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?