Do doctors "look like America" (or not?)

By Razib Khan | April 6, 2010 4:25 pm

With the passage of health care reform, and the shift of the medical profession away from private practice and toward large institutions already, I wanted to revisit some data about the political orientation of medical students and recent graduates surveyed in the mid-aughts. One of the major issues among American elites has been the occupational bifurcation politically between liberals and conservatives, with the former concentrated in the professions which are often affiliated with the managerial state, and the latter within the business sector. Until recently I had assumed that medical doctors were an example of a profession which tended toward conservatism because of the bias toward private practice and the general lack of direct state involvement (as opposed to regulation) in their occupation, but this seems an older model. Political Self-characterization of U.S. Medical Students shows that medical students actually tend toward liberalism vis-a-vis the general population, and even young adults in their primary age group. No doubt this may change as they age, but I am skeptical of this because it looks as if medicine is going to resemble a public sector occupation more, not less, as we proceed. I reformatted table 1, removing a few rows which I felt were extraneous. Additionally, I added columns which show the proportions of medical students by ethnicity and religion (where they received close to 100% response) and the general population ~2008 (from the American Community Survey & Religious Landscape Survey).



N Conserv. % Mod. % Lib. % Students % Population %
Total 4918 26 33 41
Female 2260 18 32 49 46
Male 2654 33 34 33 54
Mother’s ed.
No HS diploma 81 17 43 40
HS diploma 240 27 35 38
Some college 284 33 34 33
College 625 28 38 35
Grad school 549 20 35 46
Med school 60 17 38 45
Father’s ed.
No HS diploma 79 22 40 38
HS diploma 178 22 36 42
Some college 163 23 40 36
College 420 30 34 35
Grad school 696 25 34 41
Med school 296 23 39 38
Ethnicity
Asian 932 17 41 42 19 4
Black 388 9 33 58 8 12
Hispanic 201 15 32 53 4 15
Native/Other 242 23 40 37 5 -
White 3141 32 31 38 64 66
Religion
Atheist/None 879 9 29 63 18 16
Buddhist 78 9 42 49 2 1
Hindu 231 8 41 51 5 0.5
Muslim 119 21 43 36 2 1
Catholic 1105 30 35 35 22 24
Jewish 323 17 26 58 7 2
Other Christian 814 31 41 28 17 -
Protestant 1102 45 30 26 22 50
Other 235 9 30 61 5 -
Ever married
Yes 1002 39 31 30 20
No 3885 23 34 43 79
Specialty
Primary care 1423 25 33 43
Emergency 338 25 34 41
Family med 477 31 28 41
General internal 366 24 35 41
Ob/gyn 268 16 24 60
Pediatrics 537 21 36 43
Psychiatry 116 17 27 56
Surgery 647 34 37 29
Other 437 27 31 42

There were a few religion categories which don’t seem to map well between what was asked in the survey of medical students and the general population, so I omitted them. Specifically, it seems that many medical students are nominal Christians who simply selected “Other Christian,” while in the general population this class consists mostly of heterodox groups such as Mormons, Jehovah’s Witnesses and Christian scientists. The “Other” religious segment also seems inordinately large, and I suspect that they would be “Unaffiliated” in the Pew survey (if the question is asked so that “Atheist” is part of the category that will scare away a substantial subset of those who aren’t members of organized religions but have some vague supernatural beliefs). Finally, it seems strange to me that they clumped “Native” and “Other” races together in the medical student survey, as it seems likely that many who didn’t want to respond or were mixed-race are in this group, so I didn’t compare it to anything in general population.

