A foray into private health care

[Aimless]

I've spent much energy on discussing the perils and pitfalls of private health care, but in doing so I've neglected some of the potential benefits. Recently, I had the privilege of spending a week at a private primary care clinic and I'd like to share some of the insights I was given into private practice in Sweden.

The most important observation: patients and staff were at least as happy as they tend to be in the county-managed system... and many were happier.

This was esp. true of staff. They appreciated things like: flexibility, autonomy, sense of involvement, sense of common purpose, ease of making decisions or affecting changes, collegiality. All of them had worked for the county until fairly recently and they seem to have retained their old connections. Cooperation with the public system came with ease and seemed relatively free from resentment (on all sides). Resentment and lack of cooperation are otherwise among the greatest enemies of good healthcare, in Sweden. There was surprisingly little overutilisation and defensive medicine. Instead, they relied on the most important and most appreciated of all medical interventions: a little more time with the doctor.

It should be noted, however, that this clinic was the first and only private clinic in the whole town. In other Swedish towns, where private healthcare providers have to compete with each other, the situation can be less rosy.

The patient mix was also surprising. In many other regions, the privatisation reform has led to the neglect of complicated patients with multiple chronic diseases in favour of simple profitable patients. At this clinic, the unprofitable patients were fairly common and got the attention they needed. A large portion of the remainder were patients who'd grown dissatisfied with their previous medical homes for various reasons. Going through their experiences, a general trend emerged: their dissatisfaction was almost always due to interpersonal problems rather than to medical issues. This is, of course, not surprising--interpersonal problems are among the most important factors in complaints and lawsuits against healthcare providers. Although this clinic was not much more likely to perform unnecessary procedures etc. compared to the dissatisfied patients' previous clinics, it could offer them the most important intervention of all: a relaxed, empathetic and pedagogical consultation. I was esp. advantaged compared to the rest of the staff when it came to receiving patient love; not only because I'm cute and wonderful but also because I was given more time per patient.

There's a lot more to say, but I'd like to close with an insight about something not unique to private practice. During that single week, I met several patients who worked at the mine that is the heart of the town's economy. Every single one of them had undiagosed and/or untreated asthma, and they were all constantly exposed to fine dust. Their lungs weren't exactly getting better. I told a couple of them they should get in touch with the company's healthcare division and they all seemed (to this naive young doc) to take that to heart. I've since learned that the chances of them saying anything to anyone remotely connected to their employer are essentially zero. Here's the thing: if you have asthma, esp. poorly managed asthma, you can't work in the mine. All prospective employees have to pass a fitness exam, including a test of respiratory function... but that exam has no real hope of excluding a person with asthma and no employee will ever give the slightest hint of having anything that even remotely resembles asthma. I'd begun to forget the extent to which "reality" can screw people over, and that was a much-needed insight into how tricky it can be to be healthy in the real world.

[Dreadnaught]

Interesting -- how is the payment handled for the lower-income people? Or are they actually not too low income/splurging on care?

Just to be clear, you were there for work and not because you needed treatment for yourself, right?

[Aimless]

Interesting -- how is the payment handled for the lower-income people? Or are they actually not too low income/splurging on care?

Of course, when I say "private" I only mean that the clinic is privately owned--most of the payment for the patients still comes from the county. This is still Sweden after all There was one patient who insisted on getting a crappy and expensive treatment that she paid for all on her own.

Just to be clear, you were there for work and not because you needed treatment for yourself, right?

It was my final clinical rotation

[Loki]

The patient mix was also surprising. In many other regions, the privatisation reform has led to the neglect of complicated patients with multiple chronic diseases in favour of simple profitable patients. At this clinic, the unprofitable patients were fairly common and got the attention they needed. A large portion of the remainder were patients who'd grown dissatisfied with their previous medical homes for various reasons. Going through their experiences, a general trend emerged: their dissatisfaction was almost always due to interpersonal problems rather than to medical issues. This is, of course, not surprising--interpersonal problems are among the most important factors in complaints and lawsuits against healthcare providers. Although this clinic was not much more likely to perform unnecessary procedures etc. compared to the dissatisfied patients' previous clinics, it could offer them the most important intervention of all: a relaxed, empathetic and pedagogical consultation. I was esp. advantaged compared to the rest of the staff when it came to receiving patient love; not only because I'm cute and wonderful but also because I was given more time per patient.

