My Conversation with Ezekiel Emanuel

Very much a fun one, here is the audio and transcript, here is part of the opening summary:

Do we overrate the importance of doctors? What’s the importance of IQ versus EQ in the practice of medicine? What are the prospect for venture capital in biotech? How should medical training be changed? Why does he think the conventional wisdom about a problem tends to be wrong? Would immortality be boring? What would happen if we let parents genetically engineer their kids?

Tyler questions Emanuel on these topics and more, including the smartest thing his parents did while raising him, whether we have right to medical self-defense, healthcare in low- versus high-trust institutions, and much more.

Here is one excerpt:

COWEN: How can we improve medical education?

EMANUEL: Cut it down. Make it shorter.

COWEN: Cut it down? Why does that make it better? Or does it just make it cheaper?

EMANUEL: No, I think it will make it better. So, we have a lot of memorization, a lot of . . . So, let’s go back to the start. The four years of medical school: two years of preclinical in the classroom learning about biochemistry, genetics, anatomy, microbiology; and the two years of clinical time in the hospital, on the wards.

That dates from 1910. We haven’t really updated it much, except in this one way: we’ve cut down the preclinical time because — less of it — and it changes so fast, by the time you learn it in medical school, get out as a doctor, it’s out of date, A; and B, it’s more or less irrelevant to managing most patients…

And then, by the way, in med school, spending your time in a hospital is not the future. The future of American medicine is out of the hospital. So we need more rotations, more experiences for students out of the hospital.

No med school has made that big shift, and those are the shifts that are going to have to happen over the next 15 or so years.


COWEN: Is there a right to medical self-defense that should override FDA bans on drugs and medical devices? I want to try something that’s not approved —

EMANUEL: No. I don’t like that.

COWEN: I’m saying it’s my body. But why don’t you like it?

EMANUEL: No, no, no, no, no, no, no, no, no, Tyler.


COWEN: Now, you’ve written a much-misunderstood article about how hard you would try yourself to live past the age of 75. Would not the suspense of world and national history always keep you wanting a bit more extra time?

So, say I’m 75. I’ve decided I agree with you, but the NBA Finals aren’t over yet. I want to see game seven. I want the Mueller report to come out. Isn’t there always something?

And then, it’s kind of intransitivity of indifference. Every day there’s something, and you just keep on hanging on, even if one accepts your arguments in the abstract. Can you talk me out of that?

EMANUEL: No, no, Tyler, I think you’re exactly right. That’s why people do hang on. It’s because . . . you know, so I talked to my father, who — he says, “Zeke, you’re absolutely right. I’ve become slower, physically slower, mentally slower. My life” . . . what ends up happening is your life cones down, and you begin to overvalue certain small things. Like the NBA Finals. Like what’s in the Mueller report.

We all know, from any cosmic standpoint — even not a cosmic standpoint, just a 2,000-foot standpoint — most of those things are not irrelevant. It’s really cool to know.

You often ask — and this happens to me all the time. I teach undergraduates. Pretty smart undergraduates. Very smart undergraduates. MBA students, nurses, doctors, right? They have no understanding of history. So, whoever finishes in the NBA Finals, in five years, people have forgotten.

Recommended, interesting throughout.


Seem like the conservatives are barking up the wrong tree, trying to stack the Supreme Court in order to make abortion illegal.

All they need to do is appoint the right FDA commissioner and turn abortion into an unapproved medical procedure. And then "No, no, no, no, no, no, no, no, no, Tyler", I suppose women would no longer have any say regarding their own bodies.

Yes, there's a fundamental contradiction in the pro-choice-on-abortion, anti-choice-on-everything-else position. Conservatives have already tried a variation of your suggestion: regulating safety of abortion clinics. Predictably, the anti-choice-on-everything-else crowd suddenly realizes that patient "protection" is actually patient restriction when the topic turns to abortion.

FDA cannot force anyone to submit to some alien invasion of their body. We have protections, First, right of assembly is not to be inhibited.
Second gives us the right of defense
Thirteenths protects us from slavery.

All of these allow men and women to defensively reject foreign invaders of our bodies.

Except vaccines. Because it is for the common good. So that's ok.

You know, like Obamacare. Except less socialist.

An honest evaluation of vaccines would always result in mandatory vaccines. Vaccines have saved billions of lives since the 1950's with almost no negative side effects.

An honest evaluation of Medicare would lead to the immediate expansion of the program to everyone.

