Ezekiel Emanuel on the Practice of Medicine, Policy, and Life

Conversations with Tyler is produced by the Mercatus Center at George Mason University, bridging the gap between academic ideas and real-world problems. Learn more at mercatus.org. And for more conversations, including videos, transcripts, and upcoming dates, visit conversationswithtyler.com. Hello, this is Tyler Cowen, and I'm here today with Zeke Emanuel, who in my view needs no introduction. So let's start in on doctors. Do we overrate the importance of IQ for doctors?

Oh yeah, that's definitely the case.

So what is it we're underrating in relative terms?

We think that smarts is what counts, but I think a lot more of it is emotional intelligence, judgment under pressure, much more important. So just think about what the big challenge is for medicine today. The big challenge is the fact that 86 cents of every dollar goes for people with chronic illness. That's an illness they're going to have every day for the rest of their lives or every day for the foreseeable future. And the main thing is to get them to change their behaviors related to that. And that is not about intelligence. That is about, you know, relating to them and emotional intelligence and getting them and persuading them to change their behavior.

If not IQ, what's the best predictor of emotional intelligence in a way you might find on a Vita or a LinkedIn profile?

I'm not sure actually what the best predictor is. This isn't, you know, I'm not a person I would say I've had to cultivate my emotional intelligence. It doesn't come natively to me the way it does to one of my brothers or both of my brothers actually. But I do think the ability to understand what's going on in someone's person and the ability to tell, you know, fake from real smiles is probably really important. And, you know, we talk about a lot about empathy, and empathy is one component of emotional intelligence, but only one component of it. But there are some games that you can play in collaborative, looking at collaboration.

Should doctors be made less central in medicine if they're a group overall deficient in emotional intelligence?

So, Doc, I think increasingly doctors are just one part of a team. They are typically the captain of the team because they have some knowledge and insights that others don't, but they have to be one part of a team. We recognize a lot. You need chronic care coordinators, you need mental health specialists, you need dietitians, you need pharmacists. All of them have to be components of a team, and the doctor is typically the captain of the team, but not the only member of a team. And I do think we tend to overrate the importance of a doctor and underrate the importance of a system around the doctor.

Who in the healthcare establishment has the highest emotional intelligence?

I'm not sure. So I think there are professions that tend to have high. I would say actually one profession that has a very high that I've seen is when you properly select community healthcare workers. Not everyone has encountered a community healthcare worker, but they tend to be people who want to do good, are good listeners to other people, good problem solvers for other people. And I do think that's a group, when I've met them, tend to be really high in EQ.

Is there a shortage of physicians in the United States right now?

Well, if you listen to the Association of American Medical Colleges, the AAMC, the official body, as it were, there's a shortage. And interestingly, if you go to almost every other country, they say there's a shortage. The fact is there's no shortage at all. If you calculate out, and we did this crazy calculation, someone said, "No higher math required." just lots of division. If you look at the number of office visits that we have, you look at the number of primary care doctors we have, you actually be— are quite generous, half an hour a visit, not 12 visits a day. You can easily accommodate all the primary care visits we have and also all the primary care visits we need with the current existing doctors. It's really about how we allocate their time, and it's also about not using the office as much. There are lots of things we've brought patients in for that we don't have to bring them in for to actually give them adequate care. You can do over the phone, you can do text, you could have someone else, a nurse practitioner, even a medical assistant, the front office desk person can do it. And I think getting that, what we're, in the highfalutin language of task shifting, under our belt, we're not gonna need more doctors. And I fear that once you train a doctor, You know, it's basically $1 million or more, depending on what kind of doctor you have, of billings that you have to do to care and feed for them. And that's a lot of money.

But as you know, we have medical licensing. There are immigration restrictions on doctors. Are you saying these constraints are not binding? There is some counterfactual where we would have more doctors. Would they just not do us any good?

Yeah, no, I think they would drive up the cost. You know, medicine is a classic case of supply-induced demand. Doctors write orders, and they need— they have a certain income in mind, and they will do things to get to a certain income. And especially on the margins where we don't, what's called unnecessary care or low-value care. And that's a bad thing if you have too many doctors who need to get to a certain income and the demand's just not there.

Why can't I get a doctor to respond to my email? I have a simple question. I just wanna know. I'm stuck with Google.

Well, that I think is, again, we need to distinguish the workforce problem from the problem of the way it's structured and the way it's organized. Do we actually need more bodies or could we more efficiently more efficiently organized system. The latter is the problem, more efficiently organized system. And if you look at places that actually do a great job, they do a very good job with fewer doctors and more of other people who do respond in a timely manner to emails, and most of those questions can readily be answered without doctor's knowledge.

There's a current, much cheaper concierge model of healthcare that's spreading rapidly. Is this the future of healthcare for at least the upper middle class in this country? What do you think of it?

Ah, well, I have an ambiguous— so I'm not— I don't think there's an in-principle argument against it.

Okay.

There is an argument against it if it undermines the care that the rest of us get. If the rich buy up—

But there's no shortage of physicians, so it shouldn't take away—

Exactly. So I'm not in— that's why I say I'm not in principle against it.

But why aren't you for it?

I actually think The sick people ought to get concierge medicine. That's the real future. People who are at risk for serious complications, serious exacerbations of the illness, they're the people who need concierge medicine. And again, if you go around the country and you look at places that are really performing well, super high quality, low cost, they almost all give concierge medicine to the sick people, not just to the people who can afford it. And I think that's actually much more relevant to what we want.

So you would do that, say, with vouchers perhaps in some counterfactual world?

Yeah, there are a lot of ways of doing it. I don't think you actually need vouchers. You need to make doctors fiscally responsible or at risk, as we say in the business, for their patients' health, for the total cost of care of their patients. And then they really are going to focus their attention on more sick people. And yeah, the rich will always buy out. And we need to be— we need to recognize that, you know, 1 or 2 or 3% of the population can afford Courtauld's medicine, but 97% 97% of us, first of all, can't afford it. And for many of us, it's just not the highest priority in our life. And so we won't pay that extra money to get those docs.

How can we improve medical education?

Cut it down.

Make it shorter. Cut it down.

