Bryan Caplan  

Medical School: A Whistleblower's Story

Answering the wrong question... Don't give them anywhere to hi...
Case Against Ed.jpg Here's an email from a former medical student who heard my EconTalk with Russ Roberts.  Reprinted anonymously with his permission.

Good afternoon Drs. Caplan and Roberts,

My name is [redacted] and I recently listened to your conversation on Econtalk regarding education. I wanted to pick your brains regarding the structure and finance of medical education in the US.

I recently left medical school after one semester. I spent years and thousands of dollars on tuition, preparing and taking the MCAT, applying to medical school, going on interviews, etc. Ultimately I came to the decision that my heart wasn't 100% in medicine and I was unwilling to pay the opportunity costs.

I've actually applied to anesthesiologist assistant (AA) programs, which are just two years in length. AAs legally must work under the supervision of a physician anesthesiologist and they essentially function like physician assistants, but are specific to anesthesia. 

This got me thinking about the practice of medicine and the scope of practice issues that have come up in the last few decades across state legislatures. I am not an economist by any means, though I definitely wish I took more econ courses in college. I even though about grad school in public policy but that's a conversation for another time.

I'm not sure if any of your research has addressed the topic of medical education or not. I've heard the American Medical Association referred to as a cartel in another podcast, Freakonomics.* I think the episode was discussing the role of nurse practitioners which has made some primary care physicians uncomfortable.

Specific to anesthesia has been the ongoing battle between certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants, who have actually been around for over 40 years. According to legal precedents, anesthesia is considered both a nursing specialty as well as a medical speciality. The CRNA lobby is phenomenally politically savvy and they have blocked legislation for AAs to work in various states. Currently, AAs are only allowed to practice in 18 states. Of course the irony is not lost upon me since the very same arguments CRNAs use against AAs are the same ones physicians have used against other mid-levels.

Having worked in healthcare prior to med school, I was able to see the enormous financial decisions that go into patient care. There are clearly external forces influencing behavioral ​decision making, from C-suite executives to physicians-in-training.

As an intellectual exercise, I've often pondered about the state of medical education in the US. Nowhere else in the world are medical students required to attend college for four years before matriculating into medical school. The so-called Hopkins model has been championed by the Flexner Report of 1910 and we apparently still think it's the only appropriate pedagogical model to train the next generation of physicians.

Perhaps it was one of the major reasons why I left med school. The constant testing  and ineffective teaching strategies left much to be desired, particularly for long-term retention. Even the licensing schedule that has developed through the years has become cumbersome: Step 1, Step 2 (which has two parts), and Step 3. This does not include the exams you take in your actual specialty once you finish residency. Each exam can cost thousands of dollars, not including preparation materials that help you pass the tests.

The argument for all of this testing is always in the name of "patient safety" and to "protect the public." I think it also serves to exclude others who would otherwise try to practice medicine.

I question the sustainability of this system. Billions of dollars pour in from Medicare to fund graduate medical education and yet we're still projected to have a physician shortage. To be fair, I have also read research indicating it's not so much a shortage of physicians as it is a maldistribution of physicians. I think physicians are trying to have their cake and eat it too: restricting other providers' scope of practice while simultaneously refusing to practice medicine in underserved areas.

I see the issue of medical education as both a public policy concern as well as a curricular one. Yes, the curriculum is rigid and doesn't reflect the advances made in technology and learning sciences. It's also incredibly expensive. Some med schools charge out-of-state tuition upwards of $60,000 for ONE year. Where the money goes, I have no idea. I think if you cut out the mandatory baccalaureate degree, people would be able to save time and money. Most other countries allow students to begin medical studies right after high school.

My sister is a high school sophomore and I'm trying to steer her in the right direction so she doesn't make the same mistakes I did. My parents are immigrants from Vietnam and neither of them have a college education. We were always told to go to college and the hard work will pay off in the future. That piece of paper will mean something. And then 2008 hit and things changed. I see the proliferation of meaningless master's degrees and a certification test for X, Y, Z field. I don't think this rampant obsession with credentialism actually brings forth any value though.

As economists, what are your thoughts on the state of American healthcare? Do you think more healthcare providers makes economic sense or does it endanger patient safety?

* A similar discussion occurred in this EconTalk episode with historian Christy Ford Chapin.

Comments and Sharing

COMMENTS (6 to date)
ZC writes:

"Nowhere else in the world are medical students required to attend college for four years before matriculating into medical school."

