{"items": [{"author": "Adrian", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385571181476437", "anchor": "fb-385571181476437", "service": "fb", "text": "Please do not mistaken my following words as a argument for reducing government involvement in our healthcare system, but this is a case where there exists an argument for <gasp> capitalism and free labor markets. Assuming capitalism functions in a way such that capable surgeons are well-compensated for their services, the market would figure itself out and displace the less reliable surgeons.", "timestamp": "1333461233"}, {"author": "Danner", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385576971475858", "anchor": "fb-385576971475858", "service": "fb", "text": "Jeff, It seems like an assumption to this calculation (or at least a variable) is that there will always be someone to replace you if you were not there. to take your example, perhaps another surgeon is not available, so instead of being replaced, a family practice doctor is hired instead, and less surgeries are scheduled. Very easy to see in Boston's software job market currently, that there are not enough high quality engineers to fill all the positions, so companies are either hiring less skilled, or are reducing project scopes/load on their teams.", "timestamp": "1333462003"}, {"author": "Dan", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385593541474201", "anchor": "fb-385593541474201", "service": "fb", "text": "Adrian, sorry, the markets don't work that way in the States, at least. (And gosh, we have the freest dang ol' markets anywhere, no?) The medical profession tends to form a big white wall, and incompetent/underperforming docs are almost never gotten rid of.", "timestamp": "1333463894"}, {"author": "Jeff Kaufman", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385596651473890", "anchor": "fb-385596651473890", "service": "fb", "text": "@Adrian: surgical skill is difficult to evaluate. If the patient dies, how do we know they wouldn't have also died under another's care? If one surgeon has a low death rate, how do we know they aren't taking easy cases? This is related to why medical malpractice is such a mess.", "timestamp": "1333464206"}, {"author": "Jeff Kaufman", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385597951473760", "anchor": "fb-385597951473760", "service": "fb", "text": "Danner: true. The more of a shortage there is in a field the more likely the replacement is to be less qualified. (And \"replacement\" is complex: if me leaving pulls someone from company A and then they pull someone from company B, the eventual person pulled into the field is what counts. And they might be much worse; it's hard to say.)", "timestamp": "1333464341"}, {"author": "Adrian", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385602464806642", "anchor": "fb-385602464806642", "service": "fb", "text": "I knew I was going to get flamed for my seemly Republican-leaning comment. Alright, so first of all Jeff Kaufman, medical (of which surgical is a subset) skills can be evaluated to some extent. There is a reason for the existence of MCAT's and why good med schools are so tough to get into. At the same time, the high compensation of the profession entices capable individuals to join the industry. These are existing mechanisms to ensure high quality healthcare. HOWEVER, the problem is once our idealistic brilliant doctors graduate and begin employment, they are handicapped/corrupted/demotivated by our broken healthcare system -- this goes to Dan's point. The healthcare system is a spaghetti of backward-thinking bureaucrats, inefficient billing systems, broken malpractice liability risks and predatory insurance companies -- far from what an efficient market should be.", "timestamp": "1333464865"}, {"author": "Allison", "source_link": "https://plus.google.com/109502185221418876252", "anchor": "gp-1333465125252", "service": "gp", "text": "Location matters quite a lot, when thinking about whether to consider the good you do or merely the difference between the good you do and the average. In a big city, people are easily replaced, but in rural areas the challenge can be to find anyone qualified to fill a position.\n
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\nThis is why I have one friend who felt like in Teach For America she probably made a negative difference in her students' lives, and one who is sure that in TFA she did good. One was assigned to Chicago, where there isn't actually a teacher shortage, particularly for what she was teaching, and the other was assigned to rural South Dakota, where there is a desperate teacher shortage.", "timestamp": 1333465125}, {"author": "Jeff Kaufman", "source_link": "https://plus.google.com/103013777355236494008", "anchor": "gp-1333466108992", "service": "gp", "text": "@Allison\n Right. Though even if we assume that the 30ish children in rural South Dakota that your friend taught for two (?) years would otherwise had a much less competent teacher or many more classmates, it's extremely difficult to evaluate the benefit. I believe there's some evidence linking smaller classrooms to higher test scores, and people have all sorts of good things to say about having great teachers, but how much does it improve the lives of these students? Do they end up happier for life? (By much?) Do some of them get much better jobs? What happens to them?", "timestamp": 1333466108}, {"author": "Stephanie", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385653061468249", "anchor": "fb-385653061468249", "service": "fb", "text": "I'd like to see an example of a health care system that the majority of participants (providers and patients) agree \"works\". Does it exist, anywhere on the planet?", "timestamp": "1333470361"}, {"author": "Jeff