Medicine has been around for as long as people have, and some of its history in the era before it was tightly licensed and regulated is discouraging. Snake oil nostrums, bleeding and cupping, trephining, lobotomies...all of these things exhibited acceptance and strong demand from patients in their day, even when the best scientific evidence available at the time cast grave doubts on their efficacy or even neutrality. It's worth remembering the tale of elixir sulfanilamide that resulted in the law requiring pre-approval of new drugs by the FDA. People whose health is threatened are often desperate, and desperate people don't always make the best choices -- and there are unfortunately always hucksters willing to take advantage of their desperation.
On the other hand, the inefficiency and perverse incentives of over-regulation, with its harmful effects on innovation, are also manifest, so...ugh. Scylla, Charybdis.
The only idea I've ever thought might be worth serious exploration is government functioning more like a giant feedback machine, without picking winners itself. For example, government could allow sale of almost any drug, provided (1) it met some very basic safety tests, and (2) the manufacturer was obliged to zealously collect data on outcomes and forward them to some government agency, which then made them freely and easily accessible to potential future users. Maybe even did the statistical analyses, too, and posted them, without editorial comment or slant -- just the facts, arrayed as plain as could be.
Similarly, government could license all manner of medical practitioners, with only a very basic required training regime -- provided that those practitioners collected data on their outcomes and those, too, were readily available to potential future patients. The existence and ubiquity of the Internet, smartphones, apps, makes this more viable than ever before.
There would still be people who consulted their hopes, fears, and prejudices instead of the data to make decisions about practitioners and medicines. But people who were reasonably rational could consult the data instead, and if there are enough of them then their influence on the market would push it towards improvement, in both outcomes and efficiency. I wonder how big that "if" is, though.
In a sense, Western medicine was extremely tightly regulated from before 200 AD to after 1800 AD. It was regulated primarily by the Church, often in cooperation with civil authorities. I've written about Michael Servetus, who fled Catholic lands for Switzerland, only to be burned alive by John Calvin and Friends.
Great comment, but I would hesitate to say that snake oil nostrums are necessarily the result of demand from desperate patients. It may work the other way. Strict regulation, economic interests, and the imprimatur of the medical establishment can be just as responsible for the widespread acceptance of some horrifying therapies.
Case in point is the 1949 Nobel Prize in Medicine, which was awarded to Egas Moniz for his discovery of the therapeutic benefits of the frontal lobotomy.
Quite a lot of higher education is stuck in this model, where we continue to act as if it is AD 1350, and it is entirely plausible for a person to learn everything there is to know about every theoretical subject in 4-5 years of close study. We ignore the fact that most technical fields have expanded so much that it is only possible for a person to thoroughly grok a small sliver of it until late in the career. We train doctors who are hypothetically supposed to absorb *all* of medicine in 4 years -- and then, of course, they specialize and receive their real training as interns and residents (and sometimes fellows) in order to *actually* become experts in some area or another. For that matter, the college degree that precedes it partakes of the same delusion: you get a "general" education that farcically purports to teach you most of what is known (or even more dubiously "how to think" as its proponents put it), and even if your career intentions are already well-formed, it's not until 1-2 years into this expensive sabbatical from productivity that you even start to buckle down to learning what you'll need to learn for useful specialization.
It's very expensive, and of course inefficient, since the basic model, of the Renaissance Man who knows most everything, just in case, but necessarily specializes in order to contribute usefully to a highly specialized labor economy, is inherently mismatched to reality.
You can see struggles to change -- the very existence of jobs like PA, NP, or nurse anesthesiologist is evidence of this, as is stuff like BS-MD programs that combine a college and medical degree into one 6-year program. Or even the "coding bootcamps" that allow people to get into programming without the time and $$ investment of a 4-year degree, in which they have to write some papers on Shakespeare and the history of opera along the way.
Economic efficiency certainly suggests an expansion of the ability to specialize earlier and a recognition that measured ability in *this particular skill* needed for *this particular job* would be more efficient than requiring some bulky opaque "general competence" credential, like a degree. (There are higher-ed mavens who dream of a future in which the weighty one-size-fits-all general competence degree is replaced by a sheaf of "micro-certificates" that are each quick to earn, and focus narrowly on certain useful skills.)
