How Many Doctors Does It Take to Start a Healthcare Revolution? A New Freakonomics Radio Podcast

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(Photo: Official U.S. Navy Page)

(Photo: official U.S. Navy page)

Our latest Freakonomics Radio episode is called “How Many Doctors Does It Take to Start a Healthcare Revolution?” (You can subscribe to the podcast at iTunes or elsewhere, get the RSS feed, or listen via the media player above. You can also read the transcript, which includes credits for the music you’ll hear in the episode.) The gist of the episode: 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.

In our previous episode, we looked at the increasing use of RCTs, or randomized controlled trials, in the realm of healthcare delivery. But as conversation went on, it began to turn into a broader indictment of our healthcare system. So this week we are continuing that conversation, with a new set of questions:

  • We generally assume that if you’re not getting healthcare, you’re worse off – but is that necessarily the case?
  • How much healthcare is too much care? And how valuable is a “less is more” doctrine?
  • When you start to peel a few layers off the U.S. healthcare system, how does it really work? And who does it really serve?
(Photo: Camden Coalition of Healthcare Providers)

Jeffrey Brenner, a family doctor and community force in Camden, N.J., wants a healthcare revolution.
(photo: Camden Coalition of Healthcare Providers)

Appearing once again in this episode is Jeffrey Brenner, a family doctor in Camden, N.J., who through his Camden Coalition of Healthcare Providers is trying to radically improve outcomes for low-income patients. But that’s not all Brenner is trying to do.  He is calling for nothing less than a healthcare revolution, shifting the system from a top-down profit-first industry to a back-to-earth healing enterprise. Here are just a few choice cuts from what Brenner tells us:

BRENNER: 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 I think, you know, we’re still doing it unfortunately.

And:

BRENNER: In our system, we have an asymmetry in price. So we pay a whole lot of money if you cut, scan, and hospitalize 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 loss leader. That doctor is losing money every moment they stay in a room with your family member. The way they make money is by getting you out of that room and 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.

And:

BRENNER: As the baby boomers are aging and people in their 40’s 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 copays, and deductibles, and employee contributions get higher and higher. I think the goodwill underpinning 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 up 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? No one saved Blockbuster. I mean, there will come a point when sooner or later we’re going to let this thing go.

(photo: Suzanne Camarata)

Anupam Jena, an m.d./economist, wanted to know the effect of big cardiology conferences. His findings may surprise you. 
(photo: Suzanne Camarata)

You’ll also hear from Anupam Jena; he trained as both an m.d. and an economist, and now practices medicine at Mass General and teaches at Harvard. Jena is a co-author of a JAMA Internal Medicine paper that looked at what happens to patients with acute heart problems during one of the two big annual cardiology conferences. (Thanks to Craig Feied for bringing this paper to my attention.) In other words: when the doctor’s away, do patients pay? Jena’s assumption was yes, that the absence of many top cardiologists would result in higher mortality for acute heart patients. The data, however, told a different story. With high-risk heart failure, for instance …

JENA: 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.

We ask Jena why acute heart patients have a better chance of surviving when so many cardiologists are traveling. (Short answer: when it comes to medicine, even with an acute heart condition, it may be that less is generally more.) We also speak with the two organizations that hold these conferences (the American Heart Association and the American College of Cardiology), and we ask some docs at the latest ACC conference what they think of Jena’s findings.

You’ll also hear about the fascinating research done by Amir Hetsroni, an Israeli professor of communications. He and his students watched numerous episodes 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. Their resulting paper was called “If You Must Be Hospitalized, Television Is not the Place.” This, like many facts in this episode, may well surprise you — and change the way you think about modern healthcare.

 

 


Steve Johnson

I love the podcast. However, the most recent podcast regarding teaching hospitals and cardiology meetings oversimplifies a complex problem. It references a paper by Dr. Jenna that may suffer from significant selection bias.

Medicare data does allow for complexities regarding a medical diagnosis. But, there are many co-morbidity subtleties that the data simply does not account for. In other words, patients may have a cardiac arrest that may be more or less complicated by socioeconomic factors, time of day and so forth that is not captured by the Medicare data.

