Why Did This 60-Year-Old Man Collapse at the Supermarket?

Diagnosis is at the heart of what doctors do. In medical school, we’re taught the basics. We refine it during residency. But good doctors are constantly honing their ability to identify illness.

DHALIWAL: Thinking is our most important procedure, right? So just like we teach other procedures in medicine, like how to take out an appendix or how to deliver a baby or how to do an examination of the eyes. Thinking has a series of steps and each one of them can be isolated and practiced and critiqued.

That’s my friend, Dr. Gurpreet Dhaliwal. He’s a professor at the University of California, San Francisco, and a physician at the San Francisco VA Hospital. Most of Gurpreet’s time is spent teaching and seeing patients, but he has another job too.

DHALIWAL: My, side hustle is that I study how doctors think and how their mind comes to diagnosis^.

JENA: How do doctors think?

DHALIWAL: Pretty well. I’m biased. I think we do it all right. But there’s room to improve.

Gurpreet has been improving his own diagnostic skills for a long time. He’s pretty good at it, and in episodes five and 10 of Freakonomics, M.D., we put him to the test.

DHALIWAL: My final diagnosis is that when he’s outside, enjoying the sun and the fresh air from time to time, he may come across a mosquito. And if that’s the case, he is at risk for getting West Nile virus.

We wanted to bring Gurpreet back for another go-round, so that he could show off his skills but also so that we could try to stump him.

From the Freakonomics Radio Network, this is Freakonomics, M.D. I’m Bapu Jena. Today on the show, I’ll tell Gurpreet — and you — the story of a 60-year-old man who was shopping at the supermarket when he collapsed, and was found to have no pulse.

DHALIWAL: This is one of the most serious medical emergencies you can have.

So, what caused this man to suddenly lose consciousness?

DHALIWAL: The most common thing is that a heart attack is happening

And how does Gurpreet’s mind work as he tries to get to the bottom of this, or any, medical mystery?

DHALIWAL: Doctors go through the discussion of all the possibilities, but they’re really waiting for one clue on which the whole case will be solved.

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JENA: So I’m gonna present, some information to you and I’m gonna pause along the way and get your reaction, try to understand what you’re thinking at that moment, what additional tests, what additional information you might want. And if I have that information, I’ll give it to you. How does that sound?

DHALIWAL: That sounds great.

Since 1923, the New England Journal of Medicine has been publishing case reports drawn from the records of the Massachusetts General Hospital, where I happen to work. So, when I decided to present a case to Dr. Gurpreet Dhaliwal, that’s where I went looking. We’ve changed some of the details, but most of what you’ll hear about this patient and his condition as I describe it to Gurpreet is based on one of this vast collection of case records.

JENA: All right. So this is the story. A 60-year-old man was shopping at the supermarket and he collapsed. He was completely unresponsive. Someone called 911. Paramedics arrived just a couple of minutes later, and when they did, the man had no pulse. They started C.P.R. basically instantly. After about a couple of minutes, they were able to place an A.E.D. device or automated external defibrillator on the chest, and they measured his heart rhythm, and it was in a rhythm called ventricular fibrillation. They shocked him a few times. They gave him medications and after about 10 to 15 minutes of continuous C.P.R. and shocks, they were finally able to get a pulse. And that’s when they made the decision to transport him to the hospital. When you hear this, what are you starting to think?

DHALIWAL: This is one of the most serious medical emergencies you can have, which is the heart going into a fatal rhythm. If you back up, what happened in the grocery store is he fell. He fell almost certainly because he lost consciousness, which means his brain stopped working. And we always wonder when the brain doesn’t work well, why that is. And there’s generally two problems. Either something has happened intrinsic to the brain, for instance, a seizure is happening, or the brain was okay, but the heart and the circulatory system didn’t pump blood to the brain. Almost certainly we know that’s the case here because the A.E.D. detected that there was a very serious rhythm, called ventricular fibrillation. First and foremost, our major concern is whether he might be having a heart attack, which can, cause arrhythmia, heart failure and if not treated in a situation like this, could lead to death. Those are things we’re focusing on right off the bat when he comes into the emergency room. And we’re trying to prevent a recurrence of this heart rhythm again.

JENA: What is the difference between a heart attack and cardiac arrest?

DHALIWAL: The heart is a huge muscle. It has large arteries that feed it blood that sometimes get blocked. And if there’s a blockage of those arteries, then the heart, will be starved of oxygen that leads to tissue damage. And the electrical system of the heart goes haywire and instead of functioning normally, it starts to fire haphazardly. And if it’s really erratic, the heart no longer can function. Cardiac arrest is when that electrical activity is disorganized and essentially doesn’t allow the heart to pump effectively.

