202. How Many Doctors Does It Take to Start a Healthcare Revolution?

The practice of medicine has been subsumed by the business of medicine. This is great news for healthcare shareholders -- and bad news for pretty much everyone else.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:01Stephen J. Dubner?

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• 0:43Stephen J. Dubner?

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• 1:25Stephen J. Dubner?

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• 1:54Stephen J. Dubner?

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• 2:36Stephen J. Dubner?

  Okay, let's be honest. How much of what you know about medicine, especially emergency medicine, comes from watching TV?

• 2:45Speaker 01

  Gunshot wound's on its way.

• 2:46Speaker 02

  When?

• 2:46Speaker 01

  Now.

• 2:49Stephen J. Dubner?

  Hospital dramas have long been a staple of the Western media diet.

• 2:54Speaker 01

  Blink, find Benton, clear trauma one and notify the OR.

• 2:59Stephen J. Dubner?

  And research shows that we tend to believe what we see on fictional TV shows. One Belgian study, for instance, found that people who watch a lot of hospital dramas are more likely to overestimate the likelihood of survival of a real-life patient after receiving CPR.

• 3:15Speaker 01

  He's not breathing, he's in the intubation tray.

• 3:18Stephen J. Dubner?

  But overall, is a patient in a TV hospital more or less likely to die than a real patient? That was the question posed by Amir Hatzroni, an Israeli professor of communications, who did some research on American TV dramas. He and his students watched episode after episode of ER, Chicago Hope, and Grey's Anatomy, keeping detailed coding books on every patient, their race, approximate age, their malady, the treatment, and whether they lived or died.

• 3:49Speaker 03

  Mark died this morning.

• 3:52Speaker 03

  It's 6:04 a.m.

• 3:54Stephen J. Dubner?

  And what did Hatzroni find?

• 3:56Speaker 04

  People die on TV in TV hospitals far more than they die in real life.

• 4:04Stephen J. Dubner?

  That's right. People in TV hospitals die a lot more than they die in real hospitals. Hatzroni found that TV patients were nearly nine times more likely to die than if you or I wound up in an ER. The medical problems of the TV patients were also more dramatic. Injury and poisoning, for instance, were about four times more common on TV than in real life. Same for mental illness.

• 4:29Speaker 05

  I'm not crazy. I'm not crazy. It's okay. Haley, honey, the doctors are gonna help you.

• 4:34Speaker 06

  How you paid surgery?

• 4:35Speaker 07

  Haley May, 16, diagnosed paranoid schizophrenic. Tried to claw her eyes out. I need you to clear her before I can take her up to psych.

• 4:43Stephen J. Dubner?

  Some conditions, meanwhile, are vastly underrepresented on TV. Heart failure, heart disease, and stroke were roughly one-third as common on TV as in real life. Cancer is also underrepresented. And then there are the patients. Hatzroni found that a typical TV patient is more likely to be white, male, and young than a real patient. About a third of real patients are 65 or older, whereas hospital dramas are crawling with young patients. TV patients are also presumably much better looking, although Hatzroni did not measure this in his research. He did, however, make one more observation: that doctors on TV today are no longer viewed as infallible, like they used to be.

• 5:25Stephen J. Dubner?

  They make mistakes, make bad decisions under pressure. They are human, just like doctors in the real world. And just how fallible is the real-world medical profession? That is one of the questions we'll ask in this week's episode.

• 5:42Speaker 08

  When you read medical history, it's very humbling. We have screwed stuff up and hurt people over and over and over, and we've done it with our arrogance.

• 5:50Stephen J. Dubner?

  And we are consuming more and more health care, maybe in part because we see so much health care dished out on TV. But is more better?

• 5:59Speaker 09

  The perception of health care is that by doing more, we can improve health. It's not black and white, and it could very well be the case that in the gray, less may be more.

• 6:09Stephen J. Dubner?

  And one more question. What do you think happens when a significant portion of America's cardiologists go away at the same time to a medical conference? Do you think a lot more heart patients die during their absence? Or maybe, just maybe, the opposite?

• 6:37Speaker 10

  From WNYC, this is Freakonomics Radio, the podcast that explores the hidden side of everything. Here's your host, Stephen Dubner.

• 7:02Stephen J. Dubner?

  Our previous episode was about how people are increasingly using RCTs, or randomized controlled trials, to sort out all kinds of problems.

• 7:11Speaker 11

  I think the randomized trial is the very best way to learn about the world around us.

• 7:18Stephen J. Dubner?

  Especially a problem like how to improve health care delivery.

• 7:22Speaker 12

  So let me start by telling you an interesting story, which is the Oregon Health Insurance Experiment.

• 7:30Stephen J. Dubner?

  We also learned about super-utilizers. Those are the patients who consume way, way, way more than their share of health care.

• 7:37Speaker 08

  Yep, yep. So we learned that 1% of the patients is 30% of the payments to the hospitals, and that 5% of the patients is about 50% of the payments to the hospitals.

• 7:50Stephen J. Dubner?

  And we asked if one way to help these super-utilizers, and the rest of us, would be to enroll them in an intensive intervention.

• 7:58Speaker 08

  And if they're interested, we can send them. We then walk out of the room, and it's a randomized controlled trial. We're testing the intervention, and we hit the random button.

• 8:11Stephen J. Dubner?

  The conversation began pretty narrow about RCTs, but soon it went wide, and it began to turn into an indictment of our overall healthcare system. So this week, we are continuing that conversation with a new set of questions. We assume that if you're not getting healthcare, you're worse off. But is that necessarily the case? How much care is too much care? And when you start to peel a few layers off the US healthcare system, how does it really work? And who does it really serve?

• 8:43Speaker 08

  So, you know, the most dangerous thing in America is an empty hospital bed.

