I worry a lot of these efforts are strategically misguided. I don’t think noting ‘EA should be a question’, ‘it’s better to be inclusive’ ‘positive approach and framing’ (etc.) are adequate justifications for soft-peddling uncomfortable facts which nonetheless are important for your audience to make wise career decisions. The most important two here are:
‘High-impact medicine’ is, to a first approximation, about as much of a misnomer as ‘High-impact architecture’ (or ‘high-impact [profession X]’). Barring rare edge cases, the opportunities to have the greatest impact are tangential to (or wholly apart from) modal jobs in this profession.
In the typical case, regardless of cause area, Alice who seeks to ‘maximize her impact as a doctor’ will have ~2+ orders of magnitude less impact than Bob who seeks to maximize his impact simpliciter, and is open to leaving clinical practice or medicine as a whole to do it.
To elaborate:
I am sure many medics are put off or dispirited by my writing on medical careers. In precis:
‘Face to face’ clinical practice (i.e. what you get trained for in medical school) is not an effective means of doing good.
Scales badly (i.e. essentially can only treat the patients in front of you in sequence)
Unlikely to be a leading contributor to aggregate population health (especially in low income countries).
Marginal responses in health from medical personnel in high income countries are at best ‘mediocre’ and at worst imperceptible.
Already greatly oversubscribed with appointable candidates.
From this low baseline, the small-n multiples you could get about being smart in how you deploy your clinical practice seldom result in impressive bottom-line impact.
You can earn-to-give by picking particularly lucrative locations/fields for practice. Your earning power is still substantially lower than other typical E2G career options (e.g. banking, entrepreneurship, pharma) plausibly accessible to many medics.
You can practice in lower-income areas, where the expected ‘marginal benefit’ of additional doctors is much greater. Yet even if you extrapolate the marginal analysis I did to these (which surely overestimates impact) you get yearly impact inferior to even unoptimized medical E2G in a country like the UK or US.
Almost by definition, “effective scalable interventions to improve health in resource-constrained contexts” will not require practicioners having several years of post-graduate training and experience as pre-requisites.
Folks with medical training can do a lot of good, but in these roles they either use their medical training ‘not at all’ or ‘very little’. The story is typically not “medical practice has taught these people important skills they now leverage in this new role” but “medicine often selects for able, conscientious, and altruistic people, who can do a lot of good if they turn their hand to something else”.
Although a medical background may offer some capital for many of these roles, it is typically an inefficient use of time versus more direct strategies to get involved (even for something more medically adjecent like research, an MD/PhD +/- junior doctor years versus a PhD alone add ~5 years which could have been spent doing the research instead).
Again on priors, it would be highly surprising if ‘managing hospitals’, ‘conducting scientific research’, ‘working on health policy’ (to say nothing of further afield options) is really greatly complemented by several years of training and practice in a job with little in common with it.
Thus the ‘impact case’ for medicine is typically tightly circumscribed:
Niche cases where medical background (or practice) really is crucial for a particular career path (e.g. roles in translational research/clinical trials)
When more ‘standard’ medical options really are the best one can do, given circumstances (e.g. maybe your highest earning activity really is clinical practice)*
Your shortlist of options for your career all overlap in such a way where some medical qualification/experience is a good buy across the portfolio*. (Or when you plan or pursuing a mixed strategy longer-term)**
If you’re part way towards some medical milestone (e.g. qualification, licensure), although this wouldn’t have been a good buy from Year 0, it is more reasonable now n years have already been sunk, leaving a smaller amount remaining.
(I astericks or double asterick the options I’m typically highly sceptical of as really being good strategies—I often suspect these are rearguard actions fought to preserve an already-cherished career plan or self-image)
Yet I am unrepentant (and instead zealous) in saying these things: even if seldom kind, they are always true, and often necessary. HIM says and implies at various points it disagrees with this assessment (e.g. “We believe medical students and doctors have the potential to effectively tackle some of the world’s leading problems alongside, and learning from, clinical practice.”). Yet whilst my reasons are transparent, yours are opaque. I doubt they would be credible if made clear, but you are warmly invited to prove me wrong.
But perhaps I misunderstand, and the main disagreements are more matters of style and messaging than substance. Although the answer to high impact medicine is ‘the highest impact options usually amount to leaving the profession sooner rather than later’, most people don’t (or can’t) always take the highest impact option (cf. my own mediocre charitable donation record). It is senseless to antagonise these people, and much better to provide intermediate options: perhaps with time they come around, and regardless their contributions (e.g. in donations to effective charities) are worth celebrating in their own right.