Yeah.

Why does that make it better, or does it just make it cheaper?

No, I think it will make it better. So we have a lot of memorization, a lot of sort of, so let's go back to the start. The 4 years of medical school, 2 years of preclinical in the classroom learning about biochemistry, genetics, anatomy, microbiology, and the 2 years of clinical time in the hospital on the wards. That dates from 1910, and we haven't really updated it much except in this one way. We've cut down the preclinical time because we— less of it, and it changes so fast by the time you learn it in medical school, get out as a doctor, it's out of date, A, and B, it's more or less irrelevant to managing most patients. I mean, learning what kind of virus HIV is or herpes virus is, is it a lentivirus, is it some coronavirus? Really irrelevant to medical practice. Totally irrelevant. Why we teach it, I have no idea. Similarly, the Krebs cycle. I learned it— I counted 6 times, never used it once in practice. What are we doing? So just think about the future. In the future, all these preclinical courses are gonna be online. You're gonna have great teachers who are teaching online. Well, what's a medical school doing other than showing you videos? And we already know today A third of students show up to class. Two-thirds of them look at the videos of their class already. So I think increasingly we're going to go to, you know, you'll do the preclinical work before you get to med school, and then med school is really the clinical work. And then, by the way, in med school, spending your time in a hospital is not the future. The future of American medicine is out of the hospital. So we need more rotations, more experiences for students out of the hospital. No med school has made that big shift. And those are the shifts that are going to have to happen over the next 15 or so years.

Should I need an undergraduate degree to go to medical school if I can pass a bunch of tests?

Yes, absolutely. Because an undergraduate degree is not about skill building. It's about finding and understanding yourself deeper and understanding your place in the world, understanding your place in history, understanding your place in, you know, the economy.

So you're saying I should need it or I shouldn't need it?

You should need it. Absolutely.

But what if I know I want to be a doctor? I can pass every test you throw at me. Throw at me.

Absolutely. It's not about— again, this goes back to the EQ/IQ thing. It's not about the IQ that you keep thinking IQ here, Tyler.

What if I pass every EQ test that you can throw at me? What if I want to become a doctor?

Tyler, there are outliers, and maybe you're one of those outliers. I'm not saying me personally, but I don't think that is the major issue here. I do think that there's a lot that you learn about yourself that is very important for being a good doctor and being able to relate to patients. And again, this is where we overemphasize IQ as opposed to EQ. I mean, one of the problems, I think, of American medical training is the pre-med requirements. They are ridiculous, absolutely ridiculous. I'm in the literature saying they're ridiculous. Organic chemistry, irrelevant.

But you need to commune with your soul for 4 years, right?

I think more philosophy, more American history, more English literature, more psychology, more behavioral economics, all those, and political all those things would be better.

What if I want to become a doctor but don't want to ever have to touch a cadaver? Should there be a path for me? I just want to look at screens and do software and integrate technical systems with, say, hospital systems as a doctor and not get my hands dirty.

I don't— probably not, but I'm not 100% sure about that because there are probably areas where you don't need to— the clinical side or even the insights into the clinical side. One of the things you might say that's gone wrong with electronic health records is that they were designed by people who didn't understand the clinical interaction. And I think one of the things that totally frustrates current doctors is, you know, these things were written and damn it, they don't integrate well into my clinical experience, into seeing a patient in the office. I'm on the screen too much. I'm not interacting eye to eye with patients. And I think that's a result of people who really didn't understand the clinical world But I learned that from the dead bodies.

Wouldn't I learn that from the live body? Do I learn EQ from the dead bodies?

Yeah, well, I think you might learn something about your relationship to dead bodies and your relationship to death and your relationship to using a body and simply manipulating it. That would be important.

What non-obvious advice would you give to medical students today?

I've just, I think, said it, which is learn a lot of the other stuff about life. And, you know, the preclinical stuff is not that important. We put a lot of emphasis on that microbiology, that pathogenesis. Pathophysiology. Learning it is important, but don't overemphasize it. There's a lot of other life that you need to really understand to understand American medicine and to understand your patients and provide optimal care. I also would say to medical students coming up, I do think that this is probably the most exciting time in American medicine in a century since really about 1910, 1920. And it causes a lot of anxiety for people. So I want to be sympathetic to that. You know, change is— we all talk about change in America. We're all for change, except we don't like change. We're all conservative. We would prefer no change. But I do think if you're— if you can go with the change, this is a super exciting time when lots of things are changing and you can have a real positive impact in shaping the future, probably for at least half a century. We're gonna put in place the structure over the next decade that's gonna be in place for the next half century of American delivery.

Without citing what is pending, how much has chemotherapy improved in the last 20 years?

Huge.

How so?

Gotten fewer side effects. We have real cures for illnesses. I'll just give you one example, but it's sort of characteristic. When I started out in practice learning in 1990, I became an oncology fellow at the Dana-Farber Cancer Institute. CML, chronic myelogenous leukemia, a disease of old older people around 60 years old. It was a chronic disease, sort of smoldered along as we said, and then blasted off, transformed into acute leukemia, and within 6 months people died regardless of what you did. You threw a lot of chemotherapy at them and they died. Now, actually a colleague of mine from the Dana-Farber developed a drug called Gleevec, basically made it a chronic illness. People don't die of CML anymore. They die of some other condition. It is really a miracle cure and it's a very easy drug to take. It's very expensive, or was very expensive when it was on patent. Novartis jacked up the price tremendously. But that is one example. We now have immunotherapies that are making dramatic changes, curing kids with incurable ALL or curing people with B-cell lymphomas. In the next year or so, they're going to be treating people with myeloma with it and probably curing them. So there's been a lot, a lot of changes in the chemotherapy world.

What's the best metric for discerning how well the war against cancer is going? I tried to Google progress against cancer.

It's very hard.

I found it remarkably hard to find anything useful. But that to me is not an encouraging sign. And I'm good with Google.

You are good with Google. I know that. So I would say that actually what you want to look at is the relationship between— you want to look at 5-year mortalities and the percent of people who have 5-year mortality, but you also need to measure that by not having too much early diagnosis. So one of the things we've noted is that we can diagnose a lot of cancers that would never have been a problem for people. Almost all of us have cancer cells floating around in our body. Our immune system takes care of it. We have done a remarkable job in many things in early diagnosis.