You do understand that Medicare recipients had to pay into it until they turned 65. THEN they must pay for it as a substantial deduction from the SS. THEN they have to pay 20% or more of all costs. I bet you thought it was free!!! BUT those people advocating for Medicare for all actually want it to be free to them. They do not want "Medicare" for all they want single payer health care for free. AND they want to destroy Medicare for the retired.

If you were listening, you'd know Alyssa Milano has the solution both to abortion and to women's control over their bodies and reproductive health: Just Say No.

Apparently, that is a no-go feminist males.

Abortion is murder.

So is a cop killing a deranged criminal, both are termed homicides. In both cases the right of self defense over-rides. One cannot invent a legal crime when the Constitution allows the behavior.

Then why don't you move to Saudi Arabia? They feel the same way. Let the rest of us keep our freedoms.

"I’m saying it’s my body. But why don’t you like it?" Well done, Mr C.

"The future of American medicine is out of the hospital." How does he know?

Because hospitals are increasingly a highly unsafe place to be?

One trick pony does its one trick!

You're absolutely correct.

It's not the relatively-huge proportions of criminal aliens. it's the are massive numbers of Obama supporters.

It makes you angry if people like the other guy doesn't it?

I suck a pretty good cock too!

> How does he know?

He has absolutely no clue, which is why he says "in the next 15 years or so."

It's a dead giveaway, like Occasional-Cortex saying the world will end in 12. They have no clue.

Is that what she says? No wonder you keep wetting the bed!

Yes, that is what she says:

""We’re, like, the world is going to end in 12 years if we don’t address climate change"" AOC


Brah, you supposed to be *sweat*

Good question. Hospitals now employ over 50% of physicians. Where do hospitals wish for their employed physicians to treat/conduct diagnostics? That's right. And how is the compensation of the employed physician determined? That's right.

Where's your evidence?

What I see is hospital corporations, public and for profit, losing business that is compensated. However, as they get most funding from CMS, they are required to provide uncompensated care under EMTALA. Plus, going back to Nixon, doctors started orgabizing to compete with hospitals. First HMOs run by doctors got paid per patient, not by care, so they brought into the HMOs as much of the work done in hospitals, cutting costs, mostly by eliminating overnight stays. Even when for profit insurers got Congress to effectively make HMOs illegal, the doctors continued to collective and compete with hospitals.

Hospital corporations are either buying, or creating, these doctor collectives, and steering patients to their now non-hospital provider business. Simply sharing the name of the hospital (chain) does not make the owned doctor provider network "hospital employed doctors."

In fact, hospitals have gotten rid of doctors as employees during my life time, shifting the doctor staff to contract workers. The theory was having doctors as employees meant you were paying doctors who had no work for large amount of time, and by treating them as contractors, they would be paid only when working. I'm old enough to remember the public health care policy debate on getting rid of hospital employees, outsourcing doctors, nurses, x-ray, lab, janitors,... Ancient history, like the 60s and 70s.

If I had to guess, given the consolidation in the healthcare industry, I would say that the most likely outcome is that the distinction between working in a hospital and a traditional private medical practice is going to erode, as the services provided by the two become sort of mixed and matched.

Nice use of hyperlinks.

Hi, mouse!

Hi! Hope you are reading.

You are not just another lefty sjw with TDS, you are a sociopath.

As you like to say, "wear that on your sleeve".

You guys. I hope you are just joking around. Otherwise reactions show silliness, but not where you think.

Tyler's link literally was "read the Mueller report" and that's what you see as you roll the mouse over.

So ..

I wish you'd pushed back a bit on the undergrad stuff. Does he think doctors in Europe are inferior to their American counterparts because they didn't do 4 years of philosophy and history?

Some of the excellentt doctors here (especially cardiologsts) are from Indi a where there is no undergrad requirement ; like engineering students etc , medical students start medical college right after high school. Requiring 3 to 4 years of undergrad before medical school really lengthens their education without much benefit.

It is a thought error to think anything the educational establishment does is for the benefit of the student.

I hope online Ed will end the death grip on US higher ed, but it is hard to compete against the entrenched power of the credentialing monster.

Credentials are valuable in the market.

What do the economists say?

"Requiring 3 to 4 years of undergrad before medical school really lengthens their education without much benefit." It's of benefit to existing doctors who want to ration entry to the profession.


They can still ration with GPA and GMAT scores.

Extend that argument. Do what Allan Bloom suggested: if you're not going to assemble a serious core curriculum, quit wasting students' time and replace the four-year baccalaureate with two year courses of specialized study.

