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

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EAGxOxford 2016

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

  1. 1. Why doctors don’t do much good, and how you can do more Dr Gregory Lewis EA Global Oxford 20/11/2016
  2. 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. 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. 4. Photo credit: Wendy Darling
  5. 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. 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. 7. Source: Clio-Infra Project
  8. 8. Source: Max Roser
  9. 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. 10. McKeown (1977)
  11. 11. McKinlay and McKinlay (1979)
  12. 12. Excursus: QALYs Source: Wikipedia
  13. 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. 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. 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. 16. Making a difference?
  17. 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. 18. A Global natural experiment Data: WHO DALY ~ ‘inverse QALY
  19. 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. 20. But confounding factors! Doctors Health Sanitation Wealth Education
  21. 21. But confounding factors! Doctors Health Sanitation Wealth Education
  22. 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. 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. 24. Still an overestimate?
  25. 25. Effective impact
  26. 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. 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. 28. ~40% of world at $2 a day Me! (ish) Average UK doctor
  29. 29. Life-saving estimates AMF (Givewell) ~~ $78/DALY
  30. 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. 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. 32. Does specialty count? Medicine probably isn’t really inefficient
  33. 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. 34. Being really good?
  35. 35. How many ‘10x’ doctors?
  36. 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. 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. 38. Strong candidates: 1. Medical research 2. Public health 3. Management 4. Something else (?Outside medicine)
  39. 39. ‘EA Medicine’ google group https://groups.google.com/forum/#!forum/ea-medicine
  40. 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. 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. 42. Thanks! Any questions?

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