This is the second of two posts prompted by Dr. Robert Centor’s critique of a recent New York Times Magazine article accusing America of “stealing [sic] the world’s doctors.” In the first post, I show how US immigration policy for physicians is a boondoggle of near-comedic proportions that doesn’t even constitute an effort at “theft,” given that it’s hard-pressed to hold onto me after I graduate (as I explain, I should be one of the easier doctors to “steal”).
Now let’s look at the counterfactual situation. Suppose the it were actually easy and straightforward for physicians to immigrate to the US (or to remain, in my case), gain licensure, and be certified in their specialties. Suppose the immigration and licensure systems were designed with this very goal in mind. Would this be a bad thing?
The conventional wisdom is that the emigration of skilled professionals from less to more-developed countries is bad for the less-developed countries: this process is often referred to as “brain drain.” Critics argue that “brain drain” harms poorer countries by preventing the development of local talent, skills, and professionals that are often sorely needed. They also point to the fact that many countries subsidize education at least to some extent, only to see the investment in their citizens’ human capital slip away beyond their shores.
The conventional wisdom is wrong. As the 19th century economist Frederic Bastiat pointed out, it is best “not to judge things solely by what is seen, but rather by what is not seen.“
What is “not seen” when it comes to emigration of skilled professionals? Networks of diaspora spread ideas and expertise, strengthen economic and social ties between countries, promote peace, and promote advances in the standards of living both at “home” and “abroad.” Emigrants usually earn much more in their new country, and their remittances home are not only better able to support their family and community, but are often enough (over a lifetime) to dwarf the amount their home government spent on their educations. The option of emigration to higher-income countries creates incentives for poor countries to invest in education, and for their citizens to take advantage of it. In short, emigration of skilled professionals to richer countries enhances their productivity, which in turn has positive effects for their home country, their adopted country, and all of us along the way.
Yet even this analysis misses the fundamental point. To insist, as the New York Times does, that foreign physicians somehow “belong” to their home countries is to objectify and commodify them. When you think about it, it’s a remarkable assumption for anyone to make. Foreigners are people too. We’re not chess pieces to be pushed around a board, traded for promises of foreign aid, trade preferences, or anything else one might imagine. The Canadian government has no more claim on me and my career than the American government does on anyone who has ever attended a public school in this country.
This is a universal principle. I don’t care how poor the country is, no government can claim to “own” its people in this way. It’s absurd to suggest that the United States government should alter its immigration policy to cater to other countries’ desire to engage in this form of subtle repression, and even more absurd to think that this would actually benefit anyone.
Physicians who voluntarily leave one country for another in the hopes of making a better life are not “being stolen.” Not unless you think they’re owned by someone other than themselves. At its core, that’s what this discussion is all about. And that’s why, in my mind, there should be no ambiguity as to the right conclusion.
As I mentioned earlier, I’m starting to rev up the studying for the licensing exam. A lot of the studying takes the form of practice questions. They’re actually a lot of fun to do: they force you to think actively about the clinical scenario, keep you on your toes, and make it near-impossible for your eyes to glaze over as you semi-consciously read the same page for the 10th time in a row as your eyelids begin to feel heavy, droop, and you start to….
Yikes! Where was I? Right! The Cavalcade is back! Since I’m sure that most of you don’t believe me when I say that doing practice questions is actually fun, I’m going to use this opportunity to try to convince you. With the aid of sophisticated, peer-reviewed psychometric techniques (or not), I have converted each entry into a USMLE-style “single best answer” multiple choice question. Let’s see how you do!
Cavalcade of Risk: Step 1
Instructions: For each of the following test items, select the one answer that best answers the question posed in the stem.
From Boomer at Boomer&Echo: Which of the following behaviours of financial advisors correlates with the lowest risk of defrauding investors?
a) Claiming to have secret/exclusive insider tips that “your broker doesn’t want you to know.”
b) Counseling clients that investments with higher expected returns tend to be riskier.
c) Offering to move your money offshore to avoid taxation.
d) Pressuring you into making a hasty decision on an “exploding offer.”
e) Charging abnormally high membership fees.
From Ken Faulkenberry at the AAAMP Blog: If shares of the Notwithstanding Blog Internet Empire (NBIE) earned a 8% return in 2011 and exhibited a beta of +1.2 relative to a benchmark of shares in all medical blogs that collectively earned a 5% return, then:
a) The alpha for NBIE in 2011 was +2, making it a good investment.
b) The alpha for NBIE in 2011 was +3, making it a good investment.
c) The alpha for NBIE in 2011 was -3, making it a bad investment.
d) The alpha for NBIE in 2011 was -6.8, making it a bad investment.
e) The alpha for NBIE in 2011 cannot be calculated with this information.
