0:04

at

0:05

the the end of each episode, i encourage

0:07

you the listener to write in and let me

0:09

know know we think about the show many,

0:11

many of of you do those do

0:14

you you ask a a lot of of questions and and

0:16

questions are or good so good that sometimes

0:18

i i wish i'd thought of that myself

0:23

we've gotten lots of stop

0:25

provoking and we thought

0:27

it'd be be fun to to actually try to to answer some of

0:29

of them on the the air or at

0:31

at least talk how i try to to answer

0:33

these questions if were doing an actual

0:36

study in a loss get into what

0:38

other research your questions make

0:40

think about

0:43

in this episode i'm going to dissect your

0:45

interesting questions at sweet spot

0:47

between health and economics along

0:49

with some assistance from our producer julie

0:52

we'd , to try to do more of this so please

0:54

keep sending us as voice memos or

0:56

even an email with any questions you have

0:59

were babu at freakonomics i can't

1:02

remember try record summer quiet

1:04

and keep the voice memo to under minute thanks

1:07

for listening and we hope like in your questions

1:09

answered

1:24

today is actually about

1:26

birdwatching okay really this is

1:28

from listener named george

1:30

hi doctor dinner love the plot

1:32

after the episode that mention the fact full

1:34

moon has on driver safety started thinking

1:37

more about my driving habits and what distractions

1:39

i need to be aware of i

1:41

love bird watching and similarly

1:43

for other friends miss hobby bird soaring

1:46

above the highway can be can huge distraction went distraction

1:48

road bird watching requires

1:50

becoming hyper vigilant a bird sounds and

1:52

movement the most people to now i've

1:54

been wondering if there's an uptick in car crashes

1:57

during peak migration periods and

1:59

spring and fall bird watching his as

2:01

highest

2:04

writer julia i'm going in and when admit i'm

2:06

i i know at

2:08

us and yeah and yeah at a berdych that know lotta

2:10

bottle lot of things but i don't know

2:12

much about bird so i did have to similiar

2:14

i'd miss up with just one piece of data

2:16

was just curious when i heard his questions like

2:18

how big a deal is bird watching so the

2:21

to take wild guess how many bird

2:23

watchers there in the u s just like to add number

2:26

they're forty five million birdwatcher

2:28

there are forty five added you know

2:30

that on i know they're they're forty

2:32

five million lord watches as the in the

2:34

us so i looked in this question

2:36

that has been any research on the relationship

2:39

between bird watching

2:40

and car crash you but that has a me that birds

2:43

aren't causing lot a car crashes across the

2:45

united states but i did think about

2:47

this i , about like how

2:49

would i answer this question given it is no

2:51

into that i know of bob how to look at

2:53

it so the we're would study the fallen fallen

2:56

would try to figure out migration patterns

2:58

a bird so i figure out actual days

3:01

that birds tend to be migrating

3:03

or periods of the year when they're

3:05

most likely be likely then

3:07

identify the most common migration routes

3:10

and after that i look at the areas

3:12

that affected by those routes and

3:15

look those same routes in

3:17

surrounding week so let's say birds

3:19

migrating through virginia

3:23

in migrating second week of may every

3:25

year i would look at second week

3:27

of may and compare car accidents

3:29

and that week in virginia to

3:31

surrounding weeks before and surrounding weeks

3:33

after in that state and

3:35

perhaps it will happen is that birds migrate

3:38

across different areas across

3:40

different times a year and

3:42

so you could rely on that variation

3:45

and when birds are migrating and when

3:47

they're not to sort of identify the causal

3:49

effect so that's how would get to it

3:53