Most teaching hospitals do have a significant population for which they are the primary care provider but, they also serve as referral centers from other institutions for more complex cases. During normal times very sick patients who have cardiac problems would be referred to the teaching hospitals and cared for appropriately by the staff cardiologists. During times of limited cardiology access (during meetings for example) the outlying hospitals are more likely to refer to the teaching hospitals less complex patients that have the same diagnosis . These patients would naturally do better. As a result the teaching hospitals would have a lower mortality rate. It would appear that better results are obtained but in fact the teaching hospitals during meetings are simply treating patients who are less severely ill.

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Michael

Stephen,

I am a long-time listener and fan, and am writing about the content of your podcost on April 8th, called "How Many Doctors Does it Take to Start a Healthcare Revolution". Stated bluntly, the statistics and the conclusions drawn from them range from being misleading, to being outright false and potentially dangerous. I know your job is primarily to relay information revealed by experts, and that you are not ultimately responsible for their biases, but please be aware that they have them.

Dr. Jena pointed out the increase in the risk of mortality associated with being admitted during a period when a major academic conference was occurring, based on a large collection of medicare data. He then took this to mean that having fewer cardiology procedures is beneficial, and more broadly, less medical intervention is preferable. However, the methodology that Dr. Jena used in his study makes his results obvious, not surprising. Most cardiological interventions carry an upfront mortality risk – there is no risk-free procedure – but decrease risk of mortality in the long term, over the course of 1, 5, or 10 years. We should EXPECT 30-day mortality to be lower if fewer procedures are done: in a conference week, when fewer procedures are done, that upfront risk is reduced. That does NOT, however, mean that the people are better off overall; not getting a procedure done means a higher risk of mortality in the long-term. To say otherwise would be to ignore the volumes of large, randomized controlled trials (RCTs) done in the USA and around the world that have repeatedly demonstrated the benefit associated with a lot of cardiological intervention. If, as you point out in your previous podcast on April 1st, RCTs are the best way to eliminate bias, the countless studies already produced each individually outweigh the evidence from Dr. Jena's study, and the most certainly do when all considered together.

Dr. Jena goes on to conclude in your podcast that less medical intervention is better. This is not globally true. Again, RCTs support the use of interventions for some cases. It is an enormous logical fallacy to generalize the results of one non-randomized, non-controlled, retrospective study of acute cardiovascular diseases to the entire medical system, and to just conclude that "less medicine is better". The shades of grey here are exactly what you were pointing out in the podcast when you noted that physicians who covered for their colleagues might have been more selective above who gets a procedure and who doesn't: RCTs are limited to certain portions of the patient population, and people who fall outside of that population, results may (theoretically) be different, so physicians might in some cases be more conservative when their colleagues aren't there to back them up. You correctly use this logic, but Dr. Jena ignores it.

In my mind, the most dangerous false conclusion that Dr. Jena came to in your podcast was that the mortality decreased he observed in his study was greater than the mortality decrease from existing medical therapies. Even a quick, non-critical glance at the existing evidence shows that this is clearly wrong. Dr. Jena may simply be making incorrect comparisons between different statistical methodologies, or more frighteningly, he may be intentionally deceiving you advance his point. On the first matter, there is an enormous difference between a relative risk reduction and an absolute risk reduction. Let's say you randomize 1000 people to either placebo or an intervention. 500 receive placebo, and 500 receive the intervention. 10 people (2%) die in one group, and 50 people die in the other (10%). The relative risk for one group is 500% higher; the absolute risk is only 8% higher. If Dr. Jena cited different types of statistics, he made an apples-to-oranges comparison that is incredibly misleading to the lay public. For instance, you state in the podcast that with all existing medical therapy combined, there is only about a 2-3% difference in mortality rate. This is wrong. RCT data shows a 16% reduction in mortality from statins (Heart Lung Circ. 2014 Feb;23(2):105-13. doi: 10.1016/j.hlc.2013.07.012. Epub 2013 Aug 17.), a 30% reduction in mortality from blood pressure control (Hypertension. 2014 Nov;64(5):1012-21. doi: 10.1161/HYPERTENSIONAHA.114.03850. Epub 2014 Aug 4.), and a 9% reduction in mortality from beta-blockers (PLoS One. 2014 Mar 5;9(3):e90555. doi: 10.1371/journal.pone.0090555. eCollection 2014.). Dr. Jena's conclusion that the effect he observed is more significant than the effect of existing medical therapies suggest that he is shamefully ignorant of the existing literature. Worse still, he may choose deception because of its personal benefits: a major motivator here could be that you tend to grab a disproportionate share of the spotlight if you present something radically different than what most experts agree on (for example, the <1% of scientists who don't believe in climate change, but who get just as much TV air time as the other 99% who do). In either case, these claims are false, and insofar as they affect your listener's health behaviors, they are potentially dangerous.

