What's the difference between matter and antimatter?
If you ask a physicist, they'll tell you that a particle and its antiparticle are exactly identical in every way, except for a few specific properties, where they're exactly identical in every way except for being oriented in the opposite direction. And if they ever come together, a violent explosion occurs.
This is the best paradigm I've found for understanding "anti-racism" and "anti-fascism."
Big difference: In physics, under certain circumstances, parity does not hold--there are objective criteria by which one can distinguish matter from antimatter. (i.e., broken symmetry). Not so in the other two cases that you mentioned.
Martin Makary, a professor of surgery at Johns Hopkins, estimated the number of deaths from medical errors at 250,000 annually in the USA. From 2000 to 2021, not counting the terrorism of 9/11, there were 19 deaths in commercial aviation. Since your doctor is vastly more likely to kill you than your airline pilot and since you have some choice about doctors but merely Hobson's choice about airline pilots, it makes sense to be much more selective about your doctor than your airline pilot.
Ahhh. Yeah, we dealt with that one quite often. The relevant question is whether the attempts at due diligence with physicians actually does much to alter your odds of survival. We would have long discussions about that, and we would generally come down to “probably not a lot of difference.” Generally, opinion would swing around to the due diligence really doing more on the comfort-with-intimacy side. The other aspect of those discussions was that airlines and insurers have been set up in a way that does that due diligence for you in a really effective way. In medicine, we have established institutions that force patients to do due diligence that would be better handled by professionals in a more fully functional market. Another aspect is that 40+ years ago, your chances of dying in a plane crash were roughly 100 times the likelihood today. But even then, people didn’t check into the pilot beforehand.
If medicine would adopt the model that aviation used to reduce the mortality risk 100 fold in 40 years, patients might trust doctors more.
And as a pilot -- the public is being perfectly rational in not requiring individual inspection of the captain’s and FO’s bona fides. (And do remember on all but the smallest charter revenue flights there are two pilots in the cockpit -- one significantly junior to the other usually -- and you the passenger have no idea, or say over, which one is flying the current leg.) But I personally know commercial pilots that I wouldn’t fly with for love or money. Those kinds of pilots usually end up flying cargo, ag, or banner tow.
I’ve written a number of pieces on the similarities and dissimilarities between medical and aviation training, licensing, and regulation. I’m much happier with how aviation has progressed. I should have a little something g more on it next week coming out at a think tank. When I first started in economics, I said to a friend/ flight attendant that I assumed the most important safety device on the plane was the pilot’s desire to get home safely. She just looked me dryly and said “You haven’t met very many pilots, have you?”
I'm not sure how widely known it is that for several decades the medical specialty of anesthesiology has been consciously adopting safety practices from the field of aviation. A summary of the history can be found at https://www.apsf.org/about-apsf/apsf-history/ (APSF in that URL stands for Anesthesia Patient Safety Foundation).
I've long wondered why the rest of medicine couldn't make more of an effort to imitate the anesthesiologists.
Interesting! Next week, I’ll publish a four-part conversation with a nurse anesthetist and an MD who once supervised NA’s. Part of our conversation will involve what medicine can learn from aviation. Both of my colleagues have been amateur pilots. But I don’t believe the specific topic that you mentioned came up. When the think tank publishes the pieces, I’ll mention in Bastiat’s Window.
I'm a trauma surgeon and private pilot. The medical field has had numerous spares of trying to apply airline safety policies to the practice of medicine. There are multitudinous barriers and some good reasons why it has failed to take hold. The biggest is the professional liability system that focuses liability on the one person that currently has little to no power to change the systemic problems. The fact that there is no legal protection for errors found in root cause analysis (probably because unlike pilots physicians do not suffer from their own mistakes) makes shielding them from liability unpalatable.
Much of hospital medicine is emergent. It is less like a planned trip than a Battle of Britain era scramble to intercept. Scrubbing a case because of a perceived problem is almost never an option in my line of work (trauma and emergency surgery).
The doctors rarely work for the hospital directly. The nurses don't work for the doctors. The anesthesiologist and the surgeon aren't in the same group. Who gets to enforce safety protocols?
I would counter that if your metric is “I didn’t have a horrible experience with this surgery” the important factor is the nurses who will be caring for you post-op. I learned my lesson -- I chose an ob-gyn surgeon to do my radical hysterectomy, but didn’t check out the hospital where it would be performed. Sure, the surgery went great. And then I had to endure 48 hours of being attended to at my most vulnerable by the most hostile women I have ever encountered.
I had extensive back surgery -- a 5-vertebra fusion. I'm relatively good at handling pain. But there was one nurse who seemed to enjoy slow-walking my pain meds. The others got them to me right on schedule. That one waited until I rang for help. Looked at my chart, and came back anywhere from a half hour to an hour later. I can only assume she was a sadist.
When my wife and I were going through childbirth training, our classes were taught by a really intimidating nurse who insisted that the expectant mothers should avoid pain-killers. To practice dealing with pain, she had the partners squeeze the expectant mothers' Achilles tendons really hard. My wife--who had a pretty daunting 44-hour labor--said that tendon-pinching gives her worse memories than the memories of giving birth. The nurse had not gone through childbirth herself, and we did joke that she seemed to rather enjoy watching the tendon-squeezing episodes.
Excellent point! Poor follow-up can kill you as surely as a bad turn of the scalpel. And yet, people aren't checking up the credentials of the night nurse.
I suspect some of the difference comes from the fact that pilots are doing things that are incredibly similar, over and over. (Pilots stick to one kind of plane and a relatively few routes for many years sometimes.) OTOH, in most cases humans vary enough that every experience by the doctor is somewhat new. The number of known and unknown variables that can mess up an operation would seem to me to be many times larger than the variables in the vast majority of flights.
EXACTLY! And that was one of the points of the exercise. To ask, "If we really don't believe that patients' research materially alters to outcomes, then why do they do it?"
I believe there is a certain unspoken, or perhaps even instinctual belief that the pilot is operating with the same set of beliefs that we, his passengers hold about the value of life. When a doctor screws up, it is only the patient who bears the brunt of the mistake and the doctor goes on about her merry way. We passengers understand that if the pilot screws up, he will die along with us, so we tend to assume his level of expertise without a full investigation, trusting that his skills are equal to the task at hand, given that he is also depending on those skills to stay alive while defying the law of gravity. Or so it seems to me.
I'll repeat what I said in a previous comment: "When I first started in economics, I said to a friend/ flight attendant that I assumed the most important safety device on the plane was the pilot’s desire to get home safely. She just looked me dryly and said 'You haven’t met very many pilots, have you?'”
1. That's a load of bull. 2. It doesn't matter because the perception of the passengers is what determines their desire to perform "due diligence" and most of us (despite the flight attending's black humor) are pretty sure the pilot and/or copilot don't want to die at any particular time.
Not bull at all. 50 years ago, flying was 100 times riskier, and pilot error was often a cause. Yeah, they wanted to get home, but they were also human. And planes back then had far fewer fail-safe mechanisms. (And astonishingly, when I think about it, my conversation with the flight attendant took place close to half a century ago, when many of the safety improvements were just beginning to be developed.) The aviation industry has done an incredible job of analyzing the causalities and imposed preventive mechanisms. Pretty sure that doctors don't want to lose their licenses or pay out gigantic settlements, but they still do stupid shit that causes them to do that. Look--the point of my classroom discussions was never to take my query literally. The point was to tease out the highly complex chains of causality and to understand the incentives that liability insurers have placed on airlines but not on medical institutions. And why that's the case. The obvious answers aren't always the best. In 2023, I do a lot of research on the doctors who treat my family. I don't do any research at all on pilots, or airlines for that matter. With the latter, I am a free rider on a lot of more knowledgeable sets of eyes. Medicine has fallen short on developing that safety panopticon with its employees. And lots of it comes from the institutional arrangements in place.
Thanks for another thoughtful post. Leave it to the pragmatic, hands on wisdom of the nurse to have the answer! BTW, I don’t inquire about the pilot as I board an aircraft, but I often glance at the ID plate in the door to see how old the plane is...
The age of the plane tells you less than you might think. While catastrophic commercial airline failures are now rare events, it’s surprising how many of ones that do happen as a result of mechanical failure are not due to gross failure events like airframes coming apart, vs. pilots losing control of a highly computerized fly-by-wire system whose failure modes they do not understand.
