David R. Henderson  

What's a Doctor to Do?

PRINT
Is Welfare a Band-Aid for Nomi... Water Runs Downhill, and Schoo...

Over at Marginal Revolution, Tyler Cowen posted a question asked by a 3rd-year medical student who's a regular reader of MR. Here's the question:

I am a 3rd year medical student, and for the purposes of this question, let's assume I have equal interest and ability in the various medical specialties. In order to create the greatest good for the greatest number of people through my work in medicine (i.e., the highest return to society), what specialty should I pursue? I should add that, although I intend to practice in the U.S., I am open to devoting as much of my free time/vacation as possible to pro bono medical activities, and further, that I wish to do the interventions myself (instead, for example, or just making lots of money and then donating the proceeds to some other charitable activity). In attempting to answer this question, I've been looking at DALYs and QALYs associated with various medical interventions (e.g., cataract surgery). Am I going about answering this question the right way? Any thoughts?

I thought Tyler gave a thoughtful answer. I won't repeat it here because you can check for yourself.

A lot of commenters chimed in, of course. One who comments a lot on Tyler and whom I won't name because I don't want to encourage him, looked for the bad and, at least in his evaluation, found it.

But many other commenters had very thoughtful comments. Here were the three that I particularly liked:

1. You could help with the nurse to near-doctor pathway. That might be the best thing for social good if you can figure out how to scale that.
My [DRH] comment: Of course, whether this makes sense will depend on this particular person's skills. But I agree with the commenter that the payoff could be huge.

2. If you actually wanted to do the most good, you'd simply become an orthopedic surgeon and donate your excess earnings to a givewell.org charity.
That doesn't feel right, huh? That's because altruism is suspect. You're always serving yourself just under different timeframes and signalling patterns. It's not that you want to do the most good per se, because nobody actually wants that. You probably want to see people benefit at your hands. There's nothing wrong with that, but it's important to acknowledge to properly assess what's the best move for you.
You should try to figure out what it is about helping others that really drives you. Do you like exposure to danger, travelling to third world countries and the camaraderie of do-gooder doctors? Then maybe doctors without borders is for you. Do you like being in small town america helping Americans deal with debilitating obesity? Then maybe you should be a family doctor. Do you like a lab setting and quantitative analysis? Then research is probably right for you.
I think once you're honest about the fact that you're actual motivation is serving yourself, you'll do a better job of serving yourself and the world.
DRH comment: I think the person making this comment could be a good career counsellor.

3. My GP does Doctors without Borders for a third of the year. So 1) she's a GP which is the most needed kind of doctor in the US and 2) she does DWB which lets her do humanitarian work and travel. Plus, when I travel out of the country somewhere exotic she knows exactly what shots I need.
I'm really shocked only one other person has said general practice. You KNOW it's what we need. It's hard, it pays the least, and it's the actual boots on the ground for people here and everywhere. You don't even need to do DWB. Go set up a clinic in rural America if you want to do real aid work.

I would add one more thought. Given that the questioner reads MR regularly, he/she should apply some of the basics he/she has learned in economics and:
1. Oppose government regulation of medical care, including regulation of health insurance, restrictions on supply (licensure, CON laws, etc.), FDA restrictions that keep drugs off the market, etc.
2. Not become a nanny stater who tries to get the government to regulate our lives on sizes of soda bottles, packaging of cigarettes, etc.


Comments and Sharing





COMMENTS (17 to date)
Yancey Ward writes:

Given the stated desire, I don't see how one beats going into the highest net income specialty, and then donating all excess income to the funding of others in some of the other ideas offered.

Ted Levy writes:

Isn't it unclear what is the most helpful or needed or beneficial medical subspecialty, given the total and utter absence of a pricing market?

David R. Henderson writes:

@Yancey Ward,
Given the stated desire, I don't see how one beats going into the highest net income specialty, and then donating all excess income to the funding of others in some of the other ideas offered.
Of course. That’s the point the second commenter made. But the reason I liked the second commenter’s comment so much is that he had the sense to question whether the stated desire is the real desire and to ask what’s underneath it.

David R. Henderson writes:

@Ted Levy,
Isn't it unclear what is the most helpful or needed or beneficial medical subspecialty, given the total and utter absence of a pricing market?
Take away the “total” and “utter” and I agree with you.

Yancey Ward writes:

David,

I guess I take as a given the medical student was stating his desire accurately. Of course, the student would still have to identify how to donate his income.

