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conversations with Tyler is produced by the mercada center at George Mason University Bridging the Gap between academic ideas and real world problems learn more at arcades.in conversations withth tyler.com hello this is Tyler Cowan and I'm here
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today with Zeke Emanuel who in my view needs no introduction so let's start in on doctors do we overrate the importance of IQ for doctors oh yeah that's definitely the case so what is it we're underrating Rel we think that smarts is
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what counts but I think uh a lot more of it is emotional intelligence judgment Under Pressure uh much more important so just think about what the big challenge is for uh medicine in today the big challenge is the fact that 86 cents of
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every dollar goes for people with chronic illness that's an illness they're going to have everyday for the rest of their lives or everyday for the foreseeable future and the main thing is to get them to change their behaviors related to that and that is not about
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intelligence that is about you know relating to them and emotional intelligence and getting them and persuading them to change their behavior if not IQ what's the best predictor of emotional intelligence in a way you might find a or a LinkedIn profile I'm
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not sure actually what the best predictor is this is you know I'm not a person I would say uh I've had to cultivate my emotional intelligence it doesn't come natively to me the way it does to one of my brothers or both of my
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brothers actually but I do think the ability to understand what's going on in someone's uh person and the ability to tell you know fake from real Smiles is probably really important and you know we talk about a lot about empathy and
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empathy is one component of uh emotional intelligence but only one component of it but there are some games that you can play in collaborative looking at collaboration should doctors be made less Central in medicine if they're a group overall deficient in emotional
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intelligence so doc doc I think increasingly uh doctors are just one part of a team they are typically the captain of the team uh because they have some knowledge and insights that others don't but I they have to be one part of
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a team we recognize a lot you need chronic care coordinators you need mental health specialists you need dietitians you need pharmacists all of them have to be components of a team and the doctor is typically the captain of the team but not the only member of a
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team and I do think we tend to overrate the importance of a doctor and underrate the importance of a system around the Doctor Who in the healthc care establishment has the highest emotional intelligence H I'm not sure so I I think
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there's there are professions that tend to have high I would say actually one profession that has a very high that I've seen is when you properly select community healthcare workers not everyone has encountered a community healthcare worker but they tend to be
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people who uh want to do good are good listeners uh to other people uh good problem solvers for other people and I do think uh that's a a group when I've met them uh tend to be really high in EQ is there a shortage of physicians in the
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United States right now well if you listen to the uh Association of American medical colleges the double AMC the official body as it were there's a shortage and interestingly if you go to almost every other country they say there's a
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shortage the fact is there's no shortage at all if you calculate out and we did this crazy calculation someone said no higher math required just lots of division um if you look at the number of office visits that we have you look at
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the number of primary care doctors we have you actually be are quite generous half an hour a visit not 12 visits a day you can easily accommodate all the primary care visits we have and also all the primary care care visits we need with the current
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existing doctors it's really about how we allocate their time and it's also about using not using the office as much there are lots of things we've brought patients in for that we don't have to bring them in for to actually give them
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adequate care you can do over the phone you can do text you could have someone else a nurse practitioner even a medical assistant the front office desk person can do it and I think getting that what we're in the high futin language of task
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shifting under uh our belt we're not going to need more doctors and I I fear that once you train a doctor you know it's basically a million dollars or more depending on what kind of doctor you have of Billings that you have to do to
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care and feed for them and that's a lot of money but as you know we have medical licensing there are immigration restrictions on doctors are you saying these constraints are not binding there is some counterfactual where we would have more doctors would they just not do
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us any good yeah no I think they would drive up the cost you know medicine is a classic case of Supply induced demand doctors write orders and they need they have a certain income in mind and they will do things to get to a certain
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income and you know especially on the margins where we don't you know what's called unnecessary care or or low value care and that's a bad thing if you have too many doctors who need to get to a certain income and the demand just not there why can't I get a doctor to
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respond to my email I have a simple question I just want to know I'm stuck with Google well that I think is again we need to distinguish the the uh Workforce problem from the problem of the way it's structured and the way it's organized do
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we actually need more bodies or could we effic more efficiently organize a system the latter is the problem more efficiently organize the system and if you look at places that actually do a great job they do a very good job with
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fewer doctors and more uh of other people who do respond in a timely manner to emails and most of those questions can readily be answered without doctors's knowledge this is a current much cheaper concierge model of healthcare that's spreading rapidly is
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this the future of healthc care for at least the upper middle class in this country what do you think of it uh well I have an ambiguous so I'm not I don't think there's an in principle argument against it okay there is an argument
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against it if it undermines the care that the rest of us get if the rich buy up but there's no shortage of Physicians so it shouldn't take away exactly so I'm not in that's why I say I'm not in principle against it but why aren't you for
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it um I actually think uh the sick people ought to get concierge medicine that's the real future uh people who are at risk for serious complications serious exacerbations of the illness they're the people who need con urge medicine and again if you go around the
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country and you look at places that are really performing well super high quality quality low cost they almost all give conci urge medicine to the sick people not just to the people who can afford it and I think that's uh actually
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much more relevant to what we want so you would do that say with vouchers perhaps in some counterfactual world uh yeah there a lot of ways of doing it I don't I don't think you actually need vouchers you need to make doctors uh