Stephen, I love your show. However, the falsehoods in this podcast are obvious enough to me that it makes me doubt the validity of other things that I have learned from listening to you. I am not an expert in many things, so I am easily mislead in other arenas. In this one, however, I know enough to see that your interviewee presented you with information that ranged from being misleading to being outright wrong. Please do correct these errors, or it undermines the integrity of what you've built.

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Oliver H

Unfortunately, bad statistics like that are pretty much a common factor in all the recent posts made on healthcare. Another common factor is people getting negged for pointing out the statistical flaws....

Mark Robbins

I have been a board certified and practicing Critical care doctor for 21 years. I found the episode very good. My own observations suggest that in some case-- doing less intervention and less procedures results in a better outcome. Clearly more study is needed-- and more willingness to challenge the dogma.

Mike Cussen

Studying the cardio outcomes in Japan might be a good place to see if less intervention in beneficial. My cardiologist who I just met 6 weeks ago because I had to have a stent, says the Japanese don't like invasive procedures so much of the therapy is done with diet and drugs. I'm now on the drug regimen. Hopefully no more stents.

Peter

As an engineer and researcher, I thoroughly enjoyed the concepts, data and theory presented in this podcast on the health care system. However, in a closing remark, Dr. Brenner provided a comment that lumped the horse drawn carriage, Block Buster video and the US steel industry as the sort of businesses that have succumbed to necessary adaptive change. I can assure Freakonomics followers and Dr. Brenner that the US domestic steel industry continues to evolve, adapt and thrive in a global competitive marketplace, notwithstanding a multitude of challenges. For evidence, the American Iron and Steel Institute would be a great place to start. (www.steel.org) The steel industry adapted via technical innovation, primarily through by recycling steel scrap as a raw material. Now more than 50% of the steel produced in the United States comes from scrap, making it the largest recycled material in the country. Further, smaller, more efficient manufacturing facilities have reduced or eliminated output in traditional steelmaking centers (Pittsburgh for example) and enabled a vibrant production base in other regions of the country (South Carolina, Arkansas, Alabama. Mississippi).

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Rob Lewis

Enormous kudos to you for providing a platform for Dr. Brenner! More people need to hear him.

But points taken off for neglecting to even mention the many evidence-based measures in Obamacare, which are demonstrably working to improve care and control costs. All the predictions of disaster have failed to materialize, and opponents are left either (a) telling outright lies about the ACA, or (b) complaining that it's unpopular (true, but irrelevant).

As yet another way in which health care does not resemble a normal market, Clayton Christensen (of "Innovator's Dilemma" fame) has written that in medicine, competition tends to drive costs up, not down. Hospitals, for example, compete to offer patients the latest and greatest multimillion-dollar machine (whether or not it actually works better than previous technology), and as we all know, multimillion-dollar machines in hospitals don't just sit there unused. Ways are found to use (and bill for) them.

