How many lives does a doctor save?
80000hours.org
80000hours.org
"According to Bunker, the average person gains about 5.25 years due to medicine"
and then calculates "year of life the doctor saved" based on that. That's wrong.
The counterexample: the kid breaks the leg. The leg will "heal" even without the operation, but the form will be altered: the kid will never be able to walk normally, do the sport normally, anything you imagine (a). A few operations are performed on the kid's leg, afterwards he walks normally, lives the rest of his life normally (b). Now if the person having the problems in (a) lives the same number of years as the fully healthy (b) the statistics the whole article calculation is based don't show any contribution of the given operations, whereas these operations really did "save life" in the sense of giving somebody a healthy life that he otherwise wouldn't have.
There are immense number of equivalent examples and all are ignored in the article. Much more lives are effectively "saved" by the modern medicine than the author can see. We can also consider the lives of the family of the patient also effectively "destroyed" without the medicine.
(In short, the article appeared as (stereotypically said, more as the strong figure of speech not actually addressed at the specific author) written by 20-something male who hasn't first-hand experienced medical problems even in his family. I wasn't able to find more about "Gregory Lewis" who wrote it, but the whole "80,000 Hours" project site, on which this 2012 article was published was the result of the 2011 initiative of two Oxford students, and maybe that gives some idea about the setting.)
Sure, we all live a lot better lived with access to medicine, but the larger part of the improvement comes from improved access to nutrition and sanitation.
Besides, even if you disagree with the methodology (which they already admit is a back of the envelope calculation that is likely to be only accurate to an order of magnitude, I don't think the idea in itself, to identify the best way an individual can contribute to humanity as a whole is a bad idea.
"I think my 17-year-old self would find that pretty galling. He’d signed up to medicine to save loads of lives, and he’d find it a bit of a downer to see this his entire medical career would likely do as much good as a £10 000 donation to the right charity. But that would be the wrong way of looking at things: instead, he should see that saving 17 lives is a vast amount of good, and being able to do 30 times more good on top of that is awesome."
Well... sounds a bit better. But the whole series still looks more like an excuse for somebody to forgo his medical career (also from the Part 3):
"If I become willing to work as a doctor, then I increase the supply of doctors. If more people are willing to be doctors, then the NHS can slightly decrease the wages for doctors (1). If the wages are slightly lower, the budget can be used to hire slightly more doctors.
How this all balances out is studied by economists. If the labour market for doctors is in equilibrium, then increasing the supply of doctors by one doctor, will probably increase the number of doctors by about 0.6 (2)."
I'd like to know if the article author really grew up to be a doctor or if he's now some activist in some charity instead.
Take a look at what the site suggests as the "right careers" for impact after I've filled the "career guide":
1) Management consulting (for skill-building & earning to give)
2) Foundation grantmaker
3) Think tank research
4) Economics PhD
Well if the guys who end up on this position only know to count megadeaths and QALYs before, I really doubt they will even understand what they decide about. But they'll surely have some impact, if it's a good impact it's fully another question.
He's a practicing doctor at Churchill Hospital in Oxford.
http://www.thepolemicalmedic.com/
To the best of my knowledge, he continues to support 80,000 Hours.
https://www.givingwhatwecan.org/
http://www.thepolemicalmedic.com/saving-the-world-and-healin...
and that he has spent short time with 80,000 Hours. It seems he was really still a student as he wrote there. I hope he'll blog more about his experiences as he grows up.
As for impact, the entire site is about advising people on how to have the greatest impact, which they calculate using economic arguments. That's how they come up with those careers which they think will contribute the most.
What are your concerns about they way they're doing it?
You: "[The article] starts with the number 5.25 years...and then calculates "year of life the doctor saved" based on that. That's wrong....The counterexample: the kid breaks the leg....There are immense number of equivalent examples and all are ignored in the article.
Are you claiming that the article only accounts for deaths averted and fails to account for improved health and well being? Because the article addresses disability-adjusted life years literally 2 sentences later.
> Medicine also improves wellbeing: the average person has five more years free of disability.
(Incidentally, deaths averted are comparable in total value to injuries averted, so the article would still fulfill it's claim of getting an order-of-magnitude estimate even if it had ignored the later.)
I would focus less on ad hominems about the author's youth.
Yes, and I claim the article still misses the point. The doctor helping the patient really "saves" the patient life and the life of people in his family every time he/she helps. That's not measurable with QALYs the way it's done in the article, and to understand that, one has to live through the critical periods in his own life or the life of those closest to him, therefore the reference to the view by somebody young. Disclaimer: I've had exactly the same tunnel vision as I was younger, and I'm male, so I write based on my own experience.
