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Money and Medicine (New Edition)
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- Reviews
- Citation
- Cataloging
- Transcript
As rising health care costs threaten to bankrupt the country, MONEY and MEDICINE tackles the medical, ethical, and financial challenges of containing runaway health care spending. In addition to illuminating the so-called waste and overtreatment that pervade our medical system, this timely documentary explores promising ways to reduce health care expenditures and improve the overall quality of medical care.
MONEY and MEDICINE was filmed at UCLA Medical Center in Los Angeles and Intermountain Medical Center in Utah. While UCLA ranks among the nation's top academic medical centers, it spends considerably more than the national average on patient care. In contrast, Intermountain spends about a third less than the national average and is a model for low cost/high quality medical care. The dramatic doctor/patient stories filmed at these two hospitals illuminate the powerful forces driving soaring health care costs as well as proven strategies that effectively reign in excessive medical spending.
With remarkable candor, MONEY and MEDICINE captures the painful end-of-life treatment choices made by patients and their families, ranging from very aggressive interventions in the ICU to palliative care at home. The film also investigates the controversy surrounding diagnostic testing and screening as well as the shocking treatment variations among patients receiving a variety of elective procedures.
As the focus of health care reform shifts from the access crisis to the cost crisis, MONEY and MEDICINE makes a timely contribution to the debate over cost containment and deficit reduction that is heating up as we approach the 2012 presidential election.
Viewers guide (PDF file, requires a PDF viewer)
'Money and Medicine is a powerfully insightful view of the challenges that result from a medical system that profits from disease care. We can't move forward until we recognize these current economic barriers. This film offers a mirror for a medical system that is in need of self-reflection towards recognizing dysfunctional habits. It offers opportunities for change towards a new path that has health as its primary intent.' Dr. David Rakel, Founder and Director, Integrative Medicine Program, Associate Professor, Department of Family Medicine, University of Wisconsin
'A fascinating documentary. By contrasting two very different health care systems--UCLA and Intermountain in Utah--Roger Weisberg brilliantly illustrates the dedication of health care practitioners, ethical dilemmas facing patients and doctors, and the fundamental fiscal and clinical challenges facing our U.S. health care system.' Dr. Jonathan Skinner, Professor of Economics, Professor of Family and Community Medicine, Dartmouth College
'Money and Medicine should be required viewing for every patient, physician, and politician. It thoughtfully describes what ails American healthcare and highlights the tremendous opportunities to make it well, and to do more with less. I will use it in my own health policy and health economics classes.' Amitabh Chandra, Professor of Public Policy, Harvard University
'An excellent and thoughtful treatment of this important subject. Money and Medicine deserves the widest possible exposure because it explains clearly why our health system is so expensive and inefficient, and shows what needs to be done about it. I hope this engrossing film enjoys the popular success it should have. It could very likely help to create public support for the reforms we need.' Dr. Arnold S. Relman, Professor Emeritus of Medicine and Social Medicine, Harvard University, Author, A Second Opinion: Rescuing America's Health Care
'Honest, hard-hitting discussion of a topic critical for all Americans. These are highly qualified experts with on-the-ground experience and a comprehensive view of what needs to be done to save healthcare.' John Griffith, Professor Emeritus, Department of Health Management and Policy, University of Michigan, Author, The Well-Managed Health Care Organization
'A hard hitting, thoughtful documentary...It addresses challenging ethical, financial, professional, and human issues with appropriate nuance and stark frankness...Poignantly illustrated are major differences in medical economics comparing approaches of two major health systems to identical issues. This documentary belongs in every medical school curriculum and should be viewed by health professionals who are concerned about runaway costs across the US.' Dr. Victor Sierpina, Professor of Integrative Medicine, Professor of Family Medicine, University of Texas
'Using heart-wrenching personal dramas, Weisberg insightfully puts a human face on unnecessary procedures that may do more harm than good. An eye-opening account of an unrestrained system feeding on itself, Money and Medicine not only enlightens, but also gives hope that it is not too late for us to afford the quality medical care we deserve.' Sandy Wolf, Cinequest Film Festival
'How long should a life be prolonged by medical technology? A powerful and timely documentary, Money and Medicine takes on this difficult subject.' San Luis Obispo International Film Festival
'Excellent description of some of the big issues in modern medicine. Money and Medicine hits the mark.' Dr. Lewis R. Goldfrank, Director, Emergency Medicine, Bellevue Hospital Center and NYU Medical Center
'Money and Medicine is smashing. Every American needs to watch this.' Tom Emerick, Chief Strategy Officer, Laurus Strategies
'Terrific! [The filmmakers have] taken a subject that can be so complicated and explained it so effectively...[The film] doesn't just illuminate the problem but demonstrates that there is an alternative...A very persuasive aid for people working for health care reform. Bravo!' Julie Salamon, Author, Hospital
'Incredibly important and impressive!...Very effective in telling the story of the healthcare predicament we are in.' Rabbi Richard Jacobs, President, Union for Reform Judaism
'Nicely balanced...Should help to provoke the sort of healthy public discussion that we need.' Dr. Neil Wenger, Chair, Ethics Committee, UCLA Medical Center
'Superb...It was obviously fair, as well as sympathetic about the huge challenges that are out there...Will really get lots of people thinking.' Dr. Jerome Hoffman, Professor Emeritus, Emergency Medicine, UCLA Medical Center
'Stories--especially first--hand accounts from patients, family members, and care-givers-bring statistics and data to life, and can communicate the need for improvement in immediate and powerful ways...Money and Medicine tells the story of a healthcare system that's not serving the needs of patients and threatens national prosperity.' Maureen Bisognano, Institute for Healthcare Improvement
'Talks honestly about the incentive of profit in health care while juxtaposing the actual financial costs of various treatments and procedures with the profound human costs of undergoing those treatments.' Janice Lynch Schuster, Altarum Institute, Health Policy Forum
'As health care costs continue to soar, these crucial questions and related problems concerning the phenomenon of overtreatment need to be faced head-on. Perhaps Money and Medicine's most important lesson lies in its emphasis on the importance of peer review and the group pooling of information among medical professionals...Highly recommended.' The Midwest Book Review
'Weisberg raises a number of disturbing and compelling questions that cannot easily be answered, and the renewed focus on the subject following the Supreme Court's affirmation of President Obama's healthcare reform legislation ensures that this film will remain timely for the future. Recommended.' Video Librarian
'An excellent film...A very informative and eye-opening piece of filmmaking. It is exactly the kind of material that I would use in class discussions of medical anthropology or medical sociology...The intimate portraits of real people, both patients and kin, make for a moving and personal experience...The film is timely, important, and well-done, and I look forward to its impact on students, the public, and hopefully the medical profession.' Jack David Eller, Community College of Denver, Anthropology Reviews Online
'Looks at several strategies proven to rein in excessive spending, like executing advance directives, rethinking screening tests and learning about the risks and benefits of elective procedures.' Kathy Shattuck, The New York Times
'Provocative...The renewed focus on the subject following the Supreme Court's affirmation of President Obama's healthcare reform legislation will ensure that this film remains timely.' Phil Hall, FilmThreat
'Citing an avalanche of statistics, Weisberg argues that many screenings and treatments for breast cancer, prostate cancer and brain injuries are too costly and of little value...His numbers are compelling.' Greg Evans, Bloomberg News
'A timely contribution to the debate over health care reform and deficit reduction.' Rick Busciglio, Examiner.com
Citation
Main credits
Weisberg, Roger (film director)
Weisberg, Roger (film producer)
Other credits
Editor, Pascal Akesson; graphic design, Bill Bergeron-Mirsky; composer, Richard Fiocca, Fred Karns; cinematography, Sandra Chandler.
Distributor subjects
Aging; American Studies; Anthropology; Business Practices; Economics; Ethics; Government; Health; Hospital Management; Medicine; Insurance; Political Science; SociologyKeywords
00:00:02.333 --> 00:00:04.267
- We have this idea
in this country
00:00:04.300 --> 00:00:05.933
that when it comes
to health care,
00:00:05.967 --> 00:00:07.933
more is better.
00:00:07.967 --> 00:00:09.433
You can\'t be too thin
or too rich,
00:00:09.467 --> 00:00:11.600
and you can\'t
get enough health care.
00:00:11.633 --> 00:00:14.067
- You know, we all
come to a similar conclusion
00:00:14.100 --> 00:00:16.233
that about 30%
of U.S. health care spending
00:00:16.267 --> 00:00:18.700
is devoted
to unnecessary services.
00:00:18.733 --> 00:00:21.933
And that\'s, you know,
$800 billion a year.
00:00:21.967 --> 00:00:24.133
- You don\'t have
a significant blockage.
00:00:24.167 --> 00:00:27.267
- You have to remember
that one person\'s waste
00:00:27.300 --> 00:00:30.133
is nearly always
another person\'s income.
00:00:30.167 --> 00:00:36.000
And income turns into
strong political defenses.
00:00:36.033 --> 00:00:38.433
I have areas
that are classic waste.
00:00:38.467 --> 00:00:42.367
- We spend 2 1/2 times more
per capita
00:00:42.400 --> 00:00:45.800
than the average
Western European country spends.
00:00:45.833 --> 00:00:47.033
- Sending.
00:00:47.067 --> 00:00:48.800
- But the part
that I\'m most worried about
00:00:48.833 --> 00:00:51.967
is the waste
that actually hurts patients.
00:00:52.000 --> 00:00:55.667
- I was ready to have a stent
put in when I stopped \'em.
00:00:55.700 --> 00:00:58.100
- I see it everyday
in real human beings
00:00:58.133 --> 00:01:01.200
who get enormous amounts
of unnecessary testing
00:01:01.233 --> 00:01:03.233
and enormous amounts
of unnecessary treatment.
00:01:03.267 --> 00:01:04.967
And then the irony, of course,
00:01:05.000 --> 00:01:07.000
is that when we look
at the health Olympics
00:01:07.033 --> 00:01:11.400
and how we come out in the world
in terms of health outcomes,
00:01:11.433 --> 00:01:13.133
we end up doing terribly.
00:01:13.167 --> 00:01:14.900
You know,
we\'re just below Slovenia
00:01:14.933 --> 00:01:17.400
or next to Costa Rica.
00:01:17.433 --> 00:01:19.200
- When we spend more,
00:01:19.233 --> 00:01:22.467
the outcomes
are oftentimes worse.
00:01:22.500 --> 00:01:24.333
How can that be?
00:01:24.367 --> 00:01:27.667
- Life is so unfair.
00:01:27.700 --> 00:01:29.700
- Everything we do
in health care
00:01:29.733 --> 00:01:31.867
is innately dangerous.
00:01:31.900 --> 00:01:34.200
It\'s sometimes
extremely difficult
00:01:34.233 --> 00:01:36.933
to walk that thin line
between help and harm.
00:01:36.967 --> 00:01:39.233
And you step over it
fairly routinely.
00:01:39.267 --> 00:01:41.033
- I got a phone call
00:01:41.067 --> 00:01:43.667
that confirmed
that I had cancer.
00:01:43.700 --> 00:01:44.933
And I said,
00:01:44.967 --> 00:01:47.633
\"Life as we have known it
is over.\"
00:01:49.533 --> 00:01:53.300
- If you add up medical errors,
drug interactions,
00:01:53.333 --> 00:01:55.433
and hospital-acquired
infections,
00:01:55.467 --> 00:01:57.667
medicine itself
is the third leading cause
00:01:57.700 --> 00:02:00.300
of death in this country.
00:02:00.333 --> 00:02:04.033
- Of course I don\'t want to die.
00:02:04.067 --> 00:02:07.467
- I am paid more
when I harm my patients.
00:02:07.500 --> 00:02:09.367
I am paid more when I do more,
00:02:09.400 --> 00:02:12.833
even if it\'s not beneficial.
00:02:12.867 --> 00:02:15.233
- I don\'t want to live
like a vegetable.
00:02:15.267 --> 00:02:18.533
- When the payment incentives
are aligned towards more care,
00:02:18.567 --> 00:02:21.100
when their worries
about defensive medicine
00:02:21.133 --> 00:02:23.433
are aligned towards
giving more care,
00:02:23.467 --> 00:02:26.367
when their patients
seem to want more care,
00:02:26.400 --> 00:02:28.300
and when there isn\'t
really good evidence
00:02:28.333 --> 00:02:31.433
about what care
is the right care,
00:02:31.467 --> 00:02:33.367
it keeps driving
in the same direction
00:02:33.400 --> 00:02:35.133
towards more, more, more.
00:02:35.167 --> 00:02:36.367
- Hang in there.
00:02:36.400 --> 00:02:38.633
Every day is a miracle.
00:02:38.667 --> 00:02:41.533
- The big entitlement programs,
Medicaid, Medicare,
00:02:41.567 --> 00:02:43.433
Social Security...
With the vast majority
00:02:43.467 --> 00:02:45.700
being Medicaid and Medicare...
They\'re on autopilot.
00:02:45.733 --> 00:02:48.067
They automatically increase
year by year.
00:02:48.100 --> 00:02:50.833
By 2050,
they\'ll be consuming over 70%
00:02:50.867 --> 00:02:52.100
of the total federal budget.
00:02:52.133 --> 00:02:56.033
Oh, wait a minute,
so will interest on the debt.
00:02:56.067 --> 00:02:58.167
We can\'t afford it.
00:02:58.200 --> 00:03:00.533
- If health care costs
keep rising at the rate
00:03:00.567 --> 00:03:02.233
they\'ve been rising
for the last few years,
00:03:02.267 --> 00:03:04.433
we will bankrupt this country.
00:03:04.467 --> 00:03:06.767
We will not be able to afford
health care for any of us.
00:03:08.200 --> 00:03:09.267
- Everybody clear, please.
00:03:12.633 --> 00:03:15.167
- We\'ll create
a financial crisis
00:03:15.200 --> 00:03:18.867
of a size sufficient to destroy
the United States of America.
00:03:18.900 --> 00:03:21.600
We have no choice;
we will solve the problem.
00:03:23.400 --> 00:03:29.400
[dramatic electronic music]
00:03:39.633 --> 00:03:41.400
- When we compare UCLA
and Intermountain
00:03:41.433 --> 00:03:42.800
in terms of the use of care,
00:03:42.833 --> 00:03:47.000
what we saw is that
similar patients in Los Angeles
00:03:47.033 --> 00:03:50.467
were spending 60% more time
in the hospital.
00:03:50.500 --> 00:03:54.867
They were having
75% more frequent office visits.
00:03:54.900 --> 00:03:57.167
And of course, if you\'re
seeing more specialists,
00:03:57.200 --> 00:03:59.933
by golly, you\'re going to get
a lot more diagnostic tests
00:03:59.967 --> 00:04:01.800
and minor procedures.
00:04:01.833 --> 00:04:03.400
That led to the question,
00:04:03.433 --> 00:04:05.267
are they getting
much better health outcomes
00:04:05.300 --> 00:04:08.300
as a consequence of all this
extra time in the hospital
00:04:08.333 --> 00:04:09.733
and all
the additional procedures?
00:04:09.767 --> 00:04:12.133
And we found that they were not.
00:04:12.167 --> 00:04:15.333
- I would put our quality
rankings against anybody,
00:04:15.367 --> 00:04:18.200
\'cause to me, I think the most
important quality ranking
00:04:18.233 --> 00:04:20.100
is patient satisfaction.
00:04:20.133 --> 00:04:21.967
If we look at that measure,
00:04:22.000 --> 00:04:23.933
we\'re the number-one
academic medical center
00:04:23.967 --> 00:04:25.200
in the United States.
00:04:25.233 --> 00:04:27.500
- UCLA is a very
high-quality hospital,
00:04:27.533 --> 00:04:29.067
and I\'d want to be
taken care of there
00:04:29.100 --> 00:04:31.767
if I had an acute catastrophe.
00:04:31.800 --> 00:04:33.533
But they
also provide a lot of care
00:04:33.567 --> 00:04:35.900
that I believe is unnecessary.
00:04:35.933 --> 00:04:38.867
- I\'m certain
that we provide care,
00:04:38.900 --> 00:04:41.967
not intentionally,
that isn\'t needed.
00:04:42.000 --> 00:04:46.833
And we have to work on
decreasing those inefficiencies
00:04:46.867 --> 00:04:48.633
that don\'t add value to care.
00:04:50.533 --> 00:04:53.533
[siren wailing]
00:04:54.867 --> 00:04:58.033
- The secret to places
like Intermountain Healthcare
00:04:58.067 --> 00:05:01.200
is that they
are designing into care
00:05:01.233 --> 00:05:03.400
the best possible science.
00:05:03.433 --> 00:05:06.667
And they have shown that
it\'s possible to improve care,
00:05:06.700 --> 00:05:09.067
and by improving care,
00:05:09.100 --> 00:05:11.800
reduce the overall costs
of care.
00:05:26.733 --> 00:05:29.867
- We deliver
about 34,000 children a year.
00:05:29.900 --> 00:05:33.500
It turns out we have the ability
to start labor artificially.
00:05:33.533 --> 00:05:35.067
It\'s called elective induction.
00:05:35.100 --> 00:05:37.267
Now sometimes,
you have to do it medically.
00:05:37.300 --> 00:05:39.067
You have to get that baby
delivered
00:05:39.100 --> 00:05:40.900
because the mom\'s health
or the baby\'s health
00:05:40.933 --> 00:05:42.300
will be affected.
00:05:42.333 --> 00:05:45.733
In elective induction,
it\'s purely for convenience.
00:05:45.767 --> 00:05:47.033
The direct consequence
00:05:47.067 --> 00:05:48.567
of inappropriate
elective induction
00:05:48.600 --> 00:05:50.533
is Cesarean-section deliveries.
00:05:51.700 --> 00:05:53.000
- We\'ve seen huge differences
00:05:53.033 --> 00:05:54.567
in rates of Cesarean section
00:05:54.600 --> 00:05:55.667
across the country.
00:05:55.700 --> 00:05:57.533
And the evidence
is increasingly clear
00:05:57.567 --> 00:05:58.633
that the higher rates
00:05:58.667 --> 00:06:01.100
are not necessarily
good for patients.
00:06:01.133 --> 00:06:04.100
[camera clicks]
00:06:04.133 --> 00:06:08.667
- The national C-section rate
today is running about 34%.
00:06:10.000 --> 00:06:14.333
Intermountain as a system
is running at about 20%.
00:06:16.433 --> 00:06:18.633
- Some hospitals in this country
have C-section rates
00:06:18.667 --> 00:06:21.067
as high as 45%.
00:06:21.100 --> 00:06:24.033
- Our rates of C-section
at Santa Monica are high.
00:06:24.067 --> 00:06:29.033
We really want to do not one
more C-section than necessary.
00:06:29.067 --> 00:06:32.867
But in all of these
improvements,
00:06:32.900 --> 00:06:35.100
it\'s changing behaviors
of patients.
00:06:35.133 --> 00:06:37.533
It\'s changing behaviors
of providers.
00:06:37.567 --> 00:06:40.500
And trained as a psychiatrist,
changing behaviors
00:06:40.533 --> 00:06:42.367
is a very, very difficult thing
to achieve.
00:06:44.367 --> 00:06:47.433
- So our big day today...
Here you are 39 weeks.
00:06:47.467 --> 00:06:48.633
Can you believe it?
00:06:48.667 --> 00:06:51.133
- Mm-hmm.
- It\'s been a long pregnancy.