This is what you keep on missing in the public/private debate. For a doctor working in a government-run clinic, the patient is someone they're doing a favor to. They know the patient will come back. They know that their salary is not conditional on that patient's satisfaction. Meanwhile, a doctor at a private clinic knows that mistreating a patient means losing a patient. You can pretend that all doctors are God's gift to mankind and act entirely out of goodwill, but the reality is that most people need incentives to "do the right thing".

[Aimless]

Yeah or you can just make sure they have a good work environment, a reasonable workload and enough time per patient.

[Loki]

Again, give me a reason why a public sector doctor should be remotely friendly to a patient? And no, saying "because it's the right thing to do" doesn't count.

[Aimless]

Again, give me a reason why a public sector doctor should be remotely friendly to a patient? And no, saying "because it's the right thing to do" doesn't count.

Why are you friendly to your fiancée? Why are you friendly to your friends? Why are you friendly to your colleagues? Why are you less surly towards your mum? Why are people friendly to people they meet on the street or at the grocery store?

It's not simply "because it's the right thing to do." It's because most normal people, when they're relaxed, safe and happy, are not inclined to be total asshats. Perhaps that's the outcome of millions of years of evolution, I dunno, but it's a fact. You may not believe me, but that says more about you than it does about anything or anyone else Loki. Perhaps you believe people enjoy constant unpleasant encounters? Perhaps you think it makes life easier to be unpleasant to the people you interact with? Madness. I'd offer antipsychotics if it weren't unethical

[Aimless]

And, just to forestall further imaginary arguments, I'd like to ask you where, in this thread, you found a statement from me that the public healthcare sector in Sweden is mostly characterised by unfriendliness towards patients.

[Loki]

Why are you friendly to your fiancée? Why are you friendly to your friends? Why are you friendly to your colleagues? Why are you less surly towards your mum? Why are people friendly to people they meet on the street or at the grocery store?

People are nicer to those close to them. They dependent on them over the long term. They expect reciprocation. None of this is true of a doctor treating a patient.

Let me know when you're ready to provide a real answer.

[Aimless]

People are nicer to those close to them. They dependent on them over the long term. They expect reciprocation. None of this is true of a doctor treating a patient.

so this is why you're so uniquely unpleasant would you be nicer if I paid you to be nice?

[wiggin]

Minx - you said that most of the payment came from the state, but this was a private practice. I assume that means that the rest of the providers in most areas are employees of the state (i.e. both a single-payer and a single-provider system). How does reimbursement work? You imply the doctors had more time to spend with patients, which costs a lot of money - where did the extra funds come from? The patients' pockets?

I'm also curious when you surmised that more private competition would decrease the perceived quality of the service. I'm not sure I understand why this is the case - wouldn't increasing the number of private clinics make them compete for patient loyalty, especially on intangibles (i.e. things not directly related to care)?

Lastly, I'm curious that you suggested that 'interpersonal problems' were among the most important factors in lawsuits - I can't possibly see how this is true. Being a dick might make a patient unhappy with you, but it ain't malpractice. (Obviously I've seen the studies indicating that a doctor who's willing to admit fault for a mistake they made is less likely to be sued, but that's fundamentally based on an actual malpractice claim, not an interpersonal issue.) Do you have some evidence about this phenomenon? I'm interested to see it.

(BTW I'm not trying to attack you at all, I'm just curious about these points. Thanks for sharing your thoughts and experiences!)

This is what you keep on missing in the public/private debate. For a doctor working in a government-run clinic, the patient is someone they're doing a favor to. They know the patient will come back. They know that their salary is not conditional on that patient's satisfaction. Meanwhile, a doctor at a private clinic knows that mistreating a patient means losing a patient. You can pretend that all doctors are God's gift to mankind and act entirely out of goodwill, but the reality is that most people need incentives to "do the right thing".