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Mallory

I don't regularly comment on such things on the Internet, but this one I felt was necessary. Listening to this podcast, I reacted not only as a (hopefully) future economist, i.e. a graduate school for economics, but as a patient with a chronic condition and as an ex-pre-med student.
For starters, as a patient: I have asthma that, with medication, ranges from completely controlled to completely uncontrolled, and during college it was awful. I would go to my pediatrician, then an "adult doctor", and they would listen, run tests, tell me my breathing was totally fine, and then tell me nothing was wrong with my lungs but with my brain, saying that it was the result of anxiety. Now, there's nothing wrong with people experiencing anxiety, but I have had experiences with that in the past and I told them that this is not how my body reacts to anxiety. This goes on for three years, until totally by accent I was diagnosed with chronic sinus infections and the wrong rescue inhaler by random doctors I saw at the student health center at college. Suddenly, my health was massively improved. The doctors that were supposed to listen and be focused on my care, my primary care doctors, relied on tests to tell them that I was wrong, instead of considering both the results of the tests and what I told them, and the doctors at the student health center who you only see once, randomly assigned based on scheduling, and probably overworked, were able to get me the care I needed. In both cases, they didn't run any tests, just looked into what I was saying and said, "well, what you're saying sounds like this, let's try that and see if it works". I'm not saying that method will always work perfectly, or the first time, but the process of the doctors actually listening to me, the patient, instead of relying on tests to tell them what was going on, led to much better outcomes in my situation.
Now for my experience as a student. As I said, I was a pre-med student who got through general chemistry and general biology before realizing I would make an awful doctor (no bedside manner) and I would never make it through the memorization required for medical school. However, I continued to tutor people in chemistry and math, and what really concerned me was that these pre-med students were struggling through the critical-thinking classes to get to the memorization classes that would be more like medical school and more relevant to their future careers. I mean, no critical thinking skills whatsoever, and they weren't really interested in developing them because there wasn't any actual incentive for them to develop those skills for future use, since they were only being tested in these few initial classes they had to pass to get into what "really mattered" for learning medicine. Mind you, I don't blame them: I've never learned theoretical statistics, and have just faked it long enough to pass the classes I've had to take to get on to actual economics classes. But I definitely don't think I'd be too happy going to a doctor who couldn't use the critical thinking skills that, really, is the only thing you need to pass general chemistry.
There's a lot of problems with medical care in this country, but I definitely think the fact that doctors don't listen to patients, but listen to tests, and that doctors are not being trained in critical-thinking, are two very big problems.

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Kim Yeargin

I think this is a fascinating study but I am not surprised only because I think we have not really figured out the fine details of who would benefit from a therapy and who wouldn't. This is where the subjective art of medicine comes in. I totally agree with Dr. Jena that many factors go into this. The cardiologists who go to conferences may be the ones who are the most aggressive and least risk averse. They want to be on the cutting edge. The ones covering may be on the other end of the spectrum. We know from studies that there are subsets of patients that benefit from angioplasty and stents but there are subsets that don't. I think he was spot on when he said if we had a limited number of procedures that could be done, we would do better at finding that line, but we don't do medicine that way. So this line gets blurred because we want to do something. Some docs are more comfortable than others with using medical therapy rather than invasive therapy.

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Dan Edelman

As an aside towards the end of the podcast I believe Dr. Brenner was discussing other industries / services that have been disrupted over the years in the US.

His example of the steel industry is largely incorrect, at least as far as there being little steel production because it has been displaced by something else (or production elsewhere) - there is still a substantial amount of steel produced in the united states today (85 - 95 million tons / year).

Where it could be seen as analogous is that many historical steel producers (e.g. Bethlehem) went out of business as many elements of their business model fell behind that of other companies.

Specific to the medical sector of the economy the interesting aspect to look at is delivery systems that the big players consider substandard for some reason (quality, breadth of service, what have you) and consider could some other service distribution model displace that of the large hospital.

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Dennis

This was a really excellent program. It was consistent with the typical Freakonomics practice of using data to challenge conventional wisdom.

I think it was in "Think Like a Freak" that Levitt embarrassed himself by saying "Purchasing health care is almost exactly like purchasing any other good in the economy."