00:06:51.167 --> 00:06:54.167
Well, as we\'ve talked before,
we have kind of a couple options
00:06:54.200 --> 00:06:55.667
about how to get this baby out.
00:06:55.700 --> 00:06:59.733
And option A
was to try for a vaginal birth.
00:06:59.767 --> 00:07:02.267
And option B
is to do a C-section.
00:07:02.300 --> 00:07:03.367
- Mm-hmm.
00:07:03.400 --> 00:07:05.400
- You had a C-section last time?
- Mm-hmm.
00:07:05.433 --> 00:07:08.800
- And we talked about... we have
kind of some risks either way.
00:07:08.833 --> 00:07:10.367
- Mm-hmm.
00:07:10.400 --> 00:07:11.833
- If we went
for a vaginal delivery,
00:07:11.867 --> 00:07:15.167
the main risk would be something
called a uterine rupture.
00:07:15.200 --> 00:07:16.600
So my understanding
00:07:16.633 --> 00:07:19.300
is that we\'ve decided not to go
with the vaginal delivery,
00:07:19.333 --> 00:07:21.000
and we\'d like to do
the C-section, right?
00:07:21.033 --> 00:07:22.033
- That\'s for sure.
- Okay.
00:07:22.067 --> 00:07:23.033
[both laughing]
00:07:23.067 --> 00:07:24.100
Tell me how you really feel.
00:07:24.133 --> 00:07:25.467
- Yeah.
- All right, let\'s do this!
00:07:25.500 --> 00:07:26.933
Let\'s get this baby here!
- Okay.
00:07:29.033 --> 00:07:32.433
- This procedure
is not without risk.
00:07:32.467 --> 00:07:35.867
We get all of the consequences
of surgery, infections,
00:07:35.900 --> 00:07:41.200
blood loss,
a surgical scar in your body,
00:07:41.233 --> 00:07:43.767
which is going to have
some consequences,
00:07:43.800 --> 00:07:46.700
especially if you
want to have more children.
00:07:46.733 --> 00:07:49.467
We work to reduce
elective induction.
00:07:49.500 --> 00:07:50.900
As a consequence,
00:07:50.933 --> 00:07:52.900
we took down
our C-section rates.
00:07:56.500 --> 00:07:58.733
- Oh, my goodness, hello!
00:07:58.767 --> 00:08:02.000
Happy birthday!
00:08:02.033 --> 00:08:04.600
- What we did
was build a little protocol
00:08:04.633 --> 00:08:07.533
that anytime a woman
appeared at the hospital saying,
00:08:07.567 --> 00:08:10.267
\"My obstetrician sent me
for an elective induction,\"
00:08:10.300 --> 00:08:15.133
we first
carefully tracked the data.
00:08:15.167 --> 00:08:17.000
Turns out
that 28% of our patients
00:08:17.033 --> 00:08:20.033
were not good candidates
when we started.
00:08:20.067 --> 00:08:22.067
It was a phone call
back to their physicians saying,
00:08:22.100 --> 00:08:23.533
\"Doctor, your patient
00:08:23.567 --> 00:08:26.033
\"doesn\'t meet professional
criteria for elective induction.
00:08:26.067 --> 00:08:28.433
\"We need a consult from a
high-risk pregnancy specialist,
00:08:28.467 --> 00:08:30.233
or the department chair.\"
00:08:30.267 --> 00:08:32.200
It went down to under 3%.
00:08:32.233 --> 00:08:35.700
- We decided to go after
the highest-risk group
00:08:35.733 --> 00:08:37.300
in our preventive measures,
00:08:37.333 --> 00:08:39.233
and that\'s the people
that have had the Cesarean.
00:08:39.267 --> 00:08:42.467
- The time in the hospital may
actually decrease a little bit.
00:08:42.500 --> 00:08:43.600
- Yeah...
00:08:43.633 --> 00:08:44.700
- This team-based care...
00:08:44.733 --> 00:08:47.233
It makes your physicians
better physicians.
00:08:47.267 --> 00:08:49.300
We sometimes call it
organized care.
00:08:49.333 --> 00:08:52.600
And that\'s the shift that\'s
happening in medicine right now.
00:08:52.633 --> 00:08:54.533
It\'s from each physician
as a stand-alone expert
00:08:54.567 --> 00:08:55.800
in their own right,
00:08:55.833 --> 00:08:57.367
kind of a little law
unto themselves,
00:08:57.400 --> 00:08:59.967
godlike in their powers,
00:09:00.067 --> 00:09:03.633
to a team of physicians
managing the complex knowledge
00:09:03.667 --> 00:09:06.200
necessary to deliver best care
to a patient.
00:09:06.233 --> 00:09:08.300
[baby crying]
00:09:10.333 --> 00:09:15.267
We have a massive drop
in unplanned C-section rates.
00:09:15.300 --> 00:09:18.067
It was associated
with about $50 million per year
00:09:18.100 --> 00:09:19.833
in savings
to the people of Utah.
00:09:19.867 --> 00:09:22.633
Oh, by the way,
we were punished financially.
00:09:22.667 --> 00:09:27.233
We make more money when we
do an unplanned C-section.
00:09:27.267 --> 00:09:30.233
We get basically screwed
by the payment system,
00:09:30.267 --> 00:09:32.400
but patients come first.
00:09:33.933 --> 00:09:35.100
- Here\'s your boy!
00:09:35.133 --> 00:09:36.900
- Oh.
- There you go.
00:09:36.933 --> 00:09:38.233
- Turns out there are criteria
00:09:38.267 --> 00:09:40.400
for appropriate
elective induction.
00:09:40.433 --> 00:09:41.900
If you violate the criteria,
00:09:41.933 --> 00:09:44.233
more children
end up in the newborn ICU.
00:09:47.233 --> 00:09:51.033
- I had a C-section,
and basically, I had two seven...
00:09:51.067 --> 00:09:53.100
Babies that were
over 7 1/2 pounds a piece.
00:09:53.133 --> 00:09:56.867
So they were pretty big babies.
00:09:56.900 --> 00:09:59.633
I kind of chose
to do the C-section.
00:09:59.667 --> 00:10:02.200
- People come from literally
all over the world
00:10:02.233 --> 00:10:03.800
for complicated deliveries.
00:10:03.833 --> 00:10:07.000
And that, by definition,
drives up our C-section rate,
00:10:07.033 --> 00:10:09.333
because of the complications.
00:10:09.367 --> 00:10:12.667
But I would still say
that I think our C-section rate
00:10:12.700 --> 00:10:14.633
can be improved.
00:10:14.667 --> 00:10:18.533
- We left our newborn ICU
basically a ghost town...
00:10:18.567 --> 00:10:21.400
What a wonderful thing!
00:10:21.433 --> 00:10:22.933
If the rest of the nation
00:10:22.967 --> 00:10:26.900
had the same Cesarean-section
rate that Intermountain does...
00:10:26.933 --> 00:10:30.833
An overall rate
of 20% versus 34%...
00:10:30.867 --> 00:10:34.733
It would save the country
about $3.5 billion per year.
00:10:34.767 --> 00:10:35.767
Now, that\'s waste.
00:10:46.100 --> 00:10:48.533
- The variation
in how we care for patients,
00:10:48.567 --> 00:10:52.867
I think, has real meaning
for patients\' lives,
00:10:52.900 --> 00:10:55.200
especially when you talk about
what happens to patients
00:10:55.233 --> 00:10:57.033
as they near the end of life.
00:10:57.067 --> 00:10:58.567
- Places like Los Angeles
00:10:58.600 --> 00:11:01.767
that have more hospital beds
on a per capita basis
00:11:01.800 --> 00:11:04.700
or have more physicians
on a per capita basis
00:11:04.733 --> 00:11:07.900
will have patients spending
more time in the hospital
00:11:07.933 --> 00:11:09.967
and having them seeing
their physicians more often.
00:11:10.000 --> 00:11:11.400
- Hello, doctor.
- Good to see you...
00:11:11.433 --> 00:11:13.100
- We all know you build it
and they will come.
00:11:13.133 --> 00:11:15.233
If we have... if we have
a whole bunch of things
00:11:15.267 --> 00:11:19.167
that are profitable
and we could use them,
00:11:19.200 --> 00:11:20.600
well, we use them.
00:11:20.633 --> 00:11:21.900
- In the last two years of life
00:11:21.933 --> 00:11:23.400
for patients
with serious illness,
00:11:23.433 --> 00:11:25.800
at the University
of California Los Angeles,
00:11:25.833 --> 00:11:27.833
the average patient
spends 29 days
00:11:27.867 --> 00:11:29.067
in the hospital,
00:11:29.100 --> 00:11:30.367
whereas those at Intermountain
00:11:30.400 --> 00:11:32.167
spend 16 days.
00:11:32.200 --> 00:11:33.933
How many physician visits
do they have
00:11:33.967 --> 00:11:35.333
in the last two years of life?
00:11:35.367 --> 00:11:38.567
92 at UCLA,
00:11:38.600 --> 00:11:40.767
48 at Intermountain Healthcare.
00:11:40.800 --> 00:11:41.767
Startling difference...
00:11:41.800 --> 00:11:43.567
Almost twofold differences.
00:11:43.600 --> 00:11:44.633
And patients at UCLA
00:11:44.667 --> 00:11:46.200
spend three times as many days
00:11:46.233 --> 00:11:48.300
in the intensive care unit.
00:11:48.333 --> 00:11:49.900
As a consequence,
00:11:49.933 --> 00:11:51.267
in the last two years of life,
00:11:51.300 --> 00:11:54.333
patients at Intermountain
spend about $54,000,
00:11:54.367 --> 00:11:59.367
whereas patients at UCLA
spend about $98,000.
00:11:59.400 --> 00:12:02.467
[siren wailing]
00:12:08.167 --> 00:12:10.867
[indistinct chatter]
00:12:12.400 --> 00:12:15.267
- Mr. Toston
suffered multiple strokes.
00:12:15.300 --> 00:12:18.433
He\'s had a profound injury
to the brain
00:12:18.467 --> 00:12:20.900
from what\'s happened
most recently.
00:12:20.933 --> 00:12:24.200
The prognosis for Mr. Toston
is extremely poor.
00:12:24.233 --> 00:12:26.533
There is,
as far as what most of us
00:12:26.567 --> 00:12:29.433
would consider recovery to
meaningful neurologic status,
00:12:29.467 --> 00:12:32.467
the ability to express
themselves, recognize family,
00:12:32.500 --> 00:12:34.167
communicate in a way
that most people
00:12:34.200 --> 00:12:36.833
would be able to understand...
That\'s essentially zero.
00:12:36.867 --> 00:12:39.233
- I\'m Dr. Ravi Aysola;
I\'m the ICU doctor.
00:12:39.267 --> 00:12:40.933
I\'ve gone through his chart
in detail,
00:12:40.967 --> 00:12:43.133
and I\'ve seen
what he\'s been through.
00:12:43.167 --> 00:12:46.367
How much is he able
to interact with you?
00:12:46.400 --> 00:12:47.400
- Not that much.
00:12:47.433 --> 00:12:48.700
- Not much at all.
00:12:48.733 --> 00:12:50.367
I mean, I know
he\'s been on the ventilator.
00:12:50.400 --> 00:12:52.067
The ventilator
does the breathing for him,
00:12:52.100 --> 00:12:53.067
supports his breathing.
00:12:53.100 --> 00:12:54.167
- Yea, since January 1st.
00:12:54.200 --> 00:12:56.000
- I can tell you
that in patients
00:12:56.033 --> 00:12:58.033
who have this much support...
00:12:58.067 --> 00:13:00.767
Where the machine
is doing all of the breathing...
00:13:00.800 --> 00:13:03.967
If the heart
stops in those circumstances
00:13:04.000 --> 00:13:05.833
to the point
where we have to do CPR
00:13:05.867 --> 00:13:08.567
and press on the chest
or shock the heart,
00:13:08.600 --> 00:13:11.900
typically the chance
for recovery
00:13:11.933 --> 00:13:17.633
to functioning neurologic status
is less than 1%.
00:13:17.667 --> 00:13:19.333
If he could be here
and see what...
00:13:19.367 --> 00:13:22.067
The situation he was in...
What would he want?
00:13:22.100 --> 00:13:24.033
And that\'s what
you really have to focus on.
00:13:24.067 --> 00:13:26.533
- There are many times
that I ask him
00:13:26.567 --> 00:13:31.767
if he still want to be with us,
and he nodded his head.
00:13:31.800 --> 00:13:34.400
He wanted to be.
00:13:34.433 --> 00:13:36.833
- If his heart stops,
you want us to shock his heart
00:13:36.867 --> 00:13:41.500
and do CPR, if that\'s needed?
00:13:41.533 --> 00:13:44.467
- When that\'s needed, yeah.
00:13:44.500 --> 00:13:45.767
- Okay, okay.
00:13:45.800 --> 00:13:47.633
- Are you okay with that, Mom?
00:13:47.667 --> 00:13:48.900
- Hmm.
00:13:48.933 --> 00:13:52.367
I want him to live...
Whatever you can do to help him.
00:13:52.400 --> 00:13:54.933
- Okay, all right.
00:13:54.967 --> 00:13:58.067
- Thank you.
Thank you, Mom.
00:13:58.100 --> 00:13:59.467
[alarm buzzing]
00:14:01.567 --> 00:14:03.933
- Essentially,
to provide adequate CPR,
00:14:03.967 --> 00:14:07.267
one must essentially
have the full weight
00:14:07.300 --> 00:14:09.600
pressing upon someone\'s chest.
00:14:09.633 --> 00:14:13.700
And that
is likely to crack ribs,
00:14:13.733 --> 00:14:15.200
potentially cause bleeding,
00:14:15.233 --> 00:14:17.400
and result
in significant trauma.
00:14:19.867 --> 00:14:22.100
- Hang in there, honey.
00:14:22.133 --> 00:14:23.900
We\'ll hang in there with you.
00:14:27.800 --> 00:14:31.167
I don\'t know what to say more,
00:14:31.200 --> 00:14:34.533
but you know that we are here
00:14:34.567 --> 00:14:37.767
and that we love you so much.
00:14:37.800 --> 00:14:40.567
And I\'ll be right here
beside you.
00:14:42.133 --> 00:14:44.167
I will always love you.
00:14:45.867 --> 00:14:48.000
Life is so unfair.
00:14:49.067 --> 00:14:50.433
- I would characterize his state
00:14:50.467 --> 00:14:52.600
certainly now
as a vegetative state
00:14:52.633 --> 00:14:54.833
and potentially even worse.
00:14:54.867 --> 00:14:59.067
It is enormously troubling
to focus our resources
00:14:59.100 --> 00:15:01.967
on patients in his condition
00:15:02.000 --> 00:15:06.200
who really have no reasonable
chance for recovery
00:15:06.233 --> 00:15:07.533
to a level of function
00:15:07.567 --> 00:15:09.967
which most of us
would find acceptable.
00:15:10.000 --> 00:15:14.000
Now, what one finds acceptable
is a very personal decision,
00:15:14.033 --> 00:15:17.100
but I think we can all agree
that it\'s not how most of us
00:15:17.133 --> 00:15:20.300
envision the last days
of our lives.
00:15:22.133 --> 00:15:24.533
- The family
wants everything done.
00:15:24.567 --> 00:15:26.833
And I would challenge anybody...
00:15:26.867 --> 00:15:28.967
Come up and talk
with this family.
00:15:29.000 --> 00:15:31.233
And if you tell me
that the rules are
00:15:31.267 --> 00:15:34.967
we can withdraw care
because it\'s potentially futile,
00:15:35.000 --> 00:15:36.333
then we\'ll do it.
00:15:36.367 --> 00:15:38.467
But that\'s not the way
the system is set up.
00:15:38.500 --> 00:15:40.633
The way the system
is set up currently
00:15:40.667 --> 00:15:45.333
is that spouse,
that child, that parent,
00:15:45.367 --> 00:15:49.200
can really demand
a full-court press
00:15:49.233 --> 00:15:51.767
regardless of what the odds are.
00:15:55.233 --> 00:15:57.567
- He was in the ICU
for six days.
00:15:57.600 --> 00:15:59.233
I think the patient\'s wife
00:15:59.267 --> 00:16:02.700
was actually asking about
diagnostic test results,
00:16:02.733 --> 00:16:07.167
asking the results of the EEG,
asking results of the CT scans.
00:16:07.200 --> 00:16:09.300
When she was basically told
00:16:09.333 --> 00:16:12.733
that nothing I could do could
help him recover to any degree,
00:16:12.767 --> 00:16:16.233
she then was also willing
to accept the outcome.
00:16:17.733 --> 00:16:21.733
What we did
is start a drip of morphine
00:16:21.767 --> 00:16:24.067
and disconnected the ventilator
00:16:24.100 --> 00:16:26.133
and stopped all other medicines
and fluids,
00:16:26.167 --> 00:16:28.900
stopped diagnostic testing,
stopped monitoring.
00:16:28.933 --> 00:16:30.933
And then within a matter
of hours,
00:16:30.967 --> 00:16:34.900
in his case, approximately
four or five hours,
00:16:34.933 --> 00:16:36.067
he died.
00:16:39.867 --> 00:16:41.600
ICUs were initially designed
00:16:41.633 --> 00:16:44.200
to address
acute critical illness...
00:16:44.233 --> 00:16:46.233
To help someone recover
00:16:46.267 --> 00:16:49.500
to the point which they can
leave the intensive care unit.
00:16:49.533 --> 00:16:51.367
Often times the ICU now
00:16:51.400 --> 00:16:54.433
is the last stop
before someone dies.
00:16:56.000 --> 00:16:59.600
I, at one point,
was an ICU patient and survived,
00:16:59.633 --> 00:17:02.900
and due to the exceptional care
I received,
00:17:02.933 --> 00:17:05.000
I felt it was my obligation,
my duty,
00:17:05.033 --> 00:17:08.133
to continue
to provide that care.
00:17:08.167 --> 00:17:11.433
But I don\'t think it\'s a failure
on my part to say,
00:17:11.467 --> 00:17:14.733
\"There\'s nothing I can do
to cure your loved one.
00:17:14.767 --> 00:17:15.900
\"What I can do is make sure
00:17:15.933 --> 00:17:17.367
\"that your loved one
is comfortable,
00:17:17.400 --> 00:17:19.367
that they don\'t suffer.\"
00:17:19.400 --> 00:17:23.033
I think when we keep trying
to find interventions,
00:17:23.067 --> 00:17:27.933
procedures, drugs,
and give false hope to families,
00:17:27.967 --> 00:17:30.800
that we propagate this mythology
00:17:30.833 --> 00:17:33.533
that we can somehow
stave off death indefinitely.
00:17:36.767 --> 00:17:40.867
- Ms. Stonum, how are you?
00:17:40.900 --> 00:17:42.467
Ms. Stonum, can you see me?
00:17:42.500 --> 00:17:44.633
[electronic beeping]
00:17:44.667 --> 00:17:46.567
Are you in pain?
00:17:46.600 --> 00:17:49.267
I don\'t know
what\'s going on inside the mind.
00:17:49.300 --> 00:17:50.467
She\'s nonverbal.
00:17:50.500 --> 00:17:51.733
Ms. Stonum?
00:17:51.767 --> 00:17:53.567
But she\'s able to respond
to pain and noise
00:17:53.600 --> 00:17:54.700
and stuff like that.
00:17:55.833 --> 00:17:58.400
[machine hisses]
00:17:58.433 --> 00:18:00.400
- This has been
a long journey for you...
