What kind of doctor should I become?

by on April 3, 2014 at 7:06 am in Economics, Medicine, Philosophy | Permalink

Hi Professor Cowen,

I am a loyal MR reader and I wondered if you could comment on the following situation:

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?

An interesting corollary would be asking what job, in any field, has the highest return to society.  Is there any literature on this?

The fundamental institutional failure to overcome is that many lives “out there” are pretty happy, and very much worth living, but those individuals do not have enough money to afford reasonable doctors.  If you are seeking to maximize social welfare, look to step into some of these gaps.

But which gap in particular?

The second binding constraint, in my view, is that most people won’t in fact go through with their plan to do a lot of social good.  That means you too.  So you wish to seek out a form of do-gooding which is incentive-compatible over the long run, or in other words which is fun for you or rewarding in some other way.  This second consideration is likely to prove decisive.

For instance you might decide the fight against dengue (just an example to make a point, not an actual net assessment) is the way to go, based on a narrow cost-benefit analysis.  But it is hard as a field worker to really, fully protect yourself against dengue.  And getting dengue can be very bad indeed.  As you age, the pressures not to go into the field will mount.  You might do more good by pledging your efforts to fight a malady which you can help fix without so much direct risk or exposure to yourself, let’s say infant mortality.

You will note a difference here between pledges of individual effort and pledges of money.  A money pledger, thinking in game-theoretic Nash terms, will realize that effort pledgers will resist the fight against dengue.  That is all the more reason why throwing money at the fight against dengue may bring high returns, namely that at the margin not enough is being done from the side of volunteer and quasi-volunteer labor.  (In general this distinction creates a problem with talking up one kind of cause over another, namely that labor and money face differing incentives and should hear different messages of encouragement.)

You will note also that in a second best optimum, field workers will appear to be “consuming too many perks.”  At the same time, donated funds should be trying to push field workers out of their comfort zones, at least on the margin.

I would add two final points.  First, if you have a reasonable chance of being a research superstar, that may be the path to follow.

Second, if you are not already attached, spent time cultivating social circles (aid work, World Bank, vegetarians, etc.) where you are likely to meet a partner or spouse who will support a similar vision to help the world.

Addendum: David Henderson adds comment.

Jan April 3, 2014 at 7:15 am
prior_approval April 3, 2014 at 7:25 am

‘vegetarians’

So, the doctor to be should hang out with Sikhs to find a compatible spouse? Or Hare Krishnas? Or is there an app available to help in the quest for true love?

‘The fundamental institutional failure to overcome’ is doctors are paid too much in the U.S.? The AMA disagrees, vehemently.

‘…most people won’t in fact go through with their plan to do a lot of social good. That means you too. ‘

Asking advice from an economist – you can never be too cynical.

nl7 April 3, 2014 at 12:58 pm

A lot of people feel so good just being willing to help that it reduces their internal self-pressure to go out and actually give help. If you really want to help people, it’s best to acknowledge your own limitations, not just in terms of hours in the day or helpful skills, but in terms of future willingness to commit.

From Under the Bridge April 3, 2014 at 9:27 pm

3rd year medical student,

Sounds like you are a reader of the blog, however I don’t know if you frequent the comments section. Just some advice in case you are a comments noobie: beware of the trolls (obviously).

That said, good on ya for your willingness to do good in the world.

Roy April 3, 2014 at 7:29 am

My advoce is to do what you enjoy. A doctor is not going to starve and will always do relatively well, so just find the kind of medicine you can continue to practice well over the long haul.

For example a lot of doctors are lousy clinicians, some are brilliant. From personal observation and discussions with doctors being a good clinician is the result of attentiveness, open mindedness, and keeping up with research. Good clinicians also care about finding out what in the end was actually wrong with the patient. A good clinician is the difference not just between life and death, but also quality of life. The same is true of radiology or pathology, a good physician is mindful, curious, and keeps up on the literature.

A small illness untreated can have huge costs for the patient if maltreated.

So think about what you think will still be interesting enough in thirty years to remain engaged. In an elite profession not following your bliss is foolish because your quality of work will suffer and as a physician that is a form of malpractice, and genuinely causes harm.

Denge April 3, 2014 at 7:54 am

Rad Onc dolla dolla minimal work implies greatest social good / hr.

rayward April 3, 2014 at 7:55 am

Cowen’s answer, though evasive, is a good answer. I work with physicians in many different specialties, and I can’t say one specialty provides greater professional satisfaction than another. Two anecdotes will help make the point. First, I once asked an OB/GYN why he chose that specialty. His answer was that he didn’t initially choose OB/GYN but he came to realize that he didn’t like being around sick people. As an OB/GYN, his patients for the most part aren’t sick, they are just pregnant. And happy! The second anecdote isn’t as clear-cut. My grandfather was a physician, and served as an Army surgeon in a war zone for over six years. Rather than return directly to the U.S., he went to Europe and studied eye, ears, nose, and throat (EENT), and then established that specialty practice upon his return to the U.S. Why EENT? He died before I was born (of a staph infection he contracted while serving as an Army surgeon, confirming Cowen’s advice about dengue), so I couldn’t ask him, but I suspect it’s the result of his experience with wounded soldiers (and civilians), many with head wounds. Confirming Cowen’s advice about cultivating social circles, while training in EENT in Europe my grandfather met my grandmother, who was also training in EENT. Though my grandfather died at a young age, my grandmother practiced her specialty until she was in her 80s.

andrew' April 3, 2014 at 8:00 am

Highest return normally indicates undersupply…except in medicine…so who knows. Work younger to less cosmetic.