• 8:49Stephen J. Dubner?

  This conversation is made possible by the fact that our healthcare system generates an enormous amount of data. Innumerable inputs, innumerable outputs. For us laypeople, that can seem like a nightmare. For an economist, it's a dream.

• 9:07Stephen J. Dubner?

  For there is a lot to be learned from a clever and robust analysis of all that data. Consider the data collected through Medicare, the government-run program that provides coverage primarily to Americans 65 and older.

• 9:21Speaker 09

  So anytime a Medicare beneficiary receives any care, whether they see a doctor in an office or whether they're hospitalized, a claim is filed to Medicare for billing purposes.

• 9:33Stephen J. Dubner?

  That's Anupam Jainah. He is an assistant professor of healthcare policy and medicine at Harvard Medical School, and he sees patients one day a week at Mass. General.

• 9:42Speaker 09

  So, bread and butter cases like pneumonia, COPD, heart failure.

• 9:47Speaker 09

  The typical hospital admission.

• 9:49Stephen J. Dubner?

  But Jana is not just an M.D. He also holds a PhD in economics.

• 9:53Speaker 09

  It's becoming more common. I would say there's probably 10 to 15 of us at most in the US.

• 10:01Stephen J. Dubner?

  That dual training has very much informed the way Jana thinks about his work. When he was doing his residency, for instance, in internal medicine, a question came to mind. How helpful were the medical procedures being carried out by his elders?

• 10:16Speaker 09

  And in some instances, it was pretty clear, at least to the residents and training, that a procedure may not have been appropriate for that patient.

• 10:24Stephen J. Dubner?

  Jana also wondered about the differences between doctors in a given hospital.

• 10:28Speaker 09

  And so that got me thinking, well, what happens to patients when certain doctors aren't around or when, let's say, doctors go away to conferences? What happens to their patients during those dates?

• 10:42Stephen J. Dubner?

  Yeah. What does happen to patients when doctors go to medical conferences? When the doctor's away, does the patient pay? Let's think about cardiology, heart medicine. Every year, there are two major conferences for cardiologists in the US. The American Heart Association Conference, usually held in the fall, and the American College of Cardiology, or ACC, conference, typically held early in the year. This year, it was in March in San Diego, nice place to be after a long, cold winter back east. Out of the 30,000-plus cardiologists in the US, more than 7,000 of them are estimated to be at each of these two meetings.

• 11:20Speaker 09

  So it's not a small number of cardiologists that attend, and the purpose is to present new research findings, to hear about old research findings, to recertify, to get more information about what's up to date in the field.

• 11:33Stephen J. Dubner?

  Jana thought he knew what might happen to heart patients during these conferences. There have been a number of studies, he says, about what happens to hospital patients during off-peak hours.

• 11:42Speaker 09

  So if you're hospitalized after midnight, or if you're hospitalized on the weekend, as a patient, do you have worse outcomes? And the answer in most studies has actually been yes. Not all, but most studies find that patients receive-

• 11:54Stephen J. Dubner?

  That you have worse outcomes, yes?

• 11:56Speaker 09

  Exactly. Worse outcomes if you're hospitalized during off-hours.

• 11:59Stephen J. Dubner?

  Okay.

• 12:00Speaker 09

  And so that was kind of a natural stepping stone to say, well, what happens if you're a patient and you happen to be hospitalized with a really acute condition when cardiologists are out of town at a national meeting?

• 12:14Stephen J. Dubner?

  To answer that question, Jana, along with three co-authors, Vinay Prasad, Dana Goldman, and John Romly, turned to the Medicare data.

• 12:22Speaker 09

  So when a Medicare beneficiary dies, that information is also reported back to Medicare. And what that kind of information allows us to do is to say, when are they hospitalized? Meaning, what date are they hospitalized? And what happens to you after you leave the hospital? Do you go to a skilled nursing facility? Do you go home? Do you make it past 30 days? Are you dead within 30 days? So all of that information is available for researchers to analyze.

• 12:48Stephen J. Dubner?

  They began to overlay patient data with the dates of the cardiology conferences, covering a 10-year stretch. They looked at patients admitted during those conferences and, for comparison's sake, patients admitted in the three weeks before and after those conferences. They narrowed their analysis to the patients who were in really bad shape.

• 13:08Speaker 09

  The idea is, we want to pick conditions where a patient doesn't choose to not come to the hospital because their particular doctor is away, or because they have some knowledge that cardiologists are away during this time. And so we wanted to pick three really acute conditions. The first was cardiac arrest. Cardiac arrest is a condition where your heart stops beating completely.

• 13:28Stephen J. Dubner?

  Whoops, hang on one second. Let me just say, we were speaking to Jana back in February. I was in New York, and he was in Boston, which had just been hit by yet another monster snowstorm. Hang on one second, I was hearing some background sound like a truck or something.

• 13:42Speaker 09

  Yeah, there was a snowplow that just went by.

• 13:45Stephen J. Dubner?

  You may hear a few more snowplows before this conversation is over. Okay, back to Dr. Jana and cardiac arrest.

• 13:52Speaker 09

  Cardiac arrest is a condition where your heart stops beating. It's not a condition that someone chooses to have. It just happens to you. By definition, you die, and you're brought back to life. So it is the most acute thing that you can imagine happening to you.

• 14:06Stephen J. Dubner?

  Jana and his colleagues also looked at heart failure.

• 14:09Speaker 09

  And heart failure, as you might know, comes in a number of varieties, but we looked at patients who have really severe heart failure. So to give you a sense of the numbers involved, about 30% of these patients are not alive within 30 days of hospitalization. So it's a pretty acute condition and high morbidity condition. And the last condition that we looked at was heart attack. The medical term is acute myocardial infarction, but it's basically when one of the, one or more of the arteries that supply your heart has an acute blockage. And so, blood doesn't go to your heart. And again, the same kind of mortality rates, 30% mortality almost at about 30 days.