know whenever i hear a question whether like

3:55

this are in a research seminar i'm

3:57

reading a paper i'm always thinking

3:59

about the other questions that district

4:02

pop into my mind because it added

4:04

such thought maybe i'd share couple of immediate

4:06

reactions to this particular questions

4:08

so the other study that this remind me was

4:10

was was really cool in this is a paper that was

4:12

published in the journal science earlier

4:14

this year and what it did

4:16

is it looked at the effects on

4:18

car crashes when

4:21

municipalities post messages

4:23

about road fatalities let's

4:25

see on highway

4:28

the the idea that a town

4:30

or county would post messages about

4:32

how many people have died on this road or

4:34

die in general on roads and that's supposed

4:37

be alarming to people and get

4:39

them to want to drive more safely

4:41

and so if anything you would think that the posting

4:43

of those for to messages would

4:45

reduce road fatalities

4:48

but what they found actually with that the number of crashes

4:50

actually increases by increases little bit when

4:53

motorists are sort of confronted with these

4:55

messages and the idea think

4:57

is at the messages are distracting

4:59

so you're driving you're see this message like

5:01

oh my goodness i can have as many people are dying

5:04

on roads in this area that

5:06

distraction by itself can

5:08

actually lead to to more accent

5:10

so it's or the much of good intentions don't always

5:12

apply good outcomes applies here

5:15

when i heard about birdwatching

5:17

distractions that's where my mind

5:19

when

5:21

one of their conclusion that the researchers

5:24

me and and that said he was that

5:27

the information was to salient

5:29

it was too distracting to people

5:31

so that com and had that happen

5:33

like often with this kind of work

5:36

leg or something to be to salient

5:38

it's good question like know we've looked at

5:40

the issue of say aliens in healthcare

5:42

in variety different ways and and we've

5:44

actually found the opposite problem that lots

5:46

of things that you would think would be salient the people

5:49

or not that salient so you know we had

5:51

this episode actually on on a paper that we didn't

5:53

look that mom's we have cervical

5:56

cancer and we look to see where the not their children

5:59

are more likely

6:00

be vaccinated against hpv because

6:02

that's the the virus that causes cervical cancer

6:04

and we thought that this would be extraordinarily

6:06

sally these moms and

6:09

they wasn't clearly see alien and up because the moms

6:11

were not more likely to vaccinate their

6:13

kids against hpv so i

6:15

don't know if we have sort of uniform understanding

6:17

of when things are to salient

6:19

but i agree see what i liked about this study

6:22

was it it highlights the idea that when

6:24

you try to make seeing salient to people

6:26

have to be careful because they may

6:29

not respond in the way that you'd expect them respond

6:31

added by than a fine line that we need

6:33

to lock you and honey about

6:36

your research assistant who had an idea and

6:38

you guys looked into something else there has to do

6:40

with distraction

6:42

though when i'm trying to come up with ideas

6:44

your most time ideas that i have just gonna

6:46

come come to my mind cigarette them hearing

6:48

a question like this i think of something but

6:50

we do try to the actively

6:52

come up with ideas on how good we are at it but

6:55

will sit down few times a week myself

6:57

others at work me and will literally just

6:59

throw out ideas in most

7:01

of them including my own are bad but you know

7:03

it does really maddox all matters if have one

7:05

good idea and a few months

7:07

ago my research assistant dad's name is

7:10

charlie break charlie proposed

7:12

idea it to me and the others which

7:15

which quite strange i gotta admit when heard

7:17

of it was he talking about so with trunks

