Bapu Jena was already a double risk: a health care provider who’s additionally an economist. Now he’s a podcast host too. On this sneak preview of the Freakonomics Radio Community’s latest present, Bapu discovers that marathons will be lethal — however not for the explanations you could assume.
Hear and subscribe to our podcast at Apple Podcasts, Stitcher, Spotify, or elsewhere. Beneath is a transcript of the episode, edited for readability. For extra data on the folks and concepts within the episode, see the hyperlinks on the backside of this submit.
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Stephen DUBNER: Hey Bapu!
Bapu JENA: How’s it going?
DUBNER: I like your podcast!
DUBNER: So why don’t you simply say your identify and what you do?
JENA: My identify is Bapu Jena. I’m an economist and a doctor at Harvard. I train healthcare coverage and well being economics. I see sufferers at Massachusetts Basic Hospital, and I’m a professor at Harvard Medical Faculty.
DUBNER: As for those who want one other job, you’re on the brink of host a brand new podcast for the Freakonomics Radio Community. We’re about to play, now, for our listeners a pilot episode of your new present — which I’m extremely enthusiastic about. However first, let me simply ask — “Bapu” is just not the identify in your beginning certificates, is it?
JENA: Is that this being recorded for authorized functions? No. My first identify is Anupam. Bapu is my center identify. It’s actually extra of a nickname. It’s in all probability on each authorized doc apart from my beginning certificates. So Bapu means “father” in quite a lot of completely different Indian languages. It’s what they used to truly name Mahatma Gandhi. Not that I’m attempting to attract any — there’s essential distinctions to be made.
DUBNER: Bapu, how many individuals are there on this planet such as you which have each an M.D. and a Ph.D. in economics?
JENA: Oh, on this planet, I’d say, I don’t know, possibly 10 to twenty.
DUBNER: So, I suppose you may have a look at that two methods. One is you’re a very, very, very, very uncommon chicken, and that’s superior. Or you may have a look at it from the demand aspect and say, if there’s so little demand for that, it should be a waste of time.
JENA: I do know, precisely, if you see so few folks going into one thing, you need to surprise why, except there’s some market energy or one thing, that’s the one factor, unifying clarification.
DUBNER: So possibly that’s what you’re after then.
JENA: Yeah, precisely. I’m on a quest for market energy.
DUBNER: You could have a little bit of historical past with Freakonomics Radio. Are you able to recall what you’ve informed our viewers prior to now?
JENA: So, I’ve been on a pair instances. The primary time was a couple of research that I had with some others taking a look at what occurs to sufferers who’re hospitalized in the course of the dates of nationwide cardiology conferences, when cardiologists are away, they’re out of city at these conferences. We discovered that sufferers truly do higher. Their mortality charges fall in the course of the dates of these conferences. In order that was the primary time I used to be on the present. And then you definately did a very nice sequence on “dangerous drugs,” which I used to be on a pair instances. And I presume you didn’t ask me to affix as a result of I’m reflective of dangerous drugs.
DUBNER: No, we didn’t. So Bapu, as you understand, we love economists round right here and we additionally love docs. They every appear to have their very own mental superpowers, so is it honest to say that you’re each Superman and Batman?
DUBNER: Though Batman doesn’t even have superpowers, does he? Apart from frequent decency, which does seem to be a superpower today. The way in which that you just ended up mixing the instruments of medication and economics in your analysis, the place did these curiosities come from?
JENA: Numerous the work that I do is type of like Freakonomics meets drugs. It’s questions that relate to drugs and healthcare. That’s standards one. Standards two is that it usually requires giant quantities of information like economists are very aware of. Standards three is that there must be an strategy that’s causally legitimate. I’m not considering associations for essentially the most half in my analysis. I actually need to know whether or not X causes Y and loads of these instruments that economists use, I implement in my work.
DUBNER: A few of your analysis highlights the fallibility of docs or no less than the truth that they’re as human as the remainder of us. I’m actually curious to understand how that’s acquired within the area — if you write a paper that exhibits that older docs, for example, that their ability set appears to deteriorate.
JENA: It’s actually the case that when that research got here out, I received emails from docs who had tons of scientific expertise who mentioned, “This simply completely can’t be true.” To which I responded and I mentioned, “It will not be true for you, however that’s not likely the query I’m attempting to reply. What I’m attempting to reply is that if we took 1,000 docs above the age of 65 and 1,000 docs between 35 and 40, and we randomized sufferers to these two teams of docs, the place would we anticipate to see higher outcomes? And we’d anticipate to see higher outcomes within the docs who’re youthful.” Now, there are actually going to be docs who’re older, who’ve loads of expertise, who preserve excessive volumes of their scientific practices that will have superior outcomes. And possibly the docs who emailed me would match into that class. However it’s actually doable that a number of the individuals who emailed me didn’t. And possibly that’s why they’d time to e mail me.