Yet there is a fine line between tact and insincerity; candour is often valuable even (or especially) when it makes the recipient uncomfortable. More importantly, it is unclear whether ‘foot in the door’ or ‘door in the face’ messaging is superior: maybe you have to pick which sorts of people you are least unhappy ‘putting off’. Most importantly, not saying the most important thing risks people who could have done more good doing a lot less good. I think someone like Lucia Coulter (or Jan Brauner, or Ryan Carey, or Bridget Williams, or Brenton Mayer, or Peter MacIntryre, or Cassidy Nelson, or Lee Sharkey, or Jonas Vollmer, or Sashika Coxhead, or...) is plainly having many times more impact than their counterpart who stayed principally within in clinical practice modulo a giving pledge or similar. Thus if HIM messaging leads someone to mistake these options as equivalently good, this plausibly outweighs its positive impact so far.
Big picture, I wanted to clarify two specific points where you have misunderstood the aims of the organisation (we take full responsibility for these issues however as if you have got this impression it is possible others have too).
1. We do not necessarily encourage people to apply for and study medicine. We are not giving any advice to high school level students about degree choices and paths to impact. To quote what you wrote, “medicine often selects for able, conscientious, and altruistic people, who can do a lot of good if they turn their hand to something else.” We think this is likely true, which is why we think specifically performing outreach to, and helping people who are already studying and practicing medicine find highly impactful careers, is likely to be an appealing option.
2. We foreground transparency in all our communications with our members—and am sorry this is not something you agree with when you write that our reasons are opaque, but I think this is a strong claim to make . We aim to talk honestly about the impact of clinical medicine; discussing the articles that you have written throughout the fellowship as well as other pieces on the issue e.g. Dr Launer’s article referencing yours in the BMJ. We do not have a specific ideology we want to sell anyone on—we want to present people with important information and allow them to form their own conclusions through discussions. Disagreement with EA or existing articles is not something to be feared, but to seek out in order to improve our understanding of impact. We think this is reasonably important for community building
Specifically, I think our difference in opinion is the way we approach the idea of impact in medicine—this involves some specific disagreements (below) but also general framing and outlook.
On some of the specific points:
1. High Impact Medicine not a misnomer- I disagree with your assessment of the situation; yourself, and all the people who you mention in the article, were or are doctors, and fit under what we would define to be High Impact Medics. When you are conducting outreach, I think it makes sense to describe the profession that someone currently has, even if you were to recommend jobs ‘tangential to or wholly apart from’ jobs in that profession.
2. On the career capital and skills of medical degrees for opportunities outside medicine- I think I have addressed the above somewhat in reframing the purpose of our organisation away from pushing students into medical degrees. However, I would push back further on your claim that several years of training and practice as a medic is not good experience for several highly impactful careers. I think that it is quite difficult to attribute how much highly impactful people who are medics can attribute their career success to medicine. For someone like yourself, it might be reasonably easy to say very little.; however, I think there are very likely other individuals for which this is not the case (In our experience, and in having interviews with lots of folk doing highly impactful things, this is the case. In fact, it rings true for several of the medics you mention).
3. For the case of Alice who seeks to maximise her impact as a doctor - I think Alice would disagree with you here and there are a bunch of high impact opportunities within medicine that we foreground:
Health policy work, which is often: 1. taken alongside clinical work 2. in some instances can be done well from a bottoms up approach while working in a clinical setting, 3. Often earmarks and wants the perspective of clinicians.
Effective giving and earning to give- I think doctors in a lot of countries, especially with growth of private medicine, have quite a high earning capacity. Especially for those medics who are further along or who really love their clinical work, earning to give within medicine seems like it might be the best EtG option
Working in a LIC, particularly if you are also involved in training local healthcare workforce, likely has 2-3 orders of magnitude more impact than being a junior doctor in a big metropolitan city (happy to send the studies that support this). I think you and I may disagree on the object level about whether this reaches the bar of “other EA jobs”- I think it might. In addition, if you take into consideration that not everyone has the capacity or capability to do other EA jobs, in a lot of cases, doing some of the above might be the highest impact opportunities for that person.
4. To address your concern about whether our messaging might lead someone to think that clinical practice in a LIC or a giving pledge are equivalently good to the other individuals you cite. Firstly I think this is highly unlikely given the content of our fellowship (with case studies from some of these individuals) and podcast (a number of these individuals are interviewed) and we make clear that there is a range of impact possible from a medical background. Secondly, in circumstances for which that is not feasible or realistic for an individual, or in which that is unlikely to be the case for them, we still think it is robustly good for them to increase their impact 2-3 orders of magnitude in the ways described above.
