00:00:02.333 --> 00:00:04.267
- We have this idea
in this country

00:00:04.300 --> 00:00:05.933
that when it comes
to health care,

00:00:05.967 --> 00:00:07.933
more is better.

00:00:07.967 --> 00:00:09.433
You can\'t be too thin
or too rich,

00:00:09.467 --> 00:00:11.600
and you can\'t
get enough health care.

00:00:11.633 --> 00:00:14.067
- You know, we all
come to a similar conclusion

00:00:14.100 --> 00:00:16.233
that about 30%
of U.S. health care spending

00:00:16.267 --> 00:00:18.700
is devoted
to unnecessary services.

00:00:18.733 --> 00:00:21.933
And that\'s, you know,
$800 billion a year.

00:00:21.967 --> 00:00:24.133
- You don\'t have
a significant blockage.

00:00:24.167 --> 00:00:27.267
- You have to remember
that one person\'s waste

00:00:27.300 --> 00:00:30.133
is nearly always
another person\'s income.

00:00:30.167 --> 00:00:36.000
And income turns into
strong political defenses.

00:00:36.033 --> 00:00:38.433
I have areas
that are classic waste.

00:00:38.467 --> 00:00:42.367
- We spend 2 1/2 times more
per capita

00:00:42.400 --> 00:00:45.800
than the average
Western European country spends.

00:00:45.833 --> 00:00:47.033
- Sending.

00:00:47.067 --> 00:00:48.800
- But the part
that I\'m most worried about

00:00:48.833 --> 00:00:51.967
is the waste
that actually hurts patients.

00:00:52.000 --> 00:00:55.667
- I was ready to have a stent
put in when I stopped \'em.

00:00:55.700 --> 00:00:58.100
- I see it everyday
in real human beings

00:00:58.133 --> 00:01:01.200
who get enormous amounts
of unnecessary testing

00:01:01.233 --> 00:01:03.233
and enormous amounts
of unnecessary treatment.

00:01:03.267 --> 00:01:04.967
And then the irony, of course,

00:01:05.000 --> 00:01:07.000
is that when we look
at the health Olympics

00:01:07.033 --> 00:01:11.400
and how we come out in the world
in terms of health outcomes,

00:01:11.433 --> 00:01:13.133
we end up doing terribly.

00:01:13.167 --> 00:01:14.900
You know,
we\'re just below Slovenia

00:01:14.933 --> 00:01:17.400
or next to Costa Rica.

00:01:17.433 --> 00:01:19.200
- When we spend more,

00:01:19.233 --> 00:01:22.467
the outcomes
are oftentimes worse.

00:01:22.500 --> 00:01:24.333
How can that be?

00:01:24.367 --> 00:01:27.667
- Life is so unfair.

00:01:27.700 --> 00:01:29.700
- Everything we do
in health care

00:01:29.733 --> 00:01:31.867
is innately dangerous.

00:01:31.900 --> 00:01:34.200
It\'s sometimes
extremely difficult

00:01:34.233 --> 00:01:36.933
to walk that thin line
between help and harm.

00:01:36.967 --> 00:01:39.233
And you step over it
fairly routinely.

00:01:39.267 --> 00:01:41.033
- I got a phone call

00:01:41.067 --> 00:01:43.667
that confirmed
that I had cancer.

00:01:43.700 --> 00:01:44.933
And I said,

00:01:44.967 --> 00:01:47.633
\"Life as we have known it
is over.\"

00:01:49.533 --> 00:01:53.300
- If you add up medical errors,
drug interactions,

00:01:53.333 --> 00:01:55.433
and hospital-acquired
infections,

00:01:55.467 --> 00:01:57.667
medicine itself
is the third leading cause

00:01:57.700 --> 00:02:00.300
of death in this country.

00:02:00.333 --> 00:02:04.033
- Of course I don\'t want to die.

00:02:04.067 --> 00:02:07.467
- I am paid more
when I harm my patients.

00:02:07.500 --> 00:02:09.367
I am paid more when I do more,

00:02:09.400 --> 00:02:12.833
even if it\'s not beneficial.

00:02:12.867 --> 00:02:15.233
- I don\'t want to live
like a vegetable.

00:02:15.267 --> 00:02:18.533
- When the payment incentives
are aligned towards more care,

00:02:18.567 --> 00:02:21.100
when their worries
about defensive medicine

00:02:21.133 --> 00:02:23.433
are aligned towards
giving more care,

00:02:23.467 --> 00:02:26.367
when their patients
seem to want more care,

00:02:26.400 --> 00:02:28.300
and when there isn\'t
really good evidence

00:02:28.333 --> 00:02:31.433
about what care
is the right care,

00:02:31.467 --> 00:02:33.367
it keeps driving
in the same direction

00:02:33.400 --> 00:02:35.133
towards more, more, more.

00:02:35.167 --> 00:02:36.367
- Hang in there.

00:02:36.400 --> 00:02:38.633
Every day is a miracle.

00:02:38.667 --> 00:02:41.533
- The big entitlement programs,
Medicaid, Medicare,

00:02:41.567 --> 00:02:43.433
Social Security...
With the vast majority

00:02:43.467 --> 00:02:45.700
being Medicaid and Medicare...
They\'re on autopilot.

00:02:45.733 --> 00:02:48.067
They automatically increase
year by year.

00:02:48.100 --> 00:02:50.833
By 2050,
they\'ll be consuming over 70%

00:02:50.867 --> 00:02:52.100
of the total federal budget.

00:02:52.133 --> 00:02:56.033
Oh, wait a minute,
so will interest on the debt.

00:02:56.067 --> 00:02:58.167
We can\'t afford it.

00:02:58.200 --> 00:03:00.533
- If health care costs
keep rising at the rate

00:03:00.567 --> 00:03:02.233
they\'ve been rising
for the last few years,

00:03:02.267 --> 00:03:04.433
we will bankrupt this country.

00:03:04.467 --> 00:03:06.767
We will not be able to afford
health care for any of us.

00:03:08.200 --> 00:03:09.267
- Everybody clear, please.

00:03:12.633 --> 00:03:15.167
- We\'ll create
a financial crisis

00:03:15.200 --> 00:03:18.867
of a size sufficient to destroy
the United States of America.

00:03:18.900 --> 00:03:21.600
We have no choice;
we will solve the problem.

00:03:23.400 --> 00:03:29.400
[dramatic electronic music]

00:03:39.633 --> 00:03:41.400
- When we compare UCLA
and Intermountain

00:03:41.433 --> 00:03:42.800
in terms of the use of care,

00:03:42.833 --> 00:03:47.000
what we saw is that
similar patients in Los Angeles

00:03:47.033 --> 00:03:50.467
were spending 60% more time
in the hospital.

00:03:50.500 --> 00:03:54.867
They were having
75% more frequent office visits.

00:03:54.900 --> 00:03:57.167
And of course, if you\'re
seeing more specialists,

00:03:57.200 --> 00:03:59.933
by golly, you\'re going to get
a lot more diagnostic tests

00:03:59.967 --> 00:04:01.800
and minor procedures.

00:04:01.833 --> 00:04:03.400
That led to the question,

00:04:03.433 --> 00:04:05.267
are they getting
much better health outcomes

00:04:05.300 --> 00:04:08.300
as a consequence of all this
extra time in the hospital

00:04:08.333 --> 00:04:09.733
and all
the additional procedures?

00:04:09.767 --> 00:04:12.133
And we found that they were not.

00:04:12.167 --> 00:04:15.333
- I would put our quality
rankings against anybody,

00:04:15.367 --> 00:04:18.200
\'cause to me, I think the most
important quality ranking

00:04:18.233 --> 00:04:20.100
is patient satisfaction.

00:04:20.133 --> 00:04:21.967
If we look at that measure,

00:04:22.000 --> 00:04:23.933
we\'re the number-one
academic medical center

00:04:23.967 --> 00:04:25.200
in the United States.

00:04:25.233 --> 00:04:27.500
- UCLA is a very
high-quality hospital,

00:04:27.533 --> 00:04:29.067
and I\'d want to be
taken care of there

00:04:29.100 --> 00:04:31.767
if I had an acute catastrophe.

00:04:31.800 --> 00:04:33.533
But they
also provide a lot of care

00:04:33.567 --> 00:04:35.900
that I believe is unnecessary.

00:04:35.933 --> 00:04:38.867
- I\'m certain
that we provide care,

00:04:38.900 --> 00:04:41.967
not intentionally,
that isn\'t needed.

00:04:42.000 --> 00:04:46.833
And we have to work on
decreasing those inefficiencies

00:04:46.867 --> 00:04:48.633
that don\'t add value to care.

00:04:50.533 --> 00:04:53.533
[siren wailing]

00:04:54.867 --> 00:04:58.033
- The secret to places
like Intermountain Healthcare

00:04:58.067 --> 00:05:01.200
is that they
are designing into care

00:05:01.233 --> 00:05:03.400
the best possible science.

00:05:03.433 --> 00:05:06.667
And they have shown that
it\'s possible to improve care,

00:05:06.700 --> 00:05:09.067
and by improving care,

00:05:09.100 --> 00:05:11.800
reduce the overall costs
of care.

00:05:26.733 --> 00:05:29.867
- We deliver
about 34,000 children a year.

00:05:29.900 --> 00:05:33.500
It turns out we have the ability
to start labor artificially.

00:05:33.533 --> 00:05:35.067
It\'s called elective induction.

00:05:35.100 --> 00:05:37.267
Now sometimes,
you have to do it medically.

00:05:37.300 --> 00:05:39.067
You have to get that baby
delivered

00:05:39.100 --> 00:05:40.900
because the mom\'s health
or the baby\'s health

00:05:40.933 --> 00:05:42.300
will be affected.

00:05:42.333 --> 00:05:45.733
In elective induction,
it\'s purely for convenience.

00:05:45.767 --> 00:05:47.033
The direct consequence

00:05:47.067 --> 00:05:48.567
of inappropriate
elective induction

00:05:48.600 --> 00:05:50.533
is Cesarean-section deliveries.

00:05:51.700 --> 00:05:53.000
- We\'ve seen huge differences

00:05:53.033 --> 00:05:54.567
in rates of Cesarean section

00:05:54.600 --> 00:05:55.667
across the country.

00:05:55.700 --> 00:05:57.533
And the evidence
is increasingly clear

00:05:57.567 --> 00:05:58.633
that the higher rates

00:05:58.667 --> 00:06:01.100
are not necessarily
good for patients.

00:06:01.133 --> 00:06:04.100
[camera clicks]

00:06:04.133 --> 00:06:08.667
- The national C-section rate
today is running about 34%.

00:06:10.000 --> 00:06:14.333
Intermountain as a system
is running at about 20%.

00:06:16.433 --> 00:06:18.633
- Some hospitals in this country
have C-section rates

00:06:18.667 --> 00:06:21.067
as high as 45%.

00:06:21.100 --> 00:06:24.033
- Our rates of C-section
at Santa Monica are high.

00:06:24.067 --> 00:06:29.033
We really want to do not one
more C-section than necessary.

00:06:29.067 --> 00:06:32.867
But in all of these
improvements,

00:06:32.900 --> 00:06:35.100
it\'s changing behaviors
of patients.

00:06:35.133 --> 00:06:37.533
It\'s changing behaviors
of providers.

00:06:37.567 --> 00:06:40.500
And trained as a psychiatrist,
changing behaviors

00:06:40.533 --> 00:06:42.367
is a very, very difficult thing
to achieve.

00:06:44.367 --> 00:06:47.433
- So our big day today...
Here you are 39 weeks.

00:06:47.467 --> 00:06:48.633
Can you believe it?

00:06:48.667 --> 00:06:51.133
- Mm-hmm.
- It\'s been a long pregnancy.

00:06:51.167 --> 00:06:54.167
Well, as we\'ve talked before,
we have kind of a couple options

00:06:54.200 --> 00:06:55.667
about how to get this baby out.

00:06:55.700 --> 00:06:59.733
And option A
was to try for a vaginal birth.

00:06:59.767 --> 00:07:02.267
And option B
is to do a C-section.

00:07:02.300 --> 00:07:03.367
- Mm-hmm.

00:07:03.400 --> 00:07:05.400
- You had a C-section last time?
- Mm-hmm.

00:07:05.433 --> 00:07:08.800
- And we talked about... we have
kind of some risks either way.

00:07:08.833 --> 00:07:10.367
- Mm-hmm.

00:07:10.400 --> 00:07:11.833
- If we went
for a vaginal delivery,

00:07:11.867 --> 00:07:15.167
the main risk would be something
called a uterine rupture.

00:07:15.200 --> 00:07:16.600
So my understanding

00:07:16.633 --> 00:07:19.300
is that we\'ve decided not to go
with the vaginal delivery,

00:07:19.333 --> 00:07:21.000
and we\'d like to do
the C-section, right?

00:07:21.033 --> 00:07:22.033
- That\'s for sure.
- Okay.

00:07:22.067 --> 00:07:23.033
[both laughing]

00:07:23.067 --> 00:07:24.100
Tell me how you really feel.

00:07:24.133 --> 00:07:25.467
- Yeah.
- All right, let\'s do this!

00:07:25.500 --> 00:07:26.933
Let\'s get this baby here!
- Okay.

00:07:29.033 --> 00:07:32.433
- This procedure
is not without risk.

00:07:32.467 --> 00:07:35.867
We get all of the consequences
of surgery, infections,

00:07:35.900 --> 00:07:41.200
blood loss,
a surgical scar in your body,

00:07:41.233 --> 00:07:43.767
which is going to have
some consequences,

00:07:43.800 --> 00:07:46.700
especially if you
want to have more children.

00:07:46.733 --> 00:07:49.467
We work to reduce
elective induction.

00:07:49.500 --> 00:07:50.900
As a consequence,

00:07:50.933 --> 00:07:52.900
we took down
our C-section rates.

00:07:56.500 --> 00:07:58.733
- Oh, my goodness, hello!

00:07:58.767 --> 00:08:02.000
Happy birthday!

00:08:02.033 --> 00:08:04.600
- What we did
was build a little protocol

00:08:04.633 --> 00:08:07.533
that anytime a woman
appeared at the hospital saying,

00:08:07.567 --> 00:08:10.267
\"My obstetrician sent me
for an elective induction,\"

00:08:10.300 --> 00:08:15.133
we first
carefully tracked the data.

00:08:15.167 --> 00:08:17.000
Turns out
that 28% of our patients

00:08:17.033 --> 00:08:20.033
were not good candidates
when we started.

00:08:20.067 --> 00:08:22.067
It was a phone call
back to their physicians saying,

00:08:22.100 --> 00:08:23.533
\"Doctor, your patient

00:08:23.567 --> 00:08:26.033
\"doesn\'t meet professional
criteria for elective induction.

00:08:26.067 --> 00:08:28.433
\"We need a consult from a
high-risk pregnancy specialist,

00:08:28.467 --> 00:08:30.233
or the department chair.\"

00:08:30.267 --> 00:08:32.200
It went down to under 3%.

00:08:32.233 --> 00:08:35.700
- We decided to go after
the highest-risk group

00:08:35.733 --> 00:08:37.300
in our preventive measures,

00:08:37.333 --> 00:08:39.233
and that\'s the people
that have had the Cesarean.

00:08:39.267 --> 00:08:42.467
- The time in the hospital may
actually decrease a little bit.

00:08:42.500 --> 00:08:43.600
- Yeah...

00:08:43.633 --> 00:08:44.700
- This team-based care...

00:08:44.733 --> 00:08:47.233
It makes your physicians
better physicians.

00:08:47.267 --> 00:08:49.300
We sometimes call it
organized care.

00:08:49.333 --> 00:08:52.600
And that\'s the shift that\'s
happening in medicine right now.

00:08:52.633 --> 00:08:54.533
It\'s from each physician
as a stand-alone expert

00:08:54.567 --> 00:08:55.800
in their own right,

00:08:55.833 --> 00:08:57.367
kind of a little law
unto themselves,

00:08:57.400 --> 00:08:59.967
godlike in their powers,

00:09:00.067 --> 00:09:03.633
to a team of physicians
managing the complex knowledge

00:09:03.667 --> 00:09:06.200
necessary to deliver best care
to a patient.

00:09:06.233 --> 00:09:08.300
[baby crying]

00:09:10.333 --> 00:09:15.267
We have a massive drop
in unplanned C-section rates.

00:09:15.300 --> 00:09:18.067
It was associated
with about $50 million per year

00:09:18.100 --> 00:09:19.833
in savings
to the people of Utah.

00:09:19.867 --> 00:09:22.633
Oh, by the way,
we were punished financially.

00:09:22.667 --> 00:09:27.233
We make more money when we
do an unplanned C-section.

00:09:27.267 --> 00:09:30.233
We get basically screwed
by the payment system,

00:09:30.267 --> 00:09:32.400
but patients come first.

00:09:33.933 --> 00:09:35.100
- Here\'s your boy!

00:09:35.133 --> 00:09:36.900
- Oh.
- There you go.

00:09:36.933 --> 00:09:38.233
- Turns out there are criteria

00:09:38.267 --> 00:09:40.400
for appropriate
elective induction.

00:09:40.433 --> 00:09:41.900
If you violate the criteria,

00:09:41.933 --> 00:09:44.233
more children
end up in the newborn ICU.

00:09:47.233 --> 00:09:51.033
- I had a C-section,
and basically, I had two seven...

00:09:51.067 --> 00:09:53.100
Babies that were
over 7 1/2 pounds a piece.

00:09:53.133 --> 00:09:56.867
So they were pretty big babies.

00:09:56.900 --> 00:09:59.633
I kind of chose
to do the C-section.

00:09:59.667 --> 00:10:02.200
- People come from literally
all over the world

00:10:02.233 --> 00:10:03.800
for complicated deliveries.

00:10:03.833 --> 00:10:07.000
And that, by definition,
drives up our C-section rate,

00:10:07.033 --> 00:10:09.333
because of the complications.

00:10:09.367 --> 00:10:12.667
But I would still say
that I think our C-section rate

00:10:12.700 --> 00:10:14.633
can be improved.

00:10:14.667 --> 00:10:18.533
- We left our newborn ICU
basically a ghost town...

00:10:18.567 --> 00:10:21.400
What a wonderful thing!

00:10:21.433 --> 00:10:22.933
If the rest of the nation

00:10:22.967 --> 00:10:26.900
had the same Cesarean-section
rate that Intermountain does...

00:10:26.933 --> 00:10:30.833
An overall rate
of 20% versus 34%...