Loki, I'm not sure that the focus on the doctor here is correct. The US does have single-provider systems - notably, the VA is a huge one. Though the VA may have issues, I don't think a lot of them have to do with doctors feeling entitled to their patients. I suspect that your point resonates more with the bureaucracy surrounding the doctors (the VA is notoriously a pain in the ass to deal with), but I suspect the actual standard of care isn't that bad.

Furthermore, plenty of doctors in the private sector don't have the incentives to perform that you describe. Notably, most hospitalists and ER physicians (as well as many specialists employed by hospitals) are paid a flat salary, not contingent on the happiness of their patients. They also have a pretty guaranteed stream of patients. I'm not really convinced the lack of a competitive incentive makes them poorer physicians.

[Nessus]

so this is why you're so uniquely unpleasant would you be nicer if I paid you to be nice?

Minx, I would like to recommend to you a book at this juncture. It is by Lauri Vahtre, and a direct translation of the Finnish title is "The Super-power of the Absurd". It is a rather informal if perhaps informative look within the Soviet system by an Estonian observer. Among the stories within is an account of how waiters performed.

As per Low-key's logic, the waiter in the Soviet system had no incentive to actually serve the customer. The absurdity this lead to was rather sad in its way; a customer might get service, might not, and often they got service they didn't ask for. Eg. you could only order macaroni and tomato sauce, which might or might not be delivered to you eventually in between card games the 'service' staff played in the back. The power dynamic of the situation was such that the waiting staff knew they had a hold over you, not vice versa, and behaved accordingly. (Unless you were a party big-big, natch)

Obviously the Soviet system, even after Stalin, was in many ways a messed up organization. Mr. Vahtre does, in a possibly unfortunately racist turn, blame some of this absurdity on the Russian people. And it is true that one tends to find certain common denominators in their behaviour behind the counter, namely treating the customer as a nuisance, and so forth. It is not hard to see how this would extend to the medical care system, and not many years ago the average Russian person feared hospitals roughly as much as military service and prison. It's not nice for anyone involved, I imagine.

From mr. Vahtre's anecdotes to personal ones, I have a hard time generalizing as willy-nilly as Low-key the Soviet experience into a global one. The times I've been to awful, awful public health care services in Finland were generally nice encounters with attentive, friendly people. It is true that the waiting times are sometimes rather unpleasant; no one likes to spend several hours waiting for service. As a young and still relatively healthy person the waits have so far always coincided with situations where it was not, from a medical perspective, dangerous. And conversely for instance my grand-mother has in general been pleased with the service she has received in the care of fairly extensive spinal problems.

The encounters with private health care as provided by employer have not, in my opinion, been in any macroscopic way more positive or confidence-building. Of course in this situation I am not the payer, my employer is, and again we have a customer-service situation where the feed-back loop between my satisfaction and payment provided to the medical care facility is tenuous at best. As it happens, I have the ears of some influential people, but this is in no way apparent to the medical care personnel. So, I have received from them attentive and polite service as I would imagine any of my peers would.

To examine Low-key's logic further, I will delve into another personal anecdote. The so-called "third mission" of Finland's universities is public interaction, and on a more, hm, utilitarian front each employee has a teaching quota. Now, as per Low-key's view of the world, there isn't that much incentive for me to try and be a good teacher; there is zero direct incentive for me to try and be a good disseminator of science to the public. However, I have done my best to improve on my teaching skills, including reading many rather delightful volumes on the pedagogy of the natural sciences. I don't claim to be a particularly good teacher, but I have rated about as well as my peers in yearly reviews. Similarly, whenever I have to present myself as a scientist in front of 'the public', such as SS classes or similar, I try to do my best to cater what I am saying roughly to what I expect their level of understanding to be, and inform on what it is we do and how it relates to the functioning of society.

I am well aware that to both of these things I could more or less say faff off; my research credentials contrasted with my level of experience are more than high enough that I don't need to give two shits about teaching or public outreach. Yet I do, because they are a part of what is expected of me. It is impossible for us to gauge whether or not that makes me a 'sucker' in Low-key's rather abysmal universe, but I'd wager donuts to dollars it does. And admittedly next year I will not be teaching as much as before since I have a thesis to finish. But the idea that I shouldn't provide good 'customer service' since the customers aren't directly paying me, or even directly paying my faculty, is simply absurd.