I recall the circumstances of Air France Airbus crash after leaving Brazil. Junior pilot was so used to the computer making decisions that he didn’t know how to handle a quite manageable anomaly.
I spent years flying on Soviet-built aircraft inherited by the the baby-flots. I experienced a lot of in-flight anomalies, which were concerning at first, and I was quite aware of the various airline safety records, but on a flight once to some Stalinist backwater, I remembered a quote from Saving Private Ryan. “Sergeant, we have crossed some strange boundary here. The world has taken a turn for the surreal.” I realized I found some bizarre comfort in the fact that there were rarely survivors on the baby-flot crashes.
Unless things change and the Maoist worldview that so many formerly trusted institutions have adopted is discarded, we are back to where I was, metaphorically speaking, when that ramshackle old TU-154 started making loud, metallic clanking sounds at 20,000 feet.
Great stories. My somewhat equivalent story was being stopped on a pitch-black roadway in Liberia by a group of soldiers, shouting frantically in a language I didn't understand, with the muzzles of their machine guns protruding through the car windows. If some stranger pulls out a pen-knife as I walk down the street at night, I'm likely to quickly cross the street and quake and quiver. In that car in Liberia, I didn't feel the slightest worry. Afterward I wondered why and concluded, "Because over here, I feel like I'm just watching myself in a movie. Nothing here seems real." Everything there was a turn for the surreal, and it was somehow entertaining to watch.
I experienced the same sensation, like watching the scene from the outside looking in. I was carjacked in Maputo once at gunpoint. They forced us face down on the road and held guns against the back of our heads. I seemed to visualize the entire event from a short distance away.
Three of my colleagues were stopped at a roadblock in Liberia on their way to a project location, executed, and burned along with their vehicle back in 2003. When I heard about it, I felt as if it happened right in front of me.
How tragic. I meant to add (but got distracted) that the soldiers shouting and waving machine guns were simply pleading with us to take a woman in a labor to the hospital in Monrovia, around 30-35 miles away. I simply told the driver, "Go as fast as you can without killing us." We got her there in time.
I think you've got it wrong. The reason we don't vet pilots is that pilot-induced death is extremely rare. Extremely. Just not worth worrying about. See how that works?
Nice argument. In class, the conversation always turned in the direction, but it's ultimately unsatisfying. It begged a series of followup questions. The question is not what is the baseline risk, but rather what is the impact of consumer due diligence on that risk? Does checking up on the surgeon's ratings really alter your risk? If so, did you check up on the anesthesiologist's ratings, and if not, why not? Did you check up on the rate of hospital-borne infection, which likely presents greater risk than the surgeon? Did you check on the quality of the nurses? Or the overall survival stats for the hospital? And, while the risk of air fatality is low today, were you any more diligent 40 years ago, when the risk of death while flying was 100 times higher than today? And do you do similar due diligence on the guy who repairs your brakes, the one who installs your gas pipes, or the one who drives your bus around treacherous cliffside roads in California? Surgeon versus pilot was really just the conversation starter on how we evaluate risks and whether those evaluations do much good. The fact is that I check up our surgeons, and I don't check up on our pilots--and I never suggested to students that that was irrational. I wanted them to dig down into how we structure and analyze data and how (and whether) we mitigate risks.
I pay pretty close attention to the guy who works on my vehicles. But I think you are leaving out the fact that you don't get to spend 20 minutes talking to the pilot, and you probably wouldn't learn much if you did. The reason the rate of plane failures matters is that we trust the airlines to vet their pilots. They have skin in the game.
As I’ve noted here, anecdotally, pilots may pay less attention to their skins than we like. But you have hit on the head one of the points I made with the classes. The airlines do heavy duty vetting of pilots and equipment. Medical institutions are more relaxed and allow doctors to practice in ways that wouldn’t be tolerated in aviation. The question to the class was “Why is that the case?” Are hospitals incapable of vetting doctors as well as airlines are of vetting pilots?
I was referring to the airlines, not the pilots, having skin in the game. If hospitals had to pay out tens of millions of dollars every time one of their patients died, they would be a lot pickier about doctors AND patients. And if university endowments were on the hook for your student loan, they would be a lot more careful about the majors they offered, and the students they admitted.
YESSS! I didn't spoon-feed the students answers. I challenged them and let them wend their way around. This was one of the answers I always wanted them to discover on their own. Earlier this year, I reused an article I wrote back in the 1990s: "Old West Derivatives" (https://graboyes.substack.com/p/old-west-derivatives). It was a short story about a late-19th century cattle-driver devising a contract with a rancher to move 1,000 head of cattle through the Mexican desert into Texas. The 5th principle embodied in the contract was "Risk of lost cattle: The journey is dangerous for the cattle. They can drown, they can fall prey to disease or predators, they can be stolen by bandits, or they can just wander off. The rancher wants to provide extra incentive for taking good care of the herd, so he offers a 100-peso bonus if fewer than 2% (20) of the cattle are lost. Once the 2% threshold is passed, the rancher begins to deduct 25 pesos from the bonus pay for each head lost. So, if losses get near that 2% mark, the driver has a huge incentive to prevent further losses. The rancher knows that even the best driver is almost certain to lose at least five head, so he offers the driver an extra five cattle to take along. So, the driver is really transporting 1,005, and not 1,000." So the penalties for losing cattle are initially small--because ANY driver will lose some cattle. But the driver knows that if his losses grow too large, he will begin to suffer BIG penalties. Imagine a hospital that said, "We know there will be around ten big malpractice cases in the next year. That's normal. Errors happen. But if it goes OVER ten, the hospital's owners and employees will suffer big financial losses." You would have a VERY different dynamic with respect to malpractice.
Given a patient's desire for comfort with a physician, it isn't surprising to find that patients may prefer physicians who share whatever identities (ethnic, political, religious, gender, whatever) the patient deems important. (Ask a male ob-gyn.) That doesn't change the physician's obligations but the patient has taken no such oath. This desire on the part of patients makes the issue of race in medicine more fraught than it might be in other fields. I don't have a good alternative. I'm just saying it's complicated.
I've long thought that there should be a policy of waiving all student fees (or debts) for those in medical fields who are living kidney donors. Aside from alleviating the dire shortage of kidneys, such a policy would give budding young doctors, nurses, etc., direct experience as hospital patients in an ideal situation where they're healthy.
I can think of good reasons for kidney donors, liver donors, etc. It's a lot easier to be a marrow donor, and waiving fees and debts for anyone willing to donate marrow would probably become extremely expensive. I never donated marrow, but offer my $300,000 in waived debts, and I'll say "Start drilling." Offer me the same to donate a kidney, and I would likely balk.
The idea came out of my experience first as a kidney donor with no previous encounters with hospitals and then as a cancer patient. If you're healthy, being a kidney donor is the world's easiest good deed. The hardest part is persuading people that you should go forward with it. People grossly exaggerate the risks.
During my subsequent experience as a cancer patient, I was very grateful that I'd experienced hospitals, tests, and surgery under less stressful circumstances.
Really interesting. And, one more case of why the best ideas often come from laypersons. I read your article when it first came out and loved it dearly. (I'll also note that I was especially pleased to hear from both you and Sally after writing this article.) Your statement here exhibits courage and modesty that most of us lack. I do think a kidney donation is a more substantial decision than a marrow transplant. One is, so to speak, a renewable resource, and the other is not. There's essentially zero probability that you'll come to regret a marrow donation 20 years later. There's some nonzero probability with respect to a kidney. So, I really admire what you did. You gave a remarkable gift.
Over the past 20 or so years, I've had (Asian) Indian doctors, a Romanian, an Iranian doctor (he was really good and we got to become friends), a Black doctor, an Italian doctor, a couple of Jewish doctors, at least one Chinese doctor, and others that I don't really recall. All I'm looking for is competency.
Many years ago possibly the best doctor I ever knew practiced in a small town (pop. 1100) and was as cranky as House (this was way before House) who also got lots of calls for diagnosing unusual cases. He had a nation-spanning reputation in the 1980s for diagnostic ability over the phone when there was no web. He was great, he was just basically a small town guy who enjoyed practicing in a small town.
I suspect a huge percentage of U.S. doctors will be coming in the near future from foreign countries and foreign medical schools. My family doctor, too, was a local character with astonishing diagnostic abilities. You can read about him here: https://graboyes.substack.com/p/innovation-as-bush-fire
Sep 4, 2023·edited Sep 4, 2023Liked by Robert F. Graboyes
I think a key point is that humans, in general, are problem-solvers, tinkerers (is that a word?), innovators WHEN the social/governmental system let them be.