And, while we're at it, replace the BA as an entry requirement for law school with certificate programs which can be completed in 18 months. And replace the JD with one calendar year of study followed by an office apprenticeship, conjoined to supplementary certificates in specialized areas of law.

4 years of undergrad followed by 3 years of law school is incredibly stupidly wasteful

Based on the pre-law students I knew back in the day, I would say that the 4 years of undergrad was *cough* wasted.

But that 4 years could be crucial in giving a young person the space to realize they could do something better with their lives, than become a lawyer, and know he will only, no matter how *good* a lawyer he is, contribute to making the world worse.

In fact, I'd go farther and eliminate law schools entirely. Let self-tutoring again be the rule. Hit the books!

If it worked for Kim Kardashian....

From the NYFed data, graduate working in job that do no require any degrees,

Major %UnderEmploy
PublicPolicy/Pre-Law 63.1

The purpose of 'degrees' is to simply make barriers to entry higher. When I was treated for mountain sickness in Tibet (there's no cure, except to get off the mountain before you die, though bottled oxygen is nice) the 'doctor' was an 18 year old kid who spoke almost no English. He took my temperature, concluded it's mountain sickness (which gives a specific high temperature), told me to get to a lower elevation and I paid him some cash. There's nothing magical about medicine.

Bonus trivia: don't ask, but have you had the pertussis vaccine like I have? It saved me when a relative came out of hospital recently and contracted it, in a prestigious US hospital (but nevertheless a cesspool of germs and viruses). I never thought such a rare bacterial disease would be found in the USA anymore, but it is. I got mine, with tetanus (a not uncommon way to die back during WWII outside the USA) and diphtheria, when I was in the Philippines and it saved me here in the USA, ironically.

TDAP is standard of care in the US and thus "free" to all under obamacare. If poor and homeless, you will in most States, find the local public health eager to get you to a provider to get you a booster.

And I had surgery scheduled circa 2000 when US drug companies were outsourcing to India on government contracts, and quality issues created scarcity, but that made me a priority patient for TDAP.

And I've gotten a booster since based on computerized patient records systems flagging it as being due. Something obamacare promoted by funding sole practicing doctors to adopt, but which has been one focus of NH health care academics, eg Dartmouth, and the now gone Matthew Thornton health plan, which were competing with the Massachusetts academic and HMO provider establishments.

They also recommend a DTaP booster when you become a parent, along with anyone who plans to be in close proximity to the baby.

This idea that kids need time to grow isn't bad, but the idea that it has to be in the most expensive venue possible is kind of ridiculous.

It's cheaper to do the PCT.

Doctors are very close to being replacable by robots.

Most of their work already is simply to duplicate whats already been analyzed by a computer, read a diagnosis and script off a print out, and make you feel better because of the white coat.

Further, most that i have met were incapable of independent thought, and basically regurgitated what theyve been told

The irony in this comment is just delicious!! Carry on my white brother!!

I remember when the claim was made that doctors would be replaced by Physicians Assistants for 80% of primary care.

This was easy in theory back in the days when HMOs were legal. Ie, when a group of doctors go paid a fixed fee to provide all health care, regulated by State insurance regulators because they were there, but with no requirements for capital reserves.

HMOs were formed and run by doctors, under a tax law signed by Nixon related to employer benefits tax treatment. Employers were required to offer a choice of HMO instead of the coop BCBS or the employer paid medical care plan or the fairly rare health insurance of the time, if an HMO existed.

As HMOs operated on budgets with doctoors as employees and managers, doctors shifted responsibility to nurses, and PA trained like Army corpsmen who were in abundance due to Vietnam. HMOs and some teaching hospitals worked on certifying these veterans, but HMOs could hire them under a doctor's supervision, have them do what the doctor did, then consult with the doc to sign off legally on prescriptions.

But outside of an HMO, it was impossible to bill for services done by PAs. Insurers will only pay for work done by a doctor in contact with the patient, plus overhead, or work done by a licensed nurse, eg give shots. Laws have forced insurers to pay for some work that is not done by doctors or nurses, eg, certified pharmacists can now give shots and insurers must pay.

No computer based primary care practice is viable in the US. Will you pay $100 out of pocket to interact with a computer with nothing more than contact with a retail clerk? If the computer were to flag the need for a doctor, that would certainly be an added cost.

But no insurer will pay $100 or even $40 to the computer owner of the one you sit in front off instead of a doctor. Insurers won't pay an RN who does a better job than a doctor and faster. Eg, my provider links doctors and RNs or LPNs to set patients up for the doctor, paying them as part of overhead out of billing of doctor care, and my doc just reviews what she has entered, repeats "any other concerns we should cover?", then submits the prescriptions.