7:19

thought was there these things cause

7:21

cicadas things know lot about cicadas

7:23

but cicadas are extraordinarily

7:25

loud insects think that the loudest noises

7:28

in the insect world so they

7:30

pop up in various parts the country

7:32

every like thirteen to seventeen or something

7:35

like that's they live underground and

7:37

then it comes to service and they they

7:39

are in these broods and and they come

7:41

infrequently

7:42

the big in theory could be extraordinarily

7:44

disruptive because they're really loud and

7:47

so a trolley said was well look could

7:49

we rely on the fact that these cicada

7:52

broods just happened to come

7:54

up every now and then in different parts

7:56

the country at different points in time and

7:59

under the assumption that the

8:00

are really really loud could we then

8:02

use that to study the effects of

8:04

loud noise on health

8:06

outcomes now this isn't about distractions

8:09

i think this my how my mind think

8:11

birds fly insects fly

8:14

it just thing in the air and it's something

8:16

that's like this outside variable

8:18

yeah exactly cicadas could be distracting

8:20

so what charlie did was he actually

8:22

contacted few entomologists i'd never

8:24

work with an entomologist before and

8:26

these entomologists had for years

8:29

think collected data on broods

8:31

when and where they occurred and

8:33

, were kind enough to share with charlie that beta

8:35

would charlie did was he linked the

8:38

cicada brewed data when it

8:40

was happening where was happening any

8:42

linked it to information on health outcomes

8:44

of people who live in those areas as

8:46

he looked to see whether not

8:48

when cicada broods emerged

8:51

whether they were sent know worsening

8:53

of insomnia whether they were more

8:55

driving access more heart attacks

8:57

because of stress of are all this noise

9:00

we looked at bunch of different health outcomes

9:02

and we didn't find anything so

9:04

it's kind com and for us to investigate

9:07

things like this and not sign much and

9:09

i wish we had seen something but we didn't so

9:11

the qaeda as are absolved but the jury

9:14

is still out on birdwatch

9:18

okay bothers so our next question is

9:20

from jackson hi

9:22

there my name's jackson and i'm really big fan

9:24

of the shows and trillium sit

9:26

down in florida i've had a question for

9:28

years ever since went on a

9:31

flight unless there is medical emergency

9:34

as i'm wondering so number of medical emergencies

9:36

on flights with differ by slight

9:39

destination

9:42

okay i say this julie

9:45

she know something about in flight medical

9:47

emergencies i know more about that than a know about

9:49

bird watching oh no that's reassuring to you

9:52

have you ever responded to they

9:53

don't want physician economists to respond

9:56

is there doctor the blame yes but when say is

9:58

er doctor connors on the plane i raised my

10:00

in and nowadays of the ask

10:02

is there a podcast host on plane everybody

10:04

raises their hand i

10:07

so i actually know actually little bit about this not

10:10

about this particular question but at

10:12

before answered since answered jackson

10:14

was asking was

10:15

you know whether or not there's differences

10:18

in how often in flight

10:20

medical events or emergencies happen depending

10:23

on where plane is going there's you're flying

10:25

to replace see florida where

10:27

they're older people in florida maybe

10:29

you'd see more insight medical emergencies and think

10:31

that's possible it's true and and as i'm

10:33

not aware of any research this looked this but

10:35

the other thing that's the key driver though

10:38

how many medical emergencies or going to

10:40

get a flight is not sort the demographics

10:43

of we're the fight is coming from

10:45

or where it's going for just how large the

10:47

plane is so i just went to my parents'