But that can be bad, of course.

That's what I was about to say. What we know now with prostate cancer, we're taking out a lot of prostates. People are getting side effects, impotence, incontinence, and yet that we're not actually having a big impact on mortality. So you need to look at the impact on mortality overall and the 5-year mortality ranking, the percent of people who have a 5-year mortality controlled for stage of disease. That's a hard metric to come by for a non-oncologist to see. So we've done, for example, a remarkably good job of early diagnosis of breast cancer. 5-year survival of breast cancer in the United States is the highest in the world. But a lot of that probably is due to early diagnosis of small cancers that wouldn't have made any difference to the woman anyway. We have actually not had that big an impact on larger cancers. And so what you see is the overall mortality from breast cancer hasn't really changed. So you need to look at the overall mortality in the population.

Now Michael Webb from Stanford measures that in medicine, we're throwing more and more inputs at these problems and life expectancy is only going up at a constant rate. In the last 3 years, it's down a tiny bit. Yeah. Either the medical establishment, the scientific establishment, somewhere, right? Something is failing?

Get your expectations right. You shouldn't expect the medical establishment to have that big an impact on life expectancy. So it is a reasonable metric, but if you really want to affect life expectancy— and by the way, I'm not a big proponent of using that as a metric for all sorts of reasons. We should invest in education, better housing, more equal incomes for people, not invest $3.5 trillion in the healthcare system. The healthcare system by and large has come, you know, at the end. People already have diabetes. That's not the best place, most cost-effective place to invest. And we know that probably the opportunity cost of overinvesting in healthcare come at the cost of education, housing, and other things in society. And so it's not a surprise that we're spending a lot of money and the returns are down. It's not because Japan spends a lot of money that they have an average life expectancy of whatever, 84 years. The highest in the industrial world.

Now, biomedical ethics. In addition to your medical degree, you have a PhD in political philosophy from Harvard, right?

Yes.

What do you study to get that? Is it in the philosophy department?

Yeah, I did a lot of philosophy. I did a lot of political theory in the government— Harvard's political science department's called government. Yeah, those are the two things. I also did some law training.

So your ideas on biomedical ethics, where would you say they come from? Is it that you read people? People like say Daniel Callahan and Norman Daniels and they persuade you, or you're an intuitionist, or you read people like John Rawls that are highly abstract, or it comes from Plato and Socrates. But what connects your views on concrete issues of biomedical ethics and philosophy? What's the transmission belt? Whoa.

I don't know that anyone's actually asked me that question. And I think it's pretty complicated. I don't think it's a linear process.

But it's no accident that you studied both.

No, it isn't an accident. And I did actually do— read all those people. I read a lot of John Rawls and contemporary ethicists. I read a lot of sort of biomedical ethicists like Norm Daniels and Dan Callahan. I would say that in general, what I try to do is intuitively figure out what the right answer is to a situation and then figure out what are the principles that got me to that right answer and what are— What are we trying to do? I would say that— so this is a biographical statement about the way I do it. In general, when there's a conventional wisdom about a problem, I usually find that wrong. And I spent most of my career as like, "Oh, that's the conventional wisdom. It must be wrong. Here's the right answer and here's why it's the right answer and the conventional wisdom is wrong." And typically one of the problems I think with the conventional wisdom is is that they overemphasize one set of values and tend to underemphasize other values that are important. And I'll give you an example. For I think most of our discussions, we have overemphasized individual autonomy, certainly since I've been working in this area for the— since the mid-'80s. It's autonomy, autonomy, autonomy. And that sort of disengages people in two ways. One, it sort of removes people from their social network, whether it's family, community, religious orientation. And I think that that's just wrong. Emphasizing the individual has consequences for other people. And the second thing is it sort of ignores the economic political realities that some choices for individuals will have big economic or consequences, political consequences for other people that we need to take account of. Spending a lot of money on one person definitely means we're not spending it on other people, and we have to take that into— giving one person an organ means someone else won't get an organ, and we need to take that into account. So part of what I have— I think a lot of what my work has been is the values that we emphasize tend to be exaggerated and probably inadequate to describe the situation, and we typically need to put in more values. So once we have lots of values in the pot, as it were, we tend to be really bad about prioritizing them. And I think I tend to be one person who says, you know, here is the constellation of values and here's how you should prioritize them. Not everyone agrees with me a lot of the time, but I do think I'm trying to bring in more subtle values and widen the way we think about issues.

Does the notion of informed consent have real meaning in low-trust societies? Won't people read the supposed agreement and assume the real conditions of the experiment actually have to be something else? Because they're used to being screwed over or the actual deal being different from the stated deal.

I think that's an excellent observation, and we way overemphasize informed consent as a protection of people. I think that's very common in American society. Just give people information and they'll decide. Well, I don't have enough time to get information on everything I have to do. I have to trust lots of institutions. I have to trust the regulatory oversight bodies that are making sure the airplanes are working. I can't I can't go out and inspect the plane every time I take off and things like that. And I agree with you, in low-trust societies or societies where there aren't good institutions, relying on individuals is no substitute for relying on institutions to protect us. And I have often said that, you know, it's very hard for an individual to figure out the risk-benefit ratio of a, say, a research experiment or any medical procedure. And that you need to rely on others with expertise. And I think one of our problems at the moment is we're way over on let's give people information and they'll decide. No, it doesn't work that way. Information overload, lots of us have inertia and we have a hard time. I will tell you, I read financial information about my stocks or my bank account or my credit cards and my eyes glaze over. I'm very bad at it. It's, I'm not protecting myself. I need someone else to protect me.

Do we need to fix IRBs?

Yes. How? When I was in the White House, one of the things I did was we had regulations governing research, biomedical research. They had not been revised in decades, and they were certainly antiquated and out of date. And I initiated and led a process of revising the regulations.

But your institutional review boards, should they have less power or more power?

