BOOTH: My greatest teachers are my patients, and one woman with incurable bowel cancer was a great teacher, and we wrote a paper together
That’s Dr. Chris Booth.
BOOTH: She had some very powerful lines that I still remember: “The diagnosis of cancer quickens time and patients lose patience. The good doctor will recognize this.”
As an economist I think about health care in terms of resources. Doctors and other providers are resources. So are the buildings where they work, and the equipment they use, and the medications they prescribe. And there’s another resource that doctors sometimes don’t pay much attention to, one that we’d always like to have more of.
BOOTH: I think oncologists — we do a pretty good job, describing the potential benefits of treatments, and the side effects. I think, there’s a fair bit of attention given these days to the cost of cancer medicines and the financial cost of care. But we haven’t done a good job of really quantifying the opportunity cost of treatments. And the most important opportunity cost that we thought of was the patient’s time.
Time. When you’re a patient with cancer, time affects you in a lot of ways. Time going for treatment, time between appointments, time spent not feeling well, time spent waiting. And of course, how much time is left. It all adds up.
BOOTH: A patient will occasionally look at me and just say, “Well, do I really want to go down that road if I’m going to be spending all of that time in your waiting room or in the chemotherapy unit?” And so, it’s these very pragmatic comments from patients that actually got us thinking about: “Well, is there a way that we could quantify time toxicity and begin to at least start the conversation in our field?”
Chris and his colleagues started thinking about time, and how it’s used in medicine, especially by patients who don’t have a lot of it left. How can they, and all of us, best use time when it comes to our health?
From the Freakonomics Radio Network, this is Freakonomics, M.D. I’m Bapu Jena. Today on the show, we’re going to talk about one of the most valuable resources any of us has: time. We’ll try not to waste yours. Oncologist and researcher Dr. Chris Booth will tell us how he thinks the medical community can address what he and others have called “time toxicity.”
BOOTH: When we counted up the number of days that the patient would spend seeking treatment it could potentially take away every added day of survival.
But first, we’re going to talk about time in a different context. Dr. Adam Gaffney’s new research suggests physicians and patients are spending more time together now than they were 40 years ago. Great news, right?
GAFFNEY: So, that sounds good, but, there’s some disturbing trends within the broader picture. Time has been called the real currency of primary care But I think that phrase actually applies more broadly. Time is the currency of, I think, all healthcare.
That’s Dr. Adam Gaffney.
GAFFNEY: I do think there are good things about the American healthcare system. There are things that we do well. We certainly have cutting edge technology. I like to think we have pretty good healthcare professionals. The biggest problem with the U.S. healthcare system is how we finance it. How we pay for care, how we fail to make sure everyone can get it, regardless of their ability to pay.
These flaws as Adam sees them can impact how physicians and patients spend their time together, in a few different ways.
GAFFNEY: The first issue is really about access. And there is only a finite amount of healthcare that can be provided in a society, at least when you’re talking about services, right? And so, the question is how does that time get distributed? One way is, on the basis of a patient’s health needs. A second way is on the basis of people’s ability to pay. Ability to pay winds up being a very important barrier and an important determinant of how healthcare services are distributed in our society.
Recently, Adam and some colleagues decided to look at how healthcare services are distributed in the U.S. by focusing on time. There’s only so much of it in each day, during each appointment. A 2021 study found that, on average, doctors spend around 18 minutes with each patent per visit. Is this enough? How might time together vary by patient, or by physician? And does it matter? They relied on data from the National Ambulatory Medical Care Survey, from 1979 to 2018.
GAFFNEY: At the beginning of the period of our study, we found that Americans spent roughly 40 minutes a year with outpatient doctors. And that actually increased, over the next 40 years. Nowadays, we found that, Americans spend about 60 minutes a year with physicians face-to-face. So, that sounds like a good thing and it is. And I think, it’s explained by, the fact that there has been an increase in doctors per capita over that time period. So, there’s more doctors to provide that time, and I’ll say that that’s driven not so much by — not at all actually — by more visits per year. It’s actually explained by a rise in the amount of minutes per visit, which probably comes as a surprise, because we feel very rushed when we see a doctor. But there has been an increase in visit length and that’s been seen by others before us. So, that sounds good, but there’s some disturbing trends within the broader picture.
JENA: Can you walk me through how you tracked the actual face time between patients, and doctors? It seems like it’d be hard to do.
GAFFNEY: We looked at more than 1 million visit records over that period, and for each visit, the physician does say how long the visit was in terms of face time. And then we add up the total visit time, and we know what the race is of the patient, we know, the age of the patient for each visit. So, we can sort of basically say, “Okay, how many visit minutes do Black people have one year?” And we did that for every year from 1979 to 2018 or almost every year.
