Do As Docs Say, Not As They Do

Bapu JENA: After four years in medical school and three years training to become a doctor, I’d learned a lot about how the human body works and what it takes to keep it healthy.

But I’d also formed a habit that helped me get through the long hours of becoming a doctor.

AD READER: Haagen-Daz is so thick and creamy.

My name is Bapu Jena and I love ice cream. A lot.

AD READER: That’s why it melts so slowly. From Haagen-Daz. The longer-lasting pleasure.

Like, it was a half a pint a day habit. There wasn’t a flavor I hadn’t tried. Ice crystals on the containers at the grocery store? Not a problem. I could work through that.

But at my checkup with my primary care doctor almost 10 years ago, I had a rude awakening. My cholesterol was high. And my doctor asked me what was going on? Two words, really. Ice cream. My doctor, she gave me a stern but, you know, really empathetic look. And she told me I needed to make a change. Cut back on the ice cream, Bapu!

AD SINGER: In the land of Dairy Queen.

And I, I knew it wasn’t going to be easy.

AD SINGER: We treat you right.

But I did it. With those cholesterol numbers staring back at me, and my doctor’s orders, I basically got scared straight. I cut way back on the ice cream. It reminds me, what’s that thing that Cookie Monster says now?

Cookie MONSTER: Cookie sometime food!

Right. Cookies are a sometimes food. And ice cream, I guess, should be a sometimes food. This is a simple story, but the kind that plays out all over the world, every day. A patient meets a doctor. The doctor gives them some sort of advice. Exercise more. Eat healthier. Take this new medication. But it’s all easier said than done, right?

MONSTER: Right now, is, is SOMETIME! COOKIE! Um num num!

From the Freakonomics Radio Network, welcome to Freakonomics, M.D. I’m Bapu Jena. The name of the show is a bit of a spoiler because I’m both an economist and a medical doctor. And in each episode, I’ll dissect a fascinating question at the sweet spot between health and economics. Today: Does having more information mean a patient will make better choices? And what if that patient also happens to be a doctor?

Medicine has come a long way in the last few decades. We have better treatments for cancer, better treatments for heart disease. The list goes on. But all of these advancements in medicine? They don’t mean much if people don’t follow their doctor’s advice. We could use cutting edge technology to help a patient survive a heart attack. But if they never pick up their prescription afterward, the path to recovery could be rocky. Now, there are a lot of reasons why people may not do what their doctors suggest.

And I’ll admit that doctors haven’t always had the best advice to share.

AD READER: Doctors in all parts of the country were asked, “What cigarette do you smoke, Doctor?” Once again, the brand named most was Camel.

But what I’m talking about is advice that’s scientifically sound and still largely ignored. So why is that? I’m putting the big reasons into three categories: cost, complexity and comprehension. The three Cs.

Costs can obviously be a factor. The expense of prescriptions, procedures or doctor visits. Not to mention the time required to actually see your doctor or get other medical care.

The complexity? It can be overwhelming too. A patient might have the best of intentions, but still struggle to build new habits like taking a new medication every day.

But one of the biggest reasons might be that people just don’t understand the benefits of what their doctor is recommending to them. That’s the comprehension factor. And comprehension is what I want to focus on today.

Now, it’s worth pointing out that, when it comes to comprehending health information, there’s a lot of noise out there. People hawking all kinds of products and cures with little or usually even no scientific backing. Not great. People actively and intentionally spreading disinformation. Really not great.

And those are huge problems and worth examining more in future episodes. But today we’re looking at this common refrain in medicine. And that is, if people just had more information, they would make healthier choices. That simple idea is a huge focus of public health policy. Just think about all those public service announcements you see

VINCE: We’re here today to talk to you about Global Handwashing Day.

Michelle MORSE: We urge you to learn more about the Covid-19 vaccines and to get yours.

P.S.A. READER: The main way statins can reduce your risk of a heart attack or stroke is by lowering your cholesterol levels.

Tons of money is poured into educational campaigns like these. But they aren’t a panacea. And my question is: How much can more information really move the needle on our behavior? 

As an economist, this is the kind of big, thorny question I love. But how do we answer it? Well, first we need to find a group of people who have tons of high-quality information. And then we’ll compare their health to others.

So, let’s look at doctors. They should have the knowledge, right? It’s hard won! Think about all those years of school, the late nights spent studying, the 24-hour calls with really only two friends that you can count on. 

