Do Less, Heal More: The Case for Medical Conservatism (with John Mandrola)

What if the surgery that fixed your knee did no better than fake surgery? EconTalk host Russ Roberts speaks with Dr. John Mandrola about a striking clinical trial in which patients who received sham knee surgery (a real incision, but no actual repair) did as well or better than those who had the actual procedure--one performed 700,000 times annually in the U. S. The conversation ranges from the power of placebo and nocebo effects (how expectation of harm can cause real suffering) to the broader philosophy of "medical conservatism"--the idea that humility, watchful waiting, and honest counsel often serve patients better than the knife. Mandrola argues that financial incentives, professional identity, and language itself ("bone-on-bone," "the widowmaker") conspire to push patients toward interventions that can do more harm than good.

• 0:02Speaker 00

  Welcome to Econ Talk, Conversations for the Curious, part of the Library of Economics and Liberty. I'm your host, Russ Roberts of Shalem College in Jerusalem and Stanford University's Hoover Institution. Go to EconTalk.org where you can subscribe, comment on this episode, and find links to other information related to today's conversation. You'll also find our archives with every episode we've done going back to 2006. Our email address is [email protected]. We'd love to hear from you. Today is May 20, 2026, and before introducing today's guest, I want to let listeners know,

• 0:42Speaker 00

  we'll be doing an Econ Talk Book Club around The Iliad by Homer. The first episode of that book club will be with Ido Chivroni of Shalem College here in Jerusalem, who's been teaching The Iliad here for over a decade, and that will air, if all goes as planned, on July 6. That will provide some useful context on the book to help you get started, and we'll have at least one, if not two or more, we'll see how many episodes in the weeks that follow. And we will be using the Fagels translation, but there are many others to choose from. And now for today's guest, Dr. John Mandrola. John is a cardiac electrophysiologist,

• 1:22Speaker 00

  which is a specialization in heart rhythm disorders. Our conversation today is based on an article he wrote for the Substack Sensible Medicine, which he edits with past Econ Talk guest Adam Seifu. John, welcome to Econ Talk.

• 1:38Speaker 01

  Well, thanks for having me. It's a real honor to be on a podcast that hosted Milton Friedman and Thomas Sowell, so I'm quite excited.

• 1:45Speaker 00

  Well, thank you. The title of your article was "Bravery and Humility is Needed to Do Proper Medical Science." Let's start with some background. You're playing basketball, or tennis, or skiing, or you're just squatting to pick something up, or you're old and something gets worn out, and all of a sudden you have this terrible knee pain. You might have your knee lockup. So you go to the doctor and you find out you have a, you've damaged your meniscus. And ChatGPT will find you a nice image of a meniscus. It's a, it's a little shock absorber that protects your, the bones that make up your knee.

• 2:30Speaker 00

  So what are your choices when you get that diagnosis?

• 2:34Speaker 01

  Well, when you go to the doctor, I mean, the doctor would probably assess you, determine what the exam is like, and then he or she will probably order an MRI or some sort of x-ray, maybe after a period of time. And then if it shows an anatomic abnormality, say of the meniscus, or people get labral tears, other kinds of things, the doctor could suggest arthroscopic surgery. And what strikes me about these treatment plans is that a patient could get better because the illness just runs at course, so-called natural history.

• 3:19Speaker 01

  It could get better because of the surgery, or it could get better from a combination of things, such as the placebo or placebo effect, which is an expectation that they should get better. And so many things in medicine that we treat, there's multiple reasons why patients get better. And what struck me so much about the study that we'll talk about is how they used really a proper placebo control, which we use in drug trials, but we don't often use in surgery trials.

• 3:53Speaker 00

  Yeah, I have a friend of mine who's an emergency room physician, and when I ask him about some situation, one of us had some health issue and it gets better. And I'll ask him if it was the treatment, the drug. Forget what, doesn't matter. The drug, the treatment, the whatever. He'll shrug and say, "Or, you know, passage of time." So most doctors, a lot of doctors, don't have that perspective that you're suggesting and that this friend of mine has. But let's go to the study. And we should just say laparoscopic surgery is this is the idea of it's non-invasive,

• 4:37Speaker 00

  right? Or is it as invasive as minimally as possible? Correct?

• 4:42Speaker 01

  Well, Russ, I think if someone's sticking a sticking a tube inside of a joint, anytime that we put things into the body, I would determine, I would call it invasive. And of course, the definition of small surgery is surgery on somebody else. So I, you know, it's not, it's not like open knee surgery, but it's not nothing either.

• 5:01Speaker 00

  Okay. So how big is this problem, by the way? How, do you have any idea for how common this kind of surgery is to repair a weekend athlete who has a problem?

• 5:13Speaker 01

  I read in the introduction to the paper that in, you know, many thousands, I think here's a 700,000 arthroscopic partial meniscames, meniscames have men performed annually in the United States. So, you know, this is a big deal. I mean, 700,000 procedures.

• 5:32Speaker 00

  Seems like a lot. And what was the, what was the, the study? What did they try to, what did they do?

• 5:41Speaker 01

  So importantly, whenever you look at studies, you always have to think about who's in the study. And these were patients with sort of chronic tears that were, these were not somebody who, not, not a, you know, complete, complete acute tear that was, you know, there immediately from an acute injury, but sort of a chronic knee pain, chronic things. And what they did was they took 146 of these patients and they all had arthroscopy and

• 6:11Speaker 00

  the surgeon

• 6:13Speaker 01

  arthroscopy, a tube looking into the knee, right? So the surgeon looks into the knee and sees that there's a meniscal problem. And then there's randomization to repairing it, shaving it, making it look clean. My impression of it is that it makes the knee joint look pretty.

