Passion Struck with John R. Miles - Dr. Anupam B. Jena on Decoding the Hidden Factors in Healthcare EP 318

Episode Date: July 13, 2023

Dr. Anupam B. Jena joins host John R. Miles on the Passion Struck podcast to discuss his research on natural experiments and their impact on healthcare outcomes. Dr. Jena’s studies provide valuable insights into the effects of being a world leader on health, the consequences of playing professional football, and even the influence of birth month on ADHD diagnoses. Dr. Jena is the co-author of the new book, “Random Acts of Medicine: The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health.” Want to learn the 12 philosophies that the most successful people use to create a limitless life? Pre-order John R. Miles’s new book, Passion Struck, releasing on February 6, 2024. Full show notes and resources can be found here: https://passionstruck.com/dr-anupam-b-jena-hidden-factors-in-healthcare/  Decoding the Hidden Factors in Healthcare: Dr. Anupam B. Jena on Natural Experiments and Patient Outcomes In the world of healthcare, some discoveries come from unexpected places. Dr. Anupam B. Jena's journey into the realm of natural experiments began with a simple comment from his wife. Little did he know, this offhand remark would unravel a hidden truth about healthcare outcomes. As a medical doctor and economist, Dr. Jena was no stranger to the complexities of the field. But it was his investigation into the impact of large events, like marathons, that revealed a startling twist. The findings were astonishing, shedding light on the often overlooked factors that shape our health. Brace yourself for the unexpected as we dive into the untold story behind healthcare outcomes... Brought to you by Hello Fresh. Use code passion 50 to get 50% off plus free shipping!  Brought to you by Lifeforce: Join me and thousands of others who have transformed their lives through Lifeforce's proactive and personalized approach to healthcare. Visit MyLifeforce.com today to start your membership and receive an exclusive $200 off. Brought to you by Indeed. Head to https://www.indeed.com/passionstruck, where you can receive a $75 credit to attract, interview, and hire in one place.   --► For information about advertisers and promo codes, go to: https://passionstruck.com/deals/  Like this show? Please leave us a review here -- even one sentence helps! Consider including your Twitter or Instagram handle so we can thank you personally! --► Prefer to watch this interview: https://youtu.be/jkdvwL30bzc  --► Subscribe to Our YouTube Channel Here: https://youtu.be/QYehiUuX7zs  Want to find your purpose in life? I provide my six simple steps to achieving it - passionstruck.com/5-simple-steps-to-find-your-passion-in-life/ Catch my interview with Marshall Goldsmith on How You Create an Earned Life: https://passionstruck.com/marshall-goldsmith-create-your-earned-life/  Watch the solo episode I did on the topic of Chronic Loneliness: https://youtu.be/aFDRk0kcM40  Want to hear my best interviews from 2023? Check out my interview with Seth Godin on the Song of Significance and my interview with Gretchen Rubin on Life in Five Senses. ===== FOLLOW ON THE SOCIALS ===== * Instagram: https://www.instagram.com/passion_struck_podcast * Facebook: https://www.facebook.com/johnrmiles.c0m  Learn more about John: https://johnrmiles.com/  Passion Struck is now on the AMFM247 broadcasting network every Monday and Friday from 5–6 PM. Step 1: Go to TuneIn, Apple Music (or any other app, mobile or computer) Step 2: Search for “AMFM247” Network

Coming up next on PassionStrike. When we think about the US healthcare system and why it is that we don't have the outcomes we want, we focus on a lot of things that are important. We focus on access to care, like insurance, we focus on things like cost of care. One of the things that I think goes unnoticed, but it's really important, is the time, right? If you've got a patient in front of you, it's really difficult to make a diagnosis to build trust in 15 minutes or 10 minutes. It's nearly impossible.

And yet for many doctors, that's what there's constrained to do. And you can imagine how challenging that might be. And so the question is, all right, well, if you allow doctors more time with patients, if they weren't rushed, would they develop better relationships, would they get better outcomes? Welcome to PassionStruck. Hi, I'm your host, John Armiles. And on the show, we decipher the secrets, tips, and guidance

of the world's most inspiring people and turn their wisdom into practical advice for you and those around you. Our mission is to help you unlock the power of intentionality so that you can become the best version of yourself. If you're new to the show, I offer advice and answer listener questions on Fridays. We have long-form interviews the rest of the week

with guest-ranging from astronauts to authors, CEOs, creators, innovators, scientists, military leaders, visionaries, and athletes. Now, let's go out there and become PassionStruck. Hello everyone and welcome back to episode 318 of PassionStruck. Right by Apple is one of their top most popular health podcasts. And thank you to all of you who come back weekly to listen and learn, how to live better, be better, and impact the world.

PassionStruck is now on syndicated radio on the AMFM 247 National Broadcast. Patches Monday and Friday from 5 to 6 p.m. links will be in the show notes. If you're new to the show, thank you so much for being here. You simply want to introduce this to a friend or a family member. We now have episodes starter packs, which are collections of our fans' favorite episodes, that we organize into convenient topics that give any new listener a great way to get acclimated to everything we do here on the show. Either go to Spotify or passionstruck.com slash starter packs to get started. In case you missed it, or learn the week I interviewed

Scott Miller, a Wall Street Journal best-selling author who has spent 25 years at Franklin Covey. Ten of them is the Chief Marketing Officer and now Executive Vice President of Thought Leadership. He is the author of the new book The Ultimate Guide to Great Mentorship, 13 Rolls to Making a True Impact. Please it out, and I wanted to say thank you for your ratings and reviews. And if you love today's episode, where that Scott Miller, I would so appreciate you giving us a five star review and sharing it with your friends and family.