10:49

wedding anniversary in richmond virginia

10:51

it's small plane because richmond's small city

10:54

even though bosses a big place now i'm

10:56

going from boston to san francisco or boston

10:58

to shanghai wherever those

11:00

are gonna be big plane so you're going see more medical

11:02

emergencies when planes are bigger

11:05

which is gonna happen when planes are going from one

11:07

big city to another exit

11:12

now it turns out that these in

11:14

flight medical emergencies or actually it's

11:16

more common than you might think

11:18

there's a couple of studies that have looked this so there is a

11:20

review in a jam and network open

11:23

that said that the occur in about one

11:25

of six hundred and four flights so

11:27

that not that uncommon or

11:30

twenty four to about hundred and thirty in

11:32

flight medical emergencies per one million passengers

11:35

the most common sources

11:37

of in flight medical emergencies or probably

11:39

not that surprising to people particularly

11:42

people responded to one of these are the the first

11:44

one to the most com and is something

11:46

that because syncopate which is basically when

11:48

you pass out now that could happen

11:50

for a lot of reasons the most common reason

11:52

that people pass outs is pretty

11:54

benign but there can be instances

11:56

where someone has cardiac arrest on

11:58

a flight that obviously there

12:00

serious the other things that are pretty

12:02

common art is t i symptoms

12:04

like abdominal pain

12:06

the respiratory symptoms like shortness

12:08

of breath difficulty breathing and

12:10

then what i'd call cardiovascular symptoms

12:12

which is basically gonna be chest pain

12:15

now you might wonder

12:17

then i will what happens when is it in flight

12:19

medical emergency so typically

12:22

what happens is that flight attendants respond

12:24

they will ask if they are volunteers

12:27

on the plane a who can help and i

12:29

actually know something about that on a mentor that in a

12:31

moment's and they'll also contact

12:33

ground medical personnel

12:36

who helped manage the situation from

12:38

the ground

12:39

in every so often the plane

12:41

actually has to be diverted

12:43

and i never been on a plane that was medically diverted

12:45

but i've had friends who are on planes

12:48

were they made recommendation to actually divert

12:50

the plane and the ground medical crew of greed

12:53

for half percent of all in flight

12:55

medical emergencies roughly will lead

12:57

to the plane actually being diverted

12:59

from where are scheduled to actually

13:01

land

13:02

that is just another make that call

13:04

by the doctor any

13:05

there yeah not extremely stressful

13:07

obviously if you have medical mercy on a plane

13:09

that could be bad but ,

13:11

they seeing said are different about

13:13

planes that lead to

13:15

problems occurring to the two things

13:18

that come to mind what is this pressure differences

13:20

in the plane and there may be differences

13:23

in the partial pressure oxygen

13:25

sets available in so that might pose

13:27

problems for some people the other is

13:29

that if you're in a long plane ride this

13:31

pro long sitting in when you're sitting for

13:33

a long time time venus

13:35

slow the return of blood from

13:37

the legs through the veins back to the

13:39

heart is gonna be less so there could

13:42

just be more kind of spaces are stagnation

13:44

of blood in the legs there is

13:46

this association between air travel

13:49

in blood clots in the legs

13:51

or blood cancer they can propagate to the lungs

13:53

call a pulmonary embolism and

13:55

the blood clot that in legs we called it a deep vein

13:57

thrombosis so there is association

14:00

between airplane travel and those things it's

14:02

not be mediated through at least

14:04

as prolonged sitting so that's

14:06

sort a background that i think about when about

14:08

when talking about in flight medical emergencies

14:12

back to jackson's questions or i'm not

14:14

aware that anybody's actually looked

14:16

at it but i would say that the data does exist

14:18

so there's couple of places and i've worked with

14:21

data from an organization called med aire which

14:23

is one of these organizations that manages

14:26

slight emergencies or fight events

14:28

from the ground and so they have database

14:30

of of incidents that have used before

14:32

but i'm not aware of any by actually looking at the

14:34

specific question that

14:36

jackson has jackson has

14:38

if we didn't wanna look at it what kind

14:40

of data was you need what we know

14:42

about like the oldest places

14:44

in the country and the youngest place is obviously

14:47

we're not gonna i guess that into international

14:49

flights let's say you have been as in the united

14:52

states the

14:53

thing main and florida are the two oldest

14:55

one's i don't know what you know the youngest

14:57

one's at an auction on know what's the youngest a sorry

14:59

the country

15:00

but i could he sighs oldest states

15:02

and this is based on percentage of population

15:04

over sixty five i mean in