They should have different powers and they should emphasize different things. One of the problems is you go to an IRB and they, or, you know, their entire, almost entire focus, almost entire focus is on what's in the informed consent document. That's wrong. And we have, I've written extensively about there's an orderly process for thinking about the ethics of research and informed consent is at the bottom of the process. There are many things you need to consider. And I think the number one thing that needs to be considered is really risk-benefit ratio of a research protocol. It's the hardest thing for individuals to understand who aren't experts, and it's really where the focus should be. And if you put the focus on risks and benefits, some things that IRBs often object to might turn out not to be really that problematic, and some things that IRBs don't object to enough, they turn out to be really problematic. And so I think more emphasis on risk-benefit ratio and less emphasis on informed consent, and certainly no responsibility for the IRB in terms of confidentiality. That's someone else's, you know, some other arrangement. I think that's very important. Also, we shouldn't have IRBs at each institution. I think the whole notion of IRB, Institutional Review Board, is a mistake. If there's a protocol that's being run at hundreds of institutions, which is quite common, we should not have each institution reviewing it. It's the same risk-benefit ratio. It's the same group of people. One body can interview it, and that's much more efficient. And efficiency is also important because delaying protocols by a year Wastes a lot of money, time, and for no benefit.

Is there a right to medical self-defense that should override FDA bans on drugs and medical devices? I want to try something that's not approved. No, I don't like that. I say it's my body. But why don't you like it?

No, no, no, no, no, no, no, no, Tyler Cowen.

Is there a right to self-defense if someone attacks you?

Yeah, you're already talking about, you're talking about we need a high-trust society where we can really rely on things, and so we don't have to examine individually every time, every item, even to make the informed consent process go well. And then you say, let's get the FDA out of here because I should be able to do whatever the hell I want with my body. Wrong. We all need to rely on the fact that the medicines we take are proven safe and proven effective, and we have to have institutional structures to oversee that. Some individuals may be able to do it, but we have a society of 325 million people and we have these institutional structures to oversee what we're taking is safe and effective for for all of us, not just for the lone individual who's got a lot of money who says, "I wanna do it, damn you all." You wanna do it, damn us all. You've got enough money, you know, go to Tahiti. It's really not this institutional structure we want. And we know that because thalidomide, lots of drugs that have— unfortunately, I think the FDA has swung to approving drugs that have risks and either low or in some cases they've even approved drugs with no benefits.. And I think that's a mistake. We have to get to better approval. We have created a process of compassionate use where people, where if a drug's been proven relatively safe, not completely safe, relatively safe, patients can solicit to get it without, I think, before it's been finally approved. I don't actually, I'm not a big fan of that.

If someone starts shooting at me with a gun, maybe it is better for everyone if I simply But do I have a right to shoot back or to try to charge them and get the gun away from them and possibly create more public violence?

I guess you do have that right, but I just—

But what's the difference?

But the— because it's the possibly more violence, and in the case of drugs, that is a lot more violence and bad things that are gonna happen. And we've seen that. And I'm— I do not want to go back to snake oil salesmen where everyone's got a concoction. And we have seen in the case of nutritional supplements, that thank— and this is sarcastic— to the Utah delegation where a lot of nutritional supplements are made, that they removed FDA oversight. There's been a lot of deaths on nutritional supplements when they don't regulate them. And I don't think that's a good thing.

The first piece of—

You can't tell what's in those nutritional supplements and they're often adulterated. And that's not a good place to be.

The first piece of yours I can find was published in Dissent in 1984, The Ethics of Splicing Life. Now, to fast forward to the current day, what are your views about genetic engineering of the next generation? If we could do it more efficaciously than is currently the case, but possibly that is coming, to what extent should we regulate voluntary parental choices, if any?

Again, this goes back to, I think, emphasize, you know, typically it's a parental choice. We permit parents to have lots of choices over their kids. But having a few people make choices inevitably affects all the rest of us in all sorts of ways. And I don't think this is a way— I do think this is a very good place to draw a line, and I don't think we've had a very good national, educated national discussion about what it would mean to enhance children or not enhance children. And I think we have to have that kind of discussion before we go forward. I'm no big fan of it in part because I don't think we're wise enough to figure out what's good, and we are very likely to overemphasize the wrong thing. As I said, we tend to overemphasize certain values and ignore other values. We do this individually and we do this collectively. And so I'm not a big fan. What's the most likely? We've gotten here over, you know, millions of years of evolution. Now, we have been evolved for certain environments, which we don't necessarily have today, but I'm not sure we're wiser than evolution.

What's the most likely bias in parental choices? The kids will be too tall, they'll be too conformist, they'll be too charming.

Well, uh, no, they'll be overemphasize IQ, they'll, uh, overemphasize, uh, physical, uh, prowess. Uh, we already have that, you know. What, what's the biggest thing in your high school, in kids' high school, right? Sports, right? Is that really the thing that ought to be the most important thing in a high school? No. We tend to celebrate in the United States Sports. I remember going to Africa for the first time and happened to be in a country where the national exams, they had national exams, were done. The whole first 6 pages of the paper were the people who did really well on national exams. Go and try to figure out some American town where that's, you know, they're going to list on page 1 the top 10 kids in all the local high schools. We don't do that. You know, Friday Night Lights and football games instead. So that's what we emphasize. Is that what we really want with genetic engineering? You're gonna be better football players? Seems to me we tend to make a lot of mistakes. We're not necessarily the wisest judge. I'll give you another good example. Just go to any airport, go anyplace where people collect with kids, and watch, right? The American Academy of Pediatrics, there's almost no one who thinks a lot of screen time, especially for young kids, is a good thing. What do you see throughout these places? Lots of screen time for young kids. Why? It's easy for parents, right? Don't have to interact with their kids. They can be on their own cell phones, right? Blah, blah, blah. It's a terrible way to raise our kids. And some parents doing it voluntarily affects all of us. We've got behavior problems in class. We have different ways of learning that are probably aren't good. Imagination is curtailed that way. And yet it's voluntary choice. It's not very well thought out. People do it because it's easy rather than thoughtful. So your voluntary choice that has lots of, I guess, since I'm talking to an economist, lots of externalities for the rest of us that we tend to downplay doesn't seem to me to be a wise choice. So I'm probably sticking by that 1984 article. That's pretty good, right? 35 years, same view?

