From MIT to Freakonomics MD: Dr. Anupam B. Jena's Journey

Yeah, yeah. There's some other funny stories. This is. This is Stephanie. This is about life. You asked about my life, so that's.

What this is all about.

Yeah.

Hi, everybody, and welcome to the podcast. This is Generations MD. My name is Stephanie, and I'm joined here by my colleague Dr. Sarah Davis, who's also my mother. And today we have a very special guest. He is an internal medicine physician, has a PhD in economics. He's a professor at Harvard Medical School, host of the podcast Freakonomics MD and the author of Random Acts of Medicine. Please welcome to the podcast. Dr. Papu.

Jenna, thanks for being here.

We're so excited to have you.

Yeah, I couldn't ask for anything better on a Friday afternoon, so I'm looking forward to it.

Well, I have to admit, I'm a bit of a fan, so I'll try to just, you know, tamper it down a little bit. But to me, it's super exciting to get to talk to you. I loved your book. I love the podcast, and, of course, I love the whole Freakonomics, you know, franchise. For any of our listeners, if you have not listened to Freakonomics, you are really missing out. It's really. It's all fantastic. So, anyway, I'm a fan. I'm excited to talk to you.

I'm gonna have to take this and play it for my wife, because I'm still trying to get my wife to listen to the show and read, like, the first chapter of the book, and that hasn't happened. And she's in medicine.

So typical.

I feel like, yeah, even my friends, I try. I'll try to get them to listen to this podcast, and they're like, we hear you talk all day. Like, do we really need to listen to you more?

I've heard some variation of that statement.

As well, like, all right, I get it, I get it. But I gave you kind of a brief introduction if you kind of want to introduce yourself, and then we'll kind of dive into how you got into medicine and talk about your background a little bit.

Sure. I mean, I'm an economist and a physician. I'll start with college, maybe. I went to college at mit, studied economics and biology, and I knew I wanted to go to medical school. My mom was a doctor. She. She worked in pmnr, and she. She worked at the VA Hospital in Richmond, Virginia, took care of a lot of people who had been in. In war and had traumatic brain injury. And so she saw those kinds of patients. And I used to spend time with her at the VA Hospital. As a kid growing up and sort of, sort of became interested in that line of work. But I also knew I wanted to do research as well. And I studied biology and economics. Well, I studied biology because I wanted to go to medical school. The economics was sort of a, an afterthought. I, I didn't have any particular interest in economics and the only reason I studied it is because I thought it would help me get into medical school.

Like help your GPA or just make you look better.

Make me look better, make me look more well rounded. And at mit, economics was in the quote unquote humanities section of like of the courses. And so I could get away with that double major without having to take extra courses. So I was thinking like a pre med student like at that time. And then I'm going around the country interviewing for MD PhD programs, but not to do a PhD in economics, but to do a PhD in biology. Because I'd been working in a lab for a couple years in college and it's like December of 1999, I'm visiting the University of Chicago, I think it's December, and the guy who ran the program at that time, the MD PhD program, says to me, he's like, oh, I saw you studied economics, would you be interested in doing your PhD in economics instead? And I thought to myself, well, what does this guy think about my capabilities as a, like a biomedical researcher? Not good. Obviously. He's trying to pull me off into a completely different discipline. And I, and I said, yeah, I'd be interested. I hadn't even thought about it until that moment. And so he calls over to the Economics department. Someone happens to pick up the phone, one of the admins there and walked around, I'm guessing the department, and asked if there's any faculty around who'd meet with me. And there were a few. So I just walked over the economic summit that afternoon and met with folks and economists and I applied to the economics program the next week I got in and then I decided I would go to the University of Chicago and do an MD and a PhD in economics. And that sort of set my life on a completely different path than I was expecting. And you know Sarah, you mentioned sort of the random acts of medicine. In fact, in the beginning I described a story, but I don't describe it as a random act, but it really was because I met this, this guy, Jose Quintons was his name. If I had seen him in the afternoon on that day in Chicago, he wouldn't have had time to call over the Econ department and line up meetings. So I saw him by chance in the morning. He by chance had, you know, read through my resume carefully enough to figure out maybe I should suggest to this, this young kid to do Ph in Economics. He calls over to the Economics department. Someone happened to pick up that person, walked around the department and found people who were again, by chance available that afternoon and willing to talk to me. So a lot of things happened sort of randomly that put me down this path. And that sort of idea has influenced a lot of the work that I've done since then.

That's awesome. What a story.

Yeah. Did you like economics in college or was it. And you're like, yeah, I'm excited to do this Ph.D. or did you kind of find that out later?