15:06

florida west

15:07

virginia vermont and delaware

15:10

of to and aside youngest

15:12

states or utah alaska

15:15

texas georgia and colorado

15:18

okay are so i would use data

15:20

from one these in flight

15:22

medical event databases that

15:24

exist and i would look at flights going

15:26

to and from cities that

15:28

are the

15:29

younger vs older and

15:32

i would try to hold constant the

15:34

size of the plane because remember the point that made

15:36

earlier which is that they claim to have more medical

15:38

emergencies and small planes all

15:40

things being equal seed wanna hold that constant

15:43

jackson's questions whether not is more emergencies

15:46

when there's a flight they goes to

15:48

part of country where people are older like

15:50

a what would you do that finding and

15:52

it occurred me that like

15:54

windows a a situation where plane

15:56

is gonna have a higher probability of having

15:58

in flight medical emergencies

16:00

you might think that the attendance on those flights

16:02

could be better trained in theory

16:04

could do that you could have more

16:06

robust medical kit in standard

16:09

to the essay could mandate that for bigger

16:11

planes were the likelihood of

16:13

bigger medical problems is greater

16:15

you might when have more at the disposal

16:18

the any physician who happens to be the plane so those

16:20

are like practical things that you could do

16:23

if jackson's hypothesis turned out

16:25

to be correct

16:27

do wanna spend moment it just talk about other

16:29

things that came to my mind when i

16:31

heard jackson squish

16:36

there's the a surgeon and how service researcher

16:39

named ben mondale who's at mayo

16:41

clinic coop my backup couple years

16:43

ago sent me this email is

16:46

really really interesting question

16:48

so let's say that chicago

16:50

is hosting a big cardiology conference

16:52

in a given year are ,

16:54

there's going to be more cardiologist on those planes

16:56

going to chicago during

16:59

the week at that conference then another weeks

17:01

of the year so bet that this

17:03

data and he looked to see whether

17:05

not is any differences

17:07

in how in flight medical emergencies managed

17:10

during the day to conferences versus

17:12

the surrounding weeks and he basically found

17:15

that there is no different so there's no

17:17

increase in in flight responders

17:20

medical responders though

17:24

that's what comes to mind when

17:26

the words in flight medical emergency

17:29

are put into my head as jackson

17:31

just it as a questions so

17:33

good when i agree after

17:36

the break will talk about how covert lockdowns

17:39

did he didn't impact your health

17:42

as well as was screening for certain cancers

17:44

earlier may or may not

17:46

be worth it i'm baku jenna

17:49

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20:36

alabama you just mentioned your colleague

20:38

fan and you told him about

20:40

this episode we were preparing so ban

20:42

sent us a question

20:43

then came , and then mundo

20:46

a general surgery resident health services

20:48

researchers researchers you think that during

20:50

the coven walk downstairs and recent

20:52

incidents and island idol says development

20:55

to the more people sitting on their butts they'll

20:59

what is a pile in idol

21:01

says

21:02

so they're basically says that occur

21:04

when hair punctures through

21:07

the skin and then gets

21:09

infected and apps has conformed

21:11

they're often very painful

21:14

sometimes , have to be drained to a small

21:16

incision sometimes they respond

21:18

to warm compress says or does get better on their own

21:21

they often occurred year the tailbone

21:23

at the top of the near near the buttocks most

21:25

typically it's a risk factor for

21:27

those sis is sitting for prolonged

21:29

periods of time so think about like truck

21:32

drivers might be a classic example of

21:34

a group people who at higher risk of

21:36

developing a pile that assist

21:39

sell

21:40

people were sitting around the line at

21:42

home social distancing in those

21:44

early days of the pandemic ah

21:46

measure philly what did guys look at

21:48

though this is actually question that

21:50

we could look at we can actually get some

21:53

data to to look at it and the dealer

21:55

we use was from this company called true that are

21:57

which is an hr electronic health record

21:59

company

22:00

by the way one of benefits of electronic health

22:02

record it is that they're close to real

22:04

time so most the data

22:06

that i use is not even available during the pandemic

22:08

is it as just lags getting the data but

22:11

he hr data and be

22:13

more recent and so we looked at whether

22:15

not they're actually increases

22:17

in diagnoses of pylon

22:19

that oh sis or procedures

22:21

to treat them during the pandemic

22:24

and keynote events point i would

22:26

have expected that we might see an increase

22:28

the only thing that would have made think

22:30

that we wouldn't have is that we knew that medical

22:32

care actually sell during pandemic