AD READER: Ben & Jerry’s. We make it all better.

But do doctors — the most medically well-informed among all of us — really make better health choices? That’s where Maria Polyakova and her research comes in.

Maria POLYAKOVA: I work on different questions related to the economics of healthcare. I’m also really interested in understanding what drives inequality in health outcomes and the role of information in health decisions that people make in their everyday lives.

Maria is an economist and a professor at Stanford University’s School of Medicine. She’s also the co-author of two recent studies that explore this exact topic. The first was sparked by her experience digging for information to help her parents make better healthcare decisions. 

POLYAKOVA: One interesting thing about being an economist in the medical school is that I have access to lots of websites and tools that physicians use, and being, I guess, a weird economist who likes to read things and look for causality everywhere, I’ve started reading all of these guidelines and thinking, huh? Okay. So for this condition, the guideline says we should do this and that. And at some point, I started asking myself, what do people do who don’t really have someone who can go and read medical papers for them or who can go and read original research?

Maria and her co-authors used data from Sweden for a bunch of reasons. First, Sweden famously has universal healthcare, and that system generates a lot of amazing data. Also, the data let them see who was a doctor and who had a doctor in their family.

Even in a universal healthcare system, there’s a strong link between health and wealth. So they also zoomed in to compare doctors with only other people at the same income level. But money isn’t the only thing that makes doctors different, right? There’s also their interest in health that led them to medical school in the first place. So they needed to zoom in even further. One of Maria’s co-authors on the study, another Stanford economist, Petra Persson, knew that something special in Sweden could help them solve this problem.

Petra PERSSON: Medical school lotteries.

In Sweden, demand is so high for medical school, and there are so many qualified applicants, that the government actually runs a lottery for admissions. And what’s so special about that lottery? Well, it’s what economists call a natural experiment. That’s when you find something in the world that basically randomizes people into different situations that you want to measure. It’s serendipity that you leverage for science.

PERSSON: That’s very helpful for us because then we can compare these lottery winners and lottery losers, and we can follow them and study what happens to their health.

And that’s what they did. They tracked the lottery winners, who became doctors, and the losers, who presumably ended up in other good-paying jobs but jobs that didn’t result in them having medical expertise. Now the researchers could see whether the family members of doctors experienced health benefits that those of non-doctors did not. And they did. For example, from these two groups, people with a doctor or a nurse in their family were more likely to survive until age 80. And they were less likely to suffer from chronic medical conditions. Children with a health professional in the family were also less likely to have been exposed to tobacco in utero. And they were substantially more likely to get the H.P.V. vaccination by age 20. Maria Polyakova again.

POLYAKOVA: The randomization gets us this very nice design where we can compare these differences and really be quite confident that this is the causal effect of having a physician in the family. 

Now, while it might seem obvious that that kind of personal access to medical expertise would lead to better health, not all studies find the same result. A couple of years ago, my colleagues Michael Frakes, Jon Gruber and I evaluated a very similar question using data from the U.S.

We used military health records. And we found only trivial differences between how much doctors and non-doctors did things like get vaccinations or go in for an M.R.I. to help diagnose back pain.

Another 2013 study in the Netherlands estimated the effects of attending medical school on health outcomes of doctors vs. non-doctors. The results showed only modest impacts of becoming a doctor on health outcomes. Doctors drank a little less alcohol. But the study also found that they exercised less. And being a doctor had no significant impact on smoking or obesity rates.

And in 2019, Dr. Hannah Wunsch and her colleagues did an interesting analysis of doctors in Canada. They found that the care doctors receive at the end of their lives is actually not that different from the care that non-doctors receive.

I thought my fellow doctors would actually tend to choose less aggressive end-of-life care. But Wunsch and her team showed that just wasn’t true. In their study, doctors and non-doctors were equally likely to spend their last days in the hospital. All of this is to say that what doctors may advise their patients may not, really, fully square with the decisions they make for themselves when they’re faced with the same incredibly difficult choices.

Coming up, we’ll talk about the sequel to Maria and Petra’s research.

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Okay. Back to Maria and Petra. Intrigued by their findings that showed a somewhat — but not huge — difference in health outcomes between those with doctors in the family and those without, they teamed up again to look at this topic from a different angle. Their new study came out in March of 2021. It was kind of a sequel to their earlier work. This new one has a pretty good title too. And, and these studies don’t always have good titles, by the way.