Kaufman", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385657234801165", "anchor": "fb-385657234801165", "service": "fb", "text": "@Adrian, @Dan, @Stephanie: the question isn't how good healthcare is in the US or elsewhere, but how much good you do by choosing to go into healthcare as opposed to picking some neutral career.", "timestamp": "1333470796"}, {"author": "Adrian", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385665144800374", "anchor": "fb-385665144800374", "service": "fb", "text": "Stephanie, there will always be ppl unsatisfied with whatever system is in place, but there is no denying that the US trails behind every other developed country in the efficacy of its healthcare system. Jeff, I think the premise of your question is difficult for some of us to absorb, because the decisions of an individual are dwarfed by the complications of the system he works in.", "timestamp": "1333471634"}, {"author": "Allison", "source_link": "https://plus.google.com/109502185221418876252", "anchor": "gp-1333473850134", "service": "gp", "text": "Of course, it is difficult to evaluate! And if she hadn't gone, perhaps TFA would have assigned someone else to the position.\n
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\nBut if you want to be a doctor or teacher or something in part for altruistic reasons, it's pretty clear that those reasons are best served if you can choose to live somewhere where there is a shortage of people in your profession, and sometimes in a drastic way.", "timestamp": 1333473850}, {"author": "Mac", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385913818108840", "anchor": "fb-385913818108840", "service": "fb", "text": "The metric used in the medical and insurance industries is not \"lives saved\", because saving the life of a very old person who will die in two months is not as cost effective as saving the life of a 25 year old. The metric used is the \"quality-adjusted life year\". It is a way of comparing the cost effectiveness of interventions, medical devices, and drugs. My recollection is that if it costs somewhere between $30k and $100k per good quality year added to a life, then it's good medicine. This can be realized by 1000 people getting a $30 test. 999 people were fine and didn't need the test, but nobody knew that. And one of them had a good quality year added to her life.
http://en.wikipedia.org/wiki/Quality-adjusted_life_year", "timestamp": "1333497076"}, {"author": "Jeff Kaufman", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385954918104730", "anchor": "fb-385954918104730", "service": "fb", "text": "@Walker: I agree that thinking about things using QALYs or DALYs is better than \"lives saved\", but I didn't want to get into that so much when it was orthogonal to the central question of \"how much of what you're doing would still happen if you weren't there to do it?\".
Separately, it's depressing that we think of good medicine being anything under $100K per DALY when GiveWell estimates that deworming is around 1000x better at ~$100/DALY.", "timestamp": "1333502571"}, {"author": "Mac", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385989014767987", "anchor": "fb-385989014767987", "service": "fb", "text": "You mentioned \"lives saved\" and \"metric\" in a note. QALY seemed a useful sequeal.
When you talk of $100 per life for deworming people, are you refering to the low threshold of charity required, but not met, for Americans to save lives in third world countries?
There is a concept of \"radius of concern\". For many, it would fall somewhere between our children and a second cousin's nephew. For most Americans, it does not extend to saving lives in the third world. Sad.", "timestamp": "1333506954"}, {"author": "Mac", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=385990904767798", "anchor": "fb-385990904767798", "service": "fb", "text": "I like Adrian's first comment that in a large market, supply and demand kinna works, and an individual's diminishing of a supply is compensated by another individual's stepping in to increase the supply. But there are world champions whose departure leaves a transient depression in the supply.", "timestamp": "1333507189"}, {"author": "Jeff Kaufman", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=386183354748553", "anchor": "fb-386183354748553", "service": "fb", "text": "@Walker: \"Are you referring to the low threshold of charity required, but not met, for Americans to save lives in third world countries?\"
Yes.", "timestamp": "1333541219"}, {"author": "Stephanie", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=386344458065776", "anchor": "fb-386344458065776", "service": "fb", "text": "@Jeff, I am a nurse and I don't really think about replaceablity because there aren't enough nurses. I also think that we choose (or should choose) our careers based on what we like to do and are good at doing. If you are altruistic, you probably don't have a mentality that \"I save lives at work so I don't need to try to save lives (through charitable donations, etc) in my off time\".", "timestamp": "1333560042"}, {"author": "Jay", "source_link": "https://www.facebook.com/jefftk/posts/385545808145641?comment_id=386857634681125", "anchor": "fb-386857634681125", "service": "fb", "text": "Jeff, thank you for writing this, it brought some good clarity to some of my thoughts. I think about this idea of replaceability a lot in the global warming work that I do. I see so many people of our generation who want to do good in the world but the only model of how we do good work is to fit into a job which someone else has created for them. But that's not in itself transformative, because they could have hired the next person. What if all those people imagined what unique thing they bring to the world and pursued it themselves?", "timestamp": "1333629068"}]}