Do microdebrider tonsillotomy. I’m serious.

Otherwise you’ve already checked off your social good quota. On average, you will have plenty of trouble paying off your debt for a while.

Take some trips to Haiti or somewhere and install clean water and call it a life.

andrew' April 3, 2014 at 8:11 am

Oh, 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.

After some years do some Great Courses such as those by Anthony Goodman.

Medicine is a total mess. Fix it. I’m sitting on about 10 medical problems in my family I can’t get the correct treatment for. Figure out how to not be part of the problem in spite of your indoctrination…ahem…and it would be plenty.

andrew' April 3, 2014 at 8:14 am

My nurse near-doctor idea is that for a deep discount you can see a person who tells you no.

I’m not kidding because that is what I get now for a premium.

Andrew' April 3, 2014 at 9:12 am

It’s funny how you can point out simple agency problems with doctors and doctors think it is all about them. Don’t be like that.

Just Another MR Commodore April 3, 2014 at 8:01 am

Dear God, just what the world needs another Dr. Livingston trapsing around the Tropics! I say it’s just not a sensible thing you know to spend your life wandering around Malaya or Natal trying to save a bunch of savages.

Chris April 3, 2014 at 8:05 am

World Bank? Really? Seriously? That’s just hilarious.

Bill April 3, 2014 at 8:22 am

My advice:

Just don’t become a Dr. of Economics.

DanC April 3, 2014 at 8:27 am

1st condition is false. You are highly unlikely to have equal interest and ability in all fields. Unless you have little interest in anything and no special abilities.

Society benefits most from truly gifted, creative, hardworking individuals. By assumption you are not one of those. You are the typical average physician bringing nothing special to the table. You can contribute to society but demonstrate great hubris for being rather average in your field.

So, think where you want to work. What kind of lifestyle you want. What kind of team you want to a part of. Geographic distribution of medical skills is a problem in the world. A physician of average skills can have a greater impact in an underserved area.

Z April 3, 2014 at 8:30 am

Two things jump out to me. One, this person is seeking out an economist for guidance on a moral question. That’s a nice example of how modern economics is is viewed by society as a religion rather than a science. Second, Tyler provided a decidedly non-Libertarian response. Maybe that cult has changed up over the years, but I recall their answer to all questions like this used to be some form of “you do the most good by being as successful and rich as possible.”

As to the question, my cat’s cardiologist (that’s right, my cat has a cardiologist) was advised by is cardiologist father to go into veterinary medicine. The reason was money and quality of life. He now lives an upper-middle class lifestyle, without slaving away in a hospital, but he also is building equity in his practice.

Tracy W April 4, 2014 at 4:41 am

I note that you think that wanting advice on how to most effectively do good is a moral question that has, to you, nothing to do with science. It’s a nice example of the decay of modern education.

Z April 5, 2014 at 11:45 am

Your self-beclownment here is hilarious. You should get someone to read and explain my posts to you. That way you can maybe avoid making a fool of yourself going forward.

Jeff April 3, 2014 at 8:35 am

I thought this was an economics web site. The obvious answer is, you do what pays the most. Imagine that medicine had free entry and that patients were paying their own bills. Then it would be obvious, as no one would ever pay a doctor more than his services were worth to the patient. Back in the real world, this may still be a reasonable approximation, since no one seems to have any better way to measure the value of a doctor’s time than his fee.

Alternatively, suppose you understand that people who have lived and worked in say, Haiti, know more about how to help people there than you do. The most efficient way for you to help them is probably to make as much money as you can and donate it all to a good Haitian charity. With the money you earn as a big time heart surgeon here you could probably fund a dozen nurse practitioners there. Or you could do what Bryan Caplan says, and donate all your money to groups lobbying for open borders.

But maybe what you’re really asking is not how you can really help, but rather what specialty will score you the most points socially. If that’s the case, I don’t have a clue.

David April 3, 2014 at 8:58 am

If you believe that every life is equal, and that some things are inherently more important than others (like a person’s ability to breathe is more important than the straightness of their nose), then a doctor’s fee has little relationship with the true value of their work. QALYs at the least are a better approximation.

Z April 3, 2014 at 9:11 am

How does the fact that no one thinks every life is equal fit into your thinking?

unionman April 3, 2014 at 10:06 pm

I have to say that I love Marginal Revolution is under the “Central Planning” section of your blog roll.

KPres April 3, 2014 at 9:14 am

Does every life being equal include future lives? The unborn? If so, then the lives of people that have large impacts on future lives are exponentially more important than lives that have little impact on future lives.

That being the case, it comes back to income. Straightening an important person’s nose (generally a rich person) will be important than helping an unimportant person breathe.

The problem is income ignores political power, and only measures economic power. A politician will have massively more impact on future lives than a rich person. So the bottom line becomes “do whatever makes you the most powerful, then use that power to shape the world as you see fit.”

Andrew' April 3, 2014 at 9:24 am

QALY + do what pays the most

DanC April 3, 2014 at 9:52 am

Some activities create externalities for society that the individual preforming the activity will not collect in cash. For example, a physician who prevents an increase in communicable diseases creates a benefit to society but may be unable to bill society for the full value of those services.

If you think having a healthy population creates positive externalities to the society, and health care providers can not capture the value of that externality, health care provider income understates the benefits to society.

If you think you can provide services that will benefit society, but are unable to capture the benefits for yourself (free riders etc.), such services may be under provided.

If the medical student is seeking to find areas where she creates the greatest externalities for society, understand that such arguments are often dependent on her world view or values. Attempts to place a value on such externalities can be measured but can be subject to great bias.

