Doctors have a pretty solid reputation as do-gooders. There are regular news stories about how advances in medical science promise to help more people than ever before. Many of us have had the experience of being ill, seeing our doctor, and being made better.
So it seemed a pretty good career move for a 17-year old wanting to make a difference. Like thousands of others, I applied to read medicine. This is what I wrote on my personal statement:
I want to study medicine because of a desire I have to help others, and so the chance of spending a career doing something worthwhile I can’t resist. Of course, Doctors don’t have a monopoly on altruism, but I believe the attributes I have lend themselves best to medicine, as opposed to all the other work I could do instead.
Was I right? Is medicine a good career choice for someone wanting to ‘make a difference’?
Over the next few posts we are going to try and answer this question, and try to estimate the impact one can expect to make becoming a doctor in the UK (which will be pretty similar to the impact made anywhere else in the developed world). This post will look at the average direct impact of a doctor. To estimate this, we’ll look at the total impact of medicine and then divide it by the number of doctors. The second post will try and account for the fact that by becoming a doctor, I’ll only cause there to be additional doctors. Since the first doctor will add far more to health than the hundredth, my impact will be less than the average direct impact. The third post will account for replaceability: that if I never went to medical school, someone else would have taken my place. To wrap up, the final post will discuss how a budding doctor can make the biggest difference they can.
How much good does medicine do?
Life expectancy in the UK was around 47 in 1900; it is now 80. To what degree can medicine take credit for this vast improvement?
By the lights of most experts, not very much. During the last century the population in the developed world became better fed, wealthier, better educated, and living in safer and more hygienic environments, and these take the lion’s share of responsibility for our longer lives. Consider this graph from Mckinlay and Mckinlay of the medical effects on US mortality. Note how total mortality falls dramatically despite the small proportion of GDP spent on health, and that dramatic increases in health spending do not accelerate this downward trend:
Despite this, it is likely medicine has some effect: data from the Netherlands show that there are ‘bumps’ in life-expectancy of those with a given disease that coincide with the advent of improvements in that diseases treatment. We really want to know is how big that effect generally is: is medicine 40% responsible for our better health? 4%? 0.04%?
One approach from Bunker is to compile an ‘inventory’ of medical care (including both prevention and cure) for the commonest diseases: look at medical trials to see what life expectancy effects a given treatment has, extrapolate these effects to the wider population with the disease, and then add them all up. Bunker gives the following estimates:
- Medical care can be credited with 5 to 5.5 years of the increase in life expectancy since 1900…
- … But Iatrogenic (medicine-caused) disease reduces life expectancy by 0.5 to 1 year.
- Medicine also improves wellbeing: the average person has five more years free of disability.
Bunker’s method is likely to overestimate the impact of medicine. The impact of a treatment in a clinical trial is known to be much higher than its effect in everyday clinical practice. However, it is the only quantified estimate available, so let’s use it to try and work out how much good an individual doctor does.
How much good does a doctor do? A Fermi calculation
We do not know what it would be like to ‘subtract away’ all medical care from a population, but the 1900 population is not a bad surrogate: at this time, medicine was barely funded, unavailable to many and primitive. So ‘amount of good done by medicine between 1900 until now’ approximates ‘amount of good done by medicine’.
We’ll assume the benefits of medicine primarily consist of benefits to our health, though of course there might be others. We’ll also assume that we’re talking about doctors practicing medicine (providing care); medical research is a potentially high impact avenue beyond the remit of the current discussion.
We can use Bunker’s estimates to perform a ‘back of the envelope’ calculation of how much impact on health an average doctor has. To do this we’ll be using the Quality Adjusted Life Year (QALY) as our metric: one QALY is one year of healthy life (1). According to Bunker, the average person gains about 5.25 years due to medicine, but loses 0.75 years due to medicine-caused disease. That makes for a net gain of 4.5 QALYs. But we also need to consider how much healthy life is added by treating disability. This is trickier, but a generous estimate is to equate the ‘5 free years of disability’ to 2.5 QALYs (2).
