French vs American Surgeons - How Culture Shapes Career: Part 2

‍What the United States Taught Me About Being a Surgeon And What France Rarely Admits

L’Envers Du Décor

I practice neurosurgery in France. I did half my residency in Lebanon before moving to France. My later training and my practice are shaped by French ideals, protected by its labor laws, and formed within a system that prizes intellectual rigor and collective responsibility. 

Frances Mei and I recently wrote a piece about what France gets right: protected vacations, protected personal time independent from colleagues or management or simply the right to be sick!

But our recent discussion, over white wine and oysters facing Opera Garnier, has forced me into an uncomfortable realization : some of the things we congratulate ourselves for in France come at high costs: ones we are only recently starting to articulate and rarely confront.

This piece is not an indictment of the French system. It is a confession. And an acknowledgment that, in several crucial ways, the United States treats surgeons - and medicine itself - with a seriousness that France has gradually eroded.

The Price of a Life in Medicine

In the U.S., the first thing that strikes you is how clearly society has decided that physicians, especially surgeons, are worth paying.

The numbers are blunt. An American neurosurgeon earns several times more than their French counterpart (even after accounting for student debt and lower costs of living): a US neurosurgeon earns between 440K and up to 1million USD while a French hospital neurosurgeon makes about 75K-200K. This difference is often framed in France as a moral failure of American capitalism. But that framing is too easy and too self-satisfying.

What that pay really reflects is recognition: of years of training, of the weight of decision-making, of the risk, of the personal cost of living inside other people’s emergencies.

In France, surgeons are paid as if vocation should compensate for everything else. As if devotion should replace acknowledgment. As if loving medicine should make us immune to fatigue, responsibility or economic reality. 

Newsflash: it doesn’t.

Training: Endurance Without Interrogation

French surgical residency is not comfortable. It is long, physically exhausting, emotionally demanding, and often disorganised. We accumulate responsibility early, sometimes abruptly, and learn by immersion rather than design. What distinguishes French training is not its ease, but its opacity.

Much of residency can feel like running on a hamster wheel: rotating through services, absorbing clinical exposure, repeating tasks without any program director ever stopping to ask whether what we know is sufficient, coherent, or safe. We are trusted to be learning, but rarely formally evaluated along the way. Progress is assumed rather than measured.

This produces clinicians who are adaptable, resilient, and clinically intuitive. We learn to think before acting, to improvise, to manage uncertainty. But it also means that gaps can go unnoticed, not because we are careless, but because the system rarely double-checks what we have truly mastered.

In the United States, training is openly hard in a different way. Residents carry debt, workload, and expectations that would be unthinkable in France. But in exchange, they are subjected to continuous scrutiny. Knowledge is tested. Outcomes are tracked. Competence must be demonstrated repeatedly, not presumed.

American trainees and surgeons are evaluated relentlessly: by metrics, case numbers, exams, boards, certifications.

In France, we trust. In the United States, they measure.

The truth is that excellence requires both. And if France has sometimes erred, it is not by making training too easy but by demanding stamina without always demanding proof.

The Hidden Weight of Doing Everything Yourself

One of the most striking differences in daily practice is not ideological at first glance; it is logistical. American surgeons are surrounded by teams: physician assistants, nurse practitioners, care coordinators, scribes… These professionals do not replace the surgeon; they amplify them, absorbing the tasks that dilute attention and allowing surgeons to focus on what only surgeons can do.

In France, this support structure is largely absent. We write our own notes, chase our own tests, coordinate our own discharges, and manage administrative chaos as if it were part of the Hippocratic oath. The result is not moral purity but inefficiency, exhaustion, and a quiet erosion of time spent thinking.

This expectation that the physician should “do everything” is often framed as completeness or rigor, but it is neither accidental nor neutral. It reflects an ideological choice - and a financial one - to economize on support rather than invest in it, trusting that professional dedication will absorb the cost. Medicine is not unique in this regard: teachers, university professors, police officers… live under the same logic. What we call completeness is, in reality, a system-wide strategy of underfunding, one that gradually turns professional commitment into structural fatigue.

The Scarcity We Created: Numerus Clausus and Its Fallout

No discussion of French medicine is honest without addressing the numerus clausus: the decades-long policy that deliberately restricted the number of doctors trained in this country.

It was designed to control costs. It succeeded. It also produced a generation-spanning medical shortage whose consequences we are now living with daily : there are fewer doctors in France, not by accident, but by design. Entire regions are medical deserts. Emergency departments are overwhelmed not by complexity but by volume. A stark example is the number of neurosurgeons per 100K population: 2.84/100K in the US vs 0.77/100K in France. Hospital wards run permanently understaffed (and underpaid). Waiting times lengthen. Burnout becomes structural, not incidental.

And yet, paradoxically, doctors are still portrayed as privileged even as the system collapses under the weight of its own planning failures.

The numerus clausus did not just limit access to medical school. It limited flexibility, resilience, and surge capacity. It made every absence a crisis. We trained scarcity into the system and then blamed doctors for the consequences.

Autonomy, Risk, and Professional Adulthood

American surgeons live with more risk: legal, financial, reputational. Malpractice is real. Failure has consequences. But with that risk comes professional adulthood : the ability to shape one’s practice, to innovate, to grow, to fail and recover.

French surgeons practicing in the public health sector are safer, protected by the public system, by contracts, by uniformity. But safety can quietly become infantilization. Autonomy is limited. Initiative is often punished administratively. Innovation requires endurance more than vision.

Two Systems, Two Blind Spots

France has taught the world that medicine must remain human. The United States has shown that humanity without resources, recognition, and accountability is fragile.

One system risks dehumanization through excess. The other risks stagnation through restraint

The real failure would be to believe that we must choose. As surgeons working across cultures, our responsibility is not to defend our systems reflexively, but to ask harder questions, especially about the policies we inherited, the comforts we protect and the costs we prefer not to see.

Because medicine cannot survive on ideals alone and it cannot survive on productivity alone either. It will survive only if we are honest about both.

In Response to “What Paris Taught Me About How Surgeons Could Live”

The France that Frances Mei describes is real. I recognize it. I live in it. The protected evenings, the shared meals, the collective belief that a surgeon should also remain a citizen, a parent, a human being: these are not illusions. They are hard-won cultural choices, and they matter deeply. 

But what that portrait leaves in the margins is the price we pay to preserve it: the quiet normalization of scarcity, the erosion of professional recognition (the behavior extending to normalized calling doctors by their first names), the expectation that devotion will substitute for resources, and the long shadow of policies that traded short-term control for long-term fragility. 

If France taught her how surgeons could live, then the US taught me how medicine must be sustained: with people, with support, with accountability and with the courage to admit that protecting doctors is not the same as investing in them. These two truths are not incompatible. In fact, they are incomplete without each other. And perhaps the real lesson is not that one system should emulate the other, but that neither can afford to keep telling only half of the story.

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Read Part 1 from Frances Mei's perspective here.