No great surprise that pediatricians are more liberal than surgeons. Perhaps I’m employing stereotypes that people may find scurrilous, but I don’t particularly care. Some of the trends among specialties are confounded with the fact that there are differences in sex ratio across them; specialists or those who wish to be specialists are more likely to be male than female, and females are more likely to be liberal than male. Correlations are not necessarily transitive, but I think that’s what you’re seeing here. The liberalism of Asian Americans is not that surprising, but notice that Hindus and Buddhists are even more liberal. The majority of young Asian Americans are now of non-Christian religions, or irreligious, but a significant minority are Christians, and often conservative ones at that. The higher proportion of conservatives among the whole Asian American group is probably a function of the fact that Christians are more comfortable with the conservative movement than non-Christians. If you are a racial minority being a non-Christian makes it very difficult to identify with the modern Republican movement; being a white person at least allows for racial solidarity, while being a conservative Christian allows for ideological solidarity. No matter the “family values” or high incomes of Asian Americans, those who are non-Christian are going to be deeply alienated from the party for reasons of identity for the foreseeable future (yes, I know there are secular libertarian Asian Americans who are Republican. When I was more politically engaged I was in that category).

Interestingly, non-Hispanic whites are represented in proportion to their numbers in the general population among young doctors and medical students, though a bit overrepresented in proportion to their age bracket. As older individuals are more likely to need medical care, and these are more often non-Hispanic white, it will be common for non-white doctors to interact with older patients who grew up at a time when America was an explicitly biracial, and implicitly white, country. I have talked to young Asian American friends who recount experiences with very elderly patients whereby it is difficult for these individuals to grok that they were born and raised in the United States because these patients have an image of America which is derived from their youth.

The prominence of ethnically Asian software engineers, or in scientific institutes, is a well known feature of the American landscape. But these are not occupations which require a great deal of interface with the general American public. Professions like medicine do require that interface, that is one reason that there is focus on getting underrepresented minorities into medicine, so that they can better serve their communities. When it comes to elderly white patients who are going through chronic illnesses at the end of their lives I think it is probably not practical or appropriate to expect too much consciousness raising in regards intercultural dynamics and sensitivity. Rather, I think the onus is going to be on young Asian American doctors to try and understand the perspectives of their patients and the America from which they came, an America which they and their parents have changed in fundamental ways by their very presence.

CATEGORIZED UNDER: Culture, Medicine
  • John Emerson

    Most of the harm that socialized medicine could do to individual doctors has already been done by the HMOs. And it’s been 10-20 years since medicine was a good choice for a smart person looking for a big paycheck. (40+ years ago a doctor with high ranking family connections in medicine told me that medicine has never been the best money, though his points of comparison seemed to be MDs making $200k a year vs. businessmen making six figures. The advantage of medicine is the combination of $ and prestige.)

    Social conservativism drives away several categories of people. I used to think that this was an American thing, but I’m not so sure. Conservatives everywhere seem to rely on tabloid-reading gut thinkers with rigidly conventional ideas.

  • mike mck

    The social involvement premeds seem to feel they must do to build a good resume for med schools may be shifting the political attitudes of pre-meds and thus med students. I don’t know if this includes the high surgery or other specialty types, but it certainly seems to be the norm among lots of pre-meds.

    The smart and more conservative may go into law, although at least trial lawyers will support bad medicine as long as tort reform does not happen.

  • http://blogs.discovermagazine.com/gnxp Razib Khan

    Most of the harm that socialized medicine could do to individual doctors has already been done by the HMOs.

    this is a complicated issue, but from what little i know HMOs put the squeeze on in the 1990s, but have been having difficulties of late. the main issue is that the public hates insurance companies, but like their doctors and hospitals, so want the latter to be paid at the expense of the efficiencies/profits of the former.

    i agree that medicine is not as well remunerated today as it was in the past in real dollars, but international comparisons suggest to me that median wage can go down more (though median wages are held high in part by the fact that licensed doctors have a monopoly on many services with inelastic demand).

    The smart and more conservative may go into law, although at least trial lawyers will support bad medicine as long as tort reform does not happen.

    no. the data is pretty robust i’ve seen that lawyers are more liberal than doctors. robust enough that i’m not going to bother looking it up and citing it, i’ll just assert it unless someone can falsify the assertion. here’s a chart of donations by profession.

  • http://calculatedexuberance.blogspot.com/ Thorfinn

    Not surprising. Doctors, along with other professionals, have been trending left as their professions grow increasingly regulated.

    Interesting that Atheists/Blacks/Buddhists/Hindus/”Other” all cluster at 9% for conservative. Even Jews are twice as likely to be conservative. Muslims are even more likely! You’re right that the Christian/non-Christian is a huge predictor of conservative status, but there are other things going on. Perhaps the Jewish sample over-represents Orthodox Jews who go R for foreign policy reasons. No clue on Muslims; maybe just an N problem.