I think I found that out much, much later, actually. I, I would say it wasn't particularly interesting to me. It's not something that I would have thought ever to do a PhD in, which is sort of strange, like I, you know, to make that kind of investment. But I had insurance in the following sense. If I didn't like economics in grad school or I didn't think I could do it, I would have gone back and, and just did a PhD in immunology or cell biology or something like that. And even the first couple years of graduate school, they're very different than what I ended up doing and what I do now. I mean, it's all coursework. It's very mathematical, very technical. And it wasn't like I wasn't excited about it. I was doing it because I thought it would help me do something later on. And that something is not something I really had any insight into. But it's, it's certainly very different than what I do now. And I'd say what I do now I do get excited about. I mean, mean, I love the ideas they. I mean, I really get excited about them. And I couldn't say the same thing about the coursework in economics, but it did obviously have a role to play.

Yeah. Can you talk a little more. More about that and maybe how studying economics might have, like, changed your mindset a little bit to do the work that you're doing now?

Yeah. Let me say a few things. So you're both in medicine, you're at the early part of your career and your mom is a later part of later part of it. Not too late. We're not going to put time the same parts of our career.

Yeah.

So, Stephanie, you'll see residency is very hard, but for me, I Thought that the first year of in economics at Chicago was way harder than residency. And the reason why is because residency I felt like, you know, it's challenging in a lot of ways. It's a lot of work. You have to just absorb tons and tons of information. You make decisions, maybe not on the first day, but very quickly after the first day that have really important impacts on people's lives. But it is one of those things where if you are sort of sufficiently prepared in medical school and you're willing to put in the work, you'll get. It's not to say it's not rocket science, obviously medicine is very hard, but if you do it and you do it and you do it, you'll get it. And that wasn't the case in economics or it didn't feel like the case in economics. I was in a program where at that time probably a third to maybe a half of students didn't pass the first year coursework. So there was a lot of uncertainty in my residency class at Mass General. I don't know that there's anybody who didn't complete residency. Maybe, maybe one person, I don't know if I had to guess, but I don't, I don't recall. So the odds of success were very different. So that feeling of uncertainty, could I do this even if I worked really, really hard? That was there in economics, but it never felt that way in medicine. Cause I always felt like if I do this enough, I'll get it and everybody's done it before me and there'll be support to make it through. So that was one thing that was interesting. It was a good experience to have actually, perhaps for me before getting to residency, because a lot of people feel that residency is very difficult. So I had that difficult experience early on. And the other thing is, economics is very quantitative. It's very logic based. It's at its core we think a lot about incent, but in a lot of the work that I do, which is more sort of statistical in nature, we think a lot about causality and what causes what. And in medicine those kinds of questions come up all the time. If you give someone a drug, you do so because you think it's going to improve their health in some way. But how do you know that it's going to improve their health? How do you show that it's going to improve their health? How do you look at studies and say, well, does this study really tell me that using this medication is going to do what I think it's going to do? So having that sort of way of thinking about causality in an economics way I think has been very helpful in medicine.

Yeah, I think that's interesting. Do you think any of it you touched a little bit about feeling uncertain in those first years of grad school? Do you feel like any part of that was maybe you didn't plan on doing this whole economics aspect of things, but medicine, that was always something you wanted to do. You talked about being a pre med and kind of going into that. Do you feel like maybe a part of that was feeling uncertain about the PhD or the economics PhD versus more competent in the identity you had going towards medicine?

Great point. Yeah. So I think that was part of it. But what you said also made me think of something else, which is my experience in my PhD. I actually think it was pretty similar to other students who I was, you know, who I went to school with. Like everybody was having a hard time. But it is true that that others had prepared to do a PhD in economics. And so in theory they could have felt that the PhD in economics was not as difficult as I perceived it to be. Though I don't think that that actually was true. I think we all had a difficult time and did our best and ultimately many of us made it through. But I think what you're saying is also probably true as well.

I guess moving forward, going on to residency and choosing internal medicine. How did you land upon on that?

A little bit by chance actually. I'll say the following. I always wanted to be a surgeon. My. I'll tell you just a story about my dad. My dad is a physicist, he's a physics professor and he grew up in a very small village in India. His parents were farmers, so couldn't read or write, didn't have any high levels of education. And he always wanted to be a doctor and in fact wanted to become a surgeon. And he was really, really smart. And so he. In India they have to take these exams. So in his state he took this exam, statewide exam. And on the exam, India is a big place. So it's a lot bigger than Massachusetts. So the states in India are much bigger than Massachusetts. So he scored number three. This is the story he tells me in the entire state on that test. And this was to go to medical school. And so the way it worked there at that time was that the top scores on this test would go to the top medical school and then so forth. It just so happened that around that time there was a new medical school that was built that wasn't it didn't have a track record yet. But what they wanted to do was get good students into that medical school. So they alternated the positions on that score list, that test list. So the first student, the first ranked student in the state went to this medical school. The second best student in the state went to the sort of well established medical school. And then the third student, which was my father, would have gone to this again, less established medical school. So even though he did really well in that test, he would have been allocated to this school that was brand new. And he's like, I'm not having any of this, you know, I don't know what, you know, what I'm going to learn here. And so he actually just didn't do medicine at all and went into physics and he wanted to become a surgeon. And so I kind of had this interest in becoming a surgeon. I'm in medical school and I don't know. You haven't played any rotations, right? You haven't. So surgery is fun and you know, it's difficult, right? The hours are difficult, the personalities are a little bit difficult sometimes compared to other specialties. But like, if you don't mind the being in the. Or working with your hands, being able to solve problems in the moment is a really phenomenal feeling. And I love working with my hands. I would have become a surgeon if I wasn't going to do research. But I thought it would be impossible for me to do research for the majority of my time and be a good surgeon. And so that's really what drove me away from something that I might have otherwise wanted to do. Now why medicine vs cardiology or gastroenterology or something like that. I liked cardiology. If I had to do a medicine based specialty and I wasn't going to do research, I probably would have done cardiology. But again, it came back down to me wanting to do mostly research and did I think that I could do the kind of stuff that I do, which is sort of wild and very general, it's not specific to any particular disease, area or specialty, could I do that and be a cardiologist? And I thought it would be difficult because what department of cardiology would want some guy who's writing papers about, you know, ADHD and what month you're born, they wouldn't want that. Whereas that might survive in a, in a general medicine environment. And so that's why I did internal medicine. It wasn't because I had a particular passion for it, but because I thought it would help me do sort of what I wanted to do in a.