I know we and our guests love to see comments from our listeners. In today's episode, we have a very special guest joining us, Dr. Bapu Jenna. Dr. Jenna is the Joseph P. Newhouse Professor of Healthcare Policy at Harvard Medical School and in turn is at Massachusetts General Hospital and a faculty research fellow

at the National Bureau of Economic Research. As one of the few physician economists in the world, Dr. Jenna brings a unique perspective understanding how health care works. The employees create of natural experiments to shed light on the intricacies of the system as showcased in his enlightening, Ted Med Talk in 2020, not only that, Dr. Jenna is the host of the Freakonomics MD podcast where he delves into the hidden side of healthcare

unraveling its mysteries. In his new book that launched earlier this week, Random Acts of Medicine, the hidden forces that sway doctors, impact patients, and shape our health, Dr. Jenna takes us on a captivating journey that combines behavioral science, health, and medicine through the lens of economic principles and big data insights. Together with Christopher Worshum, a critical peer doctor at Massachusetts General Hospital,

they explore the unexpected and predictable events that profoundly influence our health. From why kids born in the summer are more often diagnosed with ADHD and the flu. To the hidden dangers of marathons, even for non-runners, to the surprising similarities between surgeons and salesmen, and even the impact of cardiologists being at national conferences instead of being in the office. Dr. Jenna and Dr. Worshima uncover the hint truth that shape our well-being.

Through ingeniously defies and natural experience, they go beyond fascinating stories to reveal the invisible forces that shape our health outcomes. Such as, is there ever a good time to have a heart attack? How do we make decisions between veteran doctors and rookies? We really need the surgeries recommended by our doctors. These questions hold life-changing significance, and Dr. Jenna empowers us to navigate the complexities of medicine,

and understand how it can work even better. Join us in the Statq revoking conversation as Dr. Bapud Jenna shares his invaluable insights and helps us see beyond the white coat, giving us a deeper understanding of the intricate world of medicine and how it impacts all of us. Get ready to be inspired and enlightened.

Let's dive in. Thank you for choosing PassionStruck and choosing me to be your host and guide and your journey to creating an intentional life. Now, let that journey began. I am so excited today to welcome Dr. Bapu, Jenna, to Passion Struck. Welcome, Bapu. Thanks for having me. Bapu, you and I met through our mutual friend, Katie Milkman, and I wanted to ask, how

did you and Katie meet and have you collaborated on any research together? I wish I could write a paper worth there. She's too busy. I have a show called Freakonomics MD and Katie was a guest on it a while ago and I've been following her work for a while. She's done a lot of really fast any work in behavioral economics and cognitive psychology and decision making and I'm a medical doctor and economist and so I was particularly interested in her work that relates to medical issues and so she did a lot of work in the COVID-19 pandemic about how to get people vaccinated and nudging them into better behaviors. So that's how I got familiar with her work. I do find it intriguing, as you just mentioned, being an economist and a doctor that you pursue

to PhD while simultaneously going to medical school at University of Chicago, which had to be no small feat. What sparked your interest in this intersection of economics and medicine? So, John, it was totally random. I went to college at MIT and I studied biology. I knew I wanted to be a medical doctor. My mom was a doctor, but I also thought I wanted to do research because my dad was a researcher. And so I was working in a basic science lab in Boston, thinking I would do an MD and a PhD in something like cell biology or immunology, something like that. And when I visited the University of Chicago, this is now 20 years ago, the director of the program there just happened to look at my CV and said, oh, I'll put, I noticed you studied economics in addition to biology, which I didn't study economics because I wanted to be an economist.

I just thought it would be interesting to study. And he said to me, well, if you wanted to your PhD in economics, instead, we'd be happy to support you. And so literally that afternoon, I went over to the Econ department at Chicago and met with people and applied a week later. That summer, I was enrolled at the University of Chicago as an MBPHC student and eight years later, I walked out with my medical degree in my PhD in economics. So it was really totally random. Well, though it was random, which is what we're going to talk a lot about today is how

do these disciplines complement each other in your work? I think in a lot of ways, if you talk to somebody and ask them what economics means to them, you're probably going to get a whole range of answers. People will talk about stock markets, about interest rates, about housing prices. Very infrequently, I think people will talk about how economic shapes human behavior, though that is a lot of what economists spend a lot of their time trying to do is to understand what are the forces that affect our lead human beings to do the things that they do mostly with respect to economic decisions, right? How to invest in education, financial investments, but also investments in things like our health. So what's always attracted to me about the intersection between medicine economics is that think about the complexity of the behaviors and the factors that go into our health. There's all the things that we do to affect our health, whether it be good things like exercise or harmful things like smoking. And then there's all these other things that are inputs into our health that are somewhat in our control, but largely out of it.

Think about the medical care that you receive, what hospital you happen to live close to, who the doctor is that happens to provide your care, whether or not you have insurance. So there are all these factors that matter for your health that economists have a lot to say about. Good or bad, I don't know, but a lot to say about. Good or bad, I don't know, but a lot to say about. Today, we're gonna be talking a lot about this concept of natural experiments. And in your Ted Med Talk, you discuss using creative natural experiments

to understand how healthcare works. Can you explain this concept of natural experiments and how they contribute to your research? Sure. So think about when you go to the doctor and your doctor prescribes you a medication. Usually, the reason that they prescribe that medication is because there's some evidence out there that's been produced typically in a randomized controlled trial.