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fiscally responsible or at risk as we say in the business for their patients health for the total cost of care of their patients and then they really are going to focus their attention on more sick people and yeah the rich will
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always buy out and we need to be we need to recognize that you know one or two or 3% of the population can afford Cy a medicine but 97% of us first of all can't afford it and for many of us it's just not the highest priority in our life and so we won't pay that extra
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money to get those docks how can we improve medical education cut it down make it shorter yeah why does that make it better or is it just make it cheaper no I think it will make it better so we have a lot of memorization a lot of sort
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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 uh Anatomy microbiology and the two years of clinical time in the hospital on the Ws that dates from 1910 and we haven't
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really updated it much except in this one way we've cut down the preclinical time because uh we less of it and it changes so fast by the time you learn it in medical school get out of a doctor it's out ofate A and B it's more or less
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irrelevant to managing most patients I mean learning what kind of virus HIV is or herpes virus is is it aent virus is it some Corona virus really irrelevant to Medical pract totally irrelevant why we teach it I have no idea similarly the
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kreb cycle I learned it I count it six times never use it once in practice what are we doing so just think about the future in the future future all these preclinical courses are going to be online you're going to have great teachers who are teaching online well
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what's a medical school doing other than showing you videos and we already know today a third of students show up to class two-thirds of them look at the videos of their class ready so I think increasingly we're going to go to you
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know you'll do the pre-clinical work before you get to med school and then med school is really the clinical work 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
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need more rotations more experiences for students out of the hospital no Med schools made that big shift and those are the shifts that are going to have to happen over the next 15 or so years should I need an undergraduate degree to
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go to medical school if I can pass a bunch of tests yes absolutely and because an undergraduate degree is not about skill building it's about finding and understanding yourself deeper and understanding your place in the world understanding your place in history
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understanding your place in you know the economy so you're saying I should need it or I shouldn't need it you should need it absolutely what if I know I want to be a doctor I can pass every test you throw at me absolutely it's not about
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again this goes back to the EQ IQ thing it's not about the IQ that you you keep thinking IQ here Tyler what if I pass every EQ test that you can throw at me what if I want to become a doctor Tyler there are there are outliers and maybe
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you're one of those outliers I'm not saying me personally but I don't think that is the major issue here I do think that there's a lot that you learn about yourself that is very important for being a good doctor um and being able to
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relate to patients and again this is where we overemphasize IQ as opposed to EQ I mean one of the problems I think of American Medical Training is the Premed requirements they are ridiculous absolutely ridiculous I'm in the literature saying they're ridiculous
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organic chemistry irrelevant but you need to commune with your soul before years right I think more philosophy more American history more English literature uh more psychology more behavioral economics all those and political
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science all those things would be better what if I want to become a doctor but don't want to ever have to touch a kadab should there be a path for me I just want to look at screens and do software and integrate uh Technical Systems with
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say Hospital Systems as a doctor and not get my hands dirty uh I don't probably not but I'm not 100% sure about that because there are probably areas where you don't need to the clinical side or even the insights into the clinical side one of
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the things you might say that's gone wrong with electronic health records is that they were designed by people who didn't understand the clinical interaction and I think one of the things that totally frustrates current doctors is you know these things were
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written and damn it they're have they don't integrate well into my clinical experience into seeing a patient in the office I'm on the screen too much I'm not interacting eye to eye with with patients and I think that's a result of
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people who really didn't understand the clinical world but I learned that from the dead bodies wouldn't I learn that from the live bod do I learn EQ from the dead bodies yeah it well I think you might learn something about your
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relationship to dead bodies and your relationship to death and your relationship to using a body and simply manipulating it that would be important what non-obvious advice would you give to medical students today learn I've just I think said it which is learn a
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lot of the other stuff about life and you know the preclinical stuff is not that important we put a lot of emphasis on that microbiology uh that pathopysiology learning it is important but don't overemphasize it there's a lot of other
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life that you need to really understand uh to understand American medicine and to understand your patients and provide op Optimal Care I also would say to uh medical students coming up I do think that this is probably the most ex exciting time in American Medicine in a
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century since really about 1910 1920 and it causes a lot of anxiety for people so I want to be sympathetic to that you know change is we all talk about change in America we're all for change except we don't like change we're all
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conservative we would prefer no change but I do think if you're if you can go with the change this is a super exciting time when lots of things are changing and you can have a real positive impact in shaping the future uh probably for at
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least half a c Cy we're going to put in place the structure over the next uh decade uh that's going to be in place for the next half century of American delivery without citing what is pending how much has chemotherapy improved in
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the last 20 years huge how so it's gotten uh fewer side effects we have real cures for illnesses I'll just give you one example uh but it's sort of characteristic when I started out in practice learning in 1990 I I became a oncology fellow at the Dana fiber Cancer
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Institute CML Chron iic myogenous leukemia a disease of older uh people around 60 years old there was a chronic disease sort of smoldered along as we said and then blasted off transformed into acute leukemia and within 6 months
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people died regardless of what you did you threw a lot of chemotherapy at them and they died now actually a colleague of mine from The Dana Farber uh developed a drug called gleevac basically made it a chronic illness people don't die of CML anymore they die