Yes. If you could do it with a healthy body, would you find immortality boring? Forget about the social ramifications. Yes, absolutely. Why boring? You're curious. You're always doing something. The shadow value of more time seems to always be positive for you.

I agree, the shadow value of more time. On the other hand, I do think we get a— and I am a person who tries to do something pretty radically new every year. About 4 years ago, I made this pledge— more than that, 5 years ago, I made this pledge that every year I try to do something really out of the box for myself. So I was a chef, I've made chocolates. I've taken up pretty, not terribly long distance, but very serious bicycle riding. But nonetheless, I do think our brains, and again, this is a general comment, there are some outliers, you know, we, there's natural selection among our neurons. The parts we use over and over again get very well done. The parts we don't use tend to die off. And it's very hard to keep that plasticity over time and to do new things and to be new and curious. If you look at the number of people who are creative after 75, who do new things after 75, and really new things, it's very small. And I think that there's a neurological reason for that. It's not just the physical body, it's also the brain and the ability to think new things, be creative, and not just be ho-hum. Even— so I'm in the midst of doing a lot of reading about Benjamin Franklin. One of the Probably the most creative person born on the North American continent in the 450 years we've been around. Constantly new. And yet if you look past 75, slows down. Yes, he does do his autobiography in his 80s and stuff, but he, even he recognizes that the mental abilities, the ability to focus in on science and make new discoveries went way down. So it's very hard for us. So I think, yes, we could do new things, have new experiences, but would we be be new and creative. I doubt it.

You've written a much misunderstood article about how hard you would try yourself to live past the age of 75. Would not the suspense of world and national history always keep you wanting a bit more extra time? So say I'm 75, I've decided I agree with you, but the NBA Finals aren't over yet. I want to see Game 7. I want the Mueller report to come out. So isn't there always something? And then it's a kind of intransitivity of indifference. Every day there's something and you just keep on hanging on, even if one accepts your arguments in the abstract. Can you talk me out of that?

Tyler, I think you're exactly right. That's why people do hang on. It's because, you know, so I talked to my father who, you know, he says, Zeke, you're absolutely right. I've become slower, physically slower, mentally slower, you know, my life What ends up happening is your life cones down and you begin to overvalue certain small things like the NBA Finals, like what's in the Mueller report. Eh, they're not all— we all know from any cosmic standpoint, even not a cosmic standpoint, just a 2,000-foot standpoint, most of those things are not irrelevant. It's really cool to know. You often ask, and this happens to me all the time, I teach undergraduates, pretty smart undergraduates, very smart undergraduates, MBA students, nurses, doctors, right? They have no understanding of history. So whoever finishes in the NBA final, in 5 years, people forgotten. You know, you ask people, I ask, Richard Nixon? They have the vaguest memory, Tricky Dick. They can't really tell you very much. Even Ronald Reagan, even Bill Clinton. You know, much less you ask them, "Bill Russell." No idea who Bill Russell is. "Oscar Robertson." No idea who Oscar Robertson is. These were my heroes. I mean, these are like phenomenal basket— the people who made modern basketball. No idea. So this idea, you're absolutely right. We tone down lower and lower the parts of what will make us satisfied. And we have to step back and realize those are pretty trivial. The NBA Finals? The Final Four? Tyler, who was in the Final Four 5 years ago?

I don't follow college basketball. They don't play very well. The ultimate excuse. What's wrong with the importance of drama? We revere Shakespeare as perhaps the smartest human ever.

Yeah, but why is that, Tyler? We revere Shakespeare not because of the drama, just sitting there in the drama, because he makes us think about the bigger things in life and the kinds of characters we want to be and the kinds of characters we don't want to be. That's the point. But, you know, if you're at 80, there's no more character building. Your character's set. You're not changing your character at 80. Who changes their character at 80?

Accidents aside, what is the probability we will be capable of creating immortal humans in the next century?

In the next century? I'm not—

Are your friends who believe it's, if not likely, plausibly possible?

I do think it's probably plausibly possible. I think we're going to figure out what elements are for immortality. Now, whether that's good immortality in the sense that the body's going to be able to work well. My brother, who is not a doctor, but a Hollywood agent, had a very insightful comment to me recently. He's like, "We're going to be able to replace my heart, my lungs, everything, but damn it, that cartilage, my back pain. Can't you figure that out?" Doctors cure back pain, the common cold. You can't do any of this simple stuff. And so living a long time with a lot of back pain, that just doesn't seem like a great life.

In the middle of all of these discussions, we have a segment called Underrated Versus Overrated, and I'm gonna toss out some names and ideas, and you tell me if you think they're underrated or overrated.

I probably won't even know who they are.

Well, let's try it. Joseph Warren.

Oh, totally underrated. You do know, you've read a lot. So no one who's listening to this podcast knows who Joseph Warren is. I'm willing to bet that.

That's the whole point.

Yes. So he was critical to the revolution. He's the guy who actually organized Paul Revere's ride. He's the guy who organized a lot of the revolt in Boston. Now Sam Adams gets a lot of attention and Sam Adams was a rabble-rouser, but Joseph Warren was the guy who organized it all, who made it coherent, who had an objective. He was president or head of almost every one of those committees that they established, the media correspondents, this and that. And he unfortunately was prematurely— he should not have done this— he ran to the Battle of Bunker Hill when it was in process.

Exercised his right of self-defense, right? And got bayoneted to death.

Yes. And we only knew that he died because of a tooth. They identified him through his teeth. He very well might have been president, certainly would have been a leading person even if not elected to a political office. In the early days. And everyone for the first 100 years after he died, everyone knew about him. Warrington, West Virginia or something. You know, lots of towns are named after him. Boston used to be, 20, 30 years ago, used to be taught about him all the time. Way underrated. He needs a great biography. That's my retirement.

Ålesund, Norway. The town, the area.

Oh, fantastic for kayaking. I've kayaked there. I love it. It is one of the great Great places, although not the best places in Norway for food. So.

But there's a good restaurant in town. The fanciest hotel in town has good food.