And what that means is you take a bunch of people, you give some of them the medication randomly, and then others get a different medication, maybe the standard of care, or maybe they get a placebo. And then you measure the house.com that you're interested in. It could be mortality, it could be cholesterol levels, blood pressure, whatever it is. That's how we generate evidence in medicine, and we use that to tell people what medications or treatments they should take. Now, that's not always possible to do these randomized experiments. And what economists and also epidemiologists have focused a lot on is this idea of natural experiments, the idea that

we are by chance because of nature sometimes exposed randomly to certain things and other times to other things. And studying that randomization that happens in the real world can allow us to say something about what causes what. So the book is all about these natural experiments in medicine and healthcare. These sort of chance occurrences that affect our lives and really interesting and profound ways things that are under the surface, but if we look, we can figure it out. And by the way, I think they also teach us something about what works and doesn't work and medicine in our health. I just wanted to ask a follow-on question to that. So if a cancer patient is getting a clinical trial

and they're in a stage one or stage two trial, are those typically randomized or in that case, is every patient actually getting the treatment protocol? It depends. So sometimes they're randomized, ideally they're randomized, but other times if the cancer is very rare, you might not have the opportunity to randomize people to one treatment versus another, maybe everybody will be on that treatment because this is their last hope and you want to take a shot at improving survival.

And so in those cases, the only thing that we have to compare their outcomes to is just historical population of patients with that same type of cancer. So we're not randomizing in that sense, but many large-scale oncology or cancer medicine trials are randomized. And that's the gold standard. Yeah, it's interesting to me. I've done a lot of podcasts over the past year on the use of psychedelics to help treat PTSD. They're now in stage two and stage three trials, but it would seem to me. You would know whether you're getting silo sivine or not. Yes.

The person who's in the trial. Yeah, that is a excellent example. One of the things that we try to do in randomized trials is to make sure that the people are quote unquote, blinded, both the patients and the doctors to the treatment that they're getting. Because if they're not blinded, meaning that they know what they're getting, that can generate this placebo effect

where maybe you change your behaviors. And let's say you're getting a medication that is designed to lower your cholesterol, but the medication has a side effect. And so if you're in a trial and you're randomized to get that medication and your stomach hurts after you take the pill where you might infer, I'm on the medication that's lowering my cholesterol. If you also change your behaviors knowing that, say, all right, well, I'm on a medication that's lowering my cholesterol.

Let me also try to eat healthier. If that happens, then in the trial, because the person wasn't really blinded, they knew what they were on. How do you pick up the effect of the drug versus the changes in their diet that they were making in terms of the effect on cholesterol? So this is a big problem in clinical trials. Today we're going to be discussing your brand new book, which launched this week, random acts of medicine.

And in it, you explore the hidden forces that impact doctors, patients, and our overall health. What inspired you and your co-author to delve into these topics and write this book? I think a few things. For the last 10 or 15 years, I've been generally interested in this idea of how chance occurrences, these sort of random things affect our health. And I was at the University of Chicago, as I mentioned earlier, one of my advisors was a guy named Steve Levit, who wrote the book Freakonomics with Stephen Dubner. And so I always had that bug in me, interested in using big data, creative questions, and economics, but because of my medical breakdown as a doctor,

I wanted to try to apply those questions to medicine. And I thought it was right for it because medicine is an area where the decisions are so complex and the impacts on our lives are enormous, I think that we carry about first is our health and well-being. And so it was that sort of intersection that got me interested in this idea.

And I've always been curious about asking questions that aren't so niche, that only a particular type of person, particular type of doctor might be interested in. I wanna work on questions that everybody can engage with and say, all right, I get it. I don't have to have any interaction with medicine, maybe even the medical system, but I get what this guy's talking about,

and it's interesting to me. So that's always been a driver of the type of work that I do, and that's what I've been working on for the last 10 years. And so Chris Worship and I, Chris is a critical care doctor at Mass General Hospital in Boston. We decided a couple years ago to put these ideas down on paper. Well, I found it to be a very fun and intriguing read all along. It's not a book like I typically get to read, so it was very enjoyable and I highly recommend it to the listener if they want a really deep dive into some of these facts that you bring up, which we're going to discuss today. And one of the first ones that you mentioned, which is a great example of this randomness,

was studies that were done by Janet Curry and Reed Walker on the connection between the introduction of the easy pass and improve newborn health outcomes in Pennsylvania, New Jersey. And I was hoping you could elaborate on that relationship and how reduced congestion, et cetera, led to healthier newborns. Yeah, it's a beautiful idea. And what they were trying to do is what a lot of people are interested in how the environment, so let's say air quality affects your health. And with the forest fires that are happening right now, it's front and center and people's minds

and their hearts and lungs literally. But it's a difficult question to study because the natural instinct would be to say let's compare areas with higher or lower air quality and look at how the outcomes in those areas. That's not a good analysis to do because people who live in areas with poorer air quality are different than people who live in areas with better air quality for a lot of different reasons. And you can't necessarily infer that any differences in health outcomes, maybe let's say asthma or lung disease, is because of the air quality.

It might be, but it could be because of all the other factors that differ between those two groups. And what economists have tried to do over the last several years is come up with these interesting natural experiments where you can try to get at the causal effect of pollution on health. And one of the examples that we outlined in the book is this easy past study where basically Janet Curry and her colleague looked at the differential introduction of easy past that

basically reduced congestion and toll booths in different parts of the country in different points in time. And when cars are at the toll booth, they're stalling, they're emitting pollutants into the air, those pollutants have this local effect on air quality and potentially on health. And what happened with easy pass was that congestion stopped. Cars just went right through the toll booth

because they had the easy pass technology. And as a result, what they can show is that pollutants were reduced. And then the next thing is that they showed that there's beneficial impacts on moms and infants. So it's really an elegant natural experiment to show how something like easy pass, which you probably never thought of as being a pollution-reducing technology that could improve health. We're thought about it for convenience. Has this unintended effect on our health, which is

interesting. But it also serves as a vehicle to understand what is the causal effect of pollution on health using easy passes and natural experiment. Well, the other one along these same lines that I thought was really interesting as well was how marathons can impact health outcomes. And as a person who's run several of these, I know they take over major elements of city's corridors if you just look at where you live in Boston and what the Boston Marathon must do to disrupt travel and traffic when that happens. What did the study show about these marathons?