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of some other condition it is really a miracle cure and it's a very easy drug to take it's very expens or was very expensive when it was on patent novaris jacked up the price tremendously but that is an one example we now have
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immunotherapies that are making dramatic changes curing kids with incurable Al or curing people with bell lymphomas in the next uh year or so they're going to be treating people with Myoma with it and and probably curing them so there's a
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been a lot a lot of changes in the the chemotherapy world what's the best metric for Discerning how well the war against cancer is going I tried to Google progress against cancer and I I found it remarkably hard to find anything useful but that to me is not an
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encouraging sign and I'm good with Google you are good with Google I know that so I I would say that actually what you want to look at is uh the relationship between you want to look at 5year mortalities and the percent of
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people who have 5-year mortality but you also need to measure that by not having too much early diagnosis so one of the things we've noted is that we can diagnose a lot of cancers that would never have been a problem for people
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almost all of us have cancer cells floating around in our body our immune system takes care of it we have done a remarkable job in many things in early diagnosis but that can be bad of course that's what I was about to say what we
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know now with prostate cancer we're taking out a lot of prostates people are getting side effects impotence incontinence and yet we're not actually having a big impact on mortality so you need to look at the impact on mortality
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overall and the 5-year mortality ranking the percent of people who have a 5-year mortality controlled for stage of disease that's a hard metric to come by for a non- oncologist to see so we've done for example a remarkably good job of early diagnosis of breast cancer
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5year survival of breast cancer in the United States is the highest in the world but a lot of that probably is due to early diagnosis of small cancer that wouldn't have made any difference to the woman anyway we have actually not had
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that big an impact on larger cancers and so what you see is a the overall mortality from breast cancer hasn't really changed so you need to look at the overall mortality in the population now Michael Webb from Stanford measures that in medicine we're throwing more and
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more inputs at these problems and life expectancy is only going up at a constant rate and the last three years it's down a tiny bit yeah so what's gone wrong with either the medical establishment the scientific establishment somewhere right something
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is Val get your expectations right you shouldn't expect the medical establishment to have that big an impact on life expectancy so it is a reasonable metric but if you really want to affect life expectancy and by the way I'm not a
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big uh proponent of using that as a metric for all sorts of reasons we should invest in education better housing more equal incomes for people not invest 3.5 trillion in the Healthcare System the healthare system by and large has come you know at the
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end people already have diabetes that's not the best place uh most cost-effective place to invest and we know that probably the opportunity cost of overinvestigation housing and other things in society and so it's not a surprise that we're
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spending a lot of money and the returns are down it's it's not because Japan spends a lot of money that they have an average life expectancy of whatever 84 years uh the highest in the industrial world now bium medical ethics are you
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have in addition to your medical degree you have a PhD in political philosophy from Harvard right yes what do you study to get that is it in the philosophy Department yeah I did a lot of philosophy uh I did a lot of political theory in the government of Harvard's
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political science department is called government uh yeah those are the two things I also did some law training so your ideas on biomedic ethics Ian where would you say they come from is it that you read people like say Daniel Callahan
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and Norman Daniels and they persuade you or you're an intuitionist or you read people like John RWS that are highly abstract or it comes from Plato and Socrates but what connects your views on concrete issues of biomedic ethics and philosophy what's the transmission Bill
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whoa I don't know that anyone's actually asked me that question and I think it's pretty complicated what I I don't think it's a a linear process but it's no accident that you studied both right no it isn't an accident and I did actually
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do read all those people I read a lot of John RS in contemporary ethesis I read a lot of sort of biomedical ethicists like Norm Daniels and Dan Kahan um I would say that uh uh in general what I try to do is intuitively figure out what the
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right answer is and to a situation and then figure out what are the principles that got me to that right answer and what are what are we trying to do I I would say that so this is a biographical statement about the way I do it in
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general when there's a uh conventional wisdom about a problem I usually find that wrong and I spent most of my career like oh that's the conventional wisdom it must be wrong here's the right answer and here's why it's the right answer and
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the conventional wisdom is wrong and typically one of the problems I think with the conventional wisdom is that they overemphasize one set of values and tend to underemphasize other values that are important and I'll give you an
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example for I think most of our uh discussions uh we have overemphasized individual autonomy uh certainly since I've been working in this area for the since the mid 80s it's autonomy autonomy autonomy and that sort of disengages people in two ways one it sort of
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removes people from their social network whether it's family community religious orientation and I think that that's just wrong emphasizing the individual has consequences for other people and the second thing is it sort of ignores the
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economic political realities that some choices for individuals will have big economic or consequences uh political consequences for other people that we need to take account of uh spending a lot of money on one person definitely means we're not spending it on other
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people and we have to take that into giving one person an organ means someone else won't get an organ and we need to take that into account so part of what I have I I think a lot of what my work has been is the values that we emphasize
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tend to be exaggerated and probably inadequate to describe the situation and we typically need to put in more values so once we have lots of values in the pot as it were we tend to be really bad about prioritizing them and I think I
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tend to be one person who says you know here's the constellation of values and here's how you should prioritize them not everyone agrees with me a lot of the time but I do think I'm try to bring in more uh subtle values and widen the way