From Van R. Mayhall III at the Insurance Regulatory Law Blog: Which of the following statements DOES NOT accurately characterize insurance company insolvency:
a) Most state-based insurance guaranty associations are more comparable to private member-based associations than true state agencies.
b) Insurance companies are subject to unique state-based insolvency protocols in lieu of entering the federal bankruptcy system.
c) Payouts from state insurance guaranty associations are subject to statutory caps.
d) Insurance guaranty associations are intended to provide “bailout” financing to prop up faltering insurers.
e) None of the above.
From Emily Holbrook at Risk Management Monitor: The shoe-shopping website Zappos.com recently earned positive press for:
a) Losing your examiner’s personal information, along with that of millions of other customers.
b) Locking out customers from your examiner’s home country for 4 days after a data breach.
c) Being named in a potentially-class action lawsuit seeking damages as a result of a data breach.
d) Having “some analysts” criticize the company’s response.
e) Having “some analysts” praise the company’s response.
From Jason Shafrin, the Healthcare Economist: Medicare’s new value-based purchasing initiative, which aims to reduce payment to “low-quality” doctors, currently uses treatment costs for which of the following chronic diseases as an element of its cost measure (as distinct from its quality measure):
b) Alzheimer’s disease
d) Lung cancer
e) Breast cancer
From Louise Norris at Colorado Health Insurance Insider: Colorado’s Medicaid program has recently undergone much change and provoked a great deal of controversy. What happened at the end of 2010 to put Colorado’s Medicaid program on better financial footing?
a) Successful negotiations to lower the fee schedule for physicians’ services.
b) A 55% increase in enrollment relative to 2007.
c) A one-time $13.7 million grant from CMS.
d) New dedicated revenue from a sales tax increase.
e) The introduction of Medicaid Managed Care programs.
From Dr. Jaan Sidorov, the Disease Management Care Blog: Which of the following is an accurate characterization of Dr. Sidorov’s assessment of Health Insurance Exchanges (HIEs) and recent Kaiser Health News commentary on the subject?
a) The left is doing their best to nurture this fledgling institution to maturity in anticipation of the PPACA’s full rollout.
b) It’s reasonable for consumers to spend more time shopping for consumer electronics than for health insurance.
c) Government-run HIEs will eventually match the ease-of-use and “cool” factor of iPhone apps and online purchasing aids.
d) Multiple insurance options on HIEs include variations in provider tiers, out-of-pocket costs, and exclusions.
e) Consumer expectations for HIEs will eventually be exceeded.
From Julie Ferguson at Workers Comp Insider: Doctors’ deaths differ from the deaths of other Americans in that:
a) Doctors often choose to forgo lifesaving chemo, radiation, and procedures.
b) Paradoxically, doctors often do not have access to the full range of lifesaving technologies as the rest of society.
c) Non-physicians tend to be more ready to accept death.
d) Doctors have a cultural bias against accepting death that isn’t shared by society at large.
e) Non-physicians who choose to fight their disease are often pressured by friends and family to be serene in the face of death.
Of course, since you read all the entries, you don’t need one! But just in case: B; A; D; E; C; C; D; A.
As always, it’s an honour and a pleasure to host the Cavalcade of Risk! If this is your first time at the Notwithstanding Blog, or if you’re coming back after a prolonged absence, I encourage you to take a moment and poke around some of other posts here. From health care policy to health professions training (i.e. medical school), I’ve got it covered.
The 150th(!) Cavalcade will be hosted on February 8th at My Wealth Builder.
It seems that I still need to work on announcing my hiatuses (hiati?) from blogging prospectively. If even CMS has agreed to assign Medicare beneficiaries to ACOs on an ex ante basis, I really have no excuse.
In my defence, I am a second-year medical student, though you might not know it from my taste in health reform jokes.
It isn’t that the content of medical school is intrinsically difficult. In a refreshing change from my previous education in economics and social sciences, there are usually right answers. Unambiguously right answers that rest on a foundation of the (usually) internally consistent logic of human pathophysiology. There are fewer clinically-relevant “models” per se, and their assumptions rarely engender as much bitter controversy as those in… say… macroeconomics. To be fair, my contention that the kidney only makes sense if you posit the existence of a sodium/unicorn dust exchanger in the loop of Henle took a while to gain acceptance.
*more crickets chirping*
What makes medical school hard isn’t the material. It’s the volume that gives us a run for our money. Not only do we have to learn “everything” in two years or less, we have to remember it. For Step 1.