JENA: And the term ventricular fibrillation, what does that mean to you?

DHALIWAL: It’s essentially, the most serious version of that, where the electric activity is completely erratic and disorganized and non-functional. It’s like a massive short circuit.

JENA: Besides heart attack, what are the other things that you’re thinking about that could cause cardiac arrest?

DHALIWAL: The heart is dependent on a lot of things to go right in order for it to function. It has to have, appropriate level of oxygen. The electrical system is dependent on us having certain chemicals in the blood like potassium and magnesium. If those are very low, those are another reason that the heart can have an electrical short circuit like this. Sometimes, we have substances that people may take, like methamphetamine and cocaine that overstimulate the heart and can lead to an arrhythmia. Those are all things that we consider along with the heart attack idea.

JENA: All right. So like I said, he was transported to the emergency department. It took about 45 minutes from the time he’d collapsed to the time he was actually rolled into the E.D. and evaluated. When he arrived to the E.D., he did have a pulse, but he was still completely unresponsive. The emergency department team decided to intubate him and they gave him insulin and dextrose, which is a sugar, and a couple of other medications literally before we’re talking right now, you were in the E.D. all day today, is that right?

DHALIWAL: That’s where I was all day.

JENA: Imagine that you are in the E.D. and you’re evaluating this patient. What are the things you’re gonna wanna get information on, at this point, above and beyond what I already told you?

DHALIWAL: Well, if, if there’s a chance to get more history, from, bystanders at the supermarket or E.M.S. or paramedics, or maybe even family members we’d certainly like to get that. So there is this acquisition of key medical data, like his vital signs matter. You know, what’s his heart rate and pulse? What’s his oxygen level? I think with those blood tests that I mentioned, things that are either a marker of a heart attack or a measure of levels like potassium or magnesium in the blood or an E.K.G. of course, is very important for us to confirm the rhythm that was seen or see if there’s evidence of a heart attack. Those are some of the basic things that we’d be spending our energy on early on.

JENA: Someone in the E.D. was actually trying to contact the patient’s family, to get more information on the man’s medical and social history and we’ll get some of that soon. In terms of his vitals when he came in, he was intubated by the time we’re getting this information and his oxygenation was actually okay. His heart rate was, quite high. 130s to 140s, and his blood pressure was somewhat elevated as well, somewhere around 160 to 170s systolic. We don’t have the bottom blood pressure, the diastolic, blood pressure. You mentioned an E.K.G., you mentioned some laboratory studies to look for a heart attack. What else would you wanna do right now?

DHALIWAL: There’s two things we’re trying to figure out: are the vital signs stable or at least adequate? We do have to figure out why his heart is going so fast. We still have the importance of studying that E.K.G. to make sure, he’s not having a heart attack.

E.K.G. stands for electrocardiogram, which is a simple, painless, routine procedure. You’ve probably had one before: electrodes are briefly attached to your chest, arms, and legs to measure your heart’s electrical signals. An E.K.G. reading consists of spikes and dips called waves; actually, they look a lot like the Freakonomics, M.D. logo. Each of these waves has a name and tells healthcare professionals a lot about how well your heart is functioning.

The patient I’m describing to Gurpreet had a troubling E.K.G. It showed that his heart had been irritated, possibly as a result of past coronary artery disease, or because of the active problem we’re seeing now. Overall, the E.K.G. was suggestive of a heart attack, but not definitively so. Some of the wave variations indicated to Gurpreet that the patient could be deficient in certain electrolytes, like potassium, that keep the heart beating normally.

There are other test results Gurpreet would like to see, though.

DHALIWAL: The measurement that might help us most judge whether heart attack is happening or not is called troponin. I think if there was the capacity to do an echocardiogram, which is an ultrasound of the heart, that would be really informative. It would tell us how well the heart is pumping. I think without a doubt, a cardiologist would be called at this point, to help with some of these decisions, including the question about is there enough data to be concerned that the patient has had a heart attack, even if we don’t have one smoking gun to take him to the cardiac catheterization lab and take a direct picture of those heart vessels that may have been blocked and set off this whole thing.

The patient’s echocardiogram showed that the left ventricle was really not working well. Gurpreet will explain what this means in a few minutes. A chest x-ray revealed that the lungs were clear, and a C.T. scan of the head found no evidence of a stroke or bleeding in the brain.