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we think about uh issues does the notion of informed consent have real meaning in low trust societies won't people read the osed agreement and assume the real conditions of the experiment actually have to be something else because they're used to being screwed over or
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the actual deal being different from the stated deal I think you that's a excellent observation and we way overemphasize informed consent as a protection of people I think that's very common in American society just give people information and they'll decide
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well I don't have enough time to get information on everything I have to do I have to trust uh lots of Institutions I have to trust the regulatory oversight bodies that are making sure the airplanes are working I can't go out and
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inspect the plane every time I take off and things like that and I agree with you in low trust Societies or societies where there aren't good uh institutions relying on individuals is no substitute for relying on uh institutions to
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protect us and I have often said that you know it's very hard for an individual to figure out the risk benefit ratio of a say a research experiment uh or any medical procedure uh and that you need to rely on others with expertise and I think one of our
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problems at the moment is we're way over on let's give in people information and they'll decide no doesn't work that way information overload lots of us have inertia and we have a hard time I I will tell you I read Financial uh information
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about my stocks or my bank account or my credit cards and my eyes glaze over I I'm very bad at it it's I'm not protecting myself I need someone else to protect me do we need to fix irbs uh yes when I was in the um in the White House
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one of the things I did was uh we had regulations governing research uh biomedical research uh they had not been revised in decades and they were certainly Antiquated and out of date and I initiated and led a process of revising the regulations um I would but
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institutional review boards should they have less power or more power uh they should have different powers and they should emphasize different things one of the problems is you go to an IRB and they or you know they entire almost
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entire FOC almost entire focus on what's in the informed consent document that's wrong and we have I've written extensively about there's an orderly process for thinking about the ethics of of research and informed consent is at
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the bottom of the process there are many things you need to consider and I think the number one thing that needs to be considered is really uh risk benefit ratio of a research protocol it's the hardest thing for IND individuals to
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understand who aren't experts and it's really where the focus should be and if you put the focus on risks and benefits some things that irbs often object to may turn out not to be really that problematic and some things that irbs
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don't object to enough they turn out to be really problematic and so I think more emphasis on risk benefit ratio and less emphasis on informed consent and certainly no responsibility for the IRB in terms of confidentiality that's someone else's you know some mother
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arrangement I think that's very important also we shouldn't have irbs at each institution I think the whole notion of IRB institutional review board is a mistake if there's a protocol that's being run at hundreds of Institutions which is quite common we
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should not have each institution reviewing it it's the same risk benefit ratio it's the same group of people one body can interview it and that's much more efficient and uh efficiency is also important because delaying protocols by
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a year waste a lot of money time um and for no benefit 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 it's my body but why don't you like it is the right to selfdefense
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if someone attacks you yeah you're already talking about you're talking about we need a high trust Society where we can really rely on things and that and and uh so we don't have to examine individually every time every item even
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to make the informed consent process go well and then you say let's get the FDA out of here uh because uh I should be able to do whatever the hell I want with my body uh wrong uh we all need to rely on the fact that the medicines we take
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are proven safe and proven effective and we have to have institutional structures to over see that 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
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we're taking as 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 um you want to do it damn us all you've got enough money you know go to Tahiti it
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it's really not this institutional structure we want and we know that because the lamide lots of drugs that have unfortunately I think the FDA has swung to approving drugs that have uh risks and either low or in some cases they've even approved drugs with no
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benefits and I think that's a mistake uh we have to yet to uh better approval we have created a process of compassionate use where people where if if a Drug's been proven relatively safe not uh completely safe relatively safe patients
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can uh solicit to get it um without uh I think before it's been finally approved I don't actually I'm not a big fan of that if someone starts shooting at me with a gun maybe it is better for everyone if I simply duck but do I have a right to shoot back or to try to
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charge them and get the gun away from them and possibly create more public violence uh I guess you do have that right but what's the difference but because it's the possibly more violence and in the case of drugs that is a lot more violence and and bad things that
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are going to happen and we've seen that and I'm I do not want to go back to snake oil salesman where everyone's got a concoction and we have seen in the case of uh nutritional supplements that uh thank and this is sarcastic to the
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Utah delegation where a lot of nutritional supplements are made that they removed FDA oversight there's been a lot of deaths on nutrition supplements when they don't regulate them and I don't think that's a good thing the first you can't tell what's in those
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nutritional supplements and they're often adulterated and that's not a good place to be the first piece of yours I can find was published in descent in 1984 the ethics of splicing life now to fast forward to the current day what are
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your views about genetic engineering of the Next Generation if we could do it more efficaciously than is currently the case but possibly that is coming to what extent should we regulate voluntary parental choices if any uh again this goes back to I think
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emphasiz you know typically it's it's a parental choice we we uh permit parents to have lots of choices over their kids but having a few people make choices inevitably affects all the rest of us in all sorts of ways and I don't think this
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is a way I do think this is a very good place to draw a line and I don't think we've had a very good National educated National discussion about it would mean to enhance children or not enhance children and I think we have to have
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that kind of discussion before we go forward I'm no big fan of it in part because I don't think we're wise enough to figure out what's good and we are very likely to overemphasize the wrong thing as I said we tend to overemphasize