In all fairness, I only provide a limited amount of direct 'customer service' in this way, and in no way do I imagine the stress level or amount of personal grief is anywhere near that of those found in the medical profession; there's a reason I chose physics over medicine. But this is a conversation on general worker dynamics rather than the specifics of medicine or 'death panels' or whatever insanities. The idea of a Prussian work ethic contrasted with the Russian/Soviet experience is a stark one indeed, and I would personally be hesitant in claiming either a universal human condition. The humanities need be far more quantitative before such analyses can be made, and societies engineered towards the most acceptable equilibrium. I would, however, posit the notion that the idea of human beings as orgasm in, good things come out is a very, very cynical idea of how people operate and need not be generally true. Beyond that, however, lies a vast plateau of alternatives and in general the kind of 'liberals liberals LIBERALS' complexities that elude the average Fox viewer

[Aimless]

Minx - you said that most of the payment came from the state, but this was a private practice. I assume that means that the rest of the providers in most areas are employees of the state (i.e. both a single-payer and a single-provider system). How does reimbursement work? You imply the doctors had more time to spend with patients, which costs a lot of money - where did the extra funds come from? The patients' pockets?

At its heart this is a voucher system with private contractors that sign deals with the counties (as most Swedish healthcare is organised at the county level). The core allowance per patient is weighted (eg. by age and medical needs) and it's mostly that allowance that covers the cost of services (for which the prices have generally been set by agreement). On top of that, there are bonuses for the number of patients that sign up at a clinic, the specific areas being served (influenced by socioeconomic factors as well as by political motives), the services offered, performance on various metrics, etc. I think that most regions also offer to subsidise initiatives for improving service (eg. various kinds of audits).

So that's where the money comes from! How can they afford more time with patients? In addition to greater efficiency and other such benefits of free market enterprise, this particular clinic had managed to fill all positions with regular full-time employees, and they had a reasonable number of patients per doctor (worth noting however that they had me working for free that week ). Counties often have to pay through the nose to hire temps in order to fill vacancies. These temps can cost several times as much as a regular employee. Still, I reckon the most important factors were these: that the reimbursement was, on the whole, generous enough to pay for longer consultations when needed; doctors here were given greater control over their workdays.

I don't know what the margins were on the various services, apart from phone-calls (where margins approach zero), but most private primary care clinics in Sweden are profitable for their owners/shareholders.

I'm also curious when you surmised that more private competition would decrease the perceived quality of the service. I'm not sure I understand why this is the case - wouldn't increasing the number of private clinics make them compete for patient loyalty, especially on intangibles (i.e. things not directly related to care)?

That's true, but the "winners" in that competition are mostly the clinics and the uncomplicated patients. In areas with greater competition, clinics start prioritising the high-margin patients and services. Old and medically complicated patients in those regions have tended to lose out to the young, simple and profitable patients. Things that can easily be handled on the phone end up "requiring" a scheduled appointment. For the winners, the "perceived quality" may still be perfectly adequate (although the scramble for profit may still lead to packed schedules in larger cities). For the losers, not so much. The losers are of course those people closest to my heart

Lastly, I'm curious that you suggested that 'interpersonal problems' were among the most important factors in lawsuits - I can't possibly see how this is true. Being a dick might make a patient unhappy with you, but it ain't malpractice. (Obviously I've seen the studies indicating that a doctor who's willing to admit fault for a mistake they made is less likely to be sued, but that's fundamentally based on an actual malpractice claim, not an interpersonal issue.) Do you have some evidence about this phenomenon? I'm interested to see it.

I can't find my own list of references atm, but for an overview focused on the American system you might want to check out:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201002/

or

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071103/

(or this classic: http://www.ncbi.nlm.nih.gov/pubmed/9032162)

Modern medical education's emphasis on communication skills and on personal/professional development (with a strong focus on empathy) isn't just born of the goodness of doctors' hearts. Research seems to support the anecdotal knowledge and experience I've gotten via classmates, teachers and colleagues: the better your relationship with your patient, and the better you deal with your mistakes, the less likely you are to be the target of a lawsuit or a formal complaint. Patients have several reasons for filing complaints or suing.