• 14:45Stephen J. Dubner?

  The Medicare data covered tens of thousands of hospitalizations for these three conditions over the 10 years' worth of annual cardiology meetings.

• 14:54Speaker 09

  It's about as close to a randomized controlled trial as you could ever hope to get. These patients are nearly identical on meeting and non-meeting days. They're the same age, the same sex, the same race. We look at 10 different chronic conditions that they have. They have identical percentages of each one of them. So, they're basically the same.

• 15:14Stephen J. Dubner?

  So, what did Jana and his colleagues find? How did the cardiologist's absence affect patient outcomes?

• 15:22Speaker 09

  We just assumed that the decreased availability of doctors would imply that outcomes would be worse. And that was our initial hypothesis. But what we found was the opposite.

• 15:33Stephen J. Dubner?

  The opposite, meaning that patients were less likely to die while the doctors were away, but only, we should point out, for certain high-risk patients in certain kinds of hospitals. Jana and his colleagues looked at teaching hospitals and non-teaching hospitals. The assumption is that teaching hospitals have more of the type of cardiologists who are likely to attend conferences, but that's only a hunch. And that is where Jana found the surprise in his data. In non-teaching hospitals, the conference didn't seem to matter. But, patients who were admitted for cardiac arrest to a teaching hospital during one of the cardiology conferences were roughly 10 percentage points more likely to survive

• 16:17Stephen J. Dubner?

  than if they were admitted on non-conference dates. Patients with heart failure, again, at teaching hospitals, were 8 percentage points more likely to survive during a cardiology conference.

• 16:30Speaker 09

  High-risk heart failure. What we found is that if you're hospitalized on a cardiology meeting date, your mortality is about 17% at 30 days, 17% to 18%. Whereas if you're hospitalized just a few days before or a few days after, your mortality is closer to 25%. So, that's a very large difference.

• 16:50Stephen J. Dubner?

  Wow.

• 16:52Stephen J. Dubner?

  It just sounds so absurd. I mean, I've read the paper. I know what you're going to say, but it still sounds so absurd. So basically, if I have a major heart condition and someone gets me to a good teaching hospital, I live in New York, my hospital's Columbia Presbyterian, that's a great teaching hospital, you're saying that I have a better chance of surviving if there's a cardiology conference going on and some of the top cardiologists are not there?

• 17:13Speaker 09

  That's correct.

• 17:14Stephen J. Dubner?

  Oof, OK. And describe for me, overall, the magnitude of this effect compared to, let's say, you know, standard cardiology treatment, whether it's beta blockers or statins, angioplasty, stents. How much better off are you by having those interventions than you are by just simply going to the hospital when the cardiologists are not there?

• 17:36Speaker 09

  So just to give you a sense, the mainstays of treatment for heart disease are beta blockers, statins, aspirin, for some individuals, a blood thinner like Plavix. If you were to combine all those therapies together, we're probably talking about reducing your mortality by about 2 to 3 percentage points.

• 17:59Stephen J. Dubner?

  Wow, percentage points, OK. And here you're talking about 8 percentage points in one case and 10 percentage points in another.

• 18:07Speaker 09

  Exactly. So these treatments are very effective, but they're not nearly as large in magnitude as what we're finding here.

• 18:20Stephen J. Dubner?

  Another finding in Janus' paper, while patients with cardiac arrest and heart failure were less likely to die during a cardiology conference, there was no difference in outcome for patients who were admitted with a heart attack. The study did find, however, that these patients received far less invasive treatments, stents and angioplasties, for instance, when many cardiologists were away.

• 18:43Speaker 09

  So an angioplasty is a procedure in which a balloon is inflated in one of the arteries that supply the heart. It basically opens up the blood vessel that was clogged. That is different than stenting. Stenting is a procedure in which an actual stent is placed in the heart and opens up the artery, and it keeps the artery open. There's nearly a third reduction in rates of angioplasty/stenting during meeting days. And remember, in heart attacks, we didn't find any difference in mortality. And so at the very least, what this would suggest is that, look, we're able to reduce these procedures by about a third, and yet we see no difference in mortality in heart attacks.

• 19:27Stephen J. Dubner?

  What does the empirical research say about the efficacy of, say, angioplasty? In other words, we hear about these invasive treatments, angioplasty and stenting and so on, and we, the public, like to think that if doctors have gone to the trouble and researchers have gone to the trouble to come up with these things, of course, they work really well, not only to come up with these things, but to use these things and to build for these things and so on. But talk to me for a moment about what we actually know or maybe don't know about the efficacy of such interventions.

• 19:56Speaker 09

  These interventions, for example, stenting or angioplasty, are extraordinarily effective. I think if you look at the interventions that have been developed in the last 30 years for heart disease, they rank at the highest in terms of their innovativeness and their effectiveness. And most of the patients for whom these interventions have been studied have been, what I would characterize as, average to moderate-risk patients. There have been some studies with very severe coronary artery disease, very sick patients for whom these interventions have been studied, and even in those studies, they do find average benefits for these procedures. So by and large, I think if you were to look at this study without any information about

• 20:39Speaker 09

  the results, you would think to yourself, by lowering rates of these invasive procedures, we are likely to harm patients.

• 20:46Stephen J. Dubner?

  But as we know, that's not what the study found. Jana admits that, given the data, it's impossible to point to an exact cause.

• 20:58Speaker 09

  The strongest limitation of the paper is that we can't tell you exactly what's going on. So what I can tell you with as close to certainty is that something is happening in the hospitals that is responsible for the lower mortality on meeting days.