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certain values and ignore other values we do this individually and we do this collectively um and so I'm not a big fan what's the most we've gotten here we've gotten here over you know millions of years of evolution now it we have been a
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Val for certain environments which we don't necessarily have today but I'm not sure we're wiser than Evolution what's the most likely bias and parental choices the kids will be too tall they'll be too conformist they'll be too Charming well uh no they'll be
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overemphasize IQ they'll uh overemphasize physical prowess uh we already have that you know what what's the biggest thing in your high in kids high school right Sports right is that really the thing that ought to be the most important thing in a high school no
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we tend to celebrate in the United States Sports I remember going to Africa for the first time and happen to uh be in a a country where uh the national exams they had National exams were done the whole first six pages of the paper
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were the people who did really well on National exams go and try to figure out some American town where that's you know they're going to list on page one the top 10 kids in all the local high schools we don't do that we do you know
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Friday Night Lights and football games instead so that's what we emphasize is that what we really want with genetic engineering you're going to be better football players seems to me we tend to uh make a lot of mistakes we're not
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necessarily the West judge I'll give you another good example just go to any airport go any place where people collect with kids and watch right the American Academy of Pediatrics there's almost no one who thinks a lot of screen
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time is especially for young kids is a good thing what do you see throughout these places lots of screen time for young kids why it's easy for parents right don't have to interact with their kids they can be on their own cell phones right blah blah blah it's a
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terrible way to raise our kids and some parents doing it voluntarily affects all of us we've got behavior problems in class we have uh different ways of uh learning that are probably aren't good imagination is curtailed that way and
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yet it's voluntary Choice it's not very well thought out people uh do it uh cuz it's easy rather than thoughtful so your voluntary Choice uh that has locks lots of I guess the since I'm talking to an economist lots of externalities for the
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rest of us that we tend to downplay doesn't seem to me to be a wise choice so I'm probably sticking by that 1984 article that's pretty good right 35 years same view yes if you could do it with a healthy body would you find immortality boring forget about the
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social ramification why boring you're curious is doing something well the shadow value of more time seems to always be positive for you I I agree the shadow value of more time on the other hand I do think we get a and and I am a
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person who tries to do something pretty radically new every year about four years ago I made us this PL more than that five years ago I made this pledge that every year I tried to do something really out of the box for myself so I
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was a chef I've made chocolates I've taken up pretty uh uh not terribly long distance but uh very serious bicycle riding but nonetheless I do think our brains and again this is a general comment there are some outliers you know we there's natur natural selection among
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our neurons the parts we use over and over again get very well done the parts we don't use tend to die off and it's very hard to keep that plasticity uh over time um and to do new things and to be new and curious if you look at the
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number of people who are creative after 75 who do new things after 75 and really new things it's very small and I think that there's a neurological reason for that it's not just the physical body it's also the brain and the ability to
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uh think new things be creative uh and not just be ho home uh even so I'm in the midst of doing a lot of reading about Benjamin Franklin one of the probably the most creative person born on the North American continent in the 450 years we've been around constantly
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new and yet if you look past 75 slows down yes he does do his autobiography in his 80s and stuff but he even he recognizes that the mental abilities the ability to focus in on science and make new discoveries went way down so it's
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very hard for us so I think yes we could do new things have new experiences but would we be new and creative I doubt it and you've written a much misunderstood article about how hard you would try yourself to live past the age of
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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 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
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out so isn't there always something and then it's a 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 Tyler I
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think you're exactly right that's why people do hang on it's because you know so I talked to my father who uh you know he says Zeke you're absolutely right I've become slower physically slower mentally slower you know my life what ends up happening is your life cones
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down and you begin to overvalue certain small things like the NBA Finals like what's in the Mueller report n they're not all you know we all know from any Cosmic standpoint even even not a cosmic standpoint just a 2000 foot standpoint
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most of those things are not irrelevant it's really cool to know you often ask you know this happens to me all the time I I teach undergraduates pretty smart undergraduates very smart undergraduates MBA students nurses doctors right they have no understanding
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of History so whoever finishes in the NBA final in five years people forgotten you know you ask people I ask Richard Nixon they have the vaguest memory tricky dick they can't really tell you very much even Ronald re even Bill
34:57
Clinton you know much less you ask them Bill Russell no idea who Bill Russell is Oscar Robertson no idea who Oscar Robertson is these were my heroes I mean these are like phenomenal basket the people who made Modern basketball no idea so this idea you're absolutely
35:15
right we cone down lower and lower the parts of what will make us satisfied um and we have to step back and realize those are pretty trivial the NBA Finals the Final Four Tyler who was in the final four five years ago I don't follow
35:29
college basketball they don't play very well theate what's wrong with what's wrong with the importance of drama we rever Shakespeare as perhaps the smartest human ever even if I will forget drama why why is that Tyler we review Revere Shakespeare not because of
35:44
the drama just sitting there in the drama because he makes us think about the bigger things in life and the kinds of characters we want to be and the kinds of characters we don't want to be that's the point but you know if you're
35:56
at 80 there's no more character building your character set you're not changing your character at 80 who changes her character at 80 accidents aside what is the probability we will be capable of creating Immortal humans in The Next Century in The Next Century I don't are
36:14
your friends who believe it's if not likely plausibly possible I do think it's probably plausibly possible I think we're going to figure out what elements are for uh immortality now whether that's good immortality in the sense