This is part of ‘big tent’ effective Altruism as we discuss above and may not be something you value as highly as we do. In general though I think this approach is likely to engage a whole lot more people initially than a ‘door in the face’ approach and that encouraging initial steps e.g. pledges or working in a LMIC will increase the likelihood of subsequent change, rather than feeling you have achieved your impact quota. We are reasonably confident that we portray the relative impact of different career options and decisions with high transparency, and enable people to maximise their impact as much they can—though perhaps we emphasise personal fit more than you would.
Speaking to all fellows at a 1:1 level after the fellowship and from the resources they have read over the fellowship, we think the risk we have lost ‘potential impact’ through individuals conflating different career options as equivalently good is very low—and rather the impact of individuals choosing to make impactful career decisions downstream predominates (hence this article).
Happy to chat more about all of this and thanks for your thoughts!
0) I am confident I understand; I just think it’s wrong. My impression is HIM’s activity is less ‘using reason and evidence to work out what does the most good’, but rather ‘using reason and evidence to best reconcile prior career commitments with EA principles’.
By analogy, if I was passionate about (e.g.) HIV/AIDS, education, or cancer treatment in LICs, the EA recommendation would not (/should not) be I presume I maintain this committment, but rather soberly evaluate how interventions within these areas stack up versus all others (with the expectation I would be very unlikely to discover the best interventions which emerge from this analysis will line up with what my passions previously aligted upon). Instead setting up a ‘Givewell for education interventions’ largely misses the point (and most of the EV ‘on the table’).
So too here. It would be surprising to discover medical careers—typically selected before acquaintance with EA principles—would be optimal or near-optimal by their lights (I’d be surprised if m/any EAs who weren’t already doctors thought it was). The face-value analysis is pessimistic on the ‘is this best’ question, notwithstanding (e.g.) there is a lot of variance within field to optimise: HIV/AIDS interventions vary in effectiveness by orders of magnitude, yet that doesn’t make them priorities on the current margin. As, to a first approximation, reality works in first-order terms, we’d want some very good reasons for second order considerations nonetheless carrying the day: sentiments like ‘big tent’, ‘EA is a question’ (etc.) can support anything (would it apply to PlayPumps?), so we should attempt to weigh these things up.
Your first point of clarification illustrates the ‘opacity’ I have in mind. “Not necessarily encouraging” folks to apply to medical school implies a lot of epistemic wiggle room: “Should I enter medicine?” and “Should I leave medicine?” are different but closely related questions (consider a 17 year old applying to medicine versus an 18 year old first year student), and answers to the former sense-check answers to the latter. If you really think having impact as a doctor is for many people some of the best things they can do, this suggests for similar people you would encourage them entering the profession (this doesn’t imply HIM should start doing this, but I think most in EA-land would find this result surprising and worth exploration—not least, it suggests a re-write of the 80k profile.) In contrast, if the answer is “even for those initially minded to enter medicine, we’d usually recommend against it as an EA career choice”, then there should be a story why this usual recommendation is greatly attenuated (or reversed?) for those already in the profession—particularly at an early stage like medical school. Again, this doesn’t govern HIM strategy—but it is informative, and knowing what you yourself think is the answer is important for transparent communication with your audience (even if they find this uncomfortable).
1) Regardless of the semantics of whether one should call someone like myself a ‘medic’ or not now, the substantive issue seems to be around whether medicine (generally speaking) is a high impact activity or not. Suppose (i.e. I’m not claiming this is the story for either of these professions I use as examples) (a):
‘High Impact law’: where the folks in the profession find their highest impact options often involve the practice of law in their ‘day job’, or ‘not strictly legal’ roles where their legal training is an important-to-crucial piece of career capital.
Contrast (b):
‘High Impact accountancy’: where folks in this profession find their highest impact options very rarely involve the practice of accountancy, and their best career options are typically those where their accounting background is only tangentially relevant (e.g. acquaintance with business operations, a ‘head for figures’).
In the latter case, ‘high impact accountancy’ looks like an odd term if the real message is to provide accountants with better career options which typically involve leaving the profession. If medicine was like (a), all seems well; but I think it is like (b), thus we disagree.
2) I’d be surprised if most of the folks I mentioned would find several years of medical experience valauble—especially (for the key question of career choice) whether this was a leading opportunity versus alternative ways of spending 10-20% of their working lives. I can ask around, but if you have testimony to hand you’re welcome to correct me. I’d guess medical experience is much more relevant for much more medically adjacent (or simply medical) careers—but, per grandparent, these careers tend to be a lot less impactful in the first place.