First of all, John, you run marathons and I'd run away from marathon. So we lived different lives. So a few years ago, my wife was running this race and it started in one part of Boston, went through an area called Beacon Hill where the hospital, that a workout called Mass General Hospital is located

and then went back to that same area that started. And she asked me to watch her on the race route because it was the first time she ran this kind of race. And so I was driving on the main thoroughfare in Boston trying to park at Mass General to watch her on the race route, but I couldn't get to the hospital because the roads were blocked. So hours later, I see her at home and I explained to her what happened. And she just makes this all-fan comment, well, gee, I wonder what happened to everybody

that needed to get to the hospital that day. And that was just an offhand comment that she made. Fast forward several months later, we assembled data from 10 different cities over 10 years. We look at when these cities host marathons, the exact dates, and we look in the days before and after those marathons are held, and we looked at older Americans, and these are Medicare beneficiaries, people who are typically above the age of 65. And we look at the likelihood that someone, an older American who has a heart attack, or a cardiac arrest, which is when your heart stops, we look at the likelihood that they die

from that event, and how that varies depending on whether or not they had that event on a marathon day versus any surrounding day before or after. And what is that the mortality rate for these individuals goes up on the days that cities host marathons compared to the surrounding days. And then also if you look in the surrounding areas in that let's say in the other suburbs in that city that were not directly affected by the marathon, there is no quote unquote marathon day effect. The more tidies flat. And we went one step further and got data from ambulance companies from a handful of these cities. And what you can see

is that the ambulance transport times go up on the mornings that the marathons are being held, but then they return back to normal in the evenings because there's no delays. So this is a story about how very small delays in care are sometimes large delays in care from a marathon affects the mortality rate of people, not who are running the marathon, but people who literally live on the marathon route.

They are more likely to die because of those road closures. As I read about that, it got me into thinking about where I live here in the Tampa Bay Area, and all the parades that we have, the triathlons, even things like we just went through with the fireworks display and how many people congregate on a certain area and tie a traffic and any one of those things could lead to the same outcome that you're talking about. Yeah, let me give you a sort of a fact.

It's a solemn fact, but more people die from road closures in marathons than died in the Boston Marathon bombings, right? The bombings were extraordinarily salient in people's minds, particularly here in Boston, Massachusetts. But this other effect, which is road closures, those unnoticed, we don't really think about it. But as you just said, it affects not just a marathon, but a Taylor Swift concert.

There was huge delays out here a few weeks ago when she was here, July 4th, celebrations, anything where there's this large aggregation of people could have this effect. On a side note to Taylor Swift, I just read yesterday that she may have the first billion dollar tour of any performer in history. Wow. Okay.

We won't put in the ledger any lives loss. I'm bit right. It's all benefits. Yeah, I know she did three dates here in Tampa and each one was sold out. So I imagine to your point, that probably tied up a lot of traffic. I got to this. There's got to be a Taylor Swift natural experiment. I haven't thought about it yet, but I don't know, like glitter allergies or something like

that. There's something out there. I just got to think more of it. It could be on this tour. How many times she's attracting rain to dress her while she's out there on stage. Yeah. Well, in the book, you write that medicine is messy, complicated, and uncertain. How do opportunities for randomness expose the hidden factors in healthcare that send to otherwise similar people down very different paths of care. Good question. Let me actually give you an analogy related to the marathon study because I think maybe it helps illuminate what we mean by that and we said that statement.

The marathon study was fun because it showed this interesting finding and that's honestly why I was very attracted to it. But as we were writing the book and trying to think about well, what is the marathon study teach us about medicine and our health? But Chris and I were struck with was when you think about your health and you think about medicine, one of the fundamental questions we always have to answer is, how quickly do we need to act? Right? You're in the hospital. Let's say you're a doctor or nurse and someone's having difficulty breathing. Do you need to call in help immediately or do you wait in half an hour or would you wait to the morning or You're a parent and you've got a three-year-old at home who's got a fever at night and a headache

You have to call the pediatrician right then or can you wait into the morning? Right that question of how quickly we need to act is so pervasive and has such important consequences in medicine, probably more so than in any other field that we operate in, except for maybe like law enforcement or defense. That's also where an area where it probably matters a lot. But in medicine, it certainly does. But you can never conduct a randomized trial, which would say, all right, we've got a thousand people with chest pain, half of you go to the emergency department immediately.

And the other half, you just hang out at home for about 30 minutes to an hour. Let's see what happens. Do we need to act? And that would be unethical to do that sort of thing. But the marathons offer this natural experiment where we can see because nature is essentially randomized some people with chest pain to these delays and care. And others not to really say, all right, does a few minutes matter. In the case of chest pain and cardiac arrest, it very much does. But you could take this

same experiment and apply it to headaches, to difficulty breathing, to gastrointestinal bleeding, any sort of medical condition where you're not sure how quickly you need to act. And I say complexity because these medical decisions are complex. You've got to weigh a lot of factors aside what to do and when to do it. But these sorts of experiments can help illuminate when you need to act, how quickly do you need to do something? Yeah, and the flip side of this, my partner practices primary care. And one of the things she complains about is that the doctor's offices are being given so little money

to do annual checkups that it's causing more and more doctors and nurse practitioners to have to spend a reduced amount of time with each patient, especially when you consider the churting that you all have to do as well. How do you think things like that impact the medical care that doctors are able to give? And there's probably a randomness to it because I'm sure some patients you've got to give more time to, which causes you to give less time to others. This is a really important idea and I think you had a really beautiful insight there. So I think the broad question

is how much does time matter in medicine? When we think about the US healthcare system and why it is that we don't have the outcomes we want, we focus on a lot of things that are important. We focus on access to care like insurance, we focus on things like cost of care. One of the things that I think goes unnoticed, but it's really important is the time, right? If you've got a patient in front of you, it's really difficult to make a diagnosis to build trust in 15 minutes or 10 minutes. It's nearly impossible. And yet for many doctors, that's what there's constrained to do. And you can imagine how challenging that might be. And so the question is, all right, well, if you allow doctors more time with

patients, if they weren't rushed, would they develop better relationships, would they get better outcomes? You could study that in a few ways. One is you could do a randomized trial where you allow doctors to have more time with some patients randomly and other patients. You don't allow that increased time and look at outcomes. You could do that, but it would be hard to do. The other is you could just look at situations where doctors spend more time with patients and doctors spend less time with patients. That's a problematic study because guess what?

