BY ANISH KOKA MD
The hottest medical school in the country right now is the New York University School of Medicine thanks to the gift of a generous benefactor that promises to make medical school free for all current and future medical students. The news was met by elation from the medical community of physicians that groans frequently about student debt loads routinely north of $ 200,000 upon matriculation. Not surprisingly, the technocrat class of public health experts and economists did not share in the jubilation. The smarter-than-the-rest-of-us empiricists are, after all, trained to think in terms of social justice and net benefits to society. The needs of medical students are far down the list of priorities when forming this social justice utopia.
Contemporary arguments for social justice in some form or the other trace their roots to the philosopher John Rawls and his 1971 magnum opus – “A Theory of Justice”. In words that would infuse liberal thought for a generation, Rawls laid out a blueprint for a just society by proposing a thought experiment called “the original position”. This was a hypothetical scenario where a group of people are asked to form the rules of a society which they will then occupy. The catch is that the people making the decision do so behind a ‘veil of ignorance’ not knowing the disadvantages conferred by any number of attributes (age, sex, gender, intelligence, beauty, etc. ) they may be reincarnated with. Rawls posited that under conditions in which there was a possibility of being born as a disadvantaged member of society, social and economic inequalities would be arranged to be of greatest benefit to the least advantaged members of society.
At first glance it would seem that the objections to tuition free medical school rests on a social justice framework that does not seem to comport with gifts to the soon-to-be-wealthy. After all, the $ 200,000 investment for medical school pales in comparison to the lifetime earnings of the average physician who is assured at least a six-figure income in seeming perpetuity. But it is not entirely clear that one has to even combat Rawlsian ideals to rebut the social justice do gooders with strong opinions on how other people should spend their money. A Rawlsian framework never intended that everyone in society would be able to achieve the same outcome regardless of starting position. Rawls actually went out of his way to argue that inequalities were justified in society as long as the operating rules served to raise the position of those worst off in society. A rising tide should lift all boats – the rich may become richer, as long as the poor become richer as well.
In this context, a prize that can be partaken just as easily by rich and poor would seem to be just what would emerge from behind the veil of ignorance. Unfortunately, in 2018 it is not enough to ensure access to opportunities, everyone must get a prize. So it has come to pass that all social prescriptions are now evaluated based on their ability to improve racial and socioeconomic diversity. At the moment, about 6% of medical students are black, and 5% are Hispanic. This is a problem, we are told, because this is not representative of the nation as a whole. Why, one may wonder? In a field where lives depend on quick thinking, experience and expertise, it would seem that the least important traits in a physician would be the color of their skin, their gender, or race.
Since we live in a world where nothing escapes quantification, researchers routinely try find the elusive needle that will tell us once and for all of the overriding importance of diversity. And so we are treated to the spectacle of esteemed researchers at even more esteemed institutions cruching data to see if patient mortality has anything to do with physician gender. I confess I would never have embarked on a study even if I had the ability because I think its a dumb question with answers that are wholly irrelevant. Patients taken care of by a male physician, may end up seeing a female colleague within the practice for an urgent medical problem or vice versa. The attending in the ICU may be male, but the senior resident could be female, and every 12 hours a different nurse is at the bedside. Who exactly owns the patient? Is there really one gender we can point to that controls the outcome that befalls the patient? Even if it was possible to definitively detect a difference that exists along gender or race, would it not be more valuable to identify the elements that lead to better outcomes and emulate them as a group?
Nuance, however, doesn’t translate to New York Times headlines and these questions did not deter these plucky researchers who used Medicare spending as a proxy to attribute hospitalized patients to physicians by gender. Since each visit by an attending physician with a patient who has Medicare generates a billing claim, hospitalizations were assigned to the gender with more billing. 51% to be exact. To clarify : On any given hospitalization, if you the patient saw a female physician for 51% of the time, your hospitalization was deemed to have been managed by the female gender. A woman’s touch in this case resulted in 0.4% lower 30 day mortality – enough for the researchers to posit that a medical system devoid of men would mean 32,000 fewer deaths every year. But before we launch a pogrom for male physicians in service of the greater good, consider that this conclusion derives from a large 1.5 million patient observational study that describes a correlation.