3) Our hypothetical Alice may be right about the options you note being ‘higher impact’ than typical practice. Yet effectiveness is multiplier stacking (cf.), so Bob (who doesn’t labour under the ‘having impact as a doctor’ constraint) can still expect 10-100x more impact. The latter two examples you give (re. earning to give and working in a LIC) allow direct estimation:
Re. E2G, US and UK doctors are in the top ~5% of their respective populations in earnings. Many other careers plausibly accessible to doctors (e.g. technical start-ups, quant trading, SWE, consulting) have income distributions which have either dramatically higher expected earnings, higher median earnings (e.g. friends of mine in some of these fields had higher starting salary than my expected peak medical salary), or both. This all sets aside that marginal returns to further money where there is a lot of aligned money looking for interventions to fund may be much lower now (cf. ‘earning to give’ careers typically finding themselves a long way down 80k recommendations; forum discourse ad nauseum about ‘talent constraint’, unease about all the lucre sloshing around, etc. etc.).
Re. LIC practice, if we take the 2-3 omag multiplier at face value (this looks implausible at the upper end), then combining that with 2ish DALYs/year of practice in a high income countries (taking my figures at face value, which are likely too high, you get 2*300 = 600 DALYs. In Givewell donations, with some conversion of (say) 40 DALYs = one ‘life saved’ (not wildly unreasonable as the lives saved are typically <5 year olds), this is ~~ 70 000 dollars/year. This is in the reach of E2G doctors (leave alone careers E2G more broadly), and the real number is almost surely lower (probably by an integer factor): the ‘medical practice’ side of the equation is much less rigorous than the givewell CEE, and should be anticipated to regress down.
As you say, various constraints (professional or personal) may rule out these other options: perhaps I aim at earning to give, but it happens that medical practice is my most lucrative employment (obviously much more plausible if one is later in one’s career); perhaps even if in general the sort of person drawn to medicine can make better contributions outside of the profession, this is not true for me in particular. Yet candour seems to oblige foregrounding such constraints often cut 90%+ of potential impact (and thus the importance of testing whether these constraints are strict).
4) Although comparators are tricky (e.g. if my writing on medical careers was vastly less effective it would be hard to tell), the content of the career plan changes noted in the OP would be more or less reassuring. re. what high impact med is accomplishing. Per above, as getting the last multipliers are important, HIM’s impact is largely determined by the tail of highest impact plan changes.
On the object-level for your examples, I think for “high-impact architecture,” having people with nontrivial background in architecture is likely useful for building civilizational refuges. More directly, I’ve talked to people who think that having 1-3 EA concierge doctors in the community (who can do things like understand our cultural contexts and weird problems and prescribe medicine in jurisdictions like the US and the UK) can be extremely helpful in increasing the impact of top talent in EA. This is analogous to the impact of e.g. existing community health or mental health workers in the community.
Potentially relevant subquestions:
To what extent does work in EA require EA alignment and acculturation?
The more you think EA orgs can hire well outside of EA for projects outside of EA natural core competencies, the more it matters that EAs target a relatively small subset of high-impact careers and skillsets to specialize in.
Conversely, if you think (as I do) that alignment and acculturation is just really important for excelling in EA jobs, it matters that we have people acquiring a wider scope of jobs and skillsets.
Do we live in a “big world” or a “small world” of EA things to do?
If we think there’s a narrow set of the best actions and causes, and a small number of people working in any of them, it matters more that individuals optimize for selecting the best things to do, on a birds’ eye view.
If, conversely, we think the range of really good actions and causes is relatively wide, then it matters more that individuals weigh factors like personal fit heavily.
An potential argument here is that the profile you wrote on doctoring was in the context of back when EA was much smaller. We may expect conditions “on the ground” to have changed a lot, and while “concierge EA doctor” would be a dumb career to aspire to five years ago, perhaps it is less so now.
(I personally think we likely still live in a relatively small world, which I think undercuts my counterarguments significantly).
Relatedly, how important is EA exploration vs exploitation?
How damning is the danger of introducing people with worse epistemics into the EA movement? And is worsening epistemics the most important/salient downside risk?
What are the best ways to prevent the above from happening?
Is it having really good first-order reasoning and arguments?
Is it having really good all-things-considered views that try to track all the important considerations, including rather estoric ones?
I have some hope that splitting out votes into two dimensions (approval and agreement) might help with situations like this. At least it seems to have helped with some recent AI-adjacent threads on LW that were also pretty divisive.
I worry a lot of these efforts are strategically misguided. I don’t think noting ‘EA should be a question’, ‘it’s better to be inclusive’ ‘positive approach and framing’ (etc.) are adequate justifications for soft-peddling uncomfortable facts which nonetheless are important for your audience to make wise career decisions. The most important two here are:
‘High-impact medicine’ is, to a first approximation, about as much of a misnomer as ‘High-impact architecture’ (or ‘high-impact [profession X]’). Barring rare edge cases, the opportunities to have the greatest impact are tangential to (or wholly apart from) modal jobs in this profession.