Broader way and did it. Are you like, happy with how that worked out?

I am happy, yeah. I mean, I spend several weeks in the hospital now. Most of my time I spend doing research. I teach undergrads, I teach medical students and grad students in health policy.

Well, and just along those lines, like what, what is like a typical week or day look like for you?

Oh, well, it depends. So when I'm on service, I get up really early, which I'm not on service a lot because I mostly do research. But when I'm on service, I get up at probably like 5 o' clock in the morning so I can go and see patients in the morning, around and then around with the team and. And then by about noon or so, most of the work on my end is done. So that way I have the whole afternoon to work on stuff or do meetings or go to teach in the undergrad campus. And that's just again several weeks of the year. Outside of that, I usually wake up, I take my daughter to school. My wife's in radiology and she's more clinical, so she's actually, her schedule is less flexible than mine. So I take her to school, come back home, I work for a few hours, probably on a, on a research paper. I talk with a lot of students and colleagues who just brainstorm. I probably spend about 45 minutes to an hour almost every day brainstorming. So today, yeah, it's fun. Like, yeah, I mean, literally, I was talking to my ra, Charlie today, and you know, we're just like looking at some, some graphs and just brainstorming about random thoughts and I'll tell you some of them and you can see if you think they're good or bad. And. And then I play soccer every day between 12 and 2, almost every day. And then I do some more meetings the afternoon and then I'm around when the kids are back home at 5:45, and then I spend the rest of the evening with them.

Oh boy. Dad would like that schedule, huh, Stephanie?

Yeah, so my dad, my dad's in internist and he. Yeah, really? Same kind of thing. Pop into the hospital, pop out, play around, golf, pop back in, you know, do it's.

Oh, really?

Do a bunch of meetings. He's a big soccer fan though too. Quite as much anymore, but yeah.

Interesting. Yeah. And I've got a. I'm very lucky. There's no doubt about it.

Yeah, that's. No, that does sound, that does sound really fun. Well, that's what I, I wanted to Ask also, I mean, you know, just listening to your book and you know, all of the different studies that you talk about in that book, and I mean, obviously I'm sure you've, you know, published many, many more. But how do you pick which things you're like, how do you land on different projects that you're going to study? How. What's the process for that?

So the ideas, I think come from two places or three places. So we, we spend almost an hour, a full hour every other day. Like, that's dedicated towards brainstorming ideas where I'll just jump on the zoom and I'll say, okay, who's got an idea? And we just talk about totally, totally random things. So some ideas come from those, what I would call idea sessions. And then I think, and I don't know this is true or not, but I think that because we just talk, talk, talk about ideas in the same way that if you became, you know, if you wanted to be an excellent surgeon, you would do a lot of surgery, or if you want to be an excellent golfer, you would play a lot of golf. And we want to come up with the best ideas that we can come up with. So we, we just think about ideas a lot. And so I think that it helps me in the second category of where ideas come from, which is that I'm just walking around and I see something that someone would otherwise ignore, and I'll be like, oh, that's kind of interesting. It makes me think of this and that makes me think of that. And it just goes like that. And then ultimately it comes back to what you said it was. How do you land on an idea? How do you pick an idea? Ultimately, my sort of threshold is the following A, is I have to be excited and interested in it. If I'm not, then I won't. I won't do it. But then I also say, all right, look, if this finding, if this question were to show sort of the following result, like, what's the best result that I could get out of this question? And would that be exciting and surprising to people? That's sort of a general thing. And could I credibly send this paper to the New England Journal of Medicine or JAMA or someplace that would be a great place to see this work done? Or another sort of like, kind of criteria I have is like, all right, if this paper comes out, could I write an op ed about it in the New York Times? Or would some major journal be newspaper be interested in the finding? Or would it be so specialized and so niche that they wouldn't be, not because it's not important, but because it's just specialized. And so that's sort of my criteria is like, a, it's got to be exciting to me. B, I have to think that it would be exciting to other people. And then, C, I have to think, tory, can I do this rigorously enough and package it in a way that I think that a good place would be interested in publishing it? And if those things don't hold, then I don't do the paper or I don't. I don't try the project.

