Gifted Issues Discussion homepage Forums General Discussion Against the bachelor's degree

We often talk about accelerating education and reducing its cost. One way to do that would be to reduce the number of careers for which
the bachelor's degree is a prerequisite.

English Literature Isn’t Brain Surgery: Why is American medicine so expensive? One reason is that doctors are forced to get bachelor’s degrees.
By Chris Pope and Tim Rice
Wall Street Journal
April 23, 2018

Count me already on board with cutting costs.

However, doctors need a wealth of skills apart from just medical knowledge, and wouldn't English Literature be a useful proxy for thing like:

- Reading and interpreting abstruse language
- Communicating with patients from a variety of backgrounds and communication modes, understanding the spoken and unspoken

?

I could just as easily put my comments below in the thread(s) we've been discussing college costs.

I think the OP is simply part of a larger problem in at least the U.S., I can't speak intelligently about other countries. That problem being that an undergraduate degree has become not necessarily necessary in order to perform certain jobs but instead a sorting tool for companies.

It wasn't that long ago where it wasn't unusual, at least where I live, for companies to employ people as engineers who didn't have a college degree in engineering but had demonstrated keen ability in their field of engineering. Most companies these days don't allow that anymore, the degree in the field of employment is a requirement for being hired.

No doubt the internet has done amazing things and provided us with opportunities that never existed prior to it's wide spread use. In the market, it lets the world become our customers......on the other hand, it also allows the world to become our competitors.

It used to be that when a new job was available, a company would post it in the local and perhaps most popular read state wide newspaper, that was the extent of who knew about the job opening. Now, the newspaper is generally ignored and anyone in the world can look at the help wanted ad posted online. That creates a huge amount of competition for a new position opening. That's of course a good thing from the perspective of the company, however, they need a way to start sorting out candidates. An undergraduate degree is often that first measuring stick to begin the process or sorting....and why not? One with an undergraduate degree has demonstrated at least SOME ability to stick with it and complete a task, they have demonstrated the ability to learn, and it's a fair bet they had to complete quite a few assignments in groups. It doesn't though, mean they'll be a good employee or that their degree is needed to accomplish the job.

This has created a situation where companies are using a very expensive means for the job seeker as a basic sorting method making that sometimes unneeded means an expensive requirement with little application to show for it after the initial sorting process.

So how do we remedy that? Good question. I'm going to have to chew on that one for a while.

Interesting idea. It would be useful to understand how health outcomes vary for patients of doctors with various levels of pre-med accreditation.

In Canada, not all medical schools require that the prerequisite undergraduate degree be earned in a STEM field (though students contesting the MCAT are certainly better positioned if they have a strong science background).

A similar case could be made for many professional certifications--law, business, communications--because students don't explicitly need undergraduate studies to be able to complete the programs. However, to a large extent extent, personal maturity and life experience factor into the ability of professionals to carry out their work effectively and efficiently, especially in fields where work tasks are heavily EQ loaded.

IMO, an argument could be made in favour of such programs requiring a certain amount of meaningful life experience (e.g. entrepreneurship, work experience, patented discovery, full-time volunteering, post-secondary education, etc.) as prerequisites to the core studies. This is the challenge with developing cookie-cutter accreditation programs, because individual experiences, maturity, EQ, communication skills, and technical qualifications vary substantially.

Adding quickly: medical school in most other countries begins directly after secondary school and lasts for 6 years. AFAIK, this is the model in Europe, Australia, and elsewhere.

Also, other countries subsidize education because their leaders see it as an investment in the health of the society and its economy. This means that people aren't paying $85,000 a year on top of whatever they paid for a BA.

Yes, doctors incur a lot of debt, but most of that usually comes from med school. In this case, eliminating bachelors degree wouldn’t really lower costs in any meaningful way.

Second, doctor’s salary’s are not the factor driving up healthcare costs. It’s how the field is structured, with pay being tied to procedures and tests rather than treatment efficiency.