In the typical case, regardless of cause area, Alice who seeks to ‘maximize her impact as a doctor’ will have ~2+ orders of magnitude less impact than Bob who seeks to maximize his impact simpliciter, and is open to leaving clinical practice or medicine as a whole to do it.
To elaborate:
I am sure many medics are put off or dispirited by my writing on medical careers. In precis:
‘Face to face’ clinical practice (i.e. what you get trained for in medical school) is not an effective means of doing good.
Scales badly (i.e. essentially can only treat the patients in front of you in sequence)
Unlikely to be a leading contributor to aggregate population health (especially in low income countries).
Marginal responses in health from medical personnel in high income countries are at best ‘mediocre’ and at worst imperceptible.
Already greatly oversubscribed with appointable candidates.
From this low baseline, the small-n multiples you could get about being smart in how you deploy your clinical practice seldom result in impressive bottom-line impact.
You can earn-to-give by picking particularly lucrative locations/fields for practice. Your earning power is still substantially lower than other typical E2G career options (e.g. banking, entrepreneurship, pharma) plausibly accessible to many medics.
You can practice in lower-income areas, where the expected ‘marginal benefit’ of additional doctors is much greater. Yet even if you extrapolate the marginal analysis I did to these (which surely overestimates impact) you get yearly impact inferior to even unoptimized medical E2G in a country like the UK or US.
Almost by definition, “effective scalable interventions to improve health in resource-constrained contexts” will not require practicioners having several years of post-graduate training and experience as pre-requisites.
Folks with medical training can do a lot of good, but in these roles they either use their medical training ‘not at all’ or ‘very little’. The story is typically not “medical practice has taught these people important skills they now leverage in this new role” but “medicine often selects for able, conscientious, and altruistic people, who can do a lot of good if they turn their hand to something else”.
Although a medical background may offer some capital for many of these roles, it is typically an inefficient use of time versus more direct strategies to get involved (even for something more medically adjecent like research, an MD/PhD +/- junior doctor years versus a PhD alone add ~5 years which could have been spent doing the research instead).
Again on priors, it would be highly surprising if ‘managing hospitals’, ‘conducting scientific research’, ‘working on health policy’ (to say nothing of further afield options) is really greatly complemented by several years of training and practice in a job with little in common with it.
Thus the ‘impact case’ for medicine is typically tightly circumscribed:
Niche cases where medical background (or practice) really is crucial for a particular career path (e.g. roles in translational research/clinical trials)
When more ‘standard’ medical options really are the best one can do, given circumstances (e.g. maybe your highest earning activity really is clinical practice)*
Your shortlist of options for your career all overlap in such a way where some medical qualification/experience is a good buy across the portfolio*. (Or when you plan or pursuing a mixed strategy longer-term)**
If you’re part way towards some medical milestone (e.g. qualification, licensure), although this wouldn’t have been a good buy from Year 0, it is more reasonable now n years have already been sunk, leaving a smaller amount remaining.
(I astericks or double asterick the options I’m typically highly sceptical of as really being good strategies—I often suspect these are rearguard actions fought to preserve an already-cherished career plan or self-image)
Yet I am unrepentant (and instead zealous) in saying these things: even if seldom kind, they are always true, and often necessary. HIM says and implies at various points it disagrees with this assessment (e.g. “We believe medical students and doctors have the potential to effectively tackle some of the world’s leading problems alongside, and learning from, clinical practice.”). Yet whilst my reasons are transparent, yours are opaque. I doubt they would be credible if made clear, but you are warmly invited to prove me wrong.
But perhaps I misunderstand, and the main disagreements are more matters of style and messaging than substance. Although the answer to high impact medicine is ‘the highest impact options usually amount to leaving the profession sooner rather than later’, most people don’t (or can’t) always take the highest impact option (cf. my own mediocre charitable donation record). It is senseless to antagonise these people, and much better to provide intermediate options: perhaps with time they come around, and regardless their contributions (e.g. in donations to effective charities) are worth celebrating in their own right.
Yet there is a fine line between tact and insincerity; candour is often valuable even (or especially) when it makes the recipient uncomfortable. More importantly, it is unclear whether ‘foot in the door’ or ‘door in the face’ messaging is superior: maybe you have to pick which sorts of people you are least unhappy ‘putting off’. Most importantly, not saying the most important thing risks people who could have done more good doing a lot less good. I think someone like Lucia Coulter (or Jan Brauner, or Ryan Carey, or Bridget Williams, or Brenton Mayer, or Peter MacIntryre, or Cassidy Nelson, or Lee Sharkey, or Jonas Vollmer, or Sashika Coxhead, or...) is plainly having many times more impact than their counterpart who stayed principally within in clinical practice modulo a giving pledge or similar. Thus if HIM messaging leads someone to mistake these options as equivalently good, this plausibly outweighs its positive impact so far.