• 6:34Speaker 01

  And then, or, or pretending that they did, so-called sham operation where they push around and, and ask for instruments and, um, basically the patient doesn't know whether they're getting, uh, real, uh, meniscal surgery or sham surgery.

• 6:52Speaker 00

  Hang on, how is that possible? Don't, don't I see you with, uh, am I awake?

• 6:58Speaker 01

  Yeah, well, no, you're under sedation, uh, light sedation, so there's, and there's a block, uh, like a, a nerve block and there's sedation. And the way we do it in cardiology is, uh, patients wear headphones and they listen to music and, uh, they're, they're sedated. So there's, they don't really know. And then of course, later on, whenever there's sham controlled studies, um, that there's a sham index where people are asked whether they can guess their, uh, uh, treatment, um, you know, treatment assignment. And, you know, usually if the blinding is pretty good, then they don't know. And so then the surgeon is off the case.

• 7:39Speaker 01

  All the follow-up is done by people who don't know whether the patient has had true surgery or a sham surgery.

• 7:46Speaker 00

  I gotta ask another question. So I'm, I'm groggy perhaps, or I'm listening to, um, you know, Bolero or, uh, Crossroads by Cream. I'm not sure. I'd love to know what people choose when they have headphones for knee surgery, but, so I'm, I'm a little bit out of it, or I don't hear certainly the, what the, what the staff is saying about my knee, but don't I have a scar? Don't I have, or do they make a scar, do they scar me to, for the sham?

• 8:15Speaker 01

  No, the, the, correct. So what's so elegant about this surgery, this, this, this study is that, that all patients had the arthroscope. Um, they, so they all had an incision in the knee, the, the tube placed into the knee, there'll be a scar afterwards. It's just one group had the actual repair through the arthroscope and the other group had no repair, had a fake repair and just left it, basically. And, and so on the outside, the patient can't tell.

• 8:47Speaker 00

  And you mentioned in the article, um, in your essay, there's some ethical questions here, right? To, to do this to someone who maybe need, quote, needs surgery, the, the goal of the study is founded if indeed the surgery is effective, but. The idea of doing this to someone and then really doing nothing is borderline unethical. It feels a little funny, but it's for the good of humankind, presumably, to find out whether this thing works or not.

• 9:14Speaker 01

  So that's a tension, isn't it? Because we just talked about 700,000 of these procedures are done annually. And then, what are the ethics of doing 700,000 procedures that really doesn't have any better effect than sham surgery? Or operating on 145 patients? And, you know, we have many examples in cardiology where patients were getting far more invasive surgeries on their heart that were, once studied under placebo, were shown to be not beneficial. And so, I'm not an ethicist, but I can understand that there's tension.

• 9:55Speaker 01

  But without doing this placebo-controlled study, we don't know whether some of these things are effective.

• 10:05Speaker 00

  This feels funny to say, because I don't agree with it, but I'm going to say it anyway. I think a lot of people would say, "Well, the 700,000 procedures that were done, and spoiler, we're going to find out that the surgery is not particularly effective relative to the placebo. It may be worse." But people would say, "But that's different, because those were done to help people. And the sham surgery was done just to gouge their knee with this fake arthroscope, this useless, non-helpful arthroscope." It's just funny how our ethical judgments are clouded by motivation, or presumed motivation. Of course, that ignores the fact that, you know, people do surgery for all kinds of reasons

• 10:50Speaker 00

  besides helping people. They do get paid. I mean, it's not a good analogy, but I think emotionally, people would assume that the 700,000 surgeries were well-intentioned, whereas this thing is just trying to find out what the truth is, which is important, okay, sure, but for those 146 people, it's kind of tough.

• 11:13Speaker 01

  Well, I guess you could, I understand your point, and I think it's an important point. But I would counter by saying that you could make an argument that the arthroscope is partially diagnostic, right? So the surgeons looking into the knee joint might find something else, and the patients having that diagnostic procedure. In cardiology, we have a very famous study where this group in London did, looked at patients with single vessel coronary disease, severe lesions of a coronary that was causing angina, and one group got a stent, got the thing fixed, and one group got a pressure wire, and then nothing was done.

• 11:58Speaker 01

  And in the end, Russ, they showed that there was no difference in exercise time from fixing these things. But the way they got along with that study, called the ORBITA study, was that they said, "Okay, you can have the stent procedure after a six-week period. You won't know whether you had the stent or had the placebo stent, but if you just wait six weeks, then we can do the stent."

• 12:21Speaker 00

  That's awesome.

• 12:22Speaker 01

  And patients in Britain have to wait more than six weeks anyways for their procedure. So they were able to learn so much. But, so there's that. There's some, I think there's some creative ways around the ethics of this. But ultimately, it's just learning what works and what doesn't work.

• 12:43Speaker 00

  Yeah, I don't have any problem with it. I was just trying to play devil's advocate there. I think it's, I think it's, it doesn't bother me. I just think emotionally, it taps into something in our, I don't know, our cultural DNA, or I don't know where it comes from. But before we talk about the actual results, do you have any idea of how often the actual surgery goes wrong?

• 13:08Speaker 00

  We're going to be looking whether it reduces pain and improves mobility and so on. That would be the normal thing to look at, but I assume sometimes there's infection from the surgery and just it's not just ineffective, it's harmful. Is that correct?

• 13:22Speaker 01

  That's correct for any surgery and it's a really important point because what it would be for, you know, arthroscopic knee surgery is X. I'm not sure I could quote that, but it's something and it's the same with any cardiac procedure, any back surgery procedure. There's going to be a finite risk, infection, anesthesia complications, bleeding, and if the surgery is no more effective than placebo, that's really important to know.

• 13:51Speaker 00

  Okay, so what did they find?