The averages he calculates are for "what contributes the doctor on average." And the averages are even true: there are enough of doctors that work more for their own benefit that for the benefit of fellow humans. The best example is the UK doctor that started the anti-vaccine craze. He had a lot of impact, and even if he was eventually expelled for having interest in spreading the craze, a lot of people still follow what he started.
But if somebody really wants to make a huge positive difference by being a doctor, he really can. Who says that he must work at the hospital in Oxford? How about spending only a few months in some mission in Africa?
Also, what number of QALYs can be calculated for an average worker of other professions, including those recommended by the 80000 hours site?
- What number of QALYs can be calculated for an average worker of other professions, especially those recommended by the 80000 hours site (e.g. QALYs saved by an average "Think tank researcher")?
- Is it even possible to calculate average QALYs in a way to really compare anything meaningful, across the different occupations? If not, why are they here calculated for "average" doctors?
When you say "average", do you mean a marginal worker of average quality, or the literally the total impact of the profession divided over its total practitioners? The definition really isn't relevant for s careers because we expect diminishing returns, and individuals can only act on the margins. (On the other hand, the government might be interested in it if they had the ability to expand the size of the entire industry.)
I don't know what the estimates are, but I would wager heavily that there are identifiable think-tank research positions with much higher leverage, even on the margins, than the highest-impact medical professions. It's just a matter of multipliers: think tanks influenc large amounts of money while doctors generally can't help beyond their own patients.
> - Is it even possible to calculate average QALYs in a way to really compare anything meaningful, across the different occupations? If not, why are they here calculated for doctors?
Yes, I think an estimate is possible, although there may be large uncertainties. 80k Hours has previously estimated the value (and chance) of things like becoming a member of parliament, or working in finance and donating most of one's salary to health charities in the developing world. Even when these are off by an order of magnitude, they often are sufficiently informative to usefully change people's plans.
80k Hours claims that over 180 people have made serious career changes that those people explicitly attribute to the organization's research.
No, this is literally what QALY are for - measuring the impact of an improvement at someones life.
https://en.wikipedia.org/wiki/Quality-adjusted_life_year
"It is used in assessing the value for money of a medical intervention"
not to compare the doctors "impact" to other occupations "impact" which is the implicit goal of the article and the explicit of the site:
https://80000hours.org/2015/07/if-you-want-to-save-lives-sho...
"If you want to save lives, should you study medicine? Probably not."
http://pulitzercenter.org/reporting/north-america-united-sta...
How many lives has the pharmaceutical industry destroyed by selling harmful substances?
http://www.amazon.com/Bad-Pharma-Companies-Mislead-Patients/...
Have you ever had serious case of bronchitis, or a high fever, or needed any kind of surgery?
Guess what? No anesthesia (yes it's a drug not just a machine), no antibiotics, very likely no you.
Now take a look at the recent articles on the UK's much hyped NHS and how they are laggards in cancer survival because they do not take advantage of pharma innovations.
Know anyone anyone with hypertension or diabetes? Ask them whether they were well controlled and side effect free on the first drug they were prescribed . That's the big reason there are a lot of "me too" drugs that sell. (and while you're asking see if they fully compiled with their doctor's diet and exercise advice)
One size does not fit all.
That's definitely not the reason why the NHS has poor cancer outcomes.
Those very expensive new cancer meds add a month or so of low quality life (and are used within the NHS).
The problem is at the diagnosis end.
Look at the five year survival rates for innovative treatments. Granted not all of them and not every time, but to generalize to "months" is a gross mis-characterization not borne out by a thorough review of the literature.
(Edit: yes, I am sure about this).
EDIT2: for one example where the UK NHS gets things wrong in diagnosis: patient finds a lump, visits GP. That GP then gives a rapid referal to a specialist, who then gives rapid screening requests.
What should happen is the GP asks for the rapid screening, and simultaneously makes the rapid referal to specialists. This would reduce time to diagnosis, and time to start treatment, and both of those are important in outcomes.
Note: They suggest some of the reasons behind this could include cancers being diagnosed later, poorer access to treatment and less investment in health systems.
PS Rapid referral to a specialist is an oxymoron in the NHS.
I counter - pointing out that the problems are at the diagnosis end.
You respond with a comment about the five year survival rate of innovative med.
I tell you that those meds are used within the NHS, and ask for an example med that is not used within the NHS. I give an example of how there are inefficiencies in the diagnosis end.
