Pondering our certification culture. We certify everything from doctors and lawyers on one end to cosmeticians and astrologers on the other. All of this certification is putatively to protect us from ourselves, which, in itself, cannot but infantilize us. Certification also is supposed to enforce standards, such that, if I go to a certified accountant or licensed surgeon, I expect some basic standards to be met.
It should be clear that certification in itself tells us nothing about the desirability or wisdom of those standards. Both chiropractors and medical doctors are certified and licensed, yet they hold to often contradictory and antagonistic principles and practices – they can’t both be right, although they can certainly both be wrong. Certified astrologers are held to standards as well, one supposes, although one also supposes those standards have nothing to do with anything happening in the real world. But then, we Pisces tend to be skeptical…
Let us leave the fringe cases and turn to the strongest. One things doctors and lawyers share historically is low public esteem.
Now there was a woman who had been suffering from hemorrhages for twelve years; and though she had spent all she had on physicians, no one could cure her.Luke 8:43-48
The unfortunate woman in Luke is not an exception. The poor could not afford doctors; the desperate rich were reliably cured of some or all of their wealth, if not their physical disorders. Where I live, there’s a park preserving the large house of one of the earliest settlers to the area. He had allegedly received some 19th century medical training back East, making him the closest thing to a doctor for many miles around, and so he became the go-to guy for health issues in that rough and tumble period. He charged 1 cowhide, upfront, before he’d look at a patient, and was not apparently very much inclined to pro-bono work. He ended up with a nice big house on a nice big ranch. I doubt he had a sterling reputation among the many.
Keep in mind that these were not modern people, who seem to believe the medical profession can and should save them from every sickness and danger. No, before the last 50 years or so, people seemed to understand that bad things happen, everyone dies, and doctors can be hoped to help, but there are no guarantees. It is only since the 1950s, for example, that going to a hospital when seriously ill would generally improve your chances of survival. Before that? Pretty much hit or miss. Before 1900, pretty much miss. When our not too distant ancestors heard of somebody undergoing treatment at a hospital and coming out alive, let alone cured, that was a sensation. When somebody went to a hospital and died, that was just life – especially since all but the rich wouldn’t even think of going until they were on the verge of death anyway.
Then, confirmation bias kicks in: the stories of cures at the hands of doctors are given great weight; the inevitable deaths are dismissed as just the way things go. The point here: it is only in modern times that being a doctor became a generally respected occupation. In the middle ages, surgery was something the local barber did; the distinction (if any) between medical care and witchcraft is a fairly modern thing, and, sadly, not clear to much of the population even now. Through most of history, an experienced doctor was a big help in setting bones and treating wounds. Check this out, for example. Otherwise? Big maybe. The general impression one gets when reading literature or history from anywhere: doctors are most often portrayed as money grubbing shysters.
The low esteem in which lawyers are even now held by the public needs hardly be mentioned. It has always been thus. The sophists of the golden age of Greece were training up what we might call lawyers – masters of rhetoric and public speaking, who used their skills to gain power and manipulate people and institutions. Socrates and Plato loathed such men; I would imagine common citizens could be counted on to loath them as well. (1)
Obviously, individual doctors and lawyers can be good people. I’m here describing what might be called a marketing problem: enough people have bad enough experiences with doctors and lawyers, historically, at least, that doctors and lawyers are held at least in suspicion, if not out and out distrust.
Enter certification and licensing. From a strictly business point of view, it is important for doctors and lawyers to calm public fears about their competence and trustworthiness. As late as the 1870s, few US doctors were licensed; as late as the 1930s, medical ‘diploma mills’ were still in operation. Gradually, doctors became one of, if not the, most highly regulated profession. Today, a doctor must get a degree from a highly regulated med school, pass a state licensing requirement, and then pass boards in any specialties he’d like to practice.
It is amusing – to me, at least – to note that all this regulation and training requirements trails overall improvements in public health. In 1900, a man could expect to live about 49 years, on average, up about 10 years from 1860. While medical care may have improved over those 40 years, that period also corresponds to a massive move from the country to towns and cities. By 1900, about 50% of everybody no longer lived on farms. Farm work, especially when using animals as muscle, is very arduous and dangerous. Horses, cows, pigs can kill you. Having to perform the brutal physical labor to plant, plow, and harvest regardless of health takes a toll, a toll expressed in a much lower life expectancy. Life expectancy has increased in America as safer, less physically demanding work has replaced farming, and machines have replaced animals for farm work.
Medicine has been bringing up the rear on these trends, for the most part, for the last 150-200 years. Vaccines and antibiotics extended the lives of many millions, but would hardly make a difference if sufficient food, water, and sanitation were not also available. Heart and cancer treatment advances largely apply to the elderly, who are the majority of the sufferers and who simply weren’t there in comparable numbers 100 years ago. Medicine, like formal education, seems to be a result rather than a cause of increasing wealth.
Many people profoundly mistrust conventional medicine. (Note: I personally don’t so much mistrust modern medicine as I like to take a look at the evidence for myself. In general, I’m willing to go with what my doctors say I ought to do almost all the time. It’s not automatic, though.) That’s why homeopathy, chiropractic, and other practices have their millions of devoted followers. These are not stupid or unusually gullible people – the medical profession has earned their mistrust, and there’s plenty of anecdotal evidence to support these practices. (2) No science, as far as I can tell, but that matters little to people when somebody they know personally tells them of their wonderful experiences.