I agree. But it's a pretty small town. What you go to Ålesund for is the kayaking around it and the beauty around it.

Surprising to me it's not more heavily touristed. So I think it's highly underrated. It's not that far away.

I agree with you.

Madagascar.

Probably overrated as an exotic place.

Why's that?

It's not that, I was not impressed that beautiful. A lot of the lemurs, it is interesting to watch them, but you can see much better wildlife in many other parts of Africa. The infrastructure, I mean, just the life of people, they're very warm, but I've been to many other parts of Africa that I would rate way over it, places that are not necessarily highly recognized. Mali, I found one of the most amazing places. People are incredibly warm. Mud mosques that you can see. The Dogon villages that are just truly amazing. Lots of cultural resonance that you just don't find in Madagascar.

Travel as a way of understanding the world.

Probably underrated, ought to be overrated, I would say. So I grew up in the '60s and my father who grew up in Israel and then went to Switzerland for medical school, always thought travel was great. We were not very rich when we grew up. He was a struggling, newly immigrated doctor to the United States. But my father saved all sorts of money. We had holey pants. We used to go to school in holey pants before holey pants were fashionable. But he would save money for international travel in the '60s. Most of our rich friends, they went to Florida, but we would go and very cheap trips to Europe, very cheap trips to Israel because he always thought going and experiencing other cultures increases your empathy, increases your understanding of the complexity of the world, different cultures. It's very important to do. Not important to go to the heavily touristed Paris, London, but I think other places like Ålesund is definitely well worth it.

Spencer Waller, overrated or underrated?

So no one knows who Spencer Waller is. Spencer Waller was my bête noire during school. He was a great friend during my first 5 grades of school at Anshe Emmet in Chicago. But he always— so if I got a B, Spencer got a B+ or an A-. If I got an A, Spencer got an A+. And he kept me running. He was a great kid. He's now actually a health law professor at Loyola. So it's always good to have a Spencer Waller in your life.

Free-range children, the idea, overrated or underrated?

I actually am not a big free-range children fan. I think it's overrated. I think children need limits, children need restrictions. They do need certain kinds of freedom within limits to be creative, but I think the entire idea of free-range children, probably overrated.

But you were a free-range kid, yes?

My parents, which is what I tried to do, had a very good a combination of free range, let the kids out, but also very good limits. We knew what was right and what was wrong. We knew that we had to defend what was right and what was wrong. And we had a lot of restrictions on what we could do and could not do. But we were also given a lot of responsibility and allowed to explore and allowed to make mistakes. So I wouldn't have called our raising free range, actually. So maybe I'm misunderstanding your notion.

No, no, it's not—

But I think limits Kids like limits. They like to know what the limits are. And I think having limits, you can— you have freedom within limits. So I'll just give you an indication of what we did for my kids, which is your room, your castle. You want it piggy, you can have it piggy. That's fine by me. I'm not— common space, you have to keep it clean because it's common with everyone else and you're living with other people. I don't consider that free range. I consider that here are the limits and here's You have freedom within these limits.

If you would decide a favorite movie, what would it be?

My favorite movie?

Yes.

There's only one.

Let's hear it.

Some Like It Hot. It's a fantastic movie from '59, black and white. It's great comedy, got Marilyn Monroe in it. It's got this fantastic element of cross-dressing, transgender, homosexuality in it. 1959, perfectly accepted. An amazing movie and it's so funny. It's fantastic. It's great. There are many other great movies, don't get me wrong, but if I had— stranded on a desert island, a movie I could see over and over again, Some Like It Hot.

Is there a truly good movie about healthcare?

Not that I know. Oh, well, maybe M*A*S*H. I like M*A*S*H. I don't know if that's a truly good movie about healthcare. It's about a lot of things, but it's got a healthcare component. Let's put it that way.

Paddy Chayefsky's Hospital or Lorenzo's Oil Oh, I don't like Lorenzo's Oil at all. A few questions about healthcare policy. As you may know, there's a recent study by Frank Lichtenberg at Columbia, and he argues that by using pharmaceuticals at a cost of less than $3,000 a year, you can add on an expected year of life to humans. Does this mean we're not spending enough on pharmaceuticals?

No, I think we're spending way too much on pharmaceuticals. $3,000 a year is a lot of money.

I would pay $3,000 a year.

Yeah, but you have a lot of money, Tyler. You're rich.

Even as a student, I would have paid $3K a year to stay alive.

I know, most students can't afford $3K a year, and I think that's— and a year of life. Remember, so there are two problems here. What's the right amount to spend on drugs? And that extra year of life when you're 80 going to 81, is that really that valuable to you? You know, if I got that extra year, if I had, you know, instead of 10 years in my 30s, if I had 11 years in my 30s, that's a different story. And $3,000, so the average— I think you have to put it in context. So part of my thinking is you have to put in context into someone's entire life and how much money they have in their entire life. The average person, American with a BA, average male with a BA— women make less— but the average male with a BA, their entire lifetime earnings about $2.2 million. Now, $3,000 a year for 70 years, about $200,000. So it's 10% of all their lifetime earnings for an extra year. That just doesn't seem to me to to be a good ratio. So it's one extra year, that's 1 over 80, that's 1.2% of a life, of your life for 10% of your dollars. That's not a good ratio. There are many other things you could spend it on.

He's not saying you need to spend $3,000 a year. He's saying an expenditure of $3,000 in expected value adds on a life year. Yeah, a one-time expenditure. It's not a one-time per year, I thought you No, no, one time in his calculations.

I don't think there's any drug I can think of where $3,000 would give you a guaranteed one year. I don't understand that calculation.

Okay, are there too many hospital mergers?

Absolutely.

Should we stop them or are they needed to keep hospitals in business?

No, stop them.

Antitrust.

Yeah, we need more antitrust enforcement, absolutely, and if we're not going to get the antitrust enforcement, we need to put a cap on what hospitals can charge private insurance Right now, if hospitals create local monopolies, where local can be pretty big, they can take a lot of money from private insurers who have to negotiate with them and have to keep them in their network if they've got a local monopoly, and that drives up the cost for all of us. So capping that, how much they can charge, if we cannot get effective antitrust, is really important.