DanC April 3, 2014 at 10:22 am

Btw hit send too soon.

A child psychiatrist who helps prevent a disturbed child from shooting up a school is providing a great benefit to society. However how do you really know if such an event was prevented. Society has an interest in preventing such events but they are hard to predict. Assume treating every potential mass killer could cost society $100 million dollars. One could argue that we on some level that the occasional mass killings are less expensive to society then betting that $100 million dollars will prevent 90% of such events.

In general, the child psychiatrist is unable to bill society for the prevention of potential damage from a disturbed child. ((BTW the vast majority of mentally ill people are not violent.) So psychiatric services are under provided from a societal view. And by most measures the country has a shortage of child psychiatrist ( Some would disagree).

The market fails to provide the needed level of service to society. Prisons are full of people with mental illness. But measuring how much the prison population would change if society provided more psychiatric services is difficult to measure.

David April 3, 2014 at 8:53 am

Quite a few crotchety anti-medicine cynics out there.

I like the Tyler’s points about long term incentives and marrying someone similar the most. The people who do crazy good are those that have precomitted their future selves. If all your friends have a similar vision, your social status will be linked to the sacrifices you’re willing to make rather than your income. If you spend enough time in a particular disadvantaged area that you feel a personal affiliation with the communities, then their suffering becomes your suffering.

Brian Albrecht April 3, 2014 at 8:57 am

What would you say to a 3rd year economics PhD student with the same question? Given the person is becoming an economist, how can they do the most good (or least harm)?

Guest April 3, 2014 at 9:17 am

Look for a job here:

http://www.povertyactionlab.org/

Jess Riedel April 3, 2014 at 10:05 am

The organization 80k Hours has written up a lot about the unusual value of the Econ PhD, and which paths from there will maximize positive impact on the world. I highly recommend taking a look.

http://80000hours.org/blog?category=22
http://80000hours.org/blog/257-the-value-of-economics-phds-a-conversation-with-robin-hanson

Jimbino April 3, 2014 at 8:59 am

Jeff is right, and this is an economics problem, not a moral one.

Doodoo-gooder Albert Schweitzer thought he’d solved the problem for himself, but arguably went on to make people’s lives more miserable. He probably should have stuck with Theology.

Your problem exists only because the gummint-medical-drug complex is doing all it can to obscure and control prices, keeping from you the price information that economists say you need to maximize your happiness and derivatively the happiness of others.

It’s a problem like that of what to use your empty semi-truck for to help folks in an area devastated by a flood. If the gummint would get the hell out of imposing price controls, you might well be delivering fuel, generators, flashlights and batteries. Trouble is, you’ll end up delivering bananas instead. Why?

Because the gummint price controls on critical needs in an emergency won’t pay you to go out of your way to deliver what’s needed. Furthermore, the warehouses in your area aren’t stocked with what’s needed in the flood zone anyway, since everyone has long since figured out that it doesn’t pay to store fuel and generators, since the costs will never be recuperated because of gummint price controls. But the warehouses will be full of bananas!

A similar thing happened in the USSA during the “oil crisis” of 1973. I was in Germany at the time, and we were astounded to see Amerikans lined up around the block to by gas—in a country that was a major producer of oil—while we in Germany—a low producer—didn’t have any fuel lines, because the German government allowed the price to rise.

Jess Riedel April 3, 2014 at 10:13 am

> Jeff is right, and this is an economics problem, not a moral one.

That’s silly. This question clearly requires very important considerations from both economics and ethics.

dearieme April 3, 2014 at 9:13 am

“In order to create the greatest good for the greatest number of people through my work in medicine”: extending the lives of old, rich people doesn’t achieve that. You’ll have to emigrate to some backward spot where you can save the lives of babes and youngsters. Some people would say that you would just be contributing to over-population of course. If you see the latter as a problem pursue veterinary medicine instead.

KPres April 3, 2014 at 9:24 am

If we’re concerned with animal well-being, then animals would probably most benefit from the extinction of humanity. In that case, your best bet to increase well-being is to become a mass-murderer.

Mark Thorson April 3, 2014 at 11:31 am

You figured it out. He should be performing abortions. That’s good for the crime rate, good for global warming, good for society and the planet in general.

yo April 3, 2014 at 9:29 am

Join the military and volunteer for conflict zones, you’ll probably be saving lives daily.

Ted Craig April 3, 2014 at 9:34 am

General practice, but that’s not the cool answer he seeks.

john April 3, 2014 at 9:36 am

You can crunch QALY numbers along with some estimates of how many patients you might see working as various types of doctor to get a number, but I don’t think that’s exactly what you’re after or your would have done it yourself. Assuming you practice in the US, the best you can do in terms of QALYs is treat kids, simply because they’re going to live for so long. For impact you want to treat kids with life-threatening treatable problems. I don’t know how much cancer fits that description. Working in a pediatric ICU may give you a big QALY return, though I’m biased about this one because of personal experience. Also lots of kids don’t make it out of the PICU. Pediatric surgery may be the best place to aim. Pediatric cardiac surgeons probably save the lives of a lot of kids who go on to lead pretty good lives. Pediatric neurosurgeons may also fit that description, though neurological injuries often can’t be completely covered from.

Dave April 3, 2014 at 9:44 am

There is no easily searchable definitive information regarding qualitative and quantitative outcomes from treatment by individual doctors. Currently all Dr. ratings are pretty much “is he nice?”, “did she keep me waiting too long?”…drivel. So, you should create an Angie’sList ratings system that provides facts about outcomes from treatments prescribed by individual physicians.