JENA: And what did you find?
GAFFNEY: The first thing that is concerning is that, if you look back over a more recent period, since about 2005, the amount of time Americans spend face to face with a primary care physician over the course of the year has actually fallen, although we are spending more time with specialists. Also, there’s major disparities in the amount of time that Americans spend with doctors, depending upon their race. So, in recent years, for instance, white people spend about 70 minutes a year face to face with a doctor, and that’s compared to about 52 minutes among Black people and 53 minutes among Hispanic people. So, there’s disparities by race and ethnicity and there’s also a growing divide, where we’re spending less time with primary care doctors. And, I’m allowed to say this cause I’m a specialist, but really so much of the lifesaving efficacy of modern medical care is delivered by primary care doctors — things like high blood pressure control, and chronic illness management. There have been a couple recent studies that have actually found that medical control of blood pressure, as well as control of diabetes, has gotten worse according to, some recent national, survey data.
JENA: So, I want to just, follow up a little bit on, the race findings. White patients spent more time per year with doctors face-to-face, than Black and Hispanic patients. How much of that is due to just a different number of visits per year across those groups versus doctors spending more time with white patients on any given visit?
GAFFNEY: In our study, it was driven basically entirely by a different number of visits, not by mean visit length per visit. This study was not designed to look at the why, which is obviously an important question. Although I can certainly speculate on a number of factors that contribute based on what we know about American health care, what we know about American society. We know for instance, that uninsurance rate is higher among Black and Hispanic people relative to white people. And we know that that keeps people from the doctor. Things like copays and deductibles, even if they’re similar among groups, they’re going to have a bigger impact, potentially ,on lower income groups. There could be issues of geographic access., we know that there isn’t, always a good match of population need and the supply of care, and there’s also the long history, unfortunately, and reality today of discrimination and racism in medicine, that could engender mistrust and reduced use of healthcare.
JENA: Did you find anything different, for older patients versus younger patients? Like, for example, was the race difference the same if you look at people above the age of 60 or 65 versus below?
GAFFNEY: It was actually strikingly different. The overall pattern we observed, of racial ethnic disparities was actually driven entirely by the under 65. In the 65 and older crowd, we didn’t see that that pattern play out, which, probably speaks, to the existence of a universal health system or payment system for people 65 and older. Medicare, right? That no doubt plays a major role. That’s not to say that there aren’t disparities in the Medicare population. But other work has also found that, as you go from being 64 to 65, that there is an attenuation of reduction in healthcare access disparities in that population. So, I think that this is just one more bit of support, for the premise that, a universal system does help to reduce disparities. It doesn’t eliminate them, but it helps address them.
JENA: Could more time spent with a physician perhaps help address some of the fundamental disparities that we know exist across racial lines?
GAFFNEY: I mean, I think, in order to really improve hypertension control, you do need to have the patient in front of you. You do need to measure their blood pressure. You do need to prescribe the medication, talk about other issues. And we didn’t find the visit length was the disparity. We found the number of visits. So, I do think that a disproportionate allocation of physician services to more advantaged groups contributes to disparities we see today. Now, we know that health disparities are not just driven by disparities in medical care access. There’s obviously environmental, issues. There’s obviously broader public health issues. There’s racism. There’s all sorts of things in our society that drive health disparities, but I do think medical care disparities matter. And I do think that ensuring equitable access, to services, is an important, critical, and necessary tool to addressing them.
JENA: Do you think that we spend enough time with patients?
GAFFNEY: Overall, I do think that we could benefit from spending more time with our primary care physicians. Now, the problem is, there’s just a lot of people who aren’t seeing a primary care physician at all. There are people who go years without seeing a doctor, who have health needs, I can’t speak to anyone, archetypal visit and how long it should take. I don’t know, but I can say that there’s a lot of people who could benefit from getting more medical care that aren’t getting it today.
There might also be some people who could benefit from getting less medical care — to optimize their time. After the break, when time is scarce, should it change the decisions we make about our health?
BOOTH: That added cost of time could be really important for someone who has very little time left.
I’m Bapu Jena, and this is Freakonomics, M.D.
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BOOTH: My name is Chris Booth. I’m a professor of Oncology and Public Health Sciences at Queens University in Kingston, Canada. I’ve also had a long-standing interest in magnitude of benefit, and to what extent cancer treatments offer meaningful gains to our patients.
In cancer care, meaningful gains are often measured by time. How much did a drug or therapy improve survival? Did a patient live longer, or not?