One could argue that the recent movement toward having routine primary care increasingly provided by bachelors-plus and masters-level professionals, such as PAs and NPs, is a response to the length and expense of doctoral-level medical training. and its impact on the supply of healthcare providers.

Sure, that's true for doctors who attend public universities (especially with scholarships). But eliminating some or all of the time spent in a bachelor's program does augment the time in which doctors can earn income and repay debt by 2 years, which is meaningful.

This isn't to say abandoning a bachelor's is the way to go, just that there are financial benefits from doing so, provided the doctor is equally well trained under both models.


Salaries are cumulative fees per procedure less overhead. The difficulty is pricing within an HMO insurance model, which superimposes an insurance-motivated pricing structure over an otherwise functioning market.

Parents would be more willing and able to pay for at least part of medical school if it were not preceded by four years of college bills. My wife's medical schooling was funded by her parents in a country where you take pre-med courses in the last 2 years of high school and then go to medical school if you are accepted. She knows her medicine as well as American-trained doctors do (she passed the USMLE exams on her first attempts) and could start her residency in the U.S., debt-free.

Instead of shoveling ever greater amounts of money into a needlessly slow and expensive educational system, change the system.

This exactly. My firm does a lot of work on optimal health system design and has found a strong argument--both in terms of costing and patient outcomes--for adopting a tiered care model.

(It's also part of the reason why I always choose a family practice that is housed inside an academic health team affiliated with a university and hospital.)

With the differences in health systems around the world, I doubt that you could make a meaningful regression analysis about whether the two years‘ worth of classes required by gen Ed’s or distribution requirements or core classes or non-STEM majors taken by US premed students make any difference in outcome.

However, considering that the US appears to be the only country in the world doing it this way and considering how easily health care professionals can move between systems once bureaucratic hurdles are overcome, my educated hunch would be „none whatsoever“.

My DH, who teaches science, has referred to studies done in the kind of „proxy education“ that Dude has referred to (so, just hearsay, no citations, sorry). The results being that the outcomes are best if you are actually specifically taught and practice what you are supposed to be able to do. Eg, if you want students to be able to read, understand and work with complex scientific texts, make them read, understand and work with complex scientific texts. As opposed to making them read Jane Austen. If you want them to effectively communicate with patients (or other health care professionals!) from Hispanic communities or countries, teach them exactly that. Don’t make them read and talk about Cervantes.

Would I want to be treated by a doctor who doesn’t care about literature or cultural issues at all? Frankly, it wouldn’t be my priority, nor do I think a college class enforced by distribution requirements could change that in a meaningful way.

It’s the doctors who cannot weigh scientific evidence or apply independent scientific thought as opposed to presenting cookie cutter solutions who scare me.

Another point of evidence: I understand that med schools simply do not care about those parts of their applicants education at all, basing admittance on a recalculated GPA excluding non STEM subjects and on MCAT results.

So, 2 years worth of classes, for up to 140.000 $ (plus 2 years’ reduction of earning potential, probably twice that sum if not more) , just to make med students/doctors appear more well rounded than they presumably were after high school? Who does it really benefit? It’s not like anyone is stopping these students from reading and enjoying Jane Austen on their own, after all.

My point is that if your goal is to reduce healthcare costs, simply doing away with the bachelors degree requirements for MDs will not have a meaningful impact. My husband made it through 4 years of undergrad with zero debt, but we have a wagon load of debt from med school. And the idea that parents will help with tuition is such a privileged idea, especially with costs being what they are today.

IF the goal is to lower healthcare cost we need to fix the system and not blame the doctors, many of whom struggle with crippling debt for years after they finish school. If we’re just talking about streamlining the process for medschool to make things easier for doctors, there are interesting points to be made, but I was referring to the discussion about healthcare. There seems to be 2 separate conversations going on.

Granted, the complexities are significant, but they're not insurmountable.

