David R. Henderson  

Dr. Henderson in Africa

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Redistributing from Capitalist... Thomas C. Leonard on Nudge...

There has been a lot of discussion on this blog lately about why there are so few doctors in America. (If you want to follow the discussion in order, see here for Garett, here for me, and here for Bryan).

One frequent commenter, zcd, seems positive that he knows the one right way to train doctors. See this comment and this comment, for example, for the flavor of his remarks.

My guess is that I will be unable to persuade zdc. My guess is also that zdc is an American doctor. Still, I think it's useful to consider the range of ways doctors have practiced modern medicine at other times and in other countries. Exhibit A is my late uncle Fred, Alfred G. Henderson, Jr. He and my late aunt "Jamie," a nurse, were medical missionaries in the Belgian Congo. Life magazine did a big story on their mission in the June 2, 1947 issue. Some excerpts from the story:

The Hendersons arrived at Monieka in November 1945, more than 4 and 1/2 years and 23,000 miles after they had set out for the Congo. En route to Africa in 1941 they were on the Zamzam, the ship which the Nazis torpedoed, as reported in LIFE (June 2, 1941). Dr. Henderson spent 2 and 1/2 years in a German prison camp before he escaped to Switzerland, where he was interned until 1944.

When he got to Monieka his first move was to paint the tiny brick hospital. Before the paint had dried he performed his first operation on a native with a strangulated hernia. Tossing a blanket over the still-wet table, he operated. Overhead mosquitoes wheeled about the gas lantern. A crowd of curious natives leaned in the windows. In one corner of the operating room stood a relative of the patient to see that no internal organs were kept by the doctor to be used for black magic. News of the patient's recovery spread rapidly and within a few days lines of natives formed outside the hospital.

Although Dr. Henderson sees only a small number of his potential 60,000 patients, he averages 300 outpatients a day. In a normal week he performs at least six major operations and a dozen others. He is so overworked that he has trained one of his male nurses to perform some operations. He was the first man to perform a thyroidectomy in the Congo and was besieged by 20 other thyroid patients in one week. [Italics mine.]


By the way, because this is an economics blog, it's important to point out that he didn't give medical care away. Here are the captions underneath two of the photos. Under a picture of my uncle with two patients:
Henderson accepts cash or copper anklets in payment for treatment of natives.

Under a picture of my uncle and aunt:
Congo clinic is held in native village by Dr. Henderson while his wife mixes medicines at table. Natives flock into villages when missionaries arrive. Dr. Henderson charges $2.73 for all abdominal operations, 68 cents for maternity cases, 11 cents for tooth extractions.


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COMMENTS (23 to date)
Tom West writes:

Isn't this simply a matter of what one considers an 'acceptable' success rate?

If you can have medical care for 1/3 the cost, but the failure rate is 5% less, is that a failure of the medical system?

(And no, I don't think the vast majority of medical consumers are going to be informed enough to make a real decision, so in practice, I think it really comes down to institutional decisions as to costs vs. success rather than personal ones.)

Tom West writes:

Oops. Failure -> Success in the second paragraph.

Bryan Willman writes:

Actually, I think zdc at least has a point.

Given a spec for what the public will accept as "a Dr." (in a market where there are many very competent physicians.)

What is the *real* process by which one gets accepted into this role?

An examination of the legal and practical constraints on medical practice would answer the question posed by zdc - that is, in what states is it *legal* to sell medical services with an MD but no residency? Can you get (required) insurance? Could you market yourself in a way that attracts patients?

The congo is a poor counter-factual because your uncle was the only Dr. anywhere near by - and the male nurse he trained could easily be the 2nd most skilled medical provider within a 100mi radius. Whether your Uncle was the best Dr. in his home country, or the worst who could meet professional and legal standards, he was light years ahead of anybody in that region of the congo.

As a general rule, any counter-factual setting in which I, a computer programmer with only educated lay person knowlege of medicine, could raise the standard of care armed with a first aid kit, is NOT a constructive model for how to evolve 1st world medicine.

V writes:

I find zdc's arguments much more convincing than a lot of the arguments Garrett, David, Bryan et al. are putting forth as it fits much more with my knowledge of the medical field.

The interesting question is how countries deal with this and it does not seem to be by cutting years of training, restrictions, etc (see even poor countries like India where the requirement to be an M.D. is the same or more in number of years of training). Instead societies seem to use price controls (similar but stricter than the RVU system we have in place).

I am not sure that answer would appeal to either Garrett, David, Bryan, etc. or zdc.

genauer writes:

I am in support of at least some of the arguments of zdc.

I have here in (eastern) Germany a GP without a Dr., which makes it sometimes a little awkward, because I do have one (in Physcis): - )
I had to go to a specialist last summer with a Dr., and ISO 9001 certified and supposedly "the" specialist in a one million people area. Even coauthor on a few papers. And we had some argument about a medication, and what it supposedly does. It was a horror show of ignorance, arrogance, and plain greed.

In Germany we are now cutting back on length of (tertiary) education.