• 21:12Stephen J. Dubner?

  And keep in mind, it's not as if there are no cardiologists in hospitals during annual meetings. Some docs cover for others, more junior staff might take over for a few days. Jana suspects that the doctors who stay behind may be more cautious.

• 21:25Speaker 09

  What we're identifying is that group of patients for whom the cardiologists who were left behind may have thought to themselves, this person may not be appropriate for this procedure. And the clinical decisions that they're making are different now. And it could be different in a way that actually improves outcomes because they're restricting procedures for those who are at the margin, who would be least likely to benefit.

• 21:52Stephen J. Dubner?

  And your explanation would be that these are docs who are covering, who might be more junior or whatnot, and they are less likely to order up what a more senior, confident, experienced doctor might order up? Is that one explanation?

• 22:06Speaker 09

  That's one explanation. Another explanation could be that the covering doctor says to himself or herself, "Look, I don't want to do this thing because I'd be better off not harming the patient by doing the procedure. Why don't I just wait and see what happens? Simply because this is not my patient. I'm covering the patient for somebody else."

• 22:25Stephen J. Dubner?

  And this, Jana says, brings us to the "less is more" dictum in medicine, which, he notes, is not universally embraced.

• 22:36Speaker 09

  The perception of healthcare is that by doing more, we can improve health. And what we need to recognize is that so much of healthcare, so many of the clinical decisions that we make, operate in this gray zone. It's not black and white. And it could very well be the case that in the gray, less may be more.

• 22:54Stephen J. Dubner?

  Could it be that, you know, the doctors who are most likely to attend these conferences are those who are involved in research and that they perhaps aren't as good at clinical care and the ones who are left behind are maybe better? Is that a possible explanation?

• 23:08Speaker 09

  That's a possible explanation. I think the reason that we find our results predominantly in teaching hospitals is because if you look at the fraction of academic cardiologists who attend these meetings and you look at the fraction of community cardiologists who attend these meetings, I think the share would be larger among academic cardiologists. We haven't been able to get any great data from the American College of Cardiology, American Heart Association, but whatever data they do publish online would support that. And so that's why it's not surprising that we saw the effects there.

• 23:38Stephen J. Dubner?

  I'm curious, Dr. Jana, have you heard from either the American Heart Association or the American College of Cardiology, the two conferences that you measured?

• 23:46Speaker 09

  Not formally. I think the American College of Cardiology released a statement, which is very well worded. It basically said it's reassuring to know that during dates of national cardiology conferences, our patients receive no worse care. Which is technically true.

• 24:04Stephen J. Dubner?

  Technically true, but I could see this being, I could see them playing it either way. They could take it as an indictment that they are, you know, they represent a bunch of people who don't contribute to better care. On the other hand, they could say, hey, you know, our conference is a major lifesaver. We draw away all these people who are doing too many procedures and that's saving a lot of lives. So, but I can't imagine they'll turn that into their slogan, would you?

• 24:28Speaker 09

  Exactly. I've tried to advocate that to my own chair to let me go to more conferences, but that hasn't worked.

• 24:39Stephen J. Dubner?

  We did ask the two organizations to respond to Jana's study. Richard Shazal is the ACC's vice president and a practicing cardiologist.

• 24:49Speaker 13

  I think many of us were actually, were reassured that there wasn't an increase in risk during those meetings because many people had hypothesized that that might be the case, that, that when there was a departure of some physicians, that the staffing levels could result in an increased risk. So I do think it's reassuring to, to the public and to you and to me that we can safely get our care at a teaching hospital during periods of time of meetings. So that part is encouraging.

• 25:21Stephen J. Dubner?

  Pretty much as expected. Dr. Shazal did add this, however.

• 25:25Speaker 13

  This is important and interesting information. The biggest concern here and the one that we have to look at is this finding and to try and tease out if we can in the future, why that is and how we modify our behaviors so that we have a lower risk at all times.

• 25:44Stephen J. Dubner?

  The American Heart Association, meanwhile, sent us a recorded response from its president, Dr. Elliot Antman. We weren't allowed to interview him. Dr. Antman says there is no evidence of cause and effect in Jana's study and that we should essentially think of it as a calendar analysis.

• 26:02Speaker 14

  So the investigators happened to analyze the period of time when cardiology meetings were occurring. They could have picked Christmas. They could have picked New Year's or Easter. We know that there are changes in the staffing schedule when there are holidays, when there are important national cardiology meetings. Bottom line for us at the American Heart Association, there's nothing in this study that we see that would lead us to recommend a change in clinical practice.

• 26:37Stephen J. Dubner?

  In my interview with Jana, I had raised the same point. Okay, is it possible that these cardiology conferences are perhaps typically held at the same time of year every year, which might be a time of the year that coincides with lower mortality?

• 26:51Speaker 09

  That's definitely possible, but you know, as it turns out, over the nearly 10 years that we looked at the data, the cardiology conferences actually varied in their time. So it wasn't that they were always at the same time in the year. They actually do vary slightly from week to week across the 10 years.

• 27:07Stephen J. Dubner?

  Right. I'm curious, has there been any similar research with psychologists or other mental health professionals? I'm wondering if anyone's ever looked at suicide and/or hospitalization or even depression outbreaks, if such a thing can be measured during psychiatric conferences, or maybe even just during August when all the shrinks in New York go to Cape Cod?

• 27:26Speaker 09

  No, that's a great question. I'm not aware of any, and I actually looked into this to see whether or not there was anything that was done. It's something that we're going to do if it hasn't been done after exhaustive search. But it's a great, it's a great example. I'll give you another example of something that we have actually looked at, which we do know data about, and I'm sure you've heard about it, is this July effect. It's the idea that patients who are hospitalized in academic medical centers in July have worse outcomes because the residents who are there are inexperienced. And by and large, what this literature has found is that the July effects, if they happen, are very small. And the question for clinicians was always, well, how is that possible?