36:26
that the body's going to be able to work well you know my brother who is not a doctor but a Hollywood agent had a very insightful comment to me recently is like you know we're going to be able to replace my heart my lungs everything but
36:41
damn it that cartilage you know my back pain can't you doctors cure back pain the common cold you can't do any of this simple stuff and so living a long time with a lot of back pain that just doesn't seem like a great life in the
36:55
middle of all of these discussions we have a segment called underrated versus overrated and I'm going to toss out some names and ideas and you tell me if you think they're underrated or overrated probably won't even know who they are well let's try it Joseph Warren oh
37:08
totally underrated you you do know you you've read a lot to so no one who's listening to this podcast knows who Joseph Warren is I'm willing I'm willing to bet that that's the whole point yes so he he was critical to the revolution
37:23
he's the guy who actually organized Paul River's ride he's the guy who organized a lot of the Revolt in Boston now Sam Adams gets a lot of attention and Sam Adams was a Rabel Rouser but Joseph Wen was the guy who organized it all who
37:37
made it coherent who had an objective he was president or head of almost every one of those committees that they established the Committee of Correspondence this and that and he unfortunately was prematurely he should not have done this he ran to the Battle
37:51
of Bunker Hill when it was in process exercised his right of self-defense right and got they uned to death yes and we only knew that he died because of a tooth uh they identified him through his teeth he he very well might have been
38:06
president certainly would have been a leading person even if not elected to a political office in the early days and everyone for the first hundred years after he died everyone knew about him Warren West Virginia or something you
38:18
know lots of towns are named after him Boston used used to be 20 30 years ago used to be taught about him all the time way underrated he needs a great biography that's my retirement Alis Norway the town the area oh fantastic for kayaking uh I've kayak
38:38
there I love it uh it is one of the great places although not the best places in Norway for food so but there's a good restaurant in town the fanciest hotel in town has good food I agree but it's but it's it's a pretty small town
38:53
what you go to alisand for is the kayaking Ara around it and the beauty around it surprising to me it's not more heavily touristed so I think it's highly underrated it's not that far away I agree with you Madagascar uh probably uh
39:06
overrated is an exotic place so I went I went there it's not that uh I I was not impressed that beautiful a lot of the Lemur is interesting to watch them but you can see much better wildlife in many other parts of Africa the uh infrastructure I mean just the life of
39:25
people that very warm but I've been to many other parts of Africa that I would rate way over it places that are not um necessarily uh highly recognized like Mali I found one of the most amazing places uh people are incredibly warm mud
39:43
mosques that you can see the Doone Villages that are just truly amazing uh lots of cultural residents that you just don't find in uh Madagascar travel as a way of understanding the world probably underrated ought to be overrated I would
39:58
say so I grew up in the 60s and my father who grew up in Israel and then went to Switzerland to uh for medical school always thought travel was great we were not very rich when we grew up uh he was a a struggling newly immigrated doctor to the United States but my
40:16
father saved all sorts of money we would we had holy pants we used to go to school and holy pants before holy pants were fashionable but he would save money for international travel in the' 60s most of our rich friends they went to
40:29
Florida but we would go and very cheap trips to Europe very cheap trips to Israel because he always thought going and experiencing other cultures increases your empathy increases your understanding of the complexity of the world different cultures um it's very
40:44
important to do not important to go to the heavily touristed Paris London but I think other places like Alison is definitely well worth it benser Waller overrated or underrated so no one knows who Spencer Waller is Spencer Waller was my bet Noir during
41:02
school he's a great friend during my first five grades of school at an EMT in Chicago but he always so if I gotta be Spencer gotta be plus or an A minus if I got an A Spencer got an A+ and he kept me running he was a great kid he's now
41:19
actually a health law professor at Lola um so it's always good to have a Spencer Waller in your life pre- range children the idea overrated or underrated I actually am not a big Freer range children fan I think it's overrated I
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think children need limits children need restrictions uh they do need certain kinds of Freedom uh within limits to be creative but I think the entire idea of free range children probably overrated but you were a Freer range kid yes my
41:47
parents which is what I tried to do had a very good uh combination of free range let the kids out but also very good limits we knew what was right and what was wrong we knew that we had to defend what was right and what was wrong and we
42:00
had a lot of restrictions on what we could do and could not do but we were uh also given a lot of responsibility and allowed to explore and allowed to make mistakes so I wouldn't have called our raising free range actually so maybe I'm
42:16
misunderstanding your notion but I think limits kids like limits they like to know what the limits are and I think having limits you can you have freedom within limits so I'll just give you an indication of what we did for my kids which is your room Your Castle you want
42:32
it piggy you can have it piggy that's fine by me I'm not common space you have to keep it clean because it's common with everyone else and you're living with other people I don't consider that free range I consider that here are the
42:43
limits and here's you have freedom Within These limits if you would decide a favorite movie what would it be my favorite movie yes there's only one let's hear it Some Like It Hot it's a fantastic movie from the from 59 black and white it's great comedy got Marilyn
42:59
Monroe in it it's got this fantastic element of you know crossdressing transgender homosexuality in it 1959 perfectly accepted it's an amazing movie and it's so funny it's fan it's great there are many other great movies don't
43:17
get me wrong but if I had if Str stranded on a desert island a movie I could see over and over again some L it hot is there a truly good movie about Healthcare not that know oh well maybe Mash I like mash I don't know if that's a truly good
43:32
movie about healthc care it's about a lot of things but it's got a healthcare component let's put it that way pf's hospital or Lorenzo's Oil or oh I don't like Lorenzo's Oil at all few questions about Healthcare policy as you may know
43:45
there's a recent study by Frank lenberg at Columbia and he argues that by using pharmaceutical at a cost of less than $33,000 a year you can add on an expected year of life life to to humans does this mean we're not spending enough
43:59
on Pharmaceuticals no I think we're spending way too much on Pharmaceuticals 3,000 $3,000 a year is a lot of money so I would pay $3,000 a year but you have a lot of money Tyler you're rich even as a student I would have paid 3K a year to
44:12
spay I don't know most students can't afford 3K a year and I think that's a and a year of Life remember so there are two problems here what's the right amount to spend on drugs and that extra year of life when you're 80 going to 81 is that really that b valuable to you
44:26
you know it's if I got that extra year if I had you know instead of 10 years in my 30s if I had 11 years in my 30s that's a different story and $3,000 so the average I think you have to put it in context so part of my thinking is you
44:40
have to put in context into someone's entire life and how much money they have in their entire life the average person American with a ba average male with a ba women make less but the average male with a ba their entire lifetime earnings
44:53
about $2.2 million now 3,00 ,000 a year for 70 years about $200,000 so it's 10% of all their lifetime earnings for an extra year that just doesn't seem to me to be a good ratio so it's one extra year that's 1 over 80 that's 1.2% of a life uh of your
