So, About Last Tuesday...

I'd feel almost neglectful if I didn't touch on the US election last week. This blog is primarily about medicine and healthcare, so my intention was to touch on the numerous effects a Trump presidency is likely to have on the health of people in America as well as those abroad. However, since starting this piece, both major media outlets and more healthcare-focused sites have provided analysis of this with various degrees of depth, and I'm not sure I have much to add. Fortunately, the effects are fairly easy to sum up without losing too much with the brevity - a large number of people, mostly poor or sick people, will lose their health insurance or will end up with less-comprehensive coverage.

Of course, health effects will depend on exactly what policies Trump choose to enact, whether unilaterally through executive action, or through legislation by working with Congress, so it's hard to say exactly what will happen. Nevertheless, the proposals presented thus far all lead to that somewhat over-simplistic conclusion above according to multiple independent analyses.

It's a striking reminder that health depends on so much more than medicine. The sum of medical knowledge and ability in the US is constantly increasing, but the health of its citizens is likely to worsen if Trump proceeds as promised during his campaign. Keeping engaged in the political process and involved in advocacy roles are both important ways for physicians to influence the wider society that has far greater effects on patient health than most physicians' direct actions.

Like many disappointed by Trump's victory, I take this result as a spur to action. No, I'm not American, but it's a reminder that undesirable outcomes are often the result of complacency and that to see sustained progress, sustained effort is required. While I do use this blog as a way to express my viewpoints openly and honestly, I would like to make a more concerted effort to be directly involved in how the world is run around me. That said, as we see protests spring up across America, I'm equally reminded that hate is not the answer to hate. Most of the protests are peaceful, but some are not, and violence cannot be the answer even when other viable options are available.

Lastly, I'm reminded that effective advocacy should be one of the final steps to enacting change, not one of the first. Before pushing for what we think is right, it's vitally important that we take the time to determine what right is. Too often, advocates assume their positions are correct without ever challenging their own viewpoints, and good intentions are no substitute for a considered, informed opinion. Reading, listening, and learning are essential before - and after - speaking out. That includes
paying attention to those viewpoints opposed to yours. Those opposing views don't need to be accepted, but they should at least be understood. Furthermore, when asking the world to change, we first should consider how we can change ourselves. No one's perfect and that's an unrealistic goal, but there is always something we can do to change our actions and behaviours to do further our own priorities for the world.

I do a lot of my advocacy through this blog and other online postings. It's not a particularly effective approach - those who come to the read the blog are typically sympathetic to my viewpoints already, so I'm largely preaching to the choir. So, I feel the need to take a few more direct steps. My first is by starting some regular charitable contributions to causes I care about, putting my (currently limited) money where my mouth is. My goal has always been to give a significant potion of my income to these or similar charities, so despite my growing debt, I might as well start now, as I'm finally on the verge of having a real income. While I've always been involved with school projects that I feel are meaningful, I'm going to try to spend my last year and hopefully my residency as well, with more direct involvement in the curricular side of medical education. Lastly, I'm looking into ways to be involved in the political process. I'm not sure what form that will take, as I'm not particularly partisan and not sure how I feel about joining any political party, but it's time I explore my options. Staying on the relative sidelines, where writing and voting are my only methods of influencing policy, just doesn't feel like enough at this stage.

Want to Help Patients As a Doctor? Donate to Charity

Students want to become doctors to help people. But how good are physicians at doing this?

I stumbled across a site on having a productive career that helps others. It has some interesting insights, but I'm particularly liking their analysis of the effects of being a physician. Physicians treat patients and presumably do a good job of it, but the overall effect physicians have on health is likely not that substantial for most patients. More importantly, physicians don't see that many patients in the grand scheme of things (though at times it certainly seems like they're seeing too many).

In medicine, a common, standardized way to evaluate how effective or how cost-effective an intervention is involved the use of Quality-Adjusted Life-Years (QALYs). I've always wanted to get an estimate of how many QALYs can be attributed to a typical physician, and the folks on this site have done a pretty good job, putting it at a maximum of around 2600 QALYs over a career. They further adjust for the marginal effect of any particular person choosing to become a physician - after all, there are diminishing returns for adding additional physicians, and if I wasn't in medical school, someone else would be. Presumably, I'm a better candidate than the person who would have replaced me, but I doubt the difference would be that substantial. They put the marginal effect of a typical person choosing to pursue medicine (and then doing so) at around 600 QALYs.

And even these numbers attribute the entire benefit of medicine to physicians, which is hardly the case. The estimates drop pretty quickly as you reduce the proportion of credit given to physicians. Anyway, it's worth checking out the analysis in full. There's a bit of room to quibble, but most of that pushes the estimates down - 2600 additional QALYs attributable to an average physician looks to be like a pretty reliable high-end estimate.

Now, saving 2600 years of life or providing the equivalent increase in quality of life is still pretty impressive, particularly in the developed world where the low-hanging fruit of improving people's lives (especially reducing poverty) has either been addressed already or is surprisingly difficult to make further strides against. Not all physicians have the same impact - higher quality physicians presumably have a greater impact and there are undoubtedly differences based on the specialty chosen and the nature of a physician's practice.

Yet, perhaps the greatest way physicians can help others is by donating to effective charities. Physicians earn a lot of money and do so rather reliably. A physician's charitable donations, if done efficiently, can provide benefits to humanity that dwarf what they provide in direct benefit to their patients, according to these authors' analyses.

There are additional avenues through which physicians can improve lives. Research and development can lead to broad improvements in quality of life across the world, well beyond what a physician can accomplish directly. However, not all research is successful in developing improvements for healthcare or overall health, and the real-world effects can often be modest. Advocacy is another avenue for improvement of overall well-being, but the average physician isn't that influential. There are ways to increase that influence though, such as formal or informal writing, or by working with advocacy groups for specific causes. Teaching can be another way to contribute, as knowledge translation is important to preserving current improvements in QALYs due to modern medicine and a strong teacher-physician may be able to improve the quality of the physicians they instruct.

So do doctors help people? Yes, but the direct impact isn't as high as many people think and there are other pathways that could have a much larger impact on humanity as a whole. Being a doctor is as much about feeling like you're doing good than it is actually doing good. That's not a criticism. It's important for us to enjoy our careers and feel valued at them - our quality of life matters too! Still, we should be aware of our own limitations and those of our profession. Physicians do good work. When I become one, I hope to do good work too, work that will hopefully help people. But the work we do isn't uniquely good and there are many ways we can have a meaningful impact on others' lives outside of our clinical practices.