Well, that kind of leads me to, you know, what I. What I wanted you to talk about a little. I mean, there were so many wonderful studies that you talk about on your podcast and your book, but the one in particular that I think most doctors know about, I mean, I mentioned it to my husband at dinner last night, and of course he was like, oh, yeah, yeah, yeah. Was the one about the cardiologists and the. And what happens when all the cardiologists are at a medical conference? If you wouldn't mind, I know you've probably told this story a zillion times, but if you wouldn't mind for our listeners, would you kind of just tell about that study and what the findings were?

Yeah, I'll tell you those things. I can tell you the backstories behind the study and everything that follows.

Well, I want to know that, too.

Yeah. Okay. All right. So the study was. I'll tell you the study finding or the question. The question was, what happens to patients who have emergency or acute cardiac problems during the dates of the American Heart association and American College of Cardiology meetings? And the idea was this is a time where certainly at teaching hospitals, a lot of cardiologists might be out of town attending these meetings. And if you are a patient and you by chance happen to have a heart attack or a cardiac arrest on one of those meeting days and you show up at the hospital, would the care that you received be any different, and would that affect your outcomes? And that was the question. And the finding was that it turns out that if you happen to be hospitalized with, like, let's say, cardiac arrest during the dates of those meetings, your outcomes are actually better. And that was not what I expected to see. I expected to see that outcomes would be worse because the staffing in the hospital would be less or the quality of the staffing would not be as good. Maybe the best people go to the meetings and sort of the other docs who are Less specialized or, you know, maybe not as clinically active. They. They remain behind and outcomes will get worse. That's what I thought we would see. And we found the opposite. The other thing that we found was that rates of stenting fall, coronary stenting, fall by about a third during the dates of those meetings. And it suggested to us that maybe what's going on is that during these meetings, the intensity or the aggressiveness of medical care that's provided just falls. And it maybe falls because the people who are doing those procedures aren't there, or maybe because there's less backup. So if something goes wrong, you won't have backup from other doctors. So maybe you say, ah, well, I'm not going to actually do this surgery or this procedure on this patient. So that was a finding. And it got A lot of. This paper came out, I think, in. I'll tell you another story. This paper came out in December of 2014, and it was. It got a lot of attention. And I remember, like, the. The feedback, I think, was generally quite good. Like, oh, this is so kind of wild. How would you know who would think of this? And I'm surprised that you even see this. And let me say it was a good, natural experiment because people don't choose to have cardiac arrests, and they don't choose to have cardiac arrests on the days of the AHA or ACC meetings because they don't know what those things are in the first place. And you can see this very clearly in the data. It's like a natural experiment where people are randomized to these very different types of care on these meetings without knowing it. And it allows you to study the effect of that care on outcomes. So that was a study. It came to me because I happened to be working in the cardiac coronary care unit sometime in training, and I think it was around the AHA or ACC meetings, and the staffing felt different. I don't know if it was different, but it felt different. But it's one of those things where, because all I do is think about ideas, I was like, oh, wow, the staffing feels different. I wonder what happens to people who get hospitalized, like, during the dates of these meetings. And that's how the study sort of emerged from that sort of random, random thought. But.

Oh, well, what you were going to say something about the backstory.

Oh, other stories. Okay. Yeah, yeah. There's some other funny story. This is. This is Stephanie. This is about life. You asked about my life, so that's.

What this is all about.

Yeah. So my wife was Pregnant with our first child at that time. She was born in December of 2014. And I remember. I think it's like the Wall Street Journal and New York Times. Someone wanted to interview me about the study, and they called when we were in the hospital. My wife was in labor. You know, labor can take a long time. And so I'm like, oh, do you mind if I just step out to take this interview? I was literally going out down the hall for, like, 12 minutes, and then I turned back and I look and people are rushing into the room. And I said, oh, no. So I go back in the room, and everything was fine. She just, like, moved a little bit. And so, like, the, you know, the things are measuring the fetal heart tracings, they went haywire. But I'll never be able to live that down. That I took an interview while she was in labor, but I just said she gave me permission. Full disclosure. So that was. That was funny. The. I remember Freakonomics. That was the first time I did Freakonomics. The. The main show. Stephen Duverner interviewed me for. For this. This particular study. And they actually went to either the AHA or ACC meetings and talked to people, cardiologists at the meetings, about whether or not they believe the study, which is fun. And I think that they interviewed either the president of the AHA or the president of the acc, who was actually a cardiologist in one of the Harvard teaching hospitals. And basically he was like, yeah, I don't really know what to make of this study. What it tells me is that our patients don't do any worse when the cardiologists are away. I was like, okay, that's one way to put it. Or they do better when the cardiologists are away.