00:18:00.433 --> 00:18:02.300
- Yes, it has.
00:18:02.333 --> 00:18:04.200
- That began with her stroke,
00:18:04.233 --> 00:18:06.533
that required
a breathing machine,
00:18:06.567 --> 00:18:10.500
feeding tube, and dialysis.
00:18:10.533 --> 00:18:14.000
- I feel like my mom
is my baby, so to speak,
00:18:14.033 --> 00:18:15.633
and so I want to nurture
and care for her
00:18:15.667 --> 00:18:16.933
in any way that I can.
00:18:16.967 --> 00:18:19.633
If there is something
that can sustain her medically,
00:18:19.667 --> 00:18:21.667
she would want that.
00:18:21.700 --> 00:18:23.767
- If the nurses were doing
their rounds and such,
00:18:23.800 --> 00:18:28.400
and they found that, you know,
her heart had stopped,
00:18:28.433 --> 00:18:32.400
at that point, would you
want us to try to do something
00:18:32.433 --> 00:18:35.000
to try to restart her heart?
00:18:35.033 --> 00:18:38.200
- One of the things
that she would want
00:18:38.233 --> 00:18:42.000
is every opportunity
to live and to enjoy life.
00:18:42.033 --> 00:18:45.600
As I look at
how she\'s doing now,
00:18:45.633 --> 00:18:47.633
I\'m glad
that I didn\'t make the decision
00:18:47.667 --> 00:18:51.867
to let nature take its course.
00:18:51.900 --> 00:18:55.633
You know, miracles happen
if you believe in miracles.
00:18:57.233 --> 00:18:58.900
- We do run out of miracles,
00:18:58.933 --> 00:19:02.300
and there is a time
for everyone.
00:19:02.333 --> 00:19:05.300
- I don\'t know
what that time frame would be
00:19:05.333 --> 00:19:07.833
that I feel,
or some family member feels,
00:19:07.867 --> 00:19:09.933
you know, she\'s really not here
with us now.
00:19:09.967 --> 00:19:13.167
I suppose something like that...
Something spiritual.
00:19:13.200 --> 00:19:15.933
- This is not something
that I would want.
00:19:15.967 --> 00:19:17.967
It would be torturing me.
00:19:18.000 --> 00:19:20.667
On the other hand, other people
feel very differently.
00:19:20.700 --> 00:19:22.267
- Just giving you
some medication...
00:19:22.300 --> 00:19:24.833
- You do everything you can
to preserve life.
00:19:24.867 --> 00:19:26.600
That\'s what my mother
would want.
00:19:28.267 --> 00:19:32.300
Okay, let\'s find
your favorite picture again.
00:19:32.333 --> 00:19:34.233
She likes to be talked to
00:19:34.267 --> 00:19:36.667
while looking
at the photographs.
00:19:36.700 --> 00:19:40.100
This is your first baby,
way back in the times.
00:19:41.433 --> 00:19:45.000
Okay,
here\'s your favorite picture.
00:19:45.033 --> 00:19:48.533
This is when
you were very young.
00:19:48.567 --> 00:19:51.600
Always very glamorous, huh?
00:19:53.833 --> 00:19:56.233
- What hasn\'t happened
in the past ten months is,
00:19:56.267 --> 00:19:58.500
she hasn\'t left the hospital.
00:19:58.533 --> 00:20:02.200
In the meantime, basically,
our hospital\'s become her home.
00:20:02.233 --> 00:20:04.800
- UCLA,
through their ethics committee,
00:20:04.833 --> 00:20:07.000
put in place
a Do-Not-Resuscitate order,
00:20:07.033 --> 00:20:09.900
which, as her durable power
of attorney, I am against
00:20:09.933 --> 00:20:11.533
and I believe my mother
would be against.
00:20:12.767 --> 00:20:15.833
If she gets any new infections,
for example,
00:20:15.867 --> 00:20:17.467
they will not treat them.
00:20:17.500 --> 00:20:18.700
In other words,
00:20:18.733 --> 00:20:22.267
they will not do heroic efforts
to save her life.
00:20:22.300 --> 00:20:25.000
Yes, oh, good.
She brushed your hair.
00:20:25.033 --> 00:20:28.033
Fortunately,
they will not terminate dialysis
00:20:28.067 --> 00:20:30.733
or the ventilator,
00:20:30.767 --> 00:20:35.033
and instead, they\'re going
to not escalate her care.
00:20:35.067 --> 00:20:38.833
- If a patient
is very unlikely to survive
00:20:38.867 --> 00:20:41.333
but the physicians
feel that there\'s some chance
00:20:41.367 --> 00:20:44.900
by using
all the available resources
00:20:44.933 --> 00:20:47.333
they might be able
to pull them through,
00:20:47.367 --> 00:20:50.667
they appropriately will use
all of those treatments.
00:20:50.700 --> 00:20:53.933
Yet they may recognize
that a further deterioration
00:20:53.967 --> 00:20:56.800
would mean that that goal
is unattainable.
00:20:56.833 --> 00:20:58.267
And under those circumstances,
00:20:58.300 --> 00:21:01.067
it would be inappropriate for
them to further escalate care.
00:21:02.067 --> 00:21:04.333
- Yes, you\'re doing good.
00:21:04.367 --> 00:21:06.133
Hang in there.
00:21:06.167 --> 00:21:08.000
Every day is a miracle.
00:21:08.033 --> 00:21:12.333
Why, all of a sudden,
am I not in a position
00:21:12.367 --> 00:21:15.900
to make decisions
about her life-ending choices?
00:21:15.933 --> 00:21:21.000
- I think there\'s a disconnect
between what we can do
00:21:21.033 --> 00:21:22.800
and what we can do that helps.
00:21:24.200 --> 00:21:26.333
- I\'m going to visit you
back again later.
00:21:26.367 --> 00:21:27.600
- We\'re in a situation
00:21:27.633 --> 00:21:33.133
where we have very powerful
technology, medications,
00:21:33.167 --> 00:21:35.400
and tools and expertise
in caring for people
00:21:35.433 --> 00:21:36.833
in critical illness.
00:21:36.867 --> 00:21:38.433
But I think
we\'ve approached a point
00:21:38.467 --> 00:21:41.200
where we\'re
almost abusing that power.
00:21:41.233 --> 00:21:44.567
- It\'s under those
extremely unusual circumstances
00:21:44.600 --> 00:21:46.733
where the goals of medicine
are being tested
00:21:46.767 --> 00:21:48.533
by the use of technology
00:21:48.567 --> 00:21:51.067
that physicians
need to begin to pull back,
00:21:51.100 --> 00:21:53.533
have intensive conversations
with families,
00:21:53.567 --> 00:21:56.533
and sometimes
consider overriding them.
00:21:56.567 --> 00:21:58.833
- Essentially,
they\'re pulling the plug.
00:21:58.867 --> 00:22:01.400
I call it a medical execution.
00:22:01.433 --> 00:22:04.433
It is essentially a death panel.
00:22:04.467 --> 00:22:09.033
- It\'s difficult when we\'re
put in an adversarial position
00:22:09.067 --> 00:22:11.400
where we have to tell
patients\' families that,
00:22:11.433 --> 00:22:14.067
\"I don\'t think this will help.\"
00:22:14.100 --> 00:22:19.833
This is exacerbated by
discussions in the general media
00:22:19.867 --> 00:22:21.767
and in politics, unfortunately,
00:22:21.800 --> 00:22:24.000
with statements
like \"death panels\"
00:22:24.033 --> 00:22:27.467
and really politicizing
a deeply personal issue.
00:22:28.700 --> 00:22:30.533
- It is euthanasia.
00:22:30.567 --> 00:22:35.567
And I feel that the decision
was made
00:22:35.600 --> 00:22:38.467
because she basically
wouldn\'t go away.
00:22:38.500 --> 00:22:42.400
- We do not practice euthanasia
under any circumstances.
00:22:42.433 --> 00:22:48.367
Euthanasia
is the active promotion of death
00:22:48.400 --> 00:22:49.967
with that intent.
00:22:50.000 --> 00:22:51.733
- I\'m gonna suction you again,
okay?
00:22:51.767 --> 00:22:55.400
- We use machines
to be able to protect patients
00:22:55.433 --> 00:22:58.000
from dying
from an underlying condition.
00:22:58.033 --> 00:22:59.667
- Just a little bit.
00:22:59.700 --> 00:23:03.367
- And it\'s possible to use these
advanced tools that we have
00:23:03.400 --> 00:23:07.400
to not help patients
but to actually prolong a death
00:23:07.433 --> 00:23:12.467
or to actually produce
more suffering or less comfort.
00:23:12.500 --> 00:23:14.400
And under those circumstances,
00:23:14.433 --> 00:23:17.400
physicians
may very well say, \"No.\"
00:23:17.433 --> 00:23:21.400
- We have to be able
to save lives, perform miracles,
00:23:21.433 --> 00:23:24.533
and we also need to figure out
the best way
00:23:24.567 --> 00:23:27.267
to allow people to pass
with dignity.
00:23:27.300 --> 00:23:29.767
But that\'s a discussion
that really doesn\'t take place
00:23:29.800 --> 00:23:32.667
when you show up to our
emergency room in extremis.
00:23:32.700 --> 00:23:34.667
That discussion
has to take place
00:23:34.700 --> 00:23:37.967
with a trusted
primary care provider
00:23:38.000 --> 00:23:41.700
that\'s been your family doc
for years, ideally,
00:23:41.733 --> 00:23:45.233
because when you come to us
with multi-organ failure,
00:23:45.267 --> 00:23:47.567
we do what we know how to do.
00:23:47.600 --> 00:23:53.200
And America has not focused
on that particular discussion
00:23:53.233 --> 00:23:55.533
in advance enough.
00:23:56.933 --> 00:23:58.967
And we\'re not talking about
death squads.
00:23:59.000 --> 00:24:01.967
We\'re talking about
having real discussions
00:24:02.000 --> 00:24:07.033
about the end of your life,
and how do you want it to be?
00:24:07.067 --> 00:24:09.967
- We have to start being able
to talk about it,
00:24:10.000 --> 00:24:12.000
and not just because
we\'re spending a huge amount
00:24:12.033 --> 00:24:13.433
of money on it,
00:24:13.467 --> 00:24:18.100
but because a medicalized death
is not what most people want.
00:24:33.300 --> 00:24:34.867
- There we go.
00:24:34.900 --> 00:24:38.367
So you had a cancer
when you were a kid,
00:24:38.400 --> 00:24:44.300
and then you\'ve had
lung and esophagus cancers
00:24:44.333 --> 00:24:45.567
now as an adult.
00:24:45.600 --> 00:24:47.467
- In my stomach now.
00:24:47.500 --> 00:24:48.633
- And stomach cancer.
00:24:48.667 --> 00:24:50.133
- Yeah.
00:24:50.167 --> 00:24:52.833
- Right now, you\'re struggling
with what we call sepsis,
00:24:52.867 --> 00:24:55.667
which is our fancy word
for a serious infection.
00:24:55.700 --> 00:25:00.267
And one of the questions
that we have to clarify
00:25:00.300 --> 00:25:04.600
in order to take care of you
the way you would like
00:25:04.633 --> 00:25:07.367
is to understand whether
there are any limits
00:25:07.400 --> 00:25:10.567
to the kinds of creative
medical technologies
00:25:10.600 --> 00:25:15.733
we could use
in order to support you
00:25:15.767 --> 00:25:18.333
if your body
really started to collapse.
00:25:18.367 --> 00:25:20.933
Sometimes the first question
that we have to answer
00:25:20.967 --> 00:25:22.700
is the lung
life support machine,
00:25:22.733 --> 00:25:26.967
called the mechanical ventilator
or the respirator.
00:25:27.000 --> 00:25:30.500
- No, I\'ve already
made up my mind.
00:25:30.533 --> 00:25:32.367
If you can help me...
00:25:32.400 --> 00:25:33.633
- Yeah.
00:25:33.667 --> 00:25:35.100
- Then that\'s fine.
00:25:35.133 --> 00:25:36.367
- Right.
00:25:36.400 --> 00:25:39.000
- But I don\'t want to live
like a vegetable.
00:25:39.033 --> 00:25:42.567
- If I told you that we might
need to go on the ventilator
00:25:42.600 --> 00:25:44.333
for a couple days
00:25:44.367 --> 00:25:50.167
and I thought
that you had a 90% chance,
00:25:50.200 --> 00:25:51.167
so nine out of ten...
00:25:51.200 --> 00:25:52.767
- Right.
00:25:52.800 --> 00:25:55.733
- That you\'d get through it
and we\'d remove the ventilator
00:25:55.767 --> 00:25:57.800
and you\'d do okay,
00:25:57.833 --> 00:26:00.400
would you want me
to put you on the ventilator?
00:26:00.433 --> 00:26:02.867
- Okay, if you could do it
that way...
00:26:02.900 --> 00:26:04.000
- Yeah?
00:26:04.033 --> 00:26:06.367
- Then I\'ll go
with the ventilator.
00:26:06.400 --> 00:26:07.933
- I see;
now comes the hard part.
00:26:07.967 --> 00:26:10.500
Would you want me to put you
on the ventilator temporarily
00:26:10.533 --> 00:26:12.667
if it was a one in ten shot
that we would get you through?
00:26:12.700 --> 00:26:16.100
- A one in ten, I\'d take it
for a couple days
00:26:16.133 --> 00:26:17.800
like we talked about.
00:26:17.833 --> 00:26:18.800
- Oh, okay, okay, okay.
00:26:18.833 --> 00:26:20.067
- But yeah...
00:26:20.100 --> 00:26:22.833
- So that\'s very helpful
for me to understand.
00:26:22.867 --> 00:26:28.133
- Like a long-term thing,
like three months, no.
00:26:28.167 --> 00:26:31.600
I just don\'t want
to tie people down.
00:26:31.633 --> 00:26:36.000
I mean, if it\'s not gonna work,
it\'s not gonna work.
00:26:36.033 --> 00:26:41.033
- The sense I got from you
is that if you got an okay shot
00:26:41.067 --> 00:26:44.667
at a reasonable amount
of independence
00:26:44.700 --> 00:26:47.067
as a result of a treatment
that we give you...
00:26:47.100 --> 00:26:48.200
- Right.
00:26:48.233 --> 00:26:49.367
- You\'d like to go for it.
00:26:49.400 --> 00:26:50.367
- I would.
00:26:50.400 --> 00:26:51.600
- Okay, okay.
00:26:51.633 --> 00:26:53.567
Then I think we ought...
Then I think we ought to.
00:26:53.600 --> 00:26:55.400
- I\'d give it a try.
00:26:55.433 --> 00:26:56.400
I would.
00:26:56.433 --> 00:26:58.200
- Okay.
00:26:58.233 --> 00:27:00.633
But I... but I want you to know,
00:27:00.667 --> 00:27:02.500
I\'m not trying to push
my fancy toys on you.
00:27:02.533 --> 00:27:03.500
- I know you\'re not.
00:27:03.533 --> 00:27:05.033
- I love to do \'em.
00:27:05.067 --> 00:27:06.867
I love to run these machines.
00:27:06.900 --> 00:27:08.933
I love to do intensive care.
00:27:08.967 --> 00:27:12.400
But my responsibility
is to you, not to me.
00:27:12.433 --> 00:27:15.467
- The patient is not
just an experimental subject
00:27:15.500 --> 00:27:17.900
as we explore how far
we can push back
00:27:17.933 --> 00:27:19.500
the boundaries of death.
00:27:19.533 --> 00:27:21.167
I need to say in passing,
00:27:21.200 --> 00:27:24.267
nobody\'s getting out
of here alive.
00:27:24.300 --> 00:27:27.067
It\'s going to happen
to all of us sometime.
00:27:27.100 --> 00:27:30.300
You get a choice
about how it happens to you,
00:27:30.333 --> 00:27:33.633
and a good physician
will support you in that choice.
00:27:43.233 --> 00:27:44.967
- So why don\'t you tell me
your understanding
00:27:45.000 --> 00:27:46.833
of your heart and kidneys?
00:27:46.867 --> 00:27:48.067
What\'s going on?
00:27:48.100 --> 00:27:51.400
- Well, I\'m in congestive
heart failure,
00:27:51.433 --> 00:27:56.433
and it\'s gotten
to a terminal point.
00:27:56.467 --> 00:27:59.867
There\'s nothing
anyone can do to cure it.
00:27:59.900 --> 00:28:01.400
- Okay.
00:28:01.433 --> 00:28:06.700
- They were at first talking
going to the ICU,
00:28:06.733 --> 00:28:12.667
but I don\'t want
to be kept alive by machines.
00:28:14.967 --> 00:28:17.900
When it\'s time, it\'s time.
00:28:17.933 --> 00:28:22.533
- My goal
is to honor what he wants.
00:28:22.567 --> 00:28:25.333
Sorry.
00:28:25.367 --> 00:28:29.067
- Of course I don\'t want to die,
00:28:29.100 --> 00:28:33.233
but going out
kicking and screaming
00:28:33.267 --> 00:28:35.867
doesn\'t change the going out.
00:28:35.900 --> 00:28:42.133
I realize that I\'m going to need
hospice at home.
00:28:42.167 --> 00:28:45.233
I\'m only six feet
from a nice place to sit
00:28:45.267 --> 00:28:48.033
in the sun in the front yard.
00:28:48.067 --> 00:28:51.900
And I love that
more than anything else.
00:28:51.933 --> 00:28:53.433
- Those sound like good goals.
00:28:53.467 --> 00:28:54.900
I think
you\'ve made a lot of peace,
00:28:54.933 --> 00:28:56.333
and you\'re
going to show your family
00:28:56.367 --> 00:28:57.800
how to do this last part
of life.
00:28:57.833 --> 00:29:00.800
- Yes, I\'m gonna do my best.
00:29:00.833 --> 00:29:01.833
- I see that.
00:29:03.033 --> 00:29:05.933
We often recommend
going out of the hospital
00:29:05.967 --> 00:29:07.233
with what\'s called
00:29:07.267 --> 00:29:09.667
a \"physician order
for life-sustaining treatment.\"
00:29:09.700 --> 00:29:10.900
- Yes.
00:29:10.933 --> 00:29:13.067
- So it\'s your wishes
turned into an order
00:29:13.100 --> 00:29:15.000
that can be followed
in the community.
00:29:15.033 --> 00:29:17.367
It would tell them
what limited interventions
00:29:17.400 --> 00:29:20.167
you\'re willing to have
and what you don\'t want.
00:29:20.200 --> 00:29:22.633
I\'m going to fill this out
like we talked about.
00:29:22.667 --> 00:29:25.167
We\'ll be watching to see
how you can get out,
00:29:25.200 --> 00:29:26.600
maybe by Monday, and get home.
00:29:26.633 --> 00:29:27.600
- All righty.
00:29:27.633 --> 00:29:28.600
- Get in that sunshine.
00:29:28.633 --> 00:29:31.200
- That\'s what I\'m hoping for.
00:29:39.333 --> 00:29:41.967
- When you start to focus on
the real needs of your patients,
00:29:42.000 --> 00:29:44.033
you find
that very often they don\'t want
00:29:44.067 --> 00:29:45.900
this over-the-top rescue care.
00:29:47.367 --> 00:29:49.367
They want dignity.
00:29:49.400 --> 00:29:52.400
- There\'s this wonderful study
that just came out
00:29:52.433 --> 00:29:58.167
that looked at cancer patients
who had standard treatment,
00:29:58.200 --> 00:30:01.533
fairly aggressive treatment,
versus palliative care.
