Is The Cure Worse Than The Disease? Reconsidering Meritocracy

crispydoc Uncategorized 2 Comments

Burger Time

The Atlantic prides itself on provocative writing that skewers and roasts the sacred cows of the elite progressive class.

While some journalists overdo it to the point of inducing iconoclast fatigue, the most deft inflict psychic wounds that cause the reader to reconsider vulnerabilities in their thought processes.

Daniel Markovits, a Yale Law Professor whose book is excerpted in a provocative piece in the latest Atlantic entitled, "How Life Became An Endless, Terrible Competition," walks the line artfully as he builds the case that the most cherished remedy to inequality is now guilty of perpetuating it, to our collective societal disadvantage.


The social mobility that once resulted from meritocracy has now led to social sclerosis where the wealthy and well-connected leverage knowledge and advantages to play the meritocracy game in a manner that outmaneuvers their lower socioeconomic status peers.

He regales us with statistics intended to make our jaws drop:

  • 4 of the most desirable elite universities enroll more students from the top 1% than from the bottom 60%
  • children of certain high income households outperform children of certain low-income households by >250 points on the SAT

Markovits' concludes, "Meritocracy has created a competition that, even when everyone plays by the rules, only the rich can win."

Those falling  into the top 1-5% of incomes are still winning at meritocracy (and however uncomfortably we may feel about acknowledging the reality, physicians generally fit this description), but those wins are coming at a steep price.

From Creative To Calculating

Markovits again: "Where aristocratic children once reveled in their privilege, meritocratic children now calculate their future—they plan and they scheme, through rituals of stage-managed self-presentation, in familiar rhythms of ambition, hope, and worry."

Meaning our privileged children are morphing into anxious, depressed and sleep-deprived resume-packing machines in order to maintain the status and privilege we conferred upon them. The ease of online university applications means that admit rates have declined precipitously just as applications to competitive schools have skyrocketed.

Prestige Over Passion

The result? Our kids never sample interests or passions because they understand (thanks to our inculcation) that the most secure paths to wealth and prestige are via finance, management, law and medicine.

Yawn, you say, these have always been the secure paths to wealth and prestige. Yes, but these workaholic jobs are profoundly different than the corresponding leisure class jobs of yesteryear. Your grandfather the lawyer billed half as many hours; your grandfather the doctor did not receive monthly metrics on patient volume or Press-Ganey scores of patient satisfaction.

Nothing Worth Eating In The Executive Fridge

Success is predicated on extreme productivity and consistent top performance, and those who achieve and maintain their status become hollow shadows of the hopes we had for them. Markovits: Meritocracy traps entire generations inside demeaning fears and inauthentic ambitions: always hungry but never finding, or even knowing, the right food.

He notes the recent calls for work/life balance from wealthy elites as one example that those at the top are fed up with what they've had to do and what it means to exist atop the professional apex [CD: Can I get an Amen?].

While he writes for the poor little rich boys and girls who suffer because of their success (us and our kids, my fellow physicians), he realizes that little of the population will feel sympathy for this privileged slice of society.

The Solution? Replace Specialists With Technicians

His solution, the weakest part of his argument, is overly simplistic: use a variety of levers, financial and structural, to open educational and economic access to those at the bottom 2/3 of the pyramid.

There are quick populist votes to be won by saying we need fewer lawyers and doctors who are merely "extravagantly trained children of rich parents," and can be replaced largely with paralegals and nurse practitioners treating bread and butter conditions.

Do As I Say, Not As I Do

Respectfully, my ED volume says otherwise - it's many of those well-intentioned but less trained health professionals whose significantly lower threshold for referring to the ED clogs the safety net with patients that primary care physicians formerly handled in the outpatient arena.

I've heard this argument before from the elite, educated academic or policy-maker who is convinced of the rightness of his reasoning. It's a fascinating intellectual discussion made shortly before I'm asked to contact the concierge physician he uses for his own health care.

Therein lies the weakness of the argument.

Comments 2

  1. Pretty deep stuff as usual CD.

    Interesting point about clogging up the ER wit a lower threshold for admission by those that are not specialized. I see a similar phenomenon in radiology where there is an increased amount of advanced imaging ordered from say mid level providers than more specialized physicians.

    Of course from an administrative point of view this is a win-win situation as mid levels are cheaper than physicians AND they are causing more revenue with more orders.

  2. It has nothing to do with meritocracy IMHO. It has to do with the man behind the curtain pulling the levers. Where you arrive is largely based on your IQ. This is the feature of the Pareto principle. The 20% smartest people acquire 80% of the property. Because Daddy has a lot of money does not mean Jr will be in the top 20%, or even in the running.

    The ED like the rest of us physicians will be replaced by algorithms which guide technicians to check boxes. Eventually Radiology will be replaced by algorithms that spit out diagnosis based on the shadows. The admin will create a “product” called “medicine” which will have little to do with treating disease. It will have to do with maximizing reimbursement. The “diagnosing” will be based on probability and the “treatment” will be based on probability so the patient will get treated in a way that satisfies that probable criteria. If the treatment actually fits the patients need, he/she will get better. If not…. NEXT!!!! Medicine will become a sea of mediocrity. It is happening already which is why your ED is clogged. It is happening at every level and it is happening by intention. I found this to be the case with my post op home health care experience and with my cardiac rehab experience. It’s a one size fits all industrial strength treatment protocol designed to fit reimbursement criteria that has NOTHING to do with individualized patient welfare.

    As medicine becomes more WOKE it will further deteriorate from providing patient care into tribal politics. The Law and the rest will follow in kind. For example In places where “green energy” has been thoroughly implemented it has been found to be totally unreliable. Not such a big deal if it interrupts your rerun of Gilligan. Have a nice time if you’re in the middle of an aneurysm clipping and the lights go off. Or in the middle of a million dollar transfer between accounts and the bits evaporate.

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