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

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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.


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.


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.



david cookson

How does the data look when considering when the patient dies? Are these procedures more risky in the short term, but likely to extend life in a quality way if they don't kill you?

Alfred Honoré

I love this show, follow it regularly! I´m a urologist on the west coast of Norway, so your podcast may be more far-reaching than you think. And your ideas are always intriguing. I´d like to share a thought I had while listening to the discussions you had around Dr. Anupams´findings.

The phenomenon of increased mortality is not that controvertial in the field of oncological surgery. This is akin to cracking eggs to make an omelette. Looking at survival in the short term, you will only see the mortality of those who are sickest plus the procedure related mortalities and morbidity. My main focus is prostate cancer, and treatment of this disease is always a long term project. If we only looked at 30d mortality, urologists would never do anything but go to conferences! We´ve wrestled with, and are still wrestling with, the concept of overtreatment. While we are becoming more and more restrictive with whom we operate, there is still good evidence to support treating the disease at an early stage. As you pointed out in the podcast, the admissions were not elective. This doesn´t mean there isn´t a chronic undercurrent to an acutely presenting disease like cardiac arrest. Heart failure is for example a long term killer.

Having said all this, the large difference between the groups compared suggests that American cardiologists do need to learn, as we say in Norway, when to keep their hands in their pockets (and possibly out of their patients...).


Seth Crosby

I call upon Dr. Brenner to allude to evidence in some of the common-sense strategies that he supports. For example, have there been trials showing improved medical outcomes in patients whose doctors spent more time in conversation with them?

Alex in Chicago

Its disappointing that none of these reformers ever address the two real problems:

1. The mandate to provide care in emergency rooms. +
2. 3rd party payer.

Puneet Teja

Really surprising (& fascinating) results of the Dr. Jena's paper.

A comment regarding the healthcare system: the key difference between hospital "business" (not the entire healthcare system though) and other businesses is that whereas in (most) other businesses you want more customers, hospitals, by definition, must work towards losing customers. The reality is exactly the reverse.

I believe in ancient China people paid doctors to keep them healthy. When a patient fell sick, payments stopped, so the doctors were driven to make them healthy again at the earliest. Simplistic, as this might seem, and daunting in its implementation scope, it seems sensible though to live in such a system.

What do Levitt & Dubner say about the Freakonomics of the healthcare system - not just in the US but in most countries worldwide.

PS: I want to send in another topic for a podcast. Which email address do I post it to?


Joe J

Except plenty of businesses should have that same basic model, anything in the repair industry, from computer repair to car repair, if you are doing your job well the customer vanishes, add to that councilors and advisors, lawyers, parole, corrections officers, police and fire etc.

M Greenawalt

the American Heart Assoc person may also consider the data on global warming inconclusive

J M Lawless

Did you correct for the change in patient behavior when their cardiologist is unavailable?

Matthew Novick

A potential main driver that was not discussed in this podcast is the level of attention the patient receives.

'Rock star' doctors often expand their number of patients too far, so each gets less attention than he or she needs. In a crisis situation, prompt responses, even from a relatively inexperienced physician, can make all the difference.

As someone with a chronic disease, I felt very fortunate to get a spot with the top doctor in my field. However, after several incidents where a lack of timely response led to an emergent situation, I switched to a less well-known physician. The quality of my care quickly improved. While this is anecdotal, I'm sure it's just one example of a greater trend.

Randee Laskewitz

Have you checked out the Association of American Physicians and Surgeons (AAPS)? They seem to be a group that is in favor of running their practices without the "help" of the government oversight, so to speak, utilizing direct payment, to the physician without the bureaucracy of the ACA.

Can you do a story with this group, while you are on the topic of health care in our country.

Jeff V.

Just as with Wall Street banks and the American auto industry, medicine as it stands is too big to fail. Too many powerful lobbying groups (most notoriously, trial lawyers and Big Pharma) stand to lose too many billions of dollars if health care were truly revolutionized. As a result, you end up with the "Affordable" Care Act.