But the patient’s lab results were sort of all over the place. His sodium and phosphorus were elevated, and so was his calcium level, which was 15 milligrams per deciliter. His glucose, or blood sugar, was really high, around 300 milligrams per deciliter. His white blood cell count, which is a marker of inflammation, was also high. His blood work showed that his markers for liver injury were slightly elevated, but not too out of the ordinary. His potassium level was 3.2 and his bicarbonate was six; both of those numbers are measured in milliequivalents per liter, and both of those levels are considered low.

JENA: And the last bit of information, which is what you asked about earlier, was several markers of cardiac injury. And one of those was including a troponin measurement. And that was really quite markedly, elevated.

DHALIWAL: There’s a lot to digest here. You can almost take each one of those things and, form a differential diagnosis or a list of possibilities around them and then you can try to synthesize them together. Let me just work in reverse cause you said the most salient thing, which was the troponin, was elevated. Depending on how high it was that may suggest that active injury is happening to the heart. The most common thing is that a heart attack is happening. That is to say that there is a blocked vessel and the blockage in oxygen supply to the heart is leading to damage and that’s what’s set off the abnormal heart rhythm. There are other interpretations to that test. Sometimes that marker of heart damage comes about not because of a blocked vessel, but because there might be an infection to the heart or inflammation inside the heart. We call that myocarditis.

You mentioned left ventricular dysfunction. It’s worth noting that the heart is a four-chamber organ and, each of the chambers has an important role. Like there’s a chamber on the right side called the right ventricle that pumps blood to the lungs where the blood picks up oxygen. But the real workhorse of the heart is the left ventricle and the left ventricle pumps blood to the entire body. So when that part of the heart is not working, that’s the most severe, and it can be life threatening. The fact that he has it not working well on the ultrasound could be one of two things. It might have been working just fine yesterday and today we’re discovering a new problem, like a heart attack happened. There is another alternative explanation, that he’s had heart injury or heart failure, that’s been indolent in the background for a period of time. And today’s event was sort of a bellwether, it was a tipping point where the diseases become much worse because a diseased heart can have one of these arrhythmias just creep up on it in the way he did.

JENA: And this is why it’s really important to be able to have information on who this person was prior to when you first saw him

DHALIWAL: Precisely. If we had an echocardiogram perhaps from a year ago that told us the heart was in the same state and the doctors would’ve probably tried to figure out what it was that caused it, we’d know much more than the guesswork we’re doing now. Some of the things you mentioned are non-specific. The white blood cell count means the body’s inflamed. It’s possible that there’s an infection that’s underlying this. It’s equally plausible that this is just a reaction to stress. So I have to put a pin in that, but I can’t draw a conclusion. Conversely, the number you gave for calcium is extremely high. A calcium of 15 is well beyond the normal range. Normally it’s in the eight to 10 range roughly. So, that’s one clue that I’m sort of locking in on. And then there are other really notable findings. Like you mentioned the bicarbonate is 6. Did I hear that correctly?

JENA: That’s correct. Yeah.

DHALIWAL: That is a very profound deficiency of bicarbonate.

The body needs bicarbonate to keep a normal acid-base balance, also called its pH balance. If your blood is too acidic, it can lead to a lot of problems. As Gurpreet mentioned, a calcium level of 15 is also really concerning. High calcium is often the result of overactive parathyroid glands, which can weaken the bones, cause kidney stones, or interfere with how well the heart and brain work.

Another test was performed on this patient called an arterial blood gas. We talked about this on the show a few weeks ago, because it’s the most accurate way to determine someone’s oxygen level. It can tell us other things too: like the fact that this patient wasn’t actually too acidic, despite his low bicarbonate, and that his potassium blood level was much lower than we had realized. It was 1.6, not 3.2. Anything below 3 is considered severe. Potassium is critical to all of our organ systems, especially the heart.

DHALIWAL: If the potassium is as low as 1.6, that makes us think of why people have a low potassium level. That can be in situations where people aren’t taking enough in in their diet, but it’s more often that the potassium is leaving the body. Either it’s, going out the gastrointestinal tract, it’s going out of the, urinary system. Rarely, it’s because the potassium is floating around in the blood, but it might shift in the cells, and one reason, can be because the person has taken a large amount of carbohydrates sometimes that causes an insulin release, and in a handful of people that leads to a really exuberant response. Or another possibility for the potassium to shift into the cells really vigorously is that someone has an overactive thyroid gland and an overactive thyroid gland can sometimes stimulate the heart to go into abnormal rhythms. You gave me two levels of potassium. 3.2 is mildly low, but 1.6 is very low. And just in general, the more abnormal a test is, the more likely it’s gonna be a clue.