We never went to a universal K-12. The lower half does 9 years of school and then goes on to apprenticeships. And instead of us adapting to other EU countries, as Barroso and Monti demanded, we are now exporting our way of life, apprenticeships, to Italy, Spain. Even stubborn Irish show some interest. Nurses start to learn their trade at age 16, and not at age 22.

Speaking of your anchestor, he travelled on an war enemy ship (Egypt), with enemy soldiers ("British-American Ambulance Corps, ... to serve with the Allied force"), to an enemy port, with an enemy passport, didn't he? A very legitimate target. US soldiers 1968 in Vietnam had much less qualms about the Geneva convention and courtesy.

MingoV writes:

I am a licensed physician, former teacher of medical students, and former member of a medical school admissions committee. Here are the reasons for the physician shortage in the USA:

1. Federal government. It prevents (through funding control) expansion of existing medical schools and construction of new ones. This has gone on for decades despite increased total population and vastly increased elderly population that needs much more medical care.

2. Costs. Medical school is expensive despite federal financial support.

3. HIV. Medical and dental school applications fell dramatically after HIV was discovered. Applications increased in the late 1990s, but the average quality of applicants was lower than in the early 1980s.

4. Difficulty. Medical school is hard. So are science and engineering programs. College students have many other options, and few choose the hard majors.

5. Frustration. Physicians who get too frustrated with the hassles of practicing medicine (a profession with more red tape and bureaucratic hassles than any other) retire early, emigrate, or switch careers.

6. Other options. Physician assistants are being used more and more. They need only a no-thesis masters degree (2 years) instead of medical degree (4 years) and family practice residency (3 years). PAs, because they usually work for a physician or a medical group, have less billing, administrative, and regulatory hassles.

Another option is to become a veterinarian. Veterinarians have minimal insurance problems and government hassles and no complaining patients.

I could list the reasons why there are too few specialists, but that's another issue.

cw writes:

Here is a post from last summer by Uwe Reinhardt, which contains links to some research on the supply and demand for physicians.

http://economix.blogs.nytimes.com/2012/08/31/from-physician-glut-to-physician-shortage/

Reinhardt's post does not seem mention the role of residency slots. However, in the most recent Handbook of Health Economics, Nicholson and Propper have a chapter on the Medical Workfoce. They discuss the role of residency slots in section 3.5.

http://www.sciencedirect.com/science/article/pii/B9780444535924000141

Tracy W writes:
Another option is to become a veterinarian. Veterinarians have minimal insurance problems and government hassles and no complaining patients.

My sister-in-law is a vet. I think she would disagree with you about the patients.

Thomas writes:

If I'd been in the Congo, I'd have willingly paid more for your Uncle's work than for the work of the nurse he trained.

Bostonian writes:

There is no need for prospective doctors to spend four years getting a BA for starting medical school.
Few other countries require this. Premed courses could be finished in one or two years. A recent Washington Post opinion piece suggesting this is

http://articles.washingtonpost.com/2013-02-22/opinions/37240409_1_school-students-medical-school-graduation
High school to med school: Fast track to an MD
By Abdullah Nasser,February 22, 2013

mm writes:

You can't do premed in 1 year- 4 semesters of chemistry, 2 semesters of biology, 2 semesters of physics - in the bad old days 2 semesters of calculus as well. That requires 2 years- can't take organic concurrently with the 1st year of chemistry. Many European countries do a combined program with 6 years to an MD, they often graduate many more MDs than they have residencies for- in effect many GPs are less than half trained by our standards.

Steve Sailer writes:

Thanks, that's great stuff about your uncle.

David R. Henderson writes:

@Steve Sailer,
Thanks. And there's a longer story to tell, based on an interview I did with him in 1993. In the German prison camp, he was assigned to take care of the medical needs of prisoners and when the Swiss came through to enforce the Geneva Conventions, he "outed" the German doctor who supervised him because the German doctor had asked each prisoner "Sind sie Jude?" The Swiss told the German doctor to stop--and he did!

Bostonian writes:

"You can't do premed in 1 year- 4 semesters of chemistry, 2 semesters of biology, 2 semesters of physics - in the bad old days 2 semesters of calculus as well. That requires 2 years- can't take organic concurrently with the 1st year of chemistry. "

A strong student entering with AP credit in calculus, physics, chemistry, and biology could.

mm writes:

Certainly some could, but the "program" is still more than one year long- that s the point.

Brent Buckner writes:

@cw

You write: "Reinhardt's post does not seem mention the role of residency slots."

It comes close when he quotes the 1996 recommendation of the Council of Graduate Medical Education: “that the number of physicians entering residency be reduced from 140 percent to 110 percent of the number of graduates of allopathic and osteopathic medical schools in the United States in 1993.”

The mechanism for controlling the number of physicians entering residency was limiting the number of residency slots.

genauer writes:

what again is the justification for

some unelected "Council" to limit "residency slots" for qualified GPs to set up shop, where ever they see fit,

in a democratic, market society?

genauer writes:

Basically every time, I look into some details of wages and costs in the US, I see gross wages for certain professions too high by a factor of 2 or more.

GM workers, Stockton police force, NY nurses, US soldiers, Doctors, Lawyers.

