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Cowboy Doctors and Health Costs

hos driving up U.S. region closely tracked end-of-life spending Skinner, a professor of economics at Dart-
healthcare costs? A recent as a whole. It was absolutely amazing how mouth, clinical evidence showed little or
study by Harvard profes- strong [the correlation] was, Cutler said. no marginal benefit derived from the extra
sors and colleagues re- The data indicate that cowboy doctors tend procedures, resulting in wasteful spend-
vealed that the culprits may be cowboy to congregate in southeastern states such as ing. Cutler suggested that doctors beliefs
doctorsphysicians who provide inten- Florida. They are also more likely to be male, in these ineffective treatments may spring
sive, unnecessary, and often ineffective and less likely to be specialists. from their self-perception as interven-
patient care, resulting in wasteful spend- Though these cowboy doctors may be tionists: I think some doctors are saying:
ing costing as much as 2 percent of the na- pushing the frontier of medicine by going I just cant accept that this patient is dy-
tions Gross Domestic Producthundreds above and beyond, said coauthor Jonathan ing and theres absolutely nothing I can do.
of billions of dollars annually. The authors, Ive got to do something.
including Eckstein professor of applied The study noted that
economics David Cutler and assistant pro- very few doctors wanted
fessor of business administration Ar- to discuss the option of
iel D. Stern, found that physicians palliative care with pa-
beliefs in clinically unsupported tients, prompting Cutler
treatment procedures can ex- to draw an analogy to
plain as much as 35 percent auto mechanics: You
of end-of-life Medicare ex- want this engine fixed,
penditures, and 12 percent Ill fix it. Im not going
of Medicare expenditures to talk to you about
overall. whether you should
Physicians treating a crit- get a new carthats
ically ill patient may decide someone elses job.
either to provide intensive But as a result, he said,
care beyond the indica- patients are Ping-
tions of clinical guidelines Ponged back and forth
(such as implanting a defi- between the primary-
brillator to counter severe care physician, who rec-
heart failure), or attempt ommends a specialist,
to make the patient more and the specialist, who
comfortable by administer- prefers to leave the ques-
ing palliative care. The re- tion of whether certain
searchers called the former treatments are necessary to
group cowboys and the lat- the primary-care physician.
ter comforters, and found that Meanwhile, medical bills rise.
their respective concentrations in a Traditionally, researchers at-

Il l u s t ra t i o n b y M i k e L e s t e r H arv ar d Maga z in e 7
Reprinted from Harvard Magazine. For more information, contact Harvard Magazine, Inc. at 617-495-5746

tempt to get a picture of physicians be- beliefs, developed throughtime. imbalance in the physician-patient rela-
liefs by analyzing their actual behaviors. The study also found that most doctors tionship: doctors tend to follow their own
The problem is that other actors, such as who recommended unnecessary proce- beliefs about the right treatment to use,
patients, can have a say in these behaviors dures werent seeking extra incomesug- leaving patients little say in the process.
as well. The ability to tease out doctors ac- gesting to Cutler that the lack of financial How to treat a patient is often a multiple-
tual beliefs proved to be the studys biggest penalty, rather than the presence of finan- choice question without a straightfor-
innovation, Cutler said. This was achieved cial reward, accounts for cowboy doctors ward, single correct answer. When mak-
by using strategic surveys that included actions. The healthcare systems current ing these decisions, Fisher said, doctors
vignettes of specific patient scenarios, and incentives, he said, often do not prompt should pay more attention to the patients
asking the responding physicians what doctors to ask the right questions, such as preferences, instead of relying on their
they would do in each situation. Such sur- whether a proposed treatment truly ben- own experience.
veys are often used in other areas of social efits the patient. If doctors restrict them- The research suggests that its time for
science, Stern explained, but had rarely selves to performing what is evidence- the cowboys to rein themselves in, and
been used before to study healthcare eco- based, Skinner pointed out, we can save learn to listen. !zara zhang
nomics. hundreds of billions of dollars a year.
Self-reports are sometimes unreliable, According to Elliott Fisher, a professor david cutler e-mail:
because respondents attempt to give the of health policy at Dartmouth, a move-
textbook answer rather than express ment is under way to shift the healthcare- david cutler website:
their true beliefs. But this time, the re- payment system toward incentivizing
searchers found that many physicians re- concrete benefits for patients. (A case in home
ported making decisions supported nei- point is the hundreds of accountable-care ariel stern e-mail:
ther by clinical guidelines nor by medical organizations around the country, which
literature. Doctors are basically not rely- seek to reward high-quality, low-cost ariel stern website:
ing on public scientific evidence, Skin- care.) The new study, Fisher suggests, is
ner said. They are relying on their own important because it highlights a power profile.aspx?facId=735581


New Light on Ancient Mars Climate

ould life ever have survived likely cold and icy instead, raising new ques- scenarioswarm and wet and cold and
on Mars? Scientists have long tions about the prospects for life on Earths icyusing a three-dimensional model
thought that billions of years ago, closest cousin. that ran on a super-computer at Harvard.
the climate of Mars was similar Assistant professor of environmental sci- The researchers found that the cold and
to that of early Earth: warm and wet. Now, ence and engineering Robin Wordsworth, icy model did a better job of explaining
a recent study by a Harvard scientist and along with other scientists, conducted the the water-erosion features that have been
his colleagues has concluded that Mars was first direct comparison between the two left behind on the Martian surface, such as
the distribution of valley networks.
The use of a three-dimensional, instead
of one-dimensional model, is a technical ad-
vance from other studies in the field, said
Bethany Ehlmann, an assistant professor at
California Institute of Technology who re-
viewed the paper, Comparison of Warm
and Wet and Cold and Icy Scenarios for
Early Mars in a 3D Climate Model (pub-
lished online on June 26 in the Journal of Geo-
physical ResearchPlanets). Wordsworth et
al. are at the top of the game here in terms

Fossil river deltas on Mars, such as this one

in Eberswalde Crater, bear many similari-
ties to river deltas on Earth. Such features
suggest that Mars once had flowing liquid
water on the surface, motivating study of
the planets early climate.

8 Se p te mb er - Oc t ob e r 20 1 5 Ph o t og ra p h b y NA S A / J PL / Ma l i n Sp a c e Sc i e n c e Sys t e m s

Reprinted from Harvard Magazine. For more information, contact Harvard Magazine, Inc. at 617-495-5746