00:10:30.867 --> 00:10:34.733
It would save the country
about $3.5 billion per year.

00:10:34.767 --> 00:10:35.767
Now, that\'s waste.

00:10:46.100 --> 00:10:48.533
- The variation
in how we care for patients,

00:10:48.567 --> 00:10:52.867
I think, has real meaning
for patients\' lives,

00:10:52.900 --> 00:10:55.200
especially when you talk about
what happens to patients

00:10:55.233 --> 00:10:57.033
as they near the end of life.

00:10:57.067 --> 00:10:58.567
- Places like Los Angeles

00:10:58.600 --> 00:11:01.767
that have more hospital beds
on a per capita basis

00:11:01.800 --> 00:11:04.700
or have more physicians
on a per capita basis

00:11:04.733 --> 00:11:07.900
will have patients spending
more time in the hospital

00:11:07.933 --> 00:11:09.967
and having them seeing
their physicians more often.

00:11:10.000 --> 00:11:11.400
- Hello, doctor.
- Good to see you...

00:11:11.433 --> 00:11:13.100
- We all know you build it
and they will come.

00:11:13.133 --> 00:11:15.233
If we have... if we have
a whole bunch of things

00:11:15.267 --> 00:11:19.167
that are profitable
and we could use them,

00:11:19.200 --> 00:11:20.600
well, we use them.

00:11:20.633 --> 00:11:21.900
- In the last two years of life

00:11:21.933 --> 00:11:23.400
for patients
with serious illness,

00:11:23.433 --> 00:11:25.800
at the University
of California Los Angeles,

00:11:25.833 --> 00:11:27.833
the average patient
spends 29 days

00:11:27.867 --> 00:11:29.067
in the hospital,

00:11:29.100 --> 00:11:30.367
whereas those at Intermountain

00:11:30.400 --> 00:11:32.167
spend 16 days.

00:11:32.200 --> 00:11:33.933
How many physician visits
do they have

00:11:33.967 --> 00:11:35.333
in the last two years of life?

00:11:35.367 --> 00:11:38.567
92 at UCLA,

00:11:38.600 --> 00:11:40.767
48 at Intermountain Healthcare.

00:11:40.800 --> 00:11:41.767
Startling difference...

00:11:41.800 --> 00:11:43.567
Almost twofold differences.

00:11:43.600 --> 00:11:44.633
And patients at UCLA

00:11:44.667 --> 00:11:46.200
spend three times as many days

00:11:46.233 --> 00:11:48.300
in the intensive care unit.

00:11:48.333 --> 00:11:49.900
As a consequence,

00:11:49.933 --> 00:11:51.267
in the last two years of life,

00:11:51.300 --> 00:11:54.333
patients at Intermountain
spend about $54,000,

00:11:54.367 --> 00:11:59.367
whereas patients at UCLA
spend about $98,000.

00:11:59.400 --> 00:12:02.467
[siren wailing]

00:12:08.167 --> 00:12:10.867
[indistinct chatter]

00:12:12.400 --> 00:12:15.267
- Mr. Toston
suffered multiple strokes.

00:12:15.300 --> 00:12:18.433
He\'s had a profound injury
to the brain

00:12:18.467 --> 00:12:20.900
from what\'s happened
most recently.

00:12:20.933 --> 00:12:24.200
The prognosis for Mr. Toston
is extremely poor.

00:12:24.233 --> 00:12:26.533
There is,
as far as what most of us

00:12:26.567 --> 00:12:29.433
would consider recovery to
meaningful neurologic status,

00:12:29.467 --> 00:12:32.467
the ability to express
themselves, recognize family,

00:12:32.500 --> 00:12:34.167
communicate in a way
that most people

00:12:34.200 --> 00:12:36.833
would be able to understand...
That\'s essentially zero.

00:12:36.867 --> 00:12:39.233
- I\'m Dr. Ravi Aysola;
I\'m the ICU doctor.

00:12:39.267 --> 00:12:40.933
I\'ve gone through his chart
in detail,

00:12:40.967 --> 00:12:43.133
and I\'ve seen
what he\'s been through.

00:12:43.167 --> 00:12:46.367
How much is he able
to interact with you?

00:12:46.400 --> 00:12:47.400
- Not that much.

00:12:47.433 --> 00:12:48.700
- Not much at all.

00:12:48.733 --> 00:12:50.367
I mean, I know
he\'s been on the ventilator.

00:12:50.400 --> 00:12:52.067
The ventilator
does the breathing for him,

00:12:52.100 --> 00:12:53.067
supports his breathing.

00:12:53.100 --> 00:12:54.167
- Yea, since January 1st.

00:12:54.200 --> 00:12:56.000
- I can tell you
that in patients

00:12:56.033 --> 00:12:58.033
who have this much support...

00:12:58.067 --> 00:13:00.767
Where the machine
is doing all of the breathing...

00:13:00.800 --> 00:13:03.967
If the heart
stops in those circumstances

00:13:04.000 --> 00:13:05.833
to the point
where we have to do CPR

00:13:05.867 --> 00:13:08.567
and press on the chest
or shock the heart,

00:13:08.600 --> 00:13:11.900
typically the chance
for recovery

00:13:11.933 --> 00:13:17.633
to functioning neurologic status
is less than 1%.

00:13:17.667 --> 00:13:19.333
If he could be here
and see what...

00:13:19.367 --> 00:13:22.067
The situation he was in...
What would he want?

00:13:22.100 --> 00:13:24.033
And that\'s what
you really have to focus on.

00:13:24.067 --> 00:13:26.533
- There are many times
that I ask him

00:13:26.567 --> 00:13:31.767
if he still want to be with us,
and he nodded his head.

00:13:31.800 --> 00:13:34.400
He wanted to be.

00:13:34.433 --> 00:13:36.833
- If his heart stops,
you want us to shock his heart

00:13:36.867 --> 00:13:41.500
and do CPR, if that\'s needed?

00:13:41.533 --> 00:13:44.467
- When that\'s needed, yeah.

00:13:44.500 --> 00:13:45.767
- Okay, okay.

00:13:45.800 --> 00:13:47.633
- Are you okay with that, Mom?

00:13:47.667 --> 00:13:48.900
- Hmm.

00:13:48.933 --> 00:13:52.367
I want him to live...
Whatever you can do to help him.

00:13:52.400 --> 00:13:54.933
- Okay, all right.

00:13:54.967 --> 00:13:58.067
- Thank you.
Thank you, Mom.

00:13:58.100 --> 00:13:59.467
[alarm buzzing]

00:14:01.567 --> 00:14:03.933
- Essentially,
to provide adequate CPR,

00:14:03.967 --> 00:14:07.267
one must essentially
have the full weight

00:14:07.300 --> 00:14:09.600
pressing upon someone\'s chest.

00:14:09.633 --> 00:14:13.700
And that
is likely to crack ribs,

00:14:13.733 --> 00:14:15.200
potentially cause bleeding,

00:14:15.233 --> 00:14:17.400
and result
in significant trauma.

00:14:19.867 --> 00:14:22.100
- Hang in there, honey.

00:14:22.133 --> 00:14:23.900
We\'ll hang in there with you.

00:14:27.800 --> 00:14:31.167
I don\'t know what to say more,

00:14:31.200 --> 00:14:34.533
but you know that we are here

00:14:34.567 --> 00:14:37.767
and that we love you so much.

00:14:37.800 --> 00:14:40.567
And I\'ll be right here
beside you.

00:14:42.133 --> 00:14:44.167
I will always love you.

00:14:45.867 --> 00:14:48.000
Life is so unfair.

00:14:49.067 --> 00:14:50.433
- I would characterize his state

00:14:50.467 --> 00:14:52.600
certainly now
as a vegetative state

00:14:52.633 --> 00:14:54.833
and potentially even worse.

00:14:54.867 --> 00:14:59.067
It is enormously troubling
to focus our resources

00:14:59.100 --> 00:15:01.967
on patients in his condition

00:15:02.000 --> 00:15:06.200
who really have no reasonable
chance for recovery

00:15:06.233 --> 00:15:07.533
to a level of function

00:15:07.567 --> 00:15:09.967
which most of us
would find acceptable.

00:15:10.000 --> 00:15:14.000
Now, what one finds acceptable
is a very personal decision,

00:15:14.033 --> 00:15:17.100
but I think we can all agree
that it\'s not how most of us

00:15:17.133 --> 00:15:20.300
envision the last days
of our lives.

00:15:22.133 --> 00:15:24.533
- The family
wants everything done.

00:15:24.567 --> 00:15:26.833
And I would challenge anybody...

00:15:26.867 --> 00:15:28.967
Come up and talk
with this family.

00:15:29.000 --> 00:15:31.233
And if you tell me
that the rules are

00:15:31.267 --> 00:15:34.967
we can withdraw care
because it\'s potentially futile,

00:15:35.000 --> 00:15:36.333
then we\'ll do it.

00:15:36.367 --> 00:15:38.467
But that\'s not the way
the system is set up.

00:15:38.500 --> 00:15:40.633
The way the system
is set up currently

00:15:40.667 --> 00:15:45.333
is that spouse,
that child, that parent,

00:15:45.367 --> 00:15:49.200
can really demand
a full-court press

00:15:49.233 --> 00:15:51.767
regardless of what the odds are.

00:15:55.233 --> 00:15:57.567
- He was in the ICU
for six days.

00:15:57.600 --> 00:15:59.233
I think the patient\'s wife

00:15:59.267 --> 00:16:02.700
was actually asking about
diagnostic test results,

00:16:02.733 --> 00:16:07.167
asking the results of the EEG,
asking results of the CT scans.

00:16:07.200 --> 00:16:09.300
When she was basically told

00:16:09.333 --> 00:16:12.733
that nothing I could do could
help him recover to any degree,

00:16:12.767 --> 00:16:16.233
she then was also willing
to accept the outcome.

00:16:17.733 --> 00:16:21.733
What we did
is start a drip of morphine

00:16:21.767 --> 00:16:24.067
and disconnected the ventilator

00:16:24.100 --> 00:16:26.133
and stopped all other medicines
and fluids,

00:16:26.167 --> 00:16:28.900
stopped diagnostic testing,
stopped monitoring.

00:16:28.933 --> 00:16:30.933
And then within a matter
of hours,

00:16:30.967 --> 00:16:34.900
in his case, approximately
four or five hours,

00:16:34.933 --> 00:16:36.067
he died.

00:16:39.867 --> 00:16:41.600
ICUs were initially designed

00:16:41.633 --> 00:16:44.200
to address
acute critical illness...

00:16:44.233 --> 00:16:46.233
To help someone recover

00:16:46.267 --> 00:16:49.500
to the point which they can
leave the intensive care unit.

00:16:49.533 --> 00:16:51.367
Often times the ICU now

00:16:51.400 --> 00:16:54.433
is the last stop
before someone dies.

00:16:56.000 --> 00:16:59.600
I, at one point,
was an ICU patient and survived,

00:16:59.633 --> 00:17:02.900
and due to the exceptional care
I received,

00:17:02.933 --> 00:17:05.000
I felt it was my obligation,
my duty,

00:17:05.033 --> 00:17:08.133
to continue
to provide that care.

00:17:08.167 --> 00:17:11.433
But I don\'t think it\'s a failure
on my part to say,

00:17:11.467 --> 00:17:14.733
\"There\'s nothing I can do
to cure your loved one.

00:17:14.767 --> 00:17:15.900
\"What I can do is make sure

00:17:15.933 --> 00:17:17.367
\"that your loved one
is comfortable,

00:17:17.400 --> 00:17:19.367
that they don\'t suffer.\"

00:17:19.400 --> 00:17:23.033
I think when we keep trying
to find interventions,

00:17:23.067 --> 00:17:27.933
procedures, drugs,
and give false hope to families,

00:17:27.967 --> 00:17:30.800
that we propagate this mythology

00:17:30.833 --> 00:17:33.533
that we can somehow
stave off death indefinitely.

00:17:36.767 --> 00:17:40.867
- Ms. Stonum, how are you?

00:17:40.900 --> 00:17:42.467
Ms. Stonum, can you see me?

00:17:42.500 --> 00:17:44.633
[electronic beeping]

00:17:44.667 --> 00:17:46.567
Are you in pain?

00:17:46.600 --> 00:17:49.267
I don\'t know
what\'s going on inside the mind.

00:17:49.300 --> 00:17:50.467
She\'s nonverbal.

00:17:50.500 --> 00:17:51.733
Ms. Stonum?

00:17:51.767 --> 00:17:53.567
But she\'s able to respond
to pain and noise

00:17:53.600 --> 00:17:54.700
and stuff like that.

00:17:55.833 --> 00:17:58.400
[machine hisses]

00:17:58.433 --> 00:18:00.400
- This has been
a long journey for you...

00:18:00.433 --> 00:18:02.300
- Yes, it has.

00:18:02.333 --> 00:18:04.200
- That began with her stroke,

00:18:04.233 --> 00:18:06.533
that required
a breathing machine,

00:18:06.567 --> 00:18:10.500
feeding tube, and dialysis.

00:18:10.533 --> 00:18:14.000
- I feel like my mom
is my baby, so to speak,

00:18:14.033 --> 00:18:15.633
and so I want to nurture
and care for her

00:18:15.667 --> 00:18:16.933
in any way that I can.

00:18:16.967 --> 00:18:19.633
If there is something
that can sustain her medically,

00:18:19.667 --> 00:18:21.667
she would want that.

00:18:21.700 --> 00:18:23.767
- If the nurses were doing
their rounds and such,

00:18:23.800 --> 00:18:28.400
and they found that, you know,
her heart had stopped,

00:18:28.433 --> 00:18:32.400
at that point, would you
want us to try to do something

00:18:32.433 --> 00:18:35.000
to try to restart her heart?

00:18:35.033 --> 00:18:38.200
- One of the things
that she would want

00:18:38.233 --> 00:18:42.000
is every opportunity
to live and to enjoy life.

00:18:42.033 --> 00:18:45.600
As I look at
how she\'s doing now,

00:18:45.633 --> 00:18:47.633
I\'m glad
that I didn\'t make the decision

00:18:47.667 --> 00:18:51.867
to let nature take its course.

00:18:51.900 --> 00:18:55.633
You know, miracles happen
if you believe in miracles.

00:18:57.233 --> 00:18:58.900
- We do run out of miracles,

00:18:58.933 --> 00:19:02.300
and there is a time
for everyone.

00:19:02.333 --> 00:19:05.300
- I don\'t know
what that time frame would be

00:19:05.333 --> 00:19:07.833
that I feel,
or some family member feels,

00:19:07.867 --> 00:19:09.933
you know, she\'s really not here
with us now.

00:19:09.967 --> 00:19:13.167
I suppose something like that...
Something spiritual.

00:19:13.200 --> 00:19:15.933
- This is not something
that I would want.

00:19:15.967 --> 00:19:17.967
It would be torturing me.

00:19:18.000 --> 00:19:20.667
On the other hand, other people
feel very differently.

00:19:20.700 --> 00:19:22.267
- Just giving you
some medication...

00:19:22.300 --> 00:19:24.833
- You do everything you can
to preserve life.

00:19:24.867 --> 00:19:26.600
That\'s what my mother
would want.

00:19:28.267 --> 00:19:32.300
Okay, let\'s find
your favorite picture again.

00:19:32.333 --> 00:19:34.233
She likes to be talked to

00:19:34.267 --> 00:19:36.667
while looking
at the photographs.

00:19:36.700 --> 00:19:40.100
This is your first baby,
way back in the times.

00:19:41.433 --> 00:19:45.000
Okay,
here\'s your favorite picture.

00:19:45.033 --> 00:19:48.533
This is when
you were very young.

00:19:48.567 --> 00:19:51.600
Always very glamorous, huh?

00:19:53.833 --> 00:19:56.233
- What hasn\'t happened
in the past ten months is,

00:19:56.267 --> 00:19:58.500
she hasn\'t left the hospital.

00:19:58.533 --> 00:20:02.200
In the meantime, basically,
our hospital\'s become her home.

00:20:02.233 --> 00:20:04.800
- UCLA,
through their ethics committee,

00:20:04.833 --> 00:20:07.000
put in place
a Do-Not-Resuscitate order,

00:20:07.033 --> 00:20:09.900
which, as her durable power
of attorney, I am against

00:20:09.933 --> 00:20:11.533
and I believe my mother
would be against.

00:20:12.767 --> 00:20:15.833
If she gets any new infections,
for example,

00:20:15.867 --> 00:20:17.467
they will not treat them.

00:20:17.500 --> 00:20:18.700
In other words,

00:20:18.733 --> 00:20:22.267
they will not do heroic efforts
to save her life.

00:20:22.300 --> 00:20:25.000
Yes, oh, good.
She brushed your hair.

00:20:25.033 --> 00:20:28.033
Fortunately,
they will not terminate dialysis

00:20:28.067 --> 00:20:30.733
or the ventilator,

00:20:30.767 --> 00:20:35.033
and instead, they\'re going
to not escalate her care.

00:20:35.067 --> 00:20:38.833
- If a patient
is very unlikely to survive

00:20:38.867 --> 00:20:41.333
but the physicians
feel that there\'s some chance

00:20:41.367 --> 00:20:44.900
by using
all the available resources

00:20:44.933 --> 00:20:47.333
they might be able
to pull them through,

00:20:47.367 --> 00:20:50.667
they appropriately will use
all of those treatments.

00:20:50.700 --> 00:20:53.933
Yet they may recognize
that a further deterioration

00:20:53.967 --> 00:20:56.800
would mean that that goal
is unattainable.

00:20:56.833 --> 00:20:58.267
And under those circumstances,

00:20:58.300 --> 00:21:01.067
it would be inappropriate for
them to further escalate care.

00:21:02.067 --> 00:21:04.333
- Yes, you\'re doing good.

00:21:04.367 --> 00:21:06.133
Hang in there.

00:21:06.167 --> 00:21:08.000
Every day is a miracle.

00:21:08.033 --> 00:21:12.333
Why, all of a sudden,
am I not in a position

00:21:12.367 --> 00:21:15.900
to make decisions
about her life-ending choices?

00:21:15.933 --> 00:21:21.000
- I think there\'s a disconnect
between what we can do

00:21:21.033 --> 00:21:22.800
and what we can do that helps.

00:21:24.200 --> 00:21:26.333
- I\'m going to visit you
back again later.

