Every year roughly 90,000 men and women receive doctorates in the United States. Of these roughly 19,000 are doctors of medicine, DOs, etc., roughly 45,000 are JDs (lawyers), and the remainder are PhDs, ScDs, and other doctorates.
Something between 60% and 70% of all healthcare spending is by the federal, state, and local governments. Government at all levels employs a lot of lawyers directly and provides various subsidies to lawyers via credentialing and statutory prosciptions against practicing law without a license. I haven’t been able to identify what proportion of PhDs are employed by public institutions but I have been able to identify the number of public degree-offering institutions: there are about three public degree-offering institutions for every private institutions, something like 20,000 in all.
My main question is what’s the relationship between government and higher education? What should it be? Is the government-higher education deadly embrace a self-licking lollipop? I.e. does it produce more people with advanced degrees who demand more government jobs to produce more people with advanced degrees who can then hold government jobs? Or government-subsidized jobs? Over time how can this work? Is higher education a solution to our economic problems or an aggravating factor to our economic problems? Both?
To bridge back to some previous discussions, IMHO too many public school systems are paying for advanced degrees in teachers without regard to whether such certifiations improve outcomes. I believe the studies have shown, with one notable exception, that primary and secondary teachers with masters or PhDs do not produce better students than those without. The exceptions are in certain fields such as math (as opposed to having a PhD in education), though some argue that teachers with advanced degrees in math are not better because of the advanced degree, but because they already enjoyed the subject and had higher mastery of the material before they studied for the degree.
These sort of automatic step-ups for advanced degrees happen in education, public administration and law enforcement, but its probably more perniciouis in education.
I know a fair number of people with doctorates, most recently my wife. All are in hard sciences and all are currently either in the military, directly employed by the federal government, or work as contractors for the government. I know a couple of people with doctorates in various liberal arts disciplines. One, a military historian, is an academic at a public university. Another was an academic for a time, mostly as an adjunct, but decided to stay at home and raise the kids after failing to land a tenure-track position.
Obviously my sample is quite biased. I suspect there are a lot of people with doctorates (and even masters) that don’t use them in their day-to-day jobs.
PD,
That reminds me, one of our friends has a doctorate in aerospace engineering. He designs satellites. When he gets out of the military he would like to teach high school math and/or physics. But he found out that his doctorate and experience won’t mean much in terms of pay and seniority until gets a stupid education degree.
I dont really know how much control govt has over the process. Kids have to want to have that PhD. I suspect it is mostly driven by market forces, knowing that some degrees pay better, herd behavior, and personal idiosyncracies. (I think a lot of folks with the odd PhDs are neuro-atypicals just following their special interests.)
For MDs, I have made some half-hearted attempts to research this, but it is unclear to me who controls how many docs we graduate. My general impression is that they numbers have been kept low to keep salaries up, but that the bottleneck is actually tightest at the residency training level. It is a pain to train new residents. AFAICT, it does not pay very well.
As to JDs, my general impression from recent writings is that law schools try to snare as many people as they can to make money and enhance prestige. There have been suits recently over law schools misrepresenting future earnings to students. Again, I am not sure of how govt would be involved, other than giving out loans. (This should be taken with a grain of salt as I am a doctor and the guild requires me to say harsh things about lawyers at least once a week.)
Steve
It also sucks to spend the night at a teaching hospital. It amazes me how archaic medical culture continues to be.
Law school pricing has elements of a veblen good, the higher the cost, the more desirable the education might be (as the profession might as well). So definitely, I think government subsidies of the student loans should either be zero or under more stringent rules.
There are too many lawyers, and I don’t see the government acting in a way to keep them employed necessarily. I think the problem might be too many lawyers involved in policy-making; who by occupation can always find a rule too simple to reflect all of the complexities and theoretical risks of life. The overly complex rule primarily shifts a cost to the private sector, without necessarily creating a job in the public sector. The government doesn’t have to enforce or understand all of its rules after all.
@Andy- If you are really sick, or have a kid with unusual problems, it sucks to spend the night at a non-teaching hospital. How would you propose we do clinical training?
Steve
The exceptions are in certain fields such as math (as opposed to having a PhD in education), though some argue that teachers with advanced degrees in math are not better because of the advanced degree, but because they already enjoyed the subject and had higher mastery of the material before they studied for the degree.
I can’t see how studying advanced algebra (group & ring theory, etc), analysis (the various Rudin books), set theory and topology can possibly make one a better teacher. However, most of the people that get MS degrees in mathematics also teach mathematics, usually up through calculus. Studying analysis and teaching calculus at the same time could potentially lead to one being a better teacher. Plus, once one gets to graduate level mathematics, all the rest of it just looks easy!
