0:05

When I went to graduate school. It was the

0:08

early nineties when then president

0:10

Clinton unleashed his health

0:12

care plan, and it was over a thousand

0:14

pages. was so huge

0:16

That's

0:16

the economist, Melissa Thomason.

0:19

I remember being struck with the thought of,

0:21

well, why do we need this? And how did

0:23

we get into this mess in

0:24

the first place? Understanding

0:27

how we got into this mess or any

0:29

mess is part of Melissa's job

0:31

as a professor at Miami University

0:34

in Ohio. She's an economic

0:36

historian, which means she

0:38

spends a lot of time thinking about the

0:40

events that set the stage

0:42

for our current economic systems,

0:45

including healthcare. In twenty

0:47

twenty, healthcare expenditures represented

0:50

around twenty percent of gross domestic

0:53

product or GDP. And

0:55

yet back in the early nineteen nineties,

0:57

when Melissa Thomason was casting

1:00

about for a dissertation topic, she

1:02

realized something. It turns out

1:05

No economists had really looked at

1:07

quantitatively understanding how

1:09

we did get into this mess in the first place. There's

1:11

been some terrific history books

1:13

written on it, some sociologists have looked

1:15

at it, but no one had really actually tried

1:17

to measure the factors that led us

1:19

to our current healthcare system.

1:23

So that's what

1:25

Melissa has spent the last two decades

1:27

doing. She's written papers about

1:29

school closures during the nineteen sixteen

1:32

polio epidemic in the US and

1:35

about the health effects of living through

1:37

the Great Depression. A lot

1:39

of her work focuses on shocks like

1:41

those, big healthcare banks,

1:44

and their lingering impacts. Recently,

1:47

she and some colleagues wrote a paper

1:49

about one especially impactful

1:51

bang. The nineteen eighteen

1:54

flu pandemic. Also known

1:56

as the great influenza. It

1:58

really shows us how a

1:59

significant shock to the healthcare

2:02

system can play out even decades

2:04

later. How

2:04

does the nineteen eighteen flu

2:07

pandemic continue to play

2:09

out decades even a century

2:11

later? And what can

2:13

we learn from it as we emerge

2:15

from another giant shock.

2:17

From

2:19

the Freakonomics Radio Network, this

2:21

is FreakonomicsMD. I'm

2:23

Bob Pujena. Today on the show,

2:25

How can Medicines Pass Help us

2:28

understand its present maybe

2:30

see its future. Looking back, it's

2:32

really natural to say, well, of course, communities built

2:35

their own hospitals. But at

2:35

the time, it was anything

2:37

but clear.

2:38

And we all know what they say about

2:40

hindsight. But is it

2:42

possible we can sharpen our foresight

2:45

to better predict when crises will

2:47

occur? Our healthcare system is

2:49

much more oriented towards disease care than

2:51

healthcare.

3:04

Right around the time of the pandemic, Middle

3:06

and upper class Americans were starting to

3:08

realize that medical care might be

3:11

a good option and going to hospitals might

3:13

be useful.

3:14

Healthcare and medicine looked a whole

3:16

lot different in nineteen eighteen when

3:18

the great influenza hit.

3:20

Let's think about nineteen hundred as

3:23

sort of a point in time where you start seeing

3:25

the modern hospital begin to develop.

3:27

Before nineteen hundred, there were

3:29

basically two kinds

3:30

of patients who would go to hospitals. One

3:33

kind of patient was what

3:35

some historians have called the working

3:37

port. They were single people

3:39

who lived in a boarding house who became

3:41

sick and who had no one to care for them.

3:43

They couldn't hire a nurse and no one at home

3:45

could nurse

3:45

them. And a lot of charities and

3:47

religious organizations opened hospice spitals

3:49

to provide them with warmth, nursing

3:52

care, and shelter. And that started to

3:54

happen maybe around the eighteen seventies

3:56

or so. The other kinds of patients were

3:58

patients with more chronic illnesses,

4:00

so those might have beenalcoholics or

4:02

unwood mothers, people who were mentally

4:04

ill, whose families had just sort

4:06

of kicked them to the curb. And cities

4:08

operated ohms houses for people

4:10

without homes who were sick to be sheltered

4:12

in. So these were called hospitals, but

4:15

they weren't really hospitals in the way

4:17

that we think about hospitals today.