Its only recently some insurance is required to pay for doctor services by video link. Not sure if any pay for consulting with a doctor by secure email or chat. Last I checked, an office visit with my primary was free 1-3 times per year, but an email consult covering the same thing was $50 out of pocket because CMS won't pay because State regulators don't require insurers to pay.

Oh for sure there's sticky points, both in terms of patients who will not accept a non-human, even if that human merely reads the results of a computer's diagnosis and prescription (I'm looking at you eye doctors and radiologists). As well as the doctors themselves who will of course smash the MRI machines with their wooden shoes.

But don't kid yourself, people fill thier own auto gas, shout food orders into a plastic clown face, give their SSN to robot voices at the bank, and bus their own tables and even mid-scale restaurants.

We're highly trainable apes after all.

I find it odd that many left-leaning people think it verbotten to use science to modify an embryo to have various traits but also think abortion comes down to "my body, my choice".

Not at all, genetic modification, releasing altered dna into the wild concerns (along with the economic class unequal access concerns) people for different reasons than what's behind the ethics behind abortion.

It's more like being pro-life and anti-cloning.

(Almost certainly) Every embryo contains gene variants that make it out into the wild (why is an "artificial" change different). Also, the whole point behind the "my body, my choice" is that the embryo is the woman's and doesn't carry with it any independent moral weight. If it is actually "my body, my choice", then people have a much harder task of providing coherent restrictions on what one can do with the embryo.

You know full well that laboratory induced gene mutations that was invented in our lifetimes is different than those naturally occurring since the dawn of time. And ought to at least be held to a high standard of proof of non-harm.

My body my choice means my decision whether to carry a baby around for nine months. Where in the moms's rights trump the child's.

It is pretty weak broth to try and extend that to I want my child to have a high IQ and blue eyes.

What if we do the genetic modifications and then abort the fetus?

I assume that’s okay.

What about in the next 30 years when we can abort based on probable height, or sexuality?

If it’s all natural but we abort based on IQ and height, does it become okay ?

The positions are inherently contradictory.

Yes there are different arguments for and against, but if you try to make the two positions coherent, they don't. Yes my body my choice is about carrying a baby to term, but it is based on an understanding that the embryo has no independent moral status and is subject to the whims of the woman. You can't square that with a prohibition on gene editing. The two positions are based on different understandings of the moral worth of the embryo.

You really don't know full well that laboratory induced gene mutations that was invented in our lifetimes is not different than those naturally occurring. What is the difference between an allele A here and an allele A there other than your hand waving??

The best reasons to be against CRISPRing right now are that it has a good chance of doing nothing much, and a reasonable probability of doing harm.

But being against embryo selection or sex selective abortion, because of some concerns about social structure and inequality, while at the same time being for a woman's right to choose about whether she has a baby or not when pregnant... that is pretty odd.

How is that left-leaning? It is the conservative position to proceed with caution especially something that could go catastrophically wrong like gene-editing.

lol. Conservatives ceded the precautionary principle to the left, like, fifty years ago,

But what if President Captain Bolsonaro prevented women from having bortions?

Brazil only allows abortions when the mother is at risk or if she was raped. Bills have been introduced to ban abortion in all situations, but it is too soon to know if anyhing will come of that.

I don't quite understand Emanuel's argument against "medical self-defense". He seems to be implying that, if an individual takes a non-approved drug, then nobody else will be able to limit themselves to only FDA-approved drugs, to the "institutional structure". How does that follow? If we allow one woman to choose an abortion, then would that mean that every other pregnant woman would have to have an abortion? Does not follow.

He's a Leftwinger and thinks most people shouldn't be able to make their own choice. Furthermore he believes that rich people in particular shouldn't be able to bypass the system. That a government approved body should make these choices for everyone.

"Some individuals may be able to do it. But we have a society of 325 million people, and we have these institutional structures to oversee what we’re taking is safe and effective for all of us, not just for the lone individual who’s got a lot of money who says, “I want to do it. Damn you all.”"

No, the left wing concern is that unscrupulous manufacturers will deceive customers, corrupt providers, spread confusion, and then leave behind medical and economic damage for the public to clean up.

The right wing concern is, um, protecting incumbents from competition. Which is basically it's reason for everything these days.

I quote his actual comments. You ignored them and out a lot of words in his mouth that he never said.

No one has ever accused McMike of good faith debate.