Why aren't insurers better at bargaining down healthcare costs, including with hospitals?

Many reasons. One reason is they typically make money on the percentage of of transactions they do. So that's an incentive to actually increase costs. Second, they typically have a small market share in any particular region, and that undermines their bargaining power in that region. Third, a lot of employers want different kinds of benefit packages, and that actually, again, undermines their ability to negotiate hard. Most big employers want to satisfy their workers, you know, Human resource departments, their number one obligation is typically not to keep healthcare costs down, but to keep kvetching down, keep down the complaints of workers. The easiest way to do that is have a wide network of hospitals, wide network of doctors. That drives costs up and handcuffs the insurer in terms of their negotiating power. Nonetheless, I think they could do better than they are doing. And I do think over the next few years, you're gonna see them do better. And one major reason is that employers have said, basically enough is enough. Now cost is at our limit and we want you to be better about cost control. And I think that's risen to number one as opposed to just rhetorically number one. I think actually it's risen pretty much to number one.

Do we in fact need malpractice reform?

Oh, I think we do need malpractice reform.

Small thing, big thing, exaggerated by conservatives, or how do you view it?

I think it's smaller than the docs say and smaller than a lot of conservatives say. We know that it's not gonna lower health healthcare costs. But it's important first, it doesn't serve anyone's interests except the plaintiff's lawyers. It doesn't serve the interests of patients. It doesn't serve the interests of doctors. It doesn't serve interests of the healthcare system. And it's too easy an excuse for doctors in the healthcare system to blame malpractice for not doing the right thing. And I think, uh, changing malpractice reform would be effective. I don't like the general conservative which is limit the length of time people can file suits, limit the amount that people can get for non-economic damages. Those turn out not to be good reforms. I do think moving to things like either safe harbors where if a doctor followed the protocols, they are presumed, that's a rebuttable presumption to not be guilty, or have what they pioneered at the University of Michigan, just say you're sorry, identify problems, offer a standard payment back for identified problems that are admitted to be problems. People can still sue, but it leads to much quicker resolution and much more focus on improving the quality of the system as opposed to hiding problems.

How good is the Singaporean healthcare system?

I'm not an expert in the Singaporean healthcare system, but what you can do in Singapore with 4 million people in an authoritarian regime is not what you can do in the United States with 325 million people They do lots of things differently than we do that we could never import. One of the things I like that they do that we could never get here is they pay their government officials a lot of money because they want the absolute best people in government. They don't denigrate their government the way we tend to denigrate our government and regulation. And that's one reason we probably will never get the Singaporean system. And I'm not even sure it's worth studying that carefully for how to import it here.

Tyler Cowen, how well can venture capital work for biotech? And here's my worry. It's really hard to pick winners in advance. And to the extent venture capital works, it's because your winners are really big, that they're rapidly scalable, their marketing expenses are not too high. There's not a 10-year approval process to put Facebook or Uber on the market. Things just happen. So here you have a biotech sector where so often you have a sales force, you need legal and regulatory expertise. It seems no easier to pick winners. So why be optimistic about venture capital in this space?

I'm not.

You're not?

No, I'm not wildly optimistic about venture capital in the biotech space. I'm wildly optimistic about venture capital in the non-biotech, non-device space.

Where, for instance?

Well, I work for a venture capital firm, Oak HCFT, and we are investing We've made lots of investments and actually, I think, catalyzed areas that have long been ignored by the healthcare system. Primary care, mental healthcare, end-of-life care, social determinants of health. The medical system has long ignored those, and we have invested in small companies that we're hoping are going to transform these areas and develop solutions that are scalable beyond them.

And— But are those rapidly scalable, or you think you're quite good at picking winners?

No, I don't know that we're quite— well, I am surprised by how wise the people who've been doing this for a long time are. And we tend to have a longer investment horizon. 10 years is the length of our investment horizon typically. And so we do a lot of incubating of firms. And I do think once we've proven things, we've proven models can improve, bigger companies come in. And wanna adopt those and scale them. And I do, you know, I do think generating these new ideas, getting really smart people to come into this space has actually dramatically improved ideas, again, in what had traditionally been backwaters, but we are now recognizing are critical for improving the healthcare delivery system.

Why doesn't Aspen, Colorado have any good restaurants? And is that still true?

Like you, Tyler, I like food and I like good restaurants. I am always surprised by the fact that Aspen, Colorado, which has the richest people in the world coming there, the restaurants are not the best in the country.

Do you blame the demand side or the supply side?

I think it's got to be the supply side because it can't be the demand side because there's more money than God in Aspen, Colorado.— and I suspect that the problem is—

Can it be the taste on the demand side? So the wealthy people in Aspen tend to be older. They don't have a wide diversity of dining experiences in every regard.

Well, what I suspect is that it's the cost of rents and the cost of the fact that it's not 12 months a year. But I have often been surprised by the fact that there are various places in the country, high concentrations of wealth, where there aren't great restaurants. Silicon Valley is a very a good example. San Francisco's got great restaurants, but Silicon Valley itself, where there's a gazillion dollars sitting there, not great restaurants.

But the Indian food in Mountain View is pretty good, I would say. But mostly I agree.

So I think it's always surprised me how— I mean, Washington, D.C. is another place where the great ethnic restaurants are not in D.C. And you have to ask yourself, why aren't they in D.C.? D.C.'s filled with young people who love ethnic restaurants, and it's got to be something like the rent. So, you know, I'm not an expert on the business side of food, but it is peculiar that you go to many interesting places that have a lot of people with money, and yet you get a lot of places that have bland or not very adventurous food.

What's the best country in the world for sampling jam?

The best country in the world for sampling jam?

The best place, yes. I have my own nomination.

Oh, really?

Mine is Azerbaijan. What's yours?

I've never been to Azerbaijan. Azerbaijan. So I think—

As a jam fan, you must go. I will go.