Hi Greg,
Thank you for your comment.
Big picture, I wanted to clarify two specific points where you have misunderstood the aims of the organisation (we take full responsibility for these issues however as if you have got this impression it is possible others have too).
1. We do not necessarily encourage people to apply for and study medicine. We are not giving any advice to high school level students about degree choices and paths to impact. To quote what you wrote, “medicine often selects for able, conscientious, and altruistic people, who can do a lot of good if they turn their hand to something else.” We think this is likely true, which is why we think specifically performing outreach to, and helping people who are already studying and practicing medicine find highly impactful careers, is likely to be an appealing option.
2. We foreground transparency in all our communications with our members—and am sorry this is not something you agree with when you write that our reasons are opaque, but I think this is a strong claim to make . We aim to talk honestly about the impact of clinical medicine; discussing the articles that you have written throughout the fellowship as well as other pieces on the issue e.g. Dr Launer’s article referencing yours in the BMJ. We do not have a specific ideology we want to sell anyone on—we want to present people with important information and allow them to form their own conclusions through discussions. Disagreement with EA or existing articles is not something to be feared, but to seek out in order to improve our understanding of impact. We think this is reasonably important for community building
Specifically, I think our difference in opinion is the way we approach the idea of impact in medicine—this involves some specific disagreements (below) but also general framing and outlook.
On some of the specific points:
1. High Impact Medicine not a misnomer- I disagree with your assessment of the situation; yourself, and all the people who you mention in the article, were or are doctors, and fit under what we would define to be High Impact Medics. When you are conducting outreach, I think it makes sense to describe the profession that someone currently has, even if you were to recommend jobs ‘tangential to or wholly apart from’ jobs in that profession.
2. On the career capital and skills of medical degrees for opportunities outside medicine- I think I have addressed the above somewhat in reframing the purpose of our organisation away from pushing students into medical degrees. However, I would push back further on your claim that several years of training and practice as a medic is not good experience for several highly impactful careers. I think that it is quite difficult to attribute how much highly impactful people who are medics can attribute their career success to medicine. For someone like yourself, it might be reasonably easy to say very little.; however, I think there are very likely other individuals for which this is not the case (In our experience, and in having interviews with lots of folk doing highly impactful things, this is the case. In fact, it rings true for several of the medics you mention).
3. For the case of Alice who seeks to maximise her impact as a doctor - I think Alice would disagree with you here and there are a bunch of high impact opportunities within medicine that we foreground:
Health policy work, which is often: 1. taken alongside clinical work 2. in some instances can be done well from a bottoms up approach while working in a clinical setting, 3. Often earmarks and wants the perspective of clinicians.
Effective giving and earning to give- I think doctors in a lot of countries, especially with growth of private medicine, have quite a high earning capacity. Especially for those medics who are further along or who really love their clinical work, earning to give within medicine seems like it might be the best EtG option
Working in a LIC, particularly if you are also involved in training local healthcare workforce, likely has 2-3 orders of magnitude more impact than being a junior doctor in a big metropolitan city (happy to send the studies that support this). I think you and I may disagree on the object level about whether this reaches the bar of “other EA jobs”- I think it might. In addition, if you take into consideration that not everyone has the capacity or capability to do other EA jobs, in a lot of cases, doing some of the above might be the highest impact opportunities for that person.
4. To address your concern about whether our messaging might lead someone to think that clinical practice in a LIC or a giving pledge are equivalently good to the other individuals you cite. Firstly I think this is highly unlikely given the content of our fellowship (with case studies from some of these individuals) and podcast (a number of these individuals are interviewed) and we make clear that there is a range of impact possible from a medical background. Secondly, in circumstances for which that is not feasible or realistic for an individual, or in which that is unlikely to be the case for them, we still think it is robustly good for them to increase their impact 2-3 orders of magnitude in the ways described above.
This is part of ‘big tent’ effective Altruism as we discuss above and may not be something you value as highly as we do. In general though I think this approach is likely to engage a whole lot more people initially than a ‘door in the face’ approach and that encouraging initial steps e.g. pledges or working in a LMIC will increase the likelihood of subsequent change, rather than feeling you have achieved your impact quota. We are reasonably confident that we portray the relative impact of different career options and decisions with high transparency, and enable people to maximise their impact as much they can—though perhaps we emphasise personal fit more than you would.