Silly me. I thought the left's main concern was correcting the fatal flaw in the Constitution that allows Republicans to win elections so that they could reduce everybody (but the elites) to an equal level of desperation and poverty.

The quote is what confuses me. If a lone individual takes a non-approved drug, then how does that ruin the "institutional structure" for the other 325 million? He seems to be saying that allowing individuals to take non-approved drugs requires abolishing the FDA. But, it doesn't. The FDA could still approve drugs, and the other 325M people could still choose to only take FDA-approved drugs.

Indeed. Someone should ask the Republicans why buying drugs from Canada is prohibited.

Your position is that no one would seek FDA approval? That seems highly unlikely.

The Mueller Report, got it. Sort of like the Protocols of the Elders of Zion for American Democrats. The Democrat party is almost entirely comprised of the stark raving mad and there is no cure.

Call The Exorcist!

The devil invented the Mueller Report to blind the simple-minded.

I'm so old I remember when they told us we had to accept the conclusions of the Mueller Report.

The only one going stark raving mad is Trump. The wagons are circling in on him. Impeachment calls from even members of his own party grow by the day. The Mad King Donald won't have a happy ending.

No med school has made that big shift, and those are the shifts that are going to have to happen over the next 15 or so years.

No, they don't have to, and the smart money says they won't.

Was Emanuel using "history" in the limited sense of such things as the NBA finals? I hope so. Otherwise, he's got a bunch of ignorant smart students that he teaches if they have no understanding of "history".

I've read his article in The Atlantic about refusing extraordinary care and diagnostics after he reaches age 75. It resonates with me. What he is referring to is self-rationing of health care, people taking it upon themselves not to consume vast amounts of health care at the end of life or when the quality of life is poor.

The system (medical plus elder care) has oriented itself towards sucking every last dollar from the elderly until they go on medicaid. Then keep sucking.

They gave a pacemaker to my dad who is almost 90. He is barely sentient. Dementia units in care units are full with walking zombies, dementia patients with pacemakers.

Really, truly, wouldn't you rather give that money to your children?

Well, there's a lot of highly expensive stuff that goes on in US hospitals that does almost nothing for mortality. And particularly this may well be the case in the US - not because of your system, but because you are a very wealthy nation with money to spare and perhaps more of a will to beat death. (Of course, there's a lot of cheap stuff that perhaps would help mortality that doesn't happen in the US and that *may* be down to your system at the margins. Or not.)

Perhaps lots of people would rather the money went to their children - but they're insured and it's really a choice either the money going on their care or nothing, not money going to loved ones.

And many more people take the stance that it's their duty to fight to keep dad or mom alive for as long as they can, and the kids will ultimately be able to take of themselves. It's easy in the abstract to put this down to a negative cultural attitude towards death, but facing this, do you honestly find it so easy to let your dad go?

Yes, we are wealthy. We are the "because we can" society.

When faced with the choice, most kids will not of course let their parents go. And many parents will not let go either. Which is what the elder care industry is built on.

And so, parents consume their savings, extending the time they get to watch tv or moan in the hallways or have thieir diapers changed, while the kids visit once a week or month or whatever. It is what it is

Unfortunately it is the only game in town, so it is very hard to opt out of. But it is utterly sane and generous to at least theoretically recognize that there is a point of diminishing returns, and you really would rather leave a six figure endowment to your kids, than extend your life by x months effectively bedridden or in dementia.

That's the curse of modern medicine, used to be at a certain point an infection or heart attack would take grandpa, and since he had had a full life of six or eight decades, and a passel of grand-kids around, and so everyone said: okay, well that was a pretty good run.

Now, that moment can drag out for decades.

But it is utterly sane and generous to at least theoretically recognize that there is a point of diminishing returns, and you really would rather leave a six figure endowment to your kids

Its certainly admirable, in a sense, assuming a certain level of comfort with the idea of inheritance. I can agree to that.

I am more leery of anything of anything that would suggest it is what the elderly *should* do with their money though; if my elderly relative had money and wanted to use it to live, well, they earned that cash and its right to use it to live if they choose, not the right of their younger relatives to live a life of comfort and ease with the money. And their should be no stigmatization of their choice either. To stigmatize people using their own money to continue to live in the benefit of the entitlement of their offspring seems deeply morally wrong.

The system (medical plus elder care) has oriented itself towards sucking every last dollar from the elderly until they go on medicaid. Then keep sucking.

Nursing homes and social assistance agencies account for 1.3% of gross revenues in this country. The share of value-added for which they account is...1.3%. The various grades of nursing aren't the most lucrative of occupations. Neither are the occupations under the heading of 'dietary staff'. The attending are generally internists or GPs, i.e. those physicians with the most modest compensation scales.