It has been mentioned many times that China lagged behind the West for centuries despite their innovations like gunpowder and moveable type. Their 'systems' routinely clamped down in order to maintain the existing systems.
We KNOW this, and yet allow the same pattern to continue. Innovation is disruptive, and the people who benefit from stable systems know that (consciously or not), hate and fear disruptive change, and thus hobble it as much as possible.
Agree with everything in paragraph 1. Civil Rights laws prohibit employers from discriminating on the basis of race when selecting employees. They do not prohibit employees from choosing employers on the basis of race.
Your kidney donor idea is interesting. I'm guessing you know all about Gary Becker's long-ago proposals for giving priority in transplant queues to those who have pledged to donate their organs. This takes those incentives to a whole different step.
Sep 2, 2023·edited Sep 2, 2023Liked by Robert F. Graboyes
Gary Becker's idea is exactly the overly clever thinking one gets from a theorist with no knowledge of how things actually work. Telling people they can't get a kidney unless they've previously pledged organs in case of death would do nothing to increase the supply of organs. (Living donors are in fact prioritized in the highly unlikely event that they later need a kidney.) The main constraint is that people have to die in exactly the right circumstances, followed by the practical constraint that their relatives have to agree (regardless of what they've said in advance). So you would have adopted a cruel, arguably unethical policy that accomplishes nothing except letting free-market smarties feel smart. The other idea much beloved of people with more IQ points than knowledge is "presumed consent," in which the law declares that organs will be taken from people who've died the right way regardless of their families' wishes unless they've previously explicitly said no. If you want to know why this would be a disaster in the U.S., you should read Michele Goodwin's Black Markets (highly recommended given your interests). But it's also not as successful in Spain, the case always cited, as people think. What really makes a difference is well-run donation centers. Kieran Healy is the person who has researched this: https://kieranhealy.org/publications/presumed-consent-law/ and https://kieranhealy.org/publications/altruism-asr/. He also has a book, which I reviewed in the NYT: https://vpostrel.com/articles/grim-harvest
You’ve had far more reason than I to think deeply about these issues. If I recall correctly, Becker was fairly modest about his idea. He said there were some legitimate reasons for concern about cash payments for organ donations. But he wanted to suggest that cash payments were not the only ways to incentivize donations. I haven’t read his WSJ in decades, but it seems to me he said there (or in followup discussion) something to the effect of “That’s one idea, come up with others.” I think he also acknowledged the practical problems implicit in enforcing “contracts” to donate. I will happily look into some of your recommendations. But I’ll still tip my hat to Becker for exploring the issue before it was on a lot of people’s radar screens. I think he started talking about this not much more than a decade after UNOS was founded.
Sep 2, 2023·edited Sep 2, 2023Liked by Robert F. Graboyes
To be fair to Becker, this may be the first time I've seen the idea attributed to him. I've heard it over and over and over and over from other free market types. There was actually an attempt to start some sort of registry to support this idea, but I've forgotten who did it or what the details were.
He's the first I heard it from. I hadn't realized that he was even interested in those questions, and he got a lot of attention from it. His idea led to a lot of interesting classroom discussions on the subject. I did my master's in health administration and then taught for 19 years at Virginia Commonwealth University. It was a point of pride there that UNOS had begun as kind of a regional, informal VCU project dealing with kidneys and then grew into the nationwide, all-organ, central clearinghouse that it became.
Sep 3, 2023·edited Sep 3, 2023Liked by Robert F. Graboyes
Obviously you speak in jest, since the subsequent New York Times headline ("The Only Way This Black Single Mother Could Go To Medical School Was By Giving A Kidney") is 100% predictable. The only way your suggestion wouldn't outrage public perception is if *every* medical student had to donate a kidney first, and nobody could "buy" his way out of it, which would certainly help with the kidney problem and winnow the field of med school applicants considerably more than sophomore organic chemistry already does -- indeed perhaps a bit too much.
Beyond that, my personal opinion is that you may overvalue experience and undervalue character here. My suspicion is that people of good character empathize sufficiently that indirect experience is generally enough to give them the understanding desired, while people of poor character won't draw any useful lesson from even the direct experience you suggest. Perhaps we should reconsider whether it was such a good idea, our several decade long gradual replacement of veneration of character or virtue with the veneration of skill or intelligence.
“Because my life was in his/her hands...” Did you ever ask your students if they knew anything about the anesthesiologist who worked their surgery? Because talk about putting your life in someone else’s hands...
In another comment, I mentioned that I have a think tank piece coming out over the next week. It’s a discussion I had with a nurse anesthetist and a urologist who used to supervise nurse anesthetists.
Asked to explain the differences between the surgeon and the pilot, the students—all medical professionals—struggled.
Med students? Hadn't they all passed through University courses in mathematics, as a condition of becoming med students? Were they so oblivious that they had never considered the very tiny probability that their single flight might crash, while millions of successful flights went well? The chance of disaster on a single flight is minute, and any person can take confidence that this one won't be different.
Now consider - where would you get a public record of probabilities of surgeries going wrong? It's not nearly as blatant of those plane flights. Those students who inquired about their individual surgeons were doing a very practical due diligence.
Sep 2, 2023·edited Sep 2, 2023Liked by Robert F. Graboyes
As a math undergrad, in grad school I got slapped down (in a nice way) by my stats prof (a Northwestern PhD) for wanting to know the underlying math. He told me, "not in class, but see me in my office." And he was quite willing to go deeply into the math. As a result I believe I understand complex structural equation models in ways that most users don't. But I could be wrong.
I taught a grad class public health policy for years, and thus read a lot of research by MDs. I tend to think they overestimate the power and usefulness of many of their methods when low numbers of cases or patients or respondents are used. I think most of them (not Wakefield, of course) mean well, but I still am hesitant to accept a lot of their conclusions. It doesn't help that 'reporters'/'journalists' with even less understanding then run with a ridiculous take. Maybe that's my real problem.
He was quite serious about the difference needed, in his belief, between math and stats. I have come to mostly agree with him. But I understand that may not be a majority opinion. lol
Great stuff. I'll note along these lines that when patients (like me) "research" a surgeon, our "study" consists of three minutes of usually-frustrating Googling and then asking three friends, "So who did you use when you had surgery?" What usually determines it for us is our PCP saying, "I know this guy. He's good."
These students were among the least oblivious humans I've ever known. Let me just repeat a response I posted to another commenter in this discussion: "In class, the conversation always turned in the direction [of MD=high-risk and airplane=low-risk], but it's ultimately unsatisfying. It begged a series of followup questions. The question is not what is the baseline risk, but rather what is the impact of consumer due diligence on that risk? Does checking up on the surgeon's ratings really alter your risk? If so, did you check up on the anesthesiologist's ratings, and if not, why not? Did you check up on the rate of hospital-borne infection, which likely presents greater risk than the surgeon? Did you check on the quality of the nurses? Or the overall survival stats for the hospital? And, while the risk of air fatality is low today, were you any more diligent 40 years ago, when the risk of death while flying was 100 times higher than today? And do you do similar due diligence on the guy who repairs your brakes, the one who installs your gas pipes, or the one who drives your bus around treacherous cliffside roads in California? Surgeon versus pilot was really just the conversation starter on how we evaluate risks and whether those evaluations do much good. The fact is that I check up our surgeons, and I don't check up on our pilots--and I never suggested to students that that was irrational. I wanted them to dig down into how we structure and analyze data and how (and whether) we mitigate risks." I do believe that much of our due diligence is really aimed at finding a provider whom we are at ease with, as opposed to trying to determine that provider's competence. Which is still a perfectly good reason to do due diligence.
I've noticed that lots of people are in favor of racism and other forms of discrimination when they are or expect to be the ones who benefit and not be the ones hurt. Odd thing, that.
I think there's a "Baptists and bootleggers" aspect to it. That term refers to the strange purported alliance of convenience by teetotalers and those manufacturing illegal liquor. The former favor prohibition out of a strong moral imperative. The latter favor prohibition because it's good for business. Same sort of thing here.
Having just watched all three "Godfather" films plus the miniseries about the making of the first ("The Offer"), I love your final sentence. As to your first two sentences, I'll post an anecdote that I've already given to two commenters: "When I first started in economics, I said to a friend/ flight attendant that I assumed the most important safety device on the plane was the pilot’s desire to get home safely. She just looked me dryly and said 'You haven’t met very many pilots, have you?'”