• 13:53Speaker 01

  They found, interestingly, that when you look at the response curves of the pain scores, these were subjective scores, that both groups improved exactly the same. There's no difference. So the placebo group improves and the actual surgery group improves. And so the actual surgery was no better than a sham surgery. Now, you don't know, without a no-surgery group, you don't know what the true placebo effect is. You just know that the surgery done 700,000 times per year is no better than placebo surgery.

• 14:36Speaker 00

  And we'll come back to that, but that they didn't look at people who had no surgery. That's a strange thing. It seems to me that if you wanted to really test this, you'd want to do that. Why didn't they do that? And that may not be clear to listeners, but we'll explain in a minute. But why didn't, you know why they didn't do that? Why they generally don't do that?

• 14:57Speaker 01

  It's generally not done. I can't explain exactly why. I can say that logistically it would be difficult. It might be assumed that there would be a difference, but it would be the only way to, I think, truly quantify the placebo effect.

• 15:19Speaker 00

  So, yeah, we'll come to that. So they found no impact relative to the sham surgery, and as you point out, kind of funny.

• 15:35Speaker 00

  Sham is what we call the people who only got the scope but not the knife. But if the knife doesn't work, it's kind of a sham.

• 15:42Speaker 01

  Yes, there's a very famous group in London, Imperial College London, that did the orbit of study that really pushes back against using the term sham because it's really a placebo procedure and if the surgery doesn't work, then the whole thing's a sham.

• 15:58Speaker 00

  And the last thing I want to say about the study, its impact, I'm reading now from the study results, more patients in the surgery arm, meaning the group that got the actual surgery, progressed to high tibial osteotomy or total knee replacement, 12% versus 4%. So I assume that's significant for that study size, but it didn't say so in what I saw. But what that's saying, if it is significant, is that the procedure itself probably weakened the knee and made a replacement more likely.

• 16:35Speaker 01

  Yes, I mean, it's 12% versus 4% or, I mean, they're small numbers, but yeah, it's not just the potential harm and cost and inconvenience of having surgery, it's potential downstream problems. I mean, the study that I wrote about in Sensible Medicine was a 10-year follow-up and these are old studies, but I mean, it's truly remarkable that they're done. And I think, Russ, the other thing that, as a clinician, I'm a practicing clinician, the other thing that we learn, you know, we learn, we sort of have a research lens to these studies and we learn what procedures work and how placebo-resistant they are. But

• 17:20Speaker 01

  as a clinician, we also learn from these studies in using the placebo effect and avoiding the nocebo effect, the opposite of the placebo effect, in clinic. And it helps us understand, I think, the component of the caregiver's relationship in the caring, sort of...

• 17:44Speaker 01

  A program.

• 17:46Speaker 00

  What is the nocebo? Explain.

• 17:49Speaker 01

  So the nocebo effect is directly opposite the placebo effect. The placebo is effect is when a patient, a doctor expects there to be an improvement. A colored pill or a big capsule, you know, makes a bigger placebo effect than a white, small capsule. And surgery is certainly a bigger expectation signal than a pill. But the nocebo is when you expect harm and the expectation of harm makes you feel ill. And, you know, there's a very common, very common medicine that we use for cholesterol called statin drugs.

• 18:29Speaker 01

  And statin drugs are a classic example of nocebo effect where the drug, you know, there's four or five different statin drugs and they lower cholesterol, they reduce the chance of having a heart attack. And in blinded trials, when a patient doesn't know whether they're on the statin or a placebo, there's absolutely no difference in side effects. But then when we look at observational studies where patients know they're taking the statin drug, there's a tremendous amount of muscle pain and ill health. And in clinic, we see it all the time that says, this statin makes me feel terrible. I'm a cyclist and cyclists who take it just say that their legs aren't as good on the

• 19:13Speaker 01

  statin because they know that could affect their muscles. And that's all mostly all nocebo effect. And it was actually shown in one of the best, in one of the best trials ever. And if I could just tell you about it because it has, it's called the Sampson trial and it's such a great story. Again, the Imperial College London group took 100 patients who they said could not take statins. These were statin intolerant patients and very clever experiment. What they did is they randomized these patients on a month's basis. In one month, the patient would take a statin. Another month, they would take a statin placebo, identical tablet. And in one month, they would take no-

• 19:55Speaker 00

  Visually identical.

• 19:56Speaker 01

  Visually.

• 19:57Speaker 00

  They're not chemically identical.

• 19:58Speaker 01

  No, they're not chemically identical. They just, they just look the same. So, one month of statin, one month a, a statin placebo, and one month, no tablets at all. And then they had an app, and every day, they, they said how they felt on the app. And what they found, Russ, is it's just so amazing, is they found that the best months were the no tablets, and they felt identically bad, whether they took a statin or a statin placebo. So, uh, and so, so there was, there was clear ill effects from the statin, but it didn't matter whether it was the statin chemical, or a statin pill that looked like a statin.

• 20:39Speaker 01

  And so, they just elegantly showed the, the placebo effect of, of statins.

• 20:44Speaker 00

  So, I apologize to whoever was writing about this. I've forgotten the source. Uh, I have a lot of leg pain right now, but maybe we'll have a chance to talk about a doctor. Uh, and because I think about, was thinking about your essay while I was limping around with sciatica. But I was reading this essay, I can't remember, we're in a book, about a guy, it's probably a very famous case. He, uh, it's a construction site, he falls off the ladder or something, and a 12-inch, horribly long nail comes up through his foot, and comes up through his boot or shoe, and he's screaming in pain, and they give him fentanyl and other things to try to, to make

• 21:27Speaker 00

  him comfortable, and they, I don't know if they can, it's just, it's a horrible, horrible experience. And they finally get his shoe off, uh, to, to see just how, how bad it is, and they discover that the nail has missed his foot. It has gone between the toes, and he has nothing, his, it didn't pierce his skin. And yet, he's visually from, it's the, it's the ultimate nocebo, right? And, and obviously, the brain, pain is a weird thing.