They gave a pacemaker to my dad who is almost 90. He is barely sentient. Dementia units in care units are full with walking zombies, dementia patients with pacemakers.

I bet there's a reason you're not the one holding the health-care proxy.

Your first point is incoherent.

Your second point makes clear you have never had to meet with siblings and decide whether your parent was serious about their DNR or not.

1. The point is coherent. It's also over your head.

2. Actually, I have had to do that. Multiple times.

Thanks, Tyler. I always figured Ezekiel Emanuel's thing about dying at 75 really was all about his dad, the old right-wing terrorist, being still alive well past then.

Benyamin Emmanuel was born in 1927. The Irgun was dissolved in the spring of 1948, when he was 21 years old. Do you have some piece of evidence that he planted bombs at the King David Hotel or shot civilians at Deir Yassin, or is it your contention that any armed Jew is a 'terrorist'?

Did Cowen and Emanuel discuss food? Emanuel is a foodie like Cowen, Emanuel even wrote many articles in The Atlantic about food and restaurants.

Restaurants are among the least healthy environments, over the long term, in the world. Restaurants are where the obesity happens, where the salt and sugar intake takes place, where people drink, and where people drink and drive home.

Restaurants choose their oils and ingredients (understandably) on the basis of cost, not the health of their customers.

Anyone doctors who're concerned about self-inflicted chronic disease, might want advise patients to consider abstaining from restaurants.

Anyone who's concerned about the sustainability of agriculture or our fisheries might also want to consider becoming a non-restaurantarian.

I thought you were going to drop the N-word.


Too obvious, but that being said, when we affluent westerners do have nausea, the runs, or simply feel crappy for a day or so, 4 out of 5 times the cause might be traceable to some restaurant kitchen or server’s thumb.

Frequency of eating out should correlate fairly robustly with self reported episodes of illness (at least gastric illness) if that's the case, being totally literal on the 4/5. Much evidence for that?

Source: My brother, a long-time restaurateur, who learned it from hygiene classes sponsored by a local board of health.

Apparently you live on a fantasy island where people don't have budget constraints, eat healthy food, and keep their kitchens spotless.

Virtue signaling with your concerns isn't a healthy habit either.

I heard somewhere some of those hospitality workers from the jungle do actually wash their hands.

A frustratingly vague term, "ultra-processed food," may actually be a thing.

It maps to restaurants, but bad frozen food also.

So either ultra processed food is bad for you, or it tastes better and you eat more.

I think they are saying both, and not coincidentally. We like the mouth feel and taste of calorie rich ultra-processed foods, and so we shovel them down.

Some grilled fish or chicken and raw vegetables might be better, but we are less enthused.

A terrifying insight into the mind of somebody who believes you cannot be trusted with your own choices and preferences.

Do you think the average consumer would do better picking his own treatments?

Or is freedom more important than outcomes?

Which outcome do you mean? The average, median, or modal outcome? Or do you mean a sum total increase in the QALYs of the affected population? And when it comes to choosing between a reduction in the primary marker but no statistically significant improvement in mortality on the one hand and no change in the primary marker but some weak evidence of an improvement in mortality in a small number of studies that had patient compliance issues, which do you think we ought to choose?

Yeah, actually I think the average consumer, armed with the internet and a community of consumer reporting mechanisms, would do better picking his own treatments.

Just like all that fruitful individual scholarship on the safety and efficacy of vaccines?


What difference with liberals is that they confuse individual consequences with externalities ?


Like, when McMike refuses to give his kids the polio vaccine, that causes social harm, like herd immunity dude. Unchill dude.

But when McMike’s unvaccinated kid smashes up and snorts OxyContin, he’s the one that like suffers, dude. Like, Purdue family made him do it dude.

Moderate here.

I see two motivations.

Public health has a self-interest component. We don't want to get Ebola.

Public health also has a compassion component. We don't like seeing others suffer.

As a moderate I would be suspicious of compassion-free arguments for low public health investment. I mean cost benefit analysis is fine, but not I think rejecting the whole thing.

I am suspicious of arguments that omit the fact that some of the people getting the vaccine will die. Start there, so where it goes then.

Some people are situational about when they are suspicious of government power or corprate lying, and some are not.

It's not risk/reward, cost/benefit, without recognizing the reward and benefit.