From the first article:

In all 3 studies, common themes emerged. The 4 predominant reasons prompting patients to file a lawsuit included 1) a desire to prevent a similar (bad) incident from happening again; 2) a need for an explanation as to how and why an injury happened; 3) a desire for financial compensation to make up for actual losses, pain, and suffering or to provide future care for the injured patient; and 4) a desire to hold doctors accountable for their actions.

Overwhelmingly, the dominant theme in these studies' findings was a breakdown in the patient-physician relationship, most often manifested as unsatisfactory patient-physician communication. Study participants described the perceived communication problems as follows: physicians would not listen, would not talk openly, attempted to mislead them, or did not warn them of long-term neurodevelopmental problems (in the case of newborn injury). Other communication problems cited included perceptions that doctors deserted patients or were otherwise unavailable, devalued patient or family views, delivered information poorly, or failed to understand the patient's perspective.

Clearly, these studies underscore the well-known principle that good communication is the cornerstone of the physician-patient relationship. As the authors have often observed, and as is well documented in the literature, patients are not likely to sue physicians with whom they have developed a trusting and mutually respectful relationship. Simply put, patients do not sue doctors they like and trust. This observation tends to hold true even when patients have experienced considerable injury as a result of a “medical mistake” or misjudgment.

Three of these wishes can often be effectively satisfied through the establishment of a good patient-doctor relationship, either before the inciting event or after.

I have it on good authority that my dad is an extremely good doctor in all respects except one: he's a real chore of a man to deal with, whether you're a patient or a colleague. The result of this has been that he's been the target of formal complaints even when he's brought patients back from the brink of death against all expectations. Conversely, I've met doctors who can make mistakes and still avoid complaints, seemingly due to their skill at establishing great relationships.




I reckon that, in our dealings with other human beings, there are many more currencies besides just currency.

[Loki]

Loki, I'm not sure that the focus on the doctor here is correct. The US does have single-provider systems - notably, the VA is a huge one. Though the VA may have issues, I don't think a lot of them have to do with doctors feeling entitled to their patients. I suspect that your point resonates more with the bureaucracy surrounding the doctors (the VA is notoriously a pain in the ass to deal with), but I suspect the actual standard of care isn't that bad.

The people I know whose fathers used VA wouldn't agree with that statement. I've also noticed that doctors in large clinics tend to be less nice than ones in smaller ones.

Furthermore, plenty of doctors in the private sector don't have the incentives to perform that you describe. Notably, most hospitalists and ER physicians (as well as many specialists employed by hospitals) are paid a flat salary, not contingent on the happiness of their patients. They also have a pretty guaranteed stream of patients. I'm not really convinced the lack of a competitive incentive makes them poorer physicians.

Haven't been at the hospital, so wouldn't know.

[Dreadnaught]

To examine Low-key's logic further, I will delve into another personal anecdote. The so-called "third mission" of Finland's universities is public interaction, and on a more, hm, utilitarian front each employee has a teaching quota. Now, as per Low-key's view of the world, there isn't that much incentive for me to try and be a good teacher; there is zero direct incentive for me to try and be a good disseminator of science to the public. However, I have done my best to improve on my teaching skills, including reading many rather delightful volumes on the pedagogy of the natural sciences. I don't claim to be a particularly good teacher, but I have rated about as well as my peers in yearly reviews. Similarly, whenever I have to present myself as a scientist in front of 'the public', such as SS classes or similar, I try to do my best to cater what I am saying roughly to what I expect their level of understanding to be, and inform on what it is we do and how it relates to the functioning of society.

I am well aware that to both of these things I could more or less say faff off; my research credentials contrasted with my level of experience are more than high enough that I don't need to give two shits about teaching or public outreach. Yet I do, because they are a part of what is expected of me. It is impossible for us to gauge whether or not that makes me a 'sucker' in Low-key's rather abysmal universe, but I'd wager donuts to dollars it does. And admittedly next year I will not be teaching as much as before since I have a thesis to finish. But the idea that I shouldn't provide good 'customer service' since the customers aren't directly paying me, or even directly paying my faculty, is simply absurd.