• 21:57Speaker 00

  Obviously, it's a mental thing, which is not helpful to say that, but it's has to be said. And the brain has some extraordinary powers that this study and the things you're talking, the nosebo studies. And the question is, how do we tap into that? So I give you, well, first, we'll come back to that, actually. Let me ask a more basic question. We talked about this issue on the program sometime in the past, especially with respect to vertebroplasty, which is you've got horrible back pain. And back pain is like many pains and a lot like leaks in the roof.

• 22:42Speaker 00

  Where you see it or where it feels like it's coming from is not always the actual source. So you have you have back pain. It's often the case of my mom, she had a cracked vertebra. So I knew that vertebroplasty in trials against pretending to do vertebroplasty, where you would open the tube of the cement so that the patient could smell it, you would inject, I think, a saline solution instead of the actual stuff, had no better effect. The actual surgery did not work. My mom got it, cured her pain instantly, instantly, the next day. She walked out of the hospital. She couldn't move before this.

• 23:27Speaker 00

  She's a 90-year-old woman or so, and she walked out of the hospital fine. Somebody commented on that episode when we talked about it before that, you know, when you put that cement in, it stiffens the back a little bit. And so she had another episode not that long after and had it done again, and it worked again. At some point, maybe she would have become brittle and it wouldn't have worked. But the problem with these studies and I

• 23:56Speaker 00

  I'm eager to hear your reaction to this. What's the lesson for what we should actually do? We're not suggesting, are we? That if you have, you play, not play tennis, because these are, as you say, older people who've got basically deterioration and your knee starts to hurt and then all of a sudden you can't really walk well. And you go to the doctor and say you have, you need surgery. And you say, well, look, you know, I read this essay by John Mandrola. Can you just pretend to do the surgery? Because that way we'll have less chance of the side effects and my brain, in fact, actually, I'll just pretend I've had it already. Now, we can't, it doesn't work that way. So what's the, what's the takeaway for you on this?

• 24:40Speaker 00

  Your takeaway is we shouldn't be doing these, but, but we have to do the fake one, it seems like, the sham. Because otherwise, since they didn't include people who didn't get any treatment, how do we, what do we do with it? What's the, what's the indication?

• 24:56Speaker 01

  Yeah, I think what we can learn from it is that we, what's so really beautiful about these studies as, as a clinician is that we, we learn from it as a clinician and we can have counsel with the patient and we can say that, you know, we are sorry that they're having pain. We, we understand that, but the pain will get better and the surgery's been shown not to be any more effective than, you know, a placebo surgery. And it will get better and we'll support you through it. And I think that, you know, I, I once gave a lecture titled, "Words Can Harm, Words Can Heal."

• 25:40Speaker 01

  And I think that what we can learn from these procedures, these sham surgeries, is that patients will get better via the natural history, they'll get better from other measures, but they will get better. And I think that we kind of have to be partners with our patients and advisors. And I know that sounds kind of lofty, but it's, it's really true.

• 26:06Speaker 00

  Well, it's hard to charge for good advice. That's one of the problems is that where you should do the surgery, it's got a nice code for Medicare and, right?

• 26:17Speaker 01

  Any doctor will tell you, Russ, 100% that it's much harder to just do the darn surgery than it is to explain why we shouldn't do it.

• 26:28Speaker 00

  Why?

• 26:31Speaker 00

  You don't get reimbursed for it, for good advice.

• 26:35Speaker 01

  You get reimbursed enough, I think. And you get the pleasure of helping somebody with your words, which is, I think, more elegant than with a knife or a catheter, honestly.

• 26:47Speaker 00

  So, the only problem, and maybe, tell me if I'm wrong. So I come in with the bad knee, and you say, "Look, the actual surgery with the knife is the sham. You shouldn't do it. You'll get better on your own." But I need the sham surgery, either the knife or the pretend knife, for my brain to do the get better part, don't I?

• 27:12Speaker 01

  No, that's where the doctor comes in. You just have to, you can tell the patient, I've had a surgeon tell me this. I had a surgeon, I had a labral tear of my hip, and it was terrible. I couldn't run, couldn't even cycle. And he says, "John, you've got a labral tear. It's going to get better. It's going to take some time." And I said, "Well, what about labral surgery?" He goes, "I wouldn't do it. You're just going to get better on your own. It doesn't really help." And that was enough for me. And I really appreciated that advice. But that advice wouldn't have occurred if someone, if we didn't have brave investigators doing these kinds of studies.

• 27:53Speaker 00

  Well, as I pointed out recently, this is, we don't give medical advice on this program. You should take anything you hear here with a grain of salt. So you're not suggesting, I assume, that all labral tears of the hip will get better?

• 28:07Speaker 01

  Thank you. Yes, of course. My labral tear got better on its own.

• 28:13Speaker 00

  I had the same thing. I tore a rotator cuff. I had two shoulder injuries. I'm going to... One was embarrassing. I did a seven-minute workout. It was, you know, some ridiculous thing that I'd seen on the web, and I tore my rotator cuff on one side. The other side, I had what's called frozen shoulder, where the cap of the shoulder starts to have trouble either from scar tissue, I don't know what it is, but you lose mobility in the shoulder. So basically, I was doomed to a life of being unable to throw a football to my grandchildren with either arm, and I might struggle to get my suitcase into the overhead rack. There's nothing more, surely the only thing that matters in life is having enough shoulder

• 28:57Speaker 00

  flexibility to boost your carry-on. And I was told to get surgery for, I think, maybe one, I got a shot. Worked like a charm, of course. I saw the needle, by the way. I don't, in the MRI or whatever it was, like the scan, of course, it could have had nothing in it. It could have been a placebo, but I did not get the frozen shoulder fixed, and I'm fine. Now, I might be lucky. I might have had a very mild case. You know, we have to recognize that a lot of people are different, correct?