But. The purpose of education isn't *just* to turn people into efficient economic cogs, it also has a human purpose. It exists to enlighten and enrich the individual human spirit. It allows us to at least sip of the heady nectar of wisdom (or at least understanding) gathered slowly, sometimes painfully, drop by drop by generations before us. If it is to be *just* job training, there is some risk of movement towards the Brave New World ideal, in which we are all bent like human bonsai towards some useful niche in the giant social machine from very early on, as soon as our stubby little fingers can click the mouse on the aptitude exams, and our chances to be free and unique are that much more hamstrung. All those kids who got into programming via bootcamps -- what if they decide in their 30s that they hate coding, and would like to write or become an opera critic instead? They have no basis at all for the switch, there is no remnant of a general education, however shallow, that can be a platform from which to launch. That's certainly efficient, because giving *everyone* a platform only a tiny minority will ever actually use is inefficient. But there's a human, spiritual cost, that should perhaps not be overlooked entirely.
I don't have any good answer to this, or even a way to assess the costs each way. I studied a lot of stuff in my school days that had absolutely no use in my career. Foreign languages, macroeconomics (ha ha), Medieval history, some odd stuff on music and religion and astronomy. All a gigantic waste of my college tuition dollars and time, in one sense. But I also cherish that stuff. I feel like having been exposed, at least, to these aspects of the vast human enterprise, makes my understanding of the world and of the human state less shallow. It never did boo to make me a more efficient producer, but it made me a happier human being, perhaps a more nuanced and interesting one.
Certainly rich people will always have the luxury of indulging any random curiosity. I hear Kim Kardashian studies law, just because she feels like it, and she can easily afford to do it for grins, because she's rich. But it would be a shame if *only* the rich were able to indulge the broad-spectrum curiosity with which we're nearly all born.
Don’t mean to sound obsequious, Carl, but just the pleasure of reading your long, long comments is enough to justify having a blog. Your comment is dense with interesting, compelling, not-at-all-obvious arguments. Nothing specific to add beyond that.
That's very kind of you, thank you. In return I'll offer that I like your blog in no small part for its wide and even eclectic range of interests, fearless originality, unfailing courtesy, and it's pleasant to have the opportunity to drop a stray thought or two into the soup.
Good ideas from both of you. How to reduce costs while improving health care, and education. You see people in both fields trying new methods for reaching people through technology. Things like Khan Academy or what Hillsdale College is doing in education (Khan Academy working more the micro credential side while Hillsdale College is working more the general education side). And you have various online initiatives by Cleveland Clinic or Mayo Clinic on the health care side and things by individuals like Dr. Brownstein trying to do more holistic, preventative care. (I'm merely giving examples rather than recommendations--I'm sure there are plenty more.) And I'd add a another issue, how do you filter out the kooks--without also filtering out the geniuses who don't happen to fit in? I suspect the best answer is to let the market play out, but then that gets back to Robert's original post: how do you get the government out of the way when there are vested interests who want to make sure the government stays in the way?
One thing that might help break the power of the regulators is the way that COVID dissenters have been treated. Doctors and Pharmacists who have been de-certified by the "professional regulators" because they didn't toe the line on COVID.
Since, for them, time and health really is money, they probably usually go with the credential, both to reduce the time searching for a professional to work with and to ensure quality. But I suspect that if you were to do a serious survey, (or just keep your eyes open for it), you'd find a non-trivial number of them are choosing APPs for some purposes.
So, I'll assume APP=Advanced Practice Provider. Here's my take:
(1) Billionaires, powerful people, Hollywood types are not necessarily the best guides to optimal care.. Their wealth gives them freedom to indulge their hypochondria and fad-mania. Many go for exhaustively comprehensive check-ups and screenings that brim over with false positives and iatrogenic illness and injury from unnecessary treatments.
(2) Billionaires and Hollywood types also drive Maseratis and fly LearJets, and it makes no sense to pass laws limiting folks in rural Mississippi to Maseratis and LearJets for their driving and flying needs. And yet, health policy wonks unconsciously make an equivalent error. Some years back, I wrote, "The Unintended Elitism of Health Care Policy" (https://insidesources.com/unintended-elitism-health-care-policy/), in which I said: "The biggest problem with health care policy may be that those who design health care policy mostly design it for people who design health care policy." My MD/APRN article was especially focused on expanding care in areas that are not populated by billionaires and Hollywood types.
(3) One reason that healthcare is scarce in rural areas is because doctors know they can make WAAAY more money in places that do have billionaires and Hollywood types, or at least in places full of millionaires and white collar types.
Medicine has been around for as long as people have, and some of its history in the era before it was tightly licensed and regulated is discouraging. Snake oil nostrums, bleeding and cupping, trephining, lobotomies...all of these things exhibited acceptance and strong demand from patients in their day, even when the best scientific evidence available at the time cast grave doubts on their efficacy or even neutrality. It's worth remembering the tale of elixir sulfanilamide that resulted in the law requiring pre-approval of new drugs by the FDA. People whose health is threatened are often desperate, and desperate people don't always make the best choices -- and there are unfortunately always hucksters willing to take advantage of their desperation.