00:30:01.567 --> 00:30:04.200
So palliative care
simply meant that nobody
00:30:04.233 --> 00:30:07.233
was going for cures
and comfort was paramount.
00:30:07.267 --> 00:30:11.367
And the question was:
what happened to those patients?
00:30:11.400 --> 00:30:12.533
And lo and behold,
00:30:12.567 --> 00:30:15.233
the palliative care patients
lived longer.
00:30:15.267 --> 00:30:18.067
- Now, some patients will
want that aggressive approach.
00:30:18.100 --> 00:30:20.333
And if they ask for it,
they will get it
00:30:20.367 --> 00:30:23.600
in this system here in Utah.
00:30:23.633 --> 00:30:27.033
The difference is
is many of them won\'t
00:30:27.067 --> 00:30:29.200
that have lived
a full and satisfying life.
00:30:29.233 --> 00:30:33.667
The last thing they want to do
is to die in an ICU.
00:30:33.700 --> 00:30:35.233
They know they\'re going to die.
00:30:35.267 --> 00:30:38.500
They want to die
in the arms of their family
00:30:38.533 --> 00:30:40.800
at the close
of a wonderful life.
00:30:40.833 --> 00:30:42.600
You see?
00:30:42.633 --> 00:30:47.033
We have built a system
that accommodates that view,
00:30:47.067 --> 00:30:50.300
not just the other
technological view.
00:30:50.333 --> 00:30:52.600
That technology is important,
00:30:52.633 --> 00:30:54.233
but knowing
how and when to apply it
00:30:54.267 --> 00:30:55.700
under a patient\'s control
00:30:55.733 --> 00:30:57.367
is at least as important.
00:30:57.400 --> 00:30:59.000
- You did good;
good job.
00:31:09.633 --> 00:31:11.400
- I was sitting in my office.
00:31:11.433 --> 00:31:14.100
And I started to feel a headache
coming on.
00:31:14.133 --> 00:31:17.533
And on the way
to my doctor\'s office,
00:31:17.567 --> 00:31:20.067
this headache just erupted.
00:31:20.100 --> 00:31:23.767
It felt like an artillery shell
going off in my head.
00:31:23.800 --> 00:31:26.867
- Your case... you have
an aneurism of this location,
00:31:26.900 --> 00:31:29.000
where the arrow is pointing.
00:31:29.033 --> 00:31:34.300
- Basically, it\'s a hemorrhage
from a balloon on the artery
00:31:34.333 --> 00:31:38.833
that breaks
and spills blood into the brain.
00:31:38.867 --> 00:31:41.900
The ultimate test
was the CT scan
00:31:41.933 --> 00:31:44.467
so that they would know
exactly where to intervene.
00:31:44.500 --> 00:31:47.900
- We have to navigate
all the way from the groin
00:31:47.933 --> 00:31:50.433
where we go in
with a very long tube
00:31:50.467 --> 00:31:51.767
that is called a catheter
00:31:51.800 --> 00:31:54.767
and put it all the way
inside of the aneurism.
00:31:54.800 --> 00:31:56.633
- They do what\'s called
embolizing it,
00:31:56.667 --> 00:32:01.633
which is essentially filling it
with little tiny platinum coils.
00:32:01.667 --> 00:32:05.000
- 50% of people
with a hemorrhage like this die.
00:32:05.033 --> 00:32:10.033
- I spent another three weeks
in the neuro-ICU.
00:32:10.067 --> 00:32:12.567
When I got out of the hospital,
00:32:12.600 --> 00:32:17.633
UCLA billed my insurance company
for $440,000.
00:32:17.667 --> 00:32:23.167
- The price that we have to pay
to treat you is miniscule
00:32:23.200 --> 00:32:25.600
compared with the benefit
that society has
00:32:25.633 --> 00:32:30.900
from being able to enjoy
the abilities that you have.
00:32:30.933 --> 00:32:32.667
- That coil
that was put in his head
00:32:32.700 --> 00:32:34.133
was invented here.
00:32:34.167 --> 00:32:36.800
So I mean, we\'re talking about...
You came to the right place.
00:32:38.333 --> 00:32:42.667
- At its best, that\'s what
rescue medicine can accomplish.
00:32:42.700 --> 00:32:45.833
At its worst,
it\'s used inappropriately
00:32:45.867 --> 00:32:49.667
in cases where the benefits
are not even available.
00:32:51.967 --> 00:32:53.233
- When it comes to rescue care,
00:32:53.267 --> 00:32:55.600
the United States
dominates the world.
00:32:55.633 --> 00:32:58.367
The rates at which we put people
on renal dialysis,
00:32:58.400 --> 00:33:01.467
the rates at which we do
aggressive cancer treatments
00:33:01.500 --> 00:33:04.433
and organ transplants...
00:33:04.467 --> 00:33:05.967
What we\'re selling is hope.
00:33:06.000 --> 00:33:08.733
Everybody
wants to be the miracle.
00:33:08.767 --> 00:33:11.433
Nobody wants to lose that.
00:33:11.467 --> 00:33:14.200
It\'s not a question
of abandoning rescue care.
00:33:14.233 --> 00:33:16.333
It\'s a question of tuning it.
00:33:16.367 --> 00:33:19.700
How do I get that save
and lose unnecessary treatments?
00:33:20.767 --> 00:33:23.267
- That medical care
saved my life.
00:33:23.300 --> 00:33:24.733
And it was very expensive care,
00:33:24.767 --> 00:33:28.367
but from my vantage point,
well worth it, of course.
00:33:28.400 --> 00:33:32.733
Once I was leaving the hospital,
it was a different situation.
00:33:32.767 --> 00:33:35.467
There was an intern
who came to my room,
00:33:35.500 --> 00:33:37.667
spent five minutes with me,
00:33:37.700 --> 00:33:41.567
wrote out some instructions
on a single-page form.
00:33:41.600 --> 00:33:44.400
So I essentially
walked out of the door
00:33:44.433 --> 00:33:49.633
with hardly a thought about
what would come next for me.
00:33:49.667 --> 00:33:52.867
- Currently the system
is designed to pay us
00:33:52.900 --> 00:33:55.667
based on how many procedures
we do.
00:33:55.700 --> 00:33:58.200
So we\'re really good
at doing procedures.
00:33:58.233 --> 00:34:00.967
And we\'re really good at volume.
00:34:01.000 --> 00:34:03.600
That\'s the way the current
American health care system
00:34:03.633 --> 00:34:04.767
is set up.
00:34:04.800 --> 00:34:07.767
As we transition to one
of population health,
00:34:07.800 --> 00:34:10.567
of course we have to be able
to still do
00:34:10.600 --> 00:34:12.167
those heroic measures,
00:34:12.200 --> 00:34:16.567
but now that transition in care
has to be addressed much more.
00:34:16.600 --> 00:34:19.767
We\'ve never been incentivized
to do that.
00:34:19.800 --> 00:34:24.700
- Although UCLA is a fabulous
high-technology hospital,
00:34:24.733 --> 00:34:26.233
certain aspects of patient care,
00:34:26.267 --> 00:34:31.033
which might actually improve
the outcomes, may be neglected.
00:34:31.067 --> 00:34:36.533
Unfortunately primary care is
crowded out by rescue medicine.
00:34:36.567 --> 00:34:39.367
- We developed literally
thousands of ways
00:34:39.400 --> 00:34:42.100
that we could intervene
to change a patient\'s future.
00:34:42.133 --> 00:34:43.833
It\'s a little bit addictive.
00:34:43.867 --> 00:34:47.167
As a physician, you get focused
over on that side.
00:34:47.200 --> 00:34:49.500
It becomes the battle
against disease
00:34:49.533 --> 00:34:53.600
as opposed to service
to the patient.
00:34:53.633 --> 00:34:57.633
And it happens to all of us
to some degree.
00:34:57.667 --> 00:34:59.567
Well, when you recognize that,
00:34:59.600 --> 00:35:02.900
you start to try to build
a culture within an organization
00:35:02.933 --> 00:35:06.300
that values the patient
as much as the technology.
00:35:06.333 --> 00:35:09.067
- I think having
an integrated system of care
00:35:09.100 --> 00:35:13.433
as Intermountain does
is a very important component
00:35:13.467 --> 00:35:15.833
of improving the quality
of care.
00:35:15.867 --> 00:35:20.667
UCLA has a delivery system,
but it\'s rather fragmented.
00:35:20.700 --> 00:35:24.433
And unfortunately,
UCLA\'s fragmentation
00:35:24.467 --> 00:35:28.333
is very representative
of our whole health care system.
00:35:43.833 --> 00:35:46.833
- He was
in a motor vehicle accident.
00:35:46.867 --> 00:35:48.767
We ordered both a CT of the head
00:35:48.800 --> 00:35:51.300
as well as
a CT of the cervical spine.
00:35:51.333 --> 00:35:52.400
- Okay, excellent.
00:35:52.433 --> 00:35:55.833
Well, you can see,
here are the CT images.
00:35:55.867 --> 00:35:58.700
And this is a nice
young person\'s brain.
00:35:58.733 --> 00:36:00.667
He\'s 24 years old.
00:36:00.700 --> 00:36:02.567
- If someone is worried
about the possibility
00:36:02.600 --> 00:36:05.200
that he\'s sustained
an important injury to his head,
00:36:05.233 --> 00:36:08.733
the only way to know for sure
is to do a CAT scan...
00:36:08.767 --> 00:36:10.433
Seems reasonable.
00:36:10.467 --> 00:36:12.500
And then it comes out normal,
and we all feel better.
00:36:12.533 --> 00:36:14.100
It sounds like that\'s
a good deal,
00:36:14.133 --> 00:36:16.533
but it\'s not a good deal,
actually, for anybody
00:36:16.567 --> 00:36:18.300
and most particularly
not for that patient.
00:36:18.333 --> 00:36:19.300
Why is that?
00:36:19.333 --> 00:36:20.733
Well, there are
many, many reasons.
00:36:20.767 --> 00:36:25.133
One is that most of the time,
almost always,
00:36:25.167 --> 00:36:28.900
I can tell clinically whether
he has an important head injury.
00:36:28.933 --> 00:36:31.600
The right test
is usually putting the eyes
00:36:31.633 --> 00:36:34.767
of an experienced physician
on a patient.
00:36:34.800 --> 00:36:36.333
- Sometimes those CT scans
00:36:36.367 --> 00:36:39.933
really do help physicians
make better diagnoses.
00:36:39.967 --> 00:36:43.433
But a good part of the time,
they\'re just being used
00:36:43.467 --> 00:36:44.800
because they\'re there.
00:36:44.833 --> 00:36:46.267
- He has nice preservation
00:36:46.300 --> 00:36:48.733
of gray-white matter
differentiation throughout.
00:36:48.767 --> 00:36:50.967
So we would call this normal.
00:36:51.000 --> 00:36:54.467
So we\'re going to give his head
a clean bill of health.
00:36:54.500 --> 00:36:55.733
- Okay.
00:36:55.767 --> 00:36:57.967
- The CAT scan itself
is not benign.
00:36:58.000 --> 00:37:02.400
And we know for sure
that doing a CAT scan,
00:37:02.433 --> 00:37:05.867
which is about 200 to 500
chest X-rays
00:37:05.900 --> 00:37:07.533
in terms of radiation...
00:37:07.567 --> 00:37:09.633
It\'s a lot of radiation...
00:37:09.667 --> 00:37:11.067
Will cause cancer.
00:37:11.100 --> 00:37:14.933
- The estimate is that tens
of thousands of cancer deaths
00:37:14.967 --> 00:37:18.833
are being caused each year
by medical radiation.
00:37:20.033 --> 00:37:21.400
- Not doing the scan
00:37:21.433 --> 00:37:23.633
and missing
that one out of a thousand
00:37:23.667 --> 00:37:25.667
is a big problem.
00:37:25.700 --> 00:37:28.433
And the medical
legal responsibility
00:37:28.467 --> 00:37:29.967
of now experts saying,
00:37:30.000 --> 00:37:32.267
\"Well, in this case, you should
have certainly done a scan,
00:37:32.300 --> 00:37:33.500
why didn\'t you do one?\"
00:37:33.533 --> 00:37:38.067
gets you into this
sort of defensive-medicine mode.
00:37:38.100 --> 00:37:40.833
And I\'m a parent
of two teenagers.
00:37:40.867 --> 00:37:42.467
I want a clean bill of health.
00:37:42.500 --> 00:37:44.233
That\'s my little girl.
00:37:44.267 --> 00:37:46.467
Are you sure
there\'s nothing you\'re missing?
00:37:46.500 --> 00:37:48.133
Well, I can\'t be 100% sure.
00:37:48.167 --> 00:37:50.400
I can tell you
the neurologic exam was normal.
00:37:50.433 --> 00:37:52.200
But there\'s
a 1-in-5,000 chance
00:37:52.233 --> 00:37:54.200
that there could be
a small bleed that I\'m missing.
00:37:54.233 --> 00:37:55.767
\"Well, yeah, I want the test.\"
00:37:57.000 --> 00:37:59.367
- When I do all sorts of tests
00:37:59.400 --> 00:38:02.933
that I don\'t really think
are abnormal,
00:38:02.967 --> 00:38:05.833
some of them are gonna
look abnormal just by chance.
00:38:05.867 --> 00:38:07.767
That\'s just how it is.
00:38:07.800 --> 00:38:11.800
And when they do look abnormal,
I\'m forced to do things to you
00:38:11.833 --> 00:38:13.867
that many times
will cause you harm
00:38:13.900 --> 00:38:18.333
and only rarely
will do any benefit.
00:38:18.367 --> 00:38:23.267
- Imaging or testing
in inappropriate circumstances
00:38:23.300 --> 00:38:26.467
just exposes you
to the risks of false positives.
00:38:26.500 --> 00:38:28.600
And working out
those false positives
00:38:28.633 --> 00:38:32.133
kills people... sometimes,
not often, thank heavens.
00:38:32.167 --> 00:38:35.767
There\'s this, oh,
deeply embedded belief
00:38:35.800 --> 00:38:37.333
that it\'s all upside.
00:38:37.367 --> 00:38:38.600
No.
00:38:57.133 --> 00:38:59.100
- Okay, relax.
00:38:59.133 --> 00:39:00.333
Okay, all finished.
00:39:00.367 --> 00:39:02.167
- All done?
- Mm-hmm.
00:39:02.200 --> 00:39:04.100
- So Melissa,
you had your big birthday
00:39:04.133 --> 00:39:05.933
this year where you turned 40.
00:39:05.967 --> 00:39:06.967
- I did.
00:39:07.000 --> 00:39:09.067
- And from age 40 on,
a little present
00:39:09.100 --> 00:39:11.633
that we like to give you
is an order for a mammogram.
00:39:11.667 --> 00:39:15.267
- When I turned 40,
my doctor said,
00:39:15.300 --> 00:39:18.600
\"Well, time
to start mammograms.\"
00:39:18.633 --> 00:39:22.267
And at that point,
I knew enough about mammography
00:39:22.300 --> 00:39:26.200
to know that the chances
that a mammogram
00:39:26.233 --> 00:39:29.967
for me in my 40s
would benefit me
00:39:30.000 --> 00:39:32.600
was a lot lower than the chances
that it would lead to harm.
00:39:34.067 --> 00:39:35.333
- There are many, many things
00:39:35.367 --> 00:39:37.733
that, under the microscope,
turn out to be cancer.
00:39:37.767 --> 00:39:39.667
But we\'d actually,
in real life...
00:39:39.700 --> 00:39:41.967
If we never looked for them,
we\'d never find them,
00:39:42.000 --> 00:39:45.333
and they\'d never
cause you a problem.
00:39:45.367 --> 00:39:47.667
Once we find them,
we don\'t know which is which.
00:39:47.700 --> 00:39:49.333
We have to do something
about it.
00:39:49.367 --> 00:39:50.933
So we\'re going to do
an intervention,
00:39:50.967 --> 00:39:53.500
which could cause you harm.
00:39:53.533 --> 00:39:55.567
It certainly will cause you
psychological concern.
00:39:55.600 --> 00:39:57.067
It will cause you
economic concern.
00:39:57.100 --> 00:39:59.667
It might interfere with
your ability to get insurance.
00:39:59.700 --> 00:40:01.333
It will change you
from a healthy person
00:40:01.367 --> 00:40:03.900
into a cancer victim.
00:40:03.933 --> 00:40:07.367
And it turns out,
in many cases we...
00:40:07.400 --> 00:40:08.640
If we had never known about it,
00:40:08.667 --> 00:40:10.233
you would never
have known about it.
00:40:10.267 --> 00:40:13.067
You would have died with it
50 years from now
00:40:13.100 --> 00:40:14.767
but not ever of it.
00:40:14.800 --> 00:40:15.967
- This is going to be
a new thing
00:40:16.000 --> 00:40:18.167
that we are going to start doing
once a year.
00:40:18.200 --> 00:40:20.267
Now, one of the questions
that a lot of the patients
00:40:20.300 --> 00:40:23.167
have had recently is,
in the news,
00:40:23.200 --> 00:40:24.233
in the last couple of years,
00:40:24.267 --> 00:40:25.667
there\'s been
a little controversy
00:40:25.700 --> 00:40:27.467
about when should we start
doing mammograms,
00:40:27.500 --> 00:40:28.667
how frequently should we do it,
00:40:28.700 --> 00:40:30.800
should we be doing them at all?
00:40:30.833 --> 00:40:33.700
We know it\'s a source
of much anxiety and worry
00:40:33.733 --> 00:40:35.400
for a lot of patients.
00:40:35.433 --> 00:40:37.033
But we love our patients.
00:40:37.067 --> 00:40:38.433
We care about our patients.
00:40:38.467 --> 00:40:40.867
And we want to do everything
we can to help keep you healthy.
00:40:43.367 --> 00:40:47.467
- Imagine screening
2,000 40-year-old women
00:40:47.500 --> 00:40:49.567
for a course of ten years.
00:40:49.600 --> 00:40:52.900
At most, one will avoid
a breast cancer death.
00:40:52.933 --> 00:40:55.000
- Okay, Nicky, just hold still.
00:40:55.033 --> 00:40:58.167
- But somewhere between
500 and 1,000,
00:40:58.200 --> 00:41:01.233
over the course of ten years,
will have one false alarm,
00:41:01.267 --> 00:41:03.233
that\'s a abnormal mammogram
00:41:03.267 --> 00:41:06.500
that makes them wary
that they might have cancer.
00:41:06.533 --> 00:41:08.733
And somewhere between
two and ten
00:41:08.767 --> 00:41:11.500
will be overdiagnosed
and treated unnecessarily
00:41:11.533 --> 00:41:12.967
for breast cancer.
00:41:13.000 --> 00:41:14.867
That means
they\'ll have a lumpectomy
00:41:14.900 --> 00:41:16.267
or a mastectomy
00:41:16.300 --> 00:41:18.000
or chemotherapy
00:41:18.033 --> 00:41:19.267
or radiation.
00:41:19.300 --> 00:41:21.800
- I wouldn\'t be surprised
if most women
00:41:21.833 --> 00:41:25.000
who knew the very tiny
likelihood of benefit
00:41:25.033 --> 00:41:27.400
and fairly substantial
likelihood of some harm,
00:41:27.433 --> 00:41:28.833
would say, \"I don\'t want it.\"
00:41:28.867 --> 00:41:30.567
- When it says,
00:41:30.600 --> 00:41:33.400
\"Oh, well, we shouldn\'t
do mammography till age 50,\"
00:41:33.433 --> 00:41:35.200
that\'s looking at populations.