• 28:08Speaker 09

  How is it possible that something that every clinician thinks to be a big issue turns out to not be a big issue when you look at the data? And what we, the insight that we had was that, you know what, every patient who comes in the hospital is different. And for most patients, it really does take a lot to, to lead to an adverse outcome. And so what happens if you focus on those patients who are the most sick? And what we did is look at the same kind of group of patients. We looked at patients who had heart attack, who were in the top third of predicted mortality. And, and these patients have a mortality rate of about, as I said, 25 to 30%. And what you see is that for those patients, there actually is a July effect. So if you're hospitalized in a teaching hospital with a very severe heart attack, you are

• 28:53Speaker 09

  five percentage points more likely to die if you're hospitalized in July versus May. So basically 25% mortality versus 20% mortality. So it's a large effect. Of course, it goes in the opposite direction of what we're saying here in the, in the sense that less is worse, but you know, that's one example of people looking at what happens around specific times of year or specific types of practices.

• 29:14Stephen J. Dubner?

  How do you account for that contradiction?

• 29:16Speaker 09

  I think the contradiction is, is going to be what, what is the clinical decision that's being made? So I, I keep on coming back to this in my mind, like, why is this happening? And all I can come down to is I think that cardiologists are just making different clinical decisions during non-meeting dates. And I think the decision that's being made is, is this patient appropriate for a procedure? Because whenever you do something, you have to have in your mind, is this person good or bad for it? And let me give you another example. If a cardiologist had 100 procedures to allocate, and that's all they could do, I'm fairly confident that each one of the people that they allocated that 100, 100 procedures to would do extraordinarily

• 30:00Speaker 09

  well, they'd have a beneficial outcome. But there's no constraint like that in reality. So you can go to the 100 first, 100 second.

• 30:07Stephen J. Dubner?

  That's such an interesting way to think about it. And it makes me think that the economist part of your brain is intruding on the medical part of your brain there. And I wonder if you're leading to some kind of relationship between cost and treatment and availability and supply and demand and so on. So do you think that's? Forget about just cardiology for a moment. Do you think that's a major component of adverse outcomes that we're looking at generally, including just, you know, the fact that we spend more, a larger share of our GDP than any other country on earth, I believe, for healthcare, and yet our outcomes are super suboptimal?

• 30:46Stephen J. Dubner?

  How much do you think that is due to a kind of endless, almost an endless supply and a relatedly very high demand?

• 30:55Speaker 09

  You know, I think the common concern is that because doctors are paid fee for service, meaning they get paid for every procedure that they do, that it leads to over incentives for them to do procedures. I'm actually not convinced that that is really the root of all the quality problems that we find. My hunch is that the reason that physicians may be doing more procedures than is clinically optimal is that they just don't know any differently. Like, if you think about what is that it impacts a physician's decision? Well, sure, what they get paid impacts it, just like it would impact anybody's decision. But what about where they went to medical school, what they learned during residency, whether or not they've been sued before?

• 31:39Speaker 09

  And most importantly, what is their level of risk aversion? I've got to imagine that that would translate somehow into clinical practice. I think that there are underlying differences in how people think, how cardiologists, how doctors think, that drive these decisions.

• 31:58Stephen J. Dubner?

  Ah, now, we are entering a slightly different realm, what's generally called evidence-based medicine. We will get into that after the break.

• 32:08Speaker 08

  What I think many people would be shocked to find out is that many of the things that we do in day-to-day care actually have very little evidence for them.

• 32:18Stephen J. Dubner?

  But we are getting better, aren't we?

• 32:20Speaker 08

  We have a really deep problem with how we're training doctors. They are not being trained to be critical thinkers.

• 32:27Stephen J. Dubner?

  That's coming up on Freakonomics Radio, but before we take the break... Let's hear what some practicing cardiologists had to say about Anupam Jana's paper, which was published in the JAMA journal Internal Medicine. A few weeks ago, we sent a producer to the annual meeting of the American College of Cardiology, or ACC, in San Diego. That is one of the two big annual conferences that Jana analyzed. The first thing we wanted to know is what kind of impression the paper has made.

• 32:55Speaker 15

  Have you heard of this study?

• 32:56Speaker 16

  No, I haven't. But I don't think, I don't really think that it might affect the mortality of the patients while they're away, because normally in the hospitals, there are plans to cover for this, for the absence of the cardiologist.

• 33:13Speaker 17

  I hope it is not affected at all, because before they leave, I'm sure they have somebody covering for them.

• 33:21Speaker 18

  Right now, my partners are covering for me while I'm out here, so I know my patients are getting excellent care and coverage while I'm not able to see them directly. I'm assuming that's the case for everybody.

• 33:31Speaker 15

  What would you say if I told you the study found that there were actually less deaths during the conference? So the mortality improved while everyone was away.

• 33:42Speaker 17

  That is very surprising, actually.

• 33:46Speaker 16

  I wouldn't expect that, that mortality is lower. I would expect that when everybody is working at the hospital, the quality of care is better. That's the normal thing.

• 34:01Speaker 19

  You should think the opposite, right? You should think the less doctors, the more dies, right? But it's interesting.

• 34:11Speaker 20

  Well, we would have to look at the methods of the study to see how robust it is.

• 34:19Speaker 21

  It just doesn't make sense to me that less access to a physician or less access to medical care would make things better. Now, having reviewed the study and the methodology, results from studies like this have to be taken with a grain of salt. Just because you have an association as scientists, we all know that, that does not mean there's causation.