Right.

So general backlash, though. What. What was it? And I guess, how did you deal with it?

You know, it was. I think the response is actually pretty positive. The sort of, you know, there weren't really any substantive criticisms about the study because we thought really hard about this. And it was, like I said, it's a clear, natural experiment. You don't have this problem when you see all these observational studies on the news where, you know, like, coffee is correlated with cancer, or coffee causes cancer, or coffee prevents cancer, whatever it might be. Like, all those studies, they're sort of horribly confounded because people who drink coffee are different than people who don't drink coffee, or people who drink moderate amounts of alcohol are different than people who don't. So you don't know what's causing what and that problem we didn't have here. So most of the sort of things that people raised about the study we actually had dealt with and addressed. And people just probably weren't reading the study itself. They're sort of like reading the news articles about it. One thing that was interesting to me in the publication process, I remember we sent this study. I won't say the name of the journal, but it's a very good journal. And one of the reviews, which was clearly from a cardiologist, suggested he's like, well, how do you know that people aren't. You know, how do you know that people aren't having cardiac arrest at lower rates or differentially during the dates of these meetings, I was like, you're a cardiologist. You got to know. I mean, like, maybe someone who's not in medicine would know that, but certainly a cardiologist would be able to figure out that people aren't choosing to have cardiac arrest on specific days versus the other. And, you know, it was. It was clearly just a way to respond to a finding that they didn't understand or they didn't. They didn't like. And, you know, we basically are finding that there are some things that we might be doing that are harmful. That's not to say that medical care is, on average, harmful. Clearly it's not. But clearly there are also places where we do things where we might be delivering more harm than benefit. And, you know, I think the nice thing about this study was that it identified a place where on the margins, maybe we're doing a little bit too much more than we should.

Yeah. I was curious, and I didn't remember you saying it in the book that, you know, what the economic incentives are in a teaching hospital. I mean, I know that's slightly different from private practice. I'm not in academics, but I know that even. Even in a teaching hospital, there are economic incentives for doing procedures. I mean, proceduralists like to do procedures. And, you know, and you got, you. You talk about the fact that you have people that, you know that we're. We have a bias towards doing stuff rather than not doing stuff, which certainly makes sense, but there's even more of a bias when doing stuff makes you money for that boat payment that you got. So I was just curious if you had, you know, I'm sure you guys obviously thought about that, but maybe it was not, you know, or. I don't know if there was any of that. In the original paper, I noticed you said boat.

You didn't use the word yacht. Yeah, Exactly. Yeah, yeah, yeah. You know, I've thought a lot about this. You know, there is this concern and there, and there is literature about this. But, you know, the question is, obviously, you know, in economics, you think a lot about incentives. And so could, could the financial incentive, like, you know, if you get paid to do a procedure, is that on the margin going to make you more likely to do so, and if so, how much more? So. So I'll say two things. One is that there's lots of medical decisions that doctors make. In fact, the majority of medical decisions that they make that they don't receive any financial reward from. So, for example, you know, when you see a person in the hospital and you order in the clinic and you order a chest X ray or you get a particular blood test, you're not getting compensated for that blood test directly, right? And yet you might order blood tests at twice the rates or half the rates as your other colleagues were in that same practice. And it might just come from the way you trained, what your tolerance is for taking risks, how familiar you are with that particular thing that you're, you're, you're assessing for has nothing to do with the financial incentives. And most decisions that we make in medicine are like that, where if we order this procedure or do this thing, we're not getting compensated directly. Now, there are situations, I think, when you're thinking about procedures where that might not be the case and even true in a teaching hospital. And there, I think there are lots of other factors that kind of constrain the ability of a physician to sort of just operate on the purpose of, I want to make money and do this procedure, medical malpractice, professional norms, sort of the fact that if you are in the business of doing things that are ultimately harmful to people, that ultimately that will come out and affect your, your, your practice. And so I think that the, the impact of medicine, of money in medicine, while it might be there, is probably over overemphasized. And it's, it, it's a problem in the sense that a lot of our healthcare policies are focused on, on affecting these incentives. You pay doctors more to do certain things, you pay doctors less to do certain things. Let's say you pay doctors more because you incentivize certain behaviors, but then you find out by paying them more, they don't actually do that much more of the thing that you wanted to improve. And you say, well, why is that doctors, you know, should respond to incentives? Well, they might like all human beings do, but it's just not, that's not the incentive that they're responding to. So I don't know, that's just like sort of a little bit of a side on my thoughts like this. This is sort of a very widespread belief and I think that there's some evidence for it, but it's outsized in terms of its importance.

Yeah, I think there's some situations where it, that, that happens more than others. You know what I mean? Once in a while you do see it and it's pretty egregious when you, when you see it, but you hope you don't see it all that often.