The best/greatest good is to interdict and destabilize the asymmetric pricing power held by the “service advisor” (physician) to find out what a consumer’s “car” (body) needs. The incentives are exactly and perniciously the same, yet worse when once considers that service advisors will not have $1/4 million dollars worth of student debt. Further, if my car isn’t repaired, I will return it to the repair establishment and it will be fixed without additional payment (usually). If I go back to a doctor because the repair prescribed did not/does not work, I have the privilege of paying more money. No warranty!! If the medical problem is never solved, there is little in the way of feedback loops that identify this incompetent “repair technician” to move him/her out of the provider stream. Please do not bother replying with “yeah but there’s malpractice awards…”. That’s way to reactive/way too far down the line of cause/effect where often the original patient is scarred/marred/dead. Trial awards don’t fix dead.

choroidal April 3, 2014 at 9:45 am

Become an ophthalmologist and specialize in cataract surgery. It is fun to do and has the most bang for the buck of any procedure done on the human body. And it can be done quite well anywhere in the world with a modest amount of equipment. Here are some amazing organizations dedicated to performing cost effective eye surgery in the third world:

http://www.aravind.org
http://www.cureblindness.org

Unfortunately the competition for ophthalmology residency positions is quite keen. So make sure you do well in all your clinical rotations, obtain stellar recommendations, and have very high USMLE scores (ophthalmology residencies are particularly hung up on test scores). You should also have a reasonable amount of fine motor control. If you have a resting hand tremor you may want to look at infectious diseases (please).

Good luck.

vimspot April 3, 2014 at 9:45 am

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.

Just Another MR Commodore April 3, 2014 at 10:01 am

Always room for a good ship’s surgeon I always say.

jseliger April 3, 2014 at 10:18 am

I am open to devoting as much of my free time/vacation as possible to pro bono medical activities

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.

The second binding constraint, in my view, is that most people won’t in fact go through with their plan to do a lot of social good

I hear over and over again: “I wanted to help people, now I hate my life and just want to pay off my student loans.” In addition, the original questioner is at least four years from hitting the ground, assuming they do an American residency.

An interesting corollary would be asking what job, in any field, has the highest return to society

The highest return may be trying to in effect train nurse practitioners and P.A.s to be better at their jobs; the supply of doctors right now is relatively fixed. The real gain to society is to un-fix it, per Alex’s book.

Abroad, it may be training / systems more generally.

It’s too late for the original questioner, but based on the many stories I’ve heard most people are better off being a nurse or PA, rather than a doctor.

Marie April 3, 2014 at 10:47 am

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.

Thelonious_Nick April 3, 2014 at 11:52 am

This. Find some small town in your state that has no GP, and set up there. It may pay the least, but living costs are also low so you will do pretty well. My step-mother’s father practiced for decades in a small town in Arkansas, and there’s not a person in the town (possibly the county) without a story of how he improved their family’s health and life.

Jimbino April 3, 2014 at 10:47 am

Anyone who works for the gummint-insurance-medical complex in the USSA is selling his soul to the enemy.

Look, you walk into a Walmart: You are greeted at the door with “Hi, welcome to Walmart.” The prices are all posted and even available on the internet. Everybody pays the same price without any wallet biopsy. You don’t have to stand in line, except at checkout. You don’t have to be referred by anybody. Every product you buy comes with a “lowest-price” guarantee. If you don’t like the product, you can take it back for a refund.

Now walk into a doctor’s office: You are greeted with “Do you have insurance?” No prices are ever posted, not even on the internet; in fact, every attempt is made to obscure pricing. You have to wait to see the doctor. Nothing comes with a guarantee; if the doc screws up, you can pay again to have the problem fixed or pay to hire a lawyer. There is terrible price discrimination, and pricing varies through the state and the country. Walmart employees are so happy that it’s harder to get a job at Walmart than get into Harvard—http://www.huffingtonpost.com/2013/11/20/walmart-acceptance-rate-harvard_n_4303527.html

If you really want to serve mankind, better to work at Walmart than in medicine and insurance, though only work in politics and high-explosives will enable you to throw out the price-fixing and regulating bastards in places like Syria, Ukraine and the USSA.

Art Deco April 3, 2014 at 10:54 am

Look at the market and look at yourself and where your comparative advantage lies.

1. If you lack a certain baseline in people skills and extroversion, you might wish to consider research (though MD/PhD programs are a bear) or disciplines which limit your interaction with patients (e.g. pathology, radiology, anaesthesiology). If you find as a practitioner you are subpar when dealing with patients, you might consider an administrative or corporate career track.

2. Avoid psychiatry unless you are committed to attending to schizophrenics and a scatter of others. It is just a very dubious business much of the time.

3. If your dispositions are such that you are well suited to managing problems rather than attempting to fix them, a geriatric practice might be your forte, most particularly one which incorporates attending at nursing homes.

4. The usual complaint is that there are too many specialists and insufficient primary care and that there are two few practicing in non-metropolitan settings. Not sure if this is true or not.

5. To be a doctor’s wife is a vocation like being a minister’s wife. It is important that you find someone who can follow that vocation. Stay away from high-maintenance women.

6. No objection to service work, but you are going to have limited free time and you are going to have demands on your free time. Not high maintenance is not no maintenance. Obligations which demand of your time and effort are always concentric: your wife and children first.

Art Deco April 3, 2014 at 10:58 am

One other thing. Medicine is not academic work. Your geographic choices are not as constrained. My father would tell you that women are nest builders by nature and it is very imprudent to induce her to build her nest anywhere but where she is pleased to build it.