From a purely business point of view, the willingness of people to try all sorts of cures and to distrust doctors is a major problem to be solved – for the highly-trained doctors. If I’m going to spend years and a fortune getting through medical school, I’m going to need to convince people to pay me, and not that snake oil salesman! I must assume and defend my professional dignity, and find a way to denigrate the competition. Licensing creates the desired division: respectable, trained, competent doctors are *certified*; all others are frauds. That’s the marketing message, at least.
In a similar way, a lawyer wants to claim the aura of respect surrounding the never-went-to-law-school lawyer Abraham Lincoln, while at the same time embracing a licensing scheme designed to keep the likes of Honest Abe out of the profession. Both lawyers and doctors tend to be rather fiercely protective of their professional designation – doctors want to be called *Doctor*; lawyers insist on being treated with the respect presumed to be due to an *esquire*.
Of course, licensing is inevitably presented as something done, not to suppress competition and aid the professions in their quest for prestige and money, but to help and protect ‘the public’. The public is treated as a bunch of children, unable to look after themselves. While this may be true – that many people are gullible rubes – it’s not clear that a) lawyers and doctors are not equally likely to be gullible rubes themselves, and b) that the practice of licensing, especially when the state gets involved and is used to suppress competition, isn’t an ultimately irresistible temptation to abuse. In other words, I’m assuming doctors, lawyers, and other high-end professionals remain of the same species as the rest of us, subject to the same temptations and failings.
I expect that many, if not most, people would by now be horrified: I’m suggesting we might be better off without licensing requirements for doctors and lawyers? Am I a madman? First off, what I would suggest is separation of professions and state: the guilds can do what they want, as far as creating all sorts of merit badges and participation trophies – and the public get to decide how much weight to give them. If an individual want to only hire doctors who have all the approvals of the guild or not, or hire a certified lawyer or rather base his decision on whether or not that lawyer has a track record with the issues that made him want to hire a lawyer in the first place – OK. Newsflash: this is what people are doing anyway. On the doctor side, there are many homeopaths and chiropractors doing solid business; Whole Earth panders to those who think probiotics and organic food is going to heal them. Lawyers get hired by reputation or recommendation.
I repeat that I’m using lawyers and doctors as examples here, because they represent the most elite certified professions. This argument applies even more so to the more pointlessly certified. If you got the state out of the certification business, and instead let the guilds develop their own practices however they like but unenforced by the state, then people would be treated like grown-ups who can make up their own minds, rather than children who need to be protected from themselves.
The underlying problem here is the inversion of cause and effect: a world increasingly set up on the assumption that we need to be protected from ourselves creates children who never grow up. Before this eternal infantilization can be changed, we must stop reinforcing it. It is good to remember that people remain people – a situation no amount of certification can change. If we need protection from ourselves, so would doctors and lawyers. Quis custodiet ipsos custodes?
Appendix (ha!) – While searching around for some materials on this topic, came across this article from Stanford:
Licensing boom: In 1950, 73 occupations required licenses in one or more states. By 1970 that number had grown to more than 500. | Reuters/Athit Perawongmethafrom the cation to a picture accompanying the article
It’s illegal to practice medicine without a license, and that piece of paper is exceedingly hard to come by. Would-be doctors face more than a decade of training and must pass rigorous board exams. Thanks to that high bar and the steep up-front ante, there are almost no quacks in American medicine today. That’s a comforting thought when you’re sick and need to see an unfamiliar physician.
So, naturally, we take it for granted that licensing requirements — now common in skilled professions, including law, architecture, and accounting — exist to protect consumers. Indeed, that’s more or less what Stanford Graduate School of Business professor Jonathan Berk assumed when he began a theoretical study of licensing and certification in the labor market.
Instead, he and coauthor Jules van Binsbergenopen in new window of the University of Pennsylvania found exactly the opposite. As they report in a new working paper, “Regulation of Charlatans in High-Skill Professions,” their model concludes that licenses enrich the incumbent providers of a service and hurt consumers — not sometimes or in certain scenarios, but every time.
Now, to be sure, if any barber could hang up a shingle and call themself a doctor, and you unwisely decided that would be a good option for hernia surgery, you might wish there’d been more stringent regulations in place. What the analysis says is that consumers as a whole are worse off under licensing — the gains to those who benefit are far outweighed by the burden on the vast majority, who don’t.
“This result was as much a surprise to me as it is to anybody,” says Berk, the A.P. Giannini Professor of Finance. “To be honest, this is not the paper we set out to write.”
- It’s telling that Plato, in his Academy, would filter out candidates for his highest training – training for the gold-souled, the would-be philosopher-kings – by math skills: he believed mastery of math was solid evidence of real intellect. He attempted to filter out the glib posers, in other words – who would be perfect pupils for the sophists. I’ve gotten to know a bunch of lawyers over the years; exactly 2 were good at math. Both came to law later in life – one was in fact an elite mathematician, the other an engineer who got into patent law. Others ranged from ‘not exactly terrified of math’ to ‘cringy math-phobes’. Plato might be amused. (aside: how would I come to know their level of comfort with math? See: my career.)
- My oldest sister, with a master’s in chemistry and a JD, and a career chasing patents for a Big Pharma company, saw her chiropractor regularly. Whether there’s anything to the theory, there’s a lot to be said for the power of human concern and human touch. Her visits with her chiropractor were one of the few regular, positive interpersonal experiences she, house-ridden with health problems, had. Unfortunately, as she was dying and we were settling the estate, we discovered he was a major shyster. But that’s another story.