Robb writes:

The second commenter could improve his analysis by splitting up "actually doing good" and "feeling good about doing good" into separate pools and addressing those separately.

But the best advice this young person could receive is to request a consultation with 80,000 Hours and talk with effective altruists generally. You know, take advantage of existing expertise.

Mark Bahner writes:

My comments included:

My second advice is that with IBM Watson doing doctoring, Watson can replace 1 million+ doctors. So I would look to something where she/he could reach millions of patients. Mr. McGuire’s one-word advice was “plastics.” Mine is “telemedicine.”

Mark

P.S. My two-word advice would be “pediatric telemedicine.”

Medical Student writes:

As the original poster of the query to Tyler, I wish to thank you for your insightful comments. May I add a few additional comments of my own?

1) Donating Income - The suggestion that one enter the highest paying specialty and donate income occurred to me, and in my question to Tyler, I specifically stated I wanted to do the interventions myself, and not to simply donate money. It likely is more "efficient" to do just that - take the highest paying job and donate excess income - in which case one should stop studying medicine and head to Wall Street. As a matter of fact, I previously worked in a Wall Street-type job making excellent income. I was miserable, and I found that the money changed me...I had a difficult time donating money for 2 main reasons: (i) I hated my job and wanted to "save up" so that I could quit/"retire" to do something useful; (ii) the culture around me was not one conducive to effective charitable giving (really it was a race to accumulate wealth, conspicuously consume). Ultimately, I decided to enter medicine so that I could spend my life DOING good (or at least trying to, or as another comment suggests, "feeling good about doing good"). Hence, my stated desire to Tyler is to do the interventions myself, for better or worse. I have very high esteem for people who manage to pull off what I couldn't, and to donate significant fractions of their income to charitable causes in a distant part of the world. I confess to my imperfect deeds and motivations. But as another poster pointed out, the donation advice simply pushes the problem back a step - now one must find charities that focus on medical interventions with the highest return to "society" (not simply U.S., but globally). If you know what these highest return activities are, please share!

A further problem with "take the highest paying job and then donate" is that in medicine, incomes are highly regulated. The specialty that makes the most money today may not tomorrow. Government reimbursement is a fickle creature. For example, ophthalmology reimbursement rates for cataract surgery have decreased ~85% since the 1980s, transforming ophthalmologists income relative to other specialties dramatically. So it's unclear what specialty will in fact make the most income over the next 40 years. Orthopedics is a good bet, but it's just somewhat unknown to me. If you happen to KNOW what specialties will have the highest earnings over the next 40 years, pray tell, as I'm sure many medical students would be curious.

(2) Pricing Market - Some suggest that if we had a good pricing mechanism in medicine, my problem would be solved. It is true that pricing in medicine is out of wack. But to me, this argument seems to ignore the HUGE externalities that exist in medicine. For example, fixing a cataract might prevent a person from getting into an auto accident due to their poor vision. A private pricing market may/will not take into account these externalities. To suggest that the government will somehow create a pricing system that does is exceedingly optimistic.

In trying to answer my question to Tyler, I actually have spent some time looking at DALYs and QALYs of medical interventions, but I have not yet found a reasonably comprehensive compilation. If you know of any, please let me know.

Once again, thank you all for the advice! And keep the comments coming, as this is a question of real importance to me.

Mark Brophy writes:

Your GP works for Doctors Without Borders for 4 months each year because her government punishes her for working by imposing an income tax. She earns all she needs in 8 months and can enjoy a vacation the rest of the year. Many doctors and dentists work part-time.

jseliger writes:

I'm really shocked only one other person has said general practice. You KNOW it's what we need. It's hard, it pays the least, and it's the actual boots on the ground for people here and everywhere. You don't even need to do DWB.

I left a response to the question that included this:

My fiancée is a doctor, which means I hear lots of doctor talk. Apparently developing countries most need surgeons and organizations like Médecins Sans Frontières really want surgeons.

I'm not sure how true this is but at least among the doctors I've met it seems to be the prevailing view.

I'm also of the view that much general practice is going to shift over time to NPs and PAs.

MingoV writes:

A physician and former medical school associate professor's advice:

Point zero: An economic/mathematical/cost analysis approach isn't worth a da*n, in my opinion. For someone like you, the goal is to improve the quality of healthcare as much as possible for as many people as possible. This barely qualifies as an economic issue. Much of it is based on how well you practice, not what you practice or where you practice.