Often, tests raise more questions than they answer. What was causing this patient’s low potassium and low bicarbonate? Why was his calcium so high? What else do we need to know about him? After the break, we’ll hear what Dr. Gurpreet Dhaliwal is thinking as I reveal more about this complicated patient.

DHALIWAL: I think they’re all important parts of his background. I think none of them are telltale signs of what’s going on.

I’m Bapu Jena, and this is Freakonomics, M.D.

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Here’s a quick review of the case I’m discussing with Dr. Gurpreet Dhaliwal today: A 60-year-old man collapsed in the supermarket. Paramedics used an A.E.D. to shock his heart, which had gone into a dangerous, often fatal rhythm called ventricular fibrillation. He was brought into the hospital and put on a ventilator. His E.K.G. was abnormal. His blood work was also concerning, as we discussed just before the break. Among other results, his labs revealed an elevated level of troponin. Anytime someone collapses and goes into cardiac arrest, as this patient did, doctors have to think about the possibility of a heart attack. Troponin is a protein found in the muscles of the heart, and when the heart becomes damaged, troponin rushes out of the muscles and into the bloodstream. A logical next step for this patient would be to take him to the cardiac catheterization laboratory to have his coronary arteries evaluated. And that’s exactly what happened. 

JENA: They evaluated his coronary arteries, and it was actually fairly unremarkable. There was no evidence of coronary artery blockages. They did draw a potassium level during the catheterization, and that was also low this time, around the low twos, so they gave him I.V. potassium in the cath lab. He was transferred to the I.C.U. And, in terms of the progression of his labs, you remember his, calcium was around 15 when he first came in? It actually fell to about nine, within a few hours., but the potassium did remain low, while he was in the I.C.U. And he continued to get, additional, potassium by I.V. The other thing is he continued to be, unresponsive, in all of this.

DHALIWAL: I think that potassium has proven itself to be a persistent problem. it makes me wonder about whether it was causal, that is to say it caused this whole, syndrome. And the fact that the coronary arteries were normal is a relief. You know, no matter what things may have detracted from the possibility of heart attack, I think it would’ve been hard to reject that hypothesis completely without doing the cardiac catheterization. But now I think we have reason to avert our gaze away from the arteries of the heart. I wonder if there’s a problem with the muscle of the heart, like something has infiltrated it or damaged it, or if there’s a problem with the electrical system in the heart itself or the minerals like potassium and magnesium that depends upon to function normally.

JENA: Let me give you a little bit more history on this, gentleman. He lived at home alone. And he used to actually work at the airport but had retired about five years ago. In terms of medical problems, didn’t have any history of diabetes or hypertension, though, remember his blood pressure was elevated when he came in. The main problem that he had was issues with substance abuse in the past, mostly opioids, but nothing as far as we know in the last few years. He was a smoker. No alcohol but besides this pretty limited medical history, his family members said that he had some chronic swelling in his legs. And he took Lasix for that, but it wasn’t clear if he was still taking it. Someone from the medical team actually called the local pharmacy and the last time he’d filled any prescription at all was about a year ago and that was for Lasix. Family said that he spent most of his time indoors, not a lot of exercise, not a great diet, lots of snacks apparently. So that’s the story on who this person was before he was found to collapse in the grocery store.

DHALIWAL: I think they’re all important parts of his background. I think none of them are telltale signs of what’s going on. The idea that he was given Lasix in the past for leg swelling suggests that maybe his heart problems predated today. It makes me wonder if his heart has been backing up and one of the ways a heart backs up is into the lungs. If it keeps backing up, it backs up into the legs, and fluid builds up there. I noticed among substances that he’s used, there was tobacco. Tobacco is intriguing, not necessarily as an explanation for today’s problem, but for that calcium, that calcium of 15 was really high, and tobacco increases the risk for a number of cancers. A number of cancers can cause a very high calcium level like that. We didn’t see evidence of it in the place we might look first, which is the lungs, where lung cancer can arise from tobacco and cause high calcium. But I took note of that. And then he’s had some, struggles with substance use in the past. I mentioned methamphetamine or cocaine can trigger an arrhythmia like this but we don’t have any other collateral information to decrease or increase our suspicion of that. I’m wondering about his social isolation. Every once in a while we learn about people who are very socially isolated and or don’t have access to food, and they do have vitamin deficiencies. But I think I need more information before I chase that down.