(If you’re a second-year medical student, consider stopping here. For your sanity, of course)
Physicians in the United States are licensed, as are physicians in countries like Canada, the UK, Australia… probably most others. As one might expect, physicians in the US are expected to pass a nationally standardized exam to qualify for licensure. As in Canada, there is one part that is taken before entering post-graduate training, and another part that is taken after at least one year of residency.
However, as politicians are quick to remind us, the US is exceptional. Because in my poking around medical licensure systems of similar countries, the United States Medical Licensing Exam is the only test with anything like Step 1.
(I said it again. Second years, I warned you.)
The simplest way to describe Step 1 of the United States Medical Licensing Exam is as follows: a seven hour long, 322 multiple-choice question, 78 seconds-per-question final exam for the first two years of medical school.
An exam with sacred texts known to medical students across the country: First Aid; Goljan; Robbins Review; the Q-Books; BRS; High Yield…
An exam for which completing a few thousand practice questions is considered “barely enough.”
An exam that plays a significant role in whether you’ll get accepted into the residency program, or even the specialty, of your choice.
An exam for which most students are given 5-8 weeks of time off in which to study full-time right before taking it.
An exam for which many students start studying six months in advance. Which for me is… now.
I tell you all of this because between now and mid-May (when 5 week journey of discovery and practice questions begins in earnest) my posting will be even more infrequent than before, and those posts that are written may well feature less of the policy commentary you’ve grown accustomed to and more… “medical student stuff.” That said, I assure you it will continue to be worth your time.
As for your intrepid blogger/test-taker… despite my flair for the dramatic, I’ll be fine. Just under six months from today, I take the next step on the road to licensure. I will take that seven-hour, 322-question exam. And I will crush it. You heard it here first.
I’m no fan of quackery, whether it’s of the homeopathic, naturopathic, chiropractic, craniosacral, ayurvedic, or other woo-tastic flavour. I’m even less of a fan when it’s practiced by people with the letters MD or DO after their name. I think it’s deceptive and unethical to promote these unproven and often disproven practices to patients who come to you for professional advice.
Earlier this year, a Florida-based lawyer wrote a piece at SBM arguing that many quacktitioners are likely committing misrepresentation, in the legal sense, and possibly fraud in some cases. This was followed up with a series examining the background and historical legal status of naturopathy, acupuncture, and chiropractic, and now a proposal to enshrine science-based medicine in law.
Read the whole blog post to get a better sense for what’s proposed. The short version is that the proposed law would limit the scope of practice of licensed healthcare professionals by imposing a two-part test to be interpreted “according to its generally accepted meaning in the scientific community”:
- Is it (a diagnosis, treatment, procedure, medication, etc.) plausible, based on “well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology?”
- If not, is it “supported, to a reasonable degree of scientific certainty” by either “good quality randomized, placebo-controlled trials” or “by a Cochrane Collaboration Systematic Review or a systematic review or meta-analysis of like quality.” If not… it’s verboten.[a trial that would pass the legal test would have a placebo control group, random assignment, no more than 25% attrition, at least 50 participants in each study arm, and publication in a "high-impact, peer-reviewed journal."]
If so, has its ineffectiveness been “demonstrate[d], within a reasonable degree of scientific certainty” by the aforementioned controlled trials or Cochrane Reviews? If so, plausibility won’t save it from being forbidden.
With a scheme like this, the devil is usually in the details. In this case, I don’t think one needs to dive in too deep to realize why this is a bad idea.
Politics is a sausage factory, and the science-based medical community should be hesitant to get it unnecessarily involved. Just because something is wrong/a bad idea (like quackery) does not necessarily mean that it should be forbidden in an ideal world. Just because something wouldn’t exist in an ideal world (like quackery), it doesn’t mean that it’s a good idea to use the force of law to ban it.
As narrowly-tailored as it aims to be, this proposed law will have the effect of legislating scientific truth. What constitutes scientific consensus? Plausibility? A high-impact journal? Do we really want these and other scientific questions that are now debated in the literature and the public sphere to be decided definitively by judge and jury? Do we want to give the power to certify science to our legislatures? The same legislatures that have already licensed all sorts of quacks at the behest of their lobbyists?
Science is politicized too easily. Where a scientific conclusion is translated by law into an inevitable legal and policy consequence, the science will make a better political target than the legislation. See this piece on the Endangered Species Act for an example of what I mean.