4:22

At

4:22

the turn of the twentieth century, if

4:25

someone was ill, THERE WASN'T MUCH A

4:27

DOCTOR OR A HOSPITAL COULD

4:29

DO FOR THEM. LET'S

4:30

SAY YOU GET SICK IN nineteen o five, YOU

4:32

GET THE FLU, YOU GET pneumonia chances are you'll

4:34

have a physician visit you in your home.

4:36

They'll tell you you have the flu or you have pneumonia

4:39

and give you fluids, give you rest, keep you

4:41

warm. Open the window, get some fresh air, and

4:43

that's about the extent of what they can do.

4:45

When the flu pandemic began in nineteen

4:47

eighteen, World War one

4:49

was still unfolding. Hospitals

4:52

were understaffed because doctors and

4:54

nurses were overseas helping

4:56

soldiers.

4:57

Whole families were sick.

4:59

Nobody was around to care for anybody.

5:02

So initially, right in the thick of the pandemic,

5:04

everybody just went to hospitals it

5:07

was standing room only and overflow

5:09

space. As the pandemic

5:11

receded, a lot of people in those

5:13

communities that were harder hit started say,

5:15

hey, we have to really do something about

5:17

it.

5:19

As the great influenza storm

5:22

through the country and around the world,

5:24

It encountered a number of medical

5:26

and scientific innovations. Germ

5:29

theory, which says that specific microscopic

5:32

organisms cause specific

5:34

diseases was developed in the

5:36

eighteen sixties. By around

5:38

nineteen twenty, it was largely accepted.

5:41

In eighteen ninety five, physicians

5:43

got the x-ray, which allowed them

5:45

to peek inside the living body for

5:47

the first time. And in

5:49

nineteen twenty one, insulin

5:51

was discovered, making it possible

5:54

to treat diabetes. All

5:56

of these new medical discoveries needed

5:58

a place to happen. At the

6:00

same time, a lot of people who were

6:02

sick with the flu needed a

6:04

place to go. So

6:06

we have new technologies, anesthesia

6:09

for childbirth, new understandings of

6:11

disease processes, And hospitals

6:13

were a natural place to locate a lot

6:15

of these technologies. Things like x-ray

6:18

were really bulky, a better understanding

6:20

of germ theory, led operating

6:22

rooms to develop before that physicians

6:24

would routinely do surgery on kitchen tables.

6:27

Hospitals became places where people would

6:29

go to get medical care as a result of the

6:31

new technology, they became more expensive.

6:37

Hospitals

6:37

changed and became

6:39

an industry. One that now

6:41

accounts for a third of all healthcare

6:43

spending in the US, or

6:45

about six percent of GDP.

6:47

Not long ago, Melissa

6:50

and some colleagues were thinking

6:52

about the COVID-nineteen pandemic, and

6:54

how it made commonplace, an element

6:56

of health care, most people

6:58

hadn't interacted with before,

7:01

telehealth. It reminded

7:03

them of how the role of hospitals changed

7:06

during the nineteen eighteen flu

7:08

pandemic. People didn't

7:10

use hospitals much until they

7:12

did. So what

7:14

factors contributed to where and

7:16

why hospitals proliferated

7:18

around the country? And

7:20

what downstream effects did this have

7:22

even today on public health.

7:25

We

7:25

went way back in time and

7:27

gathered a list of every hospital

7:29

in the US back to around nineteen

7:31

ten. When it was a little tricky, we

7:33

found it in these volumes called the American

7:35

Medical Directory.

7:36

It was like an eight

7:38

inch thick volume that listed all the

7:40

hot hospitals in every physician in the country. And

7:42

you could find the hospitals, but then it

7:44

had homes for people who were described

7:46

as mentally defective or crippled

7:48

children. And so trying to actually think about, okay,

7:51

which of these institutions are hospitals

7:53

in the sense of what we think of as hospitals?