There are some effective methods to study within-state and within-local health authority differences in clinical outcomes that could be mapped reliably to doctor credentialing. This is already done when piloting new medical school subjects across jurisdictions and specialties to justify the new program expenditure.


Canada has a blended model.

In Quebec, lower tier med schools require a CEGEP diploma (equivalent to a 2-year college certification). Lower quality medical schools in Alberta require 2 years of undergraduate study. Upper tier Quebec and rest of Canada medical schools generally require at least a 3-year bachelor's degree, with a prescribed set of science and math course requirements as prerequisites to an MD.

Foreign MD credentials are only sparsely accepted in Canada, with the majority of foreign doctors accepted being specialists from Australia, New Zealand, Britain, the US, Singapore, Switzerland, Hong Kong, and South Africa, largely from the mid-1990s onward. That excludes a lot of foreign doctors, and almost all GPs. There has been a concerted push within the Canadian medical community to build bilateral credential recognition mechanisms, even in the face of GP shortages, and the needle hasn't moved much on recognizing doctors outside a limited range of institutions. So, at least within the Canadian context, physician regulatory bodies have judged the additional training to be beneficial for patients.

(In case you're curious, I've linked the Royal College of Physicians and Surgeons of Canada credential recognition criteria below.)

http://www.royalcollege.ca/rcsite/c...gs/jurisdiction/accepted-jurisdictions-e

PM'd you on the off-topic stream!

No, it’s actually the same conversation, because you are creating an artificial line between whether the cost of your husbands education was incurred at the undergraduate or the graduate level and whether the education happened to be free at the point of delivery for your husband.

Whether he came out of the undergaduate part debt free or not, *somebody* paid for those two years worth of general ed. Your husbands parents, other students parents, tax payers, endowment donors. It wasn’t free, the costs just have been shifted. And don’t forget to opportunity costs - how much money does your husband make, on average, within a year of his professional life, times two?

If the cost for two years of general ed, delivered at huge cost at sleep away college by PhD carrying lecturers (as opposed to high school, as per the educational model of most other countries in the world) were not incurred in the first place, there would be no need to shift it around.

It doesn’t mean that you don’t still need 6 years of targeted medical education, with 4 years of clinicals and stuff, after the premed stage. It will be expensive anywhere and it doesn’t matter whether the institution that delivers say, year 3 and 4, happens to be called college or med school. But you basically shave off 25% of the cost of education the most highly paid staff in the system. It must make a difference somewhere - where, that’s up to the system.

This is one of those things that's a bit odd.

If you're doing a PhD in a STEM subject and you're paying for it, that's a very bad sign (meaning that you're probably studying at a for-profit or other very low status university).

PhD students get paid to do a PhD, but MD students have to pay a king's ransom.

One could argue that PhD students are "doing work" by doing research, and therefore should be paid. However, this simply isn't true at first, especially in the US model where they have to take classes. And med students start doing work when they get into the clinic in year 3. Sure, they're relatively clueless, but so are PhD students.

Sounds like the criteria are, quite simply: first world country, English language education (the latter partially including Switzerland, which appears to have moved further towards using English in STEM education than other European countries). Of the cuff, I can say that both Britain and Switzerland have targeted medical education right after the high school level. Britain actually stops general ed after GCSEs, at the age of 16. A student may have seen nothing but STEM subjects from 11th grade onwards. Higher ed in all of the other countries tends to be modelled after Britain.

If you were to compare outcomes across Canada, you’d have to make a regression analysis removing the differences in both quality of student intake and of premed education at CEGEPs (which are really 12th year of high school and one year of college) and other 2 year colleges compared to the 3 years bachelors degrees at more reputed colleges, And then, specifically doctors whose extra year(s) of post secondary education have been spent with subjects related to medicine as opposed to general ed.

*everything else being equal*, I challenge you to find a significant improvement in health outcomes with doctors who have spent another two years in college taking general ed classes.