00:21:26.367 --> 00:21:27.600
- We\'re in a situation

00:21:27.633 --> 00:21:33.133
where we have very powerful
technology, medications,

00:21:33.167 --> 00:21:35.400
and tools and expertise
in caring for people

00:21:35.433 --> 00:21:36.833
in critical illness.

00:21:36.867 --> 00:21:38.433
But I think
we\'ve approached a point

00:21:38.467 --> 00:21:41.200
where we\'re
almost abusing that power.

00:21:41.233 --> 00:21:44.567
- It\'s under those
extremely unusual circumstances

00:21:44.600 --> 00:21:46.733
where the goals of medicine
are being tested

00:21:46.767 --> 00:21:48.533
by the use of technology

00:21:48.567 --> 00:21:51.067
that physicians
need to begin to pull back,

00:21:51.100 --> 00:21:53.533
have intensive conversations
with families,

00:21:53.567 --> 00:21:56.533
and sometimes
consider overriding them.

00:21:56.567 --> 00:21:58.833
- Essentially,
they\'re pulling the plug.

00:21:58.867 --> 00:22:01.400
I call it a medical execution.

00:22:01.433 --> 00:22:04.433
It is essentially a death panel.

00:22:04.467 --> 00:22:09.033
- It\'s difficult when we\'re
put in an adversarial position

00:22:09.067 --> 00:22:11.400
where we have to tell
patients\' families that,

00:22:11.433 --> 00:22:14.067
\"I don\'t think this will help.\"

00:22:14.100 --> 00:22:19.833
This is exacerbated by
discussions in the general media

00:22:19.867 --> 00:22:21.767
and in politics, unfortunately,

00:22:21.800 --> 00:22:24.000
with statements
like \"death panels\"

00:22:24.033 --> 00:22:27.467
and really politicizing
a deeply personal issue.

00:22:28.700 --> 00:22:30.533
- It is euthanasia.

00:22:30.567 --> 00:22:35.567
And I feel that the decision
was made

00:22:35.600 --> 00:22:38.467
because she basically
wouldn\'t go away.

00:22:38.500 --> 00:22:42.400
- We do not practice euthanasia
under any circumstances.

00:22:42.433 --> 00:22:48.367
Euthanasia
is the active promotion of death

00:22:48.400 --> 00:22:49.967
with that intent.

00:22:50.000 --> 00:22:51.733
- I\'m gonna suction you again,
okay?

00:22:51.767 --> 00:22:55.400
- We use machines
to be able to protect patients

00:22:55.433 --> 00:22:58.000
from dying
from an underlying condition.

00:22:58.033 --> 00:22:59.667
- Just a little bit.

00:22:59.700 --> 00:23:03.367
- And it\'s possible to use these
advanced tools that we have

00:23:03.400 --> 00:23:07.400
to not help patients
but to actually prolong a death

00:23:07.433 --> 00:23:12.467
or to actually produce
more suffering or less comfort.

00:23:12.500 --> 00:23:14.400
And under those circumstances,

00:23:14.433 --> 00:23:17.400
physicians
may very well say, \"No.\"

00:23:17.433 --> 00:23:21.400
- We have to be able
to save lives, perform miracles,

00:23:21.433 --> 00:23:24.533
and we also need to figure out
the best way

00:23:24.567 --> 00:23:27.267
to allow people to pass
with dignity.

00:23:27.300 --> 00:23:29.767
But that\'s a discussion
that really doesn\'t take place

00:23:29.800 --> 00:23:32.667
when you show up to our
emergency room in extremis.

00:23:32.700 --> 00:23:34.667
That discussion
has to take place

00:23:34.700 --> 00:23:37.967
with a trusted
primary care provider

00:23:38.000 --> 00:23:41.700
that\'s been your family doc
for years, ideally,

00:23:41.733 --> 00:23:45.233
because when you come to us
with multi-organ failure,

00:23:45.267 --> 00:23:47.567
we do what we know how to do.

00:23:47.600 --> 00:23:53.200
And America has not focused
on that particular discussion

00:23:53.233 --> 00:23:55.533
in advance enough.

00:23:56.933 --> 00:23:58.967
And we\'re not talking about
death squads.

00:23:59.000 --> 00:24:01.967
We\'re talking about
having real discussions

00:24:02.000 --> 00:24:07.033
about the end of your life,
and how do you want it to be?

00:24:07.067 --> 00:24:09.967
- We have to start being able
to talk about it,

00:24:10.000 --> 00:24:12.000
and not just because
we\'re spending a huge amount

00:24:12.033 --> 00:24:13.433
of money on it,

00:24:13.467 --> 00:24:18.100
but because a medicalized death
is not what most people want.

00:24:33.300 --> 00:24:34.867
- There we go.

00:24:34.900 --> 00:24:38.367
So you had a cancer
when you were a kid,

00:24:38.400 --> 00:24:44.300
and then you\'ve had
lung and esophagus cancers

00:24:44.333 --> 00:24:45.567
now as an adult.

00:24:45.600 --> 00:24:47.467
- In my stomach now.

00:24:47.500 --> 00:24:48.633
- And stomach cancer.

00:24:48.667 --> 00:24:50.133
- Yeah.

00:24:50.167 --> 00:24:52.833
- Right now, you\'re struggling
with what we call sepsis,

00:24:52.867 --> 00:24:55.667
which is our fancy word
for a serious infection.

00:24:55.700 --> 00:25:00.267
And one of the questions
that we have to clarify

00:25:00.300 --> 00:25:04.600
in order to take care of you
the way you would like

00:25:04.633 --> 00:25:07.367
is to understand whether
there are any limits

00:25:07.400 --> 00:25:10.567
to the kinds of creative
medical technologies

00:25:10.600 --> 00:25:15.733
we could use
in order to support you

00:25:15.767 --> 00:25:18.333
if your body
really started to collapse.

00:25:18.367 --> 00:25:20.933
Sometimes the first question
that we have to answer

00:25:20.967 --> 00:25:22.700
is the lung
life support machine,

00:25:22.733 --> 00:25:26.967
called the mechanical ventilator
or the respirator.

00:25:27.000 --> 00:25:30.500
- No, I\'ve already
made up my mind.

00:25:30.533 --> 00:25:32.367
If you can help me...

00:25:32.400 --> 00:25:33.633
- Yeah.

00:25:33.667 --> 00:25:35.100
- Then that\'s fine.

00:25:35.133 --> 00:25:36.367
- Right.

00:25:36.400 --> 00:25:39.000
- But I don\'t want to live
like a vegetable.

00:25:39.033 --> 00:25:42.567
- If I told you that we might
need to go on the ventilator

00:25:42.600 --> 00:25:44.333
for a couple days

00:25:44.367 --> 00:25:50.167
and I thought
that you had a 90% chance,

00:25:50.200 --> 00:25:51.167
so nine out of ten...

00:25:51.200 --> 00:25:52.767
- Right.

00:25:52.800 --> 00:25:55.733
- That you\'d get through it
and we\'d remove the ventilator

00:25:55.767 --> 00:25:57.800
and you\'d do okay,

00:25:57.833 --> 00:26:00.400
would you want me
to put you on the ventilator?

00:26:00.433 --> 00:26:02.867
- Okay, if you could do it
that way...

00:26:02.900 --> 00:26:04.000
- Yeah?

00:26:04.033 --> 00:26:06.367
- Then I\'ll go
with the ventilator.

00:26:06.400 --> 00:26:07.933
- I see;
now comes the hard part.

00:26:07.967 --> 00:26:10.500
Would you want me to put you
on the ventilator temporarily

00:26:10.533 --> 00:26:12.667
if it was a one in ten shot
that we would get you through?

00:26:12.700 --> 00:26:16.100
- A one in ten, I\'d take it
for a couple days

00:26:16.133 --> 00:26:17.800
like we talked about.

00:26:17.833 --> 00:26:18.800
- Oh, okay, okay, okay.

00:26:18.833 --> 00:26:20.067
- But yeah...

00:26:20.100 --> 00:26:22.833
- So that\'s very helpful
for me to understand.

00:26:22.867 --> 00:26:28.133
- Like a long-term thing,
like three months, no.

00:26:28.167 --> 00:26:31.600
I just don\'t want
to tie people down.

00:26:31.633 --> 00:26:36.000
I mean, if it\'s not gonna work,
it\'s not gonna work.

00:26:36.033 --> 00:26:41.033
- The sense I got from you
is that if you got an okay shot

00:26:41.067 --> 00:26:44.667
at a reasonable amount
of independence

00:26:44.700 --> 00:26:47.067
as a result of a treatment
that we give you...

00:26:47.100 --> 00:26:48.200
- Right.

00:26:48.233 --> 00:26:49.367
- You\'d like to go for it.

00:26:49.400 --> 00:26:50.367
- I would.

00:26:50.400 --> 00:26:51.600
- Okay, okay.

00:26:51.633 --> 00:26:53.567
Then I think we ought...
Then I think we ought to.

00:26:53.600 --> 00:26:55.400
- I\'d give it a try.

00:26:55.433 --> 00:26:56.400
I would.

00:26:56.433 --> 00:26:58.200
- Okay.

00:26:58.233 --> 00:27:00.633
But I... but I want you to know,

00:27:00.667 --> 00:27:02.500
I\'m not trying to push
my fancy toys on you.

00:27:02.533 --> 00:27:03.500
- I know you\'re not.

00:27:03.533 --> 00:27:05.033
- I love to do \'em.

00:27:05.067 --> 00:27:06.867
I love to run these machines.

00:27:06.900 --> 00:27:08.933
I love to do intensive care.

00:27:08.967 --> 00:27:12.400
But my responsibility
is to you, not to me.

00:27:12.433 --> 00:27:15.467
- The patient is not
just an experimental subject

00:27:15.500 --> 00:27:17.900
as we explore how far
we can push back

00:27:17.933 --> 00:27:19.500
the boundaries of death.

00:27:19.533 --> 00:27:21.167
I need to say in passing,

00:27:21.200 --> 00:27:24.267
nobody\'s getting out
of here alive.

00:27:24.300 --> 00:27:27.067
It\'s going to happen
to all of us sometime.

00:27:27.100 --> 00:27:30.300
You get a choice
about how it happens to you,

00:27:30.333 --> 00:27:33.633
and a good physician
will support you in that choice.

00:27:43.233 --> 00:27:44.967
- So why don\'t you tell me
your understanding

00:27:45.000 --> 00:27:46.833
of your heart and kidneys?

00:27:46.867 --> 00:27:48.067
What\'s going on?

00:27:48.100 --> 00:27:51.400
- Well, I\'m in congestive
heart failure,

00:27:51.433 --> 00:27:56.433
and it\'s gotten
to a terminal point.

00:27:56.467 --> 00:27:59.867
There\'s nothing
anyone can do to cure it.

00:27:59.900 --> 00:28:01.400
- Okay.

00:28:01.433 --> 00:28:06.700
- They were at first talking
going to the ICU,

00:28:06.733 --> 00:28:12.667
but I don\'t want
to be kept alive by machines.

00:28:14.967 --> 00:28:17.900
When it\'s time, it\'s time.

00:28:17.933 --> 00:28:22.533
- My goal
is to honor what he wants.

00:28:22.567 --> 00:28:25.333
Sorry.

00:28:25.367 --> 00:28:29.067
- Of course I don\'t want to die,

00:28:29.100 --> 00:28:33.233
but going out
kicking and screaming

00:28:33.267 --> 00:28:35.867
doesn\'t change the going out.

00:28:35.900 --> 00:28:42.133
I realize that I\'m going to need
hospice at home.

00:28:42.167 --> 00:28:45.233
I\'m only six feet
from a nice place to sit

00:28:45.267 --> 00:28:48.033
in the sun in the front yard.

00:28:48.067 --> 00:28:51.900
And I love that
more than anything else.

00:28:51.933 --> 00:28:53.433
- Those sound like good goals.

00:28:53.467 --> 00:28:54.900
I think
you\'ve made a lot of peace,

00:28:54.933 --> 00:28:56.333
and you\'re
going to show your family

00:28:56.367 --> 00:28:57.800
how to do this last part
of life.

00:28:57.833 --> 00:29:00.800
- Yes, I\'m gonna do my best.

00:29:00.833 --> 00:29:01.833
- I see that.

00:29:03.033 --> 00:29:05.933
We often recommend
going out of the hospital

00:29:05.967 --> 00:29:07.233
with what\'s called

00:29:07.267 --> 00:29:09.667
a \"physician order
for life-sustaining treatment.\"

00:29:09.700 --> 00:29:10.900
- Yes.

00:29:10.933 --> 00:29:13.067
- So it\'s your wishes
turned into an order

00:29:13.100 --> 00:29:15.000
that can be followed
in the community.

00:29:15.033 --> 00:29:17.367
It would tell them
what limited interventions

00:29:17.400 --> 00:29:20.167
you\'re willing to have
and what you don\'t want.

00:29:20.200 --> 00:29:22.633
I\'m going to fill this out
like we talked about.

00:29:22.667 --> 00:29:25.167
We\'ll be watching to see
how you can get out,

00:29:25.200 --> 00:29:26.600
maybe by Monday, and get home.

00:29:26.633 --> 00:29:27.600
- All righty.

00:29:27.633 --> 00:29:28.600
- Get in that sunshine.

00:29:28.633 --> 00:29:31.200
- That\'s what I\'m hoping for.

00:29:39.333 --> 00:29:41.967
- When you start to focus on
the real needs of your patients,

00:29:42.000 --> 00:29:44.033
you find
that very often they don\'t want

00:29:44.067 --> 00:29:45.900
this over-the-top rescue care.

00:29:47.367 --> 00:29:49.367
They want dignity.

00:29:49.400 --> 00:29:52.400
- There\'s this wonderful study
that just came out

00:29:52.433 --> 00:29:58.167
that looked at cancer patients
who had standard treatment,

00:29:58.200 --> 00:30:01.533
fairly aggressive treatment,
versus palliative care.

00:30:01.567 --> 00:30:04.200
So palliative care
simply meant that nobody

00:30:04.233 --> 00:30:07.233
was going for cures
and comfort was paramount.

00:30:07.267 --> 00:30:11.367
And the question was:
what happened to those patients?

00:30:11.400 --> 00:30:12.533
And lo and behold,

00:30:12.567 --> 00:30:15.233
the palliative care patients
lived longer.

00:30:15.267 --> 00:30:18.067
- Now, some patients will
want that aggressive approach.

00:30:18.100 --> 00:30:20.333
And if they ask for it,
they will get it

00:30:20.367 --> 00:30:23.600
in this system here in Utah.

00:30:23.633 --> 00:30:27.033
The difference is
is many of them won\'t

00:30:27.067 --> 00:30:29.200
that have lived
a full and satisfying life.

00:30:29.233 --> 00:30:33.667
The last thing they want to do
is to die in an ICU.

00:30:33.700 --> 00:30:35.233
They know they\'re going to die.

00:30:35.267 --> 00:30:38.500
They want to die
in the arms of their family

00:30:38.533 --> 00:30:40.800
at the close
of a wonderful life.

00:30:40.833 --> 00:30:42.600
You see?

00:30:42.633 --> 00:30:47.033
We have built a system
that accommodates that view,

00:30:47.067 --> 00:30:50.300
not just the other
technological view.

00:30:50.333 --> 00:30:52.600
That technology is important,

00:30:52.633 --> 00:30:54.233
but knowing
how and when to apply it

00:30:54.267 --> 00:30:55.700
under a patient\'s control

00:30:55.733 --> 00:30:57.367
is at least as important.

00:30:57.400 --> 00:30:59.000
- You did good;
good job.

00:31:09.633 --> 00:31:11.400
- I was sitting in my office.

00:31:11.433 --> 00:31:14.100
And I started to feel a headache
coming on.

00:31:14.133 --> 00:31:17.533
And on the way
to my doctor\'s office,

00:31:17.567 --> 00:31:20.067
this headache just erupted.

00:31:20.100 --> 00:31:23.767
It felt like an artillery shell
going off in my head.

00:31:23.800 --> 00:31:26.867
- Your case... you have
an aneurism of this location,

00:31:26.900 --> 00:31:29.000
where the arrow is pointing.

00:31:29.033 --> 00:31:34.300
- Basically, it\'s a hemorrhage
from a balloon on the artery

00:31:34.333 --> 00:31:38.833
that breaks
and spills blood into the brain.

00:31:38.867 --> 00:31:41.900
The ultimate test
was the CT scan

00:31:41.933 --> 00:31:44.467
so that they would know
exactly where to intervene.

00:31:44.500 --> 00:31:47.900
- We have to navigate
all the way from the groin

00:31:47.933 --> 00:31:50.433
where we go in
with a very long tube

00:31:50.467 --> 00:31:51.767
that is called a catheter

00:31:51.800 --> 00:31:54.767
and put it all the way
inside of the aneurism.

00:31:54.800 --> 00:31:56.633
- They do what\'s called
embolizing it,

00:31:56.667 --> 00:32:01.633
which is essentially filling it
with little tiny platinum coils.

00:32:01.667 --> 00:32:05.000
- 50% of people
with a hemorrhage like this die.

00:32:05.033 --> 00:32:10.033
- I spent another three weeks
in the neuro-ICU.

00:32:10.067 --> 00:32:12.567
When I got out of the hospital,

00:32:12.600 --> 00:32:17.633
UCLA billed my insurance company
for $440,000.

00:32:17.667 --> 00:32:23.167
- The price that we have to pay
to treat you is miniscule

00:32:23.200 --> 00:32:25.600
compared with the benefit
that society has

00:32:25.633 --> 00:32:30.900
from being able to enjoy
the abilities that you have.

00:32:30.933 --> 00:32:32.667
- That coil
that was put in his head

00:32:32.700 --> 00:32:34.133
was invented here.

00:32:34.167 --> 00:32:36.800
So I mean, we\'re talking about...
You came to the right place.

00:32:38.333 --> 00:32:42.667
- At its best, that\'s what
rescue medicine can accomplish.

00:32:42.700 --> 00:32:45.833
At its worst,
it\'s used inappropriately

00:32:45.867 --> 00:32:49.667
in cases where the benefits
are not even available.

00:32:51.967 --> 00:32:53.233
- When it comes to rescue care,

00:32:53.267 --> 00:32:55.600
the United States
dominates the world.

00:32:55.633 --> 00:32:58.367
The rates at which we put people
on renal dialysis,

00:32:58.400 --> 00:33:01.467
the rates at which we do
aggressive cancer treatments

00:33:01.500 --> 00:33:04.433
and organ transplants...