Yes, agreed. Yeah, agreed. Yeah.

Just one thing that I did want to ask. This is kind of backtracking a little bit and just you talked about just being a very observative person and just, you know, you have these idea meetings. Have you always been like this or did this kind of develop through your experience doing research and being in a big academic hospital and having a lot of thinkers around you, or have you kind of like always been like this?

I don't think I was always like this. No. I mean, I didn't, I definitely wasn't having idea meetings when I was a kid or high school. No, I don't, I don't think that if I were to look back in middle school, high school, college, grad school, I wouldn't have thought of myself. I wouldn't say that like something I'm good at is coming up with ideas or. I wouldn't say that one of my strengths was being creative. I wouldn't, I would never have said that. I would say in the last few years one of my strengths has probably been coming up with certain kinds of ideas. You know, the kinds of ideas that we're talking about, which are sort of fun and clever and freakonomic style questions. And I think that has come just from a lot of doing, doing it. Now why do I do it so much? I actually mean I do it because I like it and, and, and, and that's what I think has allowed me to become better, better at it. But you know, I've talked with a lot of people who are sort of like minded and if they aren't like minded, when they start talking about these questions, they become more, we become more like minded and, and you know, we just bounce ideas off of each other and works out. But I wasn't always this way.

Yeah, I just thought that was interesting.

Yeah, like it's more, I mean, can be a skill that can be somewhat honed.

It seems that's what, that's what I, that's what I like when I give talks. I kind of start by that. I said, you know, if we can teach human beings how to transplant organs from a pig into a human being, or organs from a human being into another human being, how can we not teach them to be more creative? You know, we, we literally teach people to do everything that they do. How to program in a statistical language, how to, you know, become an engineer, how to become a surgeon, how to become a teacher. We just teach people how to do things, but we don't teach people how to come up with ideas. Right. It's like, you know, there's some people who are creative, some people who are not creative. That's sort of the way I think people think about it. But I don't see why we couldn't teach people to become more creative or at least try to do that and see what happens. I mean, I, I'll tell you, I work with a lot of people and when I start working with them, they don't think that the way that they do now. So clearly there's a change in how they, how they think about problems and come up with ideas that's different. Whether it's good or bad, it's hard to say. But I think it's something that can be sort of developed.

Yeah, no, I really like that.

Part of that had to do with getting the PhD in economics. Was that part of that process or. Not necessarily.

I think it, I think it was in a part, in part in the following way. Like I, if I were to think about all the disciplines that are out there, social science, various social sciences, biological sciences, physics, chemistry, whatever it is. Economics, I think is one of those fields which is just extraordinarily creative. It has a lot of other problems, but one of the problems I would not fault economics for is not placing a real sort of priority on just being ultra creative. You know, if you think about, for example, work in the basic sciences, in biology, for example, the papers that you would see in a journal like Nature or Cell or Science, I mean, they're groundbreaking papers. And a lot of that work will probably come from investigators who are creative. But a lot of it will also come from being extraordinarily well resourced and being able to attract great talent and being connected and just being able to do the brute force that's required to do these sort of foundational discoveries. In economics, it's different. You don't have teams of 50 people on a research paper. You know, one of my advisors in grad school, Steve Levitt, who is, who is one of the co authors of Economics, he was the single author on probably most of his papers or a lot of his papers. And that's true for a lot of economists, single or dual author papers. It's very rare that you see like 12 people on a research paper. And so I think that the field has had to prioritize creativity. And so that part of it I think does help. But the last thing I'll say is a lot of people I work with aren't PhD economists. Many of them are medical doctors. I work with undergrads and at least these kinds of questions that I work on are things where I don't think you need a PhD in economics to be able to come up with these kinds of ideas. Maybe you need it to be helpful to do the actual statistical work to support the final sort of product. But just coming up with the idea in the first place, I think you could do without that.

Well, that's why I really enjoy talking to people like you and spreading this on the podcast. Because sometimes I feel like with just the path that medicine is, it doesn't feel like there's a lot of room for to be creative and think of ideas and all of this stuff. So it's inspiring to hear that just because I feel like as you said before, you think of either you're a creative person and you're not a creative person. I think a lot of people who go down this path kind of maybe associate themselves as being a not creative person. At least I kind of do. I'm like, oh, I'm more stem minded. I'm not creative.

So.

So I think it's just interesting to have this conversation.

Let me tell you just one thing that happened. I was on service recently and I think when you practice, I don't know, like Sarah, when you see patients during the day, would you say that when you make decisions, treatment decisions, diagnostic decisions, that you're being creative? You'd probably say I'm not being. And in fact, it's a little bit dangerous to be creative.

Yeah, yeah. I wouldn't say creativity is high.