(Some of it is easy. If you don’t find differential equation classes easy, stop studying mathematics – it isn’t the career choice for you!)
steve,
It wasn’t the training per se, and we were actually in two hospitals. Let me explain what happened:
I was up at the in-laws house and my daughter (then 7) developed a bad abdominal pain. It seemed to be growing worse and it appeared to be located in the vicinity of the appendix, so we went to the local ER (not at the teaching hospital). We were admitted and while there we had several nurses and doctors come in and ask us the same series of questions, like, “when did the pain start, how bad is the pain, where does it hurt” etc. Meanwhile someone determined my daughter should have an MRI to image the appendix, so they came in with a big quart-size jug of contrast for her to drink. She wasn’t able to get it all down and, in fact, threw-up twice while trying. I told them it was unlikely she’d be able to drink it with her pain, the bad taste, etc. They insisted we keep trying and eventually decided to go ahead with the MRI. The contrast didn’t make it to the appendix and so the MRI didn’t show anything. It was around that time that my daughter started to feel better. The local ER decided to transfer us to a nearby children’s hospital, which is a teaching hospital (it’s the one in Cleveland, I forget the name).
We originally went into the ER at about 2pm and at midnight we took an ambulance for the transfer to Children’s. We started in the ER at Children’s and had another five or six people come and ask the same series of questions. At this point my daughter wasn’t in much pain and the docs there did not think it was appendicitis. Consequently they decided against another attempt at an MRI and told us the last ER was stupid for trying to get a child with abdominal pain to drink a quart of contrast (a point that seemed obvious to me at the time). Instead they should have given it anally (an option I didn’t know about). Anyway, they wanted to keep her for the night just in case, so we got transferred from the ER to a bed upstairs and it was now about 3am and we were exhausted. The nurse up there started asking me the same series of questions that about a dozen other medical professionals over the course of the day had asked. At that point, I’d had enough and I laid into the poor woman that I’d already answered those questions twelve f’ing times and WTF is wrong with you people that you can’t pass simple info in your own fracking hospital. Of course I apologized and she was very gracious, but the point remains. About 20 minutes later a doc-in-training came in and, sure enough, started asking me the same questions. In between each one he looked up, mentally thinking of which one he should ask next. I answered (by this time I had a lot of practice and had already vented on the poor nurse), but he missed a few. I left the room shortly after he did to use the restroom and noticed him reading something on a computer. Sure enough, as soon as I got back from the potty he was back to ask the questions he’d missed.
So, in the morning, about 6 or 7am, we had another couple of visits, a new nurse and new doctor. Same questions. My daughter’s pain was gone but she was obviously exhausted and hungry (she hadn’t been allowed to eat). About 8 or 9 was rounds and there were about 8 docs-in-training along with the actual doc. This part was actually pretty cool. He discussed the patient history, symptoms and there was a round-robin with the docs discussing various aspects of the case and there was agreement that we should be released.
About a month later I received the insurance invoice (Tricare) and the whole episode was about $4,000 “retail” with Tricare actually paying about $1800. All for what was some bad gas.
And the thing is, Steve, this kind of thing isn’t rare with my three kids. From my perspective, I have to wonder why information and answers to basic questions doesn’t get passed from nurse to doc or doc to doc much less hospital to hospital. It doesn’t make your profession look very competent when I’m asked the same thing a dozen times by people who pop in for two minutes and then leave. Secondly, it seems to me doctors rely way too much on memorization. This isn’t the first time I’ve had doctors ask a series a questions, leave to obviously do some research, and come back in to render their professional judgment. Again, I don’t know the reality, but my perception is that doctors are overly concerned with appearing to know all the answers and projecting that image even when they obviously don’t know all the answers.
In the military we rely on checklists because in high-stress environments they help keep us from fracking things up. We don’t need them all the time, but they are always at the ready just in case. Maybe if there was a checklist for the proper way to give a 7 year old an MRI that first ER wouldn’t have tried to shove a bunch of contrast down my daughter’s throat for a procedure that was a waste of time (and, naturally, my insurance still got charged for it). Why didn’t that doc-in-training have a list of questions ready instead of very obviously straining to remember them – or better yet, why didn’t he have the questions AND answered at hand since I’d already answered them many, many times?
Like I said, this kind of experience isn’t unusual, particularly for my kids. I’d say it’s a once-a-year thing and I’m at the point where I don’t want to take my kids to the ER unless they’re bleeding out. Maybe it’s a good thing, it’s certainly decreasing my utilization of medical services and my daughter is learning too – ever since that visit she is careful to point out that her tummy aches aren’t bad enough to go to the hospital.
@andy, you could take your situation to the enemy guild; they just may be perplexed as to how to make money off of it. But if you’ve swallowed a fly, you might as well swallow a rat to eat the fly.