If a doctor is spending one hour with a patient and you have quote unquote, worse health outcomes later, well, that's not causal. There's a reason they were spending an hour with that patient. Something was going on wrong that led them to spend an hour there. So it's not that the time of an hour led to worse outcomes. Obviously, that wouldn't be true. So the most clever thing that I've seen people do is they actually rely on something that your

partner probably feels very much. Sometimes you go into the office and you see a patient who's got a lot going on and you didn't plan for that in your day. And as a result of spending the time that you need to spend appropriately, everything else in the day gets backlogged and has to be rushed. And so what people have tried to do is say, can we use this natural experiment where the time I as a physician have what the patient in front of me, is impacted by how far delayed I am from what's happened earlier in the day, either because of a traffic jam or because the patients before me were more complicated and so that required me to just be more and more delayed. So when you use that sort of natural experiment, you do see that time does matter. So when doctors have less time with patients in this sort of random

way, they do make different decisions. They're more likely to prescribe things like antibiotics. They're more likely to prescribe things like opioids, all because they make decisions quickly when they would make different decisions if they just had a little bit more time. So that's the way you could get at that question causally, but I think it matters a lot. time. So that's the way you could get at that question causally, but I think it matters a lot. Yeah, I've seen firsthand most of my life, I was going to a primary care physician in the private sector and not going to the VA, but over the past four to five years, I've been using the VA more extensively. And when I have my appointment on the outside, it was 15 to 20 minutes long, whereas with the VA, it's a solid

30 to 45 minutes and you never feel rushed. And it just gives you a sense of when you take the paying aspect out of it, how different the care tends to be. And I think it's extremely important because when you have that extra time with a person, you're going to ask more questions, which may unveil different topics that could lead to the doctor finding something that otherwise would have never been approached. So I just thought it was an interesting thing to bring up with you. Yeah, I agree. My mom used to work in the VA. I mentioned she was a doctor. She worked in the VA for many years treating people with a major head trauma. And that was one of the things she appreciated, probably different VA's or different

in things of change over time, but she always felt that she had the time to be able to spend with patients. And I don't think that everybody feels that way. So when you have that, it's a valuable thing. Yes. Well, I'm going to go from this topic to presidents. And you write in the book, and I noticed this too, that it wasn't too far into President Obama's presidency before we all noticed that he had a subtle

change and was going gray. And I often wondered myself if the burden of the presidency causes a person to age faster, and it turns out that former presidents live shorter lives compared to their runner-ups. And I thought this topic would be interesting for the listeners to understand how you did the experiment to prove it. Yeah. What you just said is exactly the same thing that went through our heads years ago. So Obama, also Clinton, they seem to age when they're in office. Trump seems to get more and more vigorous, but on the president, certainly Obama and Clinton, they appear to age. And being present obviously is a stressful job. And in more recent years, we've seen candidates and presidents like President

Biden, who are on the older side of things. And so it's a reasonable question to ask, what is the impact of being a world leader, president or prime minister, whatever it is on your health? It's hard to study for the reasons we just described. If you compare presidents or prime ministers to the general population, they live longer. No, there's no surprise. The economics, the education, everything is different about a president or a world leader than the general population.

So you shouldn't infer from that that being president leads you to live longer. That would be incorrect because the groups of the people are different. So how do you get at this question and a cause away? Well, what we thought is could we look at world leaders and compare them to runners up in the elections under the idea that both groups come from similarly educated or wealthy strata of the population. And so the life expectancy that we might expect for both groups would be pretty similar. And we can see that we show that is true. But yet one group almost by chance, I mean in our countries like 50-50 basically, 50-50 chance that one person is going to be present and the other person

is not. And then following the life expectancies of those two groups over time and what we found is that those people who happen again by chance to be elected to world leader or leader of our country, they live about two and a half fewer years than runners up. So it does speak to the stress of the job, maybe the health behaviors, lifestyle behaviors of the job that might shorten the longevity. Well, I guess I could lead to why his wife does not want to run for president. Yes, she's seen it first.

Well, interestingly enough, I have a really good friend of mine who played on the Notre Dame football team from 85 to through when they won the national championship. And he was supposed to be one of the top draft to people in the NFL, but he ended up getting hurt. And it's interesting. Now, every single year, he has somewhere between 20 and 25 of his teammates come and visit him. And almost everyone of those players played in the NFL. And he tells me now when he looks back upon it, he's so glad that he didn't make that jump because about a quarter of them have unfortunately CTE. But the other ones all have knee issues, hip issues, shoulder issues, other things like that. Similar to the president, she did an experiment along these lines to try to quantify the

effect of life spans of playing Profitball. I was asking what did that experiment show? That was a really interesting one. It was an idea that a colleague of mine, a a theme of inclamonics, who's also the physician economist, he's at University of Pennsylvania. He had this idea and I was lucky to be owned for the ride, but basically the question that we were interested in, it was what is the health impact of playing professional football because of the reasons that you just described, right?

There's a lot of physical trauma that athletes endure. There's lifestyle factors that are also probably relevant for NFL athletes. If you look at NFL players and you compare them to the general population, just like with Presidents, NFL players actually live longer than the general population. And perhaps that's not surprising because think about what it took for your buddy to be able to do what he did physically, right? He's built differently than I and others are built. Those features of his body will probably correlate positively with longevity.