Question: If your teaching scores were abysmal or you basically did little more than show up to your teaching appointments, how easily/likely/quickly would your employer simply remove you?

That said, I think medical "services" versus teaching "services" often have somewhat different dynamics. Not that you don't raise good points, I'm just thinking aloud.

[Aimless]

If it's anything like Sweden then teaching (I think) is often a condition for being allowed to work on your PhD at a given institution, but you don't--strictly speaking--have to be good. But if you aren't good enough you'll prolly get hassled until you at least improve a little

[Loki]

I.E. The incentive is to be mediocre. I've seen first-hand the top teaching professor in the department driven out because of a mediocre research portfolio. The same would never happen in reverse.

[Nessus]

Question: If your teaching scores were abysmal or you basically did little more than show up to your teaching appointments, how easily/likely/quickly would your employer simply remove you?

Answer: They would not.

[Nessus]

I.E. The incentive is to be mediocre.

Ugh.

Do you concede there is a possibility that incentives other than orgasms and dollars exist?

[Aimless]

I.E. The incentive is to be mediocre.

No, it just means that you probably won't lose your PhD position. And if they're anything like Sweden there's pressure on the institution to make sure that these mediocre teachers improve their teaching skills.

[Loki]

Ugh.

Do you concede there is a possibility that incentives other than orgasms and dollars exist?

There are many incentives in play, both financial and non-financial. You seem to be denying the existence of the former.

No, it just means that you probably won't lose your PhD position. And if they're anything like Sweden there's pressure on the institution to make sure that these mediocre teachers improve their teaching skills.

I don't know about Sweden, but the pressure here is entirely to publish more. You might get a talking to if your teaching is terrible, but people leave you alone as long as you're a decent teacher. There are liberal arts colleges where the incentives are different, but even they're pushing their people to publish more, which inevitably leads to a decline in teaching.

[Nessus]

There are many incentives in play, both financial and non-financial. You seem to be denying the existence of the former.



I don't know about Sweden, but the pressure here is entirely to publish more. You might get a talking to if your teaching is terrible, but people leave you alone as long as you're a decent teacher. There are liberal arts colleges where the incentives are different, but even they're pushing their people to publish more, which inevitably leads to a decline in teaching.

This post is an exercise in irony.

I do not know what I'd have to do to get a 'talking to' for failing teaching duties, I suppose trying to hit on a student?, but it is a far-away potential at best, in reality something to be ignored.

Yet I do my best to be as good a teacher as possible, and I invest a significant amount of time, at work mind you, brain-storming with others how to improve teaching. Fair enough, the most senior person in these brain-storming sessions tends to be someone who is paid to teach more than research, but what is the incentive for the rest of us?

[Aimless]

I don't know about Sweden, but the pressure here is entirely to publish more. You might get a talking to if your teaching is terrible, but people leave you alone as long as you're a decent teacher. There are liberal arts colleges where the incentives are different, but even they're pushing their people to publish more, which inevitably leads to a decline in teaching.

The pressure to publish is there, and it's higher on post-docs. The pressure to teach is also higher on post-docs I think the emphasis on teaching skills depends very much on the culture of the institution and the programmes being taught. Med-students have been pretty good at hassling those responsible for our courses and they have, in turn, been fairly good at hassling both individual teachers/lecturers and their supervisors. In recent years we've seen some success come from simple measures like rewarding good teachers with candy and recognition or just helping them get the time they need to teach properly. I have no idea if physics institutions for example have or can develop a similar culture

Btw on the matter of incentives, teaching (well) while working on your PhD can be a significant merit.

[Loki]

Yet I do my best to be as good a teacher as possible, and I invest a significant amount of time, at work mind you, brain-storming with others how to improve teaching. Fair enough, the most senior person in these brain-storming sessions tends to be someone who is paid to teach more than research, but what is the incentive for the rest of us?

I'd like to see what your research/teaching ratio of time spent would look like if you were rewarded predominantly for teaching, not research.