Actually the best answer to the: "Why due diligence for the "Doctor" and not the "Pilot" question is this: "Because the Doctor knows that if he screws up his life is not at risk, but the pilot knows if he screws up we all go down together."
Sep 3, 2023·edited Sep 3, 2023Liked by Robert F. Graboyes
I can think of two additional reasons why the cases of commercial pilots and physicians are different, in addition to the interesting one you adduce:
1. Free riding. We usually travel not only with one pilot but simultaneously with a copilot, a bunch of flight attendants, and a few hundred other passengers, many of whom have flown far more than ourselves. The fact that several hundred *other* people, including many with way more relevant experience, are trusting the pilot with their lives at the same moment we are asked to do so, may ease our concerns, or at least diffuse our sense of responsibility. I think it's generally a phenomenon among humans that we feel less need to justify our trust when we're doing it as part of a big group.
But of course when you hire a surgeon, it's just you on whom he's operating (at least at that particular time). It would be interesting to ask people to compare choosing a surgeon with hiring a private pilot to, say, fly the family on a remote vacation -- a situation where you are *not* making a collective trust decision. It would also be interesting to ask whether rich people vet the pilots they hire for their private aircraft as thoroughly as they vet their surgeons*.
2. A greater certainty of the quality of outcome. The pilots' metric of success is nearly unambiguous: in almost all situations, if the pilot does his job right, the airplane lands successfully. There are still a few cases where mechanical or ATC failure dooms a commercial flight despite the best possible decisions by the pilot, but they're relatively rare these days -- and even then we can usually tell, after the fact, that something went wrong. It's pretty rare that a plan crashes (or disappears like MH 370) and we have no clue ever whether the pilot screwed up or the plane was doomed through no fault of his.
But by contrast, serious surgery is inherently quite dangerous, and people die all the time from it even if the surgeon and team does everything right. Furthermore, surgery, indeed medicine in general, is so complex and subtle an art that whether or not the physician is doing the right thing is something that is very difficult to objectively decide. The best minds can easily differ on whether this or that was the right choice, and even on whether a given decision led or contributed or had no effect on a bad outcome. Does this surgeon have more deaths because he's an idiot or because he takes tougher cases? Thus the enormous medical malpractice industry -- malpractice lawyers wouldn't earn nearly as much money if it was straightforward to know whether a given physician in given circumstances screwed up or not. Which means the question of physicial skill seems inherently harder to answer than pilot quality, which makes the question of trust more fraught. We probably vaguely feel like really bad pilots crash and get ejected from the career, but pretty bad surgeons can fly under the radar, so to speak, and last long enough to (gulp!) be operating on us.
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* Indeed, the poorer we are, the more we perforce place our trust in institutions, because we just lack the resources to do the research needed to choose for our ourselves, and often have no real choice anyway. This points to yet another way in which those who want to inject racist ideology into medicine are committing evil: those who suffer the most from their distortions will be the poorest among us. We can be 100% sure that no matter how the institutions are distorted, Jeff Bezos will always hire the very best brain surgeon if his wife needs surgery. He will always have the resources to find and hire the best. So will all the rich people -- they don't *need* to trust that Harvard Medical produces first-rate physicians, or that board certification doesn't measure some skill in ideological bullshit instead of the scalpel, because they have the resources to vet the individual directly. It's those of us who can't afford to do so -- who lack connections, access, time and money -- who will suffer if the institutions are corrupted. And the poorest will suffer the most.
(1) Great explanation. Nothing equivalent in medicine. Imagine if the anesthesiologist, nurses, and hospital were all on the hook when an MD screwed up a case. And we did have some classroom discussions on people flying in private craft. I thought about it when my wife and I went flying around Denali in a helicopter. I wondered, "Who is this pilot, and why am I trusting him with my life?"
(2) This is true today. It was less true half a century ago, and I'm not sure people did any more due diligence back then.
(*) This section is quite impressive. And quite true.
I'm sure you're right, that medicine could improve significantly by adopting some of the methods other industries have used to improve outcomes, make them more measureable and optimizable. For that matter, it has always mystified me why medicine has historically been so much slower to improve than almost any other technology -- especially considering it is arguably the most important technology we have.
Certainly the Greeks and Romans could've done experiments to optimize nutrition and lifestyle factors, for example. It's somewhat absurd that we have to do trials in 2023 over questions like "Is intermittent fasting or a vegan diet good for life extension?" That's an experiment that could've been run any time in the last 5000 years, and surely should have been. The answer should today been known without possible quibble for centuries. Even some basic drug agents (e.g. salicylates for pain and inflammation relief) have been known and used for centuries, and could have been cultivated and refined with chemical techniques known as far back as the 1300s or so. Why did aspirin only become widely available at the end of the 19th century? Why is there this giant pharmacopeia of folk remedies about which we know surprisingly little with certainty? Does St. John's wort work or not? What about apple cide vinegar, flaxseed oil, plant sterols? What diet optimizes the health of the gut microbiome? None of these questions require sophisticated scientific instruments to answer. They should have been answered 500 years ago.
Then there's transmissable disease, a huge killer for much of history. Why did it take the actual images of micro-organisms for the germ theory of disease to be accepted, in the mid-1800s? As a species, we certainly had the ability to do the experiments necessary to understand that infectious disease was spread by some invisible but potent agent that traveled in cases by air, by droplets, by surfaces, or by blood. We could have understood enough to know when to impose quarantines, what kind, how long. We should have known by 1000 AD to wash our hands after attending sick people.
The failure to take even basic rational steps to understand the mechanisms of health and disease, ven those needing no scientific instrumentation at all, just cool reasoning and experimentation, for a thousand years -- several thousand, if we include ancient civilizations -- is sort of baffling.
My vague thought is that it's *because* it's so important. I hazard that medicine is so extremely conservative, and has even been secretive about its outcomes for so long, *because* it's so important for people in general to believe it's as good as it can be. Even today, if I went to my physician and she were to cheerfully say "Oh! We don't know exactly how to optimize your treatment for Problem X, but there's a giant study on it, in which I'm participating, and I'm going to randomly try Solution Y, which sort of seems reasonable to me, and we'll report up to the data banks how it works out" -- I might be a little dismayed, or at least, I feel like I would be if I weren't already old enough to be skeptical about how much medicine can do anyway. We already have a hard time recruiting people into clinical trials, and in many cases these are people who pretty much have very little to lose. It may just be that holding the two thoughts in one's head simultaneously (1) I am very sick, could die, and (2) the establishment doesn't know exactly what to do about it, provokes so much cognitive dissonance that we can't handle the internal strain. We can only contemplate the importance of improving medicine (thought #2) when we are not sick (no thought #1) -- in which case the urgency we feel is low.
Once, the Hippocratic Oath meant something...over the last 50 years I have seen it largely ignored, derided, abandoned, and replaced by meaningless piles of unicorn feces...The primary motive for becoming a physician today is greed and proving yourself more 'woke' than your colleagues. Scientific articles in medicine are untrustworthy, and residents are more interested in time off than patient care...The entire profession, including nursing and paramedical professionals are more adept at nursing their computers than taking care of patients...sad, so sad...
The reason I don't need to check my pilot as I do my surgeon is that if the pilot messes up, they're going down with me and the plane. The surgeon, on the other hand, has malpractice insurance and will live to slice again...
That is the obvious, simple, and woefully inadequate answer that usually starts to conversation off. :) it’s exactly what I said in 1980 to an old girlfriend who was a flight attendant and I was the oh-so-sophisticated econ grad student. She just looked blankly at me and said, “You haven’t met very many pilots, have you?” Glance through some of the comments already posted here, and come back with more. :) of course, your point (my point in 1980) has some validity, but there are many more layers to explore. Great to see you here.
What's the difference between matter and antimatter?
If you ask a physicist, they'll tell you that a particle and its antiparticle are exactly identical in every way, except for a few specific properties, where they're exactly identical in every way except for being oriented in the opposite direction. And if they ever come together, a violent explosion occurs.
This is the best paradigm I've found for understanding "anti-racism" and "anti-fascism."
Big difference: In physics, under certain circumstances, parity does not hold--there are objective criteria by which one can distinguish matter from antimatter. (i.e., broken symmetry). Not so in the other two cases that you mentioned.