22:34

because people were afraid go the hospital

22:36

and hospitals prioritizing care

22:39

about we looked at it and so we did not

22:41

find any evidence that these pile

22:43

analysis these i'm

22:45

abscesses on your butt became

22:48

anymore com and during the pandemic

22:50

which again could have occurred because more people

22:52

were working from home possibly

22:55

sitting on their rear ends for for longer

22:57

periods time so that's

22:59

what we found i will say that this is are pretty calm

23:01

and those more than seventy thousand cases

23:03

are diagnosed each year so they're painful

23:06

and common they wouldn't lot of other research

23:08

trade that like that

23:10

there are ways in which saying home

23:12

and lockdowns did affect

23:14

people's health weather

23:16

kobe didn't do things though i because

23:19

they did

23:20

yeah yeah so again to sort of train

23:22

of thought here thinking about all the way

23:24

that the pandemic is affected how in

23:26

healthcare behaviors

23:28

outside of covert rights of the prominent

23:30

way that it's affected people is

23:32

through the disease which is covered eighteen

23:34

but does while things that also happened in a pandemic

23:37

that affect people's health and mental health for example

23:39

we know has been an issue during

23:42

pandemics the other thing that i think it's quite

23:44

interesting this been some work looking at delays

23:46

in care we

23:48

did a study which looked at delays

23:50

in mammography and call and ask

23:55

the screening for breast cancer and

23:57

colon cancer in a data that we

23:59

look

24:00

the corners could be in mammography rates

24:02

fell by about ninety percent in

24:04

the commercially insured adult population

24:06

so that's that's decline

24:09

in cancer screening and they remains

24:11

be seen what will be the impact that on

24:13

actual delays

24:15

cancer diagnoses perhaps

24:17

worsening cancer outcomes like all that remains

24:19

be seen but we know from a number

24:22

of different studies that there were delays

24:24

and care the morbidity and mortality

24:26

with the reporter the m m w ours

24:28

is called is published by the cdc they

24:31

, that by june of twenty twenty because

24:33

of concerns about coven eighteen forty

24:35

one percent of us adults had

24:37

delayed or avoid medical care and

24:39

that included even urgent or emergency

24:42

care and certainly include certainly routine

24:44

care so routine care as much more likely to

24:46

be delayed but even urgent and emergency

24:48

care was also the late i think be taught the people

24:50

who working in health care settings during

24:52

this time they would also faster than say that when

24:54

people were coming in there often coming

24:57

in at much more advanced stages

24:59

of disease

25:02

the other thing that sort of line of

25:05

questioning reminds me of there is it

25:07

steady that just came out really recently did

25:09

a couple weeks ago from national

25:11

bureau of economic research and

25:13

it's sort of it looks at the reverse issue

25:16

what

25:16

they were looking at is whether or not coburn

25:18

eighteen vaccination affected

25:21

people's propensity the

25:23

delay or skip medical care the

25:26

basic idea is that when vaccines

25:28

come out people can get vaccinated they

25:31

might feel much more comfortable

25:33

now resuming medical care they

25:35

felt uncomfortable doing before

25:38

they were vaccine because they are you worried about

25:40

getting coven making themselves or

25:42

perhaps spreading it within health care setting they

25:44

went even further had a when think as a clever

25:47

approach you don't just look people who are vaccinated

25:49

and not vaccinated what they did is

25:51

they relied on the fact that they're the specific

25:53

age cut offs for vaccine

25:55

eligibility and dumb

25:58

there is differential roll out or the

26:00

vaccines

26:01

across states over time so they use

26:03

that as a natural experiment the

26:06

look at what happens when some groups people

26:08

by chance maybe because their specific

26:11

age got access to a vaccine while

26:13

others didn't and so what they find

26:15

is that receiving a coburn nineteen

26:17

vaccine reduce the likelihood that

26:20

people would delay care for any medical

26:22

condition by about thirty seven percent

26:24

so that's huge them is that getting the vaccine

26:27

made people less likely to delay

26:29

medical care they also found something that

26:31

was really interesting which which i closer of spillover

26:34

effect so they looked at sam least and

26:36

they found that children were also

26:38

significantly less likely the

26:41

delay or skip medical care

26:43

the result of vaccine availability

26:45

for their parents the were talking

26:47

about sort of parents who by chance because

26:49

their age or where they live

26:52

get access to the vaccine when

26:54

that happens their kids are

26:56

also more likely to resume normal

26:58

routine medical care they also found

27:00

that the decline in this delayed

27:03