A large sample size is good for finding small but important effect sizes, but importantly also increases the chances of finding spurious correlations. And correlations without plausible underlying mechanisms may well lead one to the highly correlated conclusion that marriage rates in Kentucky have something to do with the number of people who drowned after falling out of a fishing boat. So the fact that no one can pinpoint a clear mechanism to explain how the difference between 32,000 patients living or dying boils down to male physicians being involved 49% of the time is a major problem. So even if one accepts as plausible that the dictates of biology mean women are better healers than men, one than has to accept as feasible that an extra u1% involvement in any given hospitalization is lifesaving. The Virgin Mary herself would struggle to be this effective.
Exposing the thin evidence for prioritizing diversity over all else would be a full time job, but unfortunately this house of cards of evidence is how we get the smartest folks in the room uniformly opposing tuition free medical school on the grounds it won’t promote diversity.
Apparently the United Colors of Benetton advertisement that the current crop of United States physicians could star in isn’t diverse enough for the champions of diversity. Almost 40% of physicians come from the Indian subcontinent and half of all physicians being trained right now are women. Increasing the percentage of under-represented minorities in medicine will do precious little to quench the massive outcome gap that currently exists between rich and poor zipcodes – the roots of which are deep and go well beyond conscriptive social policy that would put a physician to match your color/race and sexual orientation in every neighborhood.
And even so, the problem of implementing policies to engineer the right kind of diversity necessarily contradicts the society that would be formed behind the Rawlsian veil of ignorance. If going to medical school is akin to winning entry into the top 1%, does punching winning tickets based on race and color rather than merit automatically follow? There is a fundamental truth that no p value or 10 million strong study will overturn – your health may one day require an astute ER physician who chooses to push for an admission to the hospital even though the labwork looks ok, an inquisitive internist who puts together a large cardiac silhouette on an X-Ray with low voltage on an ECG to diagnose fluid collecting around the heart, and a diligent cardiologist who will get out of bed at 4 am to to stick a seven inch needle into the fluid cavity around your heart. And this little vignette is far and away the easy stuff. The point is that the sarcoma, the leaking abdominal aortic aneurysm, or the ruptured coronary plaque care not about the socioeconomic status of the hands that will be called to heal.
While there are many in society that will do the job, there are relatively few that you want to do the job. The profession of medicine should wallow in elitism like pigs wallow in mud. Make medical schools harder to get into, not less. The goal is Seal Team Six, not some band of nincompoops. In this context NYU is discharging its responsibilities well – in the minutes it took for the story of the gift to go viral, they went from being middle of the pack to becoming a destination of choice for elite college graduates.
The sad (though understandable) part is that it took a middle of the road school to fire the first shot. Much higher profile schools – think Harvard, Stanford – always have had the opportunity and ability to do what NYU did, but instead chose the virtuous path of allowing medical students to take on hundreds of thousands of dollars worth of debt.
Hubris lives large in this space. Hubris to think medical student debt makes for a more just society. Hubris to believe a better ratio of under represented minorities in medical schools will solve society’s ills. Hubris to think to know the distribution of specialties medical students should choose.
It turns out the veil of ignorance isn’t a theoretical construct after all. The overthinking class live behind it, creating fantastical worlds comfortably insulated from reality. A truly just society emerges from rejecting the collectivist principles that spring forth from this merry band of technocrats. The gift to NYU from a private benefactor is a response to an important signal from the physician community. It may not be what the economists want, but it is just what the doctor ordered.
Anish Koka is a Cardiologist in Philadelphia. He can be found trolling on twitter @anish_koka