Martin Makary, a professor of surgery at Johns Hopkins, estimated the number of deaths from medical errors at 250,000 annually in the USA. From 2000 to 2021, not counting the terrorism of 9/11, there were 19 deaths in commercial aviation. Since your doctor is vastly more likely to kill you than your airline pilot and since you have some choice about doctors but merely Hobson's choice about airline pilots, it makes sense to be much more selective about your doctor than your airline pilot.
Ahhh. Yeah, we dealt with that one quite often. The relevant question is whether the attempts at due diligence with physicians actually does much to alter your odds of survival. We would have long discussions about that, and we would generally come down to “probably not a lot of difference.” Generally, opinion would swing around to the due diligence really doing more on the comfort-with-intimacy side. The other aspect of those discussions was that airlines and insurers have been set up in a way that does that due diligence for you in a really effective way. In medicine, we have established institutions that force patients to do due diligence that would be better handled by professionals in a more fully functional market. Another aspect is that 40+ years ago, your chances of dying in a plane crash were roughly 100 times the likelihood today. But even then, people didn’t check into the pilot beforehand.
If medicine would adopt the model that aviation used to reduce the mortality risk 100 fold in 40 years, patients might trust doctors more.
And as a pilot -- the public is being perfectly rational in not requiring individual inspection of the captain’s and FO’s bona fides. (And do remember on all but the smallest charter revenue flights there are two pilots in the cockpit -- one significantly junior to the other usually -- and you the passenger have no idea, or say over, which one is flying the current leg.) But I personally know commercial pilots that I wouldn’t fly with for love or money. Those kinds of pilots usually end up flying cargo, ag, or banner tow.
I’ve written a number of pieces on the similarities and dissimilarities between medical and aviation training, licensing, and regulation. I’m much happier with how aviation has progressed. I should have a little something g more on it next week coming out at a think tank. When I first started in economics, I said to a friend/ flight attendant that I assumed the most important safety device on the plane was the pilot’s desire to get home safely. She just looked me dryly and said “You haven’t met very many pilots, have you?”
I'm not sure how widely known it is that for several decades the medical specialty of anesthesiology has been consciously adopting safety practices from the field of aviation. A summary of the history can be found at https://www.apsf.org/about-apsf/apsf-history/ (APSF in that URL stands for Anesthesia Patient Safety Foundation).
I've long wondered why the rest of medicine couldn't make more of an effort to imitate the anesthesiologists.
Interesting! Next week, I’ll publish a four-part conversation with a nurse anesthetist and an MD who once supervised NA’s. Part of our conversation will involve what medicine can learn from aviation. Both of my colleagues have been amateur pilots. But I don’t believe the specific topic that you mentioned came up. When the think tank publishes the pieces, I’ll mention in Bastiat’s Window.
I'm a trauma surgeon and private pilot. The medical field has had numerous spares of trying to apply airline safety policies to the practice of medicine. There are multitudinous barriers and some good reasons why it has failed to take hold. The biggest is the professional liability system that focuses liability on the one person that currently has little to no power to change the systemic problems. The fact that there is no legal protection for errors found in root cause analysis (probably because unlike pilots physicians do not suffer from their own mistakes) makes shielding them from liability unpalatable.
Much of hospital medicine is emergent. It is less like a planned trip than a Battle of Britain era scramble to intercept. Scrubbing a case because of a perceived problem is almost never an option in my line of work (trauma and emergency surgery).
The doctors rarely work for the hospital directly. The nurses don't work for the doctors. The anesthesiologist and the surgeon aren't in the same group. Who gets to enforce safety protocols?
It's kind of a mess really.
These are among the top things I wanted the students to realize in the course of our discussions.
I would counter that if your metric is “I didn’t have a horrible experience with this surgery” the important factor is the nurses who will be caring for you post-op. I learned my lesson -- I chose an ob-gyn surgeon to do my radical hysterectomy, but didn’t check out the hospital where it would be performed. Sure, the surgery went great. And then I had to endure 48 hours of being attended to at my most vulnerable by the most hostile women I have ever encountered.
I had extensive back surgery -- a 5-vertebra fusion. I'm relatively good at handling pain. But there was one nurse who seemed to enjoy slow-walking my pain meds. The others got them to me right on schedule. That one waited until I rang for help. Looked at my chart, and came back anywhere from a half hour to an hour later. I can only assume she was a sadist.
When my wife and I were going through childbirth training, our classes were taught by a really intimidating nurse who insisted that the expectant mothers should avoid pain-killers. To practice dealing with pain, she had the partners squeeze the expectant mothers' Achilles tendons really hard. My wife--who had a pretty daunting 44-hour labor--said that tendon-pinching gives her worse memories than the memories of giving birth. The nurse had not gone through childbirth herself, and we did joke that she seemed to rather enjoy watching the tendon-squeezing episodes.
Excellent point! Poor follow-up can kill you as surely as a bad turn of the scalpel. And yet, people aren't checking up the credentials of the night nurse.
I suspect some of the difference comes from the fact that pilots are doing things that are incredibly similar, over and over. (Pilots stick to one kind of plane and a relatively few routes for many years sometimes.) OTOH, in most cases humans vary enough that every experience by the doctor is somewhat new. The number of known and unknown variables that can mess up an operation would seem to me to be many times larger than the variables in the vast majority of flights.
Excellent point. Of course, it still begs the question, "But does the patient's due diligence and research actually impact the odds materially?"
I'd guess not, except perhaps it makes the patient more relaxed, which would seem to be a good thing.
EXACTLY! And that was one of the points of the exercise. To ask, "If we really don't believe that patients' research materially alters to outcomes, then why do they do it?"
I believe there is a certain unspoken, or perhaps even instinctual belief that the pilot is operating with the same set of beliefs that we, his passengers hold about the value of life. When a doctor screws up, it is only the patient who bears the brunt of the mistake and the doctor goes on about her merry way. We passengers understand that if the pilot screws up, he will die along with us, so we tend to assume his level of expertise without a full investigation, trusting that his skills are equal to the task at hand, given that he is also depending on those skills to stay alive while defying the law of gravity. Or so it seems to me.
I'll repeat what I said in a previous comment: "When I first started in economics, I said to a friend/ flight attendant that I assumed the most important safety device on the plane was the pilot’s desire to get home safely. She just looked me dryly and said 'You haven’t met very many pilots, have you?'”
1. That's a load of bull. 2. It doesn't matter because the perception of the passengers is what determines their desire to perform "due diligence" and most of us (despite the flight attending's black humor) are pretty sure the pilot and/or copilot don't want to die at any particular time.
Not bull at all. 50 years ago, flying was 100 times riskier, and pilot error was often a cause. Yeah, they wanted to get home, but they were also human. And planes back then had far fewer fail-safe mechanisms. (And astonishingly, when I think about it, my conversation with the flight attendant took place close to half a century ago, when many of the safety improvements were just beginning to be developed.) The aviation industry has done an incredible job of analyzing the causalities and imposed preventive mechanisms. Pretty sure that doctors don't want to lose their licenses or pay out gigantic settlements, but they still do stupid shit that causes them to do that. Look--the point of my classroom discussions was never to take my query literally. The point was to tease out the highly complex chains of causality and to understand the incentives that liability insurers have placed on airlines but not on medical institutions. And why that's the case. The obvious answers aren't always the best. In 2023, I do a lot of research on the doctors who treat my family. I don't do any research at all on pilots, or airlines for that matter. With the latter, I am a free rider on a lot of more knowledgeable sets of eyes. Medicine has fallen short on developing that safety panopticon with its employees. And lots of it comes from the institutional arrangements in place.
Thanks for another thoughtful post. Leave it to the pragmatic, hands on wisdom of the nurse to have the answer! BTW, I don’t inquire about the pilot as I board an aircraft, but I often glance at the ID plate in the door to see how old the plane is...
The age of the plane tells you less than you might think. While catastrophic commercial airline failures are now rare events, it’s surprising how many of ones that do happen as a result of mechanical failure are not due to gross failure events like airframes coming apart, vs. pilots losing control of a highly computerized fly-by-wire system whose failure modes they do not understand.
I recall the circumstances of Air France Airbus crash after leaving Brazil. Junior pilot was so used to the computer making decisions that he didn’t know how to handle a quite manageable anomaly.