CDel April 3, 2014 at 12:39 pm

2. Avoid psychiatry unless you are committed to attending to schizophrenics and a scatter of others. It is just a very dubious business much of the time.

Most medicine is a dubious business most of the time. At the hospital where I currently work, about 50% of admissions are not medically indicated, but we admit anyway and insurance/medicare reimburses. About 50% of clinic visits result in management that is not evidence based, but insurance reimburses anyway. Psychiatry has its share of hokiness, but no more than any other field. If anything, I’m inclined to believe that good psychiatrists punch above their weight compared to other specialties. Organic depression, bipolar, and personality disorders are devastating to those who suffer from them, as well as their families and communities. Successfully treating any of these disorders not only helps these individuals live somewhat normal lives, but save society far more money than, say, poorly treat gout.

Art Deco April 3, 2014 at 1:22 pm

Psychiatry has its share of hokiness, but no more than any other field.

Read Paul McHugh on the systemic deficits of psychiatry as a subdiscipline. (Quite apart from the question of just what is a mental disorder).

Dan Weber April 3, 2014 at 1:14 pm

From what i recall friends saying, GP and geriatrics are the two most under-supplied areas. Obviously there is much less bang-for-the-buck in doing geriatrics, but maybe it’s such a neglected field that a caring person could really help many people feel better in their last years and have a nice payout for society.

Andrew' April 3, 2014 at 4:10 pm

“5. To be a doctor’s wife is a vocation like being a minister’s wife. It is important that you find someone who can follow that vocation. Stay away from high-maintenance women.”

When I referred to the nurse to doctor pipeline, I was not saying “bone a bunch of nurses.”

But now I’ll say, bone a bunch of nurses. The above is probably a good outline of why doctors often bone nurses.

steve April 3, 2014 at 11:01 am

1) Pick something you like that will fit your personality. You arent doing any good if you pick something you quit.

2) Research is the most bang for the buck, but not all research is equal. Basic research has the highest potential for positive returns. Also for no return at all. Clinical research is highly variable.

3) Administrative skills and abilities will let you max out returns more than just simple clinical skills. You can redesign whole clinical systems.

4) If still not sure either do primary care, or go the ortho route and donate your excess income. If you do the latter, I predict it wont happen. You are likely to eventually have a spouse and/or children.

Steve

Peter April 3, 2014 at 11:18 am

The key question is where, not what.

Sarah April 3, 2014 at 11:29 am

I’ve given this some thought, though I’m not a doctor.

One important thing is that the leading causes of death worldwide are surprisingly close to the leading causes of death in developed countries. Cancer, heart disease, chronic respiratory disease, diabetes, etc. Of course, developing countries have more infectious disease. But I get the sense that people talking about world health in utilitarian terms have the view that most of the harm is caused by poverty and insufficient aid. By the numbers, it actually seems that most of the suffering in the world is caused by chronic diseases we don’t know how to cure.

As another data point, GiveWell, which does the most exhaustive evidence-based charity evaluations I know of, and which tends to focus on global health, has found very few charities it rates as effective. And their estimates of the cost to save a life keep rising.

What this tells me is that the largest contribution an individual *could* make to human welfare is an innovation. (Either a biomedical or a social/organizational one.) Humanity’s biggest problems are unsolved problems. The paradigmatic example being Norman Borlaug.

I’m rather skeptical of “earn a bunch of money and give to charity” as the most efficient thing a person could do. Not because there are no good charities, but because it does not seem obvious that the biggest utilitarian gains out there are things that somebody is already doing and soliciting donations for. Efficient altruism represents a very deep form of trust in society — “whatever ideas I could come up with, surely somebody else has come up with something better already.”

Instead of trying to arrange your life around doing the greatest good for the greatest number *now*, how could you maximize the chance that you could get involved in something novel that has a big impact? (while still being pretty benevolent if you fail).

My own heuristic is “learn a skill that’s becoming really important in the contemporary world and also happens to be hot/high-status” (my area of research roughly fits the bill) and try to get into a heavily entrepreneurial or scientific environment where it’s likely big ideas will be in the air.

Drifting April 3, 2014 at 12:56 pm

You can’t always innovate helping the poor out. There’s a bad tendency of people to believe that elegant ideas solve things. They don’t, and a lot of poverty needs inefficient, time-intensive solutions to mitigate.

I think individuals can have the most impact by amassing capital and using it to pay for people to address those situations. Plenty of people come up with innovative solutions to make their job or society better, but without capital and power to enact them, what can they do?

Jess Riedel April 3, 2014 at 11:57 am

> I’m rather skeptical of “earn a bunch of money and give to charity” as the most efficient thing a person could do. Not because there are no good charities, but because it does not seem obvious that the biggest utilitarian gains out there are things that somebody is already doing and soliciting donations for. Efficient altruism represents a very deep form of trust in society — “whatever ideas I could come up with, surely somebody else has come up with something better already.

An alternative characterization is that it represents a very deep form of humility — “What are the odds that my idea is better than *every single one* of the millions of ideas that have been tried? And how likely am I to deceive myself into thinking I’m the best?”.

(Also, efficient altruism is perfectly compatible with research or object-level careers. “Earn to give” is just one strategy that, importantly, serves as a clear baseline with which to judge other options.)

Jess Riedel April 3, 2014 at 11:58 am

(Oops. This is supposed to be a reply to the previous comment by Sarah.)

Sarah April 3, 2014 at 12:04 pm

Yes, I think that’s a fair assessment.

