why doctors don't do much good, and how you can do more

Why doctors don’t do much good, and how you can do moreDr Gregory LewisEA Global Oxford20/11/2016

Outline1. Introduction2. Contours of health and disease 3. What does medicine contribute?4. My research5. A comparison to charitable giving6. Peregrinations7. Where to go next

Outline1. Introduction2. Contours of health and disease 3. What does medicine contribute?4. My research5. A comparison to charitable giving6. Peregrinations7. Where to go next

Photo credit: Wendy Darling

Lewis (2006)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.

Outline1. Introduction2. Contours of health and disease 3. What does medicine contribute?4. My research5. A comparison to charitable giving6. Other peregrinations7. Where to go next

Source: Clio-Infra Project

Source: Max Roser

Outline1. Introduction2. Contours of health and disease 3. What does medicine contribute?4. My research5. A comparison to charitable giving6. Other peregrinations7. Where to go next

McKeown (1977)

McKinlay and McKinlay (1979)

Excursus: QALYs

Source: Wikipedia

Bunker’s approachTrial data for length and quality

of life benefits for #1 most commonly used medical

intervention

Trial data for length and quality of life benefits for #2 most

commonly used medical intervention

Trial data for length and quality of life benefits for #3 most

commonly used medical intervention

Trial data for length and quality of life benefits for #1 most

commonly used medical intervention

Trial data for length and quality of life benefits for #1 most

commonly used medical intervention

Trial data for length and quality of life benefits for #1 most

commonly used medical intervention

Trial data for length and quality of life benefits for #1 most

commonly used medical intervention

Trial data for length and quality of life benefits for #1 most

commonly used medical intervention

Trial data for length and quality of life benefits for #1 most

commonly used medical intervention

Trial data for length and quality of life benefits for #1 most

commonly used medical intervention

Trial data for length and quality of life benefits for #1 most

commonly used medical intervention

Trial data for length and quality of life benefits for #1 most

commonly used medical intervention

Trial data for length and quality of life benefits for #n most

commonly used medical intervention

Total impact of medicine

Bunker’s bottom line

5 Years extended lifespan 5 QALYs5 Years ‘free from disability’

2.5 QALYs

0.5 Years lost (medical error)

- 0.5 QALYs

Grand total 7 QALYs

Average ‘per person benefit’ in the US

‘Per person’ QALY benefit 7Number of people in UK ~ 62.6 millionNumber of doctors in UK ~ 172 000Impact per doctor 2250 QALYs

(~~ 2 lives saved each year)‘Saving a life’ ~ 30 QALYs, career of 40 years

Making a difference?

Outline1. Introduction2. Contours of health and disease 3. What does medicine contribute?4. My research5. A comparison to charitable giving6. Other peregrinations7. Where to go next

A Global natural experiment

Data: WHO

DALY ~‘inverse QALY

More marginal marginal returns…

𝑦=5×106

(8.96+𝑥 )+25060

DALYs @ UK Docs (289 / 100k) =26738

DALYs @ UK Docs +1 =26732

Impact of another UK doctor ~ 6 DALYs per year, ~ 240 per career

But confounding factors!

Doctors Health

Sanitation

WealthEducation

But confounding factors!

Doctors Health

Sanitation

WealthEducation

Even more marginal returnsVariable Coefficien

tStandard error P value

(Intercept) 133023.51 22058.14 <0.001

Doctors 11856.29 13103.49 0.387Education -459.89 81.18 <0.001

Wealth -3762.00 1657.70 0.037Sanitation -63.02 42.46 0.140

Inequality 17.78 155.72 0.910

UK doctors per capita (289) Marginal DALY response in the UK for one more doctor:

2.63(- 3.93 to 9.08)

~ 105 DALYs per career

Still an overestimate?

Effective impact

How much good do doctors do?Method D/QALYs

Bunker2250

( 80 lives)

Scatterplot 240

(8 lives)

Regression 105

(4 lives)

Statistical rigour

True value even lower?

Outline1. Introduction2. Contours of health and disease 3. What does medicine contribute?4. My research5. A comparison to charitable giving6. Peregrinations7. Where to go next

~40% of world at $2 a day

Me! (ish)

Average UK doctor

Life-saving estimates

AMF (Givewell) ~~ $78/DALY

Chequebook > Stethoscope

/ Cost per AMF QALY (£64) = 4375 QALYs

40 years * 10% of £70000 = £280 000

~ 45x my ‘direct’ work over this period

Outline1. Introduction2. Contours of health and disease 3. What does medicine contribute?4. My research5. A comparison to charitable giving6. Peregrinations7. Where to go next

Does specialty count?

Medicine probably isn’t really inefficient

What about working abroad?UK doctors per capita (289)

Angola doctors per capita (8)

Maybe 10 – 100x the impact in the UK.

(But much more heroic than giving 10%!)

Being really good?

How many ‘10x’ doctors?

Outline1. Introduction2. Contours of health and disease 3. What does medicine contribute?4. My research5. A comparison to charitable giving6. Peregrinations7. Where to go next

Maxims for maximising medical munificence 1. You can’t make a big difference

one patient at a time.2. Almost all medical careers that

make a big difference are going to be unconventional.

Strong candidates:1. Medical research2. Public health3. Management4. Something else (?Outside

medicine)

‘EA Medicine’ google group

https://groups.google.com/forum/#!forum/ea-medicine

Lewis (2016)

Giving around 30% (should be more!)

Year 1: About £10 000~ 160 QALYs

(So probably more good than my future medical career)

Now a Public Health academic Doc.

To close1. The pretty modest impact of

medical careers is bad news for doctors; the very immodest impact of charity is good news for everyone!

2. Common sense is not always a good guide for what to do with your life.

3. You can make a big difference

Thanks! Any questions?