I spent years flying on Soviet-built aircraft inherited by the the baby-flots. I experienced a lot of in-flight anomalies, which were concerning at first, and I was quite aware of the various airline safety records, but on a flight once to some Stalinist backwater, I remembered a quote from Saving Private Ryan. “Sergeant, we have crossed some strange boundary here. The world has taken a turn for the surreal.” I realized I found some bizarre comfort in the fact that there were rarely survivors on the baby-flot crashes.
Unless things change and the Maoist worldview that so many formerly trusted institutions have adopted is discarded, we are back to where I was, metaphorically speaking, when that ramshackle old TU-154 started making loud, metallic clanking sounds at 20,000 feet.
Great stories. My somewhat equivalent story was being stopped on a pitch-black roadway in Liberia by a group of soldiers, shouting frantically in a language I didn't understand, with the muzzles of their machine guns protruding through the car windows. If some stranger pulls out a pen-knife as I walk down the street at night, I'm likely to quickly cross the street and quake and quiver. In that car in Liberia, I didn't feel the slightest worry. Afterward I wondered why and concluded, "Because over here, I feel like I'm just watching myself in a movie. Nothing here seems real." Everything there was a turn for the surreal, and it was somehow entertaining to watch.
I experienced the same sensation, like watching the scene from the outside looking in. I was carjacked in Maputo once at gunpoint. They forced us face down on the road and held guns against the back of our heads. I seemed to visualize the entire event from a short distance away.
Three of my colleagues were stopped at a roadblock in Liberia on their way to a project location, executed, and burned along with their vehicle back in 2003. When I heard about it, I felt as if it happened right in front of me.
It’s hard to unremember some experiences.
How tragic. I meant to add (but got distracted) that the soldiers shouting and waving machine guns were simply pleading with us to take a woman in a labor to the hospital in Monrovia, around 30-35 miles away. I simply told the driver, "Go as fast as you can without killing us." We got her there in time.
"Trust can vanish in the same ways that money can."
But money is much easier to earn back. Trust, maybe never.
Great point.
Thank you, Bob. One of the most cogent arguments for going against the current tide that I have read. And push back we must.
Go henceforth and push! Thanks for the good words.
I think you've got it wrong. The reason we don't vet pilots is that pilot-induced death is extremely rare. Extremely. Just not worth worrying about. See how that works?
Nice argument. In class, the conversation always turned in the direction, but it's ultimately unsatisfying. It begged a series of followup questions. The question is not what is the baseline risk, but rather what is the impact of consumer due diligence on that risk? Does checking up on the surgeon's ratings really alter your risk? If so, did you check up on the anesthesiologist's ratings, and if not, why not? Did you check up on the rate of hospital-borne infection, which likely presents greater risk than the surgeon? Did you check on the quality of the nurses? Or the overall survival stats for the hospital? And, while the risk of air fatality is low today, were you any more diligent 40 years ago, when the risk of death while flying was 100 times higher than today? And do you do similar due diligence on the guy who repairs your brakes, the one who installs your gas pipes, or the one who drives your bus around treacherous cliffside roads in California? Surgeon versus pilot was really just the conversation starter on how we evaluate risks and whether those evaluations do much good. The fact is that I check up our surgeons, and I don't check up on our pilots--and I never suggested to students that that was irrational. I wanted them to dig down into how we structure and analyze data and how (and whether) we mitigate risks.
I pay pretty close attention to the guy who works on my vehicles. But I think you are leaving out the fact that you don't get to spend 20 minutes talking to the pilot, and you probably wouldn't learn much if you did. The reason the rate of plane failures matters is that we trust the airlines to vet their pilots. They have skin in the game.
As I’ve noted here, anecdotally, pilots may pay less attention to their skins than we like. But you have hit on the head one of the points I made with the classes. The airlines do heavy duty vetting of pilots and equipment. Medical institutions are more relaxed and allow doctors to practice in ways that wouldn’t be tolerated in aviation. The question to the class was “Why is that the case?” Are hospitals incapable of vetting doctors as well as airlines are of vetting pilots?
I was referring to the airlines, not the pilots, having skin in the game. If hospitals had to pay out tens of millions of dollars every time one of their patients died, they would be a lot pickier about doctors AND patients. And if university endowments were on the hook for your student loan, they would be a lot more careful about the majors they offered, and the students they admitted.
YESSS! I didn't spoon-feed the students answers. I challenged them and let them wend their way around. This was one of the answers I always wanted them to discover on their own. Earlier this year, I reused an article I wrote back in the 1990s: "Old West Derivatives" (https://graboyes.substack.com/p/old-west-derivatives). It was a short story about a late-19th century cattle-driver devising a contract with a rancher to move 1,000 head of cattle through the Mexican desert into Texas. The 5th principle embodied in the contract was "Risk of lost cattle: The journey is dangerous for the cattle. They can drown, they can fall prey to disease or predators, they can be stolen by bandits, or they can just wander off. The rancher wants to provide extra incentive for taking good care of the herd, so he offers a 100-peso bonus if fewer than 2% (20) of the cattle are lost. Once the 2% threshold is passed, the rancher begins to deduct 25 pesos from the bonus pay for each head lost. So, if losses get near that 2% mark, the driver has a huge incentive to prevent further losses. The rancher knows that even the best driver is almost certain to lose at least five head, so he offers the driver an extra five cattle to take along. So, the driver is really transporting 1,005, and not 1,000." So the penalties for losing cattle are initially small--because ANY driver will lose some cattle. But the driver knows that if his losses grow too large, he will begin to suffer BIG penalties. Imagine a hospital that said, "We know there will be around ten big malpractice cases in the next year. That's normal. Errors happen. But if it goes OVER ten, the hospital's owners and employees will suffer big financial losses." You would have a VERY different dynamic with respect to malpractice.
Given a patient's desire for comfort with a physician, it isn't surprising to find that patients may prefer physicians who share whatever identities (ethnic, political, religious, gender, whatever) the patient deems important. (Ask a male ob-gyn.) That doesn't change the physician's obligations but the patient has taken no such oath. This desire on the part of patients makes the issue of race in medicine more fraught than it might be in other fields. I don't have a good alternative. I'm just saying it's complicated.
I've long thought that there should be a policy of waiving all student fees (or debts) for those in medical fields who are living kidney donors. Aside from alleviating the dire shortage of kidneys, such a policy would give budding young doctors, nurses, etc., direct experience as hospital patients in an ideal situation where they're healthy.
Kidney donor seems a little extreme...I would be content with marrow donor.
I can think of good reasons for kidney donors, liver donors, etc. It's a lot easier to be a marrow donor, and waiving fees and debts for anyone willing to donate marrow would probably become extremely expensive. I never donated marrow, but offer my $300,000 in waived debts, and I'll say "Start drilling." Offer me the same to donate a kidney, and I would likely balk.
The idea came out of my experience first as a kidney donor with no previous encounters with hospitals and then as a cancer patient. If you're healthy, being a kidney donor is the world's easiest good deed. The hardest part is persuading people that you should go forward with it. People grossly exaggerate the risks.
https://vpostrel.com/articles/here-s-looking-at-you-kidney
During my subsequent experience as a cancer patient, I was very grateful that I'd experienced hospitals, tests, and surgery under less stressful circumstances.
Really interesting. And, one more case of why the best ideas often come from laypersons. I read your article when it first came out and loved it dearly. (I'll also note that I was especially pleased to hear from both you and Sally after writing this article.) Your statement here exhibits courage and modesty that most of us lack. I do think a kidney donation is a more substantial decision than a marrow transplant. One is, so to speak, a renewable resource, and the other is not. There's essentially zero probability that you'll come to regret a marrow donation 20 years later. There's some nonzero probability with respect to a kidney. So, I really admire what you did. You gave a remarkable gift.
Over the past 20 or so years, I've had (Asian) Indian doctors, a Romanian, an Iranian doctor (he was really good and we got to become friends), a Black doctor, an Italian doctor, a couple of Jewish doctors, at least one Chinese doctor, and others that I don't really recall. All I'm looking for is competency.
Many years ago possibly the best doctor I ever knew practiced in a small town (pop. 1100) and was as cranky as House (this was way before House) who also got lots of calls for diagnosing unusual cases. He had a nation-spanning reputation in the 1980s for diagnostic ability over the phone when there was no web. He was great, he was just basically a small town guy who enjoyed practicing in a small town.