Yeah, exactly. Yes, it's dangerous too, right? I mean, you just want to be like, what do I know to be true, what do I need to figure out and how do I get there and what you know, you kind of based on knowledge and experience. But I was in the hospital recently and we had this patient who was really, really sick who had end stage liver disease and was not going to be given a transplant, liver transplant. And so we. We were trying to figure out what we could do for this person. And ultimately the goal was to try to get him to a different hospital that was closer to where his family was, but there was just not. We tried a lot of stuff to help stabilize him, and it wasn't really working well. And I remember asking the team, I was like, look, okay, if you read the textbooks, here are the things that you should do, and these are the things that we have done. And I said, let's just like, take a second and think, like, what are the things that we could do that we could try for which there. There aren't studies yet to support it, There are no FDA approved drugs to try it. Like, you know, we could talk with the family and say, look, you know, our goal is to get them from here to there. It looks like it's not going to happen. With what's being done so far, what could we do differently? And, you know, we just brainstormed. We use ChatGPT, actually. It was like saying, just asking ChatGPT, you know, to think about the physiology of what was going on in this individual. What types of things would it recommend that we had not tried? And it actually had some, I mean, some bad answers, but also things that are like, all right, this physiologically makes sense. Ultimately, we didn't end up doing any of those things, but we talked for like half an hour, 45 minutes, where we weren't trying to say, oh, are you familiar with that clinical trial in Lancet? Are you familiar with that clinical trial? And blah, blah, blah. Or don't you remember reading this in med school? We were actually trying to create a treatment based on what we understood to be the physiology or pathophysiology of this person's illness. And a lot of probably medical discoveries happen in that way, but we don't surround ourselves with those opportunities. We're in the hospital just sort of taking care of problems as they arise, as opposed to saying, all right, how could we do this differently than we currently are? So that. That was fun for me. It's like the creativity is. Was now applied to a very different setting than I normally try to apply to.

Yeah, that's interesting you say that. Just last week on the podcast, we had Stephanie's brother, my son Ryan, who's a computer engineer, software engineer, and he was talking about AI stuff, and he was talking about, in that field, you have to be creative and you have to always be kind of shooting for something more and higher and better, whereas in medicine, a lot of times we're like, we're working worried about the bottom. You know, like we, we got to make sure that we don't mess something up if something, if somebody is otherwise doing well, I don't want to make them worse. I'm not trying to make them into Superman or whatever. So a lot of times we don't have the luxury of being able to try these different things unless we're in that type of situation where like, okay, I've got nothing to lose here, you know, this patient is not doing well, or one goal is to be able to get him to this next thing. And then all of a sudden we finally get to be able to like, okay, well let's try this, let's try that. But we, those situations don't that often, I think.

Yeah, no, it's interesting because you know, in medicine we say first do no harm. But you know, firms don't. There's firms in economics, they maximize expected profits. There's nothing that says first, first, don't lose money or something like what the equivalent would be. You know, it's sort of, you're, you're right in medicine. And it may be appropriately so. I don't know not or not whether it is or not. But we do focus mostly I think on the, on the downside, you know, what are the consequences if we do something wrong?

And I also love how you guys used AI to think of more ideas. I feel like a lot of people say like AI is going to decrease creativity and all of this stuff, but using it like that, of how can it spark more ideas, I increased creativity. I really like that.

Yeah. Let me give you an example. Is there any question that you've thought about recently?

I'm on break, so I haven't done a lot of thinking.

But. But you know, someone told me something else really interesting the other day about, about breaks. He had basically suggested, I think there may be some. I don't know if there's evidence for this or sort of modeling evidence, but he said, you know what happens when schools close because of snowstorms or weather related events? Can that break infectious disease transmission cycles? So basically let's say that flu is going on in an area. We know that one way in which flu spreads is in through schools and then kids bring it home to parents, grandparents, that kind of thing. So suppose that you hypothesize that if school closes just by chance for four days, could you break transmission like transmission pathways of influenza in a community? It's not a crazy thing to think of if you think about like how the disease spreads. And you could get at that in a natural experiment by looking at school breaks. You could look at when holidays happen and assume that that's not correlated with when influenza is coming or look at snow related breaks and study like patterns of flu growth in places where it snowed and it didn't snow and schools are closed or not skills. So anyway, that's what we do, Stephanie. We just sit there and come up with random ideas.

But I love that, just being able to chat about ideas, like, that's awesome. But I always ask all of our guests this and I kind of just posted a clip with a bunch of our guests that were saying their advice. But I always ask like as a first year medical student and as somebody who's just at the beginning of this journey, what advice do you have for me or other peers who are kind of at the beginning of this long journey towards medicine?

Ask Chat. GPT.

Yeah, yeah, yeah.

Good, good. Like you're already med school, so we don't, we don't need like a med school application letter.

Right.