So it's not surprising that NFL players live longer than the general population. But the right question is the question that your buddy actually posed, which is, wow, look at all these people who played in the NFL. And I might have been able to play in the NFL, but I didn't. How would my life have looked if I played in the NFL? And that's the experiment that we took. You may remember in late 1980s, 1987 from Recall correctly, there's this player strike and the movie of the replacements with Keanu Reeves is based on this. So the Lee goes on strike, few games, what happens is that the actual NFL players are not playing they're replaced by what are called the replacements in the Kenneries movie.

And these are people who had a lot of football experience, maybe even some very limited professional football experience, but were perhaps almost good enough to play in the NFL, but didn't quite make the cut. And so they actually serve as a better control group for NFL players than the general population. And if you compare NFL athletes to the replacement players, which we were able to do because we got the rosters of all these teams back in the 80s, and we matched it to mortality data for both the NFL players and the replacements. What is that the replacement players live a slightly longer lives than the NFL players,

but definitely the NFL athletes live slightly shorter lives than the replacements. And you do see higher rates of things like brain injury, higher rates of things like death to the injuries, which we think of like maybe driving or alcohol or drug related deaths. So I think your friend is on to something that the trajectory that being an NFL athlete puts you on compared to the trajectory that you as someone who might

have played in the NFL would have gone down. Is it a little bit different? Well, I can't leave the topic of the NFL without talking about Tom Brady since you bring him up in the book. And I'm a huge Michigan fan. So I know many of us Michigan fans wonder why he didn't get to play more, but you particularly cover his red shirt ear and the impact that it potentially had on as long term performance in the NFL. What did you discover? So interesting. I don't watch a lot of football,

but obviously you spend a lot of time in New England, you learn a lot about Tom Brady. And so Tom Brady spent an extra year at Michigan. And the question is, was his performance later in life attributable to some extent to the additional year? And we draw that analogy to something that we see in medicine and health. If you look at kids who are born

in August versus September, in many states in our country, including Massachusetts, if you're born in August, you can enter kindergarten, let's say, that year. But if you're born in September, you have to wait a year to enter kindergarten, because September one is the cutoff for school entry and kindergarten in our state. In many states, and every state has a cutoff by the way. And so what you observe is that those September born kids in any class, they're a year older than the August born kids. So that made us think about Tom Brady. Tom Brady was essentially a year older than a lot of his colleagues and how might that

have affected his performance. But this is a book about health, not about football, so the analogous question is, well, if you look at kids who are born in August, how do their lives differ from a health perspective than kids who are born in September, in states that have the September one cut off? And what we see is very striking finding that

kids with August birthdays are quite a bit more likely to be diagnosed with ADHD and treated medically for that condition compared to kids born in September. And the reason why is that the August born kids, they're the youngest kids in their class. And so when they're a little bit less attentive or a little bit more active compared to their peers, parents, teachers, ultimately a doctor might say, well, okay, maybe this child has ADHD. As opposed to, maybe this child is just young for their grade. They haven't had that year to mature like the September born kids.

So this is a broader, quite, it impacts a lot of people because ADHD is quite commonly diagnosed. A lot of people have kids with summer birthdays, so I think it's relevant for that. But in the book, we also talk about what it means about the idea of diagnosis under diagnosis and over diagnosis in general. And why that diagnosis itself is very challenging to make. Well, you bring up two scientists who I have always wanted to have on this podcast. And so far, they have both said no to me. So I will keep trying. One of them is Nobel Prize winning economist Richard Thaler and the other one is Harvard Legal Scholar cast

Sustine who write about nudges and sludge. Can you apply their work to understanding the financial cost of healthcare? The other thing I would want you to touch on is through that lens, how do you deal with difficult to measure non-direct costs that can get in the way of getting optimal health care? Good question. So, John, early when I spoke about health care, we think about things like financial costs. It's an obvious concern for a lot of people. It can be a barrier. But one thing that we don't

talk about are either the non-financial costs or financial costs that are not directly observed by us. So what I mean by that, now my own hospital, you gotta spend $10 or more to park. So it wouldn't be surprising that some people might not go to their primary care visit because they have to spend $11 to park at the hospital. And New York might even be more, right? That's not a medical cost per se,

but it is a cost to access the medical system. In one of the chapters in our book, we talk about this experience that I had with our, one of our kids, who's born in August, and we took him to the pediatrician, or I took him to the pediatrician in August for his three year checkup, which is when kids get checkups around their birthday. And as I'm walking out of the office, the nurse says to me, come back in a few weeks, because we'll have the flu shot ready for him. And I said, wow, had my son been born just two or three weeks later, he would have gotten the flu shot in the office that day. But instead, I had to come back. And it took hours to try to reschedule an appointment and come back to get that flu shot.

And that really highlighted in my mind, wow, we spent a lot of time thinking about the financial cost of care, but this is a very significant barrier, just getting here in the first place. And Thaler and Sunstein and others have talked about nudges and sludge, like I would call this sludge. It's an artifact of our system that doesn't need to be there, but that makes it harder for us to do what we think

is the right thing for a young child, which is to get the influence of vaccine. And so, what we talk about in the book is like, all right, well, we just need to make it easier. In the pandemic, we did find ways to make it easier for kids to get vaccinated, places like CVS and Walgreens, other pharmacies. They can do vaccinations.