Totting those up means the total gain per person is seven QALYs. On average, each of us has seven more years of healthy life (either in length or in quality) thanks to our doctors.
Now let’s look at things on a population level. Multiplying up by the 62.6 million population of the UK means medicine adds 438.4 million years of healthy life to the UK. We know there are around 2.7 doctors per 1 000 population in the UK, making around 172 000 total. So the ‘share’ per doctor is:
438 487 000 / 171 824 = 2552 QALYs
Taking stock
This doesn’t look too bad: intuitively you could think of it as saving about 90 lives. But it turns out this figure is an upper bound.
- We’ve used generous estimates for the amount of good done by medicine - most experts think it should be less than this.
- We’ve ignored the fact that the increase in life expectancy in old age is probably associated with increased disability, and so the 4.5 years of increased life expectancy should not be counted at ‘full value’.
- Doctors cannot take sole credit for the impact of medicine: what about nurses, scientists, cleaners, managers?
More importantly, the figure we’ve worked out does not tell us how much difference I might expect to make by becoming a doctor. What we need to work out is the additional good done by an extra person becoming a doctor that wouldn’t have happened otherwise.
This means taking into account two extra effects:
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Diminishing marginal returns – some tasks performed by doctors have more impact than others. If there were one fewer doctor, the highest impact tasks they perform would be given to someone else, so the total impact wouldn’t reduce proportionally with the number of doctors.
-
Replaceability – if I don’t become a doctor, someone else will. So again, the difference I make is reduced.
We’ll discuss these effects in future posts, but they will mean that the impact of me becoming a doctor is much less than our estimate. Yet in any case, I can do much more good by giving wisely. If I donate 10% of my salary to AMF, I’ll protect about 20,000 people from malaria, saving about 6 times as many QALYs, and causing many other economic and education benefits (3). I can do far more good with my chequebook then I can expect to accomplish with my stethoscope.
See part 2 on diminishing marginal returns
See part 3 on replaceability
You might also be interested in:
References and Notes
(1) For more on QALYs and measuring healthcare, see here.
(2) Bunker only talks about ‘years made free of disability’, but how valuable this is depends on how bad the disabilities are: five years free of dementia is worth much more than five years free of knee pain, for example. The WHO has a table of how much given disabilities should ‘weigh’: a weight of 0.2 means five years free of this disability is worth about as much as one extra year of healthy life. As very few conditions (and none of the commonest ones) are weighed higher than 0.5, we can be confident that the ‘five life-years made free of disability’ will equate to no more than half that amount in QALYs.
(3) There are some caveats. AMF will try to spend its funds on the most cost-effective programs first, and (hopefully!) over time the ‘lowest hanging fruit’ of cheap ways of greatly improving people’s welfare will be taken. So money I give later in my life may have less impact than current day estimates (although similar effects will likely apply to the work doctors do as well). Also, there might be different ‘knock-on’ effects of helping richer people than helping poorer people, and the wealthy might be ‘worth more’ if they can add a lot more wealth which trickles down. Anyway, the working: Average doctor salary in the UK is £69 952 a year. Assuming I give 10% of that pre-tax income, and I work for 43 years (qualify at 25, retire at 68), total given over my lifetime will be: £69 952/year * 43 years * 10% = £300 793.60 AMF’s effectiveness is thought to be around: $25/QALY. That’s around £16. So: £300 793.60 / £16/QALY = 18 800 QALYs So around 6 times the (upper bound on) direct benefit of a medical career.
Comments
Three suggestions
Hello Ryan! In approximate order:
1) I haven’t factored in financial costs, in part because I am not sure how. 2) Future posts will take a better look at the fact that doctors don’t singlehandedly do all medical care which you mention, which will drive down the upper bound significantly. 3) Replaceability corrections will depend at what stage you are at, and short-run supply medical labour is pretty inelastic, but it is not clear how it is over the longer term. But this is Ben Todd’s forte, not mine!