Ken Rhodes April 4, 2014 at 10:10 am

“Earn to give” is just one strategy that, importantly, serves as a clear baseline with which to judge other options.

Jess, that last sentence you wrote is a wonderful illustration of why ecomomics is a good place to study the original question. Not because economics is some religion, rather than a social science (see Z’s comment). Rather, the opposite–economics provides us a down-to-Earth way to address abstruse, hard-to-quantify personal issues.

S April 3, 2014 at 12:08 pm

Plastic surgeon. The world would benefit form less pretension.

Anonymous April 3, 2014 at 12:09 pm

So how about a theoretical physics phD student? What should I be doing to get the highest impact divided by effort for my work?

Jimbino April 3, 2014 at 6:54 pm

Study Chinese, as Tom Lehrer recommended to Wernher von Braun. There’s no future in the USSA now, given Obamacare and the other socialist policies.

Robert April 3, 2014 at 12:28 pm

One that doesn’t accept Obamacare.

john smith April 3, 2014 at 12:32 pm

It is arguable that you have a long way to go before you are ever a net benefit to anybody other than yourself and your family.

Despite your debt load, your training has been subsidized an additional $100k/year.

In addition, the solutions of your chosen profession are horribly outdate. You’re trained to fix catastrophic everything, and chronic nothing.

Vaccines and fluorinated water have done more for the health of the modern world than all Doctoring combined over the same period.

I would say the automation of the most industrial parts of our economy have as well, but that economic story is yet to play out.

So go cure some third world disease, or infant mortality? They’ll live long enough to starve or be killed in civil war. Well done.

My suggesting would be pursuing research to perfect transfection mechanisms, allowing us to do gene repair at the near-cellular level. But you don’t need to be a doctor for that. At all. it is a chemical and mechanical issue which you do not appear to have any competitive advantage. So be a middle-man and help run clinical trials. Or actually practice and enjoy your 50% government subsidy for all revenues.

Just don’t delude yourself into thinking that your Doctoring, to date, or in the future, will likely be a net benefit to society. Take that as a challenge, prove me wrong. Do something where human life is meaningfully and sustainably improved. Where your work doesn’t require federal protections and subsidies to be viable.

The best suggestion here was to find someone who actually is pursuing true, meaningful impact, act great personal and financial sacrifice, marry them, and support their efforts. As a team you’ll have reasonable potential to effect net-positive change. On your own, I see no way for you to repay the rents you have been extracting, and will continue to extract, by virtue of your ability to successfully positioning yourself for med-school admissions.

grichens April 3, 2014 at 5:21 pm

Google “sunk costs”.

Ken Rhodes April 4, 2014 at 10:18 am

Just don’t delude yourself into thinking that your Doctoring, to date, or in the future, will likely be a net benefit to society.
–John Smith

I get my health reviewed periodically by my family doctor. A few years ago my blood test showed a rise in my cholesterol, to a level that could portend later critical issues. My doctor put me on a regimen of healthier eating plus a daily dose of generic simvastatin, which costs me four bucks a month (retail, no insurance contribution).

My doctor gives me good attention and good advice. I follow his advice. It costs me very little, and it makes my life better. John, I think your cynicism is misplaced.

John Smith April 4, 2014 at 1:58 pm

@grichens. Sunk costs should still be factored into overall “return to society”. IMO, it’s at least three years too late for a third year medical school student to start thinking about returns to society. If this student is truly gifted, his highest returns to society are not to be found in the practice of medicine, IMO. If he’s not gifted, he’s landed himself a cush career path that is heavily subsidized by the rest of us…

@Ken. Your example is ironic, as it seems to reinforce my point. That your Doctor is making at least a six figure salary by telling your fatness how to eat healthier and providing you drugs to compensate for your fatness is absurd.

Dietitians (for diet), Nurse Practitioners (for diagnostics), and Pharmacists (for dosing) all get paid a fraction of what your primary care providers earns. And that’s completely ignoring the possibility that, with the slightest bit of intelligence and effort, you could buy this:
http://www.amazon.com/Withings-Smart-Pressure-Monitor-iPhone/dp/B004K2KYM8
this: http://www.amazon.com/Eat-Drink-Be-Healthy-Harvard/dp/0743266420/ref=sr_1_1?ie=UTF8&qid=1396633955&sr=8-1&keywords=healthy+diet
and these:
http://www.amazon.com/s/ref=nb_sb_noss_1?url=search-alias%3Daps&field-keywords=running+shoes

would be infinitely healthier and cheaper. But that would require you to be literate, and slightly motivated.

Doctors clearly do positive things. But those positive things must be weighed against their costs (sunk costs included) when figuring societal returns. It seems disingenuous to be asking this question after starting down this path.

Marie (the long-winded one) April 3, 2014 at 12:40 pm

I had an interesting talk with my kid’s pediatric endo a few months ago. There’s a shortage in the field, and I thought it was because there has been such a huge increase in autoimmune endocrine problems in children and teens. That’s part, but not all. He says his is a specialty, so it’s costly to acquire. But since there’s no surgical function (unlike, say, pediatric GI doctors who can do endoscopy), insurance pays a much lower rate (I’m assuming the same is true for government payment). The result is that there are states with only one ped endo practice, or even none (served by endos from other states), because why would you go through all that just to make barely above what a GP would.

If you want to sacrifice money for work, but want to take the long view (working overseas but not cutting out the option to return and do good work here later), you might explore situations like this.

Essentially, the medical market is dysfunctional. How can you do good work in medicine despite the dysfunction.