At the same time, there are still considerable difficulties to fill jobs, who do socially valuable, honorable work.

I begin to appreciate Deidre McCloskey "Bourgeois Dignity" more and more. What is perceived as important in a society?

As somebody on an Irish Blog (http://www.irisheconomy.ie/index.php/2013/03/08/austerity-as-an-idea/) exaggerated only slightly:

"In Germany bragging rights went to the mother who had a son apprenticing as a Machinist at Mercedes as opposed to the one with a son in law school."

In the US, to which we now therefore also export our apprenticeship model, people do at age 29 - 39, what they do here at age 16 (do google translate: http://www.tagesschau.de/wirtschaft/ausbildungskonzept100.html)

zdc writes:

@drh
My grandfather worked as a medical missionary in Zambia at a similar time to when your uncle was just north in Congo.

"My guess is that I will be unable to persuade zdc" -- Persuade me of what? Our recent debate arose when you offered up that medical school spots were the binding constraint with regards to physician supply. I certainly wasn't persuaded since ample evidence shows that such isn't the case.

"why there are so few doctors in America" -- I'll take 'Unsubstantiated generalizations for $500, Alex." So few relative to what? The number of people given the title of 'M.D.' in Cuba annually, even though those 'doctors' are insufficiently trained to offer anything anyone in this country would recognize as high-end, modern medical care? Relative to other developed countries. How about compared to your homeland, that bastion of socialized medicine, Canada. In 2009, the OECD reported that the number of physicians per 1000 people in the US at 2.4, compared to Canada's 2.1 per 1000.

If, by your anecdote, you're proposing that medicine should be allowed to be practiced by anyone who cares to put themselves forward as a practitioner of such, entirely without regulation, with zero malpractice risk for the practitioners...well that's an interesting proposal. To me, it looks like yet another proof of Erasmus's centuries old wisdom, "In the land of blind men, the one eyed man is king".

David R. Henderson writes:

@zdc,
My grandfather worked as a medical missionary in Zambia at a similar time to when your uncle was just north in Congo.
Neat.
Persuade me of what? Our recent debate arose when you offered up that medical school spots were the binding constraint with regards to physician supply. I certainly wasn't persuaded since ample evidence shows that such isn't the case.
We had two discussions or debates. One was the one you mention above; the other is about what the standards should be for who is a doctor. It was this last that I was referring to. If you recall, you insisted that to be a doctor, one must do a residency: not just that that's the law but that you think that's a desirable law.

zdc writes:

@drh
So, you think you can design an improved (not sure if this means in terms of outcomes or costs or what) system. How about something concrete from you. I'd love to see how you think someone, let's say a neurosurgeon, should be trained. How would you identify quality candidates for training, select a place for them to train, pay for their training, ensure adequate supervision during training, and ensure that they had achieved such skill as to be released into the wild to operate on someone such as yourself. And make sure your proposed system is able to train tens of thousands across the country.

David R. Henderson writes:

@zdc,
So, you think you can design an improved (not sure if this means in terms of outcomes or costs or what) system. How about something concrete from you.
No, I don't. I have no idea how to do it. I'm not sure why you think I do.

zdc writes:

@drh

Well, you've stated that you think there are too few doctors in America, "Why there are so few doctors in America."

And, you've offered up your opinion as to why this is the case, "So why aren't these people, and many like them, doctors? Because of the aforementioned restriction of supply...Coda: The binding constraint is the restriction on slots in medical schools."

Said opinion has been shown incorrect, and you learned that medical school is not the final training pathway for physicians. Now you offer up an anecdote detailing how a single person was trained to perform medical procedures in a primitive setting on patients with no other options, and highlight the fact that "he...trained one of his male nurses to perform some operations" to prove that someone can learn to perform the functions of a physician without years of training.

What I'm doing is taking this debate to its logical conclusion. You think there are too few doctors, have attempted to identify the cause for such, and usually people try to identify the source of problems to try to bring about solutions. I see the residency system in the US as be critical and necessary for ensuring a continued supply of well-trained physicians here in the US. You seem intent on persuading me otherwise, and I was eager to see you try. You think the current system is supplying a suboptimal (and low) number of physicians to the US medical workforce. If the current system is insufficient, how should it be improved upon. Without offering up concrete ways to improve upon the system (or throw it out entirely and create a new one), you're just complaining.

You see, the devil is in the details. The current medical training paradigm we have may not be perfect, but it's the most advanced and effective the world has ever seen. Sure, your uncle could train one guy to do a procedure. What's missing from that story is all the details like:
- Did his patients actually survive?
- How did their outcomes compare with those of a physician in similar cases?
- How did he go about selecting patients? Did poor patient selection lead to more harm than good?
- Did he continue to practice once your uncle left?
- Did he train anyone else to take the skills to the next village over or continue after he was unable to do so himself?

You brought up work-force issues and think there are too few physicians in the US, and lay the blame at the feet of the current training paradigms. So, how could those training paradigms be structured more efficiently (or replaced by an even better system) to produce well-trained physicians year after year? I knew you would have no idea how to do so, and that's my point.

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