On the other hand, the inefficiency and perverse incentives of over-regulation, with its harmful effects on innovation, are also manifest, so...ugh. Scylla, Charybdis.
The only idea I've ever thought might be worth serious exploration is government functioning more like a giant feedback machine, without picking winners itself. For example, government could allow sale of almost any drug, provided (1) it met some very basic safety tests, and (2) the manufacturer was obliged to zealously collect data on outcomes and forward them to some government agency, which then made them freely and easily accessible to potential future users. Maybe even did the statistical analyses, too, and posted them, without editorial comment or slant -- just the facts, arrayed as plain as could be.
Similarly, government could license all manner of medical practitioners, with only a very basic required training regime -- provided that those practitioners collected data on their outcomes and those, too, were readily available to potential future patients. The existence and ubiquity of the Internet, smartphones, apps, makes this more viable than ever before.
There would still be people who consulted their hopes, fears, and prejudices instead of the data to make decisions about practitioners and medicines. But people who were reasonably rational could consult the data instead, and if there are enough of them then their influence on the market would push it towards improvement, in both outcomes and efficiency. I wonder how big that "if" is, though.
In a sense, Western medicine was extremely tightly regulated from before 200 AD to after 1800 AD. It was regulated primarily by the Church, often in cooperation with civil authorities. I've written about Michael Servetus, who fled Catholic lands for Switzerland, only to be burned alive by John Calvin and Friends.
Carl,
Great comment, but I would hesitate to say that snake oil nostrums are necessarily the result of demand from desperate patients. It may work the other way. Strict regulation, economic interests, and the imprimatur of the medical establishment can be just as responsible for the widespread acceptance of some horrifying therapies.
Case in point is the 1949 Nobel Prize in Medicine, which was awarded to Egas Moniz for his discovery of the therapeutic benefits of the frontal lobotomy.
I'm entirely ready to concede the probability that it's a wicked confluence of the magical thinking of the patient and the cupidity of the provider :(
Is there a relatively accessible work by Goldin to start me on?
Good question. I'll look.
Here's a good one. It's an academic paper, so expect that. But she does a splendid job of outlining the history and the economics in a very approachable way. https://www.nber.org/system/files/working_papers/w10331/w10331.pdf
Quite a lot of higher education is stuck in this model, where we continue to act as if it is AD 1350, and it is entirely plausible for a person to learn everything there is to know about every theoretical subject in 4-5 years of close study. We ignore the fact that most technical fields have expanded so much that it is only possible for a person to thoroughly grok a small sliver of it until late in the career. We train doctors who are hypothetically supposed to absorb *all* of medicine in 4 years -- and then, of course, they specialize and receive their real training as interns and residents (and sometimes fellows) in order to *actually* become experts in some area or another. For that matter, the college degree that precedes it partakes of the same delusion: you get a "general" education that farcically purports to teach you most of what is known (or even more dubiously "how to think" as its proponents put it), and even if your career intentions are already well-formed, it's not until 1-2 years into this expensive sabbatical from productivity that you even start to buckle down to learning what you'll need to learn for useful specialization.
It's very expensive, and of course inefficient, since the basic model, of the Renaissance Man who knows most everything, just in case, but necessarily specializes in order to contribute usefully to a highly specialized labor economy, is inherently mismatched to reality.
You can see struggles to change -- the very existence of jobs like PA, NP, or nurse anesthesiologist is evidence of this, as is stuff like BS-MD programs that combine a college and medical degree into one 6-year program. Or even the "coding bootcamps" that allow people to get into programming without the time and $$ investment of a 4-year degree, in which they have to write some papers on Shakespeare and the history of opera along the way.
Economic efficiency certainly suggests an expansion of the ability to specialize earlier and a recognition that measured ability in *this particular skill* needed for *this particular job* would be more efficient than requiring some bulky opaque "general competence" credential, like a degree. (There are higher-ed mavens who dream of a future in which the weighty one-size-fits-all general competence degree is replaced by a sheaf of "micro-certificates" that are each quick to earn, and focus narrowly on certain useful skills.)