Great post Greg. I was surprised by the small impact of medicine on life expectancy. Is there an easy intuitive way of explaining this tiny impact to others?
While this is all very interesting, this only looks at doing good in terms of how much you can extend a person’s lifespan rather than the quality of life that they have that might otherwise be affected by illness. There is also the role of doctors in regards to health education in the population, population health policy and as a community role model.
Then again, I’m a tad biased…
“A Medical Student” above makes an excellent point that the doctors’ role does not just extend lifespan, but also improve quality of life in disease. Way back when, nutrition and sanitation was poor etc. and acute disease was what killed you. As you say, it is the aforementioned nutrition and sanitation that has contributed vastly to the improved life expectancy. However, without medical intervention, the people would then suffer (even more) years of misery of ischaemic heart disease/ diabetes, unless you argue that they would all die quickly of CVAs, which surely is not a desirable outcome in any case. Therefore, one could argue that medical intervention has a role in both increasing life expectancy AND morbidity, on a background of improved “conditions of life”.
I also can’t agree with the replaceability argument- that if you didn’t become a doctor, someone would in your place. Assuming you decided your time was better spent elsewhere, someone considered “inferior” to you in your initial application would have taken your place, and would, assuming an ideal selection process, yield a less competent doctor, giving a net decrease in quality of healthcare in the NHS (no matter how small). The next issue would be what you would do yourself instead, for you would have to displace someone else of their occupation, be it investment banker/lawyer/ whatever would earn you more money to give away. You may be earning the money, someone else isn’t, so unless that person you have just displaced was never going to donate, you have actually made no real diference to the money donated, decreased the quality of doctors in the NHS AND deprived someone of a high-paying job. In theory.
I get the overall vibe that you are trying argue that donating is a better option than being a doctor. I don’t see why this comparison is necessary, as if the two were mutually exclusive. Sure, you can donate £X and assume you’ve fed X no. of kids for a year in Rwanda, but that satisfaction cannot be compared with saving just one young lad presenting to you in ED with DKA!
Meanwhile, you can donate all you like, but someone must USE the money that you donate. And a significant (if minority) of this will be spent by doctors!
Hello everyone, these thoughts are slightly dashed off - my apologies for the errors in advance :)
Neil: I’d say something like “The lions share of the battle in health is in the living conditions of people - so much of disease is caused or exacerbated by these things. Having a population that is well fed, access to clean water, sanitation, shelter, education and financial security will fare far better than populations without these things, even if they have similar access to medical care.”
Good things to look at are intra-country social gradients of health (wealthier people live longer in the UK than poorer people, people who are homeless in the UK have a life expectancy of around 50, despite - at least in principle - having access to the NHS, etc.) Also there are neat data (which I’ll talk about next!) about how heath corresponds to health spending and number of doctors. Not sure if that helps…
A Medical Student (and Another Medical student)
1) The estimate above does try to look at wellbeing improvements instead of ‘just’ life expectancy. Bunker estimates medicine gives 5 years free of disability, which you can attempt to translate into QALYs (cf. footnote 2)
2) There are ‘second order’ effects of being a doctor in terms of being a community role model, helping out with health policy, and things like that. I’m unsure how to factor these things in: I guess the first thing that springs to mind is that the behaviour of most doctors (barring public health physicians, medical directors, etc) is directed towards clinical activities rather than health policy work, making their good reputation clear, and so on. I could be wrong about this, but I guess if it transpires the main impact (or a big chunk of the impact) of being a doctor is these things rather than their ‘direct’ work, that is pretty interesting.
3) If I may, I’m going to bracket the issue about the replaceability argument, as it will be the subject of an entire post which will (hopefully!) answer your concerns about replaceability.
4) I’m also a bit biased: I’m a member of Giving What We Can, so I’m pretty keen on people giving lots of money, and so I find it interesting to compare how much good earning to give can do compared to one’s entire medical career.