7:55

We did a lot of statistical techniques

7:58

to sort it into what we thought were hospitals.

7:59

And then in the nineteen twenties, the American

8:02

Medical Association

8:02

started doing an annual survey

8:04

of hospital So after nineteen twenty

8:06

five, we were able to actually categorize every

8:09

hospital that was registered with

8:10

the AMA in the country, all of their beds.

8:13

And

8:13

then we got a group of cities where we

8:15

actually had really good city level data

8:17

on influenza deaths because

8:19

that's hard to come by. And then we'd look at how

8:22

hospital capacity in those cities

8:24

changed based on how

8:26

many people died of the flu in nineteen eighteen

8:28

in those cities. And what did you find?

8:31

We found that cities that had higher

8:33

mortality rates from the flu

8:35

expanded hospital capacity to a

8:37

greater extent than cities that

8:39

didn't, and these tended to be higher

8:41

income cities. We were finding

8:43

big effects in mid

8:45

size to smaller cities that

8:47

maybe didn't have the hospital

8:49

infrastructure like a New York or

8:51

like a Chicago, and that those hospitals

8:53

really after the pandemic caught

8:55

up to the Chicago's and the New York's of

8:57

the world. But again, that effect was much

8:59

stronger in cities where the

9:01

population had been more negatively affected by the

9:03

flu pandemic of nineteen eighteen.

9:05

So one of

9:05

the challenges when we're taking a finding

9:07

like this and saying, alright, did

9:10

the nineteen eighteen influenza

9:13

pandemic cause more

9:15

hospital capacity to be

9:17

developed in cities than otherwise would have been

9:19

developed. This is really a cause

9:21

of finding what did the

9:23

trends look like in hospital

9:25

capacity in those areas where

9:27

influenza hit hard versus did

9:29

not hit hard? The

9:30

idea of correlation versus causation

9:32

is really crucial, but we do

9:35

look at what we call pre

9:36

trends in those cities and those were

9:38

cities that very similar to each

9:40

other prior to the pandemic hitting.

9:42

The cities that got hit harder

9:44

with influenza didn't seem

9:46

to be associated with being big or

9:48

small. It was kind of just randomly

9:51

dispersed. And so those cities look similar to each

9:53

other prior to the pandemic, and then

9:55

there is a departure with the number hospitals

9:57

they started to build. The

9:58

growth in hospital

9:59

capacity that you observed, where did it come from?

10:02

Was this public government

10:04

saying, look, we recognize this is a huge

10:06

public health issue. We need to build

10:08

hospital capacity. Or were these really

10:10

efforts where private hospitals look, we

10:12

recognize there's a market demand for better

10:14

health care provided in the hospital.

10:16

We need to meet it. Which of those

10:18

two happened? Before

10:19

looking at this, you might think, well, maybe cities

10:22

were really

10:22

worried about having another big public

10:24

health shock. Maybe this was an opportunity

10:27

for cities and counties to tax

10:29

themselves and to build bigger, nicer

10:32

city or community hospitals. But

10:34

what we find is the opposite. The

10:36

growth in the hospital industry occurred

10:38

solely among nonprofit private

10:40

hospitals. These tended to be

10:42

very filentropic community

10:45

organized hospitals that really were not owned

10:47

and operated by cities. These are not

10:49

public hospitals. Right. These are like

10:51

today's communities hospitals. Right, that a

10:53

couple wealthy donors

10:55

start. They do fun drives, bake

10:57

sales, lots of things like that. And

10:59

these hospitals are nonprofit hospitals.

11:01

These days you gotta do a lot of baking. I got

11:04

table of it. It'd be a lot of

11:06

baking and a lot of wealthy donors.

11:12

So

11:12

you have this expansion in

11:14

hospital capacity that occurs in

11:16

your view really by chance depending

11:18

on which communities were hardest hit

11:20

by the nineteen eighteen pandemic. What

11:23

is the byproduct of that? Do we then

11:25

observe better quality care?

