Bad Medicine, Part 3: Death by Diagnosis (Rebroadcast)

Podcast Summary

• The Complex Causes of the Prescription Opioid Crisis: The prescription opioid crisis in the US is a tragic consequence of over-prescription, driven by a belief in magic pills, industrialization of healthcare, and lack of measurement of performance and outcomes.

  The prescription opioid crisis in the United States is a result of a complex interplay between good intentions, greed, and the influence of consumerism on the doctor-patient relationship. This crisis, which has led to more deaths annually than traffic accidents, is a tragic consequence of the over-prescription of legal drugs meant to alleviate pain. The rise in prescription opioid use, which has increased by about 300-400% since the year 2000, is due in part to the belief in the power of a magic pill to solve problems, even as the healthcare system has become increasingly industrialized. Doctors, who once focused solely on the health of their patients, now operate in a system where the same two players are influenced by a vast industry of people buying, selling, and trading healthcare services. The lack of measurement of healthcare performance and outcomes for most patients further complicates the situation. This final episode of the Bad Medicine series on Freakonomics Radio explores this issue and raises questions about the balance of power in the doctor-patient relationship.

• Mistakes in Medicine: Reversing Old Practices and Navigating New Challenges: Medicine's progress is not without errors. Old practices are sometimes reversed, clinical trials focus on ideal patients, subjective pain can lead to opioid overprescription, and proper application and recognition of individual needs are crucial for effective treatment.

  Medicine, despite its advancements, is not without its mistakes. Some practices, like drilling holes in skulls, have been reversed as better science emerges. Clinical trials often focus on ideal patients, leaving real-world treatment decisions uninformed. Pain, a common reason for seeking medical help, is subjective and can lead to overprescription of opioids, contributing to rising mortality rates. While opioids are effective in certain situations, their overuse in chronic pain has become a problem. Medicine's effectiveness relies on proper application and recognition of individual needs.

• Balancing appropriate opioid use and minimizing overuse in pain management: Recognizing the complexities of pain management, it's crucial to work towards a more holistic approach that considers social, psychological, and pharmacological aspects.

  Effective pain management involves balancing the appropriate use of opioids with minimizing overuse. This is a complex issue with many contributing factors, including the lack of objective measures for pain assessment. Weyloo suggests that over-medication and under-medication should not be viewed as opposing extremes, but rather as interconnected issues. The American Medical Association's recent decision to remove pain as a vital sign may not be the solution. Pain management emerged as a recognized medical practice in the 1960s, but the shift towards cost containment and the rise of direct-to-consumer drug marketing led to a reliance on drugs as the quickest and cheapest solution. This, in turn, gave consumers more power in the medical realm, which has influenced clinical decision-making. However, this consumer-driven approach can lead to demand for risky painkillers, as seen with the case of OxyContin. It's essential to recognize the complexities of pain management and work towards a more holistic approach that considers the social, psychological, and pharmacological aspects of pain.

• Perverse Incentives in Patient Satisfaction: Focusing too much on patient satisfaction scores can lead to unnecessary treatments and adverse effects, prioritize improving feedback loop and measuring outcomes instead.

  The current focus on patient satisfaction in healthcare can lead to perverse incentives, potentially resulting in doctors prioritizing patient demands over their judgement and wellbeing. This consumerist culture in healthcare, driven by patient satisfaction scores, can lead to doctors feeling crushed by increasing overhead, declining pay, and other pressures, and may result in unnecessary treatments and adverse effects. However, what's truly important for patients is not the doctor's patient satisfaction score, but their judgement, skill, and empathy. Improving the feedback loop and measuring the outcomes of healthcare interventions are crucial steps towards medical reform. Despite the complexities and challenges, it's essential to prioritize these areas to ensure the best possible patient care.

• Medical errors as the third leading cause of death: Despite being the third leading cause of death, medical errors often go unreported due to billing code system and systemic issues in the US healthcare system.

  Medical errors are the third leading cause of death in the US, accounting for approximately 10% of deaths annually. However, these errors rarely make it onto death certificates due to the use of a billing code system for recording causes of death. Instead, medical errors, communication breakdowns, overdoses, and other complications often go unreported. The complexity and over-reliance on healthcare in the US, driven by both supply and demand from our healthcare insurance system, contribute to the high number of medical errors. It's important to note that most doctors are dedicated to providing quality care, but the systemic issues need to be addressed to prevent unnecessary deaths.

• Medical errors: 250,000 deaths per year: Medical errors cause 250,000 deaths annually, with errors of diagnosis and commission being the main categories. Reforms are needed to accurately track these errors.

  Medical errors are a significant cause of death in the United States, with an estimated 250,000 people dying each year due to medical mistakes. However, these errors are often hidden in the data due to how causes of death are categorized. Researchers like Marty McCarry are pushing for reforms to require doctors to specifically indicate if a medical error was involved when filling out a death certificate. Medical errors come in two main categories: errors of diagnosis and errors of commission. Errors of commission include mistakes like surgery on the wrong leg or administering the wrong medication due to allergies or incorrect dosages. Errors of diagnosis, on the other hand, can lead to longer-term problems if they result in delayed or incorrect diagnoses. It's important to note that individual decisions are not the only cause of diagnostic errors, as most thinking on the issue points to systemic problems that lead to these errors.