00:41:35.233 --> 00:41:37.067
But now, you\'re
an individual patient.
00:41:37.100 --> 00:41:41.867
Now, it\'s my wife, Andrea,
who\'s 46.
00:41:41.900 --> 00:41:44.967
Should she skip her mammography
because this new study came out?
00:41:45.000 --> 00:41:46.733
Or should she
get her mammography?
00:41:46.767 --> 00:41:50.000
And that becomes
a very, very personal decision.
00:41:50.033 --> 00:41:53.767
If it picks something up,
it could actually save her life,
00:41:53.800 --> 00:41:56.433
despite when we looked
at 5,000 women,
00:41:56.467 --> 00:42:00.233
it didn\'t statistically
improve overall life survival,
00:42:00.267 --> 00:42:02.500
because there were false
negatives or false positives.
00:42:02.533 --> 00:42:04.033
But now, this is my wife.
00:42:04.067 --> 00:42:07.933
And when you start talking about
personal individual choices
00:42:07.967 --> 00:42:09.100
and families,
00:42:09.133 --> 00:42:11.533
the evidence
kind of takes a backseat.
00:42:11.567 --> 00:42:13.467
- Guess what I\'m going to
recommend to you, okay...
00:42:13.500 --> 00:42:15.600
Is that we should
do that annually.
00:42:15.633 --> 00:42:16.600
I think it\'s just worth it.
00:42:16.633 --> 00:42:18.200
It\'s the right thing to do.
00:42:18.233 --> 00:42:19.767
- After listening
to what you said,
00:42:19.800 --> 00:42:21.300
I mean,
I feel a lot more confident.
00:42:21.333 --> 00:42:24.567
For me, it\'s, yeah,
absolutely, I\'m...
00:42:24.600 --> 00:42:28.200
Guarantee I\'m going to get
that done as soon as possible.
00:42:28.233 --> 00:42:30.167
- Half of women in ten years
00:42:30.200 --> 00:42:31.933
will have one
false positive test...
00:42:31.967 --> 00:42:34.500
One out of every two.
00:42:34.533 --> 00:42:36.267
Now, some of those,
the false positive test,
00:42:36.300 --> 00:42:38.100
they get another test,
and everything\'s okay.
00:42:38.133 --> 00:42:39.100
It\'s not that harmful.
00:42:39.133 --> 00:42:41.200
But some of them
end up losing a breast,
00:42:41.233 --> 00:42:43.100
having pain, getting infection.
00:42:43.133 --> 00:42:46.300
And, yes, there is even a risk
of the rare case
00:42:46.333 --> 00:42:51.467
where, for crazy reasons,
a seemingly routine intervention
00:42:51.500 --> 00:42:53.567
ends up causing death.
00:42:53.600 --> 00:42:55.933
- We really do tend to focus on
our ability
00:42:55.967 --> 00:42:58.900
to detect abnormalities
and do something about them.
00:42:58.933 --> 00:43:01.400
We\'re very action-oriented.
00:43:01.433 --> 00:43:05.033
Scientifically, it\'s not
a black-and-white choice at all.
00:43:05.067 --> 00:43:08.133
It\'s a massive zone of gray.
00:43:08.167 --> 00:43:10.067
And then the question is:
who decides?
00:43:11.333 --> 00:43:13.067
- And the recent mammogram
00:43:13.100 --> 00:43:15.400
showed that you have
some microcalcifications,
00:43:15.433 --> 00:43:18.333
some little small calcifications
within the breast
00:43:18.367 --> 00:43:19.633
that are an indication
00:43:19.667 --> 00:43:22.000
that something
that is concerning going on
00:43:22.033 --> 00:43:23.300
within the breast.
00:43:23.333 --> 00:43:26.100
And so on that mammogram,
after they did that,
00:43:26.133 --> 00:43:28.833
they did
the stereotactic biopsy,
00:43:28.867 --> 00:43:31.567
and it showed
that there is a breast cancer.
00:43:31.600 --> 00:43:33.200
Yours is a grade one.
00:43:33.233 --> 00:43:35.033
It\'s the least aggressive.
00:43:35.067 --> 00:43:37.000
And so there are
two surgical options
00:43:37.033 --> 00:43:38.733
when we address breast cancer.
00:43:38.767 --> 00:43:41.333
Number one is to do a lumpectomy
00:43:41.367 --> 00:43:42.900
or breast preservation,
00:43:42.933 --> 00:43:45.733
where we just take out
the breast lump
00:43:45.767 --> 00:43:48.400
and sample the lymph nodes.
00:43:48.433 --> 00:43:50.667
Now, when we save the breast,
00:43:50.700 --> 00:43:53.567
you need to have radiation
afterwards
00:43:53.600 --> 00:43:55.933
to decrease the chances
of something coming back.
00:43:55.967 --> 00:43:58.033
And then the other option
is a mastectomy...
00:43:58.067 --> 00:44:03.033
To remove the entire breast
to take care of the cancer.
00:44:03.067 --> 00:44:05.900
The most important thing
that you can hear today
00:44:05.933 --> 00:44:09.100
is you are not going to make
a bad choice.
00:44:09.133 --> 00:44:11.267
If you preserve the breast
or take the breast,
00:44:11.300 --> 00:44:12.633
the mortality,
00:44:12.667 --> 00:44:14.333
which is
the most important thing,
00:44:14.367 --> 00:44:16.233
is the same, stage for stage.
00:44:16.267 --> 00:44:18.333
- I would prefer
to do the lumpectomy
00:44:18.367 --> 00:44:20.133
over the mastectomy, by far.
00:44:20.167 --> 00:44:22.333
I want to do everything I can
to preserve the breast.
00:44:22.367 --> 00:44:26.633
- Cosmetically, it would be
a very good option for you,
00:44:26.667 --> 00:44:29.433
and it\'s a smaller surgery
and a quicker recovery as well.
00:44:30.433 --> 00:44:32.633
Our goal, obviously, is cure.
00:44:34.233 --> 00:44:36.333
- Okay, I\'m going to give you
oxygen to breathe, okay?
00:44:36.367 --> 00:44:39.133
That\'s all this is,
big breaths in.
00:44:39.167 --> 00:44:40.333
Four more deep breaths.
00:44:40.367 --> 00:44:43.400
You\'ll be asleep
by the time you get to four.
00:44:43.433 --> 00:44:45.567
Good night.
00:44:53.600 --> 00:44:55.633
- There\'s this subtle area
of calcification.
00:44:55.667 --> 00:44:57.300
That\'s the area
that they biopsied
00:44:57.333 --> 00:44:58.667
that showed that she has cancer.
00:45:01.233 --> 00:45:02.967
So there\'s a hot spot
in the armpit,
00:45:03.000 --> 00:45:05.300
identifying a sentinel node.
00:45:05.333 --> 00:45:06.700
So we\'ll send this off
to pathology
00:45:06.733 --> 00:45:08.100
to be looked at right now.
00:45:09.100 --> 00:45:10.100
Hey.
00:45:15.333 --> 00:45:18.000
- I don\'t see anything
obvious yet.
00:45:18.033 --> 00:45:20.273
Yeah, there\'s no evidence
of tumor on the frozen section.
00:45:20.300 --> 00:45:22.200
- Okay, thanks, Michael.
Appreciate it.
00:45:26.767 --> 00:45:28.133
Now I\'m going to scrub back in,
00:45:28.167 --> 00:45:30.127
and we\'re going to take care
of the cancer itself.
00:45:36.167 --> 00:45:38.667
We have the abnormality
out that we want.
00:45:38.700 --> 00:45:40.340
I\'m going to talk to her family
right now.
00:45:42.967 --> 00:45:44.633
- So things went great.
00:45:44.667 --> 00:45:47.200
We were able to do everything
that we wanted to do.
00:45:47.233 --> 00:45:49.067
First we go after
the lymph nodes.
00:45:49.100 --> 00:45:50.500
We had the pathologists
look at it.
00:45:50.533 --> 00:45:52.233
And there was no evidence
of cancer in it.
00:45:52.267 --> 00:45:54.233
And then we took out the cancer
in the breast.
00:45:54.267 --> 00:45:56.667
And we X-rayed the tissue
that we got.
00:45:56.700 --> 00:45:59.800
And it looks like
we got everything out.
00:45:59.833 --> 00:46:01.567
- Wow, okay.
00:46:01.600 --> 00:46:07.200
- It\'s just...
It\'s a big relief.
00:46:07.233 --> 00:46:08.700
- Yeah.
00:46:08.733 --> 00:46:11.600
- The doctor said things
couldn\'t have gone better.
00:46:11.633 --> 00:46:14.700
And so we\'re really happy.
- Wow.
00:46:14.733 --> 00:46:16.700
That\'s really exciting.
00:46:16.733 --> 00:46:17.933
I can\'t believe it.
00:46:17.967 --> 00:46:21.067
- Cindy absolutely probably
saved her own life
00:46:21.100 --> 00:46:26.167
or at least saved herself
additional harsh treatments
00:46:26.200 --> 00:46:28.267
by having a screening mammogram
at age 47
00:46:28.300 --> 00:46:30.167
instead of waiting till age 50.
00:46:30.200 --> 00:46:32.633
Let\'s say she waited
until age 50.
00:46:32.667 --> 00:46:34.200
That would have given
this tumor,
00:46:34.233 --> 00:46:35.567
which was not palpable...
00:46:35.600 --> 00:46:38.500
It was seen only on the
mammogram and an ultrasound...
00:46:38.533 --> 00:46:41.200
Would have given that tumor
three more years to grow.
00:46:41.233 --> 00:46:42.900
Now, there are those
who argue that,
00:46:42.933 --> 00:46:45.033
\"Well, maybe it doesn\'t
make that much difference
00:46:45.067 --> 00:46:46.567
to find a cancer later.\"
00:46:46.600 --> 00:46:48.600
But we know
that that\'s patently false.
00:46:48.633 --> 00:46:51.933
We know that screening
mammography saves lives.
00:46:51.967 --> 00:46:55.100
- Well, I think mammograms
every year is important.
00:46:55.133 --> 00:46:58.033
- Yeah, now I do too.
00:46:58.067 --> 00:46:59.033
- Have you ever had one?
00:46:59.067 --> 00:47:01.200
- Uh-uh,
I\'ve been too chicken.
00:47:01.233 --> 00:47:02.667
- It\'s just...
You\'re too chicken?
00:47:02.700 --> 00:47:05.733
- Mm-hmm,
but I\'m not gonna be now.
00:47:05.767 --> 00:47:07.400
- No, it\'s not a big deal.
00:47:07.433 --> 00:47:08.867
It\'s easy to do.
00:47:08.900 --> 00:47:11.633
And it takes 10, 15 minutes,
and you\'re out, in and out.
00:47:11.667 --> 00:47:12.733
- Oh, wow.
00:47:12.767 --> 00:47:14.667
- It\'s just a picture.
00:47:14.700 --> 00:47:17.067
- Every time someone
has a diagnosed cancer,
00:47:17.100 --> 00:47:19.967
I hope that she is, in fact,
the winner of the lottery
00:47:20.000 --> 00:47:23.600
and did have her life
saved by the test.
00:47:23.633 --> 00:47:26.067
Our estimates are,
though, in fact
00:47:26.100 --> 00:47:27.600
that\'s relatively uncommon.
00:47:27.633 --> 00:47:30.967
It\'s less than one in four,
less than 25%.
00:47:31.000 --> 00:47:32.567
There\'re two other possibilities
00:47:32.600 --> 00:47:34.900
that combined are
actually more common.
00:47:34.933 --> 00:47:38.233
One is:
she was diagnosed early,
00:47:38.267 --> 00:47:41.500
but she didn\'t benefit
from the early diagnosis.
00:47:41.533 --> 00:47:44.100
In other words, she would
have been treated just as well
00:47:44.133 --> 00:47:47.167
if her cancer
had presented clinically.
00:47:47.200 --> 00:47:49.867
- Oh, pajamas,
so I can be comfortable.
00:47:49.900 --> 00:47:52.733
- But the third possibility
is that she was overdiagnosed,
00:47:52.767 --> 00:47:54.200
that she had a cancer
00:47:54.233 --> 00:47:56.933
that was never going
to become apparent clinically,
00:47:56.967 --> 00:47:58.867
that was never going
to kill her.
00:47:58.900 --> 00:48:01.067
And yet she was treated for it.
00:48:01.100 --> 00:48:04.167
And in fact, that\'s the harm
of cancer screening.
00:48:04.200 --> 00:48:07.133
Now, I hope that\'s not the case
in Cindy\'s case.
00:48:07.167 --> 00:48:08.533
I hope she\'s a winner.
00:48:08.567 --> 00:48:11.800
But in fact, most women
with screen-detected cancer
00:48:11.833 --> 00:48:14.233
fall in one
of the other two categories.
00:48:14.267 --> 00:48:15.733
- I feel great.
00:48:15.767 --> 00:48:17.000
- Yeah, you look good.
00:48:17.033 --> 00:48:19.167
- I even feel better now
that the news is so good.
00:48:19.200 --> 00:48:20.867
[laughs]
00:48:20.900 --> 00:48:22.300
- Yeah.
- So that\'s good.
00:48:22.333 --> 00:48:24.167
- It\'s a big relief.
I know you\'ve been worried.
00:48:24.200 --> 00:48:25.367
- Oh, my gosh, I know.
00:48:25.400 --> 00:48:29.567
It\'s been a roller-coaster
of emotions,
00:48:29.600 --> 00:48:30.833
so it\'s really good.
00:48:35.100 --> 00:48:36.200
Love you.
00:48:51.067 --> 00:48:54.300
- So, Adam, I wanted to discuss
routine PSA screening with you.
00:48:54.333 --> 00:48:56.067
We\'ve talked about this
in the past.
00:48:56.100 --> 00:48:58.633
- Prostate cancer screening
is the poster child
00:48:58.667 --> 00:49:00.633
for overdiagnosis.
00:49:00.667 --> 00:49:04.700
With the advent
of the PSA blood test,
00:49:04.733 --> 00:49:06.967
which is
the prostate-specific antigen...
00:49:07.000 --> 00:49:09.700
The screening test
for prostate cancer.
00:49:09.733 --> 00:49:14.567
In the late 1980s,
this test led to a huge upsurge
00:49:14.600 --> 00:49:17.867
in the number of diagnosed cases
of prostate cancer.
00:49:17.900 --> 00:49:22.033
- This is a test
that we do on men.
00:49:22.067 --> 00:49:24.133
We offer it to them
at the age of 50 for everyone
00:49:24.167 --> 00:49:26.067
and age 40
if they\'re at higher risk.
00:49:26.100 --> 00:49:28.140
And since your dad passed away
from prostate cancer,
00:49:28.167 --> 00:49:29.733
you\'re one of those
higher-risk people.
00:49:29.767 --> 00:49:31.067
And we\'ve been
talking about this
00:49:31.100 --> 00:49:32.540
since you were 40 years old,
I think.
00:49:32.567 --> 00:49:33.967
- Correct.
00:49:34.000 --> 00:49:36.167
- What are your feelings about
getting a routine PSA test?
00:49:36.200 --> 00:49:37.867
- I have no issues about it;
I\'d rather know.
00:49:37.900 --> 00:49:38.867
- Okay.
00:49:38.900 --> 00:49:40.267
- Definitely rather know.
- Okay.
00:49:40.300 --> 00:49:42.400
- It seems like catching it
early would be a good thing,
00:49:42.433 --> 00:49:44.933
but it almost never is,
because when you catch it early,
00:49:44.967 --> 00:49:46.500
you\'re mostly
not catching cancer.
00:49:46.533 --> 00:49:49.000
You\'re catching something that
looks like cancer and it isn\'t.
00:49:49.033 --> 00:49:51.133
And when it is cancer,
it almost never is a cancer
00:49:51.167 --> 00:49:53.000
that would ever bother you
in your life.
00:49:53.033 --> 00:49:54.400
So we\'re finding it.
00:49:54.433 --> 00:49:55.700
We have to do something
about it.
00:49:55.733 --> 00:49:57.100
But it\'s trivial.
00:49:57.133 --> 00:49:59.200
It\'s only cancer
under the microscope.
00:49:59.233 --> 00:50:02.500
And the flip side is,
the few others...
00:50:02.533 --> 00:50:04.067
It\'s probably too late
to do anything.
00:50:04.100 --> 00:50:07.233
So we haven\'t found anything
that\'s good for you.
00:50:07.267 --> 00:50:08.800
On the other hand,
the treatments
00:50:08.833 --> 00:50:11.800
have a very good chance
of making you impotent,
00:50:11.833 --> 00:50:14.400
have a very good chance
of making you incontinent.
00:50:14.433 --> 00:50:17.800
It can cause all sorts
of other problems as well.
00:50:17.833 --> 00:50:20.567
- It turns out
in autopsy studies of men
00:50:20.600 --> 00:50:25.600
age 50, 60, 70,
upwards of 50% to,
00:50:25.633 --> 00:50:28.333
in the 70-year-old group,
closer to 80%
00:50:28.367 --> 00:50:31.933
have pathologic evidence
of the disease.
00:50:31.967 --> 00:50:35.333
So if we start to look
really hard for prostate cancer,
00:50:35.367 --> 00:50:39.600
we will find it
in over half of older men.
00:50:39.633 --> 00:50:43.900
There\'s evidence that since
the advent of the PSA test,
00:50:43.933 --> 00:50:48.467
it looks like we\'ve treated
about 1.3 million American men
00:50:48.500 --> 00:50:53.500
for a disease that was never
going to bother them.
00:50:53.533 --> 00:50:56.100
- The U.S. Preventive Services
Task Force
00:50:56.133 --> 00:50:58.267
said that
at the population level,
00:50:58.300 --> 00:51:00.133
we shouldn\'t be spending money
on screening,
00:51:00.167 --> 00:51:01.733
\'cause the evidence doesn\'t
support it.
00:51:01.767 --> 00:51:03.567
Researchers
look at the outcomes.
00:51:03.600 --> 00:51:07.500
Are the men who were screened
regularly for prostate cancer
00:51:07.533 --> 00:51:09.667
more likely to be alive
00:51:09.700 --> 00:51:12.400
and not having died
from prostate cancer?
00:51:12.433 --> 00:51:14.767
And the answer was, \"No.\"
00:51:14.800 --> 00:51:19.167
- For the physician, all the
incentives are just to do it.
00:51:19.200 --> 00:51:21.667
If I don\'t do it and
you end up with prostate cancer,
00:51:21.700 --> 00:51:22.900
you\'re going to be
very mad at me
00:51:22.933 --> 00:51:24.767
and you\'re gonna...
You might sue me.
00:51:24.800 --> 00:51:27.967
And you\'re certainly going to
think that I cost you your life.
00:51:28.000 --> 00:51:29.567
You\'re going to be very,
very unhappy.
00:51:29.600 --> 00:51:32.467
If I do it
and I do no benefit to you,
00:51:32.500 --> 00:51:35.000
the test is normal,
you\'ll still think I\'m a good...
00:51:35.033 --> 00:51:36.500
A good, savvy doctor.
00:51:36.533 --> 00:51:38.467
If I do it
and I do worse than that...