11:28

Do we observe just more

11:30

hospital use and greater spending on hospital

11:32

care? In our data, we can actually observe

11:34

quality of care or spending per

11:36

se. But what we can

11:37

say is that in those

11:39

cities that were harder hit, they

11:41

had greater levels of hospital capacity.

11:44

And it persisted till nineteen six So

11:47

in nineteen sixty, those

11:49

cities that were harder hit by the flu had

11:51

more beds per person

11:52

than cities that were less harder hit by

11:55

the flu. If you think that more

11:57

beds leads to more spending, which

11:59

economists do, then you could

11:59

say yes, it didn't lead to more

12:02

spending. But the big question, of course, is was

12:04

it spending helpful. Like, if you have

12:06

more beds per capita

12:08

and that allows you to provide

12:10

more high quality care per capita, then

12:12

you would expect things to get better from a

12:14

health outcomes perspective that could outweigh the

12:16

spending. But you don't have any sort of insight

12:18

as to whether care itself or outcomes

12:20

improved as a result. No.

12:22

Unfortunately, we don't measure that with our

12:24

data.

12:26

How long of

12:28

a period did you study after the

12:30

initial shock, this nineteen eighteen

12:32

shock. We see those effects on

12:34

hospital construction

12:35

until the early nineteen sixties. And what we

12:37

suspect is that Medicare which

12:39

then was in the whole another shock,

12:41

really typically evened things out. Net

12:43

competitive forces and more

12:45

resources from Medicare led to more of an

12:47

equalization across cities. And what

12:49

impact did the differential growth

12:51

in hospital capacity have on

12:54

disparities in access to hospital

12:56

care? Like, racial

12:56

or socioeconomic disparities? We

12:58

can't answer that directly with our

13:00

data, but it's quite

13:02

possible that it did There

13:04

are some other papers and literature that suggest

13:07

in

13:07

some communities when these hospitals become

13:10

available. There are lots of

13:12

advantage of them and fewer people of

13:14

color able to take advantage of them.

13:16

And so we could see inequities

13:18

and disparities develop because of

13:20

that. So

13:21

if you were to describe in

13:23

a couple sentences, what is the

13:25

contribution of this particular study to the

13:27

economics or health economics literature or public

13:29

health literature. What would it be? Oh,

13:32

boy. It really shows

13:35

us how a significant shock to

13:37

the healthcare system can play out

13:39

even decades later. And I think this

13:41

paper shows us that these

13:43

shocks even when they're over have lasting

13:45

effects.

13:47

After the break, what could the lasting

13:49

effects be of a more recent

13:51

shock to the healthcare system?

13:53

We've seen a lot more people applying and

13:56

matriculating into healthcare programs. More people

13:58

applying to medical school, nursing

14:00

school, and If you could

14:02

predict the future of your own

14:04

personal health, would you?

14:06

I'm Bob Boudana, and this is

14:08

free economic XMD.

14:25

I'm Greg Martin. I'm a pulmonary and critical

14:27

care physician at Emory University

14:30

in Atlanta where I work predominantly at Grady

14:32

Memorial Hospital. Most of my time

14:34

is spent in the ICU

14:36

where I also conduct research and

14:38

help develop new ways to take care of

14:40

patients. Developing new ways to

14:42

care for patients can take years. If

14:44

not longer. Unless, of

14:47

course, there's a pandemic. Then

14:49

things move fast. COVID

14:51

came to all of us very, very quickly

14:53

and the ICU started

14:55

off with a lot of uncertainty

14:57

about how to treat these patients. One of

14:59

the things that took us some time was to understand

15:02

and that many of the things that are the foundation

15:04

of intensive care, the way we use ventilators

15:06

trying to protect the lung, supporting the

15:08

heart, the kidneys, the other organs, often

15:11

end up being much more similar in

15:13

COVID-nineteen than they are different.

15:15

COVID occurred in surges and clusters,

15:18

in the ICU, we had to

15:21

find ways to expand the

15:23

resources that we had, so that

15:25

all the patients are getting the care that

15:27

they need.