Herd immunity is a wonderfully ironic concept to introduce to a libertarian blog

Whenever I want to get trolled for raising doubts about a global one-sized-fits-all government program that forces people to do medical procedures on their children and creates artificial monopoly markets, I go to a libertarian blog, because then it's extra funny.

I'm genuinely curious, Anonymous. Do you think the average person is anti-vax? Or do you think it's a small minority of people? Do you think the information researched by the majority of people leads them to conclude against vaccinations?

Or are you really just spooked and letting your fear bias your judgment?

I wasn't thinking most, but I was thinking that anti-vax was a nice illustration of how social media and the internet corrode .. both competence and respect for expertise.

These people reject what their doctors say, because of what they found on the internet.

And in terms of opening up uncertified treatments, we can be sure *some* would make similar foolish mistakes.

So, how important is it to you that they have that freedom?

Is your answer ideological, rather than harsh cost-benefit analysis?

You've set up a strange alternative reality in which the only time patients make catastrophically wrong decisions is when they act contrary to the advice of their doctors. The reality is that some percentage of patients suffer and sometimes die thanks to the fact that they followed their doctors orders.

You've also presented the situation as though all medically justified treatments are certified. The "off-label" use of prescription medication, usually obtained with the help and recommendation of the patient's physician directly contradicts this.

You've also presented the situation as though every correct answer is obtainable through cost-benefit analysis. This is naive. Patients can sometimes require third- and fourth-line therapeutic options despite what the majority of patients require; and it's the majorities that drive conclusions in cost-benefit analysis, despite what is medically justified at the tails of the distribution. Are you arguing that it's more scientific to base medical decisions on majoritarian economics than on individual patient needs?

It makes no difference whether I agree with you about an imaginary world in which all certified treatments are the best therapeutic choice for all patients and all doctors are infallible. In the real world, doctors frequently make mistakes and patients must frequently fight through courts and advocacy groups to overturn guidelines and procure real medicine that really works for their real conditions.

It should not have to be such a fight. Is my saying so ideological?

Was all that to say expertise is bad?

I'm pretty sure the average consumer would do better by consulting his doctor and making a decision than by (1) voting for a set of politicians, (2) convincing other voters to vote for the same set of politicians, (3) evaluating which set of politicians will appoint which people to run the FDA, (4) balancing those concerns with other political concerns that a person cares about, (5) and even after all that recognizing that none of that may matter because, in the end, public choice factors like regulatory capture may dominate regardless of who is elected.

I think you jumped into politics too soon.

This is at a more basic level a question of expertise, and whether it is healthy for a society to reject expertise for ameteur hour (medicine, engineering, environment, whatever).

The discussion of biotech venture capital was not highly informed. It is true that therapeutics almost never produce 100x returns. But Biotech venture can indeed make money consistently. But it's less of a unicorn-driven model.

See, e.g.,

At least I can suck a lot of cock here!

Such is America in Trump's life.

Well that was a poor showing.

For a guy who literally ran healthcare policy he is shockingly blind to ... healthcare policy. Take his comments about medical school. Medical school curricula are not controlled by the schools. It is controlled by the Liaison Committee on Medical Education (LCME) or the Commission on Osteopathic College Accreditation (COCA). Both bodies put forth "standards" which medical schools have to pass in order to be able to stamp MD (or DO) onto the graduates degrees. In theory, they just make sure things are up to code. In reality, their "suggestions" become binding code.

It is further silliness to talk about the need for a bachelor's degree and finding oneself before becoming a MD. Even in the US there are schools that do not require them. George Washington University, for instance has a combined BS/MD that is only 7 years. Across town, Howard University lets students do it in 6. Plenty of other schools do this as well, my favorite is Penn State which, from 1963 to 1980 managed the whole shebang in 5 years and from 1980 to 2015 did in six and only changed because of changes to the MCAT. How on earth you can talk about needing to shorten medical school (something I agree with), but then say a 4 year undergrad is needed is beyond me. I defy the good doctor to show me data that says Penn State, Temple and the rest actual churn out subpar physicians. And all of them meet all the criteria of domestic US physicians.