The best of policies can be undone by politics. I’ve given a fair bit of thought to how one might design an anti-quack law that doesn’t have the potential to go drastically awry. I can’t, though this is likely a result of insufficient creativity on my part.
In general, there are two types of people in government. “Our people” and “their people.” Who they are may vary based on the party or based on the issue, but both types will always be there. And both types win and lose elections.
Here’s the question: do you trust “their people” to exercise good stewardship of scientific truth? If not, let’s not be too hasty in handing over the reins to the politicians.
Physicians for a National Health Plan (PNHP), as the name suggests, is the biggest and best-known group of American physicians who support replacing the current health care system with a national single-payer. I used to be a big booster of this idea, but it doesn’t take much poking around this website to figure out that my feelings towards American single-payer reform have cooled considerably (to say the least).
I’ve been fortunate to attend a number of events run by senior PNHP officers at SUMS and at other venues (e.g. the AMSA conference back in March). At one of the more recent events, I had the privilege of speaking at length to some of their representatives at length. As you might expect, the resulting discussion was direct but cordial.
Though I disagree with their proposed policies, I do respect PNHP as an organization. It is one of the biggest mobilizers of physicians and medical students who are in favour of radically changing how American health care operates. Their passion is palpable at even the most informal event. They do have a contribution to make to the health policy conversation. Unfortunately, while there is an intellectually-coherent case to be made for single-payer (a mistaken case, in my view, but respectable and honest), I have yet to hear it from anybody at PNHP (n=small).
I harbour no illusions about my ability to persuade hard-core single-payer believers in a short blog post. I do, however, have some friendly and hopefully helpful advice on how to talk to the uninitiated and the un-converted more productively:
1) Don’t try to twist the data to support your case. It shows. At best, data on Medicare-vs.-private administrative costs are equivocal, cross-country infant mortality comparisons are spurious, life expectancy at birth captures a lot of mortality that is out of the hands of the healthcare system, and so on. The empirical case for single-payer superiority is thin gruel.
2) When someone asks whether you’d trust a Republican President and Congress to implement single-payer well, don’t duck the question. It’s a more important one than you seem to acknowledge. If you want to centralize control in government, be prepared to talk about how you will deal with your ideological opponents who tend to win elections every now and then.
3) Your moral argument is a lot stronger than your empirical argument. Why not make it explicit? Americans don’t tend towards collectivism, but neither are most people data-oriented policy wonks. Instead of making a weak case based on weak data, you should be prepared to talk about the moral strengths of single-payer relative to the alternatives. Where are the mentions of equity, obligation, and collectivism? (I ask this seriously, not passive-aggressively)
4) Be fluent in the language business, politics, and economics. When your executives are being matched point-for-point by medical students who majored in biochemistry and similar fields, you know you have a problem. If you’re going to call for the dismantling of private insurance, have some idea of how the sector actually operates. If you want to give control of the health system to government, be able to discuss the nuances of Washington power structures. Be able to respond to phrases like “deadweight loss,” “price-vs.-income problems,” and “underwriting” with more than a blank stare.
5) Anecdotes are rarely dispositive of policy questions. When someone points this out about anecdotes involving people you know, don’t get offended; this rarely advances discussion. When you introduce your friend’s problems to the debate, it’s not your opponent who’s trying to use them to score “cheap points.”
6) Milton Friedman is said to have told an up-and-coming Walter Williams, after the latter appeared on TV to discuss school choice, that “[Williams] was right about everything but [had] made one mistake [...], when you talk about liberty, you have to smile.” You may not be talking about liberty as Friedman understood the term, but his advice is every bit as applicable.
July 2011 has given us many causes to celebrate, and we’re not even half-way in! Early July is when we see Canada/Independence/Bastille Day celebrations in Canada, the United States, and France respectively. This past Saturday was the first day of independence for the brand-new Republic of South Sudan. And today, for the 135th iteration of the Cavalcade of Risk blog carnival, I am pleased to present nine incredibly informative and insightful submissions (plus one of my own) for your edification.
In recognition of all of the countries with July independence days, we’re going to be running a carnival sideshow at this blog carnival today. Interspersed with the submissions will be a small number of flags with trivia-esque hints for countries with July national days; the names of the countries will be at the end of the post. Hopefully this will be an entertaining mid-July “trivial pursuit” to accompany the serious business of risk discussed in the submissions!
Two related posts from Jacob Irwin and a guest blogger at My Personal Finance Journey discuss the perils of e-commerce and sharing financial information online. Jacob dissects an example of a common ‘phishing’ scam, and the red flags that should cause one to be suspicious of an email that seems designed to separate you from your personal information (and eventually, your money!). His guest blogger, Les Roberts, talks about how to stay safe while shopping online, and discusses some of the basic technical aspects of secure online transactions.