45:12
life for 10% of your dollars that's not a good ratio there are many other things you could spend it on he's not saying you need to spend $3,000 a year he's saying an expenditure of $33,000 in expected value adds on a life year yeah
45:27
a one time expenditure it's not a one time per year I thought you said no no one time in his calculations I don't think there's any drug I can think of where $3,000 would give you a guaranteed one year I don't understand that then are there too many Hospital mergers
45:42
absolutely should we stop them or are they needed to keep hospitals in business no stop them antitrust yeah we need more antitrust enforcement absolutely and uh if we're not going to get the antitrust enforcement we need to
45:54
put a cap on what hospitals can charge private insurance right now if hospitals create local monopolies uh where local can be pretty big they can take a lot of money from private insurers uh who have to negotiate with them and have to keep
46:08
them in their network if they've got a local Monopoly and that drives up the cost for all of us so capping that how much they can charge uh if we cannot get uh effective antitrust is really important why aren't insurers better at bargaining down healthcare costs
46:21
including with hospitals many reasons one reason is they typically make money on the percentage of transactions they do so that's an incentive to actually increase cost second they typically have a small market share in any particular
46:36
region and that undermines their bargaining power in that region third a lot of employers want different kinds of benefit packages and that actually again undermines their ability to uh negotiate hard most big employers want to satisfy
46:53
their workers you know human resource department ments their number one obligation is typically not to keep healthcare costs down but to keep fetching down keep down the complaints of workers the easiest way to do that is have a wide network of hospitals wide
47:06
network of doctors that drives costs up and handcuffs the insurer in terms of their negotiating power nonetheless I think they could do better than they are doing and I do think over the next few years you're going to see them do better
47:19
and one major reason is that employers have said basically enough is enough now cost is at our limit and we want you to be better about cost control and I think that's risen to number one as opposed to just rhetorically number one I think
47:32
actually it's risen pretty much to number one do we in fact need malpractice reform oh I think we do need malpractice reform it the small thing big thing exaggerated by conservatives or how do you view it I think it's smaller than the doc say and smaller
47:47
than a lot of conservatives say we know that it's not going to lower Healthcare cost but it's important first it doesn't serve anyone's interests except the plaintiff lawyers it doesn't serve the interest of patients it doesn't serve
47:58
the interest of doctors it doesn't serve interest of the Health Care system and it's too easy an excuse for doctors in the Health Care system to blame malpractice for not doing the right thing and I think uh changing malpractice reform would be effective I
48:14
don't like the general conservative approach which is limit the length of time people can file suits limit the amount that people can get for uh non-economic damages those turn out not to be good reforms I do think moving to
48:28
things like either safe harbors where if a doctor followed the protocols they are presumed that's a rebuttable presumption to not be guilty or have uh what they pioneered at the University of Michigan just say you're sorry identify problems
48:43
uh offer a standard payment back for identified problems that are admitted to be uh problems people can still Sue but it leads to much quicker resolution and much more focus on improving the quality of the system as opposed to hiding
48:56
problems how good is the Singaporean Healthcare System I'm not an expert in the Singaporean Healthcare System but what you can do in Singapore with 4 million people in an authoritarian regime is not what you can do in the United States with 325 million people um
49:09
they do lots of things differently than we do that we could never import I one of the things I like that they do that we could never get here is they pay their government officials a lot of money because they want the absolute
49:20
best people in government they don't denigrate their government the way we tend to denigrate our government and regulation uh and that's one reason we probably will never get the Singaporean system and I'm not even sure it's worth
49:31
studying that carefully for how to import it here how well can Venture Capital work for biotech and here's my worry it's really hard to pick winners in advance and to the extent Venture Capital works it's because your winners are really big that they're rapidly
49:45
scalable their marketing expenses are not too high there's not a 10-year approval process to put you know Facebook or Uber on the market things just happen so here you have a biotech sector where so often you have a Salesforce you need legal and Regulatory
50:01
expertise it seems no easier to pick winners so why be optimistic about venture capital in this space I'm not you're not no I'm not wildly optimistic about venture capital in the biotech space I'm wildly optimistic about
50:12
venture capital in the uh non biotech non device space where for instance well I I work for a venture capital firm uh Oak hcft and we are investing we've made lots of Investments uh and actually I think catalyzed areas that have long
50:30
been ignored by the Health Care System Primary Care Mental Health Care end of Life Care social determinance of Health the medical system has long ignored those and we have invested in small companies that we're hoping are going to
50:44
transform these areas and develop solutions that are scalable Beyond them but are those rapidly scalable or you think you're quite good at picking winners no I don't know that we're quite well I I am surprised by how wise uh the
50:58
people who've been doing this for a long time are and we tend to have a longer investment Horizon uh 10 years is is the length of uh what our investment Horizon typically and so we do a lot of incubating of of firms and I do think once we've proven things we've proven
51:15
models can improve uh bigger companies come in and want to uh adopt those in scal them and I do you know I do think generating these new ideas getting really smart people to come into this space has actually dramatically improved
51:31
ideas again in what had traditionally been backwaters but we are now recognizing are critical for improving the healthc care delivery system why doesn't Aspen Colorado have any good restaurant and is that still true so uh like you Tyler I I like food
51:48
and I like good restaurants and I am always surprised by the fact that Aspen Colorado uh which has you know the richest people in the world coming there uh the restaurants are not the best in the country you blame the demand side or
52:03
the supply side I think it's it's got to be the supply side because it can't be the demand side because there's more money than God in Aspen Colorado and I suspect that the problem is can it be the taste on the demand side so the wealthy people in Aspen tend to be older
52:19
they don't have a wide diversity of dining experiences in every regard well what I what I suspect is that it's the cost of rents and the cost of the fact that it's not 12 months a year but I have often been surprised by uh the fact
52:33
that there are various places in the country high concentrations of wealth where there aren't great restaurants Silicon Valley is a very good example San Francisco's got great restaurants but Silicon Valley itself where there's gazillion dollars sitting there not
52:46
great restaurants but the Indian food and Mountain View is pretty good I would say but mostly I agree so I think it's always surprised me h h i mean Washington DC is another place where the great ethnic restaurants are not in DC
52:59
and you have to ask yourself why aren't they in DC DC is filled with young people who love ethnic restaurants and it's got to be something like the rents so I you know I'm not an expert on the business side of food but it is peculiar
53:12
that you go to many interesting places that have a lot of uh people with money and yet you get a lot of places that have Bland or not very adventurous food what's the best country in the world for sampling Jam the best country in the world for sampling the best place yes I