Nor is this some unique glaring obliviousness to the reality of medical education. After all this is the same man who said anyone who has conscience objections to abortion referrals should just practice another area of medicine. Okay, fine grant that all docs should refer or go into a "safe" specialty. What are those? Well there is radiology and pathology and ...? Yeah, nothing. Pediatrics explicitly covers teenagers so that's out. EM? Are you kidding me, do you know how many times we get to tell somebody the reason they have intractable vomiting is due to undesired pregnancy and morning sickness? Family or Internal (AKA the two largest)? Good luck even making it through residency without being in a position where abortion and referral might come up. OB/Gyn? Get real. Medical genetics? Worse than OB for people who do not wish to carry trisomies. Neurology? Do woman taking teratogenic anti-epileptics get pregnant and want to terminate, oh right. Psychiatry? Yeah remember those anti-epileptics, turns out most of them also are mood stabilizers. What is left? PMR? Do young female atheletes get pregnant and want referrals? Being generous you have some surgery disciplines, optho, anesthesia, and derm (oh wait, never mind, isotrenitoin failures). These, plus rads, are some of the most competitive specialties in medicine; half of MS4s are not remotely competitive for these specialties.

Given this sort of silliness I find it highly dubious that he is remotely correct about cost structures and incentives. After all, if you pay for "quality" the best option is to hire better patients. If you correct for patient quality (e.g. compliance, income, comorbidities), upcoding just got a lot more lucrative. If you cannot trust your physicians to practice medicine without padding orders to improve their personal bottom lines, how one earth can you trust them to code correctly? After all, Well's Criteria for Pulmonary Embolism (e.g. should I order a CT scan) gives 25% of its total value to my subjective clinical judgement (and another 25% is pretty subjective as well). If I want to bill an expensive test I can easily find a reasonable indication.

And this is what is silly to me. If you have no ethics, you will easily game the system. If this system is full of costly checks and hassle (e.g. deadweight loss while I sit on the phone with some insurance company), then ethical physicians lose time (and money) while the guys who hack the system make out like bandits.

I remember watching the 2013 NBA Finals six years ago and hope I will still remember them at 75.

"Rebound Bosh, back out to Allen, his three-pointer... BANG!"

Emanuel said chemo improvements have been "huge" over the past 20 years and that is completely uniformed bullshit. Immunotherapy *will* be big in the 2020s but not there yet as it has helped a tiny percentage of cancer patients as of May 2019.

There was no discussion of A.I. and diagnostics which wasn't surprising since Tyler was interviewing. Nor was it surprising that Emanuel, who also knows nothing about A.I. in medicine thinks that he can give advise to medical students out to 2035.

IBM has exited healthcare with its 'Jeopardy' playing robot.

How many times have you brayed like a jackass about that?

So much for AI.

You make a lot of sense here. After all, one computer company leaving health care does mean the end of A.I. in health care.

Great selective editing

You consciously omitted the qualifier, 'in early testing'

Many a slip between cup & lip, Todd!

Tips for young players: Don't believe everything you read about tech behemoths 'conquering' biomedicine-particularly in their own press releases.

Remember what happened to IBM!

The "in early testing" is in the quote. Being better than six radiologists looks pretty good to me.

"Tips for young players: Don't believe everything you read about tech behemoths 'conquering' biomedicine-particularly in their own press releases"

Poor Todd.

Vanity Fair?

Google's system outperformed six radiologists in detecting lung cancer. The article didn't mention anything about that A.I. system. Perhaps you sent the wrong article from the tech magazine, Vanity Fair.

May 20th: "Google unveiled an artificial intelligence system that — in early testing — demonstrated a remarkable talent for seeing through lung cancer’s disguises.

A study published in Nature Medicine reported that the algorithm, trained on 42,000 patient CT scans taken during a National Institutes of Health clinical trial, outperformed six radiologists in determining whether patients had cancer."

This was an excellent interview. Sometimes I think Cowen is too soft on his guests, but here the style really paid off. He gave Emanuel plenty of rope to hang himself with.

its very good services

If I was commissioned to increase longevity, I'd look at trying to reduce homicide and accidents, and right now opioid deaths. His methods seem wrong to me.

I might also want to look at preventing infant deaths from 1 month old to 1 year old. Maybe by sending social workers out.

I looked up this in with respect to Emanuel's claim that the advances in chemotherapy have been "huge" over the past 20 years: "We now have immunotherapies that are making dramatic changes, curing kids with incurable ALL [acute lymphoblastic leukemia], or curing people with B-cell lymphomas. "

A 2017 survey estimated that among all Americans dying from cancer, assuming they could afford immunotherapy and have access to it, only 8 percent could benefit.

"Who is to blame for the disconnect between reality and hype? All of us. Doctors, researchers, the pharmaceutical industry, reporters, patient advocates — all use sensational language to describe these drugs."

It will be "huge" seven to ten years from now

Of course, the only interesting question here is what does a libertarian kid so when he's 75 and faced with the plug he paid for all by himself or sticking around to find out if the booby-traps he set outside his freehold really work.

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