00:51:38.500 --> 00:51:40.033
It gets a false positive
00:51:40.067 --> 00:51:42.167
and I end up doing all sorts
of interventions
00:51:42.200 --> 00:51:44.733
and you end up impotent
00:51:44.767 --> 00:51:46.767
for something that you
had no reason ever to undergo
00:51:46.800 --> 00:51:47.767
in the first place...
00:51:47.800 --> 00:51:49.200
You\'re still going to thank me.
00:51:49.233 --> 00:51:51.267
You\'re going to say, \"Phew,
the doctor saved my life.
00:51:51.300 --> 00:51:52.500
\"Isn\'t that great?
00:51:52.533 --> 00:51:54.767
I had prostate cancer,
and now I\'m better.\"
00:51:54.800 --> 00:51:57.000
And I get paid more.
00:51:57.033 --> 00:51:59.800
Unfortunately,
that\'s not always what\'s best
00:51:59.833 --> 00:52:01.800
for the patient.
00:52:01.833 --> 00:52:05.067
- I think practitioners
will ignore the recommendations.
00:52:05.100 --> 00:52:08.733
And the reason for that
is that PSA
00:52:08.767 --> 00:52:14.300
is as simple as checking a box
on a laboratory requisition
00:52:14.333 --> 00:52:16.800
and sending a patient
for a blood test.
00:52:16.833 --> 00:52:19.100
It\'s counterintuitive
to patients and to doctors
00:52:19.133 --> 00:52:21.000
that that could possibly
be harmful.
00:52:21.033 --> 00:52:22.467
- I\'d rather know now,
00:52:22.500 --> 00:52:24.233
rather than wait
till it\'s late-stage
00:52:24.267 --> 00:52:26.433
and there\'s nothing
I can really do.
00:52:26.467 --> 00:52:31.400
- The central issue
is not an issue of screening,
00:52:31.433 --> 00:52:32.900
even though
that\'s the discussion.
00:52:32.933 --> 00:52:35.933
The central issue
is being smarter about treatment
00:52:35.967 --> 00:52:39.800
or choosing not to treat
in men whom we do diagnose
00:52:39.833 --> 00:52:41.433
with prostate cancer.
00:52:41.467 --> 00:52:44.667
- As you know, we have
the results in from the biopsy.
00:52:44.700 --> 00:52:45.833
And as you know, it does show
00:52:45.867 --> 00:52:47.333
that there\'s a cancer
in the prostate
00:52:47.367 --> 00:52:51.200
as we suspected there would be
based on that PSA test.
00:52:51.233 --> 00:52:54.100
Let\'s review the options
that we\'ve talked about.
00:52:54.133 --> 00:52:56.167
There\'s surgery,
which is an operation
00:52:56.200 --> 00:52:58.000
called radical prostatectomy.
00:52:58.033 --> 00:53:00.333
It can be done
through an open incision,
00:53:00.367 --> 00:53:01.667
which is the traditional way.
00:53:01.700 --> 00:53:03.167
It\'s been around for decades.
00:53:03.200 --> 00:53:06.767
Or it can be done the newer way
with a robotic assistant.
00:53:06.800 --> 00:53:08.767
Another option
is radiation therapy.
00:53:08.800 --> 00:53:12.067
Radiation can be given
as an external beam,
00:53:12.100 --> 00:53:14.167
which we call IMRT,
00:53:14.200 --> 00:53:16.767
or it can be given
as radioactive pellets,
00:53:16.800 --> 00:53:17.967
or brachytherapy,
00:53:18.000 --> 00:53:20.267
implanted directly
into your prostate.
00:53:20.300 --> 00:53:22.733
If you want to use
a proton machine,
00:53:22.767 --> 00:53:24.467
you have to go
to where that machine is,
00:53:24.500 --> 00:53:26.367
and there\'s several
around the country.
00:53:26.400 --> 00:53:28.400
Another option
is active surveillance...
00:53:28.433 --> 00:53:32.533
You go onto a rigid protocol
of regular PSA tests
00:53:32.567 --> 00:53:35.933
and regular repeat biopsies,
and if it progresses,
00:53:35.967 --> 00:53:40.433
then we revisit the idea
of considering active therapy.
00:53:40.467 --> 00:53:43.633
- It would nice for me to be
around for the next ten years
00:53:43.667 --> 00:53:48.500
without the use of catheters
and diapers and other things
00:53:48.533 --> 00:53:51.300
if it was not necessary
to save my life.
00:53:51.333 --> 00:53:55.033
- The prostate cancer
can be treated very effectively,
00:53:55.067 --> 00:53:56.333
but it\'s not free.
00:53:56.367 --> 00:53:58.833
The human cost
of that treatment,
00:53:58.867 --> 00:54:03.533
in terms of urinary problems,
sexual problems, bowel problems,
00:54:03.567 --> 00:54:05.967
may all be significant.
00:54:06.000 --> 00:54:07.133
- You might say,
00:54:07.167 --> 00:54:09.233
\"Gee, how is the patient
possibly gonna decide
00:54:09.267 --> 00:54:10.800
\"between these therapies
00:54:10.833 --> 00:54:12.733
\"with so little evidence
to guide us
00:54:12.767 --> 00:54:14.567
\"about whether one
is better than the other
00:54:14.600 --> 00:54:17.633
in terms of either
cancer control or side effects?\"
00:54:17.667 --> 00:54:20.400
- People rely on us
to help them make decisions.
00:54:20.433 --> 00:54:21.900
But if it turns out
that your doctor
00:54:21.933 --> 00:54:23.000
doesn\'t have information
00:54:23.033 --> 00:54:24.733
about which one is good
or which isn\'t...
00:54:24.767 --> 00:54:26.500
And your doctor
could do a much better job
00:54:26.533 --> 00:54:27.600
if she knew that,
00:54:27.633 --> 00:54:29.000
because we studied it
and we said,
00:54:29.033 --> 00:54:31.100
\"This treatment\'s good.
This treatment isn\'t good.
00:54:31.133 --> 00:54:32.800
That test is good.
This one isn\'t.\"
00:54:32.833 --> 00:54:35.667
That would help your doctor
help you make a decision.
00:54:35.700 --> 00:54:37.633
Why don\'t we do
the type of research
00:54:37.667 --> 00:54:40.067
that tells us what actually
works and what doesn\'t work?
00:54:40.100 --> 00:54:41.233
- So the first question is:
00:54:41.267 --> 00:54:43.000
do I recommend
that you be treated?
00:54:43.033 --> 00:54:44.967
There are a few reasons
I do recommend...
00:54:45.000 --> 00:54:47.867
- Until we as a nation start
to measure the effectiveness
00:54:47.900 --> 00:54:51.567
of what we\'re doing
as a routine part of practice,
00:54:51.600 --> 00:54:56.100
we are flying the health care
airline with no instruments.
00:54:56.133 --> 00:54:58.233
We are crashing.
00:54:58.267 --> 00:54:59.733
We don\'t know how high we are.
00:54:59.767 --> 00:55:01.100
We don\'t know where we\'re going.
00:55:01.133 --> 00:55:02.773
We don\'t know
how much gas is in the tank,
00:55:02.800 --> 00:55:05.133
because we don\'t measure
the effectiveness
00:55:05.167 --> 00:55:09.033
of anything we do
in health care.
00:55:09.067 --> 00:55:11.667
- Medicine really
has been this cottage industry
00:55:11.700 --> 00:55:14.333
where each doc learned
from an apprentice model,
00:55:14.367 --> 00:55:15.833
and then goes and practices
00:55:15.867 --> 00:55:17.400
in their own
little private practice.
00:55:17.433 --> 00:55:19.800
If you don\'t pool
that information together
00:55:19.833 --> 00:55:21.767
and really use evidence as a way
00:55:21.800 --> 00:55:26.067
to come up with decision-making,
you never advance.
00:55:38.167 --> 00:55:40.067
- I had a blood test
00:55:40.100 --> 00:55:42.000
and was a little surprised
to get a call
00:55:42.033 --> 00:55:43.867
from my physician about that.
00:55:43.900 --> 00:55:47.100
He said that I had not
done so well with PSA.
00:55:47.133 --> 00:55:48.133
So at that point,
00:55:48.167 --> 00:55:50.633
it was time
to schedule a biopsy.
00:55:50.667 --> 00:55:52.867
- You\'re not gonna pass out.
00:55:52.900 --> 00:55:54.433
- There are a number
of different plugs
00:55:54.467 --> 00:55:55.900
they take out of the prostate,
00:55:55.933 --> 00:55:58.333
and some of them, in my case,
were cancerous.
00:55:58.367 --> 00:56:01.833
And being as young as I am
at 55,
00:56:01.867 --> 00:56:05.067
my view is that surgery
is the best option for me.
00:56:05.100 --> 00:56:08.200
- I never envisioned our life
together
00:56:08.233 --> 00:56:10.900
to be possibly shortened,
you know.
00:56:10.933 --> 00:56:13.000
We were looking to cruising off
into the sunset.
00:56:13.033 --> 00:56:15.767
And we\'re still
actively raising children.
00:56:15.800 --> 00:56:17.833
And here we are,
and you have this diagnosis.
00:56:17.867 --> 00:56:20.133
It\'s just hard to do.
00:56:20.167 --> 00:56:23.033
- It changed my view
of my future quite a bit.
00:56:23.067 --> 00:56:26.200
And I gradually came around
to the point of view
00:56:26.233 --> 00:56:27.867
that I\'m actually fortunate
00:56:27.900 --> 00:56:31.333
that if I had to have a tumor
of this sort,
00:56:31.367 --> 00:56:32.667
this is an oppor...
00:56:32.700 --> 00:56:34.967
This is a much easier one
to find at an early stage
00:56:35.000 --> 00:56:38.600
and to be able
to take, you know,
00:56:38.633 --> 00:56:40.500
aggressive action against it.
00:56:40.533 --> 00:56:42.067
- I\'m ready if you are.
- Great, yeah.
00:56:42.100 --> 00:56:43.067
- I\'m ready.
00:56:43.100 --> 00:56:44.233
So we\'ve talked a little bit
00:56:44.267 --> 00:56:46.167
about the advantages
and disadvantages
00:56:46.200 --> 00:56:47.900
of the robotic surgery.
00:56:47.933 --> 00:56:51.367
The major advantages of
robotic are, in my experience,
00:56:51.400 --> 00:56:54.200
that your recovery
will be faster,
00:56:54.233 --> 00:56:56.567
perhaps a little bit less pain;
00:56:56.600 --> 00:56:59.433
the risk of bleeding
is significantly lower;
00:56:59.467 --> 00:57:03.500
and at least in our hands here,
the chances of actually getting
00:57:03.533 --> 00:57:05.500
what we call
a negative surgical margin...
00:57:05.533 --> 00:57:09.300
That is getting the cancer out
without any margins around it...
00:57:09.333 --> 00:57:11.033
At least in my hands,
have been lower
00:57:11.067 --> 00:57:12.800
with the robotic approach.
00:57:12.833 --> 00:57:15.700
So put you to sleep, and
we\'ll go ahead and get started.
00:57:18.033 --> 00:57:19.100
- It\'s never enough?
00:57:19.133 --> 00:57:24.367
- Never enough, no.
- Okay.
00:57:24.400 --> 00:57:26.467
So answer your email;
don\'t worry about me.
00:57:26.500 --> 00:57:28.600
- Yeah, when you get home,
you\'ve got chores to do so...
00:57:28.633 --> 00:57:30.167
- Yeah, yeah, I know.
00:57:30.200 --> 00:57:32.033
- Buck up, honey.
00:57:32.067 --> 00:57:34.200
- No heavy lifting for a while.
00:57:34.233 --> 00:57:35.567
- She\'ll think of something.
00:57:35.600 --> 00:57:37.233
- That\'s true actually,
no heavy lifting.
00:57:37.267 --> 00:57:38.267
- Dishes, dishes.
00:57:38.300 --> 00:57:39.700
- Well, folding laundry
doesn\'t...
00:57:39.733 --> 00:57:42.233
- There\'s an assumption
on the part of the public,
00:57:42.267 --> 00:57:44.567
and even on the part
of many physicians,
00:57:44.600 --> 00:57:47.433
that, you know,
physicians are scientists,
00:57:47.467 --> 00:57:51.400
and that science mediated
through my brilliant judgment
00:57:51.433 --> 00:57:53.333
is somehow going to lead
to the correct treatment
00:57:53.367 --> 00:57:57.733
for you, my patient, every time,
you know, for every patient.
00:57:57.767 --> 00:58:00.200
Nothing could be further
from the truth.
00:58:00.233 --> 00:58:02.167
- It\'s a little bright.
00:58:02.200 --> 00:58:05.800
- There\'s so little science
behind many of these decisions.
00:58:05.833 --> 00:58:08.133
The same patient
is gonna be treated
00:58:08.167 --> 00:58:09.133
in a different way
00:58:09.167 --> 00:58:11.033
at one hospital
versus another hospital.
00:58:11.067 --> 00:58:12.967
- Geography is destiny.
00:58:15.200 --> 00:58:18.967
What you get in health care
depends more on where you live
00:58:19.000 --> 00:58:22.967
and who you see
than on evidence.
00:58:23.000 --> 00:58:25.367
It\'s really hard to fathom
00:58:25.400 --> 00:58:28.667
that more is being done
in one place versus another
00:58:28.700 --> 00:58:30.100
just by your ZIP code.
00:58:30.133 --> 00:58:34.833
- Very highly trained people
with great skills and knowledge
00:58:34.867 --> 00:58:38.233
who\'ve put in a career at
being the best at what they do,
00:58:38.267 --> 00:58:40.767
you put them in one place
versus another place,
00:58:40.800 --> 00:58:42.900
and they act very differently.
00:58:42.933 --> 00:58:48.533
And that cannot be
because of a medical reason.
00:58:48.567 --> 00:58:51.533
It can\'t be \'cause it\'s better
in one place to do something
00:58:51.567 --> 00:58:53.033
and another place not to do it.
00:58:53.067 --> 00:58:55.067
- If you identify variation
00:58:55.100 --> 00:58:57.600
that\'s 10-fold,
15-, 20-fold,
00:58:57.633 --> 00:58:58.967
like we see in prostate cancer
00:58:59.000 --> 00:59:00.233
from one area of the country
00:59:00.267 --> 00:59:01.500
to another,
00:59:01.533 --> 00:59:03.767
then we know that it\'s
an example of a disease
00:59:03.800 --> 00:59:07.400
that ought to be treated
less frequently.
00:59:07.433 --> 00:59:10.133
The majority of men
treated for prostate cancer
00:59:10.167 --> 00:59:13.967
in retrospect wouldn\'t have died
from their disease,
00:59:14.000 --> 00:59:17.200
and therefore by definition,
we\'re overtreating those men
00:59:17.233 --> 00:59:18.633
with prostate cancer.
00:59:18.667 --> 00:59:20.333
- I believe
that I may be one of the people
00:59:20.367 --> 00:59:22.867
whose life was saved,
or at least extended,
00:59:22.900 --> 00:59:24.933
by going in aggressively.
00:59:24.967 --> 00:59:27.800
But I understand that there is
a lot of unnecessary treatment
00:59:27.833 --> 00:59:30.067
that people undergo.
00:59:30.100 --> 00:59:32.167
But I\'m not comfortable
carrying a tumor around
00:59:32.200 --> 00:59:34.500
if I don\'t know
how lethal it is.
00:59:34.533 --> 00:59:35.867
- That organ there...
00:59:35.900 --> 00:59:40.500
- We may know from studies
that too many or too few people
00:59:40.533 --> 00:59:42.800
in a population
are being treated.
00:59:42.833 --> 00:59:45.767
But it\'s hard to look
at any one person and say,
00:59:45.800 --> 00:59:51.033
\"Yes, Mr. Jones was overtreated;
Mrs. Smith was undertreated,\"
00:59:51.067 --> 00:59:54.533
\'cause we can never be sure
whether we\'re doing some good
00:59:54.567 --> 00:59:58.167
or doing some harm
in an individual case.
00:59:58.200 --> 01:00:01.467
- Did Kim let you know
when she\'s coming home?
01:00:01.500 --> 01:00:02.833
Going into the surgery,
01:00:02.867 --> 01:00:05.467
I was aware
of the potential side effects,
01:00:05.500 --> 01:00:08.300
that I might be giving up
some things
01:00:08.333 --> 01:00:09.900
that I would rather not give up,
01:00:09.933 --> 01:00:12.633
and as it\'s turned out,
I did give up something,
01:00:12.667 --> 01:00:15.067
but prostate cancer
kills people.
01:00:15.100 --> 01:00:16.367
And I would do it again.
01:00:17.633 --> 01:00:20.267
- You have to remove
about 15 prostates
01:00:20.300 --> 01:00:22.900
to prevent one
prostate cancer death.
01:00:22.933 --> 01:00:25.133
The problem is,
at the individual level
01:00:25.167 --> 01:00:28.100
all 15 of those men
will think it was them
01:00:28.133 --> 01:00:29.133
whose life was saved.
01:00:29.167 --> 01:00:30.400
1 of them is right.
01:00:30.433 --> 01:00:31.800
14 are wrong.
01:00:31.833 --> 01:00:33.567
But we don\'t know which one.
01:00:33.600 --> 01:00:35.733
- And I may well be
one of the 14
01:00:35.767 --> 01:00:38.767
for whom this wasn\'t
particularly lifesaving
01:00:38.800 --> 01:00:40.400
or in any way important,
01:00:40.433 --> 01:00:46.667
but since I can\'t know that,
I\'m not going to mess around.
01:00:46.700 --> 01:00:48.300
- Warm, I\'m cold.
- You\'re cold?
01:00:48.333 --> 01:00:50.033
And I think
that the consequences
01:00:50.067 --> 01:00:52.633
and the side effects
are unfortunate,
01:00:52.667 --> 01:00:55.233
but at least I\'m not left
with the concern
01:00:55.267 --> 01:00:59.800
that I could have done more
and didn\'t act.
01:01:04.300 --> 01:01:08.200
- Treatments that are powerful
enough to heal can also harm.
01:01:08.233 --> 01:01:10.200
I trained in surgery.
01:01:10.233 --> 01:01:13.900
To be a good surgeon, you
have to believe in what you do.
01:01:13.933 --> 01:01:16.233
You really do.
01:01:16.267 --> 01:01:18.067
And so the advice
we give to patients
01:01:18.100 --> 01:01:20.033
is much too aggressive,
01:01:20.067 --> 01:01:22.100
more aggressive
than they would probably choose
01:01:22.133 --> 01:01:24.900
if they had a true fair choice.
01:01:24.933 --> 01:01:30.333
But maybe I need my counselor
who advises the surgery
01:01:30.367 --> 01:01:31.700
to not be the surgeon.
01:01:36.567 --> 01:01:39.300
- I got a phone call
from the urologist
01:01:39.333 --> 01:01:42.133
that confirmed
that I had cancer.
01:01:42.167 --> 01:01:46.400
I turned to my wife...
I got the phone call,
01:01:46.433 --> 01:01:47.533
and I said,
01:01:47.567 --> 01:01:51.867
\"Life as we have known it
is over.\"
01:01:51.900 --> 01:01:54.267
And that\'s where I was headed.
01:01:54.300 --> 01:01:57.600
I did not know about
proton treatment at that time.
01:01:59.367 --> 01:02:01.433
- The key
to successful cancer treatment
01:02:01.467 --> 01:02:04.733
is avoiding the normal tissues
surrounding the cancer.