But. The purpose of education isn't *just* to turn people into efficient economic cogs, it also has a human purpose. It exists to enlighten and enrich the individual human spirit. It allows us to at least sip of the heady nectar of wisdom (or at least understanding) gathered slowly, sometimes painfully, drop by drop by generations before us. If it is to be *just* job training, there is some risk of movement towards the Brave New World ideal, in which we are all bent like human bonsai towards some useful niche in the giant social machine from very early on, as soon as our stubby little fingers can click the mouse on the aptitude exams, and our chances to be free and unique are that much more hamstrung. All those kids who got into programming via bootcamps -- what if they decide in their 30s that they hate coding, and would like to write or become an opera critic instead? They have no basis at all for the switch, there is no remnant of a general education, however shallow, that can be a platform from which to launch. That's certainly efficient, because giving *everyone* a platform only a tiny minority will ever actually use is inefficient. But there's a human, spiritual cost, that should perhaps not be overlooked entirely.
I don't have any good answer to this, or even a way to assess the costs each way. I studied a lot of stuff in my school days that had absolutely no use in my career. Foreign languages, macroeconomics (ha ha), Medieval history, some odd stuff on music and religion and astronomy. All a gigantic waste of my college tuition dollars and time, in one sense. But I also cherish that stuff. I feel like having been exposed, at least, to these aspects of the vast human enterprise, makes my understanding of the world and of the human state less shallow. It never did boo to make me a more efficient producer, but it made me a happier human being, perhaps a more nuanced and interesting one.
Certainly rich people will always have the luxury of indulging any random curiosity. I hear Kim Kardashian studies law, just because she feels like it, and she can easily afford to do it for grins, because she's rich. But it would be a shame if *only* the rich were able to indulge the broad-spectrum curiosity with which we're nearly all born.
Don’t mean to sound obsequious, Carl, but just the pleasure of reading your long, long comments is enough to justify having a blog. Your comment is dense with interesting, compelling, not-at-all-obvious arguments. Nothing specific to add beyond that.
That's very kind of you, thank you. In return I'll offer that I like your blog in no small part for its wide and even eclectic range of interests, fearless originality, unfailing courtesy, and it's pleasant to have the opportunity to drop a stray thought or two into the soup.
Good ideas from both of you. How to reduce costs while improving health care, and education. You see people in both fields trying new methods for reaching people through technology. Things like Khan Academy or what Hillsdale College is doing in education (Khan Academy working more the micro credential side while Hillsdale College is working more the general education side). And you have various online initiatives by Cleveland Clinic or Mayo Clinic on the health care side and things by individuals like Dr. Brownstein trying to do more holistic, preventative care. (I'm merely giving examples rather than recommendations--I'm sure there are plenty more.) And I'd add a another issue, how do you filter out the kooks--without also filtering out the geniuses who don't happen to fit in? I suspect the best answer is to let the market play out, but then that gets back to Robert's original post: how do you get the government out of the way when there are vested interests who want to make sure the government stays in the way?
One thing that might help break the power of the regulators is the way that COVID dissenters have been treated. Doctors and Pharmacists who have been de-certified by the "professional regulators" because they didn't toe the line on COVID.
The elites - billionaires and powerful people, Hollywood types - are given a choice.
Do they choose MDs, or APPs?
Before I answer, what is an “APP”? Some variation on APRN? Computer app? Forgive me if the answer is obvious.
Perhaps, from Sonny Morton's comment on 10/10, Advanced Practice Providers?
I'll go with that.
Since, for them, time and health really is money, they probably usually go with the credential, both to reduce the time searching for a professional to work with and to ensure quality. But I suspect that if you were to do a serious survey, (or just keep your eyes open for it), you'd find a non-trivial number of them are choosing APPs for some purposes.
So, I'll assume APP=Advanced Practice Provider. Here's my take:
(1) Billionaires, powerful people, Hollywood types are not necessarily the best guides to optimal care.. Their wealth gives them freedom to indulge their hypochondria and fad-mania. Many go for exhaustively comprehensive check-ups and screenings that brim over with false positives and iatrogenic illness and injury from unnecessary treatments.
(2) Billionaires and Hollywood types also drive Maseratis and fly LearJets, and it makes no sense to pass laws limiting folks in rural Mississippi to Maseratis and LearJets for their driving and flying needs. And yet, health policy wonks unconsciously make an equivalent error. Some years back, I wrote, "The Unintended Elitism of Health Care Policy" (https://insidesources.com/unintended-elitism-health-care-policy/), in which I said: "The biggest problem with health care policy may be that those who design health care policy mostly design it for people who design health care policy." My MD/APRN article was especially focused on expanding care in areas that are not populated by billionaires and Hollywood types.
(3) One reason that healthcare is scarce in rural areas is because doctors know they can make WAAAY more money in places that do have billionaires and Hollywood types, or at least in places full of millionaires and white collar types.
The tale of Steve Jobs's final illness is a sobering illustration of your point (1).
It certainly is. Thanks.