You post a link that doesn't mention meds; does mention delays in diagnosis and treatment. You still haven't posted an example of a cancer medication that provides good outcomes that is not used in the NHS.
Your little dig about referal times is weird. What do you think the referal times are? There is a legally enforced maximum 2 week time from GP referral to see a cancer specialist.
http://www.nhs.uk/choiceintheNHS/Rightsandpledges/Waitingtim...
> Patients with urgent conditions such as cancer and heart disease will be able to see a specialist more quickly. For example, you have the right to be seen by a specialist within a maximum of two weeks from GP referral for urgent referrals where cancer is suspected.
You appear to have a political ax to grind. That would be okay if you weren't spreading lies and misinformation.
EDIT: you made an antiNUS documentary? You don't think that's the kind of thing you should mention? I'd be interested in fact checking it because, looking at this thread, you probably made a right fucking mess of it.
I did work a documentary on Rheumatoid Arthritis patients across Europe, not just the UK and not focused on health systems. The patients experiences with their respective health service were out of scope and not on screen. I did however speak with them at length on the subject. Before you go casting about accusations please have some rudimentary idea of what you are talking about.
The NHS patients we met with each mentioned that in order to see a specialist on a timely basis they had to get private insurance after which their months longs waits dissolved to days. A close friend who was a staunch defender of the NHS after being diagnosed with MS has soured on the program and has also secured private insurance for specialist access. In another instance a young woman with a bowel perforation secondary to Crohn Disease has been waiting for at least two months to have surgery scheduled. Yes, yes I know anecdotal experience and all that but I guess it's just a poisson distribution that everyone I've ever known met or heard of that has needed specialty care from the NHS has gone the route of private insurance for access to specialists.
Take a close look at the quote from the article I posted with the prefix "Note:" and then sound it out. Use your vowels and note that it VERY CLEARLY states that one of the problems is "poorer access to treatment".
If you want to go on a formulary hunt to see which drugs are not paid for by the NHS that are recommended under NCCN guidelines or spend your night frothing over pubmed searches be my guest.
PS I have no axe to grind. I'm not the one bringing profanity and personal accusations into this. You don't know me. You clearly have no clue about my politics but are clearly incensed that someone deigns to take issue with the NHS. The bottom line is that patients are dying sooner in the UK than elsewhere. If that is okay with you then great, I'm just saying as a personal opinion informed by my reading and personal experiences that it is not a system I would choose to live under or advocate the adoption of in my country.
If you are happy with the health care system in your country that's great.
http://www.nhs.uk/choiceintheNHS/Rightsandpledges/Waitingtim...
> You have the legal right to start your non-emergency NHS consultant-led treatment within a maximum of 18 weeks from referral, unless you choose to wait longer or it is clinically appropriate that you wait longer.
> If you want to go on a formulary hunt to see which drugs are not paid for by the NHS that are recommended under NCCN guidelines or spend your night frothing over pubmed searches be my guest.
You made the claim, you should back it up. You said that poor cancer outcomes on the NHS was caused by lack of access to new cancer meds. Your inability - over four posts - to name any drugs that are not available on the NHS is telling. Your choice to support your claim with an undetailed BBC report is odd. It certainly doesn't say what you think it says: poorer access to treatment is exactly what I describe in edit2 above.
> Yes, yes I know anecdotal experience and all that but I guess it's just a poisson distribution that everyone I've ever known met or heard of that has needed specialty care from the NHS has gone the route of private insurance for access to specialists.
What's your sample size? How do you counter the fact that there is legally enforced maximum waiting times in the NHS?
> but are clearly incensed that someone deigns to take issue with the NHS.
I criticise the NHS, in this thread. I am angry that someone continues to lie about the NHS, even after their lies have been debunked.
A. You have debunked nothing.
B. There are no lies here.
C. Just because some random guy on the internet tells me to do something, I am no obligation to do that.
D. "Access to treatment", could mean the moon is made of green cheese but it is unlikely.
E. Since you are angry about it, cite specifically the the formulary content of the NHS and compare it to available treatments at Sloan Kettering. Since your so convinced it's true, prove it. (two can play at that)
F. Support you assertion that novel treatments only extend life by "a few months" with multiple citations from peer reviewed journals, oh and make sure their recent.
G. As far as the legal mandates. I am sure that everything in the UK is done exactly to the letter of the law in all cases and that deadlines are never missed.
H. You're assertion that closing the two week gap between when the GP starts testing and the specialist would start testing would close the mortality gap between the UK and Europe strains credulity and common sense.