Point one: No medical student has equal ability or interest in all specialties. Any medical student who believes that should do society the greatest good by changing professions.

Point two: A medical student with equal ability and interest in a few specialties who wants to do the most good has to pick how. Good can be done by being a generalist in areas with limited access to physicians or being a specialist in areas with too few of that specialty. Example 1: Many rural areas have too few physicians for the dispersed population. An internal medicine or family practice doctor would have a positive impact on the quality of health care. Example 2: Many regions, including urban ones, have too few of certain specialists such as psychiatrists. Going into one of those specialties would have a positive impact on the quality of health care.

Point three: Keep up with your field. Being a physician who practices 2014 medicine in 2034 is not improving the quality of care, regardless of which route taken.

Point four: Don't add so many patients that your schedule is crammed every day and you're bombarded with calls every evening and throughout your weekends. Physician burnout deprives all your patients of medical care.

Joel Davis writes:

In response to Yancey and the second commenter in David's piece, the original questioner states explicitly that they don't want to just make as much as they can and donate it.

...I wish to do the interventions myself (instead, for example, or just making lots of money and then donating the proceeds to some other charitable activity)

Although they have not explicitly said they care more about how they feel about their charitable work than the good it does, I feel like it's fairly strongly implicitly stated.

vikingvista writes:

If the student were driven by the magnitude of indirect good his actions did for others, the level of economic knowledge that compels him to consume MR on a regular basis would have likely driven him to remain on Wall Street, unconcerned by the relatively insignificant conspicuous consumption of his and his peers.

I'm skeptical, however, that anyone is so driven, at least for long. He was likely unhappy with his Wall Street position because he was unhappy with the day-to-day mundane intellectual experience of it.

The medical specialties are sufficiently different, that his approach is effectively a crap shoot for his professional happiness. And that makes it a crap shoot for his effectiveness. The kind of person who will be happy/effective as an orthopedic surgeon is not the same who will be happy/effective as an internist--a standard teaching in med schools that students would do well to consider.

It is partly for the same reason that pursuing DALY and QALY is a terrible way to direct one's vocation--it ignores what actually stimulates and sustains your mind day to day. But what's more, the XALY are yet more attempts to objectify inherently subjective phenomina, and must always be variously wrong, varying by individual perspective.

A large burden of unpleasant tasks plagues all physicians today, and the outlook is for those burdens to grow even while compensation falls. If there isn't something you regularly find compelling in the minute--without regard to broader social consequences--then do yourself and your patients a favor, and find another profession.

Todd Kreider writes:

Mark Bahner:

My second advice is that with IBM Watson doing doctoring, Watson can replace 1 million+ doctors.

I just added to Mark's comment at MR:

And The Son of Watson will replace whoever is left.

Mark V Anderson writes:

I think the most important issue is the kind of medicine you want to do, and what you are best at (which are usually the same thing). Not only will this result in a more interesting career, it will also result in better results for your patients and probably more money (which can be donated if that is what you feel is best). I know you say you entered medicine to do good, but it is a happy coincidence that what you do best at is usually also the most fun and the most remunerative.

I know little about the practice of medicine myself, but it is clear from the comments of others that there is great variety in practices, such as general clinician, specialist, research, psychiatry, surgeon. All those will be done well by completely different types.

If medicine was a less regulated profession, I would simply suggest make the most money as possible. Then the amount of money received would correlate pretty well with how well others value your work, which is about as objective of the worth as you could get. But that won't work too well with medicine.

Seth writes:

@Medical Student - I like David's last two points in his post the best of all I've seen.

I'll add one more. Do you what you like and you will probably do the most good.

Doing what you like is obviously important to you. The excellent income you earned from your Wall Street-like job wasn't worth the trade-off of doing something you didn't like.

I'll venture a guess that doing something you don't like in the medical profession will not be worth the trade off of believing you are doing the most good (you really won't know if you are), or to be more accurate, the trade-off of believing what fallible economists and blog commenters thought did the most good. You'll go nuts & quit that, too.

Do what you like and you'll do that far better than anything else, which will more likely do the most good. And life is unpredictable. Do what you like and you might discover something that has a far greater impact for the better. Good luck.

David R. Henderson writes:

@Seth,
Good advice. Thanks. BTW, I clicked on the link to your blog and enjoyed your personal story about how your views evolved.

Comments for this entry have been closed
Return to top