  • http://blogs.discovermagazine.com/gnxp Razib Khan

    the jewish numbers are interesting, but i think it is reasonable in light of the fact that 20-30% of jews vote republican on the presidential level (with a peak in recent years of 45% in 1984, but a more recent tendency of voting in the low 20s for republicans). muslims are socially conservative, fiscally liberal. they’re also more likely to self-identify as moderate. this is what i’ve seen in other data. remember that muslim doctors are likely to be creationists, while hindus are not at all.

    i don’t think it’s gov. regulation that makes a group liberal. on the contrary, onerous regulation can make one anti-government. rather, nearly 50% of money spent on medicine in the united states is now coming from the government. lawyers are by their nature enmeshed in government because even private attorneys need the gov. to adjudicate their cases. as a profession becomes absorbed in the managerial corporate state it has a state in maintaining gov. expenditures. i believe that public sector unions just surpassed private sector unions this year. the only thing that probably will prevent massive warfare between the bureaucratic and state-dependent elites and the private sector elites which fancy themselves oppositional to gov. (though we know that large corporations often try to rent-seek when they can, or mold regulations to their benefit) is the revolving door between gov. and the private sector.

  • http://tispaquin.blogspot.com Doug Watts

    “Do doctors “look like America” (or not?)”

    Have you ever asked people who have no health coverage at all?

    When you’ve got nothing, it doesn’t really matter what the doctors look like. You just want them to treat you.

    Isn’t this whole story sort of beside the point, unless you already have great health coverage?

    Or is that the point?

  • http://blogs.discovermagazine.com/gnxp Razib Khan

    dude, the post isn’t about what you want to talk about. deal.

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  • http://avinashmachado.blogspot.com Avinash Machado

    What about Sikhs?

  • Spawn of Cthulhu

    It would be a lot more interesting to see the results both immediately after these students have completed their residency training and then 5 years after that. It’s very easy to go into Medical School with left-wing opinions (social justice, etc). Several years of intense training in a major big city hospital where you see people up close that you never interacted with while in high school and college will significantly alter your opinions of reality.
    I’m an emergency physician and I have often said that while you may not start out as a conservative, after several years in the job you will end up that way. It’s very analogous to the definition of a conservative as being a liberal who got mugged.
    Thus, the apparent liberality of current medical students may simply reflect that of the typical university student. Unlike those that go on to ordinary jobs (which medicine definitely isn’t), the scales will be forcibly removed form their eyes.

  • miko

    I’m not sure about this, but I think the phenomenon of “doctor” being an elite (in terms of salary) profession was just a few decades deviation from it being “just” a solid trade. My grandfather was an MD in a specialty that makes a lot of money now, then it was certainly an upper middle class job, but nothing like the last 20 years–you could not get rich doing it. He quit his clinical practice when the practice of taking kickbacks from drug companies became routine (and no longer considered ethically suspect) and went to work at a VA hospital. This was about the time that doctors, like drug companies and to a clumsier extent insurers, started to learn to game an irresistibly game-able and unregulated system. Our current system makes medical services impossible to price by market forces–obviously in some circumstances they are inherently unpriceable (when do you stop paying to save your child’s life?). However, our future economic security depends on this stopping, and this will mean doctors making less, medical services generating smaller profit margins, and regulating consumers and doctors overusing services.

  • John Emerson

    I worked in a medical school / research hospital for 23+ years (1975-2002 with gaps), and while it’s all anecdotal, I have a very strong feeling that by 1990-1995 the word was out that being an MD was not a good choice for very ambitious people. This is based on interactions with medical students and working doctors of various ages. It was even part of medical school orientation and counseling, I think. One MD my age (old) said that he was on the clock all day long, x minutes per patient depending on the procedure and diagnosis.

    In America the top is very, very high and the middle is fairly low. There are people who think that $80,000 / year is very good money, and there are people who think it’s poverty. Medicine is good if you want to make $100,000 — 150,000 (which is really much less when debt and long years of unpaid work are considered), but $150,000 is not a goal for ambitious people; it’s failure.