Longer can have different meanings. If a patient with advanced cancer gains a few extra months as a result of treatment, it’s important to also think about how and where they’re spending that time.
BOOTH: Within oncology, we have some treatments that have transformative impacts on patients and provide large benefits, and that’s what you read about in the newspaper. But we also have a whole bunch of treatments that have very, very small benefits, and we’ve not done a good job in our field of distinguishing one treatment from the other. So, the average, cancer drug that is now approved by the F.D.A. or other regulators worldwide for use in patients with cancer, it extends life by about two or three months. Clearly there’s some drugs that are home runs and really transformative for care, but most of them, these gains are fairly modest. And so, those modest survival gains need to be balanced against the downside.
The downside is something we talked about earlier: time toxicity.
BOOTH: So, broadly, it’s the time spent pursuing medical care. And so, we see that as being, a decision that a patient has to make. We’re not proposing that we have the answer about how patients should spend their time. We feel that our job as oncologists and as scientists is to generate data so that clinicians can present information to patients so they can make informed choices about whether they want to pursue treatment.
Chris and a few other researchers have studied time toxicity to help patients and physicians figure out, together, the best use of their time when it’s not clear they’ve got much left. It might sound like an obvious thing to do, but it can be hard to quantify time in this way, under these circumstances. So, Chris and his colleagues designed a formula to try to make it easier.
BOOTH: The time toxicity measurement we’ve proposed is most useful in the context of an advanced incurable malignancy, when life expectancy is probably less than a year, and we’ve tried to keep it pretty simple and we’ve quantified it as a “home day,” which is a day when the patient’s at home and does not need to leave the house to seek medical care, or a “health system day,” where there’s physical contact with the health system. And so, we’ve been able to do some retrospective analysis of clinical trials and observational data to try to estimate that.
Their findings haven’t been terribly encouraging.
BOOTH: There’s an example that we used in one of our recent papers for advanced biliary cancer where treatment improved overall survival by about two months. And what we showed is the number of days that the patient would spend seeking treatment to get that care — it could potentially take away every added day of survival, what would be one extra day in the hospital or in the chemotherapy unit. And I think that’s important information for patients to know.
Why don’t they know it? How can oncologists like Chris help guide patients using data, at a time when emotion tends to take over? And should measures of time toxicity be routine across medicine?
BOOTH: I think it very much generalizes. In fact, I think oncology is late to the game. Our colleagues in critical care and surgery have quantified this in other settings. The complex thing with oncology is: the timeline’s a little bit longer. It’s not these 30- or 60- or 90-day post-acute care, episodes. It’s longer than that. So, I think it’s a really important conversation to have, especially when we’re talking about treatments that have very real side effects and can certainly interrupt quality of life.
JENA: So, why is oncology behind the game on this? Why do you think it took so long to start talking about these issues?
BOOTH: I think one of the issues, Bapu, is that the narrative in oncology for many years has been: every treatment is a step forward and an advance. And we’ve gotten ourselves into a bit of trouble — and, I say when I lecture students that we have a value crisis right now in oncology, whereby we have an explosive number of new medicines. Some of them are very useful, but most of them are pretty modest with their benefits. They have very real side effects, and only a handful of these medicines have actually been shown to even improve overall survival. We’ve become obsessed in oncology about tumor measurements on a C.T. scan — something called progression-free survival. Many new cancer medicines that are now approved and used every day, there’s no proven benefit that they help people live longer lives or better lives. What they’ve been shown to do is delay growth of a tumor on a CAT scan. So, in that context, I think it’s been tricky to even, you know, start broaching other end points. But I think it’s time for us to start measuring the amount of time spent pursuing medical care, and then sharing that with patients so they can make decisions, especially near the end of life, about how they want to spend their time.
JENA: Have you done any work where you’ve presented patients with this information to see if their decision-making changes?
BOOTH: As I’ve gained experience clinically, I’ve started, I think, to be a bit more explicit in this and try to explain to patients some of the limitations of our treatment. And we’ve been doing work lately, been presenting information to patients about whether they would want to have a cancer treatment that will not improve overall survival, will have side effects, but will control tumor growth on a CAT scan for a period of time. And we found that when we use plain language, and don’t use the word “survival”— because: “progression-free survival,” of course, the third word in that phrase has very strong meanings for patients. But when we describe the tumor measurement paradigm, the vast majority of patients say, “Actually, I wouldn’t want that treatment. I wouldn’t take that treatment for just tumor control if it’s not going to help me live longer, and it’s going to have side effects.” And so, I think that’s an important point for all of us, as oncologists, to consider. Because a lot of what we do is based on that endpoint. And so, I think we really need to go back to the drawing board.