[Loki]

Btw on the matter of incentives, teaching (well) while working on your PhD can be a significant merit.

Except there's a massive trade-off there. You have a finite amount of time and can't spend it on both preparing material and doing research. The professor I mentioned earlier would have lesson slides with over a gigabyte of various video/audio material for each lecture, which he regularly updated, and on which he spent several hours a day. As a result, he couldn't spend 60-80 hours a week on research, which meant no tenure for him. Unlike him, most people take the hint, and allocate their time "appropriately".

And in case you think it's just my department, all the biology/chemistry people I know in my college (and they're in a top 10 program in the country) regularly spend 12 hours a day at the lab. I can guarantee that they're not spending those 12 hours thinking of a way to improve their teaching.

[Nessus]

I'd like to see what your research/teaching ratio of time spent would look like if you were rewarded predominantly for teaching, not research.

Hang on. The time I 'waste away' from research, which according to you is my only incentive, is not enough?

[Loki]

You need to invest a certain amount of time to not feel like a failure/not be mocked by your students/talked down to by your colleagues. I still guarantee that you spend far more time on research than on teaching.

Historically, liberal arts colleges in the US have focused entirely on teaching (this is changing now). As a result, the professors there would spend a vast majority of their time making lesson plans, having office hours, etc, and would publish perhaps one article every 5 years. Needless to say, the quality of teaching in those colleges is far superior to the research institutions, which prioritize research.

[Aimless]

Except there's a massive trade-off there. You have a finite amount of time and can't spend it on both preparing material and doing research. The professor I mentioned earlier would have lesson slides with over a gigabyte of various video/audio material for each lecture, which he regularly updated, and on which he spent several hours a day. As a result, he couldn't spend 60-80 hours a week on research, which meant no tenure for him. Unlike him, most people take the hint, and allocate their time "appropriately".

And in case you think it's just my department, all the biology/chemistry people I know in my college (and they're in a top 10 program in the country) regularly spend 12 hours a day at the lab. I can guarantee that they're not spending those 12 hours thinking of a way to improve their teaching.

I have no doubt of that. There's no law preventing institutions from being more flexible and figuring out ways to let some people focus more on teaching while letting others focus more on research. I'd rather have a teacher who actually has the time and the desire to teach properly. Academia is a world of messed-up incentives and unrealistic goals. And yet, I've had excellent teachers who've been undergrads, grad-students, post-docs, interns, residents.

[Nessus]

You need to invest a certain amount of time to not feel like a failure/not be mocked by your students/talked down to by your colleagues. I still guarantee that you spend far more time on research than on teaching.

Historically, liberal arts colleges in the US have focused entirely on teaching (this is changing now). As a result, the professors there would spend a vast majority of their time making lesson plans, having office hours, etc, and would publish perhaps one article every 5 years. Needless to say, the quality of teaching in those colleges is far superior to the research institutions, which prioritize research.

As you are not familiar to the culture in Finland, we can pardon your idea of students 'mocking' their teacher in any way that can be expected to reach the teacher. You complained to Minx and I that we were ignoring non-orgasmic incentives, and yet now you parade a bunch of them before me in an attempt to explain why I spend more than the least time possible on teaching?

I do not disagree with you that jobs in our level are geared at research; they should be. If anything, the teaching that 'they' require from 'us' is a joke. Yet, for some peculiar reason, I and a host of my colleagues invest a bunch of time in that joke. According to your views on health care, we should all simply be faffing off and basically sleeping while TAing. And yet you now found a bunch of reasons for us not to. Can't you see the disconnect here?

[Loki]

If you actually read what I said, I never denied the existence of non-economic incentives. You, however, deny the existence of economic ones.

I have no doubt of that. There's no law preventing institutions from being more flexible and figuring out ways to let some people focus more on teaching while letting others focus more on research. I'd rather have a teacher who actually has the time and the desire to teach properly. Academia is a world of messed-up incentives and unrealistic goals. And yet, I've had excellent teachers who've been undergrads, grad-students, post-docs, interns, residents.

Some people respond better to non-economic incentives than to economic ones. Virtually everyone responds to both to at least some extent.