PD Shaw,
Faith healing is looking increasingly attractive, but then I realize I’m agnostic.
It doesn’t make your profession look very competent when I’m asked the same thing a dozen times by people who pop in for two minutes and then leave.
But it does reiterate that it is a profession when all 12 individuals bill your insurance company. I can’t believe that only cost $4,000!
Yeah, more scientists, that’s what we need. Just get a STEM degree and watch the job offers roll in….
Andy,
I have lots of empathy for the medical odyssey you experienced with your daughter and her abdominal pain problems. I’ve had similar episodes, in the ER, with my Mom and also son. However, the very nature of a ‘teaching hospital’ means that there are medical personnel running around who are taking on patients as part of their learning process. Patients, in essence, become part of their classroom curriculum, including taking physicals, patient histories, asking detailed questions, and going through the whole nine yards of patient assessment in their attempts to render a diagnosis and treatment.
Oftentimes, when shift rotations end, the cycle of questioning just starts all over again, as a new group of student nurses, interns come on board. It’s exasperating, time-consuming, and repetitious. But, as a student nurse myself, a while back, I was part of that whole recycled crew of good-intentioned people….And, yes I’m sure there is a better way to achieve a better blend of learning and care-giving.
And on the subject of teaching math, here’s an example from Chicago.
Jan,
I understand that and I don’t have a problem with the teaching aspect. Like I said, even though I had to wait two hours for the group of doctors to make rounds in order to get discharged, it was pretty cool being there to watch them talk about the case. The annoying issues I experienced at both the teaching and non-teaching hospital and are issues I’ve had in many places. It speaks to training in the profession in general. My initial comment was too snarky and I apologize for that.
@icepick, a little googling revealed two things to me. One is that there is something called an M.A. in mathematics that might be an entirely different program than you are thinking of. Do the studies differentiate? I don’t know.
The other is that there also apparently are studies that indicate a negative correlation between advanced math degrees and teaching outcomes. I’m not entirely surprised; I’m not sure teaching is an entirely learned skill — there are innate personality traits that come to bear.
I wouldn’t mind if there were no automatic step-ups for advanced degrees in teaching, that everything was teacher-specific, but I think we probably need to encourage more STEM proficient teachers in high school in some way.
The MA may or may not be the same thing. Some institutions offer a Masters degree that has an emphasis on teaching. At UF the idea was that those folks could later teach at JuCos and similar institutions. Some education coursework was a part of it, and I imagine it would help a little in getting credentialed to teach below that level, but I don’t know.
The folks getting that degree had to take the same core classes the rest of us did, but got to skip the rather nasty (and archaic) ‘first year’ exams used to flog the rest of us. Everyone considered the education coursework and absolute joke, but it was good for inflating overall GPAs, which may or may not have helped later when looking for work.
As for whether or not those with advanced degrees would be better teachers, it would depend on who has what degree. I would imagine that most probably wouldn’t be, because generally one doesn’t go to graduate school in mathematics with the intent of teaching a bunch of young skulls full of mush how ‘to do’ fractions. Even for the applied guys, abstraction is the name of the game. A bunch of bags of protoplasm expecting you to do something is not abstract.
The one thing I can guarantee is that the person with the advanced degree would know what the Hell they were talking about, and I’m not sure the same can be said of with straight education degrees. However, knowing what you’re talking about and communicating it effectively are two different things entirely, and yes I do have two separate professors in mind. Make that three! But the third was teaching linear algebra and that is a notoriously hard class to teach. (I mean the theory-laden LA course, not the computational ones. Even the algebra guys seemed to think getting stuck teaching the LA classes was a form of punishment!)
One other thing: the degree program I just described at UF was a terminal degree, at least as far as the math department was concerned. You could not use that to propel yourself onto the PhD track, not in mathematics.
I don’t know that more degrees make a better teacher. But people who are really excited by a field often make better teachers, and those people may be the ones who pursue higher degrees.
Andy: I’m with Ice. I can’t believe you got off for 4 grand. For all that doctoring and nursing? I would have guessed that was 10 grand worth of high-octane medical attention.
One trip to ER with my son when he was very young and seemed to be having trouble breathing. We were new parents and didn’t know anything or we would have known that just taking the kid outside to breathe some cold air usually does the trick, as it did on our way to the ER where we eventually spent much of the night. But nowadays we’d have checked online and found that out in advance.
Unfortunately, the system does not support the well-informed patient. I recently had an ER trip for a UT infection. Before we got there I’d looked it up, knew what it was, knew exactly what they’d prescribe, knew about possible drug interactions etc…. Still, many hours and thousands of dollars for what could have been handled with a call to a pharmacy.