Historically, they haven't done them in younger kids, but they're much more available geographically. The hours are much better. The scheduling is much easier. You can get a young child vaccinated at a clinic, right? That's a way to just fix that sludge problem. And there's lots of other examples of like that in healthcare where there is a barrier, which is not financial, but which is something that is more structural

where I would call that sludge, like just in the words of a cast and Richard Daler. Well, I believe there definitely is too much sludge in this system. And one person you might wanna bring on your own podcast is Amy Finkelstein, not sure if you know her from MIT, but I just interviewed her about her thoughts on how to overhaul healthcare insurance. And I think she would agree that there's

too much sludge in the system. Yeah, yeah, totally agreed. Well, you write about cardiologist a couple times in the book. I almost felt like you were picking on them there for a second. But it's fascinating to discover that cardiac patients have better outcome when the country's most distinguished cardiologists are actually out of town at national conferences and not in the office. Can you give some of your insights because this is something that surprised me? Sure, by the way, if you can see me, I'm Indian,

if you can hear me, my name is Bob, who's so I'm Indian, and there's a lot of Indian cardiologists. So I feel like I'm like 10% cardiologist, so I feel like I can get away with what I do. But John, this is based on a story that happened to me when I was in residency. This is when doctors train after medical school and I happened to be in the hospital

around the times that one of these large cardiology conventions are held. There's two big ones called the American College of Cardiology and the other one is called the American Heart Association annual meeting. And it felt to me like the hospital staffing was different. And I don't know if it was to be honest, but it just felt that way. And I thought, well, could it be the case that the doctors who normally would be at the hospital seeing patients, providing care, some of them are away at these meetings, because these are important means to learn, to present research, particularly at a large academic medical

center, like I work that. And so what we did is we looked to see if you've got an acute cardiac condition, and you happen to have that and be hospitalized during the dates of one of these meetings compared to the surrounding weeks before or after, are your outcomes any different? Perhaps because the staffing is different, the levels or the types of doctors who remain behind are different. And what we found is that the outcomes actually do differ, but not in a way that I would have expected. I would have expected John that we would see worse outcomes during the dates of these meetings,

because staffing would be lower. But in fact, what we see is better outcomes. So to give you some numbers, if you look at people who have a cardiac arrest in the elderly population, 70% of those individuals die within 30 days of having that arrest, if they make it to the hospital live. If you happen to have a cardiac If they make it to the hospital alive, if you happen to have a cardiac arrest

and make it to the hospital on the dates of one of these meetings, your mortality is 60%. So it's an enormous reduction. It's way more impactful than the impact of lipitor or aspirin or blood pressure medications or stenting. All those things combined don't generate this same magnitude of benefit. So it was something about the types of doctors and the way that they provide care

during the meeting dates versus the non-meeting dates that was really impactful for mortality. The other data point that we found was that a certain type of procedure happened much less often during those meeting dates. And so it spoke to me about the idea that sometimes in medicine, when we intervene, we do so in a way that is improving health outcomes. But other times, we might do more than we need to do. This idea that people have talked about called less is more. Sometimes doing less might be more for a patient.

And here's an example where that might be the case that if we did less intensive care, which appears to be the case during the dates of these meetings, outcomes could improve. Now, that's always true, not always true, but it could be sometimes true. Well, that leads me to wonder what qualities make a good doctor and how do these qualities differ

from what we traditionally consider as credentials? I'll tell you what, maybe a doctor economist. No, I don't know. Great question. And we look a lot, we've done a lot of research on this topic. We were lucky to have data on the characteristics of many doctors and almost close to 800,000 doctors in the US. And we could link that information about their outcomes. And so we've looked at things like how your doctor's experience matters. So if your doctor is older or younger, how do outcomes vary or if your doctor is a man or a woman or trained at a foreign medical school versus trained in this country. Maybe I'll just highlight one of those findings, the experienced one because I think a lot of people

probably have preconceived notions of what an experienced doctor might do for them. So if you walk into a room and you see a doctor with gray hair versus all dark hair like you, John, who's the doctor that you want? I think a lot of people would say I would prefer a doctor with the gray hair because that doctor's more experienced. They've just seen a lot more things. They'd get me better outcomes. And sometimes that is true.

So for example, in surgery, we do see that the older doctors tend to have better outcomes for their patients. But for general medical conditions, like an ammonia or a problem with your heart or problem with your kidney, sort of general medical conditions, what we actually see is that the doctors who get the best outcomes in the hospital are the doctors who are just a few years out of their training. They seem to do better than the doctors who get the best outcomes in the hospital are the doctors who are just a few years out of their training.

They seem to do better than the doctors who are 10 or 15 years out. And the reason we think that's happening is because there's a trade-off, the older and more experienced you are, the more that you've seen. And that's obviously very valuable. But it's also the case that you know more about

contemporaneous medical knowledge, medical technology when you're right out of training because you spend 80 hours or more a week in the hospital that's all you're doing. You're learning about what's the latest, greatest medical technology. And if you look at the doctors who come right out of residency, they're just more familiar with what's up to date. Whereas the older doctors, it's harder for them to do that because they've spent more their time just seeing patients in their practice. And so they rely more

on experience. And so the experience outcomes profile is quite interesting because it's not what I would expect it. I think the sweet spot is probably someone in the first five to 10 years out of residency. And the other thing I'll say is the volume matters. So if you look at an older doctor who sees a lot of patients, that tends to help, that tends to preserve their skill. It's really the older doctors who see very few patients where I think there'd be a little bit more concern.

I've always heard if you're going in for a major surgery, let's say you had to get the Whipple surgery and you have pancreatic cancer that you always want to go to doctors who have performed this surgery hundreds if not thousands and thousands of time because of the repetition and knowing the complications that will come up in it. So I do think there's elements to that. I also see where you're going where younger doctor having more access to more recent treatment protocols or science that's out there, where I'm not saying that an older doctor wouldn't be looking at those studies, but they might not

be as well studied on them because of when they went to medical school. Exactly. I think that's right. Yeah, it's not, certainly not to say that older doctors aren't incredible in a lot of ways. They certainly are. And they have a lot of benefits. And I think the sweet spot is to be able to build that experience, but also be able to rely on current medical knowledge. And the future of medicine is going to be partly trying to make sure that we can leverage

both when doctors have experience, also making sure that they have access to that medical knowledge that's constantly evolving. One other thing that you went into along these lines of observing doctors is that they perform better when being observed, and that raises questions about the impact of external monitoring on the decision making that goes on. Can you discuss this presence of oversight and the effects that it has on doctors and the life or death decisions that they make? Yeah, so we had a really fun chapter. It's called Big Brother is watching. And what we showed is that there is this organization in medicine and healthcare that accretates hospitals. They visit hospitals every few years. These are unannounced inspections.