But I certainly don’t think they’re mutually exclusive (I want to do both myself!) And medicine is a pretty good way of both earning lots of money as well as the satisfaction you get from directly helping others. I would say, though, that we should try to give priority to stuff that does lots of good over what makes us feel satisfied we are doing good, and because there are lots of people willing to help directly, there’s still plenty of room for people earning to give.
Hello! Just discovered this community! Great stuff so far.
I have some thoughts on the above article. I think you raise some valid points and I would recommend the (provided for free by the authors) book Testing Treatments (http://www.testingtreatments.org/wp-content/uploads/2011/06/testing-treatments.pdf) that also delves further in to how to be efficient and successful physicians and how to approach treatments and patients in a scientifically verifiable and mutually respectful (doctor/patient relations) approach.
However. I think you need to distinguish between different disciplines of medicine as well, would I put an infectious disease specialist working in sub-saharan africa trained at the same school as the plastic surgeon with a huge clinic down the road under the same category?
I think not. As the other med-students on here I’m obviously biased, but deciding on medicine was a three-year hitching-around-the-world process for me in deciding how to best be able to bring something to a community other than your own uneducated labor (the last thing many regions in the world needs more of), and how medicine not only lets you interact with people and help them in immediately tangible ways, but gives you a certain level of respect (can be abused, to be sure) that can help you influence other areas of a community. “Men should let their families sleep with them under the mosquito nets provided by NGO’s” and similar commentary.
Where you go on to practice medicine, as well as what kind will have tangible effects, as I’m sure you will agree on, and then, who is to say that you need to limit yourself to medical practice exclusively? Look at someone like Hans Rosling, who works with international policy changes (most effective in helping to alleviate large scale inequality), whilst working from a unique perspective of having dressed wounds and infections of the very people he wants to go on to help, with their wants, needs and expectations clear to him.
The important thing is to not let yourself be limited as well, I might go on to practice medicine, but that doesn’t mean that I don’t take immense interest in the financial and social policies that go on around me, and try to do my part in directing them in more sustainable directions.
Er, that was a bit ramble, but I really wanted to address some things I came to think of.
Surely working out the financial cost is easy - just look at total medical spending.
Are you planning on looking at the RAND healthcare experiments? There’re some good overoming bias posts on it.
Great post Gregory. I hadn’t encountered this research on the proportion of life expectancy gains which come from medicine before and find it interesting. It makes sense that a lot of the gains are from living conditions, nutrition, and public health. 7 QALYs per person is actually a lot, and is an intuitively reasonable estimate. Most people in the UK would value this at above £140,000 worth of value, so I don’t think doctors (or aspiring doctors) need treat this estimate as putting a low value on their services.
One issue I noticed is that the health gain data is for 1900 to about 2000, and if it is based on mortality data, that is for people dying by 2000. However, if you are an 18 year old considering medicine in 2012, you will retire in 2062. So some of the people you treat will be in 2062, some of whom will die in 2140 or later. Life expectancy is expected to rise quite a lot more, so this matters. It might be worth looking into some estimates on this, or even just eyeballing it on the chart. Intuitively, it seems that this kind of thing could make the impact from medicine as much as twice as good as your numbers (since what we want is the impact from medicine during the time of your career). Note that even if medicine doesn’t improve, but other things increase lifespan, this still makes medicine higher value as saving the life of a twenty-year-old will then save 100 years of life instead of 60 (or whatever).
“Multiplying up by the 62.6 million population of the UK means medicine adds 438.4 million years of healthy life to the UK.”
Does it really make sense to add it up like this? Medicine also provides birth control options, which remove healthy life from the UK (which had only 1.66 children per female in 2009).
This article is right to point out that medicine is only one of many determinants of human life expectancy, but its approach to appreciating the value of the medical profession is fundamentally problematic.
Firstly, the article perpetuates the dated notion that the main job of doctors is to ‘save lives’. In the first world, saving lives is a diminishing role of a doctor. Many doctors take roles that do not directly ‘save lives’, but improve the quality of life of patients in addition to serving important social functions.