I suspect a huge percentage of U.S. doctors will be coming in the near future from foreign countries and foreign medical schools. My family doctor, too, was a local character with astonishing diagnostic abilities. You can read about him here: https://graboyes.substack.com/p/innovation-as-bush-fire
I think a key point is that humans, in general, are problem-solvers, tinkerers (is that a word?), innovators WHEN the social/governmental system let them be.
It has been mentioned many times that China lagged behind the West for centuries despite their innovations like gunpowder and moveable type. Their 'systems' routinely clamped down in order to maintain the existing systems.
We KNOW this, and yet allow the same pattern to continue. Innovation is disruptive, and the people who benefit from stable systems know that (consciously or not), hate and fear disruptive change, and thus hobble it as much as possible.
I think someone censored your last sentence. :)
Agree with everything in paragraph 1. Civil Rights laws prohibit employers from discriminating on the basis of race when selecting employees. They do not prohibit employees from choosing employers on the basis of race.
Your kidney donor idea is interesting. I'm guessing you know all about Gary Becker's long-ago proposals for giving priority in transplant queues to those who have pledged to donate their organs. This takes those incentives to a whole different step.
Gary Becker's idea is exactly the overly clever thinking one gets from a theorist with no knowledge of how things actually work. Telling people they can't get a kidney unless they've previously pledged organs in case of death would do nothing to increase the supply of organs. (Living donors are in fact prioritized in the highly unlikely event that they later need a kidney.) The main constraint is that people have to die in exactly the right circumstances, followed by the practical constraint that their relatives have to agree (regardless of what they've said in advance). So you would have adopted a cruel, arguably unethical policy that accomplishes nothing except letting free-market smarties feel smart. The other idea much beloved of people with more IQ points than knowledge is "presumed consent," in which the law declares that organs will be taken from people who've died the right way regardless of their families' wishes unless they've previously explicitly said no. If you want to know why this would be a disaster in the U.S., you should read Michele Goodwin's Black Markets (highly recommended given your interests). But it's also not as successful in Spain, the case always cited, as people think. What really makes a difference is well-run donation centers. Kieran Healy is the person who has researched this: https://kieranhealy.org/publications/presumed-consent-law/ and https://kieranhealy.org/publications/altruism-asr/. He also has a book, which I reviewed in the NYT: https://vpostrel.com/articles/grim-harvest
You’ve had far more reason than I to think deeply about these issues. If I recall correctly, Becker was fairly modest about his idea. He said there were some legitimate reasons for concern about cash payments for organ donations. But he wanted to suggest that cash payments were not the only ways to incentivize donations. I haven’t read his WSJ in decades, but it seems to me he said there (or in followup discussion) something to the effect of “That’s one idea, come up with others.” I think he also acknowledged the practical problems implicit in enforcing “contracts” to donate. I will happily look into some of your recommendations. But I’ll still tip my hat to Becker for exploring the issue before it was on a lot of people’s radar screens. I think he started talking about this not much more than a decade after UNOS was founded.
To be fair to Becker, this may be the first time I've seen the idea attributed to him. I've heard it over and over and over and over from other free market types. There was actually an attempt to start some sort of registry to support this idea, but I've forgotten who did it or what the details were.
He's the first I heard it from. I hadn't realized that he was even interested in those questions, and he got a lot of attention from it. His idea led to a lot of interesting classroom discussions on the subject. I did my master's in health administration and then taught for 19 years at Virginia Commonwealth University. It was a point of pride there that UNOS had begun as kind of a regional, informal VCU project dealing with kidneys and then grew into the nationwide, all-organ, central clearinghouse that it became.
Obviously you speak in jest, since the subsequent New York Times headline ("The Only Way This Black Single Mother Could Go To Medical School Was By Giving A Kidney") is 100% predictable. The only way your suggestion wouldn't outrage public perception is if *every* medical student had to donate a kidney first, and nobody could "buy" his way out of it, which would certainly help with the kidney problem and winnow the field of med school applicants considerably more than sophomore organic chemistry already does -- indeed perhaps a bit too much.
Beyond that, my personal opinion is that you may overvalue experience and undervalue character here. My suspicion is that people of good character empathize sufficiently that indirect experience is generally enough to give them the understanding desired, while people of poor character won't draw any useful lesson from even the direct experience you suggest. Perhaps we should reconsider whether it was such a good idea, our several decade long gradual replacement of veneration of character or virtue with the veneration of skill or intelligence.
“Because my life was in his/her hands...” Did you ever ask your students if they knew anything about the anesthesiologist who worked their surgery? Because talk about putting your life in someone else’s hands...
In another comment, I mentioned that I have a think tank piece coming out over the next week. It’s a discussion I had with a nurse anesthetist and a urologist who used to supervise nurse anesthetists.
Yeah, I like to meet them and ask a few questions.
Asked to explain the differences between the surgeon and the pilot, the students—all medical professionals—struggled.
Med students? Hadn't they all passed through University courses in mathematics, as a condition of becoming med students? Were they so oblivious that they had never considered the very tiny probability that their single flight might crash, while millions of successful flights went well? The chance of disaster on a single flight is minute, and any person can take confidence that this one won't be different.
Now consider - where would you get a public record of probabilities of surgeries going wrong? It's not nearly as blatant of those plane flights. Those students who inquired about their individual surgeons were doing a very practical due diligence.
If you've read much of the research done by MDs you'll notice they aren't always that good on stats. Just saying.
I'll agree with your comment, but many of my students were brilliant at math.
As a math undergrad, in grad school I got slapped down (in a nice way) by my stats prof (a Northwestern PhD) for wanting to know the underlying math. He told me, "not in class, but see me in my office." And he was quite willing to go deeply into the math. As a result I believe I understand complex structural equation models in ways that most users don't. But I could be wrong.
I taught a grad class public health policy for years, and thus read a lot of research by MDs. I tend to think they overestimate the power and usefulness of many of their methods when low numbers of cases or patients or respondents are used. I think most of them (not Wakefield, of course) mean well, but I still am hesitant to accept a lot of their conclusions. It doesn't help that 'reporters'/'journalists' with even less understanding then run with a ridiculous take. Maybe that's my real problem.
He was quite serious about the difference needed, in his belief, between math and stats. I have come to mostly agree with him. But I understand that may not be a majority opinion. lol
Great stuff. I'll note along these lines that when patients (like me) "research" a surgeon, our "study" consists of three minutes of usually-frustrating Googling and then asking three friends, "So who did you use when you had surgery?" What usually determines it for us is our PCP saying, "I know this guy. He's good."
My question is, "If my case was your Mom, who would you recommend?"
YUP! My Mom used to ask doctors that question. My brother is a retired doctor, so the question was more than academic in our family.
These students were among the least oblivious humans I've ever known. Let me just repeat a response I posted to another commenter in this discussion: "In class, the conversation always turned in the direction [of MD=high-risk and airplane=low-risk], but it's ultimately unsatisfying. It begged a series of followup questions. The question is not what is the baseline risk, but rather what is the impact of consumer due diligence on that risk? Does checking up on the surgeon's ratings really alter your risk? If so, did you check up on the anesthesiologist's ratings, and if not, why not? Did you check up on the rate of hospital-borne infection, which likely presents greater risk than the surgeon? Did you check on the quality of the nurses? Or the overall survival stats for the hospital? And, while the risk of air fatality is low today, were you any more diligent 40 years ago, when the risk of death while flying was 100 times higher than today? And do you do similar due diligence on the guy who repairs your brakes, the one who installs your gas pipes, or the one who drives your bus around treacherous cliffside roads in California? Surgeon versus pilot was really just the conversation starter on how we evaluate risks and whether those evaluations do much good. The fact is that I check up our surgeons, and I don't check up on our pilots--and I never suggested to students that that was irrational. I wanted them to dig down into how we structure and analyze data and how (and whether) we mitigate risks." I do believe that much of our due diligence is really aimed at finding a provider whom we are at ease with, as opposed to trying to determine that provider's competence. Which is still a perfectly good reason to do due diligence.
I've noticed that lots of people are in favor of racism and other forms of discrimination when they are or expect to be the ones who benefit and not be the ones hurt. Odd thing, that.
I think there's a "Baptists and bootleggers" aspect to it. That term refers to the strange purported alliance of convenience by teetotalers and those manufacturing illegal liquor. The former favor prohibition out of a strong moral imperative. The latter favor prohibition because it's good for business. Same sort of thing here.
How about - if the surgeon screws up badly, they go home at the end of their shift.
The pilot has a much more vested interest in successfully landing the plane.