15:31

Wagon's colleagues relied on what they

15:33

already knew, but also

15:35

had to innovate quickly with

15:37

the world watching. In the

15:39

earliest phases, there was rampant

15:41

uncertainty surrounding testing,

15:44

supplies, and even space.

15:46

Where were they put all the sick people?

15:48

They were overloaded with

15:50

patients and also with

15:52

something else. The

15:54

uncertainty around care was

15:56

exacerbated by the tsunami

15:58

of information, and some of that was

16:00

fostered and facilitated by

16:02

social media even the biomedical literature

16:04

was overwhelmed with reports and

16:06

information that we were trying to share

16:08

and parse through which was the highest quality,

16:10

which was going to apply to our patients and how do

16:12

we implement that. So

16:15

there's the lack of information on one

16:17

hand. There's A tsunami of information on the

16:19

other hand and trying to put those two

16:21

together became very challenging.

16:26

It's easy to look back at the ways medicine

16:28

was and wasn't prepared for

16:30

COVID. It's harder to say

16:32

what comes next as a result

16:34

of it. In twenty twenty

16:36

one, Greg and a group of critical care

16:38

physicians from around the world

16:41

published a paper that tried to

16:43

do just that. Much of the advance

16:45

particularly in critical care medicine

16:47

was ways to ensure the resources are

16:49

available for each individual patient

16:51

as they come in. I think of that as

16:53

the three p's, the people, the places, and the

16:55

paraphernalia.

16:58

So the people are

17:00

the specialized people that are providing the

17:02

care to the patient, the nurses, the

17:05

physicians, the other physician

17:07

provider groups, but also

17:09

you have the pharmacist, the rehab

17:11

specialist, the respiratory therapist, all

17:13

working together, and that

17:15

became a real challenge because The

17:17

next piece that we needed to expand was

17:19

the places, meaning we needed more

17:21

ICU rooms or more ICU beds to

17:23

care for these patients. And

17:25

then the last part is the paraffinalia, which you can imagine

17:27

we needed ventilators and dialysis machines.

17:30

Within an individual hospital,

17:33

you can expand many of those You can open

17:35

new spaces for critical care

17:37

patients. You can try and expand the

17:39

capability of the individual's work

17:42

in the ICU for instance, but

17:44

the paraffinalia piece became particularly

17:46

challenging because most of those are

17:49

very limited there's only so many dialysis machines, there's only

17:51

so many ventilators. We learned a

17:53

lot about the

17:55

medical side of patient care, but really

17:57

that earliest phase was

17:59

understanding the

17:59

healthcare side. What do we really need to do

18:02

to care for those patients? And what

18:04

were the major medical innovations that

18:06

emerged during the pandemic

18:08

that were heavily used in the ICU.

18:11

Many interventions came along.

18:13

One of the earliest was the understanding of

18:15

corticosteroids or immunosuppression therapy

18:18

to really help blunt some of the inflammatory

18:20

response that was inducing the

18:22

injury and causing the illness.

18:24

So using dexamethasone, one

18:26

of the most common interventions that we still use

18:29

today was shown in several trials to be

18:31

effective and particularly as

18:33

effective in people who are more severely

18:35

ill and that's one of the core things that

18:37

we learned very early on. We've

18:39

seen other interventions, things that are

18:41

more targeted at very specific aspects of

18:44

the immune system, So if you're

18:46

trying to blunt a specific

18:48

cytokine or a specific part of the

18:50

immune response, we can do that

18:52

effectively too. And certainly the other part

18:54

that we've seen is the antiviral therapy,

18:56

which is more broadly effective, and

18:58

we tend to use that

19:00

really in the earliest phases of illness.