00:33:04.467 --> 00:33:05.967
What we\'re selling is hope.

00:33:06.000 --> 00:33:08.733
Everybody
wants to be the miracle.

00:33:08.767 --> 00:33:11.433
Nobody wants to lose that.

00:33:11.467 --> 00:33:14.200
It\'s not a question
of abandoning rescue care.

00:33:14.233 --> 00:33:16.333
It\'s a question of tuning it.

00:33:16.367 --> 00:33:19.700
How do I get that save
and lose unnecessary treatments?

00:33:20.767 --> 00:33:23.267
- That medical care
saved my life.

00:33:23.300 --> 00:33:24.733
And it was very expensive care,

00:33:24.767 --> 00:33:28.367
but from my vantage point,
well worth it, of course.

00:33:28.400 --> 00:33:32.733
Once I was leaving the hospital,
it was a different situation.

00:33:32.767 --> 00:33:35.467
There was an intern
who came to my room,

00:33:35.500 --> 00:33:37.667
spent five minutes with me,

00:33:37.700 --> 00:33:41.567
wrote out some instructions
on a single-page form.

00:33:41.600 --> 00:33:44.400
So I essentially
walked out of the door

00:33:44.433 --> 00:33:49.633
with hardly a thought about
what would come next for me.

00:33:49.667 --> 00:33:52.867
- Currently the system
is designed to pay us

00:33:52.900 --> 00:33:55.667
based on how many procedures
we do.

00:33:55.700 --> 00:33:58.200
So we\'re really good
at doing procedures.

00:33:58.233 --> 00:34:00.967
And we\'re really good at volume.

00:34:01.000 --> 00:34:03.600
That\'s the way the current
American health care system

00:34:03.633 --> 00:34:04.767
is set up.

00:34:04.800 --> 00:34:07.767
As we transition to one
of population health,

00:34:07.800 --> 00:34:10.567
of course we have to be able
to still do

00:34:10.600 --> 00:34:12.167
those heroic measures,

00:34:12.200 --> 00:34:16.567
but now that transition in care
has to be addressed much more.

00:34:16.600 --> 00:34:19.767
We\'ve never been incentivized
to do that.

00:34:19.800 --> 00:34:24.700
- Although UCLA is a fabulous
high-technology hospital,

00:34:24.733 --> 00:34:26.233
certain aspects of patient care,

00:34:26.267 --> 00:34:31.033
which might actually improve
the outcomes, may be neglected.

00:34:31.067 --> 00:34:36.533
Unfortunately primary care is
crowded out by rescue medicine.

00:34:36.567 --> 00:34:39.367
- We developed literally
thousands of ways

00:34:39.400 --> 00:34:42.100
that we could intervene
to change a patient\'s future.

00:34:42.133 --> 00:34:43.833
It\'s a little bit addictive.

00:34:43.867 --> 00:34:47.167
As a physician, you get focused
over on that side.

00:34:47.200 --> 00:34:49.500
It becomes the battle
against disease

00:34:49.533 --> 00:34:53.600
as opposed to service
to the patient.

00:34:53.633 --> 00:34:57.633
And it happens to all of us
to some degree.

00:34:57.667 --> 00:34:59.567
Well, when you recognize that,

00:34:59.600 --> 00:35:02.900
you start to try to build
a culture within an organization

00:35:02.933 --> 00:35:06.300
that values the patient
as much as the technology.

00:35:06.333 --> 00:35:09.067
- I think having
an integrated system of care

00:35:09.100 --> 00:35:13.433
as Intermountain does
is a very important component

00:35:13.467 --> 00:35:15.833
of improving the quality
of care.

00:35:15.867 --> 00:35:20.667
UCLA has a delivery system,
but it\'s rather fragmented.

00:35:20.700 --> 00:35:24.433
And unfortunately,
UCLA\'s fragmentation

00:35:24.467 --> 00:35:28.333
is very representative
of our whole health care system.

00:35:43.833 --> 00:35:46.833
- He was
in a motor vehicle accident.

00:35:46.867 --> 00:35:48.767
We ordered both a CT of the head

00:35:48.800 --> 00:35:51.300
as well as
a CT of the cervical spine.

00:35:51.333 --> 00:35:52.400
- Okay, excellent.

00:35:52.433 --> 00:35:55.833
Well, you can see,
here are the CT images.

00:35:55.867 --> 00:35:58.700
And this is a nice
young person\'s brain.

00:35:58.733 --> 00:36:00.667
He\'s 24 years old.

00:36:00.700 --> 00:36:02.567
- If someone is worried
about the possibility

00:36:02.600 --> 00:36:05.200
that he\'s sustained
an important injury to his head,

00:36:05.233 --> 00:36:08.733
the only way to know for sure
is to do a CAT scan...

00:36:08.767 --> 00:36:10.433
Seems reasonable.

00:36:10.467 --> 00:36:12.500
And then it comes out normal,
and we all feel better.

00:36:12.533 --> 00:36:14.100
It sounds like that\'s
a good deal,

00:36:14.133 --> 00:36:16.533
but it\'s not a good deal,
actually, for anybody

00:36:16.567 --> 00:36:18.300
and most particularly
not for that patient.

00:36:18.333 --> 00:36:19.300
Why is that?

00:36:19.333 --> 00:36:20.733
Well, there are
many, many reasons.

00:36:20.767 --> 00:36:25.133
One is that most of the time,
almost always,

00:36:25.167 --> 00:36:28.900
I can tell clinically whether
he has an important head injury.

00:36:28.933 --> 00:36:31.600
The right test
is usually putting the eyes

00:36:31.633 --> 00:36:34.767
of an experienced physician
on a patient.

00:36:34.800 --> 00:36:36.333
- Sometimes those CT scans

00:36:36.367 --> 00:36:39.933
really do help physicians
make better diagnoses.

00:36:39.967 --> 00:36:43.433
But a good part of the time,
they\'re just being used

00:36:43.467 --> 00:36:44.800
because they\'re there.

00:36:44.833 --> 00:36:46.267
- He has nice preservation

00:36:46.300 --> 00:36:48.733
of gray-white matter
differentiation throughout.

00:36:48.767 --> 00:36:50.967
So we would call this normal.

00:36:51.000 --> 00:36:54.467
So we\'re going to give his head
a clean bill of health.

00:36:54.500 --> 00:36:55.733
- Okay.

00:36:55.767 --> 00:36:57.967
- The CAT scan itself
is not benign.

00:36:58.000 --> 00:37:02.400
And we know for sure
that doing a CAT scan,

00:37:02.433 --> 00:37:05.867
which is about 200 to 500
chest X-rays

00:37:05.900 --> 00:37:07.533
in terms of radiation...

00:37:07.567 --> 00:37:09.633
It\'s a lot of radiation...

00:37:09.667 --> 00:37:11.067
Will cause cancer.

00:37:11.100 --> 00:37:14.933
- The estimate is that tens
of thousands of cancer deaths

00:37:14.967 --> 00:37:18.833
are being caused each year
by medical radiation.

00:37:20.033 --> 00:37:21.400
- Not doing the scan

00:37:21.433 --> 00:37:23.633
and missing
that one out of a thousand

00:37:23.667 --> 00:37:25.667
is a big problem.

00:37:25.700 --> 00:37:28.433
And the medical
legal responsibility

00:37:28.467 --> 00:37:29.967
of now experts saying,

00:37:30.000 --> 00:37:32.267
\"Well, in this case, you should
have certainly done a scan,

00:37:32.300 --> 00:37:33.500
why didn\'t you do one?\"

00:37:33.533 --> 00:37:38.067
gets you into this
sort of defensive-medicine mode.

00:37:38.100 --> 00:37:40.833
And I\'m a parent
of two teenagers.

00:37:40.867 --> 00:37:42.467
I want a clean bill of health.

00:37:42.500 --> 00:37:44.233
That\'s my little girl.

00:37:44.267 --> 00:37:46.467
Are you sure
there\'s nothing you\'re missing?

00:37:46.500 --> 00:37:48.133
Well, I can\'t be 100% sure.

00:37:48.167 --> 00:37:50.400
I can tell you
the neurologic exam was normal.

00:37:50.433 --> 00:37:52.200
But there\'s
a 1-in-5,000 chance

00:37:52.233 --> 00:37:54.200
that there could be
a small bleed that I\'m missing.

00:37:54.233 --> 00:37:55.767
\"Well, yeah, I want the test.\"

00:37:57.000 --> 00:37:59.367
- When I do all sorts of tests

00:37:59.400 --> 00:38:02.933
that I don\'t really think
are abnormal,

00:38:02.967 --> 00:38:05.833
some of them are gonna
look abnormal just by chance.

00:38:05.867 --> 00:38:07.767
That\'s just how it is.

00:38:07.800 --> 00:38:11.800
And when they do look abnormal,
I\'m forced to do things to you

00:38:11.833 --> 00:38:13.867
that many times
will cause you harm

00:38:13.900 --> 00:38:18.333
and only rarely
will do any benefit.

00:38:18.367 --> 00:38:23.267
- Imaging or testing
in inappropriate circumstances

00:38:23.300 --> 00:38:26.467
just exposes you
to the risks of false positives.

00:38:26.500 --> 00:38:28.600
And working out
those false positives

00:38:28.633 --> 00:38:32.133
kills people... sometimes,
not often, thank heavens.

00:38:32.167 --> 00:38:35.767
There\'s this, oh,
deeply embedded belief

00:38:35.800 --> 00:38:37.333
that it\'s all upside.

00:38:37.367 --> 00:38:38.600
No.

00:38:57.133 --> 00:38:59.100
- Okay, relax.

00:38:59.133 --> 00:39:00.333
Okay, all finished.

00:39:00.367 --> 00:39:02.167
- All done?
- Mm-hmm.

00:39:02.200 --> 00:39:04.100
- So Melissa,
you had your big birthday

00:39:04.133 --> 00:39:05.933
this year where you turned 40.

00:39:05.967 --> 00:39:06.967
- I did.

00:39:07.000 --> 00:39:09.067
- And from age 40 on,
a little present

00:39:09.100 --> 00:39:11.633
that we like to give you
is an order for a mammogram.

00:39:11.667 --> 00:39:15.267
- When I turned 40,
my doctor said,

00:39:15.300 --> 00:39:18.600
\"Well, time
to start mammograms.\"

00:39:18.633 --> 00:39:22.267
And at that point,
I knew enough about mammography

00:39:22.300 --> 00:39:26.200
to know that the chances
that a mammogram

00:39:26.233 --> 00:39:29.967
for me in my 40s
would benefit me

00:39:30.000 --> 00:39:32.600
was a lot lower than the chances
that it would lead to harm.

00:39:34.067 --> 00:39:35.333
- There are many, many things

00:39:35.367 --> 00:39:37.733
that, under the microscope,
turn out to be cancer.

00:39:37.767 --> 00:39:39.667
But we\'d actually,
in real life...

00:39:39.700 --> 00:39:41.967
If we never looked for them,
we\'d never find them,

00:39:42.000 --> 00:39:45.333
and they\'d never
cause you a problem.

00:39:45.367 --> 00:39:47.667
Once we find them,
we don\'t know which is which.

00:39:47.700 --> 00:39:49.333
We have to do something
about it.

00:39:49.367 --> 00:39:50.933
So we\'re going to do
an intervention,

00:39:50.967 --> 00:39:53.500
which could cause you harm.

00:39:53.533 --> 00:39:55.567
It certainly will cause you
psychological concern.

00:39:55.600 --> 00:39:57.067
It will cause you
economic concern.

00:39:57.100 --> 00:39:59.667
It might interfere with
your ability to get insurance.

00:39:59.700 --> 00:40:01.333
It will change you
from a healthy person

00:40:01.367 --> 00:40:03.900
into a cancer victim.

00:40:03.933 --> 00:40:07.367
And it turns out,
in many cases we...

00:40:07.400 --> 00:40:08.640
If we had never known about it,

00:40:08.667 --> 00:40:10.233
you would never
have known about it.

00:40:10.267 --> 00:40:13.067
You would have died with it
50 years from now

00:40:13.100 --> 00:40:14.767
but not ever of it.

00:40:14.800 --> 00:40:15.967
- This is going to be
a new thing

00:40:16.000 --> 00:40:18.167
that we are going to start doing
once a year.

00:40:18.200 --> 00:40:20.267
Now, one of the questions
that a lot of the patients

00:40:20.300 --> 00:40:23.167
have had recently is,
in the news,

00:40:23.200 --> 00:40:24.233
in the last couple of years,

00:40:24.267 --> 00:40:25.667
there\'s been
a little controversy

00:40:25.700 --> 00:40:27.467
about when should we start
doing mammograms,

00:40:27.500 --> 00:40:28.667
how frequently should we do it,

00:40:28.700 --> 00:40:30.800
should we be doing them at all?

00:40:30.833 --> 00:40:33.700
We know it\'s a source
of much anxiety and worry

00:40:33.733 --> 00:40:35.400
for a lot of patients.

00:40:35.433 --> 00:40:37.033
But we love our patients.

00:40:37.067 --> 00:40:38.433
We care about our patients.

00:40:38.467 --> 00:40:40.867
And we want to do everything
we can to help keep you healthy.

00:40:43.367 --> 00:40:47.467
- Imagine screening
2,000 40-year-old women

00:40:47.500 --> 00:40:49.567
for a course of ten years.

00:40:49.600 --> 00:40:52.900
At most, one will avoid
a breast cancer death.

00:40:52.933 --> 00:40:55.000
- Okay, Nicky, just hold still.

00:40:55.033 --> 00:40:58.167
- But somewhere between
500 and 1,000,

00:40:58.200 --> 00:41:01.233
over the course of ten years,
will have one false alarm,

00:41:01.267 --> 00:41:03.233
that\'s a abnormal mammogram

00:41:03.267 --> 00:41:06.500
that makes them wary
that they might have cancer.

00:41:06.533 --> 00:41:08.733
And somewhere between
two and ten

00:41:08.767 --> 00:41:11.500
will be overdiagnosed
and treated unnecessarily

00:41:11.533 --> 00:41:12.967
for breast cancer.

00:41:13.000 --> 00:41:14.867
That means
they\'ll have a lumpectomy

00:41:14.900 --> 00:41:16.267
or a mastectomy

00:41:16.300 --> 00:41:18.000
or chemotherapy

00:41:18.033 --> 00:41:19.267
or radiation.

00:41:19.300 --> 00:41:21.800
- I wouldn\'t be surprised
if most women

00:41:21.833 --> 00:41:25.000
who knew the very tiny
likelihood of benefit

00:41:25.033 --> 00:41:27.400
and fairly substantial
likelihood of some harm,

00:41:27.433 --> 00:41:28.833
would say, \"I don\'t want it.\"

00:41:28.867 --> 00:41:30.567
- When it says,

00:41:30.600 --> 00:41:33.400
\"Oh, well, we shouldn\'t
do mammography till age 50,\"

00:41:33.433 --> 00:41:35.200
that\'s looking at populations.

00:41:35.233 --> 00:41:37.067
But now, you\'re
an individual patient.

00:41:37.100 --> 00:41:41.867
Now, it\'s my wife, Andrea,
who\'s 46.

00:41:41.900 --> 00:41:44.967
Should she skip her mammography
because this new study came out?

00:41:45.000 --> 00:41:46.733
Or should she
get her mammography?

00:41:46.767 --> 00:41:50.000
And that becomes
a very, very personal decision.

00:41:50.033 --> 00:41:53.767
If it picks something up,
it could actually save her life,

00:41:53.800 --> 00:41:56.433
despite when we looked
at 5,000 women,

00:41:56.467 --> 00:42:00.233
it didn\'t statistically
improve overall life survival,

00:42:00.267 --> 00:42:02.500
because there were false
negatives or false positives.

00:42:02.533 --> 00:42:04.033
But now, this is my wife.

00:42:04.067 --> 00:42:07.933
And when you start talking about
personal individual choices

00:42:07.967 --> 00:42:09.100
and families,

00:42:09.133 --> 00:42:11.533
the evidence
kind of takes a backseat.

00:42:11.567 --> 00:42:13.467
- Guess what I\'m going to
recommend to you, okay...

00:42:13.500 --> 00:42:15.600
Is that we should
do that annually.

00:42:15.633 --> 00:42:16.600
I think it\'s just worth it.

00:42:16.633 --> 00:42:18.200
It\'s the right thing to do.

00:42:18.233 --> 00:42:19.767
- After listening
to what you said,

00:42:19.800 --> 00:42:21.300
I mean,
I feel a lot more confident.

00:42:21.333 --> 00:42:24.567
For me, it\'s, yeah,
absolutely, I\'m...

00:42:24.600 --> 00:42:28.200
Guarantee I\'m going to get
that done as soon as possible.

00:42:28.233 --> 00:42:30.167
- Half of women in ten years

00:42:30.200 --> 00:42:31.933
will have one
false positive test...

00:42:31.967 --> 00:42:34.500
One out of every two.

00:42:34.533 --> 00:42:36.267
Now, some of those,
the false positive test,

00:42:36.300 --> 00:42:38.100
they get another test,
and everything\'s okay.

00:42:38.133 --> 00:42:39.100
It\'s not that harmful.

00:42:39.133 --> 00:42:41.200
But some of them
end up losing a breast,

00:42:41.233 --> 00:42:43.100
having pain, getting infection.

00:42:43.133 --> 00:42:46.300
And, yes, there is even a risk
of the rare case

00:42:46.333 --> 00:42:51.467
where, for crazy reasons,
a seemingly routine intervention

00:42:51.500 --> 00:42:53.567
ends up causing death.

00:42:53.600 --> 00:42:55.933
- We really do tend to focus on
our ability

00:42:55.967 --> 00:42:58.900
to detect abnormalities
and do something about them.

00:42:58.933 --> 00:43:01.400
We\'re very action-oriented.

00:43:01.433 --> 00:43:05.033
Scientifically, it\'s not
a black-and-white choice at all.

00:43:05.067 --> 00:43:08.133
It\'s a massive zone of gray.

00:43:08.167 --> 00:43:10.067
And then the question is:
who decides?

00:43:11.333 --> 00:43:13.067
- And the recent mammogram

00:43:13.100 --> 00:43:15.400
showed that you have
some microcalcifications,

00:43:15.433 --> 00:43:18.333
some little small calcifications
within the breast

00:43:18.367 --> 00:43:19.633
that are an indication

00:43:19.667 --> 00:43:22.000
that something
that is concerning going on

00:43:22.033 --> 00:43:23.300
within the breast.

