Book Review (Super freakonomics)

For the past few years I have been intrigued by the field of behavioral economics and economics in general; the works of Daniel Kahneman, Richard Thaler, Dan Ariely, Steven Levitt (writing with Stephen Dubner), Thomas Sowell, Paul Krugman have influenced my outlook on all aspects of life including healthcare.  With medicine increasingly consuming a larger part of our nation's resources, economic analysis of the efficiency and efficacy of doctors, hospitals, and healthcare policies has and hopefully will continue to produce better theory that will in turn yield tangible results in improving outcome per dollar spent.

Superfreakonomics written by Levitt and Dubner, mentioned above, contains an interesting data-crunching-analysis section regarding the outcome of emergency room visits covering 620,000 visits over eight years, and more than 300 doctors involved in patient care.  In their chapter they discuss various topics including which common complaints are linked to higher death rates (clot, fever, infection, and shortness of breath) and which are linked to lower death rates (chest pain, dizziness, numbness, and psychiatric).

"So a patient with chest pains is no more likely than the average ER patient to die within a year, whereas shortness of breath more than doubles the death risk.  Similarly, roughly 1 in 10 patients who show up with a clot, a fever, or infection will be dead within a year; but if a patient is dizzy, numb, or has a psychiatric condition, the risk of dying is only one-third as high."

Other findings note that you want a doctor who attended a prestigious medical school and residency program, an extra ten years on the job yields the same result as having served a residency at a top hospital, and women in general do a better job at keeping people alive.

The part I found most fascinating was the analysis on what constitutes a good ER doctor.  Essentially, the authors looked at the survival rates of patients after randomizing situations to get a fair comparison of each doctor's ability.  Additionally, they asked the doctors to rank their colleagues to gauge the strength of each physician's reputation.  Surprisingly, the reputation of a doctor had little correlation with the survival rate of his/her patients with overall parity between all physicians analyzed.

What they did find however, was that the best doctors - based on collegial ranking - achieved the same outcomes as weaker ranked physicians with less healthcare dollars spent.  Which means that the best doctors ordered less tests, less medications, and less intervention and still produced the same results as weaker colleagues.  This makes sense: if you have a better fund of knowledge and your deductive skills are stronger, you do not need as many tests to confirm what you can glean from a good history and physical.

No doubt this translates into the primary care setting as well, as insurance companies with their treasure troves of data could easily confirm.  The best doctors do no need as many x-rays, blood tests, and specialist referrals to treat their patients appropriately - of course, in the right situation all of these need to be ordered, but in judicious fashion.
Additionally, the best doctors will utilize less medications and prescribe the cheapest ones available where efficacy is synonymous; this requires a deeper understanding of the psychopathology of disease and the pharmcokinetics of drugs available.  And, of course, in many instances the astute physician will prescribe no medications at all where nature will run its course and healing will occur regardless of intervention.

Judicious use of resources will not only ensure the most economically sound outcome for the patient, but it will limit their exposure to radiation, reduce overall pain from needle sticks and procedures, and circumvent untoward side effects of unnecessary medications.  Less money, less pain, less side effects - it is a win, win, win situation.  As economists devote more attention to healthcare, I hope the ensuing data analysis will assist the medical field as a whole in becoming more efficient and efficacious.