It's an artefact of the monetization models.

Doctors have a guaranteed, highly predictable client base with a strongly validated proof of concept in their field. Also, demand for health services is more inelastic (less sensitive to prices) than R&D activities because of the universality and the perceived immediacy of need for what they're offering.

PhD researchers are developing the PoC and generally must make a case for financing their activities to serve a largely undefined client base. Also, because their activities are more detached from the every day experience of most of the population (especially in early stage development), it's more politically challenging to build support from non-traditional sources.

Differences in the incidence of tuition fees across MDs vs PhDs is largely about compensating PhDs on a risk-adjusted basis. The stream of income for most PhD researchers is more variable than for MDs over time and across disciplines. So, high risk equals high reward, in a nutshell.

Nope, these are credential recognition criteria for specialties. Within those countries, recognition is done on an institution-by-institution basis.

ETA for clarity: International GP intake is funneled at the provincial level and based on a standard of meeting "Canadian or US equivalency" as designated by either the Committee on Accreditation of Canadian Medical Schools or by the Liaison Committee on Medical Education of the United States of America.

It's not arbitrary. These are the Canadian checklists used, and individual site-selection and evaluation is done on a per-institution basis--

https://www.afmc.ca/accreditation/interim-accreditation-review-process-irp/checklists


Correct, and that's what's done.


Ah, but you're mis-specifying the base case if you're referring to Canada.

As I mentioned above, in Canada, these doctors aren't taking gen ed classes--they're taking mostly prescribed science and math subjects as prerequisites to med school. So it's not +2 years in gen ed vs not, it's +1/2 years of undergraduate level science training at the third or fourth year vs non-US international models where students do not take a separate gen ed undergrad.

If we're talking the US, then yes, base case is no gen ed vs +2 years gen ed to med school. You'd need to specify a vector of elective courses and weight their quality by institution.

My hunch is that, even in the US, you'd have significant improvements in clinical outcomes for some psychology and pre-pharmacology courses, because there's good research out there to support empathy training among family practitioners and enhanced pharmacy training for high-risk patient populations.

Where there's significant cultural or linguistic variability in a patient population, the presence of multiple language credits would correlate strongly with patient compliance for treatment regimens simply by dint of more effective doctor-patient communication. This is something of substantial value in major cities with diverse populations. Similarly, if doctors are working among at-risk populations, courses in social work that link medical patient outcomes to community-based program offerings and home-based care can improve medical outcomes through partnership with tertiary service providers. It's all relevant.

You've got me curious. Any chance you work for a grant-issuing organization that's interested in funding this research?

But you are proving my point, aren’t you?
I’m sorry, I didn’t feel up to delving into that link you so thoughtfully provided. (Twobad nights with sick kid...ugh).

My point was that the criterion for recognition was NOT where the education systems in these countries place the transitions from general education/general STEM/targeted medical education and training at the ages of 16/18/20 or 22, with the UK and the US being at opposite ends of the spectrum. The criterion is these specialists’ medical education and training, and if the credentials they bring happen to be in the English language and acquired in education systems the Canadian body feels familiar with, you end up with this specific set of countries.

Haha, I wish, lol. No, comparative education must, at thistime remain my hobby (i think it started for me when i read Gaudy Night at the age of 12 or so). Still trying to find ways to turn this passion into a career, but it would probably mean to go back for a PhD.

No worries, just delighted to have an interesting conversation with you! You're asking all the right questions, IMO, and they deserve to be answered (if not by me, then by someone with the funding).

Sorry the kiddos aren't feeling well. Rest up and take it easy!

Keep me posted and feel free to PM any time on this subject. It's definitely an interesting one, and I'm loving hearing your thoughts.

You’re editing even faster than I am.