00:43:23.333 --> 00:43:26.100
And so on that mammogram,
after they did that,

00:43:26.133 --> 00:43:28.833
they did
the stereotactic biopsy,

00:43:28.867 --> 00:43:31.567
and it showed
that there is a breast cancer.

00:43:31.600 --> 00:43:33.200
Yours is a grade one.

00:43:33.233 --> 00:43:35.033
It\'s the least aggressive.

00:43:35.067 --> 00:43:37.000
And so there are
two surgical options

00:43:37.033 --> 00:43:38.733
when we address breast cancer.

00:43:38.767 --> 00:43:41.333
Number one is to do a lumpectomy

00:43:41.367 --> 00:43:42.900
or breast preservation,

00:43:42.933 --> 00:43:45.733
where we just take out
the breast lump

00:43:45.767 --> 00:43:48.400
and sample the lymph nodes.

00:43:48.433 --> 00:43:50.667
Now, when we save the breast,

00:43:50.700 --> 00:43:53.567
you need to have radiation
afterwards

00:43:53.600 --> 00:43:55.933
to decrease the chances
of something coming back.

00:43:55.967 --> 00:43:58.033
And then the other option
is a mastectomy...

00:43:58.067 --> 00:44:03.033
To remove the entire breast
to take care of the cancer.

00:44:03.067 --> 00:44:05.900
The most important thing
that you can hear today

00:44:05.933 --> 00:44:09.100
is you are not going to make
a bad choice.

00:44:09.133 --> 00:44:11.267
If you preserve the breast
or take the breast,

00:44:11.300 --> 00:44:12.633
the mortality,

00:44:12.667 --> 00:44:14.333
which is
the most important thing,

00:44:14.367 --> 00:44:16.233
is the same, stage for stage.

00:44:16.267 --> 00:44:18.333
- I would prefer
to do the lumpectomy

00:44:18.367 --> 00:44:20.133
over the mastectomy, by far.

00:44:20.167 --> 00:44:22.333
I want to do everything I can
to preserve the breast.

00:44:22.367 --> 00:44:26.633
- Cosmetically, it would be
a very good option for you,

00:44:26.667 --> 00:44:29.433
and it\'s a smaller surgery
and a quicker recovery as well.

00:44:30.433 --> 00:44:32.633
Our goal, obviously, is cure.

00:44:34.233 --> 00:44:36.333
- Okay, I\'m going to give you
oxygen to breathe, okay?

00:44:36.367 --> 00:44:39.133
That\'s all this is,
big breaths in.

00:44:39.167 --> 00:44:40.333
Four more deep breaths.

00:44:40.367 --> 00:44:43.400
You\'ll be asleep
by the time you get to four.

00:44:43.433 --> 00:44:45.567
Good night.

00:44:53.600 --> 00:44:55.633
- There\'s this subtle area
of calcification.

00:44:55.667 --> 00:44:57.300
That\'s the area
that they biopsied

00:44:57.333 --> 00:44:58.667
that showed that she has cancer.

00:45:01.233 --> 00:45:02.967
So there\'s a hot spot
in the armpit,

00:45:03.000 --> 00:45:05.300
identifying a sentinel node.

00:45:05.333 --> 00:45:06.700
So we\'ll send this off
to pathology

00:45:06.733 --> 00:45:08.100
to be looked at right now.

00:45:09.100 --> 00:45:10.100
Hey.

00:45:15.333 --> 00:45:18.000
- I don\'t see anything
obvious yet.

00:45:18.033 --> 00:45:20.273
Yeah, there\'s no evidence
of tumor on the frozen section.

00:45:20.300 --> 00:45:22.200
- Okay, thanks, Michael.
Appreciate it.

00:45:26.767 --> 00:45:28.133
Now I\'m going to scrub back in,

00:45:28.167 --> 00:45:30.127
and we\'re going to take care
of the cancer itself.

00:45:36.167 --> 00:45:38.667
We have the abnormality
out that we want.

00:45:38.700 --> 00:45:40.340
I\'m going to talk to her family
right now.

00:45:42.967 --> 00:45:44.633
- So things went great.

00:45:44.667 --> 00:45:47.200
We were able to do everything
that we wanted to do.

00:45:47.233 --> 00:45:49.067
First we go after
the lymph nodes.

00:45:49.100 --> 00:45:50.500
We had the pathologists
look at it.

00:45:50.533 --> 00:45:52.233
And there was no evidence
of cancer in it.

00:45:52.267 --> 00:45:54.233
And then we took out the cancer
in the breast.

00:45:54.267 --> 00:45:56.667
And we X-rayed the tissue
that we got.

00:45:56.700 --> 00:45:59.800
And it looks like
we got everything out.

00:45:59.833 --> 00:46:01.567
- Wow, okay.

00:46:01.600 --> 00:46:07.200
- It\'s just...
It\'s a big relief.

00:46:07.233 --> 00:46:08.700
- Yeah.

00:46:08.733 --> 00:46:11.600
- The doctor said things
couldn\'t have gone better.

00:46:11.633 --> 00:46:14.700
And so we\'re really happy.
- Wow.

00:46:14.733 --> 00:46:16.700
That\'s really exciting.

00:46:16.733 --> 00:46:17.933
I can\'t believe it.

00:46:17.967 --> 00:46:21.067
- Cindy absolutely probably
saved her own life

00:46:21.100 --> 00:46:26.167
or at least saved herself
additional harsh treatments

00:46:26.200 --> 00:46:28.267
by having a screening mammogram
at age 47

00:46:28.300 --> 00:46:30.167
instead of waiting till age 50.

00:46:30.200 --> 00:46:32.633
Let\'s say she waited
until age 50.

00:46:32.667 --> 00:46:34.200
That would have given
this tumor,

00:46:34.233 --> 00:46:35.567
which was not palpable...

00:46:35.600 --> 00:46:38.500
It was seen only on the
mammogram and an ultrasound...

00:46:38.533 --> 00:46:41.200
Would have given that tumor
three more years to grow.

00:46:41.233 --> 00:46:42.900
Now, there are those
who argue that,

00:46:42.933 --> 00:46:45.033
\"Well, maybe it doesn\'t
make that much difference

00:46:45.067 --> 00:46:46.567
to find a cancer later.\"

00:46:46.600 --> 00:46:48.600
But we know
that that\'s patently false.

00:46:48.633 --> 00:46:51.933
We know that screening
mammography saves lives.

00:46:51.967 --> 00:46:55.100
- Well, I think mammograms
every year is important.

00:46:55.133 --> 00:46:58.033
- Yeah, now I do too.

00:46:58.067 --> 00:46:59.033
- Have you ever had one?

00:46:59.067 --> 00:47:01.200
- Uh-uh,
I\'ve been too chicken.

00:47:01.233 --> 00:47:02.667
- It\'s just...
You\'re too chicken?

00:47:02.700 --> 00:47:05.733
- Mm-hmm,
but I\'m not gonna be now.

00:47:05.767 --> 00:47:07.400
- No, it\'s not a big deal.

00:47:07.433 --> 00:47:08.867
It\'s easy to do.

00:47:08.900 --> 00:47:11.633
And it takes 10, 15 minutes,
and you\'re out, in and out.

00:47:11.667 --> 00:47:12.733
- Oh, wow.

00:47:12.767 --> 00:47:14.667
- It\'s just a picture.

00:47:14.700 --> 00:47:17.067
- Every time someone
has a diagnosed cancer,

00:47:17.100 --> 00:47:19.967
I hope that she is, in fact,
the winner of the lottery

00:47:20.000 --> 00:47:23.600
and did have her life
saved by the test.

00:47:23.633 --> 00:47:26.067
Our estimates are,
though, in fact

00:47:26.100 --> 00:47:27.600
that\'s relatively uncommon.

00:47:27.633 --> 00:47:30.967
It\'s less than one in four,
less than 25%.

00:47:31.000 --> 00:47:32.567
There\'re two other possibilities

00:47:32.600 --> 00:47:34.900
that combined are
actually more common.

00:47:34.933 --> 00:47:38.233
One is:
she was diagnosed early,

00:47:38.267 --> 00:47:41.500
but she didn\'t benefit
from the early diagnosis.

00:47:41.533 --> 00:47:44.100
In other words, she would
have been treated just as well

00:47:44.133 --> 00:47:47.167
if her cancer
had presented clinically.

00:47:47.200 --> 00:47:49.867
- Oh, pajamas,
so I can be comfortable.

00:47:49.900 --> 00:47:52.733
- But the third possibility
is that she was overdiagnosed,

00:47:52.767 --> 00:47:54.200
that she had a cancer

00:47:54.233 --> 00:47:56.933
that was never going
to become apparent clinically,

00:47:56.967 --> 00:47:58.867
that was never going
to kill her.

00:47:58.900 --> 00:48:01.067
And yet she was treated for it.

00:48:01.100 --> 00:48:04.167
And in fact, that\'s the harm
of cancer screening.

00:48:04.200 --> 00:48:07.133
Now, I hope that\'s not the case
in Cindy\'s case.

00:48:07.167 --> 00:48:08.533
I hope she\'s a winner.

00:48:08.567 --> 00:48:11.800
But in fact, most women
with screen-detected cancer

00:48:11.833 --> 00:48:14.233
fall in one
of the other two categories.

00:48:14.267 --> 00:48:15.733
- I feel great.

00:48:15.767 --> 00:48:17.000
- Yeah, you look good.

00:48:17.033 --> 00:48:19.167
- I even feel better now
that the news is so good.

00:48:19.200 --> 00:48:20.867
[laughs]

00:48:20.900 --> 00:48:22.300
- Yeah.
- So that\'s good.

00:48:22.333 --> 00:48:24.167
- It\'s a big relief.
I know you\'ve been worried.

00:48:24.200 --> 00:48:25.367
- Oh, my gosh, I know.

00:48:25.400 --> 00:48:29.567
It\'s been a roller-coaster
of emotions,

00:48:29.600 --> 00:48:30.833
so it\'s really good.

00:48:35.100 --> 00:48:36.200
Love you.

00:48:51.067 --> 00:48:54.300
- So, Adam, I wanted to discuss
routine PSA screening with you.

00:48:54.333 --> 00:48:56.067
We\'ve talked about this
in the past.

00:48:56.100 --> 00:48:58.633
- Prostate cancer screening
is the poster child

00:48:58.667 --> 00:49:00.633
for overdiagnosis.

00:49:00.667 --> 00:49:04.700
With the advent
of the PSA blood test,

00:49:04.733 --> 00:49:06.967
which is
the prostate-specific antigen...

00:49:07.000 --> 00:49:09.700
The screening test
for prostate cancer.

00:49:09.733 --> 00:49:14.567
In the late 1980s,
this test led to a huge upsurge

00:49:14.600 --> 00:49:17.867
in the number of diagnosed cases
of prostate cancer.

00:49:17.900 --> 00:49:22.033
- This is a test
that we do on men.

00:49:22.067 --> 00:49:24.133
We offer it to them
at the age of 50 for everyone

00:49:24.167 --> 00:49:26.067
and age 40
if they\'re at higher risk.

00:49:26.100 --> 00:49:28.140
And since your dad passed away
from prostate cancer,

00:49:28.167 --> 00:49:29.733
you\'re one of those
higher-risk people.

00:49:29.767 --> 00:49:31.067
And we\'ve been
talking about this

00:49:31.100 --> 00:49:32.540
since you were 40 years old,
I think.

00:49:32.567 --> 00:49:33.967
- Correct.

00:49:34.000 --> 00:49:36.167
- What are your feelings about
getting a routine PSA test?

00:49:36.200 --> 00:49:37.867
- I have no issues about it;
I\'d rather know.

00:49:37.900 --> 00:49:38.867
- Okay.

00:49:38.900 --> 00:49:40.267
- Definitely rather know.
- Okay.

00:49:40.300 --> 00:49:42.400
- It seems like catching it
early would be a good thing,

00:49:42.433 --> 00:49:44.933
but it almost never is,
because when you catch it early,

00:49:44.967 --> 00:49:46.500
you\'re mostly
not catching cancer.

00:49:46.533 --> 00:49:49.000
You\'re catching something that
looks like cancer and it isn\'t.

00:49:49.033 --> 00:49:51.133
And when it is cancer,
it almost never is a cancer

00:49:51.167 --> 00:49:53.000
that would ever bother you
in your life.

00:49:53.033 --> 00:49:54.400
So we\'re finding it.

00:49:54.433 --> 00:49:55.700
We have to do something
about it.

00:49:55.733 --> 00:49:57.100
But it\'s trivial.

00:49:57.133 --> 00:49:59.200
It\'s only cancer
under the microscope.

00:49:59.233 --> 00:50:02.500
And the flip side is,
the few others...

00:50:02.533 --> 00:50:04.067
It\'s probably too late
to do anything.

00:50:04.100 --> 00:50:07.233
So we haven\'t found anything
that\'s good for you.

00:50:07.267 --> 00:50:08.800
On the other hand,
the treatments

00:50:08.833 --> 00:50:11.800
have a very good chance
of making you impotent,

00:50:11.833 --> 00:50:14.400
have a very good chance
of making you incontinent.

00:50:14.433 --> 00:50:17.800
It can cause all sorts
of other problems as well.

00:50:17.833 --> 00:50:20.567
- It turns out
in autopsy studies of men

00:50:20.600 --> 00:50:25.600
age 50, 60, 70,
upwards of 50% to,

00:50:25.633 --> 00:50:28.333
in the 70-year-old group,
closer to 80%

00:50:28.367 --> 00:50:31.933
have pathologic evidence
of the disease.

00:50:31.967 --> 00:50:35.333
So if we start to look
really hard for prostate cancer,

00:50:35.367 --> 00:50:39.600
we will find it
in over half of older men.

00:50:39.633 --> 00:50:43.900
There\'s evidence that since
the advent of the PSA test,

00:50:43.933 --> 00:50:48.467
it looks like we\'ve treated
about 1.3 million American men

00:50:48.500 --> 00:50:53.500
for a disease that was never
going to bother them.

00:50:53.533 --> 00:50:56.100
- The U.S. Preventive Services
Task Force

00:50:56.133 --> 00:50:58.267
said that
at the population level,

00:50:58.300 --> 00:51:00.133
we shouldn\'t be spending money
on screening,

00:51:00.167 --> 00:51:01.733
\'cause the evidence doesn\'t
support it.

00:51:01.767 --> 00:51:03.567
Researchers
look at the outcomes.

00:51:03.600 --> 00:51:07.500
Are the men who were screened
regularly for prostate cancer

00:51:07.533 --> 00:51:09.667
more likely to be alive

00:51:09.700 --> 00:51:12.400
and not having died
from prostate cancer?

00:51:12.433 --> 00:51:14.767
And the answer was, \"No.\"

00:51:14.800 --> 00:51:19.167
- For the physician, all the
incentives are just to do it.

00:51:19.200 --> 00:51:21.667
If I don\'t do it and
you end up with prostate cancer,

00:51:21.700 --> 00:51:22.900
you\'re going to be
very mad at me

00:51:22.933 --> 00:51:24.767
and you\'re gonna...
You might sue me.

00:51:24.800 --> 00:51:27.967
And you\'re certainly going to
think that I cost you your life.

00:51:28.000 --> 00:51:29.567
You\'re going to be very,
very unhappy.

00:51:29.600 --> 00:51:32.467
If I do it
and I do no benefit to you,

00:51:32.500 --> 00:51:35.000
the test is normal,
you\'ll still think I\'m a good...

00:51:35.033 --> 00:51:36.500
A good, savvy doctor.

00:51:36.533 --> 00:51:38.467
If I do it
and I do worse than that...

00:51:38.500 --> 00:51:40.033
It gets a false positive

00:51:40.067 --> 00:51:42.167
and I end up doing all sorts
of interventions

00:51:42.200 --> 00:51:44.733
and you end up impotent

00:51:44.767 --> 00:51:46.767
for something that you
had no reason ever to undergo

00:51:46.800 --> 00:51:47.767
in the first place...

00:51:47.800 --> 00:51:49.200
You\'re still going to thank me.

00:51:49.233 --> 00:51:51.267
You\'re going to say, \"Phew,
the doctor saved my life.

00:51:51.300 --> 00:51:52.500
\"Isn\'t that great?

00:51:52.533 --> 00:51:54.767
I had prostate cancer,
and now I\'m better.\"

00:51:54.800 --> 00:51:57.000
And I get paid more.

00:51:57.033 --> 00:51:59.800
Unfortunately,
that\'s not always what\'s best

00:51:59.833 --> 00:52:01.800
for the patient.

00:52:01.833 --> 00:52:05.067
- I think practitioners
will ignore the recommendations.

00:52:05.100 --> 00:52:08.733
And the reason for that
is that PSA

00:52:08.767 --> 00:52:14.300
is as simple as checking a box
on a laboratory requisition

00:52:14.333 --> 00:52:16.800
and sending a patient
for a blood test.

00:52:16.833 --> 00:52:19.100
It\'s counterintuitive
to patients and to doctors

00:52:19.133 --> 00:52:21.000
that that could possibly
be harmful.

00:52:21.033 --> 00:52:22.467
- I\'d rather know now,

00:52:22.500 --> 00:52:24.233
rather than wait
till it\'s late-stage

00:52:24.267 --> 00:52:26.433
and there\'s nothing
I can really do.

00:52:26.467 --> 00:52:31.400
- The central issue
is not an issue of screening,

00:52:31.433 --> 00:52:32.900
even though
that\'s the discussion.

00:52:32.933 --> 00:52:35.933
The central issue
is being smarter about treatment

00:52:35.967 --> 00:52:39.800
or choosing not to treat
in men whom we do diagnose

00:52:39.833 --> 00:52:41.433
with prostate cancer.

00:52:41.467 --> 00:52:44.667
- As you know, we have
the results in from the biopsy.

00:52:44.700 --> 00:52:45.833
And as you know, it does show

00:52:45.867 --> 00:52:47.333
that there\'s a cancer
in the prostate

00:52:47.367 --> 00:52:51.200
as we suspected there would be
based on that PSA test.

00:52:51.233 --> 00:52:54.100
Let\'s review the options
that we\'ve talked about.

00:52:54.133 --> 00:52:56.167
There\'s surgery,
which is an operation

00:52:56.200 --> 00:52:58.000
called radical prostatectomy.

00:52:58.033 --> 00:53:00.333
It can be done
through an open incision,

00:53:00.367 --> 00:53:01.667
which is the traditional way.