Speaking to all fellows at a 1:1 level after the fellowship and from the resources they have read over the fellowship, we think the risk we have lost ‘potential impact’ through individuals conflating different career options as equivalently good is very low—and rather the impact of individuals choosing to make impactful career decisions downstream predominates (hence this article).
Happy to chat more about all of this and thanks for your thoughts!
Howdy, and belatedly:
0) I am confident I understand; I just think it’s wrong. My impression is HIM’s activity is less ‘using reason and evidence to work out what does the most good’, but rather ‘using reason and evidence to best reconcile prior career commitments with EA principles’.
By analogy, if I was passionate about (e.g.) HIV/AIDS, education, or cancer treatment in LICs, the EA recommendation would not (/should not) be I presume I maintain this committment, but rather soberly evaluate how interventions within these areas stack up versus all others (with the expectation I would be very unlikely to discover the best interventions which emerge from this analysis will line up with what my passions previously aligted upon). Instead setting up a ‘Givewell for education interventions’ largely misses the point (and most of the EV ‘on the table’).
So too here. It would be surprising to discover medical careers—typically selected before acquaintance with EA principles—would be optimal or near-optimal by their lights (I’d be surprised if m/any EAs who weren’t already doctors thought it was). The face-value analysis is pessimistic on the ‘is this best’ question, notwithstanding (e.g.) there is a lot of variance within field to optimise: HIV/AIDS interventions vary in effectiveness by orders of magnitude, yet that doesn’t make them priorities on the current margin. As, to a first approximation, reality works in first-order terms, we’d want some very good reasons for second order considerations nonetheless carrying the day: sentiments like ‘big tent’, ‘EA is a question’ (etc.) can support anything (would it apply to PlayPumps?), so we should attempt to weigh these things up.
Your first point of clarification illustrates the ‘opacity’ I have in mind. “Not necessarily encouraging” folks to apply to medical school implies a lot of epistemic wiggle room: “Should I enter medicine?” and “Should I leave medicine?” are different but closely related questions (consider a 17 year old applying to medicine versus an 18 year old first year student), and answers to the former sense-check answers to the latter. If you really think having impact as a doctor is for many people some of the best things they can do, this suggests for similar people you would encourage them entering the profession (this doesn’t imply HIM should start doing this, but I think most in EA-land would find this result surprising and worth exploration—not least, it suggests a re-write of the 80k profile.) In contrast, if the answer is “even for those initially minded to enter medicine, we’d usually recommend against it as an EA career choice”, then there should be a story why this usual recommendation is greatly attenuated (or reversed?) for those already in the profession—particularly at an early stage like medical school. Again, this doesn’t govern HIM strategy—but it is informative, and knowing what you yourself think is the answer is important for transparent communication with your audience (even if they find this uncomfortable).
1) Regardless of the semantics of whether one should call someone like myself a ‘medic’ or not now, the substantive issue seems to be around whether medicine (generally speaking) is a high impact activity or not. Suppose (i.e. I’m not claiming this is the story for either of these professions I use as examples) (a):
‘High Impact law’: where the folks in the profession find their highest impact options often involve the practice of law in their ‘day job’, or ‘not strictly legal’ roles where their legal training is an important-to-crucial piece of career capital.
Contrast (b):
‘High Impact accountancy’: where folks in this profession find their highest impact options very rarely involve the practice of accountancy, and their best career options are typically those where their accounting background is only tangentially relevant (e.g. acquaintance with business operations, a ‘head for figures’).
In the latter case, ‘high impact accountancy’ looks like an odd term if the real message is to provide accountants with better career options which typically involve leaving the profession. If medicine was like (a), all seems well; but I think it is like (b), thus we disagree.
2) I’d be surprised if most of the folks I mentioned would find several years of medical experience valauble—especially (for the key question of career choice) whether this was a leading opportunity versus alternative ways of spending 10-20% of their working lives. I can ask around, but if you have testimony to hand you’re welcome to correct me. I’d guess medical experience is much more relevant for much more medically adjacent (or simply medical) careers—but, per grandparent, these careers tend to be a lot less impactful in the first place.
3) Our hypothetical Alice may be right about the options you note being ‘higher impact’ than typical practice. Yet effectiveness is multiplier stacking (cf.), so Bob (who doesn’t labour under the ‘having impact as a doctor’ constraint) can still expect 10-100x more impact. The latter two examples you give (re. earning to give and working in a LIC) allow direct estimation:
Re. E2G, US and UK doctors are in the top ~5% of their respective populations in earnings. Many other careers plausibly accessible to doctors (e.g. technical start-ups, quant trading, SWE, consulting) have income distributions which have either dramatically higher expected earnings, higher median earnings (e.g. friends of mine in some of these fields had higher starting salary than my expected peak medical salary), or both. This all sets aside that marginal returns to further money where there is a lot of aligned money looking for interventions to fund may be much lower now (cf. ‘earning to give’ careers typically finding themselves a long way down 80k recommendations; forum discourse ad nauseum about ‘talent constraint’, unease about all the lucre sloshing around, etc. etc.).