• 29:34Speaker 01

  Absolutely. And I don't want listeners to think that, I think that we should just tell patients they don't need surgery. There are clearly things, there are clearly things that get better. But for instance, for instance, Russ, my example, and I have colleagues who've had it, is we've developed atrial fibrillation, an irregular rhythm of the heart. Millions of people get it. And I got it. I couldn't believe it. I'm a heart rhythm doctor with atrial fibrillation. And the most frightful thing for me of having this arrhythm disorder was having a procedure. Scared the crap out of me, even though I do the procedure every day.

• 30:08Speaker 00

  Wow.

• 30:09Speaker 01

  So I just, I just said, I'm just gonna see what happens. I just slow rolled it and it got better. And then I, when I give lectures-

• 30:18Speaker 00

  So you didn't do it? You did not do the-

• 30:21Speaker 01

  No, I just dealt with it and took some medicines for a while and it got better. I have this beautiful example of the cyclist who came to me. And he was having all this atrial fibrillation. And he has this monitor and he put all, he's an engineer. So he put all the AFib episodes in red boxes and he had this calendar full of red. And I said, "That's terrible." And then, he was also conservative and didn't want to do anything. So then I say that in July, the AFib's all better. All green squares. It's basically gone. And I say, "If he had had a procedure in February, we would have called that procedure successful."

• 30:59Speaker 00

  Absolutely.

• 31:00Speaker 01

  Even though the condition gets better. Labral tears are like this, atrial fibrillation's like this. Many things are like this. I mean, so, as a clinician, we just, I think it's elegant and beautiful and fun to harness all of the ways that patients can get better. And rather than intervening early and often.

• 31:25Speaker 00

  The worry I have is that, I'm worried that, you know, I just mentioned I have pain in my leg. My son said, "You need to go to a doctor, Dad." And I, of course, being a veteran Econ Talk listener, I'm thinking about all the placebo effects and the studies that show things don't work and medical reversal where something that looks like it works doesn't work. It turns out when it's studied more carefully. So I feel very intellectually secure in waiting. And I also, but I have to confess, and this is the humility, I don't know if that's the humility in your title of your essay, but I'm also afraid.

• 32:05Speaker 00

  I have an emotional aversion to procedures, shots, surgery. And so I worry that, and I don't want listeners to make the same mistake, that I justify my inaction by an intellectual veneer when the real reason is, "I'm just afraid." And I just, I'm being myopic. I'm hoping it'll turn out well. And sometimes it does, which makes me feel even better about my intellectual contrarianism. But, and probably annoys my doctors. What do you think about that?

• 32:43Speaker 01

  You and I are 100% similar because I'm much more afraid of intervention than I am of any condition, but we should set out that conditions differ. And there are some things that are very reasonable to watch under, you know, careful surveillance of an intelligent physician who's an expert and he partners, she or she partners with you, and it's very okay to watch certain things. There are other things that are more scary and you need a wise, you know, counsel to

• 33:23Speaker 01

  say, to say, Russ, a lot of things we can wait and we can slow roll, but this is something that we shouldn't and it's hazardous and we should intervene. But in the vast majority of these chronic conditions, leg pain, numbness and tingling in the foot or something, or in the hand, even atrial fibrillation, you can, you can, you can watch and be conservative, really. Voltaire famously said, "The best physician humors the patient until nature heals the patient." And so I call it the Voltaire approach and it's, it's, it's underused, but it's really effective and elegant.

• 34:08Speaker 00

  So let's talk a little bit about medical reversal. You know, we did an episode on it, probably did more than one, actually, now that I think about it. It's, the idea is that you do some observational study, meaning you look at a whole group of people, you don't control for anything because you don't have the data, it's just, you have maybe self-reported things, you don't have everything you might need, and you find an impact of some procedure or some drug. And when you do a clinical trial where you actually have a control group, it, the procedure turns out not to work. And it's really fun to discover these. We've been enjoying the, these examples of placebo effects in our conversation.

• 34:50Speaker 00

  But of course, there are, I hope, many things that work in randomized control trials. So you kind of want to know what the numerator and the denominator are. Because, you know, being the contrarian I am and being afraid, my natural impulse is to say, "Well, we'll get better." But, and that's because I see, you know, you have a table in your essay with all this medical, I just had, you said Claude found a bunch of reversals for me. I think there's like 15 or so. And it's horrifying. It means that we spent money, risked lives, had negative side effects from these things that actually did not do good. They did harm. But there's a big denominator, or is there? Are any things that turn out to actually work?