Drifting April 3, 2014 at 12:47 pm

You should do whatever will make you filthy rich, and then fund other doctors to do the work you want. One thing that I only noticed when it was too late is that it’s the people with capital who change society, not the line employees; they just follow the ideas of who pay their bills. You volunteer for some charitable place, and you’re going to get frustrated at all the rules in place that prevent you from doing what you want or need to do.

Mark Bahner April 3, 2014 at 12:47 pm

Hi,

My first advice is that if this medical student is ever in Durham, NC, I’d like to buy him/her a beer to discuss the issue.

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.”

P.P.S. Oh…the answer to the question about what job, in any field, has the highest return to society, is of course environmental engineering. Followed closely by lumberjack and lion tamer.

Todd Kreider April 4, 2014 at 6:54 pm

“Watson can replace 1 million+ doctors.”

And The Son of Watson will replace whoever is left.

nl7 April 3, 2014 at 1:03 pm

Probably the safest route is to just become a high earner and donate the money to needed causes, with the option to donate services to needy patients (possibly including travel to them). As people’s medical needs shift, experts trained in one way to help may have less impact than they did before; but charity will always need resources, so earning and distributing wealth will always be critical to charity.

But if the intent is to gain personal satisfaction from people directly helped, and not to merely provide the most effective help, then maximizing charitable impact seems to matter less. It’s no longer about the maximum assistance; it’s about maximum assistance in the capacity of a guardian angel. I’d probably go for something that involves travel but not infectious diseases; most likely to get heroic and fawning photo ops of you with the villagers you saved.

Medical Student April 3, 2014 at 1:17 pm

As the original poster of the query to Tyler, I wish to thank all of 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.

Andrew' April 3, 2014 at 3:47 pm

I came here when I remembered this, maybe there are better out there, this is the one I know of.
http://www.garynorth.com/public/department148.cfm
http://www.garynorth.com/public/1099.cfm
https://www.youtube.com/watch?v=qsZbDZK3JAs

Start small: You will have your hands full just becoming a good surgeon. You also need to like your job. You’d like to be diversified (general or orthopedic surgery) to be able to follow your passions not to mention reimbursement rates (artificial scarcity) as well as actual scarcity (e.g. medical missions).
To do good, you have to actually do stuff that does good – that is procedures that actually work – i.e., no stents…unless they actually work…you are the GD MD, you tell us. Birthing babies feels good, but do we really need doctors to birth babies?

Here is the case for microdebrider tonsillotomy- not because you will actually do it, but to see the logic that goes into 2 words on an MR comment section.

1. Kids don’t pay for stuff, so kids services may be underfunded.
2. You can do 20 of these per day every day for 60 years.
3. Like birthing babies, it works, feels good, etc.
4. I know the current practice is inferior and this method is a vast improvement, except almost no one does it (thanks government!), thus more doctors should do it- I’m sure other people have different examples from their experience, this is mine.
5. We went from a kid whose sleep apnea wrecked all of our sleep and thus affected every part of our lives and could have doomed him to learning disabilities and health problems (we probably averaged 10+ strep throats per year and have since had less than 1 per year) to restoring sanity to the family and is one of the smartest kids in class. No other medical service has come close (I don’t count vaccine development as a medical service).
6. Yes, it’s probably over-prescribed, but probably not relative to everything else. And multiply #5 by lifespan minus 4 years old and that is some heavy QALYs.

In his Great Courses video on physiology Anthony Goodman makes a similar comment about some procedure done to correct the esophagus of babies or something in similar terms. Something like “The procedure just works, and being able to tell parents of a baby that you made them better feels great.”

Ron April 3, 2014 at 1:30 pm

“As you age, the pressures not to go into the field will mount.” Why? An alternative perspective is that once you’ve accomplished most of your personal and professional goals, and secured your economic future, you have far less to lose. Everything past 50 or 60 is “extra credit”. Maybe it’s the oldest drivers who should be driving most fast.

John Schilling April 3, 2014 at 2:20 pm

“[many] individuals do not have enough money to afford reasonable doctors. If you are seeking to maximize social welfare, look to step into some of these gaps”

Not sure that’s helpful. If you identify a class of problem where people can’t afford the doctors they need, and become an ordinary doctor specializing in that class of problem, then you are one more doctor the problem cases can’t afford. If you become an extraordinary doctor in the sense of providing competent care at half the price of other doctors in the field, that’s probably psychologically unsustainable (and maybe economically unsustainable) in the long run – except as occasional pro bono work, but that may be weakly coupled to one’s professional specialty. If the plan is that adding one more doctor to the sub-field in question sends price signals that marginally reduces the equilibrium price level, that would seem to contradict the explicit desire to “do the interventions myself” rather than just pushing money in the general direction of goodness.

Seems like the ideal problems for this prospective solution, are the ones where people could afford a doctor except there isn’t a doctor. General Practitioner in a small town is an obvious candidate. Abortion provider in a small red-state town, if one has a particular combination of belief and risk tolerance. Probably others I can’t think of.

MingoV April 3, 2014 at 5:50 pm

Point one: No medical student has equal ability or interest in all specialties. Any medical student who believes that is too stupid to practice medicine and 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 that specialty 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 helpful, regardless of which route taken.

Point four: Don’t add so many patients that your schedule is crammed every day. Physician burnout deprives all those patients of medical care.