53:28
have my own nomination oh really mine's azaran but what's yours I've never been to aeran so I as a jam fan you must go I will go um I actually think that there are a lot of great homemade jams it's funny this morning we were eating Jam
53:43
that we had brought back from San Francisco uh from The fery Building farmers market it was outrageously expensive Jam like $17 a jar phenomenally good apricot Jam um I like to make jams this year we're sort of uh I think our goal is to try to get
54:02
apricots to make jam we hope it's a good apricot season and blackberries I have not made blackberry jam yet I have made a very good uh raspberry jam and I like that a lot uh but we're going to try uh blackberries and apricots this year it's
54:15
a lot of fun by the way it's also a good thing to do with kids okay what's the most important tip for buying the best dark chocolate well you so the most important tip is you need to get something between 70 and the high 7s I
54:29
would not go into the 80s and above it's typically too much chocolate the second thing is make sure you have try to make sure if you can to get creyo beans and then make sure you've got the beans from the right country and I also think that
54:42
there are a series of Manufacturers I won't name all the great ones that really have phenomenal consistently make phenomenal uh chocolate my the place the guy I do my chocolate with Sean asheni asheni chocolate I think is fantastic
54:56
consistently a fruition in uh the Hudson Valley makes uh husband and wife team make great chocolate uh Rogue in out of Massachusetts I really love uh his chocolates there's a guy named um why am I blinking on it uh dick uh he's from Eureka California dick Taylor great
55:16
chocolates most of these are very small manufacturers and what they do is they Source their own beans or make sure that their beans are really uh good so we're now my next chocolate which I'm going to make in May we're sourcing out of uh uh
55:30
Ecuador we're getting only crioyo beans should be a phenomenally good chocolate and what's the most important tip for making the best dark chocolate well there which you can now do right what I can now do there are two key steps in
55:44
the flavor of dark chocolate one is the fermenting process that happens at the farm uh and there's no substitute for going to the farms and seeing how they ferment and making sure that they ferment and dry the the uh cacao beans
55:56
well and then it's all in the roasting light coffee uh lighter roast rather than darker roast if you someone advertises dark roast coffee you know they burnt it to hell and uh it's probably not great you know the the new I think recognition is a lot more
56:10
volatiles volatile Organics are critical for Great Taste and that's the same thing in chocolate so when I made my chocolate we roasted for about 7 Minutes uh 7 minutes and 40 seconds um and that really allowed a very bold start a very
56:25
long tale which is what I try to get in my chocolates very last section of this chat is all about you oh no but easy questions what's the smartest thing your parents did bringing you up having two brothers having two brothers I think actually uh having
56:42
Brothers Living with the brothers we slept in the same room for the first 10 years of my life really really important lots of negotiation lots of challenge lots of competition but also lots of friendship you know I talk to my brothers three four times a week talk to
56:59
my younger brother yesterday I talk to my middle brother Ram uh the day before uh we trade back book recommendations we trade back we spend some vacations together uh we're we're planning a big vacation to Antarctica so it yeah having
57:14
Brothers is probably the smartest choice they made to taking ballet lessons as a kid help you any I'm sure it did but I hated them and although I can still do all the i s uh ironically enough but it also I mean look what did it do uh my
57:30
parents were very good about raising us and having us know what was right and defend what was right even if the majority of people were against us and so we would be made fun of because we were took ballet lessons but we defended
57:45
that and we defended ourselves and I think that idea that you didn't have to go with the flow if there's anything that characterizes my brothers and myself it's we don't go with conventional wisdom uh we make our own judgment and we defend that you have an
57:58
activist side similar to your mother's yes it is true I think uh all of us learned from my mother that and from my father that part of our role in in life is to do good sometimes you do good on an individual basis I think my father
58:14
was very much that you know he's not a guy who does big policy issues he did good uh you know a family that had uh the the fourth child who came to him was free every kid after three was free because you know he knew it was a burden
58:29
to charge them um but he did good on a local level my mom tended to do be more of a community organizer and uh interested in public policy and I think that's rubbed off certainly on me and you know part of the job in this world
58:42
is to make it better and the easiest way to make it better for more people is through public policy 2009 to the New York Times you said I quote I don't have a car I don't have a TV don't have a house I do however have four cell phones
58:54
so go figure is this sufficient or is this was that a temporary State of Affairs that was no I I still don't have a car and I you know ride a bike and take public transportation I do now have a house uh I love a h i love houses I love renovating houses uh I have one
59:12
cell phone uh because I don't work for the government don't need multiple person and it's a personal cell phone so no one can complain I'm using you know public or or even University funds on on other things but I I so I tend on a
59:27
personal level to have an aesthetic element I don't have fancy clothes I don't you know have a lot of fancy furniture and stuff uh but I do Splurge uh on experiences because uh I think having good experiences and interesting experiences are what create a rich life
59:43
they're more memorable uh I like the experience of eating food I like the experience of meeting people so uh that's where I spend my money so you will not find me with a lot of material uh items uh but you will find me me trying to get a lot of interesting
59:56
experiences and finally what is it you wish to do next including your next book but not only what what do I wish to to do next that you can plausibly expect to do next well so uh yeah I am finishing a book uh hopefully it'll be done in the
1:00:10
next 10 weeks uh I would say that there are two things that I would really like to do one is we're uh working with a lot of players in the healthcare system to try to transform various parts of the healthcare system to dramatically
1:00:22
increase the quality uh I'm super excited about that we're trying to work on uh getting the drug choices better so that they're cheaper for people we're trying to uh get Primary Care better by paying doctors differently so that they'll think about the total cost of
1:00:38
care they're also dramatically improved quality so that's a super we're launching a venture on that that's a super exciting uh part of my sort of academic uh life the other thing is uh I'd like to get back into government
1:00:50
again one of the great things I think is that uh changing government policy has a big impact I think there are a number of things the government can do to actually improve the American healthare system and one of the reasons I really focus on
1:01:04
the American healthare system is if we can really bring down costs we can create have money to spend on other things whether it's individually whether it's as a society and governments and I think there are lots of lwh hanging
1:01:17
fruit in that direction regulating drug prices is but one area as I mentioned limiting what hospital can charge uh so that uh they don't get too much money out of the Healthcare Systems another way transforming how doctors are paid also will uh uh we've got some good
1:01:34
evidence can transform and uh how they deliver care the quality of care and reduce costs and so uh that's a second thing I would love to get back into zek Emanuel thank you very much this has been great Tyler thank you thanks for listening to
1:01:50
conversations with Tyler you can subscribe to the podcast in iTunes Stitcher or your favorite podcast app and if you like this podcast please consider rating it on iTunes and leaving a review this helps other people find the [Music] show