JENA: I will say that he’d had a serum and urine toxicology that was performed and there was nothing, no illicit substances or anything that was concerning from that perspective.

DHALIWAL: That’s helpful information. I think we have reason in this case to turn our gaze elsewhere.

JENA: So Gurpreet, that’s, about all the information that I have for you. I don’t know if that’s enough for you to put your money down on what might be, going on with this gentleman.

DHALIWAL: Not yet, but maybe I’d have to define for myself what the problem is that we’re trying to solve here. That there was a man who had an episode of ventricular fibrillation that was not caused by a heart attack, but we found the signatures of a number of, I would say, chemical imbalances, that he has acid buildup in the body. That he had a high level of calcium and phosphorus. That he had a low potassium, and he had a high blood sugar. All of which were kind of, unexplained, based on his past medical history. One general sense I have is that there was some sort of excess sympathetic charge that his body had, and I don’t know whether it was longstanding or whether it was relatively acute. But just that his heart rate is going fast, his white count is elevated, his blood sugar is elevated, make me wonder if maybe there’s a chemical imbalance and if it’s not external in the way that I mentioned that it might be internally generated. Sometimes there are substances that the body generates, which in excess can cause these problems. Like an excess of one hormone called cortisol, or an excess of another family of hormones called catecholamines. And sometimes there are tumors in the adrenal glands. These are the small hormone generating glands that sit on top of the kidney that might be responsible for a large part of this profile. So for instance, if the gland is producing too much cortisol, it can cause problems like high blood pressure, high sugar, low potassium. It doesn’t oftentimes cause a low bicarbonate, but we don’t have to have the patient fit every part of the textbook. Patients don’t read the textbook, we’re fond of saying, and this certainly is the case here. I’m even intrigued by the possibility of a rare syndrome called pheochromocytoma, which is that same gland instead of producing cortisol, produces essentially epinephrine. And sometimes that can present in a very dramatic fashion that looks all the world like a cardiovascular collapse, but it’s just this rapid release of hormones. That would be something I’d be interested in studying This would require, a closer look at the heart and lung. So involve CAT scans and, echocardiogram. even sometimes a biopsy of the heart or a nuclear medicine scan of the heart or an M.R.I. of the heart. I’m intrigued to know if he was eating, something unusual. There are rare instances where something like an excess of licorice, taken up in isolation, can lead to a very low potassium. And that might have set off a cascade of events. It’s a very particular type of licorice by the way, but when taken, it causes a very low potassium and other problems like this.

JENA: Tell me a little bit more about the licorice, actually.

DHALIWAL: I was mentioning that there’s a gland on top of the kidney that produces a number of hormones. One class of hormones that matters are called the mineralocorticoids. So, believe it or not, that small gland cranks out a bunch of different hormones and the job of that hormone is to keep the blood pressure in the body intact. It has a lot of things it does, but it tells the body to hold onto sodium. And it sort of gets rid of potassium in a very measured way. There’s a very specific type of licorice which has a chemical. I think it starts — I think it’s called glyceric acid or something —.

JENA: It’s actually called glycyrrhizic acid, Gurpreet.

DHALIWAL: That if someone takes it in excess, can mimic that same hormone and what it does is it gets rid of much more potassium than our body would normally, and can leave too little potassium in the bloodstream and that could set off the cascade that we are talking about here.

JENA: Okay, well, we’re on video. You see me smiling a little bit. What’s your final diagnosis then?

DHALIWAL: I’m gonna say that, although we don’t have the full complement of tests that we want, based on the depth of this potassium, based on social isolation, may have found his way into an abnormal or unusual diet, might be ingesting, excess black licorice that has led to a low potassium level, leading to this cardiac arrhythmia and the subsequent medical events.

JENA: I think you clued in on, this fact, which was the potassium was low and it continued to be low despite attempts to replete it. I think someone who’s listening to this is gonna say, you know, how did this guy take a question stem, which was an individual in a grocery store who had a cardiac arrest and arrived to this pretty, esoteric diagnosis. That’s not what it’s like in the real world. Is it?