• 34:39Speaker 22

  I have heard of this study, a sort of a running joke in the department that they should, you know, pay more money to send us to conferences to improve outcomes in our hospital. But yeah, if you had asked me before, I wouldn't have guessed that that would sort of be the result. I probably would have guessed there's no difference. And, you know, it just makes us wonder if, because if you're the person sort of left over when everyone else is at the conference, it's a time when, you know, there's fewer tests that can be done, people aren't available, it takes longer to get things done, and makes us wonder a little bit if it's a little bit better sometimes not to have easy access to all the technology right away. Sometimes it might be better to sort of slow things down and sort of see how they evolve.

• 35:19Speaker 16

  Sometimes, in the cardiology field, the intensity of care can be aggressive. And maybe sometimes some procedures are done without being strictly necessary.

• 35:37Speaker 17

  It is very interesting that the quality improved and the mortality went down. So maybe they need to stay at the ACC in San Diego.

• 35:50Speaker 15

  Check, check. So if I could, start with your name, your title, and where you practice.

• 35:55Speaker 16

  My name is Ariel Pimentel, and I'm a cardiologist, and I practice in Santo Domingo, Dominican Republic.

• 36:03Speaker 17

  My name is Kadir Osman. I'm a interventional cardiologist, Yuma, Arizona.

• 36:09Speaker 18

  I'm Lynn Panous, Assistant Professor of Medicine at Temple University.

• 36:13Speaker 19

  My name is Pablo Toro. I'm coming from Honduras, Central America, and I'm an internal medicine practitioner.

• 36:18Speaker 20

  Mary Gleva. I am an Associate Professor of Medicine at Washington University in St. Louis, and I'm an electrophysiologist.

• 36:27Speaker 21

  Victor Mejia, practice in Louisiana, a cardiologist. Pierangelo Rinella, pediatric cardiologist out of Orange County and at UCLA.

• 36:37Speaker 22

  I'm Victor Sukas. I'm an attending cardiologist at the University of Virginia.

• 36:51Stephen J. Dubner?

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• 37:36Stephen J. Dubner?

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• 37:54Stephen J. Dubner?

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• 38:58Stephen J. Dubner?

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• 39:33Speaker 10

  From WNYC, this is Freakonomics Radio. Here's your host, Stephen Dubner.

• 39:46Stephen J. Dubner?

  In our previous episode about the use of randomized controlled trials in healthcare delivery, we spoke with Jeffrey Brenner. He's an MD in Camden, New Jersey, one of the poorest cities in the US. He's a family doctor.

• 39:58Speaker 08

  So I see kids, adults, and deliver babies.

• 40:02Stephen J. Dubner?

  Brenner also founded the Camden Coalition of Healthcare Providers. It works with low-income patients to coordinate their care among a network of medical and social service organizations. The coalition's overarching goal, Brenner says, is to improve care while also reducing costs. That sounds like an admirable goal. It also sounds like what should be a common goal within the healthcare profession. Is it, in fact, a common goal to deliver healthcare for less money?

• 40:31Speaker 08

  Not at all. The major imperative for most organizations in healthcare is to get bigger and bigger and bigger. And money is like fertilizer. And the way you get bigger is getting more money, more market share, more customers.

• 40:47Stephen J. Dubner?

  Brenner believes that the practice of medicine has been subsumed by the business of medicine. The activities that are incentivized, he believes, aren't necessarily good medicine. And this doesn't leave much room for doing something as basic and helpful as a doctor sitting down and talking with patients.

• 41:04Speaker 08

  That's why I went into family medicine. I love to get to know my patients and talk with them. And I've always felt that the trick to healing and the trick to wellness and to change, like changing behavior, is relationship building and having a trusting relationship with someone who walks through the journey of life with you and helps nudge you in various directions. And that requires, you know, really talking with people.

• 41:33Stephen J. Dubner?

  But the current healthcare business model discourages that, Brenner says.

• 41:37Speaker 08

  In our system, we have an asymmetry in price. So we pay a whole lot of money if you cut, scan, and hospitalized patients. If they have procedures, if they go through machines, we pay an enormous amount of money for those things. If you talk to a patient, you actually lose money in many instances. So when a cardiologist walks in the room and talks to your family member, that's actually a lost leader. That doctor is losing money every moment they stay in the room with your family member. The way they make money is by getting you out of that room, back into the scanner that they're leasing in the back of the office. That's not their fault. That's the fault of how we've structured the incentives in the system.

• 42:21Stephen J. Dubner?

  Spending time talking with patients might just seem like a feel-good connection. But Brenner says it provides real benefits that aren't currently factored into the system.

• 42:30Speaker 08

  We know that lots of people walk out of doctors' offices every day in America and really have no idea what the doctor said to them. We know that we have lots of safety errors. We have a lot of medication confusion. And I would argue a lot of those things are tied to communication as well. We know that in Medicare, that 25% of Medicare recipients are readmitted within 30 days. I would say a part of that is communication failure, that oftentimes when patients leave the hospital, they have very little understanding of what physician said to them.

• 43:05Stephen J. Dubner?

  Brenner is a proponent of what's known as evidence-based medicine. Like Anupam Jain, who found that cardiologists' absence leads to lower mortality. Brenner believes that a wise use of big data can lead to massive improvements in healthcare delivery, but that we aren't there yet. We aren't even close to there yet.

• 43:26Speaker 08

  And what I think many people would be shocked to find out is that many of the things that we do in day-to-day care actually have very little evidence for them. They are habit that has been passed down from one generation to the next, but doesn't have literature backing it up. Building out research literature in medicine is expensive, it's complicated, it's difficult. Even once you've got the literature built out, moving that literature into practice can take 10 to 15 years. There is so much information overload now that doctors have a hard time even keeping up with all the evidence. So, you know, we have both the problem generating enough evidence and funding that, and then

• 44:09Speaker 08

  we have a metadata problem of how do we synthesize all the evidence and make sure that it's available to doctors every day when they need it.