Re. LIC practice, if we take the 2-3 omag multiplier at face value (this looks implausible at the upper end), then combining that with 2ish DALYs/year of practice in a high income countries (taking my figures at face value, which are likely too high, you get 2*300 = 600 DALYs. In Givewell donations, with some conversion of (say) 40 DALYs = one ‘life saved’ (not wildly unreasonable as the lives saved are typically <5 year olds), this is ~~ 70 000 dollars/year. This is in the reach of E2G doctors (leave alone careers E2G more broadly), and the real number is almost surely lower (probably by an integer factor): the ‘medical practice’ side of the equation is much less rigorous than the givewell CEE, and should be anticipated to regress down.
As you say, various constraints (professional or personal) may rule out these other options: perhaps I aim at earning to give, but it happens that medical practice is my most lucrative employment (obviously much more plausible if one is later in one’s career); perhaps even if in general the sort of person drawn to medicine can make better contributions outside of the profession, this is not true for me in particular. Yet candour seems to oblige foregrounding such constraints often cut 90%+ of potential impact (and thus the importance of testing whether these constraints are strict).
4) Although comparators are tricky (e.g. if my writing on medical careers was vastly less effective it would be hard to tell), the content of the career plan changes noted in the OP would be more or less reassuring. re. what high impact med is accomplishing. Per above, as getting the last multipliers are important, HIM’s impact is largely determined by the tail of highest impact plan changes.
I think your two comments here are well-argued, internally consistent, and strong. However, I think I disagree with
in the context of EA career choice writ large, which I think may be enough to flip the bottom-line conclusion.
I think the crux for me is that I think if the differences in object-level impact across people/projects is high enough, then for anybody whose career or project is not in the small subset of the most impactful careers/projects, their object-level impacts will likely be dwarfed by the meta-level impact.
On the object-level for your examples, I think for “high-impact architecture,” having people with nontrivial background in architecture is likely useful for building civilizational refuges. More directly, I’ve talked to people who think that having 1-3 EA concierge doctors in the community (who can do things like understand our cultural contexts and weird problems and prescribe medicine in jurisdictions like the US and the UK) can be extremely helpful in increasing the impact of top talent in EA. This is analogous to the impact of e.g. existing community health or mental health workers in the community.
Potentially relevant subquestions:
To what extent does work in EA require EA alignment and acculturation?
The more you think EA orgs can hire well outside of EA for projects outside of EA natural core competencies, the more it matters that EAs target a relatively small subset of high-impact careers and skillsets to specialize in.
Conversely, if you think (as I do) that alignment and acculturation is just really important for excelling in EA jobs, it matters that we have people acquiring a wider scope of jobs and skillsets.
Do we live in a “big world” or a “small world” of EA things to do?
If we think there’s a narrow set of the best actions and causes, and a small number of people working in any of them, it matters more that individuals optimize for selecting the best things to do, on a birds’ eye view.
If, conversely, we think the range of really good actions and causes is relatively wide, then it matters more that individuals weigh factors like personal fit heavily.
An potential argument here is that the profile you wrote on doctoring was in the context of back when EA was much smaller. We may expect conditions “on the ground” to have changed a lot, and while “concierge EA doctor” would be a dumb career to aspire to five years ago, perhaps it is less so now.
(I personally think we likely still live in a relatively small world, which I think undercuts my counterarguments significantly).
Relatedly, how important is EA exploration vs exploitation?
How damning is the danger of introducing people with worse epistemics into the EA movement? And is worsening epistemics the most important/salient downside risk?
What are the best ways to prevent the above from happening?
Is it having really good first-order reasoning and arguments?
Is it having really good all-things-considered views that try to track all the important considerations, including rather estoric ones?
???
It seems bizarre that, without my strong upvote, this comment is at minus 3 karma.
Karma polarization seems to have become much worse recently. I think a revision of the karma system is urgently needed.
I have some hope that splitting out votes into two dimensions (approval and agreement) might help with situations like this. At least it seems to have helped with some recent AI-adjacent threads on LW that were also pretty divisive.
Yes, that is also my hope. Thanks for developing this.
It might this might just be the work one or two people. Maybe the mods can take a look?
We could create a script (using a sprinkling of NLP or classifier) to identify unreasonably downvoted comments and show how prevalent this is.