or foregone care that was caused

27:05

by getting the vaccine was actually

27:07

quite bit stronger among minorities

27:09

and those and in low socioeconomic group

27:11

so sort of pointed to an important

27:13

way which vaccination might

27:15

help promote more routine care

27:17

or might reduce delays in care across

27:20

socio economic or race baselines

27:23

that's really interesting and seats to

27:25

even really why the vaccines were

27:27

even more important than me the

27:30

we

27:33

get her to other that about cancer screenings

27:35

for me or answering the past it acts

27:37

as a lot fans and how it may

27:39

have affected our health so we didn't get a question

27:42

along those lines from another with

27:45

okay so let's hear what are listener name's

27:47

sarah as

27:49

hydro keep up you big fan of eve

27:51

week know makes and the podcast my

27:53

questions he you is t thing

27:55

cancer screening programmes flag or

27:58

does lead time biased them back

28:01

third love to hear your take and

28:03

yeah thank you for the podcast

28:07

what is lead time buyers let's

28:09

start by explaining what that means though

28:12

liter by as is this is his idea that

28:14

when you are screening to identify cancer

28:17

if you screen and find cancer

28:19

earlier the neck cancer would

28:21

have been diagnosed based on the

28:23

say symptoms that

28:25

lead time buyers can cause a problem

28:27

because the earlier diagnosis may do nothing

28:30

to change the course of disease so

28:32

all you've done is identified that someone had cancer

28:34

earlier that

28:36

changing their ultimate prognosis or

28:38

that the day literally the dates and

28:40

which they would die the reason people

28:42

call it lead time bias because if

28:44

you measure survival

28:47

from the time of diagnosis that

28:49

can be misleading it's a lemmy give you

28:51

an example the pose

28:53

you've got

28:54

man who sixty seven years old and

28:56

he comes to you as shortness of breath and

28:59

and a cough and he's a smoker let's

29:01

say seed be think about lung cancer let's

29:03

suppose has lung cancer he's found have lung cancer

29:06

and then and then at age seventy so

29:08

he was sixty seven had symptoms found

29:11

have lung cancer and and died age seventy

29:14

now suppose we had screen that man for lung cancer

29:16

earlier they because it it a diagnostic

29:19

test like a cities can it

29:21

would allowed you to do so so you screen

29:23

that man or lung cancer at

29:25

age sixty five

29:27

the key question is whether not screening

29:30

at age sixty five would

29:32

have made that man live a day

29:34

longer eight seventy which

29:36

is when he died in the first scenario

29:39

if not all you did was

29:41

find his cancer earlier it didn't affect

29:43

survival and the reason we we

29:46

see this is an elite time biases if

29:48

you measure his survival from

29:51

that time a which he was diagnosed

29:53

with cancer you would say

29:55

he survived three years from diagnosis

29:58

for made sixty seventy eight seventy

30:00

if you didn't said how long would he survived

30:02

from the time of diagnosis if you

30:05

measure to survival with the screening test

30:07

you to live five years

30:09

so that naive comparison you might say oh well

30:11

we should have screen them because he lived five

30:13

years from the time diagnosis

30:16

but that's not correct all you really care about

30:18

is winded this individual dot

30:21

the

30:23

particular question that was asses

30:25

you know what is the relationship

30:27

between or is there any evidence

30:30

that cancer screening affects

30:32

our comes in the in our say that there is next

30:34

have another thing on it's own admission a second so

30:37

there's a couple cancer that very common

30:39

like breast cancer lung cancer cervical

30:42

cancer colon cancer for

30:45

for most of these cancers they're actually robust

30:47

randomised that he's looking at various cancer screening

30:49

strategies that , demonstrated

30:52

that screenings effective in prolonging survival

30:54

so that's important to keep in mind

30:56

so blatant bias is not issue there

30:59

because we're looking at when people are actually dying

31:01

that survival and live

31:03

longer there isn't a famous

31:05

steady that was published the new in journal of medicine

31:07

few years ago called the national

31:09

lung screening trial so in that

31:11

trial they looked at about sixty thousand

31:14

people we're at high

31:16

risk for lung cancer and a

31:18

randomized them to one of two

31:20

screening approaches one group of these individuals

31:23

were screened with and they caught and low dose

31:25

e t skin and they did we see that

31:27

annually for three years the

31:29

other group received a chest x ray annually

31:32

for three years so the city is is is

31:34

gonna be able to give you much more granular

31:36

image and tell you what's happening and that

31:38

in test much more so than a chest

31:40

x ray and it a randomized trial

31:42

the researchers found relative reduction in lung

31:45

cancer mortality about twenty

31:47