I could have (and should have been able to) filled out an online form with a list of symptoms, drive over to CVS, and had the whole thing cost nothing but the price of Cipro.
If we mean to cut usage we need to empower the competent health care consumer. Will there be some increased risk? Maybe. But I suspect I was in greater danger from some infection picked up at the ER than I would have been from a misdiagnosed UTI.
I can tell you with confidence from first-hand knowledge that technology was available 30 years ago. One barrier: technology must not only be as good as a live physician it must be provably better than a live physician to get approval.
@Andy- Wish I had a good answer. First, some redundancy is needed, partially for teaching, but also because people forget stuff. Last week I had a patient who was asked 4 times if anyone in the family had any problems with surgery or anesthesia, including malignant hyperthermia. She said no. She said the same thing on her written survey. When she woke up, she thanked me for getting her through alive because her son had malignant hyperthermia. She told everyone no because she had been tested and thought she was negative. The tests are not super reliable. At least once a month I am the 4th or 5th person to talk with a patient who suddenly remembers something. It is annoying. I understand, but if I am responsible, I want to ask the questions myself. That said, if I had my way we would have fewer people ask all those questions. Many of the people doing this are doing it just to fill out a form. They will never use the info.
As to checklists, I was Air Force. Lots of checklists. I largely agree with you. We use them. However, they are pretty generic. Occasionally I remember something I wish I had asked, so I go back and ask. I’d rather do the right thing.
Finally, I think that a lot of general ERs dont really know what to do with 7 y/os for things like MRIs for an appy. I have heard this before. Not sure why it continues to happen.
And that’s the dumb thing, really. Voice recognition for phones wasn’t better than humans until it had been tested for many years (to the annoyance of all of us) and then, suddenly, it worked. ATMs in the early years used to eat your card and only real-world experience forced the realization that the damned things could just swipe rather than suck in. You can’t expect a technology to outperform before it’s tested in the real world, it’s the real world experience that perfects the technology.
It’s all just a bullshit dodge to maintain physician incomes. The consumer is treated either like a child or as some junkie-in-waiting. I’ve taken Ambien for at least five years without a problem and I still have to get a note from my doctor for each monthly refill. You can’t get high off Ambien, and if I wanted to kill myself I think I could do the job with any 30 day supply. So WTF?
The thing that doesn’t even get accounted for is the waste of my time. To get my kid into camp I have to physically go to the doctor with him, answer questions I could have answered on-line and have her fill out a paper form that is nothing but what’s on her computer and could have been emailed. Blue Cross pays a hundred bucks and I lose two hours of my life.
Educate the consumer, put all this stuff online, stop wasting our time and money with chickenshit and put the savings toward the quarter million bucks it will cost to buy me two extra pain-wracked weeks at the end of my life.
Steve,
Thanks for your perspective and I can certainly see why you’d want to make sure and hear the answers directly. And now that I’m thinking about it there have been times when I forgot some aspect of medical history when asked the first time.
Ice, Michael,
I’m working from memory – it may have been more than $4k. I have the paperwork filed way somewhere. I seem to remember that the two biggest line-items were the MRI and the hospital transfer.
Yeah, I’ve had to deal with that too. Sometimes all I need is a current immunization record, but I can’t get it unless I drive in and get a hard copy. I understand the need for patient privacy and security, but it’s not like that’s hard to do online anymore.
Plus there is stuff that’s billed but not actually accomplished. In my example, my insurance got charged for a failed MRI that didn’t image what was supposed to be imaged. Maybe the ER people would be more cognizant of how to do an MRI for a 7 year old if they didn’t get paid for fucking it up.
In a more extreme case good friend’s son had liver cancer when he was 2 and he received a liver transplant. There was some kind of post-op daily physical therapy as part of the recovery, but most days there was a scheduling conflict or the kid was sleeping so it was missed. He actually got the therapy maybe once or twice a week. Months later when my friends got the itemized list of procedures from the insurance company, it listed a daily charge for the physical therapy. Granted, the therapist showed up so they probably should get paid something, but that was thousands of dollars for services that weren’t provided. Not saying it’s fraud – maybe it’s normal, but it sure is a lot of wasted dollars.
@Andy- I happen to think that a lot of physical therapy is a scam, but that aside, there is generally a separate code, at least in my specialty, for billing for services that cancel due to issues on the pt side. So when I drive in at 0530 to set up a big case and then have the pt showing up for surgery, but they stopped for breakfast on the way, we still get some minor reimbursement. What my group does is not submit a bill unless it was something especially egregious on the part of the pt. If someone shows up sick or cannot make it because they have family issues, we do not bill, even if we can.
I actually agree on the physical exam thing. As to the shot record, folks are truly paranoid about HIPAA stuff.
Steve