01:02:04.767 --> 01:02:09.033
And protons allows us
to miss more normal tissue
01:02:09.067 --> 01:02:11.667
than we\'re able to
with other forms of radiation.
01:02:14.433 --> 01:02:17.333
- I call it a,
instead of a shotgun approach,
01:02:17.367 --> 01:02:18.533
a .22 approach...
01:02:18.567 --> 01:02:22.300
When it comes in
and stops with all of its energy
01:02:22.333 --> 01:02:23.467
right at the prostate
01:02:23.500 --> 01:02:25.400
and doesn\'t go on
through the body
01:02:25.433 --> 01:02:28.733
and causing damage
to other inner organs.
01:02:30.000 --> 01:02:33.267
I was able to avoid
having surgery,
01:02:33.300 --> 01:02:36.767
having a catheter
for two to three weeks,
01:02:36.800 --> 01:02:39.633
having incontinence
and impotence.
01:02:39.667 --> 01:02:42.300
It\'s the most effective thing
on Earth.
01:02:42.333 --> 01:02:46.233
- The cost of a proton facility
can run up to $150 million.
01:02:46.267 --> 01:02:49.700
So it is more expensive to build
the facility than others,
01:02:49.733 --> 01:02:51.433
but it really
comes down to the cost
01:02:51.467 --> 01:02:54.233
to the individual patient.
01:02:54.267 --> 01:02:57.633
- I had to sign papers
that I\'d be responsible
01:02:57.667 --> 01:02:59.667
for all the cost.
01:02:59.700 --> 01:03:03.667
It\'s between
$70,000 and $200,000.
01:03:03.700 --> 01:03:04.967
- By far and away,
01:03:05.000 --> 01:03:07.700
we have the best tool
to destroy prostate cancer.
01:03:07.733 --> 01:03:10.867
- It\'s very American, I think,
to think that higher tech
01:03:10.900 --> 01:03:12.500
is better than lower tech,
01:03:12.533 --> 01:03:15.100
new tech
is better than old tech.
01:03:15.133 --> 01:03:19.900
And so we\'ve created this way
of thinking about health care
01:03:19.933 --> 01:03:23.367
that is ultimately inflationary.
01:03:23.400 --> 01:03:27.167
- Unfortunately, the innovation
gets well ahead of the science.
01:03:27.200 --> 01:03:29.700
So I think
we have to be really cautious
01:03:29.733 --> 01:03:31.600
about new cancer therapies
01:03:31.633 --> 01:03:34.400
and make sure
that they\'re really tested
01:03:34.433 --> 01:03:37.667
and that we know that they
actually confer some advantage,
01:03:37.700 --> 01:03:42.133
because they certainly confer
a lot of additional cost
01:03:42.167 --> 01:03:44.300
and may actually cause harm.
01:03:46.667 --> 01:03:49.233
- It has saved my life.
01:03:49.267 --> 01:03:51.367
I have the satisfaction
in my mind
01:03:51.400 --> 01:03:53.400
that I don\'t have cancer.
01:03:53.433 --> 01:03:57.000
In fact, I think of getting
all my affairs in order.
01:03:57.033 --> 01:03:58.367
I bought a new suit.
01:03:58.400 --> 01:04:01.567
I\'m going to live, not die.
01:04:01.600 --> 01:04:06.200
The suit is for living,
not for my funeral.
01:04:06.233 --> 01:04:09.900
- In Mr. Thompson\'s case,
I hope it changed his outcome.
01:04:09.933 --> 01:04:13.033
But again, one person\'s story
doesn\'t tell you
01:04:13.067 --> 01:04:14.933
whether the treatment
really helps.
01:04:14.967 --> 01:04:16.567
In fact, it\'s possible
01:04:16.600 --> 01:04:18.400
that he may not
have even needed treatment.
01:04:18.433 --> 01:04:19.567
You just don\'t know.
01:04:19.600 --> 01:04:22.200
- It really is a problem
that we don\'t have
01:04:22.233 --> 01:04:24.300
good, comparative
effectiveness studies
01:04:24.333 --> 01:04:27.900
to show us that, particularly
the more expensive treatments,
01:04:27.933 --> 01:04:30.333
things like robotic radical
prostatectomy
01:04:30.367 --> 01:04:32.267
or proton beam therapy,
01:04:32.300 --> 01:04:35.667
despite being so much more
expensive, are any better.
01:04:35.700 --> 01:04:38.600
And they could even be worse
in terms of cancer control
01:04:38.633 --> 01:04:39.967
or side effects.
01:04:40.000 --> 01:04:44.767
- In American health care,
the bar to adapt new technology
01:04:44.800 --> 01:04:47.633
has been relatively low.
01:04:47.667 --> 01:04:50.067
And I think
we\'ve developed that culture.
01:04:50.100 --> 01:04:52.633
To develop a new drug,
01:04:52.667 --> 01:04:54.733
we have a lot of hurdles
to go through.
01:04:54.767 --> 01:04:58.600
To develop a new technology,
in this case proton treatment,
01:04:58.633 --> 01:05:03.033
the bar really is that
it\'s not harmful, or not worse,
01:05:03.067 --> 01:05:05.500
not that it necessarily
needs to be better.
01:05:05.533 --> 01:05:07.000
And it may be better,
01:05:07.033 --> 01:05:09.367
but when something
costs that much,
01:05:09.400 --> 01:05:13.167
one would truly like to know
it\'s better
01:05:13.200 --> 01:05:15.367
if society
is gonna bear the cost.
01:05:18.067 --> 01:05:21.167
- He\'s 83 years old
with a PSA 117,
01:05:21.200 --> 01:05:23.100
Gleason score four plus three,
01:05:23.133 --> 01:05:25.533
adenocarcinoma in 9 of 12 cores,
01:05:25.567 --> 01:05:28.133
but the involved cores
were 50% to 100% involved.
01:05:28.167 --> 01:05:29.967
- I\'d sure feel
a lot more comfortable
01:05:30.000 --> 01:05:32.167
about even just saying
intermittent therapy.
01:05:32.200 --> 01:05:34.067
- Doing the kitchen sink
approach may be better.
01:05:34.100 --> 01:05:35.967
- He could probably wait
a couple years.
01:05:36.000 --> 01:05:37.533
- Do you have those results?
- I do.
01:05:37.567 --> 01:05:39.133
- One of the things
that we\'ve invested in
01:05:39.167 --> 01:05:40.367
very heavily at Intermountain
01:05:40.400 --> 01:05:41.667
is data.
01:05:41.700 --> 01:05:43.600
Data is your ability to see.
01:05:43.633 --> 01:05:45.767
We can tell what works.
01:05:45.800 --> 01:05:48.833
That\'s the first key
for being able to innovate.
01:05:48.867 --> 01:05:51.167
You have to be able to tell
if a change was an improvement.
01:05:51.200 --> 01:05:53.767
That\'s how you find best care.
01:05:53.800 --> 01:05:56.400
We try to build those data
right into the flow of work.
01:05:56.433 --> 01:05:58.967
We try to give our clinicians,
our physicians, our nurses
01:05:59.000 --> 01:06:02.400
a clear picture
of what this means to patients.
01:06:02.433 --> 01:06:03.767
When we\'ve done that,
01:06:03.800 --> 01:06:06.333
it\'s been associated
with fairly massive improvements
01:06:06.367 --> 01:06:07.733
in patient results.
01:06:07.767 --> 01:06:10.400
And the funny thing is,
it\'s nearly always associated
01:06:10.433 --> 01:06:12.467
with significantly lower
health care costs.
01:06:13.467 --> 01:06:15.233
- Which is your nerves...
01:06:15.267 --> 01:06:17.467
- There are surgeons
who cut things out...
01:06:17.500 --> 01:06:19.367
- And you\'re
in the favorable group...
01:06:20.733 --> 01:06:21.933
- Good, good to see ya.
01:06:21.967 --> 01:06:24.633
The good news
is that it\'s very unlikely
01:06:24.667 --> 01:06:26.367
that it spread outside
your prostate.
01:06:26.400 --> 01:06:28.333
It\'s very, very unlikely,
you know,
01:06:28.367 --> 01:06:30.467
that it\'s gone to lymph nodes
or anything like that.
01:06:30.500 --> 01:06:31.900
You know,
in years past, certainly,
01:06:31.933 --> 01:06:33.700
we\'d treat, you know,
small amounts of cancer
01:06:33.733 --> 01:06:36.567
very aggressively in young men,
do surgery,
01:06:36.600 --> 01:06:38.733
and certainly cure rates
are very, very good with that.
01:06:38.767 --> 01:06:40.133
- Mm-hmm.
01:06:40.167 --> 01:06:42.433
But the real question is:
Did we really need to do that?
01:06:42.467 --> 01:06:45.000
You know, did we
really need to treat that?
01:06:45.033 --> 01:06:49.033
And so that\'s where that whole
idea of the watchful waiting is.
01:06:49.067 --> 01:06:52.033
- If I pursue
the watchful waiting approach,
01:06:52.067 --> 01:06:56.767
and is some number excluding one
of these two main procedures?
01:06:56.800 --> 01:07:00.433
- Yes, if you have anything
that\'s rising rapidly,
01:07:00.467 --> 01:07:03.000
or we get up to where that PSA
is close to ten,
01:07:03.033 --> 01:07:05.467
which is where we start
worrying about extension,
01:07:05.500 --> 01:07:07.633
you know, outside the prostate
or into the lymph nodes,
01:07:07.667 --> 01:07:08.800
we say,
01:07:08.833 --> 01:07:11.533
\"Okay, no more watchful waiting;
Now we treat.\"
01:07:11.567 --> 01:07:14.267
- The clinician
needs to fill in the patient
01:07:14.300 --> 01:07:16.300
on the options, the outcomes,
01:07:16.333 --> 01:07:17.967
and how likely
they are to happen.
01:07:18.000 --> 01:07:21.133
But there\'s transfer of
information the other way too.
01:07:21.167 --> 01:07:24.967
The patient is the expert
at what they value,
01:07:25.000 --> 01:07:29.633
and they need to transmit
those preferences and values.
01:07:29.667 --> 01:07:33.767
And I think
matching the best outcomes data
01:07:33.800 --> 01:07:36.700
from clinical research
and evidence-based medicine
01:07:36.733 --> 01:07:38.500
with the patient preferences
01:07:38.533 --> 01:07:40.600
is what gets us
to the best decision.
01:07:40.633 --> 01:07:42.800
- The good situation is,
this disease
01:07:42.833 --> 01:07:45.100
is very unlikely to cause you
any harm
01:07:45.133 --> 01:07:46.567
in the immediate short term.
01:07:46.600 --> 01:07:48.600
You\'re in no immediate distress.
01:07:48.633 --> 01:07:52.067
But everybody
wants to be immortal
01:07:52.100 --> 01:07:53.700
and live as long as they can.
01:07:53.733 --> 01:07:55.667
The upside
to immediate treatment is,
01:07:55.700 --> 01:07:57.300
you could eradicate the cancer.
01:07:57.333 --> 01:07:59.867
\"It\'s early, and
I don\'t have to worry about it.\"
01:07:59.900 --> 01:08:03.400
Or you could say, \"You know,
doc, treatment has side effects.
01:08:03.433 --> 01:08:06.200
\"I probably don\'t need
the treatment for a while.
01:08:06.233 --> 01:08:08.167
Why don\'t we just delay things
for a while,\"
01:08:08.200 --> 01:08:10.000
which is... or forever...
01:08:10.033 --> 01:08:12.533
Which is also not
an unreasonable approach in you.
01:08:14.000 --> 01:08:17.033
- So I guess I\'m safe for now.
01:08:17.067 --> 01:08:18.467
- You\'re safe for now.
01:08:18.500 --> 01:08:21.433
- I might have to make
a decision at some point.
01:08:21.467 --> 01:08:26.100
Since my cancer
is low-grade and early-stage,
01:08:26.133 --> 01:08:29.800
watchful waiting seems like
a reasonable approach.
01:08:29.833 --> 01:08:31.933
- I think
it\'s a very reasonable approach.
01:08:31.967 --> 01:08:32.933
- Thanks.
01:08:32.967 --> 01:08:35.400
- If we are good
at aligning care
01:08:35.433 --> 01:08:37.833
with what patients really value,
01:08:37.867 --> 01:08:41.167
we learn that they choose
less aggressive treatment.
01:08:42.533 --> 01:08:45.167
- When you give patients
a true fair choice,
01:08:45.200 --> 01:08:47.400
it typically reduces
surgical treatment rates
01:08:47.433 --> 01:08:49.633
by 40 to 60%.
01:08:49.667 --> 01:08:51.933
Their consumption rate drops.
01:08:51.967 --> 01:08:55.633
It comes to about the same level
that physicians themselves show
01:08:55.667 --> 01:08:57.700
when we get these conditions.
01:08:57.733 --> 01:09:00.267
- Prostate cancer
is an example of a disease
01:09:00.300 --> 01:09:03.067
where we ought to be smarter
about whom to treat
01:09:03.100 --> 01:09:04.833
and whom to observe.
01:09:04.867 --> 01:09:06.000
And in that way,
01:09:06.033 --> 01:09:08.700
there are a lot of dollars
to be saved
01:09:08.733 --> 01:09:10.467
that could be put to better use
01:09:10.500 --> 01:09:15.100
to improve the health
of many, many more people.
01:09:27.867 --> 01:09:32.933
- It\'s really hard to explain,
but something wrong here.
01:09:32.967 --> 01:09:38.000
- Okay, and how long
does that stay like that?
01:09:38.033 --> 01:09:39.933
A few seconds, a few minutes?
01:09:39.967 --> 01:09:41.167
- A few seconds.
01:09:41.200 --> 01:09:45.333
- So here\'s a gentleman
who had some symptoms
01:09:45.367 --> 01:09:47.300
which were not typical
of angina.
01:09:47.333 --> 01:09:48.700
He didn\'t have chest pain.
01:09:48.733 --> 01:09:51.800
He had some shortness of breath
when he exercised.
01:09:51.833 --> 01:09:54.000
But he has
a positive family history,
01:09:54.033 --> 01:09:55.367
so he\'s very anxious.
01:09:55.400 --> 01:09:59.233
The conservative approach
would say to use medicines
01:09:59.267 --> 01:10:02.167
to maybe lower your cholesterol.
01:10:02.200 --> 01:10:06.833
The other option is to be
more aggressive and to say,
01:10:06.867 --> 01:10:10.400
\"Well, let\'s find out
absolutely what\'s going on.\"
01:10:10.433 --> 01:10:12.867
And that would mean
doing an angiogram.
01:10:12.900 --> 01:10:15.000
- If you are doing
the angiogram...
01:10:15.033 --> 01:10:16.133
- Yes.
01:10:16.167 --> 01:10:19.867
- If something severe
inside somewhere,
01:10:19.900 --> 01:10:23.533
you will to using balloon
to put a stent inside it.
01:10:23.567 --> 01:10:24.933
- Yes.
- Oh, okay.
01:10:24.967 --> 01:10:26.533
It just makes sense,
01:10:26.567 --> 01:10:29.333
if we find
a significant blockage,
01:10:29.367 --> 01:10:32.133
to go ahead and treat it
at that time.
01:10:32.167 --> 01:10:34.767
- Is there any risk
to angiogram itself?
01:10:34.800 --> 01:10:35.967
- There are risks.
01:10:36.000 --> 01:10:37.600
There\'s risks
at everything that we do.
01:10:37.633 --> 01:10:38.867
- Okay.
01:10:38.900 --> 01:10:43.267
- But we do thousands
of angiograms every year,
01:10:43.300 --> 01:10:46.500
so the risk of the angiogram
and taking the picture
01:10:46.533 --> 01:10:48.367
is very, very small.
01:10:48.400 --> 01:10:51.033
- If not necessary,
I don\'t want to install...
01:10:51.067 --> 01:10:52.333
- Absolutely.
01:10:52.367 --> 01:10:55.167
- The stent inside, you know.
- Absolutely, right.
01:10:55.200 --> 01:10:57.767
- Otherwise,
you will take medicine forever.
01:10:57.800 --> 01:10:59.000
- That\'s right, right.
01:10:59.033 --> 01:11:00.567
This is a university.
01:11:00.600 --> 01:11:03.200
I\'m on salary.
01:11:03.233 --> 01:11:06.967
I don\'t get paid special
just for doing these procedures.
01:11:07.000 --> 01:11:08.533
- Yes.
01:11:08.567 --> 01:11:11.567
- I think that either way
is reasonable.
01:11:11.600 --> 01:11:15.767
So if you feel comfortable
with a conservative approach,
01:11:15.800 --> 01:11:17.467
then we do the medicines.
01:11:17.500 --> 01:11:19.600
If you say,
01:11:19.633 --> 01:11:21.400
\"Well, I\'m concerned.
01:11:21.433 --> 01:11:23.233
I have this thing inside of me.
01:11:23.267 --> 01:11:25.000
I\'m afraid I may die.
01:11:25.033 --> 01:11:27.167
I want to find out
what\'s going on.\"
01:11:27.200 --> 01:11:28.533
Then it\'s better for you
01:11:28.567 --> 01:11:30.967
to do the angiogram
and find out.
01:11:31.000 --> 01:11:33.600
- One of the most important
developments
01:11:33.633 --> 01:11:36.367
in caring for peoples\' hearts
01:11:36.400 --> 01:11:38.233
and also now one
of the most overused
01:11:38.267 --> 01:11:40.467
is the cardiac catheterization.
01:11:40.500 --> 01:11:43.167
- We observe huge differences
across the country, you know,
01:11:43.200 --> 01:11:45.200
10-, 15-fold
in the frequency
01:11:45.233 --> 01:11:49.833
with which patients undergo
catheterization procedures.
01:11:49.867 --> 01:11:52.100
- This is
a fairly safe procedure.
01:11:52.133 --> 01:11:54.167
But a certain number
of people will die.
01:11:54.200 --> 01:11:55.333
And a certain number of people
01:11:55.367 --> 01:11:56.767
will have heart attacks
and strokes
01:11:56.800 --> 01:11:58.567
because of the procedure.
01:11:58.600 --> 01:12:01.100
- We tend to see the good
that we might achieve.
01:12:01.133 --> 01:12:03.133
We tend to discredit the risks.
01:12:03.167 --> 01:12:05.967
We discount them.
We explain them away.
01:12:06.000 --> 01:12:08.300
But this stuff is not safe.
01:12:08.333 --> 01:12:10.700
It\'s just that
in certain circumstances,
01:12:10.733 --> 01:12:12.600
the benefits are much larger
than the risks,
01:12:12.633 --> 01:12:14.200
so it\'s a wise choice.
01:12:21.000 --> 01:12:22.700
- Okay, ready?
01:12:22.733 --> 01:12:24.533
- Sending.
01:12:24.567 --> 01:12:25.567
Inject.
01:12:29.467 --> 01:12:30.467
- Great.
01:12:30.500 --> 01:12:31.967
So the artery
is nice and smooth.
01:12:32.000 --> 01:12:34.700
There\'s no areas
of blockages here.
01:12:37.467 --> 01:12:39.700
He\'s probably going to live
to be 92.
01:12:43.433 --> 01:12:47.433
- All right, Mr. Ku,
can you wake up?
01:12:47.467 --> 01:12:48.633
We\'re all done.
01:12:48.667 --> 01:12:49.633
- Done?
01:12:49.667 --> 01:12:50.700
- Yeah, all done.
01:12:50.733 --> 01:12:53.133
Everything looks really good,
okay?