19:02

Once people become critically ill,

19:05

it's less likely that antiviral

19:07

therapy is going to work There's

19:09

a part of

19:12

the pandemic that we haven't talked about yet,

19:14

and that's how to deal with the

19:16

supply constraint. So for

19:18

example, if you had to

19:19

choose between which patients would

19:21

receive ventilator support

19:24

versus not, How much of that did you

19:26

personally witness in your own

19:28

ICU? And did we have a

19:30

good medical ethical framework

19:32

for thinking about who to prioritize

19:35

treatments in and and who not

19:37

to. We had a conceptual framework

19:39

for how to deal with these kinds of surges

19:41

and how do you make triage decisions,

19:43

which patients are going to get which resources,

19:46

and that's called crisis standards

19:48

of care. And in some cases that has been developed

19:50

around disaster medicine.

19:52

But when you get to a pandemic and

19:54

it's no longer the urgency

19:57

of an immediate disaster

19:59

that you're having people come in over hours,

20:01

days, and even weeks, that

20:03

pace becomes more challenging. It's not

20:05

just allocating resources. It's also

20:08

potentially removing resources. Do

20:10

you take a ventilator away from a

20:12

patient that's currently in the hospital

20:14

in the ICU because they're less likely to

20:16

survive and you now give that to the

20:18

person who's more likely to survive.

20:20

What

20:22

has

20:24

changed in hospital care and

20:27

critical care medicine? That

20:29

will change the way health care is

20:31

delivered in the future.

20:34

Certainly, one thing that's changed due to

20:36

COVID is we

20:38

realize that there's a need to

20:40

be able to expand capacity

20:42

and that we now understand better how

20:44

to do that. One of the things we also learned is that you

20:46

need to be able to maintain that

20:49

capability over time. And

20:51

then much of the communication

20:54

began to occur outside

20:55

of individual hospitals. So in

20:57

the past, when a patient is,

21:00

let's say, sick, in a community hospital, in a rural

21:02

area, they may call a

21:04

referral center and say, I need to transfer my

21:06

patient. And there were referral

21:08

networks that had been built up.

21:10

But when an individual hospital was overwhelmed

21:12

or too full, it made it

21:14

much more difficult to transfer and

21:17

move patients to having a critical

21:19

care coordination center, which they've tried

21:21

to build in some places, would

21:23

be extraordinarily helpful

21:25

for long term planning and being able to respond to future

21:27

issues like this. I'm

21:29

particularly

21:29

interested in this point because prior

21:32

to the pandemic, if you

21:34

had a person who came into their

21:36

local hospital with an

21:38

acute respiratory condition where

21:40

the local doctors in the hospital were

21:43

thinking we need to transfer this

21:45

patient to a referral center. Is

21:47

it possible that in the future

21:49

they would be less likely to do that because

21:51

they are more equipped to handle

21:53

that type of severity

21:55

in the hospital. And

21:58

if so, do you think that that will lead to

21:59

better outcomes on average or potentially

22:02

worse outcomes on average? Because you can

22:04

imagine both being true. On

22:06

one hand, if you feel like you're better

22:08

able to deal with the types of

22:10

patients that you're getting, you

22:11

might keep them in the hospital, but that might

22:13

not be a good thing. It might be better to

22:15

transfer those patients to highly specialized centers. But it

22:18

could also be a good thing if you get

22:20

early treatments on board, then

22:22

decide whether or not to keep or transfer

22:24

the patient It might be that outcomes

22:26

improve. Most people

22:27

desire to get their care somewhere

22:30

proximate to family and friends in their

22:32

support environment. What

22:34

we've seen is that there is an expanded

22:37

capacity for caring for patients now

22:39

in local hospitals. By

22:41

worry that that expanded capacity

22:43

will wane over time as education and training

22:45

and resources get scaled back or they

22:47

fall back to a traditional baseline.