• 35:35Speaker 01

  Well, yes. I see where you're going with this question. There are a lot of reversals, more than there should be, mainly because of our hubris and our ability to be bamboozled by observational, non-random studies. There's a lot of those. There's too many, in my opinion, and there's a way around that, I think, which gets to the medical conservatism. But there are many, many more things that work in medicine. And it's never been a better time to be a doctor or a patient. We have many drugs. We've transformed, for instance, congestive heart failure care. Patients with congestive heart failure used to die of their condition in a year or two. And now it's not uncommon to take care of people with congestive heart failure 20

• 36:20Speaker 01

  years. Cancer has been transformed. Many cancers are chronic diseases. And so I would want to be, I would not want to be pessimistic or nihilistic about the, you know, medicine now. It's wonderful. But what we learn from medical reversals, I think, Russ, is to, is to have the humility to understand that many things don't work. And before things get accepted, they should be evaluated in, in proper trials. So I've been a big advocate of, of rather than accepting some of these procedures, that we should have proper trials initially to show that there's an effect. Now,

• 37:05Speaker 01

  People would push back a little bit on that and they would say, John, you have to be careful with that because first generation devices, first generation surgeries are often not as effective and procedures iterate and you have to let the procedure iterate so that things get better. But again, I really, really believe that, that we should be very careful about observational, non-random things that we think make people better because we observe it. And we should be more of a, have more of a culture of randomization. For instance, I've been blessed to go to Denmark many times. And when you walk through a hospital in Denmark, they'll take you through, and probably a third or more of patients in

• 37:49Speaker 01

  a Danish hospital is in a randomized trial of one sort or another. And so there's patients getting care, but they're randomized to one thing or another. Maybe a different temperature in a, you know, cooling in the ICU, or maybe a different saline solution, or this or that. And they're just constantly studying things. And so they have a culture of, of randomization. And then we would be better off, I think, as a, as a field, if we did more of that. Even now, Russ, because we've done so many good things that we're sort of on the plateau phase of medicine, where it's harder to make big improvements. And I think it's even more important to, to study things before we accept them.

• 38:32Speaker 00

  So, I raise this question. I mean, your, your essay was called bravery and humility. I assume the bravery is to admit that sometimes something you're, you've been doing isn't right. And that's also the humility, right?

• 38:45Speaker 01

  Yeah, bravery is to randomize patients to sham surgery, I think. It's brave.

• 38:51Speaker 00

  Yeah, that's true. Brave for both the surgeon and the, the patient. But here's the thing. So this, I don't know when, this study came out this year. This, this is the, a 10-year follow-up from this original study. It's called the Fidelity Study. For those listeners who want to look it up, we'll try to put a link to it if, if we can. And then fidelity's actually a clever, a clever acronym.

• 39:16Speaker 00

  But you'd think, after the study comes out, if you were right about its effectiveness as a study and showing that these meniscus repairs don't do anything, you'd think that would be the end of those kind of surgeries. But I just have a suspicion that it doesn't have that big an effect. I don't think all the orthopedic surgeons in the world looked at this and said, "Oh, well, that's embarrassing. We did 700,000 of these last year. We shouldn't have done any. And I guess I'll put my knife away and I'll hang up my knife."

• 39:54Speaker 01

  No, that's a really good point. And I think that, I'm not an orthopedic surgeon, but I know that many of the issues with translation of these trials to the clinic is that, I mean, these were 146 patients or 148 patients. So these are very highly selected patients. And that's a problem with clinical trials. So a clinical trial is, they highly select their patients. And that's okay, because you want to know for that group of patients, does the surgery work? Does the medicine work? But then patients we see

• 40:34Speaker 01

  in clinic come in many different varieties. And you'll often see 1,000 patients screened, 140 enrolled. And what about those other, you know, 800 to 900 patients? So I think a surgeon would say, for this highly select group, it's not beneficial. But there are many, many different kinds of meniscal injuries or knee injuries that are different from this study. And I think that we have to be careful translating highly selective studies to a clinic where there's all different manner of patients.

• 41:09Speaker 00

  But of course, if you have a hammer, everything looks like a nail. To use a bad image relative to my earlier example of the construction site. And I think that the challenge of using this kind of knowledge effectively is that the people who should be consuming this knowledge, the surgeons and the people in the clinic, it's costly. They don't want to hear it. And so they find a reason, just like I find a reason not to do it, they find a reason to do it. Say, "Well, for this patient." And of course, it often works. They often see their patients are happy. They see them a week later, say, "I'm feeling great." They don't talk to them 10 years later when they need the knee replacement. If they do, they say, "Well, you probably wouldn't need the knee replacement either way. It's probably genetic."

• 41:54Speaker 00

  So I think it's a fascinating question of how you keep from fooling yourself when it's your livelihood. And by the way, you say it's kind, to use your words, to heal people, but it's also, that takes a lot of bravery to say to somebody, "You're going to get better." But the patient's saying, "Doctor, I want the drug." Or, "Doctor, put me under the knife. Take care of me." And you're saying, "No, no, no. It'll get better on its own." There's so many forces working against that for the practitioner, it seems.

• 42:32Speaker 01

  It is true. It is true. And I think an example in my world of cardiology is we have known, we've known for probably 15 to 20 years that doing a stent or fixing a coronary blockage doesn't reduce heart attacks, doesn't make someone live longer. And yet, it's very difficult to walk away from those things.

• 42:58Speaker 01

  So, and it's not just financial. It's also your career in fixing things. And there's just, there's really, Vignesh Prasad talks about this, it's like the double whammy. You get paid and you get good feelings about fixing these things. But again, what strikes me about proper placebo-controlled trials is we learn humility. We learn that things get better. And we learn that not everything that we do works as well as we think it does. And I just find it beautiful and fascinating.

• 43:38Speaker 00

  Yeah, I agree. And I've mentioned on the program before, when my mom asked my advice on whether she should get the cement button or vertebrae, I said, yes. And it worked. I had, I was very uncomfortable about it, partly because I knew the complexity of it and the data, but also because I knew that the particular surgeon that she had been going to wanted to put her under general anesthesia for the procedure, which many practitioners don't, but he did. And I know that adds an extra risk, you know, and if it didn't work, I've got that side effect of the cost of anesthesia. But we so often err on the side

• 44:19Speaker 00

  of doing something, of being active rather than passive. And it's a, it's a human, it's a human thing. You know, so many people, we've talked about this many times on the program with respect to other treatments and surgeries, you know, it's, once you find out you've got something in your body that could kill you, even if it might take a long time, and even if it will not affect your quality of life, most people want to take it out. Even if the taking, I'm thinking of, you know, prostate cancer and other cancers,

• 44:58Speaker 00

  they, the idea of it is just, it's too, the advice, take, you know, it's slow growing, it'll take a long time, it doesn't comfort, they want action.