JENA: Can you think of an instance where you felt pulled to treat a patient, even though you suspected that it might not make a difference — it might even waste their time?
BOOTH: To be honest, in oncology this happens more than we’d want to admit. The “battle” narrative in cancer, I think, has been problematic for years. The idea that it’s a fight in a war, and you have to keep on fighting. And so, it’s not uncommon for us to, in the second or third line, have these very difficult conversations with patients where we say, “The current treatment you’re on is not working. We have a treatment that we could offer.” And I try to be pretty clear about, the magnitude of benefit. And I do leave it up to the patient about whether they want to pursue treatment. I will, you know, counsel them, or give them my best advice, but at the end of the day, it’s their decision to be made. And I think all of us have seen patients adopt treatments that maybe we wouldn’t have done in our own decision-making. But our job is to provide information and support the patient through that process.
JENA: What kind of conversations surrounding time toxicity should patients and physicians be having, both before and during treatment?
BOOTH: I think the first step is for our community to generate this information. We’ve tried to keep this metric of “home days” pretty simple and pragmatic, and I think then at least we could present information to say: “Look, your cancer has grown. We have a treatment, or we could focus on symptom management, hospice, and palliative care.” And, on average, patients who went on this clinical trial, they lived for about nine months. Of those nine months, they spent about, you know, three months pursuing treatment — extra biopsies, extra emergency room visits. So, there’s a trade-off there. And with no treatment, your home days, might be about seven months. With treatment, you’ll live nine months, but have about six months of home days. And I think the first step is to generate the information, but then most importantly, it’s to do the hard, mixed-methods, qualitative work with patients to understand how they want this information presented, what the best way is to present it, and how, real patients would value and weigh these competing priorities.
JENA: So, Chris, one way to think about the time toxicity of medical care for cancer patients at the end of life is the time that they spend seeing the doctor that they might not want to spend if they knew how much time it was going to take. But there’s another channel that is operating here, which is: that time is being spent by doctors and other providers in the medical system, and could be spent on other people whose cancer care might be delayed, for example, because of these issues. So, how do you think about time toxicity as it parlays into the broader cost to the medical system?
BOOTH: This is a really important point. So, these are opportunity costs, kind of beyond the individual patient’s time. Another opportunity cost is to recognize that about three-quarters of patients with cancer come to their appointments with a family member or a loved one, so when we think about opportunity cost and time, there’s also a time cost for the family member. There’s opportunity cost for the health system, where physicians, nurses, and other elements of the system — time taken away from delivering other care. The other kind of potential opportunity cost here is if we’re designing very large clinical trials to identify very small benefits — in the research ecosystem, the most precious resources are patients that are willing to go on trials plus, funding to support the research. And so, we’ve done a modeling exercise where, if you design a large clinical trial — 1,200 patients with advanced cancer to detect a fairly small benefit — well, for the same dollar cost, and the same number of patients, you could run three clinical trials to answer three separate questions, and you’re trying to identify a treatment benefit that would be larger and more beneficial for patients. So, there’s all these complex trade-offs. The other issue is the broken system of cancer drug pricing. I’m not an economist, but, in my world, if I’m shopping for a bicycle and I spend more money, I’m likely to get a faster bicycle. If I’m looking for a house and I spend more money, I’ll get a nicer home. And we asked this question empirically of cancer medicines a few years ago, published the results in Lancet Oncology. And we found that not only is there no relationship between the magnitude of benefit of a cancer medicine and its drug price; if anything, there’s an inverse relationship, whereby the drugs that have the smallest clinical benefits have the largest price tags. I don’t think you need to be an economist to know that that system is broken. So, we’ve got a number of competing opportunity costs here in addition to the time for the individual patient.
JENA: Are you starting to see time toxicity being factored into patients’ decisions at all?
BOOTH: We just started publishing this work in the last year, and so I think it’s probably too early to see: empirically, has it changed conversations? But the concept has really taken off. So, I’ve been approached many, many times by colleagues who are doing work in this space. We’ve inspired a number of other teams to start doing work actively. There’s large clinical trial cooperative groups throughout Canada and the U.S. that are now engaged and actually going to measure time toxicity. So, I think it’s probably a concept that was hidden. Everyone knew it existed, but it just wasn’t really being talked about. And now that we’ve started to broach the subject, it’s really taking off.