Take the example of a psychiatrist. Psychiatrists treat illness like depression and schizophrenia which are a main cause of suicide, homicide and loss of productive/ meaningful life. In the UK, there are 140,000 suicides and 6,000 suicide deaths every year. I have been taught that for every two suicides, one is successfully halted by a mental health professional. The author or Bunker fails to take into account these statistics.
(http://www.bbc.co.uk/health/emotional_health/mental_health/mind_suicide.shtml)
Importantly, many patients with mental illnesses don’t kill themselves or others. They basically just lose out with society. Patients with schizophrenia (like John Nash) can be perfectly normal before getting ill, but are rendered non-functional because of the hallucinations and delusions they experience as from their illness. Psychiatrists are able to intervene so that more than two thirds of these patients can return to a relatively normal life. Depressed patients, if untreated, suffer immensely from their poor mood. Just imagine how much ‘happiness’ psych doctors produced as a result of their counselling, drug and other treatment. Again, the authors dismiss these ‘good things’ done by doctors on the basis that they do not extend the life expectancy of patients.
Fundamentally, the problem with the author’s quantitative approach is that he reduces human existence into ‘living’ or ‘not-living’. He neglects how doctors improve the quality of life of patients. A day spent lying on a bed sucking food from a straw is very different from a day spent learning at school, playing football and going out with friends. The entire article struck me as highly theoretical and out of touch with reality. Life is not a number that you live up to. It is a continuum where you become gradually disabled and dysfunctional by ageing and various diseases. Doctors do a lot of good by halting that progress.
Another example that came to my mind - orthopaedic surgeons. They save very few lives by your standards. Having all your bones and joints broken will not kill you. The only bone disease that can kill you is bone cancer because it can damage other vital organs like your lung and brain. It is very rare anyway. But just think of how much good an orthopaedic surgeon has done just by doing joint replacement surgery of the knee. 15% of the 45+ population experiences knee pain due to degenerative osteoarthritis (OA) and by 65 years old 10% of the population cannot walk because of OA. After surgery these people can walk again, do sport, and basically have an active life. Without such treatment they will be confined at home or to a wheelchair. What a difference. But under your analyses their work isn’t of worth because not a life is saved. This is pretty absurd.
Finally, I find the idea of choosing an occupation purely based on how much lives it can save quite disturbing, and I would not give such career advice to anyone. Like it or not, you spend 8+ hours a day working and if the nature of your job bores you, you will be devastated, even if the job yields good returns (ethical, monetary, etc). When you’re operating on a patient, you are not thinking of saving lives. You are thinking of how you use your scalpel to cut tissue and stop bleeding by diathermy. That the patient’s life is saved as a result of the operation is only a secondary outcome. Just as I imagine the author as a very theoretical and quantitative person who has an intention of doing good to society (saving lives), I don’t think he will enjoy talking a woman out of death even if it may save her life. That reminds us that there are many personalities out there and it is important to find a job that fits your own abilities and interests. To conclude I think a medical career offers ample opportunities to do good so if you are intellectually capable and that helping others on a human level is your strength, I would invite you to consider it.
I’m surprised that so many readers think Greg isn’t taking quality of life improvements into account. He uses QALYs to measure the health improvement, which are quality adjusted life years. There’s problems with this measure, but it’s the best out there at the minute.
I agree with the last comment that making a difference (or, in this case, ‘saving lives’) is not the only thing that matters in choosing a job. But it does matter. Sometimes it can be more important than what you’ll enjoy. http://80000hours.org/blog/62-don-t-do-what-you-re-passionate-about-part-1
Hello everyone - I have not mastered the formatting of comments, so apologies for style as well as substance:
FOR TOBY
The issue you raise is something I completely missed when thinking about this, so thanks for pointing me in the right direction. :)
I think you are right that life expectancy should continue increasing - and further, it is likely that increasing proportions of that increase will be thanks to medical care. So there might be some reason to think that future impact of a doctor might be higher in the future.