00:53:01.700 --> 00:53:03.167
It\'s been around for decades.

00:53:03.200 --> 00:53:06.767
Or it can be done the newer way
with a robotic assistant.

00:53:06.800 --> 00:53:08.767
Another option
is radiation therapy.

00:53:08.800 --> 00:53:12.067
Radiation can be given
as an external beam,

00:53:12.100 --> 00:53:14.167
which we call IMRT,

00:53:14.200 --> 00:53:16.767
or it can be given
as radioactive pellets,

00:53:16.800 --> 00:53:17.967
or brachytherapy,

00:53:18.000 --> 00:53:20.267
implanted directly
into your prostate.

00:53:20.300 --> 00:53:22.733
If you want to use
a proton machine,

00:53:22.767 --> 00:53:24.467
you have to go
to where that machine is,

00:53:24.500 --> 00:53:26.367
and there\'s several
around the country.

00:53:26.400 --> 00:53:28.400
Another option
is active surveillance...

00:53:28.433 --> 00:53:32.533
You go onto a rigid protocol
of regular PSA tests

00:53:32.567 --> 00:53:35.933
and regular repeat biopsies,
and if it progresses,

00:53:35.967 --> 00:53:40.433
then we revisit the idea
of considering active therapy.

00:53:40.467 --> 00:53:43.633
- It would nice for me to be
around for the next ten years

00:53:43.667 --> 00:53:48.500
without the use of catheters
and diapers and other things

00:53:48.533 --> 00:53:51.300
if it was not necessary
to save my life.

00:53:51.333 --> 00:53:55.033
- The prostate cancer
can be treated very effectively,

00:53:55.067 --> 00:53:56.333
but it\'s not free.

00:53:56.367 --> 00:53:58.833
The human cost
of that treatment,

00:53:58.867 --> 00:54:03.533
in terms of urinary problems,
sexual problems, bowel problems,

00:54:03.567 --> 00:54:05.967
may all be significant.

00:54:06.000 --> 00:54:07.133
- You might say,

00:54:07.167 --> 00:54:09.233
\"Gee, how is the patient
possibly gonna decide

00:54:09.267 --> 00:54:10.800
\"between these therapies

00:54:10.833 --> 00:54:12.733
\"with so little evidence
to guide us

00:54:12.767 --> 00:54:14.567
\"about whether one
is better than the other

00:54:14.600 --> 00:54:17.633
in terms of either
cancer control or side effects?\"

00:54:17.667 --> 00:54:20.400
- People rely on us
to help them make decisions.

00:54:20.433 --> 00:54:21.900
But if it turns out
that your doctor

00:54:21.933 --> 00:54:23.000
doesn\'t have information

00:54:23.033 --> 00:54:24.733
about which one is good
or which isn\'t...

00:54:24.767 --> 00:54:26.500
And your doctor
could do a much better job

00:54:26.533 --> 00:54:27.600
if she knew that,

00:54:27.633 --> 00:54:29.000
because we studied it
and we said,

00:54:29.033 --> 00:54:31.100
\"This treatment\'s good.
This treatment isn\'t good.

00:54:31.133 --> 00:54:32.800
That test is good.
This one isn\'t.\"

00:54:32.833 --> 00:54:35.667
That would help your doctor
help you make a decision.

00:54:35.700 --> 00:54:37.633
Why don\'t we do
the type of research

00:54:37.667 --> 00:54:40.067
that tells us what actually
works and what doesn\'t work?

00:54:40.100 --> 00:54:41.233
- So the first question is:

00:54:41.267 --> 00:54:43.000
do I recommend
that you be treated?

00:54:43.033 --> 00:54:44.967
There are a few reasons
I do recommend...

00:54:45.000 --> 00:54:47.867
- Until we as a nation start
to measure the effectiveness

00:54:47.900 --> 00:54:51.567
of what we\'re doing
as a routine part of practice,

00:54:51.600 --> 00:54:56.100
we are flying the health care
airline with no instruments.

00:54:56.133 --> 00:54:58.233
We are crashing.

00:54:58.267 --> 00:54:59.733
We don\'t know how high we are.

00:54:59.767 --> 00:55:01.100
We don\'t know where we\'re going.

00:55:01.133 --> 00:55:02.773
We don\'t know
how much gas is in the tank,

00:55:02.800 --> 00:55:05.133
because we don\'t measure
the effectiveness

00:55:05.167 --> 00:55:09.033
of anything we do
in health care.

00:55:09.067 --> 00:55:11.667
- Medicine really
has been this cottage industry

00:55:11.700 --> 00:55:14.333
where each doc learned
from an apprentice model,

00:55:14.367 --> 00:55:15.833
and then goes and practices

00:55:15.867 --> 00:55:17.400
in their own
little private practice.

00:55:17.433 --> 00:55:19.800
If you don\'t pool
that information together

00:55:19.833 --> 00:55:21.767
and really use evidence as a way

00:55:21.800 --> 00:55:26.067
to come up with decision-making,
you never advance.

00:55:38.167 --> 00:55:40.067
- I had a blood test

00:55:40.100 --> 00:55:42.000
and was a little surprised
to get a call

00:55:42.033 --> 00:55:43.867
from my physician about that.

00:55:43.900 --> 00:55:47.100
He said that I had not
done so well with PSA.

00:55:47.133 --> 00:55:48.133
So at that point,

00:55:48.167 --> 00:55:50.633
it was time
to schedule a biopsy.

00:55:50.667 --> 00:55:52.867
- You\'re not gonna pass out.

00:55:52.900 --> 00:55:54.433
- There are a number
of different plugs

00:55:54.467 --> 00:55:55.900
they take out of the prostate,

00:55:55.933 --> 00:55:58.333
and some of them, in my case,
were cancerous.

00:55:58.367 --> 00:56:01.833
And being as young as I am
at 55,

00:56:01.867 --> 00:56:05.067
my view is that surgery
is the best option for me.

00:56:05.100 --> 00:56:08.200
- I never envisioned our life
together

00:56:08.233 --> 00:56:10.900
to be possibly shortened,
you know.

00:56:10.933 --> 00:56:13.000
We were looking to cruising off
into the sunset.

00:56:13.033 --> 00:56:15.767
And we\'re still
actively raising children.

00:56:15.800 --> 00:56:17.833
And here we are,
and you have this diagnosis.

00:56:17.867 --> 00:56:20.133
It\'s just hard to do.

00:56:20.167 --> 00:56:23.033
- It changed my view
of my future quite a bit.

00:56:23.067 --> 00:56:26.200
And I gradually came around
to the point of view

00:56:26.233 --> 00:56:27.867
that I\'m actually fortunate

00:56:27.900 --> 00:56:31.333
that if I had to have a tumor
of this sort,

00:56:31.367 --> 00:56:32.667
this is an oppor...

00:56:32.700 --> 00:56:34.967
This is a much easier one
to find at an early stage

00:56:35.000 --> 00:56:38.600
and to be able
to take, you know,

00:56:38.633 --> 00:56:40.500
aggressive action against it.

00:56:40.533 --> 00:56:42.067
- I\'m ready if you are.
- Great, yeah.

00:56:42.100 --> 00:56:43.067
- I\'m ready.

00:56:43.100 --> 00:56:44.233
So we\'ve talked a little bit

00:56:44.267 --> 00:56:46.167
about the advantages
and disadvantages

00:56:46.200 --> 00:56:47.900
of the robotic surgery.

00:56:47.933 --> 00:56:51.367
The major advantages of
robotic are, in my experience,

00:56:51.400 --> 00:56:54.200
that your recovery
will be faster,

00:56:54.233 --> 00:56:56.567
perhaps a little bit less pain;

00:56:56.600 --> 00:56:59.433
the risk of bleeding
is significantly lower;

00:56:59.467 --> 00:57:03.500
and at least in our hands here,
the chances of actually getting

00:57:03.533 --> 00:57:05.500
what we call
a negative surgical margin...

00:57:05.533 --> 00:57:09.300
That is getting the cancer out
without any margins around it...

00:57:09.333 --> 00:57:11.033
At least in my hands,
have been lower

00:57:11.067 --> 00:57:12.800
with the robotic approach.

00:57:12.833 --> 00:57:15.700
So put you to sleep, and
we\'ll go ahead and get started.

00:57:18.033 --> 00:57:19.100
- It\'s never enough?

00:57:19.133 --> 00:57:24.367
- Never enough, no.
- Okay.

00:57:24.400 --> 00:57:26.467
So answer your email;
don\'t worry about me.

00:57:26.500 --> 00:57:28.600
- Yeah, when you get home,
you\'ve got chores to do so...

00:57:28.633 --> 00:57:30.167
- Yeah, yeah, I know.

00:57:30.200 --> 00:57:32.033
- Buck up, honey.

00:57:32.067 --> 00:57:34.200
- No heavy lifting for a while.

00:57:34.233 --> 00:57:35.567
- She\'ll think of something.

00:57:35.600 --> 00:57:37.233
- That\'s true actually,
no heavy lifting.

00:57:37.267 --> 00:57:38.267
- Dishes, dishes.

00:57:38.300 --> 00:57:39.700
- Well, folding laundry
doesn\'t...

00:57:39.733 --> 00:57:42.233
- There\'s an assumption
on the part of the public,

00:57:42.267 --> 00:57:44.567
and even on the part
of many physicians,

00:57:44.600 --> 00:57:47.433
that, you know,
physicians are scientists,

00:57:47.467 --> 00:57:51.400
and that science mediated
through my brilliant judgment

00:57:51.433 --> 00:57:53.333
is somehow going to lead
to the correct treatment

00:57:53.367 --> 00:57:57.733
for you, my patient, every time,
you know, for every patient.

00:57:57.767 --> 00:58:00.200
Nothing could be further
from the truth.

00:58:00.233 --> 00:58:02.167
- It\'s a little bright.

00:58:02.200 --> 00:58:05.800
- There\'s so little science
behind many of these decisions.

00:58:05.833 --> 00:58:08.133
The same patient
is gonna be treated

00:58:08.167 --> 00:58:09.133
in a different way

00:58:09.167 --> 00:58:11.033
at one hospital
versus another hospital.

00:58:11.067 --> 00:58:12.967
- Geography is destiny.

00:58:15.200 --> 00:58:18.967
What you get in health care
depends more on where you live

00:58:19.000 --> 00:58:22.967
and who you see
than on evidence.

00:58:23.000 --> 00:58:25.367
It\'s really hard to fathom

00:58:25.400 --> 00:58:28.667
that more is being done
in one place versus another

00:58:28.700 --> 00:58:30.100
just by your ZIP code.

00:58:30.133 --> 00:58:34.833
- Very highly trained people
with great skills and knowledge

00:58:34.867 --> 00:58:38.233
who\'ve put in a career at
being the best at what they do,

00:58:38.267 --> 00:58:40.767
you put them in one place
versus another place,

00:58:40.800 --> 00:58:42.900
and they act very differently.

00:58:42.933 --> 00:58:48.533
And that cannot be
because of a medical reason.

00:58:48.567 --> 00:58:51.533
It can\'t be \'cause it\'s better
in one place to do something

00:58:51.567 --> 00:58:53.033
and another place not to do it.

00:58:53.067 --> 00:58:55.067
- If you identify variation

00:58:55.100 --> 00:58:57.600
that\'s 10-fold,
15-, 20-fold,

00:58:57.633 --> 00:58:58.967
like we see in prostate cancer

00:58:59.000 --> 00:59:00.233
from one area of the country

00:59:00.267 --> 00:59:01.500
to another,

00:59:01.533 --> 00:59:03.767
then we know that it\'s
an example of a disease

00:59:03.800 --> 00:59:07.400
that ought to be treated
less frequently.

00:59:07.433 --> 00:59:10.133
The majority of men
treated for prostate cancer

00:59:10.167 --> 00:59:13.967
in retrospect wouldn\'t have died
from their disease,

00:59:14.000 --> 00:59:17.200
and therefore by definition,
we\'re overtreating those men

00:59:17.233 --> 00:59:18.633
with prostate cancer.

00:59:18.667 --> 00:59:20.333
- I believe
that I may be one of the people

00:59:20.367 --> 00:59:22.867
whose life was saved,
or at least extended,

00:59:22.900 --> 00:59:24.933
by going in aggressively.

00:59:24.967 --> 00:59:27.800
But I understand that there is
a lot of unnecessary treatment

00:59:27.833 --> 00:59:30.067
that people undergo.

00:59:30.100 --> 00:59:32.167
But I\'m not comfortable
carrying a tumor around

00:59:32.200 --> 00:59:34.500
if I don\'t know
how lethal it is.

00:59:34.533 --> 00:59:35.867
- That organ there...

00:59:35.900 --> 00:59:40.500
- We may know from studies
that too many or too few people

00:59:40.533 --> 00:59:42.800
in a population
are being treated.

00:59:42.833 --> 00:59:45.767
But it\'s hard to look
at any one person and say,

00:59:45.800 --> 00:59:51.033
\"Yes, Mr. Jones was overtreated;
Mrs. Smith was undertreated,\"

00:59:51.067 --> 00:59:54.533
\'cause we can never be sure
whether we\'re doing some good

00:59:54.567 --> 00:59:58.167
or doing some harm
in an individual case.

00:59:58.200 --> 01:00:01.467
- Did Kim let you know
when she\'s coming home?

01:00:01.500 --> 01:00:02.833
Going into the surgery,

01:00:02.867 --> 01:00:05.467
I was aware
of the potential side effects,

01:00:05.500 --> 01:00:08.300
that I might be giving up
some things

01:00:08.333 --> 01:00:09.900
that I would rather not give up,

01:00:09.933 --> 01:00:12.633
and as it\'s turned out,
I did give up something,

01:00:12.667 --> 01:00:15.067
but prostate cancer
kills people.

01:00:15.100 --> 01:00:16.367
And I would do it again.

01:00:17.633 --> 01:00:20.267
- You have to remove
about 15 prostates

01:00:20.300 --> 01:00:22.900
to prevent one
prostate cancer death.

01:00:22.933 --> 01:00:25.133
The problem is,
at the individual level

01:00:25.167 --> 01:00:28.100
all 15 of those men
will think it was them

01:00:28.133 --> 01:00:29.133
whose life was saved.

01:00:29.167 --> 01:00:30.400
1 of them is right.

01:00:30.433 --> 01:00:31.800
14 are wrong.

01:00:31.833 --> 01:00:33.567
But we don\'t know which one.

01:00:33.600 --> 01:00:35.733
- And I may well be
one of the 14

01:00:35.767 --> 01:00:38.767
for whom this wasn\'t
particularly lifesaving

01:00:38.800 --> 01:00:40.400
or in any way important,

01:00:40.433 --> 01:00:46.667
but since I can\'t know that,
I\'m not going to mess around.

01:00:46.700 --> 01:00:48.300
- Warm, I\'m cold.
- You\'re cold?

01:00:48.333 --> 01:00:50.033
And I think
that the consequences

01:00:50.067 --> 01:00:52.633
and the side effects
are unfortunate,

01:00:52.667 --> 01:00:55.233
but at least I\'m not left
with the concern

01:00:55.267 --> 01:00:59.800
that I could have done more
and didn\'t act.

01:01:04.300 --> 01:01:08.200
- Treatments that are powerful
enough to heal can also harm.

01:01:08.233 --> 01:01:10.200
I trained in surgery.

01:01:10.233 --> 01:01:13.900
To be a good surgeon, you
have to believe in what you do.

01:01:13.933 --> 01:01:16.233
You really do.

01:01:16.267 --> 01:01:18.067
And so the advice
we give to patients

01:01:18.100 --> 01:01:20.033
is much too aggressive,

01:01:20.067 --> 01:01:22.100
more aggressive
than they would probably choose

01:01:22.133 --> 01:01:24.900
if they had a true fair choice.

01:01:24.933 --> 01:01:30.333
But maybe I need my counselor
who advises the surgery

01:01:30.367 --> 01:01:31.700
to not be the surgeon.

01:01:36.567 --> 01:01:39.300
- I got a phone call
from the urologist

01:01:39.333 --> 01:01:42.133
that confirmed
that I had cancer.

01:01:42.167 --> 01:01:46.400
I turned to my wife...
I got the phone call,

01:01:46.433 --> 01:01:47.533
and I said,

01:01:47.567 --> 01:01:51.867
\"Life as we have known it
is over.\"

01:01:51.900 --> 01:01:54.267
And that\'s where I was headed.

01:01:54.300 --> 01:01:57.600
I did not know about
proton treatment at that time.

01:01:59.367 --> 01:02:01.433
- The key
to successful cancer treatment

01:02:01.467 --> 01:02:04.733
is avoiding the normal tissues
surrounding the cancer.

01:02:04.767 --> 01:02:09.033
And protons allows us
to miss more normal tissue

01:02:09.067 --> 01:02:11.667
than we\'re able to
with other forms of radiation.

01:02:14.433 --> 01:02:17.333
- I call it a,
instead of a shotgun approach,

01:02:17.367 --> 01:02:18.533
a .22 approach...

01:02:18.567 --> 01:02:22.300
When it comes in
and stops with all of its energy

01:02:22.333 --> 01:02:23.467
right at the prostate

01:02:23.500 --> 01:02:25.400
and doesn\'t go on
through the body

01:02:25.433 --> 01:02:28.733
and causing damage
to other inner organs.

01:02:30.000 --> 01:02:33.267
I was able to avoid
having surgery,

01:02:33.300 --> 01:02:36.767
having a catheter
for two to three weeks,

01:02:36.800 --> 01:02:39.633
having incontinence
and impotence.

01:02:39.667 --> 01:02:42.300
It\'s the most effective thing
on Earth.

01:02:42.333 --> 01:02:46.233
- The cost of a proton facility
can run up to $150 million.

01:02:46.267 --> 01:02:49.700
So it is more expensive to build
the facility than others,

01:02:49.733 --> 01:02:51.433
but it really
comes down to the cost

01:02:51.467 --> 01:02:54.233
to the individual patient.

01:02:54.267 --> 01:02:57.633
- I had to sign papers
that I\'d be responsible

01:02:57.667 --> 01:02:59.667
for all the cost.

01:02:59.700 --> 01:03:03.667
It\'s between
$70,000 and $200,000.

01:03:03.700 --> 01:03:04.967
- By far and away,

01:03:05.000 --> 01:03:07.700
we have the best tool
to destroy prostate cancer.

01:03:07.733 --> 01:03:10.867
- It\'s very American, I think,
to think that higher tech

01:03:10.900 --> 01:03:12.500
is better than lower tech,

01:03:12.533 --> 01:03:15.100
new tech
is better than old tech.