DUBNER: Why did you need to make this podcast, aside from the truth that I known as you and begged you to do it?
JENA: Yeah. I don’t have anything to do! You already know, I feel that there’s a actual curiosity within the intersection between economics, human habits, and drugs — and that’s precisely my candy spot.
DUBNER: So, the thought right here is that each episode, you’ll dive right into a single medical research — together with some research that have been executed by you and your colleagues and others executed by different researchers. Why is that the proper technique to speak via a problem?
JENA: I feel the construction of a research, it follows the construction of a podcast. It begins with a query. After which, what would it is advisable reply that query? What would the info should be to reply that query? All proper, now you’ve got the info. How would you reply it? What strategy would you’re taking? All proper, you’ve got an strategy. You could have a solution that’s tentative. Now, how are you aware that that’s the proper reply? What kinds of the way do you need to interrogate your strategy to just remember to’ve gotten to the proper conclusion? That’s precisely what researchers attempt to do in each research that they publish. After which the very last thing is: So what? What can we do about this? And that’s essentially the most fascinating half, developing with these implications.
DUBNER: Now that you’re a medical physician and a Ph.D. economist and a podcast host, how a lot more durable would you say it’s to be a podcast host than to be simply a health care provider or an economist?
JENA: Oh, I imply, I feel being a podcast host is essentially the most extremely tough factor on this planet. It requires immense ability, intelligence, and actually defining beauty. Is that, is that appropriate?
DUBNER: That’s just about the reply I used to be going for, yeah. And humility.
DUBNER: Glad we’re on the identical web page there.
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I’m going to name immediately’s episode: In your mark, get set, croak!
In Boston, the place I dwell, there’s a giant annual occasion that I really like to look at each spring. The Boston marathon. It’s the oldest annual marathon on this planet. They usually’ve run it yearly since 1897 — besides final 12 months, due to the pandemic. This 12 months, it’s been delayed till October. However it nonetheless seems like marathon season right here in Boston.
Yearly, the marathon attracts a couple of half 1,000,000 spectators alongside its 26-mile route that begins within the suburbs and strikes its method all the way in which into downtown Boston.
Now, I’ve by no means run a marathon. In reality, the closest I’ve in all probability come to it’s watching a Harry Potter marathon on T.V., which I acknowledge is just not fairly the identical. However my spouse runs. And though she’s by no means run a marathon, about 5 years in the past, she ran a 5K charity race right here in Boston. The route for that race went proper by Massachusetts Basic Hospital, which is the massive instructing hospital the place I work. I’ve received a parking spot there, so on the day of the race I made a decision to drive into town and park at Mass Basic so I’d have a great place near the route.
It was my spouse’s first time doing a race like this and it was essential to each of us that I be there to cheer her on. However as I drove to the hospital, I hit a snag: It seems that one of many foremost roads was blocked off due to the race. The hospital was just some blocks away, however there was no method for me to detour round that roadblock. I used to be minimize off from the hospital — and from my good spot — due to the race.
So, I used to be cursing my determination to not take public transportation, and I rotated and headed again dwelling. Hours later, my spouse received dwelling after ending the race. And understandably, she was a bit of bit shocked that I hadn’t proven up and I felt horrible that I’d missed the race.
However after I defined to her what occurred — and she or he’s a radiologist, by the way in which — she considered it for a minute. After which she mentioned: I’m wondering what occurred to all the opposite individuals who wanted to get to Mass Basic this morning? And I assumed: What did occur to all these individuals who wanted to get the hospital? Particularly the sufferers. What if somebody had an emergency?
I’m a health care provider, however I’m additionally an economist. And nothing offers me extra of a thrill than a query that actually will get each side of my mind going. That doesn’t occur each day. Right here, a type of questions had fallen into my lap. And I solely needed to miss my spouse’s race to get it.
There are millions of marathons held yearly world wide. And anybody who’s lived in a metropolis internet hosting a marathon is aware of how disruptive they are often — like my spouse’s 5K, however within the case of marathons, it’s clearly a lot worse. Blocked roads for miles. Inconceivable to get round. Visitors grinding to a halt on the morning of a race. For sufferers who’re sick and must get to the hospital shortly, these kinds of disruptions could possibly be a recipe for catastrophe.
So I questioned: wouldn’t it be doable to measure whether or not marathons trigger delays in remedy? As a result of if I may measure that, I’d have a technique to measure one thing else: How a lot of a distinction does that delay make within the survival of these sufferers.
So I put collectively a small staff of researchers at Harvard to investigate the info. We made a listing of the 11 largest marathons in america. We included cities like New York, L.A., Honolulu, and Chicago. And we mapped their routes. Then we checked out greater than a decade of Medicare information to search out individuals who lived in ZIP codes alongside these race routes who occurred to have both a coronary heart assault or a cardiac arrest on the day a marathon was held of their metropolis.