• 45:10Speaker 01

  I couldn't agree more. And I've heard you talk to Vinay about screening. And one of the things that I, one of the things that I don't allow my doctor to do is a PSA, because I don't even want to know. Because if I, if I know the PSA, then I'm going to worry about it. Then I might lead to a, then it might lead to a biopsy, and then that might lead to whatever. And it's like if a mouse, if you give a mouse a cookie, and it's best to, for me, not even start the cascade. And it's the same with colonoscopy, since there's a study that shows it doesn't change your, your longevity, I just, I don't do it. And I don't have any, I don't have any regrets about it. And, and it is true when, when you, when you find out these things. So.

• 45:51Speaker 01

  I'm okay with it. I'm okay with not, not looking.

• 45:54Speaker 00

  Yeah, I tell my doctor not to do the PSA. PSA is a test that we've talked about many, many times on the program. Eric Tobel for sure. I don't know who else. You can probably Google it and find it. But, and I don't know where the, where the mainstream consensus is on this issue now. I haven't paid any attention to it for a while, but, but I probably have mentioned it where I tell my doctor, I don't want it. And then I get my results back and it's, there it is. And I tell my doctor, I said, I told you I didn't want it. And he said, well, it's just, it's kinda, it's routine. It's part of the, you know, it's part of the workup. And I'm, it's like, it's just, it's cruel, actually. It's expensive. There's a cost involved, obviously, for the, whoever's paying for it. But more than that, it's just

• 46:35Speaker 00

  the cost on me if it had been a bad score. And then, anyway, so it's a, it's a fascinating example.

• 46:42Speaker 01

  Another example, since we're talking about orthopedics, is I see tons of patients who the surgeon has told them they have bone on bone. Bone on bone is one of the most harmful phrases in, in, in medicine. Because, and I'll ask the patient, I say, well, how did, does your knee hurt? No. But the doc, why are you having knee surgery? I have bone on bone. And so the, the notion that there's bone on bone just gets into people's heads. And they say, I said, you don't really need to worry about it. They're like, they're like, you're not an orthopedic surgeon. I'm like, well, if my knee didn't hurt, I wouldn't be having surgery.

• 47:18Speaker 00

  Yeah, my, my dad had a friend, if there was any, if this car was making noise, my dad would say, you know, what is that? He goes, oh, it's just two pieces of metal rubbing up against each other. One of them will wear the other one down and it'll go away. That's the bone on bone, right? It's, but it, but it had, it's funny, when soon as you said that phrase, I actually had a physical reaction with the hair on my arm. I could feel a ten, a fear response from that phrase, bone on bone. It's a, it's a terrible thing. And what a, what a. What a clever marketing technique for surgeons, but.

• 47:56Speaker 01

  I mean, we have the, we are just as guilty in cardiology. We have the widow maker, right? So if you have a widow maker, you're going to want to have a stent in it, even though studies, studies show that doesn't make a difference. We have, when a patient comes in and they have a stress test that's positive, we say they failed the stress test. And so we have all of these, these words in syntax that sort of create a milieu where patients are more willing to have intervention.

• 48:22Speaker 00

  Yeah, I was at the dentist this week and he, he decided, he wasn't going to do it at first, but he decided that he needed to give me a shot to, anesthetize, what's the right word I want?

• 48:38Speaker 01

  Numb.

• 48:38Speaker 00

  To numb my, my gum. And I'm 71. And when I hear the phrase, I'm going to give you a shot, I get that response, the fear response. Because when I was six and seven and eight years old, in the 50s and early 60s, a shot really hurt because the needle was very blunt and thick. Shots today are really remarkably painless, but I have to really work at it to not have it be painful because I, I have this emotional connection to it. So he says, he starts to give me the shot and he says, uh, this, this is going to pinch and, and

• 49:20Speaker 00

  it'll hurt. And I'm thinking, all you have to say is the pinch part. I wanted, I didn't have time to talk to him afterwards, but I wanted to explain to him that once he says it's going to hurt, he's, he's, he's hurting me. He doesn't, and not because I'm emotionally reacting to it. My brain is going to look for the pain. It's going to be the, the nail through the shoe thing.

• 49:41Speaker 01

  There are, I could show you empirical studies that show the exact same thing. And, and I try not to do this when we give, when we give a local anesthetic. We say, this isn't going to hurt hardly at all. This is going to be fine. And, and rather than, you know, I used to say when I was young, this is going to, this is going to feel like a bee sting, which, which is a terrible thing to say because, because bees hurt like hell.

• 50:04Speaker 00

  Yeah, it's a terrible thing to say. Plus, you're, most of us have experienced that when we're very young. And it has, I mean, just again, just mentioning a bee sting, I can still feel it's weird. Anyway, let's close and talk about sort of this general philosophy where you're sharing. Back in 2019, you wrote an essay with, with Adam Seifman, I Prasad, Andrew Foy, The Case For Being a Medical Conservative. We had Adam on the program to talk about it here on Econ Talk. Now that was seven years ago, and you've espoused some of this view in our conversation. I'm curious about two things.

• 50:49Speaker 00

  One, I want you to share with the audience, really just say exactly what you mean by a medical conservative. You've called yourself that earlier. And I'm curious if in writing that essay and practicing, you've gotten criticism, I assume, pushback, some praise. Have your views changed at all in the, in the years? And I'm sure you talked to your, your colleagues about this, this question. Is this a lonely club that you're in with, with Adam and I and Andrew? Or is it a growing recognition of our limits as interveners? Tell me, talk about it.