Small point of his argument, but you're not required to do 4 years of undergrad (or even have a degree) prior to starting medical school in the US. Additionally, while European students may matriculate to medical school straight from high school, the duration of 'medical school' study in Europe is typically 6 or 7 years. There are several school in the US which offer combined BS/MD programs that are less than 8 years duration.

Mike W writes:

Here's a response from a Facebook friend:

"btw, I have been an CRNA for 38 years and have practiced in multiple states. I have never laid eyes on an Anesthesia Assistant. They are not, in fact, everywhere. CRNAs can practice solo. AA's can not...and should not."

Maybe, economics professors just don't really know what's going on in the world outside their campus.

Thomas Sewell writes:

@Mike W,
Perhaps you missed that this was written by a student, who included this?

The CRNA lobby is phenomenally politically savvy and they have blocked legislation for AAs to work in various states. Currently, AAs are only allowed to practice in 18 states.
Otherwise, your comment doesn't make much sense to me.

This line is one of the keys to the incentives of the whole thing:

think it also serves to exclude others who would otherwise try to practice medicine.
The AMA acts as a guild to restrict entry and thus limit competition. They have a major influence on related regulations and laws.

If we actually wanted to improve the supply of medical professionals in the U.S., we wouldn't require foreign trained folks to start over as much, we'd cut the +4 years requirement the rest of the world doesn't have and we'd either lighten-up on residency requirements or else ensure there was a residency available for anyone qualified to complete one. Toss in loosening up restrictions on practice for non-Doctors, for good measure.

john hare writes:

IMO it shouldn't take a decade of schooling to recognize that, "yes you have the flu that's currently going around, which I recognize because the symptoms are the same as the other 63 patients that came in with it this week." The extensive training is required for some original diagnoses, not for every sniffle, cut, and bruise.

Sally Oh writes:

Wonderful. I hope this student is now practicing outside the medical model altogether by now!

In today's pharmaceutically-driven "healthcare" system, I don't go to doctors and wouldn't for anything short of an emergency. Doctors are in the business of symptom suppression, not healing. Most of them don't have a clue about nutrition, preventive care, or know how to get the body into homeostasis.

And, as a group, they are dangerous. Doctor and hospital error is the 3rd leading cause of death: That study does not include medical mistakes and poor decisions that don't end in death.

Everywhere you look are victims of the medical establishment. Trust in doctors is alarmingly high. A friend just told me her husband got the flu so her doctor put her on Tamiflu, a double dose, for 10 days. Tamiflu. Nobody reads the package insert because the doctor (who also didn't read it) told her to take it.

Articles like this give me hope that perhaps, just perhaps, people are waking up to being responsible for their own health, their own bodies and those of their families. The information is out there.

Now, when my fellow humans wake up to the fact that the agencies supposedly protecting our food, water and air actually work for the companies poisoning us, that will be a glorious day indeed.

Thank you.

Arnold Layne writes:

I went through the whole medical training bit, got my MD (and a PhD to boot), so I loooove school. You can’t beat the lifestyle of the student. Plus, tomorrow, and all its promises, are always far off in the future, so you always have something to look forward to. I wish I could go back to being a student.

Having said that, Dr. Caplan’s letter writer makes some great points.

1) I hardly use anything I learned in medical school. Not sure what the whole point of learning all that stuff was.

2) The medical guild system is a racket to protect income. Nice to note the CRNAs are doing the same thing to the AAs.

3) “Patient care” is like patriotism. It’s obvious that everything we do in medicine is about patient care, but people only bring it up when they’re pushing something for their own benefit. My BS detector goes off whenever someone brings up patient care in any committee.

4) So, now that you’ve recognized that medicine is a racket, and the CRNA thing is a racket, and the AA folks are trying to come up with their own racket, the smart thing to do is to play the game, not to fight a long and pointless fight as the lowest man in the pecking order. Go back to medical school and become an anesthesiologist in a big city. If you’ve burned that bridge, become an RN and do CRNA work. This is one of those inadequate equilibria. You have special knowledge, but how do you make money off of it? You can’t. The system is too entrenched. The people who will figure out how to make money off of it will be those with enough money to push the system to their liking, and then you, as an AA, will just be working for those people.

5) All the testing that will happen after step I is for show, so don’t sweat it. The money they charge is like blackmail money, but negligible in the grand scheme of things.

6) Dr. Calplan’s book is awesome. I love his work, his blog, and his special way of seeing the world. He has all this special knowledge about education being a scam. Yet, where has he chosen to work? In academia. Low stress. High status. Good money. You should do the same. Go back to med school and make your immigrant parents proud. I did.


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