We appeared particularly at information from Medicare sufferers as a result of that routinely narrows it right down to the over-65 crowd. And the over-65 crowd, just because they’re older, are the group that’s probably to have coronary heart assaults and cardiac arrests.
Now, why did we concentrate on coronary heart assault and cardiac arrest versus some other type of medical care? Effectively, for one, they’re emergencies, and meaning they’re random — folks don’t select after they occur.
The second cause we checked out coronary heart assaults and cardiac arrest is that these are critical enterprise. A coronary heart assault is when a blood vessel that provides your coronary heart is blocked off. There’s a clot that types and blood can’t get to the guts, and your coronary heart muscle dies. So it’s a giant deal.
A cardiac arrest is a good larger deal. It’s when your coronary heart stops pumping blood to the physique. It’s the closest you may come to being useless. Typically we’re fortunate to deliver folks again to life from a cardiac arrest. So these are each actually critical situations, and the remedy is de facto time-sensitive. Each minute counts.
Similar to me attempting to get to my parking spot to look at my spouse’s race, sufferers who dwell close to a marathon may get minimize off from the closest hospital by blocked roads and detours. So, right here was our aim: We needed to see if dwelling close to the marathon route made it extra seemingly that you’d die for those who had a coronary heart assault or a cardiac arrest on the day of a race.
We checked out information from marathon days. And since coronary heart assault mortality can truly differ day-to-day, we in contrast mortality on marathon days to information from the identical day of the week because the marathon, however within the 5 weeks earlier than and the 5 weeks after the race. The non-race days mainly served as a management group. So, if the race fell on a Sunday, we appeared on the 5 Sundays earlier than and 5 Sundays after the marathon.
Now, it’s doable, although actually unlikely, that coronary heart assault mortality could possibly be larger on race days than non-race days for causes which can be unrelated to marathons and ambulance delays. So, to handle this risk, we had a second management group as properly. We checked out related sufferers on marathon and non-marathon days who lived in ZIP codes simply exterior areas affected by the race routes. These are sufferers who mustn’t have been affected by any marathon-related delays.
All in all, we checked out 1,145 sufferers who have been hospitalized for a coronary heart assault or cardiac arrest within the cities that we studied. And we in contrast them to simply over 11,000 hospitalizations for sufferers on non-race days.
What did we discover? For sufferers in areas close to marathon routes, the share who died inside 30 days of being hospitalized — the 30-day mortality fee — was 13 p.c larger if they’d a coronary heart assault or cardiac arrest on race day than if they’d both a type of situations on a non-race day.
We didn’t discover any improve in mortality on marathon days in these individuals who lived in close by ZIP codes that have been unaffected by the race route, which makes loads of sense. Their journey to the hospital shouldn’t have been affected by blocked roads.
You is likely to be pondering — correlation isn’t causation.
After we do a research like this, we’ve got to you should definitely eradicate all the opposite doable causes for the impact that we’re seeing. So what are a few of these different doable explanations?
What if the folks having coronary heart assaults have been truly operating within the race? Effectively, we studied sufferers aged 65 years and older — and, okay, there are many runners who’re over 65. So we checked out folks with a number of medical situations — individuals who have been chronically in poor health and subsequently have been actually unlikely to be operating a marathon.
Or what if, for some cause, the sufferers having coronary heart assaults on marathon days have been simply completely different from sufferers on some other day? It doesn’t appear believable, no less than to not me, however to double-check, we in contrast affected person traits — like their age, or different cardiac issues. And we discovered that these traits have been about the identical on race days vs. non-race days.
What if hospitals are short-staffed on marathon day? That didn’t clarify it both, as a result of hospitals have been performing all of their typical cardiac procedures on marathon days. Which suggests that there have been loads of folks readily available to take care of coronary heart assault sufferers.
It happens to me that these of us will need to have gotten an early begin on their commute in order that they didn’t get caught in site visitors!
What if ambulances took sufferers to hospitals that have been additional away to keep away from roadblocks. We discovered that the hospitals that sufferers have been taken to have been truly the very same on marathon days and non-marathon days. It simply took sufferers longer to get there.
All we have been left with to clarify the distinction in mortality was a delay in remedy.
So what sort of delays are we speaking about right here? On a typical, non-marathon day, the common journey time in an ambulance for sufferers with a coronary heart assault or cardiac arrest was 13.7 minutes. On a race day? That went as much as 18.1 minutes.
Meaning, on common, it took about 4 and a half minutes longer — 32 p.c longer — for sufferers to get remedy on the day of a marathon. That won’t seem to be a protracted delay on your common commuter, however even small delays in care can result in vital coronary heart injury — which, by the way in which, is why we are saying in drugs that on the subject of coronary heart assaults, “time is tissue.”