Oh and just because you are dead bone wrong, http://www.telegraph.co.uk/news/11788507/NHS-accused-of-sham...
"A cancer drug hailed as one of the biggest breakthroughs since chemotherapy will not be made available on the NHS, despite research showing it doubles survival"
Can you here me now.
One of the paper's highlighted cases of " doctor-caused death" from its own summary , was a case where a kid had an unprovoked heart failure while running track, and the doctor forgot to tell him that doing that again might kill him, and then he kid ran again, and had another failure, and died. That's ridiculous to blame on faulty care.
If 10 people have heart attacks, and medicine saves 5, suboptimal care fails to save 3, and 2 cases were beyond the reach of even perfect care, that research paper would say medicine killed 3 and heart disease killed 2, ignoring the 5 saved. Medicine has room for improvement, but is an absolutely massive net win.
NNT, RR, basic statistical perspective. People are so often bad at understanding (or even acknowledging) the counterfactual.
The majority of deaths are categorized as caused by hospital infections (80,000) or adverse drug reaction (106,000).
Let's get real--this is said over, and over again, and I've never bought it. I won't go into the mind of the typical pre-med student, but being altruistic is not a trait I have seen in U.S. Medical students, and their sense of altruism doesn't improve with age.
It's a short article, and I honestly didn't read it closely, but I'd rather have it titled "How many lives does a doctor improve?"
There are a few questions I ask myself, whenever I meet a new doctor, and it's these; "What is this doctor's estimated kill card(the patients who died under their care), and does this doctor make conditions worse?"
I do take external factors into account when I make this unscientific judgement call; like the doctor's willingness to take on the sickest patients. The socio-economic status of the doctor's patients. The real reason this person became a doctor(it's usually not that hard to figure out on first impressions). I can usually spot the soley financial ones, and run!
(I have met a few altruistic doctors, and will bend over backwards to help them, or make their practice easier. They are appreciated, and respected! They are few and far between these days though? I don't know if the profession changed, or I changed?)
> > I want to study medicine because of a desire I
> > have to help others
>
> Let's get real--this is said over, and over again,
> and I've never bought it.
http://www.wwltv.com/videos/news/health/2015/07/28/trauma-su...
Norman McSwain was one man but through his work developing PHTLS (Pre-Hospital Trauma Life Support) and introducing modern EMS practices to numerous countries around the globe he truly did save countless lives. He has been credited for doing more to reduce the homicide in New Orleans than any mayor or police commissioner because he taught the trauma surgeons that increased survival from penetrating wounds and was an incredibly skilled surgeon himself. His work with the Tactical Combat Casualty Care Committee helped reduce battlefield fatality rates to historic lows.
The statistics don't take into account the kind of doctor you choose to be. If you choose to join a posh private practice and treat little old ladies who "just don't feel quite right" you may not save a lot of lives. But if you choose to be on the front lines, for instance one of the last doctors out of Charity hospital after Katrina, and spread knowledge far and wide you may just save more than "ninety lives".
We all get the same 24 hours in each day. Norman just used them better than most of us.
That's my bad - thanks for reporting this bug, and I'm sorry for the hassle. I've just pushed a fix.
U.S. graduate schools are filled with people from other countries, because students know that compensation for scientific careers is awful. We squander enormous amounts of intellectual capital making physicians, while people involved in nobel-prize winning advancements often have to leave their careers for lack of funding (c.f. http://discovermagazine.com/2011/apr/30-how-bad-luck-network...). It's a horrible failure of our medical system that the incentives are so misplaced.
Keeping that in mind I think that averaging numbers is not a great representation of doctors impact, the same way average latency isn't a great representation of what users see. What's the 95% percentile of QALYs? E.g. are doctors making one life (e.g. kid with a broken leg as mentioned in a comment here) better for 50 years when 9 people will just never break a leg?
If looking at shifts in distributions the story might (I could not find raw data) look very different.
When you hit 40 you get a glimpse how fragile we are and how valuable the consistency of health is.
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.
The question is, if you're considering becoming a doctor, what's the potential benefit that's due to your choices? How much good do you do that wouldn't have happened anyway?
(i have no idea how much doctors are paid; is it not a good career path from a financial perspective?)
https://80000hours.org/career-guide/basics/
We also think "corruption risk" should be taken very carefully, which is why we advocate making a public pledge of your intention to donate, and being part of a community.
We also don't think you should take a high-earning career if it causes significant harm.
I wish people would stop using that phrase. Stalin "made a difference."