I'm somewhat hopeful that this episode is partially done to atone for that absurd opinion.

Sudipnandy

A really good episode, thank you. I'm pleased that you are now beginning to realise that an American-style market in healthcare is fundamentally flawed (from the point of view of the best interests of the patient). Less is often more in medicine (which is why Mr Levitt's analogy between healthcare and automobiles from last year doesn't work if you understand what healthcare interventions do to you). #savetheNHS

Cameron Smith

As a Dr. I wasn't very surprised by the findings. I think Brenner is right. People (patients and physicians) are fed up with the healthcare system. It will continue to be a top political topic and I'm not sure what will end up happening. Fixing the system isn't difficult in concept but I would be out of a job if it were actually fixed. I perform a valuable skill but there are too many of us performing the skill and others could do it for less money. My mother went to the ER the other week for a visit that cost $8000. I guarantee that a large part of that bill was useless. Clinics are closing and ERs are opening with advertisements all over the roads about wait times. If you have a true emergency there isn't a wait time. But a small problem that can be easily solved in a clinic can make a hospital a lot more money done in the ER. Better yet, wait a few days and the problem will usually go away without the aid of a Dr.

Actually I do know what will happen unfortunately. The government will continue putting bandaids on the problem until it bankrupts the country just like everything else. To really fix the problem would hurt too much in the short-term.

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David cardiac RN

It seems you implied that only the most senior cardiologists attend the conferences. It seems to me that the cardiologists who want to keep up on the latest inovations and advance their careers would want to go. Being the most senior cardiologist doesn't make you want to attend the conference. San Diego is a nice place for a conference but conferences can be really dry/ boring. It's NOT a privelage to go to the conference. Maybe more junior cardiologist went so patients had better outcomes?

Also, you don't seem to understand the division of labor. Cardiologists are very well compensated. I want them doing the tasks that lessor trained medical professionals are not trained to do. (like all the time!) putting in stents/ cardioverting/ adjusting medication/ setting a plan of care. Do we really need cardiologists to tell patients to eat oatmeal for breakfast instead of bacon and eggs? to quit smoking? to exercise? or any of the other psyco-social problems that become apparent where you talk to and spend time with the patient. This is and should be the role of the RN. I suggest that healthcare in the United States would improve more if we valued nursing widsom more. (Did you even aknowldge a role for nurses in your story?) Nurses aren't valued until you need one and to get more nurses we need their role needs to be aknowledged/ valued and funded in advance!

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Gail Nacht

Why do discussions of the medical profession NEVER mention the restraints put on physicians by the legal profession? So much of how a physician practices is outlined by the FEAR of being sued. If an outcome for a patient isn't 100% perfect then a suit may follow. Logically, by "bell curve" rationality what works for one patient may not work perfectly for another patient even when presented with identical symptoms. As one example... Doctors are forced to order a multitude of unnecessary tests because IF they don't…….!!!!!... and at the same time the public complains that all this is done because a physician is getting some sort of financial reward (NOT) for doing so. Why can't the United States be like every other civilized country in the world and reduce the LAWYERS influence of medical decision making. The added expense caused by needless lawsuits is horrendous.

pete baston

The truest words in this " As baby boomers become powerful government figures they will react with anger and fury at how the healthcare system treats their parents and themselves " then the current healthcare bubble will implode and the entire industry change ( As they have done with every other major factor in American life )

barbara ensor

Here's what I wrote when I just posted this on facebook

Hats off to Stephen Dubner my former colleague at NY magazine. You can listen while you are cleaning out your junk drawer. I'm a sucker for good journalism about topics too big for sound bites that aren't exactly timely. especially if they matter. nice job.

Really enjoyed listening to this while walking in the rain today. Thanks for telling me what I sort of thought I already thought but didn't know how to wrap my arms around with some gee whizz statistics that make it easier to conceptualize. Also the upbeat boomers will fix it ending! You rock Dubner. That diamond piece was pretty damn amazing too.