It’s additionally value noting that we confirmed that ambulances have been delayed. However in our information, about 50 p.c of people that had coronary heart assaults didn’t arrive by ambulance. Somebody drove them.
These folks seemingly confronted even bigger delays as a result of non-public automobiles can’t do the identical issues ambulances can do, like going via crimson lights, or breaking the velocity restrict.
Simply to recap: what we discovered was that even small delays in care result in 13 p.c larger mortality in these sufferers. And that discovering pertains to one of many basic questions we ask ourselves in drugs: how briskly do we have to act when somebody is sick? Do we’ve got days, hours, or simply minutes?
The gold normal for experiments in drugs is the randomized managed trial. In that form of trial, we determine a giant group of comparable sufferers, and a few of them get one remedy whereas others get a special remedy, or in some instances, even a placebo. The sufferers don’t know which group they’re in, and neither do the docs.
Now, we may by no means have performed a randomized trial the place some coronary heart assault sufferers have been informed, “Hey, cling on a few minutes,” and others got remedy instantly after which we noticed who did higher. That wouldn’t be moral, as a result of we already know that appearing quick can save lives — like I mentioned, “time is tissue” when the guts is underneath this type of stress. However we simply don’t know precisely how briskly we actually should be.
This research truly gave us what economists name a pure experiment to assist us reply that query. In a pure experiment, situations out on this planet, that we’ve got no management over, randomize sufferers for us, if solely accidentally.
In our research, the mixture of randomly timed emergency occasions, and extremely time-sensitive medical situations, allowed us to reply the query of simply how time-sensitive this care is.
So, if there’s one factor I would like you to take from this research, it’s this: For those who’re experiencing chest ache, don’t hesitate. Name an ambulance.
For me, this research was proper within the candy spot the place economics and drugs converge. And it was all prompted by my spouse’s commentary. Typically it simply takes a random thought — or a random site visitors snag — to get the thoughts happening a much bigger query.
And it’s questions like these that we’re going to discover on this podcast. Like, what can supermarket-pricing ways train us about which sufferers get cardiac surgical procedure? And what does that inform us about the issue of overuse in medical care?
Questions like: why youngsters with summer time birthdays usually tend to get the flu. And what that discovering exhibits us in regards to the significance of creating healthcare extra handy.
I’m hoping that this podcast offers you a number of the analytical instruments that can aid you look underneath the hood of the newest medical headlines, distinguish correlation from causation, and weigh prices and advantages in your personal healthcare selections.
I’ll finish this pilot with a public service message: If there’s a race occurring in your metropolis — and somebody you’re keen on occurs to be operating in it and is de facto relying on you to be on the sideline, despite the fact that it’s solely a 5K and it’s over in about half an hour — don’t rely in your regular parking spot. Go actually early. Or take public transportation, okay?
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Freakonomics Radio is produced by Stitcher and Renbud Radio. This episode was produced by Matt Frassica. The Freakonomics Radio Community employees additionally contains: Alison Craiglow, Greg Rippin, Joel Meyer, Tricia Bobeda, Mark McClusky, Rebecca Lee Douglas, Zack Lapinski, Mary Diduch, Morgan Levey, Brent Katz, Jasmin Klinger, Emma Tyrrell, Lyric Bowditch, and Jacob Clemente. Our theme music is “Mr. Fortune,” by the Hitchhikers; the remainder of the music was composed by Luis Guerra. You will get all of the Freakonomics Radio Community exhibits on Apple Podcasts, Spotify, Stitcher, or wherever you get your podcasts.
Right here’s the place you may be taught extra in regards to the folks and concepts on this episode:
- Bapu Jena, professor of healthcare economics and healthcare coverage at Harvard Medical Faculty, doctor at Massachusetts Basic Hospital, and host of the Freakonomics Radio Community’s latest podcast sequence.
- “Doctor Age and Outcomes in Aged Sufferers in Hospital within the US: Observational Examine,” by Yusuke Tsugawa, Joseph P. Newhouse, Alan M. Zaslavsky, Daniel M. Blumenthal, and Anupam B. Jena (BMJ, 2017).
- “Delays in Emergency Care and Mortality throughout Main U.S. Marathons,” by Anupam B. Jena, N. Clay Mann, Leia N. Wedlund, and Andrew Olenski (The New England Journal of Drugs, 2017).
- “Mortality and Remedy Patterns Amongst Sufferers Hospitalized With Acute Cardiovascular Circumstances Throughout Dates of Nationwide Cardiology Conferences,” by Anupam B Jena, Vinay Prasad, Dana P Goldman, John Romley (JAMA Inside Drugs, 2015).