I actually think that there are a lot of great homemade jams. It's funny, this morning we were eating jam that we had brought back from San Francisco from the Ferry Building Farmers Market. It was outrageously expensive jam, like $17 a jar, phenomenally good apricot jam. I like to make jams. This year we're sort of, I think our Our goal is to try to get apricots to make jam. We hope it's a good apricot season. And blackberries. I have not made blackberry jam yet. I have made a very good raspberry jam and I like that a lot, but we're gonna try blackberries and apricots this year. It's a lot of fun, by the way. It's also a good thing to do with kids.

Okay, what's the most important tip for buying the best dark chocolate?

Well, you— so the most important tip is you need to get something between 70 the high 70s. I would not go into the 80s and above. It's typically too much chocolate. The second thing is make sure you have— try to make sure if you can to get Criollo beans, and then make sure you've got the beans from the right country. And I also think that there are a series of manufacturers— I won't name all the great ones— that really have phenomenal— consistently make phenomenal chocolate. My— the place— the guy I do my chocolate with, Sean Ashkenazi, Ashkenazi Chocolate, chocolate, I think is fantastic consistently. Fruition in the Hudson Valley makes— husband and wife team make great chocolate. Rogue out of Massachusetts, I really love his chocolates. There's a guy named— why am I blanking on it? Dick— he's from Eureka, California. Dick Taylor, great chocolates. Most of these are very small manufacturers and what they do is they source their own beans or to make sure that their beans are really good. So we're— my next chocolate, which I'm gonna make in May, we're sourcing out of Ecuador. We're getting only Criollo beans. Should be a phenomenally good chocolate.

And what's the most important tip for making the best dark chocolate?

Well, there—

Which you can now do, right?

Well, I can now do. There are two key steps in the flavor of dark chocolate. One is the fermenting process that happens at the farm, and there's no substitute for going to the farms and seeing how they ferment and making sure that they ferment and dry the cacao beans well. And then it's all in the roasting, like coffee. Lighter roast rather than darker roast. If you've— someone advertises dark roast coffee, you know they've burnt it to hell and it's probably not great. You know, the new, I think, recognition is a lot more volatiles. Volatile organics are critical for great taste, and that's the same thing in chocolate. So when I made my chocolate, we roasted for about 7 minutes. 7 minutes and 40 seconds, and that really allowed a very bold start and a very long tail, which is what I try to get in my chocolates.

The very last section of this chat is all about you.

Oh no.

But easy questions. What's the smartest thing your parents did bringing you up?

Having two brothers.

Having two brothers.

I think actually having brothers, living with the brothers, we We slept in the same room for the first 10 years of my life. Really, really important. Lots of negotiation, lots of challenge, lots of competition, but also lots of friendship. I talk to my brothers 3, 4 times a week. Talked to my younger brother yesterday. I talked to my middle brother, Ram, the day before. We trade back book recommendations. We trade back. We spend some vacations together. We're planning a big vacation to Antarctica. Antarctica. So it, yeah, having brothers is probably the smartest choice they made.

Did taking ballet lessons as a kid help you any?

I'm sure it did, but I hated them. And although I can still do all the positions, uh, ironically enough, but it also made— I mean, look, what did it do? Uh, my parents were very good about raising us and having us know what was right and defend what was right, even if the majority of people were against us. And so So we would be made fun of because we took ballet lessons, but we defended that and we defended ourselves. And I think that idea that you didn't have to go with the flow, if there's anything that characterizes my brothers and myself, it's we don't go with conventional wisdom. We make our own judgment and we defend that.

You have an activist side similar to your mother's.

Yes. It is true. I think all of us learned from my mother that, and from my father, that part of our role in life is to do good. Sometimes you do good on an individual basis. I think my father was very much that. You know, he's not a guy who does big policy issues. He did good, you know, a family that had the fourth child who came to him was free. Every kid after three was free because, you know, he knew it was a burden to charge them. But he did good on a local level. My mom tended to be more of a community organizer and interested in public policy, and I think that's rubbed off certainly on me. And, you know, part of the job in this world is to make it better, and the easiest way to make it better for more people is through public policy.

2009, to the New York Times, you said, I quote, "I don't have a car, I don't have a TV, don't have a house. I do, however, have 4 cell phones, so go figure." Is this sufficient, or is this— was that a temporary state of affairs that was very—

No, I still don't have a car. And I, you know, ride a bike and take public transportation. I do now have a house. I love a house. I love houses. I love renovating houses. I have one cell phone because I don't work for the government, don't need multiple personal, and it's a personal cell phone, so no one can complain I'm using, you know, public or even university funds on other things. But I, so I tend on a personal level to have an ascetic element. I don't have fancy clothes. I don't, you know, have a lot of fancy furniture and stuff, but I do splurge on experiences because I think having good experiences and interesting experiences are what create a rich life. They're more memorable. I like the experience of eating food. I like the experience of meeting people. So that's where I spend my money. So you will not find me with a lot of material items, but you will find me trying to get a lot of interesting experiences.

And finally, what is it you wish to do next, including your next book, but not only?

What do I wish to do next?

That you can plausibly expect to do next.

Well, so, yeah, I am finishing a book. Hopefully, it'll be done in the next 10 weeks. I would say that there are 2 things that I would really like to do. One is we're working with a lot of players in the healthcare system to try to transform various parts of the healthcare system to dramatically dramatically increase the quality. I'm super excited about that. We're trying to work on getting the drug choices better so that they're cheaper for people. We're trying to get primary care better by paying doctors differently so that they'll think about the total cost of care. They're also dramatically improved quality. So that's a super— we're launching a venture on that. That's a super exciting part of my sort of academic life. The other thing I'd like to get back into government. Again, one of the great things I think is that changing government policy has a big impact. I think there are a number of things the government can do to actually improve the American healthcare system. And one of the reasons I really focus on the American healthcare system is if we can really bring down costs, we can create, have money to spend on other things, whether it's individually, whether it's as a society in government. And I think there are lots of low-hanging fruit in that direction. Regulating drug prices is but one area. As I mentioned, limiting what hospitals can charge so that they don't get too much money out of the healthcare system is another way. Transforming how doctors are paid also will— we've got some good evidence— can transform how they deliver care, the quality of care, and reduce costs. And so So that's a second thing I would love to get back into.

Zeke Emanuel, thank you very much.

This has been great, Tyler. Thank you.

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