percent

31:48

the low dose e t group and actually

31:50

they had lower overall mortality

31:52

not just focusing on lung cancer if

31:54

they received a low dose e t compared

31:57

to test sex or and so that sort of actually made it

31:59

into the guidelines as

32:01

practice recommendations for people

32:03

who are at high risk of lung cancer for

32:05

example from a history of smoking

32:09

it lead time by is only

32:12

relevant to cancer screening

32:14

and cancer detection

32:16

it's primarily relevant to their but it's really

32:18

true for any disease in which screening

32:20

for something so let's say talk about heart disease

32:23

okay and you're you're measuring

32:25

the degree a plaque in someone's heart

32:27

you might identify something that

32:30

would not cause problems but

32:32

if you measure like the time of survival

32:34

from the time that you identify court court heart

32:36

disease you say that this person's living

32:38

longer from the time of diagnosis

32:40

but it's only because you diagnose problem would

32:43

never have actually lead to an issue in the first place

32:46

what can we do anything about the time buyers

32:48

yeah think can't i think that the way

32:50

to deal with this problem v time by

32:52

some a for people who do these studies

32:54

to know what lead time bias is and

32:57

be when you're talking about

32:59

survival in any condition

33:02

not to focus on survival from

33:04

the time of diagnosis necessarily sometimes

33:06

it's okay but you know just like an

33:08

overall survival or that age at

33:10

which you die so any screening

33:12

intervention that does not make

33:14

people live longer is

33:17

not effective even if a

33:19

diagnosis you with cancer earlier

33:25

the

33:25

to sort of makes me think of like if

33:27

someone is diagnosed earlier than they

33:29

may be otherwise would have been and either

33:31

they had pretty good quality of life

33:33

then they had ended on cancer treatment

33:35

so says simply just another

33:37

his treatment for longer period of time

33:40

without actually doing anything to extend

33:42

their life is that an issue

33:44

yeah that's a huge issue and think like

33:46

some people may want to know that

33:48

they have cancer not because

33:51

identifying the cancer in treating it would affect

33:53

how long they live simply because

33:55

they might do things differently so that

33:57

juliet the get your point is is it really important

33:59

ones the when i'm talking about lead

34:01

time bias and what screening

34:03

program should should not focus on being

34:06

little bit fast and loose i'm in i'm talking

34:08

about mortality but why things matter

34:10

besides mortality so if you can

34:12

tell someone that they have a medical problem

34:15

that's going ashore in their lives even

34:17

if you can't extend their life

34:19

in any way perhaps quality

34:22

the remaining life might be different because

34:24

of how they choose to live their life maybe they quit

34:26

work baby to spend more time with family eats

34:28

maybe travel more whatever

34:31

may be the first i think that will import

34:33

okay would out to be like question and now

34:35

we have one more question

34:37

he bought his my name is crystal when the

34:40

piece resident around chicago illinois my

34:42

question to you is very

34:44

increase in adverse patient

34:46

outcomes during the july or august

34:49

timeframe

34:50

when new residents are starting and

34:52

current residents are transitioning into

34:54

more senior roles

34:56

the crystal crystal crystal

34:58

from chicago based on the ice crystal

35:00

clear yeah that's a really good question

35:03

and it's so good that we're going devote

35:05

an entire episode two next

35:07

week

35:10

my first day i showed up and

35:13

, one of the third year residents was finishing

35:15

his year and about to leave leave

35:18

handed me the me and

35:20

said good and soccer every

35:22

july a medical training rite

35:24

of passage occurs medical school

35:26

graduates begin their residency programs

35:28

as interns and current residence

35:31

and fellows a said that training

35:33

ladder but where does all

35:35

this li patients somehow

35:38

the system has to train new physicians and

35:40

any time you have physicians and position they're going to be

35:43

some learning curve we're going to

35:45

talk about what's known in medicine as the

35:47

july effect is real

35:49

and if it is what should we be doing

35:51

about it there

35:52

he great variability of

35:55

how people and approach this

35:57

in a thoughtful way so that

36:00

the record as have positive experience

36:02

and that

36:03

or not harmed thats , week

36:05

on freakonomics m d thanks

36:07

for listening and thanks to my producer julie

36:09

canford rejoining me on this episode

36:12

episode forget send us more of questions either

36:14

as voice memo on email wherever

36:17

at freakonomics dot com and

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36:27

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37:01

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