01:03:15.133 --> 01:03:19.900
And so we\'ve created this way
of thinking about health care

01:03:19.933 --> 01:03:23.367
that is ultimately inflationary.

01:03:23.400 --> 01:03:27.167
- Unfortunately, the innovation
gets well ahead of the science.

01:03:27.200 --> 01:03:29.700
So I think
we have to be really cautious

01:03:29.733 --> 01:03:31.600
about new cancer therapies

01:03:31.633 --> 01:03:34.400
and make sure
that they\'re really tested

01:03:34.433 --> 01:03:37.667
and that we know that they
actually confer some advantage,

01:03:37.700 --> 01:03:42.133
because they certainly confer
a lot of additional cost

01:03:42.167 --> 01:03:44.300
and may actually cause harm.

01:03:46.667 --> 01:03:49.233
- It has saved my life.

01:03:49.267 --> 01:03:51.367
I have the satisfaction
in my mind

01:03:51.400 --> 01:03:53.400
that I don\'t have cancer.

01:03:53.433 --> 01:03:57.000
In fact, I think of getting
all my affairs in order.

01:03:57.033 --> 01:03:58.367
I bought a new suit.

01:03:58.400 --> 01:04:01.567
I\'m going to live, not die.

01:04:01.600 --> 01:04:06.200
The suit is for living,
not for my funeral.

01:04:06.233 --> 01:04:09.900
- In Mr. Thompson\'s case,
I hope it changed his outcome.

01:04:09.933 --> 01:04:13.033
But again, one person\'s story
doesn\'t tell you

01:04:13.067 --> 01:04:14.933
whether the treatment
really helps.

01:04:14.967 --> 01:04:16.567
In fact, it\'s possible

01:04:16.600 --> 01:04:18.400
that he may not
have even needed treatment.

01:04:18.433 --> 01:04:19.567
You just don\'t know.

01:04:19.600 --> 01:04:22.200
- It really is a problem
that we don\'t have

01:04:22.233 --> 01:04:24.300
good, comparative
effectiveness studies

01:04:24.333 --> 01:04:27.900
to show us that, particularly
the more expensive treatments,

01:04:27.933 --> 01:04:30.333
things like robotic radical
prostatectomy

01:04:30.367 --> 01:04:32.267
or proton beam therapy,

01:04:32.300 --> 01:04:35.667
despite being so much more
expensive, are any better.

01:04:35.700 --> 01:04:38.600
And they could even be worse
in terms of cancer control

01:04:38.633 --> 01:04:39.967
or side effects.

01:04:40.000 --> 01:04:44.767
- In American health care,
the bar to adapt new technology

01:04:44.800 --> 01:04:47.633
has been relatively low.

01:04:47.667 --> 01:04:50.067
And I think
we\'ve developed that culture.

01:04:50.100 --> 01:04:52.633
To develop a new drug,

01:04:52.667 --> 01:04:54.733
we have a lot of hurdles
to go through.

01:04:54.767 --> 01:04:58.600
To develop a new technology,
in this case proton treatment,

01:04:58.633 --> 01:05:03.033
the bar really is that
it\'s not harmful, or not worse,

01:05:03.067 --> 01:05:05.500
not that it necessarily
needs to be better.

01:05:05.533 --> 01:05:07.000
And it may be better,

01:05:07.033 --> 01:05:09.367
but when something
costs that much,

01:05:09.400 --> 01:05:13.167
one would truly like to know
it\'s better

01:05:13.200 --> 01:05:15.367
if society
is gonna bear the cost.

01:05:18.067 --> 01:05:21.167
- He\'s 83 years old
with a PSA 117,

01:05:21.200 --> 01:05:23.100
Gleason score four plus three,

01:05:23.133 --> 01:05:25.533
adenocarcinoma in 9 of 12 cores,

01:05:25.567 --> 01:05:28.133
but the involved cores
were 50% to 100% involved.

01:05:28.167 --> 01:05:29.967
- I\'d sure feel
a lot more comfortable

01:05:30.000 --> 01:05:32.167
about even just saying
intermittent therapy.

01:05:32.200 --> 01:05:34.067
- Doing the kitchen sink
approach may be better.

01:05:34.100 --> 01:05:35.967
- He could probably wait
a couple years.

01:05:36.000 --> 01:05:37.533
- Do you have those results?
- I do.

01:05:37.567 --> 01:05:39.133
- One of the things
that we\'ve invested in

01:05:39.167 --> 01:05:40.367
very heavily at Intermountain

01:05:40.400 --> 01:05:41.667
is data.

01:05:41.700 --> 01:05:43.600
Data is your ability to see.

01:05:43.633 --> 01:05:45.767
We can tell what works.

01:05:45.800 --> 01:05:48.833
That\'s the first key
for being able to innovate.

01:05:48.867 --> 01:05:51.167
You have to be able to tell
if a change was an improvement.

01:05:51.200 --> 01:05:53.767
That\'s how you find best care.

01:05:53.800 --> 01:05:56.400
We try to build those data
right into the flow of work.

01:05:56.433 --> 01:05:58.967
We try to give our clinicians,
our physicians, our nurses

01:05:59.000 --> 01:06:02.400
a clear picture
of what this means to patients.

01:06:02.433 --> 01:06:03.767
When we\'ve done that,

01:06:03.800 --> 01:06:06.333
it\'s been associated
with fairly massive improvements

01:06:06.367 --> 01:06:07.733
in patient results.

01:06:07.767 --> 01:06:10.400
And the funny thing is,
it\'s nearly always associated

01:06:10.433 --> 01:06:12.467
with significantly lower
health care costs.

01:06:13.467 --> 01:06:15.233
- Which is your nerves...

01:06:15.267 --> 01:06:17.467
- There are surgeons
who cut things out...

01:06:17.500 --> 01:06:19.367
- And you\'re
in the favorable group...

01:06:20.733 --> 01:06:21.933
- Good, good to see ya.

01:06:21.967 --> 01:06:24.633
The good news
is that it\'s very unlikely

01:06:24.667 --> 01:06:26.367
that it spread outside
your prostate.

01:06:26.400 --> 01:06:28.333
It\'s very, very unlikely,
you know,

01:06:28.367 --> 01:06:30.467
that it\'s gone to lymph nodes
or anything like that.

01:06:30.500 --> 01:06:31.900
You know,
in years past, certainly,

01:06:31.933 --> 01:06:33.700
we\'d treat, you know,
small amounts of cancer

01:06:33.733 --> 01:06:36.567
very aggressively in young men,
do surgery,

01:06:36.600 --> 01:06:38.733
and certainly cure rates
are very, very good with that.

01:06:38.767 --> 01:06:40.133
- Mm-hmm.

01:06:40.167 --> 01:06:42.433
But the real question is:
Did we really need to do that?

01:06:42.467 --> 01:06:45.000
You know, did we
really need to treat that?

01:06:45.033 --> 01:06:49.033
And so that\'s where that whole
idea of the watchful waiting is.

01:06:49.067 --> 01:06:52.033
- If I pursue
the watchful waiting approach,

01:06:52.067 --> 01:06:56.767
and is some number excluding one
of these two main procedures?

01:06:56.800 --> 01:07:00.433
- Yes, if you have anything
that\'s rising rapidly,

01:07:00.467 --> 01:07:03.000
or we get up to where that PSA
is close to ten,

01:07:03.033 --> 01:07:05.467
which is where we start
worrying about extension,

01:07:05.500 --> 01:07:07.633
you know, outside the prostate
or into the lymph nodes,

01:07:07.667 --> 01:07:08.800
we say,

01:07:08.833 --> 01:07:11.533
\"Okay, no more watchful waiting;
Now we treat.\"

01:07:11.567 --> 01:07:14.267
- The clinician
needs to fill in the patient

01:07:14.300 --> 01:07:16.300
on the options, the outcomes,

01:07:16.333 --> 01:07:17.967
and how likely
they are to happen.

01:07:18.000 --> 01:07:21.133
But there\'s transfer of
information the other way too.

01:07:21.167 --> 01:07:24.967
The patient is the expert
at what they value,

01:07:25.000 --> 01:07:29.633
and they need to transmit
those preferences and values.

01:07:29.667 --> 01:07:33.767
And I think
matching the best outcomes data

01:07:33.800 --> 01:07:36.700
from clinical research
and evidence-based medicine

01:07:36.733 --> 01:07:38.500
with the patient preferences

01:07:38.533 --> 01:07:40.600
is what gets us
to the best decision.

01:07:40.633 --> 01:07:42.800
- The good situation is,
this disease

01:07:42.833 --> 01:07:45.100
is very unlikely to cause you
any harm

01:07:45.133 --> 01:07:46.567
in the immediate short term.

01:07:46.600 --> 01:07:48.600
You\'re in no immediate distress.

01:07:48.633 --> 01:07:52.067
But everybody
wants to be immortal

01:07:52.100 --> 01:07:53.700
and live as long as they can.

01:07:53.733 --> 01:07:55.667
The upside
to immediate treatment is,

01:07:55.700 --> 01:07:57.300
you could eradicate the cancer.

01:07:57.333 --> 01:07:59.867
\"It\'s early, and
I don\'t have to worry about it.\"

01:07:59.900 --> 01:08:03.400
Or you could say, \"You know,
doc, treatment has side effects.

01:08:03.433 --> 01:08:06.200
\"I probably don\'t need
the treatment for a while.

01:08:06.233 --> 01:08:08.167
Why don\'t we just delay things
for a while,\"

01:08:08.200 --> 01:08:10.000
which is... or forever...

01:08:10.033 --> 01:08:12.533
Which is also not
an unreasonable approach in you.

01:08:14.000 --> 01:08:17.033
- So I guess I\'m safe for now.

01:08:17.067 --> 01:08:18.467
- You\'re safe for now.

01:08:18.500 --> 01:08:21.433
- I might have to make
a decision at some point.

01:08:21.467 --> 01:08:26.100
Since my cancer
is low-grade and early-stage,

01:08:26.133 --> 01:08:29.800
watchful waiting seems like
a reasonable approach.

01:08:29.833 --> 01:08:31.933
- I think
it\'s a very reasonable approach.

01:08:31.967 --> 01:08:32.933
- Thanks.

01:08:32.967 --> 01:08:35.400
- If we are good
at aligning care

01:08:35.433 --> 01:08:37.833
with what patients really value,

01:08:37.867 --> 01:08:41.167
we learn that they choose
less aggressive treatment.

01:08:42.533 --> 01:08:45.167
- When you give patients
a true fair choice,

01:08:45.200 --> 01:08:47.400
it typically reduces
surgical treatment rates

01:08:47.433 --> 01:08:49.633
by 40 to 60%.

01:08:49.667 --> 01:08:51.933
Their consumption rate drops.

01:08:51.967 --> 01:08:55.633
It comes to about the same level
that physicians themselves show

01:08:55.667 --> 01:08:57.700
when we get these conditions.

01:08:57.733 --> 01:09:00.267
- Prostate cancer
is an example of a disease

01:09:00.300 --> 01:09:03.067
where we ought to be smarter
about whom to treat

01:09:03.100 --> 01:09:04.833
and whom to observe.

01:09:04.867 --> 01:09:06.000
And in that way,

01:09:06.033 --> 01:09:08.700
there are a lot of dollars
to be saved

01:09:08.733 --> 01:09:10.467
that could be put to better use

01:09:10.500 --> 01:09:15.100
to improve the health
of many, many more people.

01:09:27.867 --> 01:09:32.933
- It\'s really hard to explain,
but something wrong here.

01:09:32.967 --> 01:09:38.000
- Okay, and how long
does that stay like that?

01:09:38.033 --> 01:09:39.933
A few seconds, a few minutes?

01:09:39.967 --> 01:09:41.167
- A few seconds.

01:09:41.200 --> 01:09:45.333
- So here\'s a gentleman
who had some symptoms

01:09:45.367 --> 01:09:47.300
which were not typical
of angina.

01:09:47.333 --> 01:09:48.700
He didn\'t have chest pain.

01:09:48.733 --> 01:09:51.800
He had some shortness of breath
when he exercised.

01:09:51.833 --> 01:09:54.000
But he has
a positive family history,

01:09:54.033 --> 01:09:55.367
so he\'s very anxious.

01:09:55.400 --> 01:09:59.233
The conservative approach
would say to use medicines

01:09:59.267 --> 01:10:02.167
to maybe lower your cholesterol.

01:10:02.200 --> 01:10:06.833
The other option is to be
more aggressive and to say,

01:10:06.867 --> 01:10:10.400
\"Well, let\'s find out
absolutely what\'s going on.\"

01:10:10.433 --> 01:10:12.867
And that would mean
doing an angiogram.

01:10:12.900 --> 01:10:15.000
- If you are doing
the angiogram...

01:10:15.033 --> 01:10:16.133
- Yes.

01:10:16.167 --> 01:10:19.867
- If something severe
inside somewhere,

01:10:19.900 --> 01:10:23.533
you will to using balloon
to put a stent inside it.

01:10:23.567 --> 01:10:24.933
- Yes.
- Oh, okay.

01:10:24.967 --> 01:10:26.533
It just makes sense,

01:10:26.567 --> 01:10:29.333
if we find
a significant blockage,

01:10:29.367 --> 01:10:32.133
to go ahead and treat it
at that time.

01:10:32.167 --> 01:10:34.767
- Is there any risk
to angiogram itself?

01:10:34.800 --> 01:10:35.967
- There are risks.

01:10:36.000 --> 01:10:37.600
There\'s risks
at everything that we do.

01:10:37.633 --> 01:10:38.867
- Okay.

01:10:38.900 --> 01:10:43.267
- But we do thousands
of angiograms every year,

01:10:43.300 --> 01:10:46.500
so the risk of the angiogram
and taking the picture

01:10:46.533 --> 01:10:48.367
is very, very small.

01:10:48.400 --> 01:10:51.033
- If not necessary,
I don\'t want to install...

01:10:51.067 --> 01:10:52.333
- Absolutely.

01:10:52.367 --> 01:10:55.167
- The stent inside, you know.
- Absolutely, right.

01:10:55.200 --> 01:10:57.767
- Otherwise,
you will take medicine forever.

01:10:57.800 --> 01:10:59.000
- That\'s right, right.

01:10:59.033 --> 01:11:00.567
This is a university.

01:11:00.600 --> 01:11:03.200
I\'m on salary.

01:11:03.233 --> 01:11:06.967
I don\'t get paid special
just for doing these procedures.

01:11:07.000 --> 01:11:08.533
- Yes.

01:11:08.567 --> 01:11:11.567
- I think that either way
is reasonable.

01:11:11.600 --> 01:11:15.767
So if you feel comfortable
with a conservative approach,

01:11:15.800 --> 01:11:17.467
then we do the medicines.

01:11:17.500 --> 01:11:19.600
If you say,

01:11:19.633 --> 01:11:21.400
\"Well, I\'m concerned.

01:11:21.433 --> 01:11:23.233
I have this thing inside of me.

01:11:23.267 --> 01:11:25.000
I\'m afraid I may die.

01:11:25.033 --> 01:11:27.167
I want to find out
what\'s going on.\"

01:11:27.200 --> 01:11:28.533
Then it\'s better for you

01:11:28.567 --> 01:11:30.967
to do the angiogram
and find out.

01:11:31.000 --> 01:11:33.600
- One of the most important
developments

01:11:33.633 --> 01:11:36.367
in caring for peoples\' hearts

01:11:36.400 --> 01:11:38.233
and also now one
of the most overused

01:11:38.267 --> 01:11:40.467
is the cardiac catheterization.

01:11:40.500 --> 01:11:43.167
- We observe huge differences
across the country, you know,

01:11:43.200 --> 01:11:45.200
10-, 15-fold
in the frequency

01:11:45.233 --> 01:11:49.833
with which patients undergo
catheterization procedures.

01:11:49.867 --> 01:11:52.100
- This is
a fairly safe procedure.

01:11:52.133 --> 01:11:54.167
But a certain number
of people will die.

01:11:54.200 --> 01:11:55.333
And a certain number of people

01:11:55.367 --> 01:11:56.767
will have heart attacks
and strokes

01:11:56.800 --> 01:11:58.567
because of the procedure.

01:11:58.600 --> 01:12:01.100
- We tend to see the good
that we might achieve.

01:12:01.133 --> 01:12:03.133
We tend to discredit the risks.

01:12:03.167 --> 01:12:05.967
We discount them.
We explain them away.

01:12:06.000 --> 01:12:08.300
But this stuff is not safe.

01:12:08.333 --> 01:12:10.700
It\'s just that
in certain circumstances,

01:12:10.733 --> 01:12:12.600
the benefits are much larger
than the risks,

01:12:12.633 --> 01:12:14.200
so it\'s a wise choice.

01:12:21.000 --> 01:12:22.700
- Okay, ready?

01:12:22.733 --> 01:12:24.533
- Sending.

01:12:24.567 --> 01:12:25.567
Inject.

01:12:29.467 --> 01:12:30.467
- Great.

01:12:30.500 --> 01:12:31.967
So the artery
is nice and smooth.

01:12:32.000 --> 01:12:34.700
There\'s no areas
of blockages here.

01:12:37.467 --> 01:12:39.700
He\'s probably going to live
to be 92.

01:12:43.433 --> 01:12:47.433
- All right, Mr. Ku,
can you wake up?

01:12:47.467 --> 01:12:48.633
We\'re all done.

01:12:48.667 --> 01:12:49.633
- Done?

01:12:49.667 --> 01:12:50.700
- Yeah, all done.

01:12:50.733 --> 01:12:53.133
Everything looks really good,
okay?

01:12:53.167 --> 01:12:54.867
You don\'t have
a significant blockage.

01:12:54.900 --> 01:12:56.100
- Okay.

01:12:56.133 --> 01:12:57.633
- So I\'m going to show you
the pictures.

01:12:57.667 --> 01:12:59.567
Can you see this screen
over here?

01:12:59.600 --> 01:13:01.100
So right in here,

01:13:01.133 --> 01:13:03.167
there\'s a little bit
of narrowing,

01:13:03.200 --> 01:13:05.033
maybe it\'s 20%.

01:13:05.067 --> 01:13:08.467
And the right coronary artery
is also very good.

01:13:10.233 --> 01:13:13.800
I\'m jealous, because I don\'t
know what my arteries look like,

01:13:13.833 --> 01:13:16.400
and these
are probably better than mine.