  • John Emerson

    “The public hates insurance companies”

    There’s more to it than that. Despite all the propaganda, the administration cost and rakeoff of private insurance companies is far, far greater than that of socialized medicine. American common sense on this question is diametrically opposed to the truth.

    Per capita, Americans pay much more for health care than anyone, even though many get very poor health care. As far as that goes, America spends more government money for health care than many countries, even without socialized medicine. The per capita health results are only average.

    I haven’t seen a cost-per-patient / results comparison which excludes people without insurance or money (the unhealthiest segment), but my bet is that even for those relatively well off and insured, more money is paid for healthcare without better results or better care.

    It is possible (not certain) that someone with unlimited money and complete freedom of choice might end up deciding that the best American healthcare is the best in the world. Otherwise, though, American healthcare is the most expensive in the world and only average in quality.

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  • http://blogs.discovermagazine.com/gnxp Razib Khan

    What about Sikhs?

    i think they’d be “other.” but punjabis are only 25% of indian americans, so that’s an upper bound (and as you know, many punjabis indians are hindu).

    , but my bet is that even for those relatively well off and insured, more money is paid for healthcare without better results or better care

    yes, but my understanding is that a lot of it has to do with lack of price signals & third party payment. in other words, when insurance companies tried to squeeze efficiencies in the 1990s it was a public relations nightmare. so they just increase premiums instead. even granting the stuff about administrative overhead, the main issue at this point is the rate of growth on spending of medical care, which is exceptionally high compared to other nations.

  • John Emerson

    Insurance depends on ignorance. The combination of for-profit insurance and increased foreknowledge of medical risks leads ideally to the end of insurance. Low-risk people will get moderately-priced plans that amount to prepayment, plus catastrophe insurance for the still-unpredictable, moderate-risk people (including all fertile women) get expensive insurance, and high risk people get no insurance and (where insurance goes with jobs) are also unemployable.

    Socialized medicine would amount to low risk people being forced paying for high risk people. From a libertarian point of view that’s unacceptable, but for me that’s just another reason why I’m not a libertarian.

    Any kind of single-payer or public option would sometimes deny service, the same way that private insurance companies do, and the same way that fee-for-service does, but if hatred for government is your only political idea, you get mad about one and not the other two.

  • http://blogs.discovermagazine.com/gnxp Razib Khan

    john, you’re talking orthogonal to me now. my only point is that insurers who clamp down on costs are going to get totally reamed in P.R., so you have medical costs ballooning as people feel they’re insulated from price signals for treatments and procedures which have diminishing or no returns. i think that is what miko was pointing to, and it touches upon the fact that though medicine is not as remunerative on a per hour basis as it used to be, it is more remunerative than might be the case if treatments of little use were eliminated through efficient price signals. of course lots of people in the health care sector benefit from this besides doctors; one person’s waste is another person’s revenue.

  • rec1man

    The higher IQ segment of punjabis is Khatri and these are mostly Hindus
    The lower IQ segment of punjabis is Jat and these are mostly Sikh

    So assuming 20% of Hindu MDs are Khatris that would make it about 50 Khatri Hindus and possibly 20 Jat Sikhs

  • http://calculatedexuberance.blogspot.com/ Thorfinn

    rec1man,

    The local Punjabi group also overweights banias; Bobby Jindal for instance.

  • Brian Too

    Interesting stuff.

    My main comment is that we should not be aiming for doctor salaries sufficiently high to reward very aggressive, status seeking, money motivated individuals. What we want is a system that attracts people with an interest in medicine and a drive to help patients.

    This is simply to observe that the best people in any career are those with a passion for their profession. That’s what drives excellence, high service levels, and satisfied customers (patients). Not money.

    The best management information I have says that money can be a negative motivator if it’s too low. However there’s a cutoff point or zone. Above certain salary levels, increasing compensation does not drive increasing performance, or career satisfaction, or personal happiness.

    From a personal perspective, I would not want a doctor who is only a doctor because he gets a huge paycheque. I want a doctor who believes he can help me and is willing to put some time into doing so. Otherwise, when that doctor looks at me, what he sees is a revenue opportunity walking in the door. Not a human being.