They last about a week. And they go through the hospital and make sure all the processes are in place to ensure safe and effective care. That's what they do. But these inspections, these visits can be very stressful. There's inspections in all sorts of industries like in airlines and food and restaurant service. There's always inspections and they're always stressful. And the question we had as well during the period of inspection when there is this additional oversight might outcomes going on, outcomes could actually get worse because you're throwing off your game. There's certain things that you're typically used to doing. And now you're asked to do something differently.

That might be your recipe for disaster. What we find actually that it seems to actually improve outcomes, that oversight in that short period of time where people are being monitored, someone is checking on their behavior, the outcome seem to improve. And it could be because people are doing what they're being monitored to do. For example, have better hand hygiene, document better, implement protocols better, or it could just be more generalized in terms of the phenomenon, which is someone's watching me.

I'm going to be spending more time thinking about the clinical issues here, focusing on clinical care and maybe less distracted by other things that I normally might be distracted by. What's in the news? What's the reason sporting events that's happening? That sort of thing. So we do find it matters, right? We estimate that tens of thousands of Americans could be saved each year if the same behaviors

that occurred during the date of these inspections were happening across the entire year. Now, the solution is not to have inspections all year round. That would be very stressful for medical professionals, but it's to say, all right, well, what is it that they're doing differently? How do we measure that in a, maybe, an anthropologic way? And then how do we replicate that? The thought experiment for me. Okay, and another interesting topic that you get into is when should patients push back on doctor's opinions, especially as patients try to navigate subconscious biases and mental shortcuts that may influence the medical decisions at the bedside? I think always it's interesting.

In medicine, we talk about personalized decision making and patient-centered care. That's a mantra in medicine that a lot of people describe to and they say it's important. But when push comes to shove, we don't see it as often. I think in medicine is in a lot of ways also very paternalistic. In that 15-minute encounter that we just spoke about, it's really difficult to get to the bottom of what is it is that makes a patient afraid or what is it that they prioritize. That sort of thing takes time. So I think the bedrock of all of this care is time spent between a clinician and a patient. I think a good doctor always realize that when a person is asking them questions, maybe

even disagreeing with the assessment that is coming from a good place, right? It's their health that matters. And our job as a doctor is to help them lead the best possible life. So I'm always an advocate for, I don't know the word, pushing doctors, but certainly engaging in a discussion about your health absolutely has to happen. And it's the job of the doctor to make sure that there's a time to do that. Okay, Bapu. And the last question I would ask is, what would you hope a reader or listener would take away from your book? First of all, I wanted to be entertaining. I enjoy what I do. I love it.

I look forward to it. So when someone reads this book, I want them to feel the same. That this is really interesting. And I had a fun time reading it. And I learned something from it. The other thing that we talk about in the book, it's an undercurrent is in medicine and in everything that we do in life, creativity is so important, but it's underappreciated. So we are in business or we're in opening a restaurant.

We need to have good ideas about how to develop products, how to solve problems. In this book, we try to walk the reader through that creative process and say, look, all right, if you see this pattern, what ideas come to mind? How would you think about the world differently? So I hope people leave the book with a little bit more curiosity about health and their lives and a spark of creativity. That's my hope. Okay, and the last thing I was hoping you could touch on is one, if you could tell the audience

about your podcast because I listened to a few of the episodes myself and I found them fascinating, and then where can people go if they want to learn everything about you? Oh, okay. Well, the podcast is called Freakonomics MD. It's part of the Freakonomics Radio Network. The book is called Freakonomics MD. It's part of the Freakonomics Radio Network. The book is called Random Axe of Medicine. If you're interested in the book and this kind of work, we also have a substack called Random Axe of Medicine that we just launched. And the goal is to get readers who

are interested in the material in the book to engage with this, the throughout ideas. There's a lot of stuff that we talked about in the book that has others related and interesting findings. And there's a bunch of stuff that never made it into the book. has others related and interesting findings. And there's a bunch of that never made it into the book. So we'll be writing about that over the course of the next year or so. And that'd be probably the best way to stay engaged. Okay. Well, Bapu, thank you so much for joining us on the podcast. And congratulations on the launch of this fascinating book. Thank you so much, Jenna. Appreciate it.

I thoroughly enjoyed that interview with Dr. Bapu, Jenna, and I wanted to thank Bapu, Katie Melkman, and Penguin Random House for having him appear on the show today. Links to all things Bapu will be in the show notes at passionstruck.com. Please use our website links if you purchase any of the books from the guests that we feature here on the show. All proceeds go to supporting this show. Videos are on YouTube at both John Ar. Miles and PassionStruck Clips. I'm on the AMFM 247 National Broadcast, where you can listen to the show every Monday and

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Does a thought experiment? What if, maybe just for an hour, just for a day, or a week, we just decided to feel neutral or even positive about our own voice? What changes might we see in our life in that week? In how we speak up, in how much we trust our ideas, in how much we go from thought to breath to speaking, rather than letting our throat get in the way to sort of censor us? But if you felt absolutely neutral about your voice? The fee for the show is that you share it with family or friends when you find something useful or interesting. If you know someone who's really interested in today's episode, then please share it with those that you love and care about.

In the meantime, do your best to apply what you hear on the show so that you can live what you listen. And until next time, go out there and become Ash and Straw.