• 44:17Stephen J. Dubner?

  I've always wondered, do you think that the reluctance to pursue evidence, to gather data in the realm of medicine is in part because the history of medicine and the history of becoming a doctor encourages doctors to think of themselves as not necessarily godlike, but somewhere between humans and god? And that the evidence can be an implicit challenge to their wisdom, authority, intuition, and so on?

• 44:45Speaker 08

  I think it's, I think what you're describing is absolutely correct. I think there's even a deeper problem, which is that medical training bypassed the Enlightenment almost altogether. So if you look back in the roots of medicine as training, as a pedagogy, it goes back to Greek tradition. And in that Greek tradition, it was a lot of memorization, and it was fealty to authority. It was a tradition that was passed down through, through the generations. It was almost like a priesthood. And med school is really being inducted into a priesthood of power, money, and influence.

• 45:26Speaker 08

  And the Enlightenment was really about self-critical thinking and about, you know, use of rational thought and a scientific method to prove and disprove things in an objective way. And very few physicians really understand the scientific method. So you don't necessarily have to have a science degree to go to med school. And when you're in med school, most of med school is just memorization. So, you know, if you look at how medicine is taught, the first two years are mostly memorization, and then the second two years are rounding on patients with senior physicians in a very steep hierarchy where you learn to do what you're told, and you don't challenge

• 46:11Speaker 08

  or embarrass the senior physicians.

• 46:19Stephen J. Dubner?

  So it sounds like what you're describing is a situation wherein, in healthcare or in healthcare delivery, you've got the potential generation of millions, billions, trillions of data points because there are a lot of inputs and a lot of outputs. And yet, it sounds as though most of the practitioners within that scenario aren't really that either concerned with or attuned to, or at least practiced in, the assimilation of all that data and what it can tell us, yes?

• 46:51Speaker 08

  I think that's very true. And they're not trained in critical thinking skills that would enable you to pull that evidence apart, nor are they trained in now a very deep literature in psychology about how distorted evidence can be when you explain it to people around all of the implicit biases that you can set up in decision-making. So, you know, I think that you would not only want to train people in how to interpret evidence, but then you would also want to train people in the communication skills necessary to describe risk to patients. Many of these discussions really revolve around helping patients understand risk. And those are very hard concepts to explain. There are tremendous ways that doctors

• 47:31Speaker 08

  can bias those conversations. And we don't do a good job of that, nor are we paid in a way that would even encourage you to have those conversations.

• 47:40Stephen J. Dubner?

  Can you give an example of that kind of conversation where you're trying to deliver a message and how it can be misinterpreted or just not heard?

• 47:47Speaker 08

  So my favorite example recently is about mammograms. So for women 40 to 50, mammograms do not save lives. Boy, that's a staggering thing to say. You know, we have been told as a society that go get your mammogram, it'll save your life. And our best statistical evidence is that mammograms 40 to 50 will not save your life and actually could cause you harm. Well, there were plenty individual anecdotes that may say otherwise, but it's likely that the cancers that were discovered for people 40 to 50 will regress on their own and are not life-threatening cancers. Well, that's a, that's a really hard idea to get your head around. So, you know, you have some ridiculous statements by physicians in the media that really show

• 48:32Speaker 08

  a misunderstanding of how to interpret statistics and data, which I think are frightening. I mean, you know, it's not that different than doctors 200 years ago deflending bloodletting, and then 100 years later, the biggest argument in Europe was whether or not to wash your hands. And the leading cause of death in Europe was infection during childbirth. And it took 100 years to get doctors to wash their hands based on evidence. You know, then we turn the clock even further forward. You know, we hurt a lot of people with thalidomide. We hurt people with calcium channel blockers. We hurt people with inappropriate use of arthroscopy, of angioplasty.

• 49:13Speaker 08

  We're still hurting people today by using treatments that are not evidence-based and that are not statistically valid treatments, for which we have literature that they shouldn't be using these treatments. So, you know, we have a really deep problem with how we're training doctors. They are not being trained to be critical thinkers. You know, I'm a huge student of medical history, and when you read medical history, it's very humbling. We have screwed stuff up and hurt people over and over and over, and we've done it with our arrogance. So, you know, I think, you know, we're, we're still doing it unfortunately.

• 49:55Stephen J. Dubner?

  So economists, healthcare economists particularly, would say, you know, a lot of the problems with healthcare and healthcare delivery is created by inefficiencies in the market. And if you just let the market work the way the market should work, then things would get better and things would get cheaper. Do you agree? Is that a solution? Or is that not the solution to the problem as it now stands?

• 50:21Speaker 08

  I think it's a very idealistic solution. But, you know, the ultimate market inefficiencies are created by asymmetries of knowledge, where the customer doesn't have perfect knowledge about what they're buying. Either they don't have price knowledge, or they don't have knowledge about the product. The irrational marketplace of healthcare put me out of business. So I was happily going to work every day, taking care of poor people in Camden, had a small three-exam-room office, and loved my job, and loved my office. And my office is currently boarded up and closed. And it's closed because the market didn't work. The Medicaid rates kept dropping in New Jersey.

• 51:02Speaker 08

  And by the time I was closed, I was getting sometimes $19 to $35 per visit, and it's impossible to keep the lights on and pay the overhead. So, you know, the irrational marketplace of healthcare didn't work.

• 51:17Stephen J. Dubner?

  That is, it didn't work for him. Big hospitals, meanwhile, get bigger. And with that supply, Brenner says, comes demand.

