feel “standard of care.”
The oath to do no harm quietly gets edited to: “Do no obvious, litigable harm.” If the outcome wasn’t catastrophic and the procedure was technically defensible, then what’s the problem? The problem is that the patient’s trust was used as leverage, not as a responsibility. The problem is that you turned someone’s fear and ignorance of the system into your margin.

A medical degree should not be a ticket into a very polite, very white-coat version of the casino. But look around at how care is delivered and billed, and tell me it doesn’t look like the house is always supposed to win.

Meanwhile, in Pediatrics, We’re the Rounding Error
Now let me step into my own world for a second. Pediatrics. The land of snotty noses, vaccines, growth charts, and goldfish crackers crushed into car seats. Children make up about a quarter of the population, yet only about 9–10% of total personal health-care spending is on kids. We’re a small slice of the pie compared with adults and seniors, who soak up the bulk of the dollars through chronic disease, hospital stays, and specialty care.
In other words, in the grand casino of American healthcare, pediatricians are sitting at the low-stakes table. We’re not where the real money is. If I spend your visit talking you out of unnecessary antibiotics, unnecessary imaging, unnecessary surgery for your child, I have not exactly discovered the next great revenue stream. I’ve actually reduced billable opportunities—mine and everyone else’s.

But imagine, just for fun, that the rest of the system behaved the way we beg it to: doing what’s necessary and appropriate, not what’s justifiable and profitable. If kids get ~10% of spending, that means the other 90% is being chewed up by adults and older adults. Now imagine even a small fraction of the waste, fraud, and abuse in that 90% finally being cut. The savings would dwarf every insurance “reform” we argue about.
We fret over premiums and policy names while billions leak out through unnecessary tests, redundant hospitalizations, cosmetic dentistry dressed up as “health,” and “procedures of unclear benefit” that somehow manage to clear the billing committee just fine. You wouldn’t need to invent the perfect insurance program if the care you were insuring wasn’t bloated on the front end.

Dentists, Doctors, and the Art of Exploiting Assumptions
Dentistry deserves a special mention, because the evidence is explicit: overtreatment is a documented, serious issue. In areas like orthodontics and implantology, the line between “helping the patient” and “beautifying the balance sheet” can get disturbingly thin. Parents are told their child “needs” certain appliances or procedures, when in reality, the driving factor is often the provider’s preference, practice style, or financial pressures, not an emergency in the child’s mouth.

Medicine is no better. Think of the elective procedures that ballooned before anyone asked hard questions: tonsillectomies, specific orthopedic surgeries, imaging for minor pain, neurologic workups for headaches that didn’t need them. The justification is often vague—“We just want to be thorough”—but the billing is very specific.
What makes this possible is not just greed. It’s the assumption baked into our culture that “Doctor recommended” automatically means “best for me.” Patients rarely see the competing pressures: production targets, fee-for-service incentives, competitive local markets, fear of online reviews that punish the doctor who doesn’t “do something.”

When we build systems where it’s easier and more lucrative to overtreat than to explain why something isn’t needed, we shouldn’t be shocked when overtreatment becomes the norm.

The 90% Problem: Where the Real Money Lives
If children’s care accounts for about 10% of personal health-care spending, the remaining 90% is in adult medicine and geriatrics, where chronic disease, hospitalizations, expensive medications, and endless diagnostics live. That’s where the real “lottery” is.
Pediatricians, for all our flaws, are generally taught to think in terms of long-term benefit: prevention, vaccines, early intervention, avoiding harm over decades. We are not the ones ordering a fifth imaging study this month for the same chronic back pain, or scheduling yet another elective procedure for marginal gain at high cost.
Now imagine if the physicians and dentists who control that 90% of spending made clinical decisions with the same restraint we beg parents to use: ask if it’s really necessary, ask whether it changes management, ask whether the risk of doing it outweighs the risk of not doing it.

You would see an immediate drop in waste, fraud, and abuse. The kind of drop that makes entire pieces of policy theater—massive debates about who pays for what—look ridiculous in retrospect. If the outflow is irrational, no amount of rearranging who funds it will fix the math.

Why This Matters to Families
For families, the difference between a doctor who remembers their purpose and one who treats their degree like a lottery ticket is measured in more than dollars. It’s measured in trust, in anxiety, in risk you didn’t need to take.
The doctor who tells you “no, we don’t need that test” is not lazy; they’re doing the harder work. They’re taking responsibility for an informed decision rather than outsourcing it to a machine and a billing code. They’re accepting that medicine has limits—and that your child’s body is not a playground for every possible intervention.
Conversely, the doctor or dentist who always has “one more thing we can try” rarely pays the price for that cascade. You do. Your child does. Your future premiums do. The system does. They get to keep the narrative that they “did everything,” while you’re left with the consequences of everything.

If more clinicians treated the degree as a duty, not a ticket, health care would still be expensive—sick people, complex procedures, and new technology are not cheap—but it would be expensive for reasons that make sense, not because someone found a way to turn fear into a revenue line.

Sources:
Centers for Medicare & Medicaid Services (CMS). “U.S. Personal Health Care Spending By Age and Sex, 2020.” Shows that children 0–18 are about 23–24% of the population but only ~10% of personal health care spending.
Bui AL et al. “Spending on Children’s Personal Health Care in the United States.” Health Affairs, 2017. Analysis of U.S. health-care spending patterns for children by age, condition, and type of care.
CMS. “National Health Expenditure (NHE) Fact Sheet, 2024.” Overview of total U.S. health-care spending, growth rates, and major categories of expenditures.
Health Care Cost Institute. “Children’s Health Services 2020 Report.” Describes spending trends and service use for children with employer-sponsored insurance.
CMS / VA / health plans. Fraud, waste, and abuse definitions and training materials, including:
“Fraud, Waste and Abuse (FWA) Provider Training.” HealthCare Partners.
“FRAUD, WASTE, AND ABUSE” training document, Community Health Choice.
VA Fact Sheet: “Preventing and Reporting Fraud, Waste and Abuse.”
The Health Plan. “Healthcare Fraud, Waste, and Abuse.”
AccountableHQ. “Fraud, Waste, and Abuse in Healthcare: Definitions, Examples, and Requirements.” Overview of how overutilization, unnecessary services, and abusive billing drive costs.
AHIMA / related calls to action on “Busting Bad Medicine” and addressing healthcare fraud, waste, and abuse.
IADR Abstract Archives. “Overtreatment in Dentistry: An Ethical and Empirical Analysis.” Documents overtreatment as a serious issue, especially in orthodontics and implantology, with fee-for-service incentives and erosion of professional ethics.
Lurie Children’s Hospital. “Behavioral Health Spending Spikes to 40% of All Children’s Health Expenditures.” Example of how specific sectors (like pediatric behavioral health) now dominate pediatric spending.