Again, I think you are proving my point - it’s targeted education that has a chance of improving health outcomes, not proxy education. Pharmacology, psychology, communicating with at risk populations - that’s not the same thing as “3 credits in social sciences, 3 credits in language and literature etc. All of this should be part of medical education, but you need to prescribe it, not trust that a student who may not even be sure about med school at that point, somehow stumbles their way there. If you then squeeze all of the targeted education into 4 years of med school, those subjects probably fall by the wayside more often than not,

Thank you, I’m blushing! If at any point my high needs kids turn into medium or even low needs kids I might actually find the time to at least seriously think about this. So much more interesting than the taxation PhD I dropped out of. Maybe I’ll compare the various laws, and implementation therof, on inclusion in education with special regards to both gifted kids and kids with disabilities or something, to straddle disciplines. I hear that Canada does great on inclusive models!

Sure, there's probably not a lot of daylight between our arguments. I do wonder what proportion of students self-select into those kinds of courses. If there's significant overlap and those general credits are being met with practical material, then that approximates a specialized credential.

I do maintain that the Canadian model is an excellent one in making those requirements explicit. (But maybe that's just national pride showing and junk, a priori conjecture.)

And yes, x1,000 that med school provides inadequate coverage of many important subjects that should properly be broken out as core classes. Here's a small example of that--in Canada, GPs receive 1 hour of instructional time on breastfeeding. This is a universal food and a vaccine, and yet it receives less instructional time than the rhythm method in family planning.

Reducing the debt burden on doctors would not have as great an impact on overall health costs because of the way the system is structured. For instance, there is a wide disparity between what doctors make depending on what kind of treatment they provide. This has some correlation with how much training they must undertake post-residency, but it is not strictly tied to that. Additionally, the salaries are set across the board, with doctors in smaller cities making relatively the same salary as a counterpart practicing in a metropolitan area with a much greater cost of living (although they are sometimes compensated with housing subsidies if the costs are too outrageous). There is also little salary incentive when it comes to supply and demand. There are often a shortage of pediatric specialties because they are among the lowest paid physicians, often making far less than their adult medicine counterparts. In rural areas this can lead to higher costs as the county may have to chip in to offer a physician a sizable bonus to attract them to the area. But why does the correlation between DR salary, education level, and treatment population seem so caddywhompus?

Those salaries are based on billing. Meaning, the doctor's are paid based off of what they can bill for - in clinic visits, testing and lab work, surgery and procedures, etc... This effects the treatment decisions that your doctor makes, often running more tests than are required, and even sometimes recommending surgery when it may not 100% be required. More tests and more procedures means that you pay more overall and the doctor gets a cut for his services.

Here's a case I'm currently dealing with. My 3 y/o has severe allergies so we need to start immunotherapy. Our allergist offers an oral therapy option (which would be awesome, because - no shots - and we can do it at home instead of weekly office visits), but it's generally not covered my insurance, even though traditional immunotheraphy injections are covered. Why? Since we do administer the medication at home the doctor's can't bill for an office visit, so it hasn't been widely adopted as an allergy treatment in the U.S. However, it is quite commonly used in European countries where salaries are not tied to billing.

This model has all sorts of implications for how offices are run, how research is conducted and where health services are available.

So yes, you can lower the debt incurred by doctor's, but that isn't going to reduce healthcare costs. It is a structural flaw in the billing system that is the cause of inflated costs. Unless that is fixed, lowering the debt burden will only result in greater take home pay for the physicians.

*Squeal!!* A fellow tax geek! Gifted/2E inclusion! PM coming your way.

I love Davidson.

/Sorry to everyone else, this thread has clearly appealed to my inner nerd-dom. Thanks for politely putting up with the OEs flying here.

Seem so what? Caddywhompous? This is not a real English word, is it?

And pray, who is running this show? The insurance should JUMP at the chance of paying the cheaper option. It’s the doctors who need to pay off their med school debts who must insist on Bulling office visits - the insurance doesn’t profit.

Let the OEs fly!