01:12:53.167 --> 01:12:54.867
You don\'t have
a significant blockage.
01:12:54.900 --> 01:12:56.100
- Okay.
01:12:56.133 --> 01:12:57.633
- So I\'m going to show you
the pictures.
01:12:57.667 --> 01:12:59.567
Can you see this screen
over here?
01:12:59.600 --> 01:13:01.100
So right in here,
01:13:01.133 --> 01:13:03.167
there\'s a little bit
of narrowing,
01:13:03.200 --> 01:13:05.033
maybe it\'s 20%.
01:13:05.067 --> 01:13:08.467
And the right coronary artery
is also very good.
01:13:10.233 --> 01:13:13.800
I\'m jealous, because I don\'t
know what my arteries look like,
01:13:13.833 --> 01:13:16.400
and these
are probably better than mine.
01:13:16.433 --> 01:13:17.567
- Really?
01:13:17.600 --> 01:13:20.600
- Right, so I\'m gonna be
on the table next.
01:13:20.633 --> 01:13:23.933
- I think it will make
a big difference for Mr. Ku,
01:13:23.967 --> 01:13:27.600
because it decreases
the patient\'s anxiety.
01:13:27.633 --> 01:13:29.067
It helps his physicians
01:13:29.100 --> 01:13:31.800
who will care for him
in the future
01:13:31.833 --> 01:13:34.233
know exactly what\'s going on.
01:13:44.533 --> 01:13:45.567
- Because of my age
01:13:45.600 --> 01:13:47.867
and because of the history
of my dad,
01:13:47.900 --> 01:13:52.067
I went in
and had a simple stress test,
01:13:52.100 --> 01:13:54.967
It showed that there
was a potential for a blockage.
01:13:55.000 --> 01:13:56.033
And then after that,
01:13:56.067 --> 01:13:58.200
I went back in
and had the angiogram.
01:14:04.833 --> 01:14:07.500
- The first shot here...
We can see the narrowing
01:14:07.533 --> 01:14:10.700
at the proximal portion
of the LAD.
01:14:10.733 --> 01:14:13.433
And it appears to be
right in that range
01:14:13.467 --> 01:14:14.967
of approximately 70%,
01:14:15.000 --> 01:14:17.167
at which you would maybe
want to go in there
01:14:17.200 --> 01:14:19.500
and open the artery up
with a stent.
01:14:21.633 --> 01:14:22.667
- I was on the table
01:14:22.700 --> 01:14:24.933
and ready
to have a stent put in,
01:14:24.967 --> 01:14:26.607
because that\'s what they
were gonna to do.
01:14:26.633 --> 01:14:28.600
And I was on the table,
and I stopped \'em.
01:14:28.633 --> 01:14:30.700
- It was the patient who said,
01:14:30.733 --> 01:14:32.067
\"Wait a minute.
01:14:32.100 --> 01:14:36.233
\"You know, I may have this
severe reaction to aspirin.
01:14:36.267 --> 01:14:38.567
\"I\'ve had a life-threatening
bleed in the past.
01:14:38.600 --> 01:14:39.733
\"Can we hold off
01:14:39.767 --> 01:14:44.400
and talk about
what the treatment options are?\"
01:14:44.433 --> 01:14:47.200
- We have a major
randomized controlled trial
01:14:47.233 --> 01:14:49.700
that suggests that
half of all cardiac stenting
01:14:49.733 --> 01:14:51.233
that\'s performed
in the United States
01:14:51.267 --> 01:14:52.967
is non-beneficial.
01:14:53.000 --> 01:14:54.733
Well, I don\'t want somebody
doing that to me.
01:14:54.767 --> 01:14:55.833
The reason?
01:14:55.867 --> 01:14:57.567
It means
that I\'ll be on an anticoagulant
01:14:57.600 --> 01:14:59.500
for the rest of my life.
01:14:59.533 --> 01:15:00.867
That drug is dangerous.
01:15:00.900 --> 01:15:03.600
Again, it has consequences.
01:15:03.633 --> 01:15:06.233
- I was not ready
to have a stent put in
01:15:06.267 --> 01:15:09.233
because of the bleeding ulcer.
01:15:09.267 --> 01:15:11.867
But there\'s no question
that in a different situation,
01:15:11.900 --> 01:15:14.900
I would have had either a stent
or bypass surgery.
01:15:14.933 --> 01:15:16.800
- There is
this very strong bias to action
01:15:16.833 --> 01:15:18.833
that almost any good
interventionalist, surgeon,
01:15:18.867 --> 01:15:20.667
cardiologist will show.
01:15:20.700 --> 01:15:22.633
The interesting thing is,
is if they don\'t,
01:15:22.667 --> 01:15:25.533
you don\'t really trust them
to do the procedure.
01:15:25.567 --> 01:15:28.500
They need to have that belief
in what they do.
01:15:28.533 --> 01:15:29.500
Boy, throw on top of that
01:15:29.533 --> 01:15:30.900
that every time
they place a stent,
01:15:30.933 --> 01:15:32.500
they make more money.
01:15:32.533 --> 01:15:34.167
I don\'t believe
that\'s their main driver.
01:15:34.200 --> 01:15:35.867
They certainly try not to.
01:15:35.900 --> 01:15:37.233
You know, the money they receive
01:15:37.267 --> 01:15:38.800
is just the burden
they have to bear
01:15:38.833 --> 01:15:41.400
for the good
that they\'re achieving.
01:15:41.433 --> 01:15:42.600
You see?
01:15:42.633 --> 01:15:44.333
But you kind of get
this witches\' brew,
01:15:44.367 --> 01:15:48.667
this perfect alignment of forces
that says, \"Let\'s do it.\"
01:15:48.700 --> 01:15:51.100
The net impact of that
is the decision-making
01:15:51.133 --> 01:15:53.000
transfers away from the patient,
01:15:53.033 --> 01:15:54.533
who should be making
the decision,
01:15:54.567 --> 01:15:56.567
to the physician.
01:15:56.600 --> 01:15:58.200
- I wasn\'t involved in his care
01:15:58.233 --> 01:16:00.600
at the time
of the diagnostic angiogram,
01:16:00.633 --> 01:16:03.900
but the past history
of gastrointestinal bleeding
01:16:03.933 --> 01:16:06.633
made it
potentially dangerous for us
01:16:06.667 --> 01:16:10.000
to commit to blood thinners,
like aspirin,
01:16:10.033 --> 01:16:13.033
in combination with Plavix
for an extended period of time.
01:16:13.067 --> 01:16:16.300
And so we went back
and reassessed
01:16:16.333 --> 01:16:17.800
whether or not that narrowing
01:16:17.833 --> 01:16:20.167
was something that needed
to be treated or not.
01:16:20.200 --> 01:16:22.333
- Have you ever had a nuclear
stress test done before?
01:16:22.367 --> 01:16:23.367
- No.
01:16:23.400 --> 01:16:26.100
- Okay,
basically the procedure...
01:16:26.133 --> 01:16:27.500
We start an IV in your arm.
01:16:27.533 --> 01:16:29.900
Through that IV, we inject
a small amount of radioactivity.
01:16:29.933 --> 01:16:31.700
It circulates
close to your heart muscle.
01:16:35.400 --> 01:16:37.833
- The concept behind the test
is that if there is an area
01:16:37.867 --> 01:16:40.567
of significant narrowing,
then the muscle downstream
01:16:40.600 --> 01:16:44.433
of that narrowing won\'t have
the same blood supply.
01:16:44.467 --> 01:16:46.833
But as you can see
on the stress images,
01:16:46.867 --> 01:16:48.933
that blood flow in that region
looks robust.
01:16:48.967 --> 01:16:50.267
It looks completely normal.
01:16:50.300 --> 01:16:52.700
So good news,
we don\'t see anything here
01:16:52.733 --> 01:16:54.800
that warrants treatment,
whether that\'s stent,
01:16:54.833 --> 01:16:56.367
whether that\'s
balloon angioplasty,
01:16:56.400 --> 01:17:01.200
whether, as you talked about,
a limited bypass surgery.
01:17:01.233 --> 01:17:03.600
And I wouldn\'t do anything else
at this point.
01:17:03.633 --> 01:17:04.600
- Excellent.
01:17:04.633 --> 01:17:05.833
- We\'ll see you in three months.
01:17:05.867 --> 01:17:07.400
- Turns out
that when you start to work
01:17:07.433 --> 01:17:08.767
in an organized care system,
01:17:08.800 --> 01:17:13.700
you talk an awful lot about
indications guidelines.
01:17:13.733 --> 01:17:15.000
It relies on data.
01:17:15.033 --> 01:17:16.000
When is there a benefit?
01:17:16.033 --> 01:17:19.400
How do I properly advise
a patient?
01:17:19.433 --> 01:17:22.333
When you start to make this
explicit so people can see it,
01:17:22.367 --> 01:17:24.300
it changes their behavior...
01:17:24.333 --> 01:17:26.567
Even my good,
aggressive surgeons.
01:17:26.600 --> 01:17:28.867
By the way,
we won\'t lose clinical outcomes
01:17:28.900 --> 01:17:30.667
if we do this.
01:17:30.700 --> 01:17:32.900
We\'ll lose
a lot of complications.
01:17:32.933 --> 01:17:34.600
We\'ll lose
a tremendous amount of cost.
01:17:34.633 --> 01:17:37.033
We\'ll probably lose
a few deaths.
01:17:37.067 --> 01:17:40.367
We\'ll get care
that\'s a lot better, not worse.
01:17:40.400 --> 01:17:42.967
This isn\'t withholding
necessary care.
01:17:43.000 --> 01:17:45.700
This is withholding
unnecessary injuries.
01:17:48.000 --> 01:17:50.967
- Your heart
went into a funny rhythm.
01:17:51.000 --> 01:17:53.567
It\'s called
ventricular fibrillation.
01:17:53.600 --> 01:17:56.000
And you
were very, very fortunate,
01:17:56.033 --> 01:17:59.767
because 90% of people
who have that or more
01:17:59.800 --> 01:18:02.967
don\'t survive
to even make it to the hospital.
01:18:03.000 --> 01:18:05.200
- I feel very, very fortunate,
so...
01:18:05.233 --> 01:18:07.033
My wife did CPR.
01:18:07.067 --> 01:18:09.400
- And I think that\'s why
you\'re here today.
01:18:09.433 --> 01:18:11.100
- Well.
01:18:11.133 --> 01:18:12.667
- After you
were recovered enough
01:18:12.700 --> 01:18:16.700
from the initial ventricular
fibrillation episode,
01:18:16.733 --> 01:18:18.533
we went ahead
and did the angiogram.
01:18:18.567 --> 01:18:21.033
And in fact, the artery
on the front of your heart,
01:18:21.067 --> 01:18:22.500
that\'s the most important
artery,
01:18:22.533 --> 01:18:27.733
one that we call the LAD,
was 100% blocked.
01:18:27.767 --> 01:18:31.233
And another artery
is 80% blocked.
01:18:31.267 --> 01:18:34.667
- So when Dr. Miner called me,
I reviewed your films
01:18:34.700 --> 01:18:36.933
that he\'d done
and saw the two big blockages.
01:18:36.967 --> 01:18:39.767
And you have some things that
made us lean towards surgery.
01:18:39.800 --> 01:18:42.100
They\'re both
pretty tight blockages,
01:18:42.133 --> 01:18:43.933
and they\'re both
pretty far up in the arteries.
01:18:43.967 --> 01:18:46.767
So if they were
to totally block both of \'em,
01:18:46.800 --> 01:18:49.200
you could wipe out
almost the entire heart.
01:18:49.233 --> 01:18:50.733
So tomorrow,
01:18:50.767 --> 01:18:52.333
we\'re going to plan on
doing an operation
01:18:52.367 --> 01:18:55.233
that will hopefully
take care of all that for you.
01:18:55.267 --> 01:18:56.300
- I\'m ready.
01:18:56.333 --> 01:18:59.867
It\'ll be a trip
of a lifetime, huh?
01:18:59.900 --> 01:19:01.367
- We\'re going to do two grafts.
01:19:01.400 --> 01:19:03.633
We\'re gonna do one on the front
and one on the side.
01:19:03.667 --> 01:19:06.933
The chance of you dying
or having a stroke...
01:19:06.967 --> 01:19:09.233
Those are sort of the real
feared complications...
01:19:09.267 --> 01:19:11.767
I would say
would be 1% to 2%, very low...
01:19:11.800 --> 01:19:14.867
Doesn\'t really get
any lower than that.
01:19:14.900 --> 01:19:17.400
- I\'ve got
too much living to do.
01:19:17.433 --> 01:19:23.067
And I don\'t want to be worrying
about my heart.
01:19:23.100 --> 01:19:27.533
- And pretty much 100% recovery,
is that what we\'re anticipating?
01:19:27.567 --> 01:19:30.600
- That\'s our plan.
01:19:30.633 --> 01:19:34.267
- Turns out that surgery
sometimes is a major advantage.
01:19:34.300 --> 01:19:36.000
Now, on the other hand, for me,
01:19:36.033 --> 01:19:38.733
I don\'t think
I\'d let \'em do it to me.
01:19:38.767 --> 01:19:42.233
That\'s because I trained
as a surgeon.
01:19:42.267 --> 01:19:46.033
When you go into surgery,
it\'s never as good as new.
01:19:46.067 --> 01:19:47.933
There\'s always a price you pay.
01:19:47.967 --> 01:19:51.033
Surgery
is always the last option.
01:19:52.933 --> 01:19:54.500
What I really believe is
is that patients
01:19:54.533 --> 01:19:56.067
should be able to make
their own choices
01:19:56.100 --> 01:19:57.133
in a fair and honest way.
01:20:00.933 --> 01:20:03.067
- Hey.
- Hey.
01:20:03.100 --> 01:20:04.067
- See you in there, okay?
01:20:04.100 --> 01:20:05.967
- All right.
01:20:29.267 --> 01:20:31.333
- All right,
you ready to go home?
01:20:31.367 --> 01:20:32.933
- Yes, I am.
01:20:32.967 --> 01:20:34.767
- Okay, so you\'re going home
on the oxygen,
01:20:34.800 --> 01:20:38.400
and you want to keep it on
about two liters, continuously.
01:20:38.433 --> 01:20:40.367
You\'ll go home
with a heart care handbook.
01:20:40.400 --> 01:20:42.867
That\'s a good reference
for your recovery,
01:20:42.900 --> 01:20:44.633
your nutrition, diet.
01:20:44.667 --> 01:20:46.200
We want to encourage you
to walk,
01:20:46.233 --> 01:20:47.833
but no strenuous exercises.
01:20:47.867 --> 01:20:48.833
- Got it.
01:20:48.867 --> 01:20:50.900
- All right, any questions?
01:20:50.933 --> 01:20:52.800
- No, but thank you so much.
- Oh, you\'re welcome.
01:20:52.833 --> 01:20:54.700
- It\'s been really wonderful.
- Oh, no problem.
01:20:54.733 --> 01:20:55.900
- It gave you another chance.
01:20:55.933 --> 01:20:57.600
- Gave me another chance
at life so...
01:20:57.633 --> 01:20:58.933
You guys handled it beautifully.
01:20:58.967 --> 01:21:00.133
- You\'re welcome.
01:21:00.167 --> 01:21:02.033
See you next year for skiing.
01:21:02.067 --> 01:21:03.300
- You got it.
01:21:03.333 --> 01:21:05.433
- When we moved to this hospital
three years ago,
01:21:05.467 --> 01:21:07.600
our mortality rate
for coronary bypass
01:21:07.633 --> 01:21:08.833
was at the national average.
01:21:08.867 --> 01:21:11.967
And then we started
to really implement some
01:21:12.000 --> 01:21:13.933
what we thought
were minor things,
01:21:13.967 --> 01:21:15.367
but it tended
to effect everything.
01:21:15.400 --> 01:21:17.933
So we tried to get people up
01:21:17.967 --> 01:21:19.667
and moving quickly
after surgery.
01:21:19.700 --> 01:21:22.033
We tried to take
their breathing tube out.
01:21:22.067 --> 01:21:23.600
We conserved their blood.
01:21:23.633 --> 01:21:25.800
We tried to prevent
giving them transfusions.
01:21:25.833 --> 01:21:27.600
We watched their blood sugars.
01:21:27.633 --> 01:21:29.733
All of these things
combined, gradually...
01:21:29.767 --> 01:21:32.400
Each had a little piece
to reduce the risk of death
01:21:32.433 --> 01:21:34.533
after open-heart surgery.
01:21:34.567 --> 01:21:37.133
- The mortality rate
for open-heart surgery
01:21:37.167 --> 01:21:38.733
runs about 3%.
01:21:38.767 --> 01:21:40.867
We\'re less than half that.
01:21:40.900 --> 01:21:42.567
And it comes from
applying these methods.
01:21:42.600 --> 01:21:46.833
Oh, it\'s not just
that half as many people die.
01:21:46.867 --> 01:21:49.400
It\'s cheaper too.
01:21:49.433 --> 01:21:51.467
If the rest of the country
delivered care
01:21:51.500 --> 01:21:55.400
to Medicare patients
the way that we do here in Utah,
01:21:55.433 --> 01:21:59.367
the total cost of care
would fall by about 34%,
01:21:59.400 --> 01:22:01.400
and we would not be in the midst
01:22:01.433 --> 01:22:03.567
of a national health care
cost crisis.
01:22:06.967 --> 01:22:08.633
- One of the myths
of American medicine
01:22:08.667 --> 01:22:11.633
is that we have to ration
in order to reduce costs.
01:22:11.667 --> 01:22:16.367
I think our research shows
that\'s absolutely not necessary,
01:22:16.400 --> 01:22:18.700
that if you look at
some of the examples
01:22:18.733 --> 01:22:20.233
of great care
around the country,
01:22:20.267 --> 01:22:22.967
it is possible
to redesign our care
01:22:23.000 --> 01:22:25.267
in ways that are great for us
as patients
01:22:25.300 --> 01:22:28.033
and great for us as physicians,
by the way,
01:22:28.067 --> 01:22:30.833
and that reduce the costs
of care.
01:22:30.867 --> 01:22:34.900
This is about redesign,
not rationing.
01:22:34.933 --> 01:22:36.300
- It\'s not rationing
01:22:36.333 --> 01:22:39.567
to get rid of stuff
that\'s bad for you.
01:22:39.600 --> 01:22:41.100
It\'s not rationing
01:22:41.133 --> 01:22:44.567
to get rid of care
that won\'t benefit you.
01:22:44.600 --> 01:22:45.700
It\'s rational.
01:22:48.700 --> 01:22:51.033
- Let\'s go.
Let\'s get out of here.
01:22:56.300 --> 01:22:59.967
[machine whirs]
01:23:00.067 --> 01:23:03.333
[treadmill whirs]
01:23:07.000 --> 01:23:08.500
- I\'m not trying to push you.
01:23:08.533 --> 01:23:09.633
- No, I under...
01:23:09.667 --> 01:23:11.400
- I\'m just trying
to understand you.
01:23:11.433 --> 01:23:12.633
- It\'s good.
01:23:12.667 --> 01:23:15.967
- The diameter of this artery,
maybe it\'s 20%.
01:23:26.333 --> 01:23:28.667
[tool whirs]
Distributor: Bullfrog Films
Length: 84 minutes
Date: 2012
Genre: Expository
Language: English
Grade: 10 - 12, College, Adults
Color/BW:
Closed Captioning: Available
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