Gregory Lewis April 4, 2014 at 4:15 pm

I’m a practising doctor, and I’ve also been thinking a lot about how I can best make the biggest impact. My approach has been more to try and tease apart very large aggregate measures of health (e.g. regressing DALYS per capita against physicians per capita, GDP, etc. etc.) than looking at impacts of a given procedure. (Most recent stuff here: http://prezi.com/bi0iu6xslbw6/why-doctors-dont-do-much-good/, and here: http://www.thepolemicalmedic.com/2012/10/how-many-lives-does-a-doctor-save/. Comments welcome!)

Some pieces of practical advice:

1) Clinical practice anywhere in the western world is not a good way to make the world a better place.

This isn’t because medicine is rubbish, but in the western world all the easy low hanging fruit have been picked. To put it in perspective, my own guestimation of the impact of an additional doctor in the UK is that they add 3-10 QALYs every year they work. As others have mentioned, even giving (say) 10% of the median salary of someone in the developed world can do much more than this if given to the right cause (~~ $50 per QALY, so you can comfortably beat a doctor by giving a thousand bucks away). Now you might be an above average doctor working in a particularly effective way, but it seems hard to imagine this will make you 10x-100x better than the average to outweigh this effect (borrowing Taleb, I think medicine is mediocristan not extremestan, as the most able can’t scale and leverage like a top scientist or writer can).

2) Clinical practice in the developing world is better, but not great.

The graph of DALYs per 100 000 (a measure of disease burden) versus physician density is approximately hyperbolic, and so going somewhere where there are fewer doctors promises to have a much bigger marginal impact (and yes, many confounders which are doing the bulk of the causal work, but the ‘bigger impact in places where fewer doctors are’ persists). This gives a factor of 10 or so if you pick somewhere really deprived. Again, this doesn’t look like it will ‘beat’ earning to give, especially if one gives a fairly extravagant amount (50%) of a generally pretty large doctors salary in the western world. If you want to ‘maximize amount of good I’m doing with my own hands’, though, this might be a good call.

3) It looks like medical markets are pretty inefficient, so it is hard to tell where the greatest undersupply of doctors relative to social value lies.

If you want to work in the developed world and want to focus on doing good with your own hands (rather than picking something very lucratively paid and giving it away), it is tricky to offer advice. One suggestion is to pick fields which are less prestigious and less well paid, on the grounds that they may be under appreciated relative to their ‘health value’, and (thinking on the margin), you might be much more skilled than the candidate you displaced, rather than being fractionally better than the other stellar med student who missed the Mayo Clinic Cardio residency. Then again, it might be that we renumerate approximately efficiently, and maybe it really matters having the very best in something like neurosurgery, whilst theres no great social value in being a top top family practitioner. I broadly agree with Cowan’s remarks here.

4) Non clinical stuff likely wins, because scaling.

I think research careers, public health, policy work and things like this probably offer the best avenue to ‘direct’ impact, simply because they are easily ‘scaled up’: a better drug for HIV can be given to millions, whilst even a stellar HIV physician can only treat so many patients each day. The two downsides (esp for the medical student) are that these tend to be power-law distributed, where the superstars make the lions share of the difference (or, at least, reputation of making the difference). So even if the average expected impact of HIV per researcher is very high, the most likely outcome for someone going into HIV research is they achieve very little. The other downside is that it lacks the ‘hands on’ factor. I really enjoy clinical medicine, and although I think public health may well save far more lives than clinical practice, I would miss not being involved in it.

Toad Hall Harlowe Place April 4, 2014 at 10:24 pm

Three observations that have not been previously made (to add to some of the good ones already made): Forget about scaling. As a loyal reader of this blog, you surely have heard of Hayek, who would have told you that you are almost certainly not smart enough to plan your efforts in a scaleable way and in such a fashion as to avoid the risk of being more likely to harm, rather than benefit, mankind. And, unless your comment was written in a persona that is not yourself, nothing you said indicates that you are likely to be an exception to Hayek’s rule. Second, think about going into Gerontology or Work with borderline autistic people. Why? In 30 years, almost all of the old people of today will be dead. Autism will probably be on the road to being a curable condition and will be receding into the past. However, nobody will be able to go back in time and alleviate the suffering of the present victims of lonely old age and the present victims of autism who did not receive talented, caring help. You can fill both those roles right now, and not many other people can. (By the way, if you do work with old people, dress nicely. It is extremely hard to underestimate how much an old lady who has not had much attention from a well-dressed person in years and years appreciates it when a well-dressed young man walks in the door to talk with her, even if it is only about her medical problems; and vice versa for the men, and so on). Third, read, and read again with a commentary, with at least as much attention as if you were reading a really well-written biochemistry or epidemiology text, the Biblical books of Leviticus, Proverbs, and Luke, which deal in exhausting detail with medical questions (Leviticus), with how to live a good and healthy life (Proverbs), and with how to cure people through faith, as written by a medical doctor of genius trained in the vintage years of the Roman Empire (Luke). Even if the books ultimately mean nothing to you, they will help you better understand a sizeable percentage of your more enlightened patients.

Greg Andreassian April 6, 2014 at 8:32 am

Speaking form the perspective of a General Surgeon of over twenty years in practice, the strictly utilitarian answer to your question is to pursue Family Practice. By such simple things as providing appropriate immunizations and educating your patients about health risks, you will save lives by the thousands. The results will not be apparent to the general public, not as sexy as say the heart surgeon that pulls a child back from the brink of death, but I think it is the clear choice given the way you word your question. I would add, however, that a physician in any field can have a positive impact on the lives of his/her patients throughout their career. Much depends on the individual setting and how that person prioritizes. My advise is to pursue the field that is most fulfilling to you. You can then set up a practice that brings the most utility.

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