01:13:16.433 --> 01:13:17.567
- Really?

01:13:17.600 --> 01:13:20.600
- Right, so I\'m gonna be
on the table next.

01:13:20.633 --> 01:13:23.933
- I think it will make
a big difference for Mr. Ku,

01:13:23.967 --> 01:13:27.600
because it decreases
the patient\'s anxiety.

01:13:27.633 --> 01:13:29.067
It helps his physicians

01:13:29.100 --> 01:13:31.800
who will care for him
in the future

01:13:31.833 --> 01:13:34.233
know exactly what\'s going on.

01:13:44.533 --> 01:13:45.567
- Because of my age

01:13:45.600 --> 01:13:47.867
and because of the history
of my dad,

01:13:47.900 --> 01:13:52.067
I went in
and had a simple stress test,

01:13:52.100 --> 01:13:54.967
It showed that there
was a potential for a blockage.

01:13:55.000 --> 01:13:56.033
And then after that,

01:13:56.067 --> 01:13:58.200
I went back in
and had the angiogram.

01:14:04.833 --> 01:14:07.500
- The first shot here...
We can see the narrowing

01:14:07.533 --> 01:14:10.700
at the proximal portion
of the LAD.

01:14:10.733 --> 01:14:13.433
And it appears to be
right in that range

01:14:13.467 --> 01:14:14.967
of approximately 70%,

01:14:15.000 --> 01:14:17.167
at which you would maybe
want to go in there

01:14:17.200 --> 01:14:19.500
and open the artery up
with a stent.

01:14:21.633 --> 01:14:22.667
- I was on the table

01:14:22.700 --> 01:14:24.933
and ready
to have a stent put in,

01:14:24.967 --> 01:14:26.607
because that\'s what they
were gonna to do.

01:14:26.633 --> 01:14:28.600
And I was on the table,
and I stopped \'em.

01:14:28.633 --> 01:14:30.700
- It was the patient who said,

01:14:30.733 --> 01:14:32.067
\"Wait a minute.

01:14:32.100 --> 01:14:36.233
\"You know, I may have this
severe reaction to aspirin.

01:14:36.267 --> 01:14:38.567
\"I\'ve had a life-threatening
bleed in the past.

01:14:38.600 --> 01:14:39.733
\"Can we hold off

01:14:39.767 --> 01:14:44.400
and talk about
what the treatment options are?\"

01:14:44.433 --> 01:14:47.200
- We have a major
randomized controlled trial

01:14:47.233 --> 01:14:49.700
that suggests that
half of all cardiac stenting

01:14:49.733 --> 01:14:51.233
that\'s performed
in the United States

01:14:51.267 --> 01:14:52.967
is non-beneficial.

01:14:53.000 --> 01:14:54.733
Well, I don\'t want somebody
doing that to me.

01:14:54.767 --> 01:14:55.833
The reason?

01:14:55.867 --> 01:14:57.567
It means
that I\'ll be on an anticoagulant

01:14:57.600 --> 01:14:59.500
for the rest of my life.

01:14:59.533 --> 01:15:00.867
That drug is dangerous.

01:15:00.900 --> 01:15:03.600
Again, it has consequences.

01:15:03.633 --> 01:15:06.233
- I was not ready
to have a stent put in

01:15:06.267 --> 01:15:09.233
because of the bleeding ulcer.

01:15:09.267 --> 01:15:11.867
But there\'s no question
that in a different situation,

01:15:11.900 --> 01:15:14.900
I would have had either a stent
or bypass surgery.

01:15:14.933 --> 01:15:16.800
- There is
this very strong bias to action

01:15:16.833 --> 01:15:18.833
that almost any good
interventionalist, surgeon,

01:15:18.867 --> 01:15:20.667
cardiologist will show.

01:15:20.700 --> 01:15:22.633
The interesting thing is,
is if they don\'t,

01:15:22.667 --> 01:15:25.533
you don\'t really trust them
to do the procedure.

01:15:25.567 --> 01:15:28.500
They need to have that belief
in what they do.

01:15:28.533 --> 01:15:29.500
Boy, throw on top of that

01:15:29.533 --> 01:15:30.900
that every time
they place a stent,

01:15:30.933 --> 01:15:32.500
they make more money.

01:15:32.533 --> 01:15:34.167
I don\'t believe
that\'s their main driver.

01:15:34.200 --> 01:15:35.867
They certainly try not to.

01:15:35.900 --> 01:15:37.233
You know, the money they receive

01:15:37.267 --> 01:15:38.800
is just the burden
they have to bear

01:15:38.833 --> 01:15:41.400
for the good
that they\'re achieving.

01:15:41.433 --> 01:15:42.600
You see?

01:15:42.633 --> 01:15:44.333
But you kind of get
this witches\' brew,

01:15:44.367 --> 01:15:48.667
this perfect alignment of forces
that says, \"Let\'s do it.\"

01:15:48.700 --> 01:15:51.100
The net impact of that
is the decision-making

01:15:51.133 --> 01:15:53.000
transfers away from the patient,

01:15:53.033 --> 01:15:54.533
who should be making
the decision,

01:15:54.567 --> 01:15:56.567
to the physician.

01:15:56.600 --> 01:15:58.200
- I wasn\'t involved in his care

01:15:58.233 --> 01:16:00.600
at the time
of the diagnostic angiogram,

01:16:00.633 --> 01:16:03.900
but the past history
of gastrointestinal bleeding

01:16:03.933 --> 01:16:06.633
made it
potentially dangerous for us

01:16:06.667 --> 01:16:10.000
to commit to blood thinners,
like aspirin,

01:16:10.033 --> 01:16:13.033
in combination with Plavix
for an extended period of time.

01:16:13.067 --> 01:16:16.300
And so we went back
and reassessed

01:16:16.333 --> 01:16:17.800
whether or not that narrowing

01:16:17.833 --> 01:16:20.167
was something that needed
to be treated or not.

01:16:20.200 --> 01:16:22.333
- Have you ever had a nuclear
stress test done before?

01:16:22.367 --> 01:16:23.367
- No.

01:16:23.400 --> 01:16:26.100
- Okay,
basically the procedure...

01:16:26.133 --> 01:16:27.500
We start an IV in your arm.

01:16:27.533 --> 01:16:29.900
Through that IV, we inject
a small amount of radioactivity.

01:16:29.933 --> 01:16:31.700
It circulates
close to your heart muscle.

01:16:35.400 --> 01:16:37.833
- The concept behind the test
is that if there is an area

01:16:37.867 --> 01:16:40.567
of significant narrowing,
then the muscle downstream

01:16:40.600 --> 01:16:44.433
of that narrowing won\'t have
the same blood supply.

01:16:44.467 --> 01:16:46.833
But as you can see
on the stress images,

01:16:46.867 --> 01:16:48.933
that blood flow in that region
looks robust.

01:16:48.967 --> 01:16:50.267
It looks completely normal.

01:16:50.300 --> 01:16:52.700
So good news,
we don\'t see anything here

01:16:52.733 --> 01:16:54.800
that warrants treatment,
whether that\'s stent,

01:16:54.833 --> 01:16:56.367
whether that\'s
balloon angioplasty,

01:16:56.400 --> 01:17:01.200
whether, as you talked about,
a limited bypass surgery.

01:17:01.233 --> 01:17:03.600
And I wouldn\'t do anything else
at this point.

01:17:03.633 --> 01:17:04.600
- Excellent.

01:17:04.633 --> 01:17:05.833
- We\'ll see you in three months.

01:17:05.867 --> 01:17:07.400
- Turns out
that when you start to work

01:17:07.433 --> 01:17:08.767
in an organized care system,

01:17:08.800 --> 01:17:13.700
you talk an awful lot about
indications guidelines.

01:17:13.733 --> 01:17:15.000
It relies on data.

01:17:15.033 --> 01:17:16.000
When is there a benefit?

01:17:16.033 --> 01:17:19.400
How do I properly advise
a patient?

01:17:19.433 --> 01:17:22.333
When you start to make this
explicit so people can see it,

01:17:22.367 --> 01:17:24.300
it changes their behavior...

01:17:24.333 --> 01:17:26.567
Even my good,
aggressive surgeons.

01:17:26.600 --> 01:17:28.867
By the way,
we won\'t lose clinical outcomes

01:17:28.900 --> 01:17:30.667
if we do this.

01:17:30.700 --> 01:17:32.900
We\'ll lose
a lot of complications.

01:17:32.933 --> 01:17:34.600
We\'ll lose
a tremendous amount of cost.

01:17:34.633 --> 01:17:37.033
We\'ll probably lose
a few deaths.

01:17:37.067 --> 01:17:40.367
We\'ll get care
that\'s a lot better, not worse.

01:17:40.400 --> 01:17:42.967
This isn\'t withholding
necessary care.

01:17:43.000 --> 01:17:45.700
This is withholding
unnecessary injuries.

01:17:48.000 --> 01:17:50.967
- Your heart
went into a funny rhythm.

01:17:51.000 --> 01:17:53.567
It\'s called
ventricular fibrillation.

01:17:53.600 --> 01:17:56.000
And you
were very, very fortunate,

01:17:56.033 --> 01:17:59.767
because 90% of people
who have that or more

01:17:59.800 --> 01:18:02.967
don\'t survive
to even make it to the hospital.

01:18:03.000 --> 01:18:05.200
- I feel very, very fortunate,
so...

01:18:05.233 --> 01:18:07.033
My wife did CPR.

01:18:07.067 --> 01:18:09.400
- And I think that\'s why
you\'re here today.

01:18:09.433 --> 01:18:11.100
- Well.

01:18:11.133 --> 01:18:12.667
- After you
were recovered enough

01:18:12.700 --> 01:18:16.700
from the initial ventricular
fibrillation episode,

01:18:16.733 --> 01:18:18.533
we went ahead
and did the angiogram.

01:18:18.567 --> 01:18:21.033
And in fact, the artery
on the front of your heart,

01:18:21.067 --> 01:18:22.500
that\'s the most important
artery,

01:18:22.533 --> 01:18:27.733
one that we call the LAD,
was 100% blocked.

01:18:27.767 --> 01:18:31.233
And another artery
is 80% blocked.

01:18:31.267 --> 01:18:34.667
- So when Dr. Miner called me,
I reviewed your films

01:18:34.700 --> 01:18:36.933
that he\'d done
and saw the two big blockages.

01:18:36.967 --> 01:18:39.767
And you have some things that
made us lean towards surgery.

01:18:39.800 --> 01:18:42.100
They\'re both
pretty tight blockages,

01:18:42.133 --> 01:18:43.933
and they\'re both
pretty far up in the arteries.

01:18:43.967 --> 01:18:46.767
So if they were
to totally block both of \'em,

01:18:46.800 --> 01:18:49.200
you could wipe out
almost the entire heart.

01:18:49.233 --> 01:18:50.733
So tomorrow,

01:18:50.767 --> 01:18:52.333
we\'re going to plan on
doing an operation

01:18:52.367 --> 01:18:55.233
that will hopefully
take care of all that for you.

01:18:55.267 --> 01:18:56.300
- I\'m ready.

01:18:56.333 --> 01:18:59.867
It\'ll be a trip
of a lifetime, huh?

01:18:59.900 --> 01:19:01.367
- We\'re going to do two grafts.

01:19:01.400 --> 01:19:03.633
We\'re gonna do one on the front
and one on the side.

01:19:03.667 --> 01:19:06.933
The chance of you dying
or having a stroke...

01:19:06.967 --> 01:19:09.233
Those are sort of the real
feared complications...

01:19:09.267 --> 01:19:11.767
I would say
would be 1% to 2%, very low...

01:19:11.800 --> 01:19:14.867
Doesn\'t really get
any lower than that.

01:19:14.900 --> 01:19:17.400
- I\'ve got
too much living to do.

01:19:17.433 --> 01:19:23.067
And I don\'t want to be worrying
about my heart.

01:19:23.100 --> 01:19:27.533
- And pretty much 100% recovery,
is that what we\'re anticipating?

01:19:27.567 --> 01:19:30.600
- That\'s our plan.

01:19:30.633 --> 01:19:34.267
- Turns out that surgery
sometimes is a major advantage.

01:19:34.300 --> 01:19:36.000
Now, on the other hand, for me,

01:19:36.033 --> 01:19:38.733
I don\'t think
I\'d let \'em do it to me.

01:19:38.767 --> 01:19:42.233
That\'s because I trained
as a surgeon.

01:19:42.267 --> 01:19:46.033
When you go into surgery,
it\'s never as good as new.

01:19:46.067 --> 01:19:47.933
There\'s always a price you pay.

01:19:47.967 --> 01:19:51.033
Surgery
is always the last option.

01:19:52.933 --> 01:19:54.500
What I really believe is
is that patients

01:19:54.533 --> 01:19:56.067
should be able to make
their own choices

01:19:56.100 --> 01:19:57.133
in a fair and honest way.

01:20:00.933 --> 01:20:03.067
- Hey.
- Hey.

01:20:03.100 --> 01:20:04.067
- See you in there, okay?

01:20:04.100 --> 01:20:05.967
- All right.

01:20:29.267 --> 01:20:31.333
- All right,
you ready to go home?

01:20:31.367 --> 01:20:32.933
- Yes, I am.

01:20:32.967 --> 01:20:34.767
- Okay, so you\'re going home
on the oxygen,

01:20:34.800 --> 01:20:38.400
and you want to keep it on
about two liters, continuously.

01:20:38.433 --> 01:20:40.367
You\'ll go home
with a heart care handbook.

01:20:40.400 --> 01:20:42.867
That\'s a good reference
for your recovery,

01:20:42.900 --> 01:20:44.633
your nutrition, diet.

01:20:44.667 --> 01:20:46.200
We want to encourage you
to walk,

01:20:46.233 --> 01:20:47.833
but no strenuous exercises.

01:20:47.867 --> 01:20:48.833
- Got it.

01:20:48.867 --> 01:20:50.900
- All right, any questions?

01:20:50.933 --> 01:20:52.800
- No, but thank you so much.
- Oh, you\'re welcome.

01:20:52.833 --> 01:20:54.700
- It\'s been really wonderful.
- Oh, no problem.

01:20:54.733 --> 01:20:55.900
- It gave you another chance.

01:20:55.933 --> 01:20:57.600
- Gave me another chance
at life so...

01:20:57.633 --> 01:20:58.933
You guys handled it beautifully.

01:20:58.967 --> 01:21:00.133
- You\'re welcome.

01:21:00.167 --> 01:21:02.033
See you next year for skiing.

01:21:02.067 --> 01:21:03.300
- You got it.

01:21:03.333 --> 01:21:05.433
- When we moved to this hospital
three years ago,

01:21:05.467 --> 01:21:07.600
our mortality rate
for coronary bypass

01:21:07.633 --> 01:21:08.833
was at the national average.

01:21:08.867 --> 01:21:11.967
And then we started
to really implement some

01:21:12.000 --> 01:21:13.933
what we thought
were minor things,

01:21:13.967 --> 01:21:15.367
but it tended
to effect everything.

01:21:15.400 --> 01:21:17.933
So we tried to get people up

01:21:17.967 --> 01:21:19.667
and moving quickly
after surgery.

01:21:19.700 --> 01:21:22.033
We tried to take
their breathing tube out.

01:21:22.067 --> 01:21:23.600
We conserved their blood.

01:21:23.633 --> 01:21:25.800
We tried to prevent
giving them transfusions.

01:21:25.833 --> 01:21:27.600
We watched their blood sugars.

01:21:27.633 --> 01:21:29.733
All of these things
combined, gradually...

01:21:29.767 --> 01:21:32.400
Each had a little piece
to reduce the risk of death

01:21:32.433 --> 01:21:34.533
after open-heart surgery.

01:21:34.567 --> 01:21:37.133
- The mortality rate
for open-heart surgery

01:21:37.167 --> 01:21:38.733
runs about 3%.

01:21:38.767 --> 01:21:40.867
We\'re less than half that.

01:21:40.900 --> 01:21:42.567
And it comes from
applying these methods.

01:21:42.600 --> 01:21:46.833
Oh, it\'s not just
that half as many people die.

01:21:46.867 --> 01:21:49.400
It\'s cheaper too.

01:21:49.433 --> 01:21:51.467
If the rest of the country
delivered care

01:21:51.500 --> 01:21:55.400
to Medicare patients
the way that we do here in Utah,

01:21:55.433 --> 01:21:59.367
the total cost of care
would fall by about 34%,

01:21:59.400 --> 01:22:01.400
and we would not be in the midst

01:22:01.433 --> 01:22:03.567
of a national health care
cost crisis.

01:22:06.967 --> 01:22:08.633
- One of the myths
of American medicine

01:22:08.667 --> 01:22:11.633
is that we have to ration
in order to reduce costs.

01:22:11.667 --> 01:22:16.367
I think our research shows
that\'s absolutely not necessary,

01:22:16.400 --> 01:22:18.700
that if you look at
some of the examples

01:22:18.733 --> 01:22:20.233
of great care
around the country,

01:22:20.267 --> 01:22:22.967
it is possible
to redesign our care

01:22:23.000 --> 01:22:25.267
in ways that are great for us
as patients

01:22:25.300 --> 01:22:28.033
and great for us as physicians,
by the way,

01:22:28.067 --> 01:22:30.833
and that reduce the costs
of care.

01:22:30.867 --> 01:22:34.900
This is about redesign,
not rationing.

01:22:34.933 --> 01:22:36.300
- It\'s not rationing

01:22:36.333 --> 01:22:39.567
to get rid of stuff
that\'s bad for you.

01:22:39.600 --> 01:22:41.100
It\'s not rationing

01:22:41.133 --> 01:22:44.567
to get rid of care
that won\'t benefit you.

01:22:44.600 --> 01:22:45.700
It\'s rational.

01:22:48.700 --> 01:22:51.033
- Let\'s go.
Let\'s get out of here.

01:22:56.300 --> 01:22:59.967
[machine whirs]

01:23:00.067 --> 01:23:03.333
[treadmill whirs]

01:23:07.000 --> 01:23:08.500
- I\'m not trying to push you.

01:23:08.533 --> 01:23:09.633
- No, I under...

01:23:09.667 --> 01:23:11.400
- I\'m just trying
to understand you.

01:23:11.433 --> 01:23:12.633
- It\'s good.

01:23:12.667 --> 01:23:15.967
- The diameter of this artery,
maybe it\'s 20%.

01:23:26.333 --> 01:23:28.667
[tool whirs]