Now, operating on a mafia boss' favorite daughter - maybe that would be similar
Having just watched all three "Godfather" films plus the miniseries about the making of the first ("The Offer"), I love your final sentence. As to your first two sentences, I'll post an anecdote that I've already given to two commenters: "When I first started in economics, I said to a friend/ flight attendant that I assumed the most important safety device on the plane was the pilot’s desire to get home safely. She just looked me dryly and said 'You haven’t met very many pilots, have you?'”
Actually the best answer to the: "Why due diligence for the "Doctor" and not the "Pilot" question is this: "Because the Doctor knows that if he screws up his life is not at risk, but the pilot knows if he screws up we all go down together."
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Search the other comments for “flight attendant.”
I can think of two additional reasons why the cases of commercial pilots and physicians are different, in addition to the interesting one you adduce:
1. Free riding. We usually travel not only with one pilot but simultaneously with a copilot, a bunch of flight attendants, and a few hundred other passengers, many of whom have flown far more than ourselves. The fact that several hundred *other* people, including many with way more relevant experience, are trusting the pilot with their lives at the same moment we are asked to do so, may ease our concerns, or at least diffuse our sense of responsibility. I think it's generally a phenomenon among humans that we feel less need to justify our trust when we're doing it as part of a big group.
But of course when you hire a surgeon, it's just you on whom he's operating (at least at that particular time). It would be interesting to ask people to compare choosing a surgeon with hiring a private pilot to, say, fly the family on a remote vacation -- a situation where you are *not* making a collective trust decision. It would also be interesting to ask whether rich people vet the pilots they hire for their private aircraft as thoroughly as they vet their surgeons*.
2. A greater certainty of the quality of outcome. The pilots' metric of success is nearly unambiguous: in almost all situations, if the pilot does his job right, the airplane lands successfully. There are still a few cases where mechanical or ATC failure dooms a commercial flight despite the best possible decisions by the pilot, but they're relatively rare these days -- and even then we can usually tell, after the fact, that something went wrong. It's pretty rare that a plan crashes (or disappears like MH 370) and we have no clue ever whether the pilot screwed up or the plane was doomed through no fault of his.
But by contrast, serious surgery is inherently quite dangerous, and people die all the time from it even if the surgeon and team does everything right. Furthermore, surgery, indeed medicine in general, is so complex and subtle an art that whether or not the physician is doing the right thing is something that is very difficult to objectively decide. The best minds can easily differ on whether this or that was the right choice, and even on whether a given decision led or contributed or had no effect on a bad outcome. Does this surgeon have more deaths because he's an idiot or because he takes tougher cases? Thus the enormous medical malpractice industry -- malpractice lawyers wouldn't earn nearly as much money if it was straightforward to know whether a given physician in given circumstances screwed up or not. Which means the question of physicial skill seems inherently harder to answer than pilot quality, which makes the question of trust more fraught. We probably vaguely feel like really bad pilots crash and get ejected from the career, but pretty bad surgeons can fly under the radar, so to speak, and last long enough to (gulp!) be operating on us.
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* Indeed, the poorer we are, the more we perforce place our trust in institutions, because we just lack the resources to do the research needed to choose for our ourselves, and often have no real choice anyway. This points to yet another way in which those who want to inject racist ideology into medicine are committing evil: those who suffer the most from their distortions will be the poorest among us. We can be 100% sure that no matter how the institutions are distorted, Jeff Bezos will always hire the very best brain surgeon if his wife needs surgery. He will always have the resources to find and hire the best. So will all the rich people -- they don't *need* to trust that Harvard Medical produces first-rate physicians, or that board certification doesn't measure some skill in ideological bullshit instead of the scalpel, because they have the resources to vet the individual directly. It's those of us who can't afford to do so -- who lack connections, access, time and money -- who will suffer if the institutions are corrupted. And the poorest will suffer the most.
(1) Great explanation. Nothing equivalent in medicine. Imagine if the anesthesiologist, nurses, and hospital were all on the hook when an MD screwed up a case. And we did have some classroom discussions on people flying in private craft. I thought about it when my wife and I went flying around Denali in a helicopter. I wondered, "Who is this pilot, and why am I trusting him with my life?"
(2) This is true today. It was less true half a century ago, and I'm not sure people did any more due diligence back then.
(*) This section is quite impressive. And quite true.
I'm sure you're right, that medicine could improve significantly by adopting some of the methods other industries have used to improve outcomes, make them more measureable and optimizable. For that matter, it has always mystified me why medicine has historically been so much slower to improve than almost any other technology -- especially considering it is arguably the most important technology we have.
Certainly the Greeks and Romans could've done experiments to optimize nutrition and lifestyle factors, for example. It's somewhat absurd that we have to do trials in 2023 over questions like "Is intermittent fasting or a vegan diet good for life extension?" That's an experiment that could've been run any time in the last 5000 years, and surely should have been. The answer should today been known without possible quibble for centuries. Even some basic drug agents (e.g. salicylates for pain and inflammation relief) have been known and used for centuries, and could have been cultivated and refined with chemical techniques known as far back as the 1300s or so. Why did aspirin only become widely available at the end of the 19th century? Why is there this giant pharmacopeia of folk remedies about which we know surprisingly little with certainty? Does St. John's wort work or not? What about apple cide vinegar, flaxseed oil, plant sterols? What diet optimizes the health of the gut microbiome? None of these questions require sophisticated scientific instruments to answer. They should have been answered 500 years ago.
Then there's transmissable disease, a huge killer for much of history. Why did it take the actual images of micro-organisms for the germ theory of disease to be accepted, in the mid-1800s? As a species, we certainly had the ability to do the experiments necessary to understand that infectious disease was spread by some invisible but potent agent that traveled in cases by air, by droplets, by surfaces, or by blood. We could have understood enough to know when to impose quarantines, what kind, how long. We should have known by 1000 AD to wash our hands after attending sick people.
The failure to take even basic rational steps to understand the mechanisms of health and disease, ven those needing no scientific instrumentation at all, just cool reasoning and experimentation, for a thousand years -- several thousand, if we include ancient civilizations -- is sort of baffling.
My vague thought is that it's *because* it's so important. I hazard that medicine is so extremely conservative, and has even been secretive about its outcomes for so long, *because* it's so important for people in general to believe it's as good as it can be. Even today, if I went to my physician and she were to cheerfully say "Oh! We don't know exactly how to optimize your treatment for Problem X, but there's a giant study on it, in which I'm participating, and I'm going to randomly try Solution Y, which sort of seems reasonable to me, and we'll report up to the data banks how it works out" -- I might be a little dismayed, or at least, I feel like I would be if I weren't already old enough to be skeptical about how much medicine can do anyway. We already have a hard time recruiting people into clinical trials, and in many cases these are people who pretty much have very little to lose. It may just be that holding the two thoughts in one's head simultaneously (1) I am very sick, could die, and (2) the establishment doesn't know exactly what to do about it, provokes so much cognitive dissonance that we can't handle the internal strain. We can only contemplate the importance of improving medicine (thought #2) when we are not sick (no thought #1) -- in which case the urgency we feel is low.
The pilot dies with the passenger. The surgeon doesn't. Skin in the game explains it all.
Explains some. Doesn't explain all, or even most of it. Lots more lies in medicine's much inferior systems of monitoring, reward, and punishment.
Once, the Hippocratic Oath meant something...over the last 50 years I have seen it largely ignored, derided, abandoned, and replaced by meaningless piles of unicorn feces...The primary motive for becoming a physician today is greed and proving yourself more 'woke' than your colleagues. Scientific articles in medicine are untrustworthy, and residents are more interested in time off than patient care...The entire profession, including nursing and paramedical professionals are more adept at nursing their computers than taking care of patients...sad, so sad...
Wow.
Hi Bob,
The reason I don't need to check my pilot as I do my surgeon is that if the pilot messes up, they're going down with me and the plane. The surgeon, on the other hand, has malpractice insurance and will live to slice again...
Cheers, Jonathan Wight
That is the obvious, simple, and woefully inadequate answer that usually starts to conversation off. :) it’s exactly what I said in 1980 to an old girlfriend who was a flight attendant and I was the oh-so-sophisticated econ grad student. She just looked blankly at me and said, “You haven’t met very many pilots, have you?” Glance through some of the comments already posted here, and come back with more. :) of course, your point (my point in 1980) has some validity, but there are many more layers to explore. Great to see you here.