You know, I would say the following, and I don't know how easy it is to remember this or to feel this when you're going to be in the moment, but I have been thinking about this issue more recently, which is if you think about medicine as an occupation or a profession compared to law or you know, say your son's doing engineering or whatever it is nowadays, many of these occupations will pay more and compensate more than medicine. They might be even fewer hours than medicine, but the one way in which they can't compensate you is that there is really no better feeling that a human being can get than when they help someone feel better. Like it really makes somebody feel differently if they're able to do that. And it's hard to get that feeling if you like solve a coding task for somebody or do whatever you do for them. But it's true in medicine. And so one of the sort of, like I said, like the richest forms of compensation that doctors receive or that healthcare providers receive is through this. And I would ask you to think about whether that feels the same today as it probably felt 30 or 40 years ago when people are in practice. And Sarah, neither you or I were around practicing back then, but I would hypothesize that people in the profession felt differently then. And I don't know why that is the case now. So I would say to you, like, you know, you're going to go through medical school you're going to go through residency, it's going to be very tiring. You're going to feel the need to learn lots of stuff. There'll be lots of other pressures. But if in each encounter, you can think to yourself, like that person who's coming to see you, they're coming to see you for. For a reason, and you have an opportunity in that moment to change the trajectory of their day, right? And, like, I never thought about this very much until the last last few years, but, you know, now when I'm on service, you know, we spend a lot of time emphasizing, like, teaching the residents and things like that. But, like, I would much rather spend 10 minutes less looking at Epic in the EMR than go into a person's room and just talk with them. Because what I never really fully appreciate is that when you go into a patient's room in the hospital, they might be smiling and chatting with you. Maybe they'd be cracking jokes, but they were looking forward to that discussion and that conversation with you for the entire. That's the only reason they're in the hospital, is to have that discussion. And so if you go in there and you go out and it's quick, and you haven't taken your sort of opportunity to make that person feel better, there's a great thing that was sort of lost. Now, how do you keep that feeling? I don't know. It's difficult. Like, I've tried to do a lot more of that now than I used to. I go and I asked people like, you know, talked about their lives, where they're from, what they like, and we. And I enjoy it. I think it makes them feel better, and it makes me feel good about. About what I'm doing. So I don't know. That's what I would say.

That's interesting.

What do you think? What do you think, Sarah?

No, I agree. You know, I'm lucky enough that sometimes my patients, you know, will. You know, they send you notes sometimes, and. And I do. And of course, I keep them in this little drawer, and I do once in a while just go through and read them. And that's helpful. But, you know, I mean, people don't write things down all that often. And so maybe that's something like where you kind of journal, you know, when you kind of have that feeling from a patient or a patient tells you something. If you like, write that down somewhere in your little notes on your phone or something, and then you can revisit that when you're having those times of feeling Lower. Maybe I need to start doing that, too, because unfortunately, we have those biases. We have that sort of negativity bias that you can have 10 great interactions and then you have one poor one, and that one poor one sticks in there and festers and bothers you. And you really need to go back and focus on those 10 great ones or any great ones to try to even the score.

Yeah, I mean, I think. But I, you know, I love healthcare policy researchers, right? They, like, write about lots of interesting things, but to me, sort of the, the scarcest resource in all of medicine is time, right? Like, how can you, if you're seeing someone in 15 minutes, how can you develop that glow that. I'm talking about, the glow that's going to make them feel better, the glue that's going to make you feel better. It's impossible to do it in like 10 or 15 minutes. Right. And, you know, maybe some things you literally can solve and everybody can feel fine if you do it in 10 or 15 minutes. But other things, they require more time. But the way that medicine is sort of done now, it doesn't prioritize, it prioritizes just the diagnosis, right? Like, you can make probably within 15 minutes an appropriate diagnosis and treatment plan for most patients who were 15 minutes or 30 minutes, whatever it might be, you could do that. But does that mean that the encounter, the person leaves there feeling better than they otherwise would have felt? Do they think, well, you know, I trust this doctor. She spent a lot of time talking to me. She understood what I was worried about, whatever it might be. You can't get all that in 15 minutes. And the question is, like, if you're a healthcare consumer, what's the product that you're buying? Are you buying the diagnosis? Are we ensuring just the diagnosis or are we doing something more? And I think that we, We. We're doing something more, but it. It doesn't work that way.

Yeah.

So, Stephanie, you should go to concierge practices. When I'm.

Well, that's what she do.

That's what she does.

Oh, perfect.

Exactly.

There you go. I didn't know that, but now.

Yeah, but as we're kind of wrapping up, do you have anything that you want to plug? Any socials, Your book? Where can you.

Oh, yeah, we have a book called Random Acts of Medicine. It's a. It's a fun read. It's like Freakonomics meets medicine. I have a podcast, Freakonomics md. We don't have any new episodes, but still, you can listen to a couple hundred episodes are online. I think close to that. And then I have a new column. I'm doing a Time magazine with my co author, Chris Worsham. So we had a piece come out last week about science and values, and we've got another one coming out pretty soon about taxicabs and Alzheimer's disease. Wow, that's. I know. I ended up on a cliffhanger.

No, I know. We love it. We love it. And you guys know where to find us @Generations MD on TikTok enerations MD on Instagram. And if you have any questions, you can email us@askgenerations md.com and we will talk to you next week.