POLYAKOVA: A taste of their own medicine.

A taste of their own medicine. It’s like the summer blockbuster of medical studies, except, uh, instead of Dwayne “The Rock” Johnson, this stars more Swedish data.

Maria and Petra knew they could identify doctors and their families again. This time, they looked at how often those families followed 63 government guidelines about prescription drugs. The guidelines were things like the best medicines to take after a stroke. Or the medicines to avoid during a pregnancy. Here’s Petra again.

PERSSON: Our drug records capture all drugs picked up in outpatient pharmacies. Let’s take a pregnant woman who consumes antidepressants. Then we can see in the data whether she stops taking that antidepressant when she gets pregnant or not.

The average patient? It turns out they follow the guidelines — either stopping or starting a prescription — just over half the time, which obviously isn’t great. But what about doctors and their families? Maria was surprised by the results.

POLYAKOVA: Physicians and their family members adhere to guidelines less, not more.

You heard that right — doctors and their families were 3.8 percent less likely to follow the guidelines about prescriptions.

POLYAKOVA: If they adhere less, then it really raises the question whether the adherence that we observe in the general population, is that really about patients misunderstanding or somehow not being able to comprehend what these guidelines are about?

So my summary of this really interesting literature and these studies by Maria and Petra and their colleagues is that being a doctor doesn’t seem to confer much better decisions when it comes to some really common forms of medical care.

What do we take away from all this? How do we get patients to listen to their doctors more?

I’m actually not sure anybody knows for sure. And if I did, I’d be rich!

But at the beginning we talked about the three Cs: cost, complexity and comprehension.

Driving down costs may help. But even in settings like Sweden where people don’t have large out-of-pocket medical costs, people only take their prescribed medications about half the time.

Making treatment less complex, that may help. Can we make drugs that need to be taken less frequently or create solutions that cure rather than just treat diseases?

But that’s a slow, expensive, and really unpredictable way to improve people’s health outcomes.

So we’re back to that third C again, comprehension. Doctors should have it! I mean, they have the expertise after all. 

But while Maria and Petra’s research shows some evidence of a link between health expertise and behavior, doctors and their families really don’t behave that differently from the general population.

And to me, that’s a little bit surprising. But maybe it shouldn’t be too surprising. Doctors are only human too, right? And changing behavior is actually really difficult.

But Petra thinks there’s an important and maybe overlooked layer to the results of the first study we talked about. The one about seeing improved health outcomes in doctors’ families.

PERSSON: I think trust is important here. It’s easy for us to sit in our ivory tower and think everyone ought to know that you should stick to taking prescribed medications. But out there in the real world, there are many competing sources of information. So in that cloud of information, sometimes misinformation, we found it plausible that access to an expert, but not just an expert but a trusted expert, a family member who’s a nurse or a doctor, can make a difference for health behaviors. But if the trusted expert has to be a family member, then that’s a little bit of bad news if we’re trying to design policy. Because in practice, it isn’t really feasible to expand the number of nurses and doctors in society so that everyone could get one in their family. General public health campaigns, you know, like get your flu shot today, may not carry the same level of influence as an intimate dinner table discussion or persistent prodding among family members. There could be other ways that society can improve its exposure to medical expertise, more targeted or personal communication efforts, community health worker or nurse outreach programs.

So, maybe it’s not just about getting the message. It’s about people trusting the messenger. What’s that old saying?

They don’t care how much you know until they know how much you care.

And speaking of doctors who care, I’m happy to report that my ice cream consumption is now down to one pint a week, or maybe every two weeks. My doctor has been very proud.

All right. That’s it for Freakonomics, M.D. this week. You can find the links to all the studies we mentioned at freakonomics.com.

Coming up next week: Why are kids with summer birthdays more likely to get the flu?

Thanks for listening, and I hope you subscribe or follow the show. It would be great if you could give us a review on Apple Podcasts or wherever you’re listening.

And if you have any thoughts on the show, I’d really love to hear from you. You can email me at bapu@freakonomics.com. That’s B A P U at freakonomics dot com.

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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. This show is produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. This episode was produced by Tricia Bobeda and mixed by Adam Yoffe. Original music composed by Andrew Edwards. Our staff also includes Alison Craiglow, Greg Rippin, Joel Meyer, Emma Tyrrell, Lyric Bowditch, Jasmin Klinger and Jacob Clemente. If you like this show or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.