Tom Drake at the Canadian Finance Blog has a comprehensive post addressing what he claims is the conventional wisdom regarding life insurance: buy term and invest the difference. He argues that while the strategy has its obvious appeal, it’s highly sensitive to the assumptions used in the term vs. permanent comparison. Well worth a read!
Hank Stern, writing at InsureBlog, notes in the context of recent floods in North Dakota that sometimes taking a risk with your insurance coverage can be justified, but as with the analysis in the previous post, that it all comes down to how robust your assumptions are. Come to think of it, isn’t that the case with just about anything?
Wondering about health insurance exchanges? Dr. Jaan Sidorov (aka the Disease Management Care Blog) took one for the team and dove into the depths of the details of Utah’s already-existing exchange. He notes that setting up an exchange is far more complicated than one might think at first glance, and that it’s unlikely that they will be functional in every state of the union come the 2014 deadline. He also ponders the potential for exchange listing/delisting to be used as a quasi-extra-legal cudgel (my words, not his!) by state insurance regulators seeking additional ways to force insurers into line.
“Oh no they didn’t!” is a common refrain from business owners wondering how that absurd claim could have been paid out by their workers’ compensation carrier. Nancy Germond has a clear and concise explanation of why, “oh yes they did!“, along with an interesting history of how workers’ comp came to be in the first place. Read on at Allbusiness.com.
Do you remember the Dodd-Frank bill? Thought it only applied to big banks and high-falutin’ investment securitization shenanigans? Van Mayhall III has a post at his Insurance Regulatory Law blog reminding us that the new provisions of the law could also affect larger insurance companies and their affiliates in ways that management will want to be aware of well in advance of anything going wrong.
At Colorado Health Insurance Insider, Louise Norris asks whether eligibility criteria for the newly-established federal high-risk health insurance pools is hampering enrollment. Colorado is an interesting vantage point from which to observe this: the twenty-year-old program “CoverColorado” is very similar to the new federal one. The differences between the two programs’ eligibility rules generate good insight into where the federal program is going wrong in attracting enrollees.
Workers Comp Insider Julie Ferguson and I seem to have been on the same wavelength for this blog carnival! I recently wrote a post arguing that the problem of poor price transparency in health care may be an objection to the use of consumer-directed health plans now, but that early adopters will pave the way forward for the rest of us. The chicken-and-egg issue is not all that intractable! Julie Ferguson, on the other hand, has a far superior post addressing the same topic. She points out the immense price differences for the same medical services that exist across state lines and across street intersections alike, and provides links to seven (count’em!) different resources for employers and individuals to use to get the best bang for their medical buck.
This brings CoR-135 to a close. Thank you to all of the submitters for their quality posts on risk, and thank you to Hank Stern for his tireless work managing the behind-the-scenes logistics of every edition of this blog carnival. It really is an honour for this callow medical student to be invited to sit at the grown-ups’ table and host the Cavalcade!
The next edition of Cavalcade of Risk will be hosted by Jacob Irwin at My Personal Finance Journey on July 27th.
For those of you who tried your hand at the national flags-and-trivia sideshow, the answers are here.
The first one was something of a trick question. It’s France! French Guiana sits atop the northern coast of South America, and is every bit a part of France as Paris or Nice, and as such France has land borders with Brazil and Suriname. Bastille Day: July 14.
It’s not an American flag, but there is a reason it sorta-kinda looks like one. Liberia was established as a place to which to “repatriate” black Americans in the early 19th century, the idea being that they could live a life of greater freedom there than in the antebellum United States. James Monroe was one supporter of this effort: the Liberian capital is Monrovia, after him. Proclamation of independence from the United States: July 26.
Next up: Belgium! It’s been quite a while since they’ve had an official government, and the country is wracked by political tensions between the Flemish and Walloon communities. Oath of the first King of the Belgians: July 21.
St. Thomas in Portuguese is Sao Tome (can’t figure out accents, sorry!), and the flag is that of Sao Tome and Principe, a small island nation located along the Equator in the waters west of Gabon and Equatorial Guinea. Independence from Portugal: July 12.
Prior to 1995, the Pacific island country of Kiribati was split by the international date line. Makes inter-state time zone differences in the US seem incredibly convenient by comparison, doesn’t it? After kinking the IDL a bit to the east to accommodate the entire country on one side, Kiribati was positioned to be the first country in the world to see each new day. Independence from the UK: also July 12.