• 51:27Speaker 08

  One of the problems is that we have a giant economic bubble underlying this, where we have hospital financing authorities underpinning, that are run by states, that help hospitals float bonds. And we have this giant bond market called the hospital bond market that's considered very secure, very safe, good investment. And, you know, that bond market has floated too much hospital capacity, and created and brought online too many hospital beds, far more hospital beds than we need in America. So, you know, the most dangerous thing in America is an empty hospital bed.

• 52:07Speaker 08

  In the center of New Jersey, near Princeton, a couple of years ago, we built two brand-new hospitals. These are two $1 billion hospitals, 10 miles apart, very close to Princeton. So, one is called Capital Health, and the other's Princeton Medical Center. I don't remember anyone in New Jersey voting to build two brand-new hospitals, but we are all going to be paying for that the rest of our lives. We'll pay for it in increased rates for health insurance. And, boy, you better worry if you go to one of those emergency rooms, because the chances of being admitted to the hospital, when there are empty beds upstairs that they need to fill, are going to be much, much higher than when all the beds are full, whether there's medical necessity or you need it or not.

• 52:52Speaker 08

  So, I'd be very worried if you live in Princeton that there are now two $1 billion hospitals waiting to be filled by you.

• 53:03Stephen J. Dubner?

  But a system like this one, Jeffrey Brenner argues, is unsustainable. Or maybe we should say, he hopes it's unsustainable.

• 53:13Speaker 08

  There comes a point in a democracy when the public's had enough, and they stand up and they get upset. And, you know, the baby boomers shifted every public system they've ever touched. They shifted schools, colleges, and universities. They changed the institution of marriage, of child rearing, of employment. I think that they're probably going to change the institution of aging, medical care, and dying, ultimately. And I think you're starting to see, you know, lots of dialogue emerging about how people want to die. It would not take very much change in taste and preference to collapse the system. It's become so brittle, and so overwrought, and so overbonded, and so overcapacity, that the next great American bailout

• 53:58Speaker 08

  could be our academic health centers, our research centers. With a small cut in NIH funds, a small cut in Medicare payments, a small cut in the subsidies for training doctors, in what are called "dish payments," it would not take much to collapse academic health centers. And then, as a society, we'd need to ask, are we... do we want to bail them out? Are we getting our money's worth?

• 54:21Stephen J. Dubner?

  The humanist in me, and just the plain old human in me, agrees with you entirely about the desire and need to change and/or collapse the current model. On the other hand... Our healthcare spending is something close to, I believe, 20% of GDP now, is that right?

• 54:40Speaker 08

  Yep.

• 54:42Stephen J. Dubner?

  And I just look at that and I look at it as if it's a mafia of some kind that's got a stranglehold, that's got so much money flowing from so many different directions with so many different avenues of revenue, many of which are, as you've pointed out, counterproductive and maybe even dangerous. And maybe I just don't have the imagination to envision what kind of public response to that would collapse a system with so much at stake. Can you just tell me how to get that picture in my mind?

• 55:15Speaker 08

  So, no one in the CIA could imagine Mubarak ever being out of power, right? You know, complex adaptive systems go through state changes and they do it in very complex and unpredictable ways where one day they're one way and the next day there's been a dramatic shift. And, you know, the way that you undermine a complex adaptive system is you begin to undermine the inputs that sustain it. So, the inputs that sustain complex adaptive systems are energy, money, goodwill. And, you know, I think the healthcare system's doing a very good job of eroding all those things. You know, I don't know when it's going to happen, I don't know exactly how it's going to happen, but it's a very brittle

• 55:56Speaker 08

  system. It's a very leveraged system. It's hurting more and more people, not through, I don't think, an act of commission, but an act of omission. It's just its own complexity now is injuring people. The number of times I've been behind the scenes in a, the number of times I've been in a legislator's office and this heartrending story pours out of them about their own parents, you know, as the baby boomers are aging and people in their 40s are caring for their parents and watching what the system does to them, I think there's going to be a growing anger, you know, as the co-pays and deductibles and employee contributions get higher and higher. I think the goodwill underpinning

• 56:41Speaker 08

  the system is going to begin to break down. You know, there comes a point in a system in America where it no longer serves any of the purposes that it was originally set to serve. And America does disrupt things. You know, I don't see a lot of horse and buggy manufacturers. I don't see the steel industry here, right? You know, no one saved Blockbuster. I mean, there will come a point when, you know, sooner or later, we're going to let this thing go.

• 57:42Stephen J. Dubner?

  Hey, podcast listeners. On the next Freakonomics Radio, how a happily married couple won a big diamond at a raffle and how that led to nothing but trouble. She wanted to keep it. He wanted to sell it.

• 57:55Stephen J. Dubner?

  I would say we both did at one time say we wish we never would have won it. We did. I would say that's how it did get to that level. And why are diamonds worth so much, anyway?

• 58:06Speaker 03

  One of the great allusions of our time is that diamonds are forever valuable. They are not.

• 58:16Stephen J. Dubner?

  Diamonds are a marriage counselor's best friend. That's next time on Freakonomics Radio.

• 58:30Speaker 10

  Freakonomics Radio is produced by WNYC and Dubner Productions. Our staff includes Greg Rosalsky, Caroline English, Susie Lechtenberg, Merritt Jacob, and Christopher Wirth, with help from David Herman, Anna Hyatt, Rick Kwan, Daniel DeZula, and Paul Schneider. If you want more Freakonomics Radio, you can subscribe to our podcast on iTunes or go to Freakonomics.com, where you'll find lots of radio, a blog, the books, and more.

• 59:06Stephen J. Dubner?

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• 59:37Stephen J. Dubner?

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