1.
Why doctors don’t
do much good, and
how you can do
more
Dr Gregory Lewis
EA Global Oxford
20/11/2016

2.
Outline
1. Introduction
2. Contours of health and disease
3. What does medicine contribute?
4. My research
5. A comparison to charitable giving
6. Peregrinations
7. Where to go next

3.
Outline
1. Introduction
2. Contours of health and disease
3. What does medicine contribute?
4. My research
5. A comparison to charitable giving
6. Peregrinations
7. Where to go next

4.
Photo credit: Wendy Darling

5.
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.

6.
Outline
1. Introduction
2. Contours of health and disease
3. What does medicine contribute?
4. My research
5. A comparison to charitable giving
6. Other peregrinations
7. Where to go next

7.
Source: Clio-Infra Project

8.
Source: Max Roser

9.
Outline
1. Introduction
2. Contours of health and disease
3. What does medicine contribute?
4. My research
5. A comparison to charitable giving
6. Other peregrinations
7. Where to go next

10.
McKeown (1977)

11.
McKinlay and McKinlay (1979)

12.
Excursus: QALYs
Source: Wikipedia

13.
Bunker’s approach
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 #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

14.
Bunker’s bottom line
5 Years extended lifespan 5 QALYs
5 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

15.
‘Per person’ QALY benefit 7
Number of people in UK ~ 62.6 million
Number of doctors in UK ~ 172 000
Impact per doctor 2250 QALYs
(~~ 2 lives saved
each year)
‘Saving a life’ ~ 30 QALYs, career of 40 years

16.
Making a difference?

17.
Outline
1. Introduction
2. Contours of health and disease
3. What does medicine contribute?
4. My research
5. A comparison to charitable giving
6. Other peregrinations
7. Where to go next

18.
A Global natural experiment
Data: WHO
DALY ~
‘inverse QALY

19.
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

20.
But confounding factors!
Doctors Health
Sanitation
Wealth
Education

21.
But confounding factors!
Doctors Health
Sanitation
Wealth
Education

22.
Even more marginal returns
Variable Coefficient Standard error P value
(Intercept) 133023.51 22058.14 <0.001
Doctors 11856.29 13103.49 0.387
Education -459.89 81.18 <0.001
Wealth -3762.00 1657.70 0.037
Sanitation -63.02 42.46 0.140
Inequality 17.78 155.72 0.910

23.
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

24.
Still an overestimate?

25.
Effective impact

26.
How much good do doctors do?
Method D/QALYs
Bunker 2250
( 80 lives)
Scatterplot 240
(8 lives)
Regression 105
(4 lives)
Statistical rigour
True value even lower?

27.
Outline
1. Introduction
2. Contours of health and disease
3. What does medicine contribute?
4. My research
5. A comparison to charitable giving
6. Peregrinations
7. Where to go next

28.
~40% of world at $2
a day
Me! (ish)
Average UK doctor

29.
Life-saving estimates
AMF (Givewell)
~~ $78/DALY

30.
Chequebook > Stethoscope
/ Cost per AMF QALY (£64) = 4375 QALYs
40 years * 10% of £70000 = £280 000
~ 45x my ‘direct’ work over this period

31.
Outline
1. Introduction
2. Contours of health and disease
3. What does medicine contribute?
4. My research
5. A comparison to charitable giving
6. Peregrinations
7. Where to go next

32.
Does specialty count?
Medicine probably isn’t really inefficient

33.
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%!)

34.
Being really good?

35.
How many ‘10x’ doctors?

36.
Outline
1. Introduction
2. Contours of health and disease
3. What does medicine contribute?
4. My research
5. A comparison to charitable giving
6. Peregrinations
7. Where to go next

37.
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.

38.
Strong candidates:
1. Medical research
2. Public health
3. Management
4. Something else (?Outside medicine)

39.
‘EA Medicine’ google group
https://groups.google.com/forum/#!forum/ea-medicine

40.
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.

41.
To close
1. 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

42.
Thanks! Any questions?