• Measuring healthcare effectiveness with insufficient data: Doctors need incentives to focus on preventive care and maintaining patient health, and accurate data collection is crucial to determine treatment effectiveness.

  The healthcare system lacks sufficient data collection and measurement of patient outcomes, making it difficult to determine the effectiveness of treatments and care. Dr. Marty McCarry argues that this is a systemic problem, as most procedures and treatments do not have robust follow-up data. He suggests creating a marketplace centered around value rather than quantity, which would require incentives for doctors to focus on preventive care and maintenance. Dr. Anupam Jena's research aimed to assess the value of experienced doctors, but the challenge lies in comparing patient outcomes for experienced doctors and newer doctors, as more experienced physicians often treat sicker patients. To address this, they focused on hospitalists, who tend to work exclusively in hospitals and have a consistent patient population. By focusing on these specific doctors, they hoped to gather more accurate data and provide patients with valuable information to make informed decisions about their care.

• Doctor's experience and patient outcomes: Older doctors may have higher mortality rates for their patients, but surgeons' experience can lead to better outcomes. Staying updated on medical advancements is crucial for all doctors to provide optimal care.

  The experience level of doctors can impact patient outcomes, but the effect is not consistent across all specialties. The study found that doctors with more experience, specifically those who have been practicing for over a decade, have higher mortality rates for their patients within 30 days of hospitalization, except for high-volume doctors. This is likely due to the fact that medicine is constantly evolving, and older doctors may not keep up with the latest knowledge and treatments as rapidly as their younger counterparts. However, surgeons seem to be an exception, as their experience can lead to improved outcomes due to the muscle memory and skill development in the surgical field. For doctors like the speaker, who have been out of medical school for a while and don't practice full time, it's crucial to stay updated on the latest medical advancements to ensure the best possible care for their patients.

• Resistance to change in healthcare: Despite evidence, senior figures' biases hinder progress, but collecting better patient data and feedback can lead to improved outcomes and effective practices.

  The medical field, despite entering the era of evidence-based medicine, still relies heavily on the experience and biases of senior figures. This can hinder progress and reform, as those in power may resist change due to comfort and the perceived disruption it brings. However, there are promising initiatives, such as collecting better patient feedback and data, which can lead to improved outcomes and more effective healthcare practices. Ultimately, it's crucial for medical professionals to embrace the notion of challenging the status quo and maintaining a healthy skepticism towards established practices.

• Leveraging patient data for improved healthcare: Startups and tech community focus on tracking patient experiences and outcomes to make data-driven conclusions. Improvement, not punishment, is the goal. Tailored strategies for each specialty, like surgery's benchmarking and confidential data sharing, and precision medicine's customized diagnoses and treatments, are key to future advancements.

  The future of healthcare lies in leveraging first-hand patient data to improve quality and standardize care. This trend is being driven by startups and the tech community, who are focusing on tracking patient experiences and outcomes to make data-driven conclusions. However, improvement, not punishment, should be the goal. The complexities of medicine mean that strategies to enhance quality and care must be tailored to each specialty. For instance, in surgery, benchmarking and sharing data confidentially among doctors can lead to significant improvements. Precision medicine, which involves customized diagnoses and treatments based on individual patient data, is also a promising area for the future. While challenges exist, the optimism among innovators and researchers in the field is palpable. They envision a future where medicine is more precise, autonomous, and individualized.

• Exploring the Future of Medicine: The future of medicine promises advancements, but requires caution, rigorous study, open-mindedness, and commitment to evidence-based practices for safer, more effective treatments.

  The future of medicine holds great promise with advancements in science and technology leading to better, more personalized treatments. However, it's important to approach new interventions with caution and rigorous scientific study to minimize bias and ensure effectiveness. The optimism for the future of medicine also lies in the promotion of open-mindedness and diversity of thought in the medical community. The commitment to evidence-based medicine, transparency, and data sharing are steps in the right direction towards making medicine safer and more effective for patients. Ultimately, the goal is to continue discovering new fundamental biology and translating it into better medicines, ultimately changing the way we treat patients in the future.

• NFL's handling of player health and retirement: The NFL needs to have an open and honest conversation about player health and long-term risks, especially in light of recent research on brain damage.

  The NFL's handling of player health and retirement, particularly in light of recent research on long-term brain damage, requires a more open and honest conversation. The abrupt retirement of a high-profile player, especially when followed by such research, underscores the need for transparency and a greater focus on the long-term risks and rewards of playing professional football. Delaying this conversation through denial, excuses, and avoidance only hinders progress in addressing this critical issue. Listen to Freakonomics Radio for more in-depth discussions on this topic. Freakonomics Radio is produced by WNYC Studios and Dubner Productions, and can be found on Apple Podcasts, Stitcher, or wherever you get your podcasts. Visit Freakonomics.com for transcripts, research, and contact information. Follow us on Twitter, Facebook, or email us at radio@freakonomics.com.