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

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

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 #n most


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?

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

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?

~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

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?

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?

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

Health & Medicine