As Adam Gaffney pointed out earlier, time is a finite resource within medicine. We only have so much of it, both to give and to receive care. How do we want to use it? In some cases, it might mean spending more time with a physician. In other cases, when a patient doesn’t have much time left, spending less of it getting medical care may actually improve their quality of life. Like much of medicine, it’s a balancing act, and not an easy one. And on that note, my time’s up on today’s show but there is one idea that I’d like to leave you with.
Measuring how much time people spend face to face with doctors is hard. You either need to rely on surveys, which can be inaccurate, or literally have someone use a stopwatch. I recently had a chance to work with some interesting data on face-to-face time that’s based on electronic sensors. That data, which is early and from a company called DAMSR, shows that patients spend, on average, about one hour and four minutes in doctor’s offices but only 20 minutes of that time is spent face to face with a doctor. That’s a lot of time waiting.
Anyway, I’d like to thank my guests, Adam Gaffney and Chris Booth. And thanks to you, of course, for listening. Let us know what you thought about this episode. Do you think doctors and patients spend enough time together? How can we deal with the problem of time toxicity? Send us an email at bapu@freakonomics. com. That’s email@example.com.
Coming up next week: Odds are, at some point, you or a loved one has been, or will be, seen in a medical setting by someone who is not a doctor—but rather, a physician assistant or a nurse practitioner. So, what do we know about the care and costs they generate, compared to doctors?
CHAN: We surprisingly know very little.
In next week’s episode, we’ll find out a bit more.
MORGAN: After balancing, for those factors, we were surprised. We expected that to be the same.
That’s all coming up on Freakonomics, M.D. Thanks again for listening.
Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter at @drbapupod. This episode was produced by Julie Kanfer and mixed by Eleanor Osborne, with help from Jasmin Klinger. We also had help this week from Katherine Moncure. Our staff also includes Neal Carruth, Gabriel Roth, Greg Rippin, Lyric Bowditch, Rebecca Lee Douglas, Morgan Levey, Zack Lapinski, Ryan Kelley, Jeremy Johnston, Daria Klenert, Emma Tyrrell, Alina Kulman, and Stephen Dubner. Original music composed by Luis Guerra. 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.
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GAFFNEY: Scotland has gotten rid of parking fees at hospitals, and I think we should have that.
JENA: You know, you can’t say something like that to me and expect me not to want to study it. Scotland eliminated the cost of parking? I’ve got to look at what happened as a result of that. We’re going to change the whole episode now.
- Christopher Booth, professor of oncology and public health sciences at Queens University.
- Adam Gaffney, assistant professor of medicine at Cambridge Health Alliance.
- “Trends and Disparities in the Distribution of Outpatient Physicians’ Annual Face Time with Patients, 1979-2018,” by Adam Gaffney, David U. Himmelstein, Samuel Dickman, Danny McCormick, Christopher Cai, and Steffie Woolhandler. (Journal of General Internal Medicine, 2022).
- “The Time Toxicity of Cancer Treatment,” by Arjun Gupta, Elizabeth A. Eisenhauer, and Christopher M. Booth. (Journal of Clinical Oncology, 2022).
- “Measuring Primary Care Exam Length Using Electronic Health Record Data,” by Hannah T. Neprash, Alexander Everhart, Donna McAlpine, Laura Barrie Smith, Bethany Sheridan, and Dori A. Cross. (Medical Care, 2021).
- “Trends in Diabetes Treatment and Control in U.S. Adults, 1999–2018,” by Michael Fang, Dan Wang, Josef Coresh, and Elizabeth Selvin. (New England Journal of Medicine, 2021).
- “Changes in Racial and Ethnic Disparities in Access to Care and Health Among US Adults at Age 65 Years,” by Jacob Wallace, Karen Jiang, Paul Goldsmith-Pinkham, and Zirui Song. (JAMA Internal Medicine, 2021).
- “Patient perspectives of value of delayed disease progression on imaging (imaging PFS). A treatment trade-off experiment,” by Andrew G. Robinson, Jennifer O’Donnell, Christopher Booth, Rachel Koven, Elizabeth Eisenhauer, and Michael Brundage (Journal of Cancer Policy, 2021).
- “Assessment of Overall Survival, Quality of Life, and Safety Benefits Associated With New Cancer Medicines,” by Sebastian Salas-Vega, Othon Iliopoulos, and Elias Mossialos. (JAMA Oncology, 2017).
- “Delivery of meaningful cancer care: a retrospective cohort study assessing cost and benefit with the ASCO and ESMO frameworks,” by Joseph C. Del Paggio, Richard Sullivan, Deborah Schrag, Wilma M. Hopman, Biju Azariah, C. S. Pramesh, Ian F. Tannock, Christopher M. Booth (The Lancet: Oncology, 2017).