DHALIWAL: No, the real world, first of all, I don’t have an hour to do it. We have far less. I also don’t have these goofy headphones. I think the upfront job is very much like I described. You know, why was there a heart attack happening? Are the vital signs stable? On the back end when the patient gets to the hospital and the stabilization has happened, that’s when we get to sort of delve into the mysteries of what might be going on. One thing that struck me, I think this is a really good example too, of where the social history matters, right? We talk a lot about medicine social determinants of health, and I think it was at least important to know that he was living alone and not going out too much, somewhat isolated because it’s not deterministic, but it does travel with sometimes restrictive or unusual diets. Now, the truth is anyone can have a single candy or a single type of food that they take in excess. We probably all do for our favorites, but just maybe if nothing else, it heightened my consideration of his diet, compared to some of those other things I was mentioning that might be the final explanation.

JENA: And in the case record, from the Mass General, the individual actually passed away, primarily because of a failure to regain a good neurologic prognosis. So, it’s unfortunate, but there’s a lot of learning that was possible in that case. And I think, we learned a lot from you. How did it feel? Did you know where I was going? How much uncertainty was there in your mind because  you kind of arrived at the right diagnosis, but I tried awfully hard not to give you too many clues.

DHALIWAL: You are a skilled storyteller and to be fair, I was really jostling around a lot of ideas, right? This is a case that started with a common scenario and I was waiting for what’s called the pivot point. Many decades ago, there was a study of the New England Journal of Medicine C.P.C.s, where someone looked at how the doctors solved the cases. And the doctors go through the differential and discussion of all the possibilities, but they’re really waiting for one clue on which the whole case will be solved. You can only go so far with an abnormal heart rhythm. You can only go so far with a high blood pressure or a high pulse rate. You need something that kind of has both a narrow range of possibilities and a very organized way to analyze it. And that’s called the pivot point. So it might be a high type of cell count, like eosinophils. Or it might be, a specific x-ray finding, like a lung and mass. Or in this case it was a very specific lab finding.

DHALIWAL: And it wasn’t clear that potassium was going to be the answer here. You threw out a lot of tantalizing alternatives, right, to chase after the acidosis in the blood, to chase after the calcium of 15. But one thing that’s, sometimes guidance is like how wildly abnormal something is. And while the acidosis was notable, it wasn’t the most severe and while the calcium was high, it resolved quickly, but that potassium, that was markedly low and stayed low. I mean, so much so that doctors were giving potassium even after the cardiac procedure. That was a clue that the answer was going to have to explain that. It may not have to explain anything else in the case, but it was likely gonna have to explain low potassium.

A case presentation is a story. It’s a foundation of medical education, and of clinical medicine in general. It’s also something I haven’t done in a while! So thank you for bearing with me, and with Gurpreet, as we worked through this patient’s serious, and ultimately tragic, medical event to get to the bottom of what caused it. We rely on these cases to become better doctors, better thinkers, even after years and decades of practicing medicine. And we’re grateful to patients like this one, who give us the gift of a story.

DHALIWAL: I think the best way to honor someone’s memory and generosity if they’re involved in letting us share their case is make sure that we learn from it, and can use it to treat other people well and maybe solve their case at an earlier stage.

That’s it for today’s show. I’d like to thank my guest and friend, Dr. Gurpeet Dhaliwal, and thanks to you, of course, for listening.

We’d love to do more episodes like this, because medical mysteries teach us a lot about how the body works, why it sometimes doesn’t, and how doctors think. Do me a favor: let us know how you felt about my chat with Gurpreet today! Send us an email, leave us a review on Apple podcasts, or tell your friends about the show. Send us a signal. My email is bapu@freakonomics.com. That’s B-A-P-U at Freakonomics dot com.

Coming up next week: In medicine, when you analyze data, it can take you to some unexpected places.

BRENNER: It started to tell a story that was horrible, which is that a small sliver of patients were going back over and over for all kinds of reasons.

We’re going to revisit an episode from this past summer, in which Dr. Jeffrey Brenner told us all about this small sliver of patients.

BRENNER: They were going back and forth all the time to the hospital. But they weren’t getting care. They were getting treatment, but they weren’t getting care.

Jeff and his team developed an innovative approach to help these complex patients, also known as super-utilizers. But did improving their care also decrease costs?

DOYLE: They were getting a lot of praise for their program and they honestly wanted to rigorously determine whether it was saving money on its own.

That’s coming up next week on Freakonomics, M.D. Thanks again for listening.

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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. 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. Lyric Bowditch is our production associate. Our executive team is Neal Carruth, Gabriel Roth, 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.

JENA: You’re like an actor, so, you know, this is about as close as we’re both gonna get to Bollywood.

DHALIWAL: Yeah. The radio version, I think.