I truly appreciate your podcasts.
The problem is that we have all been brought up in a system of sickcare; we just call it healthcare. Until recently, or unless you were involved in public health or primary care, we ignored preventive medicine and maintenance of health and concentrated on rescue medicine and treatment after the body started to fail. I live in a state that has refused to consider Medicaid expansion. But I'm not sure you can put all the blame on our elected representatives. They have been conditioned to think that the more money you put into the health system, the more it will consume, and the trend line never plateaus. And that has been our experience. It's hard to imagine being able to eventually save money if we invest in prevention now. But I've learned one thing as a freak, the right incentives will change behavior. Like the example from early China, pay providers to keep people well and let the consumer carry more of the costs of poor health choices. This requires a societal shift, and we have yet to make that move.


Eric Frizzell

i loved the pod cast. One possible confounding factor is the cardiology fellows (trainees) are also attending the conference.
Good judgement comes from experience. I've found that Trainees are often more aggressive, having not had bad outcomes to temper their enthusiasm.

Oliver H

"DUBNER: That’s right, people in TV hospitals die a lot more than they die in real hospitals. Hetsroni found that TV patients were nearly nine times more likely to die than if you or I wound up in an E.R. 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."

This is simply not tenable, given that it assumes the patients we see in a TV show are the ONLY patients being treated at these institutions. It's evident that the rate would be higher because we see the dramatic cases ONLY. If, however, these dramatic cases were the only cases, the hospitals at issue would likely have gone bankrupt ages ago, simply not having the patient load to be sustainable.

So, since we have to assume that the vast majority of cases is not shown but assumed to happen off-screen, the actual rate is nonquantifiable, but certainly massively lower than can be calculated from emissions.



Just maybe -
during the conference periods there are no elective procedures scheduled,
so the patient count is reduced, permitting more attention by the nursing staff.


In the first part of the show we had an amount of data followed up by what sounded more like agenda focused speculation than "robust analysis" I couldn't help remembering that the even before the study, the doctor concerned was critical of the behavior of his "elders" Perhaps it was just an unfortunate juxtaposition but to go from that to a study, the results of which apparently cast doubt on the methods of the aforesaid elders, made me wonder. Most people when presented with such counter-intuitive results may have entertained doubts about the efficacy of their research methods: that didn't seem to happen here.
In the second part we had either "too much" or "not enough" data to support the views of someone clearly at odds with his profession or at least the way it is run. The speculation that followed seemed to politely ignore the previous point i.e. that the all important data was missing.
The show invests its credibility in the "just the facts, ma'am" efficacy of hard data. But sometimes, perhaps in an effort to be entertaining, a certain amount of fast and loose is played with that principle. This is concerning. After all, you wouldn't want to be confused with the Fox News "Just in, a new survey says that regular prayer helps you live longer" approach to research.



So the transcript has FIFTY sentences that begin with a superfluous "So." So what? (So note: the use in the preceding sentence wasn't superfluous.) So maybe you could edit it out. So because it's annoying as hell. So this would also make a great Freakonomics topic: So why Northeastern and West Coast cultural elites (and their affiliated public-radio types everywhere) insist on doing this.

So thanks.


everyone on duty when the main doc's are away are scared sh#tless. They do every wee tiny thing by the book, follow hospital procedure, actually read the patient's living will or DNR.


or the charge nurse has a bigger say in treatment?


Brilliant! THANK YOU! At our primary-care pediatric practice we give two behavioral health screens at each well exam (one written and one verbal). We do this for two reasons: 1. We think they are a good tool to identify behavioral health needs early; and 2. The Rosie D. lawsuit (Google it). Anyway, since insurance won't cover "talking" time, we end up sending a lot of $9 bills to patients because their plan adds a co-pay or pushes it to the deductible. A piece of my soul dies each and every time I have to explain to patients why they are being billed for this preventative service. I say, "Single Payer Now!"