於蠡函層 The NeW ENGLAND journal of medicine Perspective NOVEMBER 21, 2013 Are We in a Medical Education Bubble Market? David A. Asch, M.D., M.B.A, Sean Nicholson, Ph. D, and Marko Vujicic, PhD n November 1636, the prices of tulip bulbs in the ble, in which prices of Internet Dutch market rose rapidly from their normal level stocks rose until 2000 and then plummeted. Bubbles burst when to the point where a single bulb might sell for 10 some new sense of lower intrin- times the annual earnings of a typical worker. Just sic value appears. The last buyers as quickly, in May 1637, tulip-bulb prices had shot up in the first paid too much for and can no prices returned to their previous place. Clearly, tulipmania was a longer unload. It's like being alues. The causes of this dramat- bubble market fueled by specula- caught without a chair when the ic rise and fall remain in dispute. tion rather than intrinsic valuation. music stops, but whereas even the The event occurred during the After all, why would people be losers at musical chairs knew that Dutch Golden Age, when stock willing to pay 10 times the average at some point someone would be exchanges, central banking, and annual wage for a single tulip bulb left standing, bubble markets are many of the fundamental struc- unless they were confident that usually recognized only in retro- tures that govern contemporary they could sell it to an even great- spect- the losers never saw it capital markets and the approach- er fool willing to pay even more? coming es deployed by MBAs today were Bubble markets are created Are we in a bubble market in developed hen an asset trades for increas- medical education? In medicine One modern economic analy- ingly higher prices as it is bought students buy their education from is suggests that the precipitous by people who are hopeful about medical schools and residency decline in tulip-bulb prices re- its future value and then sold to programs(which pay wages that sulted from a February 1637 others with even more optimistic are lower than the value of the change in the way that futures views of that value. Recent exam- work that residents provide in re- contracts were enforced, which ples include the U.S. housing bub- turn). This education is trans immediately reduced the value of ble, in which home prices rapidly formed into skills and credentials those contracts by 97%, but this rose until 2007 and then just as that are then sold to patients in analysis doesn't explain why the rapidly fell, and the dot-com bub- the form of services. So long as it N ENGL J MED 369: 21 NEJM. ORG NOVEMBER 21, 2013 1973Perspective The NEW ENGLAND JOURNAL of MEDICINE november 21, 2013 n engl j med 369;21 nejm.org november 21, 2013 1973 as quickly, in May 1637, tulip-bulb prices returned to their previous values. The causes of this dramat￾ic rise and fall remain in dispute. The event occurred during the Dutch Golden Age, when stock exchanges, central banking, and many of the fundamental struc￾tures that govern contemporary capital markets and the approach￾es deployed by MBAs today were developed. One modern economic analy￾sis suggests that the precipitous decline in tulip-bulb prices re￾sulted from a February 1637 change in the way that futures contracts were enforced, which immediately reduced the value of those contracts by 97%,1 but this analysis doesn’t explain why the prices had shot up in the first place. Clearly, tulipmania was a bubble market fueled by specula￾tion rather than intrinsic valuation. After all, why would people be willing to pay 10 times the average annual wage for a single tulip bulb unless they were confident that they could sell it to an even great￾er fool willing to pay even more? Bubble markets are created when an asset trades for increas￾ingly higher prices as it is bought by people who are hopeful about its future value and then sold to others with even more optimistic views of that value. Recent exam￾ples include the U.S. housing bub￾ble, in which home prices rapidly rose until 2007 and then just as rapidly fell, and the dot-com bub￾ble, in which prices of Internet stocks rose until 2000 and then plummeted. Bubbles burst when some new sense of lower intrin￾sic value appears. The last buyers are stuck with something they paid too much for and can no longer unload. It’s like being caught without a chair when the music stops, but whereas even the losers at musical chairs knew that at some point someone would be left standing, bubble markets are usually recognized only in retro￾spect — the losers never saw it coming. Are we in a bubble market in medical education? In medicine, students buy their education from medical schools and residency programs (which pay wages that are lower than the value of the work that residents provide in re￾turn). This education is trans￾formed into skills and credentials that are then sold to patients in the form of services. So long as it Are We in a Medical Education Bubble Market? David A. Asch, M.D., M.B.A., Sean Nicholson, Ph.D., and Marko Vujicic, Ph.D. I n November 1636, the prices of tulip bulbs in the Dutch market rose rapidly from their normal level to the point where a single bulb might sell for 10 times the annual earnings of a typical worker. Just