  • anondoc

    Brian Too,

    Even the U.S. arguably already has reached the point that it does not have ” doctor salaries sufficiently high to reward very aggressive, status seeking, money motivated individuals.” This is especially true in light of what professions that do seek to acquire those types of personality (investment banking, VC, etc.) pay, which is many multiples of what even the higher-paying medical specialties offer.

    The specialty in which I am training offers middling compensation (higher than the GP’s but much less than the subspecialty surgeons), and I am already questioning whether it is worth the sacrifice. First, there is the opportunity cost of a minimum of seven years’ post-undergraduate education and training during which one earns either no money (incurring enormous tuition and living expense debt all the while) or gets paid peanuts for miserable hours. In most specialties that period lasts even longer (in my case, it will be about 10 years of medical school + residency + fellowship which is the bare minimum necessary to get a job in this particular field). So we’ve given up our lives into at least our late twenties or even well into our thirties and racked up huge debt and now we’re not supposed to make anything? How are we supposed to save for retirement or support families?

    Physician payment accounts for a relatively small portion of total health care expenditure (a little over 20%). Physician compensation has also been falling while overall health care expenditures have been rising. Therefore, no serious health care reformer can really expect to control costs simply by financially kneecapping doctors. My cynical self suspects that envy is as much a motivator for such action as any real desire for effective reform. If the most draconian payment reforms are put into place, I suspect that once the realization of the seemingly endless training, painful personal debt, limited prestige, limited compensation, long hours, and stress of medicine sets in, it will rightly scare people away.

  • kw

    Anondoc, I agree that with the medical education status quo, it’s ridiculous to consider the majority of physicians overpaid. You pointed out the years of education required, the limited compensation during the training period when you are actually working and caring for patients, the enormous debt load.

    That said, do you believe medical education could change without compromising patient care? Could it become briefer, for instance? Is there way to make it more efficient so that training doesn’t eat up so many years of a life? What if once an individual spent at least two or three years in direct patient care in which he is in all but name in charge of said care, a law were passed in which a so-called trainee was compensated at a rate closer to a full-fledged attending? That would certainly give the power-that-be an incentive to shorten the training period.

    I recall being a grad assistant years decades ago when I was responsible for all aspects of teaching classes except choosing the textbooks. My paycheck didn’t work out to be much more than subsistence level. Back then we allowed ourselves to be used, but since then I have heard of grad students and Ph.D. candidates banding together and demanding more pay and benefits for doing the same work as tenured faculty. No one expects the same pay as a tenured professor, but the pittance of a stipend is frequently on the opposite end of the pay spectrum. Could medical residents and fellows ever consider doing the same?

  • geeta

    I agree mostly with Brian Too above.
    For some of the rest of the comments and the article itself, linking pay to smartness is as absurd as linking smartness to school GPA. But as for the rest of the ‘links’ to religion, political inclination, national origin, I am totally lost – is someone trying to put together statistics-based data for one of those research papers that only serve to keep the researcher from getting ‘perished’?
    The insurance companies – if you’ve seen the way they operate and employ many times more than they actually need to get things going (not unlike any other kind of booming business) you will know that they are biggest drains in the present healthcare ‘system’. They are as political as the worst politician and as deceitful as the worst lender. IMO, their elimination as middle-men will make the actual care affordable. I do not believe in socialized healthcare just as much as I donot believe in socialized any other type of system – why should getting medicine be any more ‘socialized’ than getting food and housing and other basic needs. Moreover, there are all kinds of feel-good and cosmetic ‘treatments’ that some use their coverage for.

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This blog is about evolution, genetics, genomics and their interstices. Please beware that comments are aggressively moderated. Uncivil or churlish comments will likely get you banned immediately, so make any contribution count!

About Razib Khan

I have degrees in biology and biochemistry, a passion for genetics, history, and philosophy, and shrimp is my favorite food. In relation to nationality I'm a American Northwesterner, in politics I'm a reactionary, and as for religion I have none (I'm an atheist). If you want to know more, see the links at http://www.razib.com

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