Is there a relatively accessible work by Goldin to start me on?

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Oct 11·edited Oct 11Liked by Robert F. Graboyes

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.

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We can take this on one step at a time. APRNs and CRNAs do have a BS, so Carl’s very interesting concerns about narrow knowledge are a long way into an uncertain future. More immediately, the fact that the various states differ so widely in their treatment of advanced practice providers tells us that there is something more than educational philosophy involved. The guild interest is quite strong in some states, not so much in others.

This one seems solvable. First, trust patients. They want the same thing we all want, good care at an affordable price, and absent fraud they will figure it out. Give them the chance. Second, in a bow to political reality, states that have not yet removed the shackles from APPs should couple a relaxation of oversight rules with a (funded) prospective study of outcomes including quality of care, cost of care, geographic distribution of providers, etc. A couple of rigorous studies should answer the questions.

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Oct 14Liked by Robert F. Graboyes

The elites - billionaires and powerful people, Hollywood types - are given a choice.

Do they choose MDs, or APPs?

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