That said, I’m not sure how to factor these things in the face of empirical and normative uncertainity. On the empirical side, although life expectancy is projected to increase, there’s also a retangularization thesis - our ‘natural maximum’ lifespan appears fairly unchanged, so improvements to health push us closer and closer to this limit. Further afield (which I guess is your forte), there are all sorts of future technologies (not to mention any black swans) that could completely change the life expectancy of a child born in the next 50 years or so. So I’m unsure how to better forecast the impact of a doctor starting now: I guess extrapolating the current linear trend is the best bet as you suggest.
Normatively, there’s a big debate about how long should we ‘ideally’ live, and so the underlying assumption used that all QALYs are broadly equal (or even a good thing) might be violated - perhaps three-score and ten is ideal, but getting ourselves to all live to 150 (or 15000) is net negative. (Hedonic Treader makes a related point in how QALYs may diverge from common morality - fertility services might be QALY negative). Population ethics starts to loom large here.
I might try (when I get time!) to write some more on likely future importance of medical care.
FOR MEDICAL STUDENT THE THIRD
One of pleasant problems of trying to investigate something like this is you end up finding lots of avenues to investigate further. I agree we should look at medical sub specialities, as they end up doing very different things: the ID doc in africa probably does more good than the archetypal cosmetic surgeon, but the latter will earn a lot more money, and giving it wisely could fund quite a few more ID docs, etc. etc. Rohling exemplifies yet another way doctors can do good through public advocacy and education.
For now I am focusing on the ‘direct’ good doctors do - via bandages, drugs, and all the stereotypes of clinical practice. I hope to address the wider question of what doctors should try to do to maximize the good they accomplish later. If you want to help me out, please do get in touch!
FOR JILL
I’ve looked at the RAND experiments, (and Hanson’s work), I’m unsure how well it extrapolates out of the US system. The main thing I will be looking at in the next posts is intra-country comparisons, particularly between developed countries: does lifespan or DALYs/100000 change when you spend a bit more on health (or hire a few more doctors) when you are already a developed country?
Fascinating stuff. Could I suggest reading the brilliant “The Dressing Station” by Jonathan Kaplan. It completely changed my views on my career by highlighting the many ways in which doctoring is undertaken. Not all of them good. There is one point where he is working as a surgeon and someone comes to build a well - he realises the impact he has made compared to the engineer over the same time and is utterly humbled, as was I.
But to dismiss medicine as not helping enough people is nonsense. Sure, the impact of another doctor in the NHS is far less than one treating NTDs in Africa in terms of lives saved, but are you really suggesting its some sort of competition? I am lucky enough to work in an acute medical speciality, although this means that in work I am likely to help just a handful of very rich (globally) individuals, most of whom are at (least partly) unwell due to their relative afluence. I say lucky as I get to see the lives I save. It happens in front of me. Truly, I can count those I have saved myself on my fingers alone but nonetheless the impact I have made to those individuals is profound. And if they are earning and contributing themselves (or go on to cure cancer, or make mosquito nets), then I have to factor some of that positivity into the overall effect I have had. I think care needs to be taken when declaring that I can “do more good with my cheque book”. It needs some context.
Does that make me complacent and arrogant about the impact I can have on a global scale? Not at all (I hope!). I still have that well in my mind every day, and still give what I can (earning nothing like the estimates on this site, I can assure you!) as I know that to the world’s poorest, this is the best way to really make a difference.
Did I go into medicine because I thought I could save the world? No. And anyone who does is likely to be disappointed. Do I think my job makes a difference? Of course. Will a well engineer in a third world country save more people than me over my career? Undoubtedly, but if you’re unfortunate enough to have a heart attack I know who will be more useful.
So my humble advice to the doubting medical students posting here is: be good doctors; AND contribute to helping the wider world. You’ll do good with both.
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