22:51

What I hope is that we'll continue

22:53

on a trajectory with technology

22:55

filling part of that gap. One example

22:57

would be telecritical care

23:00

which allows you to visualize a patient,

23:02

see the actual data that's being collected,

23:04

even see the patient on a

23:06

camera where you can see their ventilator

23:08

the waveforms and the information on their bedside

23:11

monitor. And what that really

23:13

facilitates is a decision for

23:15

whether that patient needs to

23:17

transfer or can they

23:19

safely be managed at their local

23:21

hospital where they're closer to friends and

23:23

family? But on the other hand, I

23:25

would not expect the highest

23:27

levels of trauma care, stroke care, cardiac

23:29

arrest care to be available in

23:31

every hospital of every size throughout the

23:33

world. We can't really talk

23:34

about the future of how the healthcare

23:37

system evolves without thinking about

23:39

the actual workforce. The pandemic

23:41

has had a lot of effects on people burn

23:43

out in particular but there's another effect

23:45

that I think we talk a lot less about, and

23:48

that's how the

23:51

experience of doctors in training.

23:53

Across all specialties, actually changed

23:55

tremendously. I mean, you could have been a dermatology

23:58

intern, but half the staff at

24:00

COVID ICU and

24:02

I'm curious what you think that shock

24:04

to how doctors were

24:07

trained, how that will impact the

24:09

future supply of physicians who are

24:11

interested in critical care medicine or

24:13

who have some expanded

24:15

expertise to be able to manage those

24:17

issues in whatever line of work they

24:19

go into. What's

24:20

interesting and maybe not surprising is

24:22

that we've seen a lot more people applying

24:24

and matriculating into healthcare programs.

24:26

More people applying to medical school, nursing

24:29

school, that's fantastic. Are they going

24:31

to choose to work in a specialty

24:33

like pulmonary critical care or

24:35

emergency medicine where to

24:38

be expected to work long

24:40

hours to provide the care and maybe

24:42

be stretched beyond your normal capacity.

24:44

We're looking at the different

24:47

generations of physicians and nurses and

24:49

other providers in trying to

24:51

understand how we can best support that

24:53

workforce.

24:53

As

24:56

a

24:56

critical care physician, most of

24:58

doctor Greg Martin's clinical work

25:01

focuses on acute illness. Caring

25:03

for patients in the throes of a current and

25:06

serious

25:06

medical condition. He's often

25:08

making

25:08

predictions about what will happen to

25:11

their health on a daily or

25:13

even hourly basis. Over

25:15

the

25:15

last few years though, Greg

25:17

has become more interested in

25:19

long term predictions It's part of his

25:21

job now as director of

25:24

Emery's Predictive Health Institute. But

25:26

the individual level, the idea is

25:28

to try and proactively prevent illness and

25:31

even to predict illness. And that could be

25:33

anything from diabetes, sleep

25:35

apnea, high blood pressure, all

25:37

the way through cancer, and all of those diseases

25:40

have a relatively long

25:42

prodromal period, meaning that the disease is

25:44

beginning to exist before we actually

25:46

are able to make the diagnosis. If

25:48

we could identify that

25:50

period, that's the opportunity

25:52

for making an

25:54

intervention that really puts people back on the healthy trajectory

25:56

and it may completely prevent

25:58

the onset of that illness. Our system

25:59

is really much more oriented

26:02

towards disease care than healthcare.

26:05

I think

26:07

there are sort of two benefits or

26:09

predictions So one is there's a benefit

26:11

to people because

26:12

they can make lifestyle changes, they

26:15

can get on treatments that

26:17

can change the trajectory of disease.

26:19

But is there a benefit of prediction

26:22

about future health even if

26:23

there aren't any adequate treatments?

26:26

It's something we've also dealt

26:28

with within predictive health. And it

26:31

often comes down to an

26:33

educational and even an ethical issue

26:35

of what you do with the information. There

26:37

are some people who would want to know,

26:39

and other people would say, no, I don't

26:41

want to know. We're still really

26:43

trying to understand the best way to

26:45

do that because We're not far away from being able to

26:48

genotype every individual in

26:50

the world. And once we get there, we

26:52

really need to understand what to do with

26:54

that information. What should

26:56

we

26:57

do with all of this information

27:00

about our own personal health and

27:02

also the health care system

27:04

itself? They say what's past

27:06

is prologue. So

27:08

what can we expect to see from this

27:11

pandemic? Based on

27:11

prior ones, Melissa

27:13

Thomason has some ideas. Healthcare

27:16

can develop sometimes in ways we don't think

27:18

about. For us looking back, it's really natural

27:20

to say, well, of course, community

27:22

spoke their own hospitals, but at

27:23

the time it was anything but

27:26

clear. When I look at the

27:28

pandemic today, what I see is

27:30

new methods of operation. see

27:32

things like psychotherapy services

27:33

that are available on a nationwide basis.