Tigerle,

I grew up in a small town in the mid-west, which affords me the use of lots of colorful colloquialisms


I've submitted a claim to the insurance for authorization, so hopefully they will cover it. I had the same logic. Wouldn't they want to if it is cheaper overall? But with these big corporations often times if something is not already standardized in the playbook they try to avoid dealing with it.

The insurance doesn't profit, but the entire medical system does, which is run like a for-profit corporation. So, you're right that the doctor's benefit from this system. (Some, not all. My husband is a pediatric endocrinologist and makes a salary on the lower end of the MD spectrum. Diabetes patients are the bread and butter of his profession and most of their care is dealt with at home - so no regular billing for office visits.)

Do you expect that if the doctor's have lower debt burdens that they will, out of the goodness of their hearts, take a salary cut? Some doctors choose their particular profession strictly because of the take home pay incentive. The current system allows some to inflate their take home pay by gaming the billing system, sending unnecessary charges to the insurance, who then pay the medical facility. All of this drives up out-of-pocket costs as well as insurance costs.

In a private clinic setting, you're correct, it's the doctors making these decisions. In a larger facility, these decisions are taken out of doctors' hands.

On the surface, your logic about insurers would appear to be correct. However, given that they're mandated to spend a certain percentage of their income on healthcare, they're incentivized to pay for more costly procedures. More spending equals more profits, so long as they can continue to pass on the costs to their customers. And the insurers have figured out a basic truth, which is that their customers will dig deep into their pockets and accept all kinds of quality-of-life compromises when the alternative is suffering for themselves and their loved ones.

I am not so naive as to think that everyone with less student loan debt will ask for less compensation, but I will note that those with higher debt are forced to seek higher compensation. One of the reasons my sib in family practice is able to maintain (barely) a private primary care practice open to underserved populations is that med school at an elite was accomplished without any student loan debt at all--but that's also owing to the investment of a few additional years and effort into an MD/PhD. Peers from the same med school cohort did not have the same option, since they had to find specialties and positions that would optimize student loan payback in short(er) order.

And I would agree that primary care and almost all pediatric specialties are significantly disadvantaged by the current reimbursement system. Which, incidentally, also disproportionately affects female physicians.

On another note, I admit to considerable ignorance regarding economics (but I have friends who are economists!), but I'm still finding aquinas and tigerle's exchange quite entertaining.

Now you are talking about individual doctors again.

It is all ab It how you incentivise a system, and which lobbies shape the incentives.

Clearly, a system in which office visits are artificially inflated benefits neither insurers nor patients, but doctors - as long as every single office visit is reimbursed on a scale that makes economic sens. The insurance simply won’t care, as long as they can shift the cost to the patients in the long run. So, inflating office visits must be a policy that has been lobbied for by doctors‘ professional associations, whose primary motivator is driving up income.

Can there be any other motivator, you ask? Sure, there professional ethics and pride, but those need room to work! If the system ie shaped diffentlym eg if insurance contributions are capped, or if a single payer acts to keep costs down, you can cap the revenue from office visits. Suddenly, patients who turn up are more work than they are worth. Overworked NHS GPs do not lobby for more office visits, even if they were to generate a somewhat higher income, because they do not have astronomical debts to service.
Hopefully, doctors then should have an incentive to lobby to be reimbursed for exactly the number of office visits from a patient they need in order to do their job, and do it well.

If you have a workforce made up of servants indentured to their student loan companies, the primary motivator must always be driving up income generating costs, It’s not about doctors being good or bad people, it’s about whether professional ethics endanger your preofessional and financial existence.

Edited to add that I do hope this situation works out with the least burden on you and our child!

I’m not really just talking about individuals or good vs bad. But we have a system that encourages profit seeking over patient care. They try to mitigate this with patient satisfaction surveys, but these tend to be unreliable. And I’ve witnessed pressure from the top to meet office visit quotas. When working in a larger system the doctors are made to conform to certain profit models.