• 51:32Speaker 01

  Well, number one, nothing has changed and I think that as medicine has plateaued and as the push to do more and more, it's made me even more medically conservative, number one. Number two, you know, Russ, I have a kind of a small podcast in cardiology called This Week in Cardiology Podcast, comes out every Friday. And I hear from young people all over the world when I go to a meeting, young people will come up to me and they say, "I can't say anything about this to my professors, but I just want you to know that you've influenced me and Andrew and Adam and Vinay." And I will get notes from young people who say that influences.

• 52:17Speaker 01

  So I think it's kind of a quiet, below-the-surface effect on young people and it gives me great pleasure to hear that. And I guess explaining the medically conservative approach, I liken it a lot to Thomas Sowell's constrained and unconstrained views, is that as medical conservatives, we sort of have a constrained view of what medicine can do. I think an unconstrained doctor is these enthusiasts, so to speak, they just think if they do enough that they can make everything better. And a medical conservative appreciates medicine, appreciates the progress that we made, but

• 52:59Speaker 01

  we also recognize that a lot of things we do don't have substantial benefit and could be treated more conservatively. And we also believe that while there's a profit motive and when there's a confluence of interest between industry and medical progress, that there are many things that industry helps us with, but their interests are different than our interest in some cases. And that we just believe that things should be shown to be effective in proper trials before they're widely accepted. And I think that's the essence of it. So, no, I haven't changed, I've become more that way.

• 53:44Speaker 01

  And I think our following is strong in the young people and it's growing.

• 53:54Speaker 01

  And I think that's great.

• 53:56Speaker 00

  The Thomas Sowell references his book, which I recommend, A Vision of the Anointed. I'm sure he talks about it elsewhere, but in that book, he talks about those people who think human beings can be perfected. Those are the anointed ones who are very similar to Adam Smith's Man of System, who thinks you can move the people around or their bodies around as if they were pieces on a chessboard without a movement of their own. Versus the conservative, and this is not, it does often align with political conservatism also, but the idea that human beings are flawed and our ability, and they have their own interests, and our ability to manipulate them is limited.

• 54:41Speaker 00

  So in medicine, I guess the analogy is, you know, the human body is just, you can just, everything's fixable, and we just keep pushing out the frontiers of progress until we can fix more and more things. And it's not a bad perspective. It is approximately true. It's just that on Wednesday in True Slim in May of 2026, it may not be true about this particular thing we're talking about. And I think that's a, that humility there, which is a very strong part of Sowell's view about intervention. It also comes back to Sowell's point of, you know, there aren't, which I always get wrong, but I think he got it from Arthur Smithy now. I think I got that right. There are no solutions, only trade-offs.

• 55:26Speaker 00

  You know, things that you want to fix in the body don't come free. They come with other costs, whether it's pain or misdiagnoses, type one or type two errors that offset the well-intentioned intervention, the unintended consequences. So it's a, it's a very interesting example, and I want to just give you one more piece of this, which I think is, you know, as you get older, you have to confront it. The same friend I was talking about, who's an emergency room doctor, says, you know, families will come in with a loved one who's got something terribly wrong with them, and

• 56:06Speaker 00

  they'll intervene in some way, and it might work for a while, but it doesn't completely solve the problem. And then the patient's condition gets worse, and then the family says, so what do we do now? And the doctor says, well, there's really nothing to do. It's your loved one is probably going to die. And no one wants to hear that. They want to be, they say, but where's the switch? We can turn from off to on to cure it. Where's the drug? What drug now do we try if those other ones didn't work? What surgery now do we try that didn't work before? And we so want that to be true.

• 56:50Speaker 00

  I think both as, you know, loved ones of, you know, friends and, and family members, we want them to live forever. And part of the humility, I think you're talking about is the understanding that there comes a point where we rely on the body's natural ability to heal itself. But sometimes that comes to an end and you have to confront that there's nothing left to do. And we, it's just, it's in 2026. That's unacceptable.

• 57:23Speaker 01

  It's such a difficult problem. And of course, in cardiology, it, all of our patients, all of many of our patients end up dying of heart disease or they die with their cardiac devices and we have to face this. My, my wife Stacy is a retired hospice and palliative care physician. So I have a unique perspective on this. And the one phrase that you used there in that statement, you said, there's nothing else we can do. And I, I guess I would push back on that concept of, of, of there's always something we can do. It might be different than a life prolonging therapy, but we can change our goals of therapy to, to more of a comfort care.

• 58:07Speaker 01

  And so I, I like to say that there's always something we can do and caring is involved. It might be different than turning that switch and curing that cancer or curing that heart disease, but we can change our goal of care. And the goal of care, instead of life prolonging, might be improving comfort, being at home with family, maximizing the time that, that, that people have. And so, but it is, this is one of the, then this is one of the most difficult, the most difficult things because you just think.

• 58:44Speaker 01

  I just think you might be able to do one more thing to help this patient, one more surgery, one more pacemaker lead, one more stent. And saying, counseling patients and finding the time to say, "It's time to change our goal of care" is one of the most difficult things.

• 59:05Speaker 00

  My guest today is John Mandrola. John, thanks for being part of Econ Talk.

• 59:10Speaker 01

  Thank you.

• 59:17Speaker 00

  This is Econ Talk, part of the Library of Economics and Liberty. For more Econ Talk, go to EconTalk.org, where you can also comment on today's podcast and find links and readings related to today's conversation. The sound engineer for Econ Talk is Rich Goyette. I'm your host, Russ Roberts. Thanks for listening. Talk to you on Monday.