27:37

There are places now that will treat

27:39

obesity and it's all teletherapy. A

27:41

lot of the emergencies that paramedics respond

27:44

to don't necessarily require

27:46

transport to an emergency room.

27:48

They can now link up on their iPad ads

27:50

and treat those patients themselves.

27:52

That saves the healthcare system a lot of money

27:54

and saves the patients a lot of

27:56

discomfort. For virtual surgeries, so

27:58

maybe everybody can get a Cleveland

28:00

Clinic experience even if you're at a local

28:02

community hospital. And that has

28:04

important ramifications for patients in

28:06

developing countries, patients in rural areas,

28:08

patients where there is maybe a lack of

28:10

effective

28:10

medical care. And again, I think that

28:12

the COVID-nineteen pandemic accelerated this.

28:15

I guess we'll just have

28:15

to wait and see, but

28:18

hopefully not for another century.

28:20

That's it for today's

28:21

show. I'd like to thank my guests,

28:23

Melissa Thompson and Doctor Greg

28:25

Martin. And thanks to you, of

28:27

course, for listening to the show and

28:29

for

28:29

telling your friends and family to do

28:32

the same. Let me know what you thought

28:34

about today's episode. What

28:36

changes

28:36

have you noticed in healthcare since the

28:38

pandemic started? What do you think

28:40

we'll see fifty or even a hundred

28:43

years from now. Here's an idea

28:44

to leave you with based on my conversation

28:47

with Melissa and Greg. During

28:49

the COVID-nineteen pandemic,

28:52

many has portals have been to develop expertise

28:54

in treating critically ill patients

28:56

in a way that they hadn't

28:59

before. It makes me

29:00

wonder whether this current

29:02

pandemic could have a silver

29:03

lining if the quality and

29:06

outcomes of hospital care improve

29:08

as a result. One

29:10

way to study this would be to look

29:12

at smaller hospitals that were

29:15

disproportionately affected by COVID-nineteen to

29:17

see if

29:17

their overall hospital mortality

29:20

rates

29:20

for other conditions fall in

29:22

the future compared

29:24

to what they were before the pandemic.

29:27

Think about it. And in the

29:29

meantime, next week on the show, More

29:32

people are insured now than

29:34

ever. But does

29:35

health insurance make us healthier? It

29:37

is an

29:37

obvious question to ask, but it is

29:39

a much harder question to answer than you

29:42

might

29:42

think. I'll talk with my friend Kate Baker

29:45

about a one of a kind experiment

29:47

SHE LED THAT TRIES TO ANSWER THAT QUESTION.

29:49

IT IS

29:50

A MUCH MORE COMPLICATED STORY

29:52

THAN SIMPLY SAYING

29:54

YES, INSURANCE WORK or know it

29:56

didn't

29:57

work. That's coming up next week

29:59

on freakonomics

29:59

MD. Thanks again for

30:02

listening. Foonomics

30:04

MD is part of the

30:06

Freakonomics Radio Network, which

30:08

also includes Freakonomics Radio,

30:10

no stupid questions, and

30:13

people I mostly admire. All

30:15

our shows are produced by Stitcher and

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Renbud Radio. You can find

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us on Twitter at doctor

30:22

BapuPod. This episode was

30:24

produced by Julie Canfor and mixed by Eleanor

30:27

Osbourne. Learick Boudic is our production

30:29

associate. Our executive team

30:31

is Neil Karuth, Gabriel

30:33

Roth, and Steven Dubner,

30:36

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31:00

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31:00

enough attention to history, but we shouldn't

31:03

really pay attention to history. It seems like

31:05

things tend to repeat themselves.

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