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June 12, 2018 - Making Sense - Sam Harris

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#129 — An Insider’s View of Medicine

Sam Harris speaks with Dr. Nina Shapiro about the practice of medicine. They discuss the unique resiliency of children, the importance of second opinions, bad doctors, how medical training has changed in recent years, medical uncertainty, risk perception, vaccine safety, and other topics. If the Making Sense podcast logo in your player is BLACK, you can SUBSCRIBE to gain access to all full-length episodes at samharris.org/subscribe.

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	Welcome to the Making Sense Podcast.
	This is Sam Harris.
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	Today I'm speaking with Dr. Nina Shapiro.
	Nina is a pediatric otolaryngologist.
	She's a pediatric ENT surgeon.
	And she's also a professor of head and neck surgery at UCLA.
	She's been featured in the New York Times, Time, the Wall Street Journal, NPR, CNN.
	And she's written a new book, the title of which is Hype, A Doctor's Guide to Medical Myths, Exaggerated Claims, and Bad Advice, How to Tell What's Real and What's Not.
	And Nina is just a fantastic doctor, so I wanted to have her on the podcast to give us an insider's view of medicine.
	I wanted to know what it's like to be a patient as a doctor.
	What should patients know that doctors know?
	So we spend most of the hour talking about that, but then we touch on her book a little bit at the end.
	Anyway, it was great to talk to Nina, and I hope you find this conversation useful.
	And now I bring you Nina Shapiro.
	I am here with Nina Shapiro.
	Nina, thanks for coming on the podcast.
	Thanks for having me.
	Great to be here.
	Unlike many of my guests, you are someone I know personally and as a client, you're a fantastic doctor who has written a book that we'll be talking about.
	But so I just want to give that context because I can attest to the quality of your bedside manner and the quality of your friendship.
	So I've got a better view of you than most guests.
	Before we get into practical questions of health and your book, just remind me and tell our listeners about your background, because you were sort of born to be a doctor, if I'm not mistaken.
	I guess so.
	Yeah, I do come from a medical family and, you know, I don't have one of those really, really cool backstories about how I was first on Broadway and then ended up in medical school.
	I pretty much Followed the track to medical school all on the East Coast.
	Did my residency training and medical training back in Boston.
	Moved out to California for a year, and that was 22 years ago.
	Certainly kind of like arriving like Dorothy in Oz, I realized how nice it was out here, so I decided to stay.
	And I've been in academic medicine at UCLA for about 21 years now.
	And my specialty, which is really small and very narrow, is pediatric otolaryngology, so pediatric ear, nose and throat surgery.
	And I'm a professor at UCLA, so I do some teaching and a lot of what we call tertiary or quaternary care medicine.
	So, you know, sort of the referral cases that come from all over the country and actually all over the world to take care of, you know, pretty sick kids.
	So you did your medical degree at Harvard.
	Did you work anywhere else or you went straight to UCLA?
	So yeah, so I did my medical school at Harvard and I did my residency at Harvard and then I did a combined pediatric otolaryngology fellowship part of the year at Great Ormond Street Hospital in London and then part of the year at Rady Children's Hospital in San Diego.
	And that's how I landed in California.
	Did you go straight into working with kids, or did you work with adults for any significant period of time?
	So, my residency was a mix of kids and adults, and that's pretty standard for all otolaryngology residency.
	And then once I did my fellowship, right after residency, I've been working with kids ever since then.
	I'm always struck by how different the careers are depending on what type of doctor you decide to be.
	I mean, the overlap between being an ER doc and a dermatologist, as far as I can tell, is almost zero in terms of just what their life experience is like.
	So where would you put your specialty in terms of the high stress side of things and the technically difficult side of things?
	You're a surgeon as well as someone who just actually diagnoses problems.
	Right, so I sort of put my specialty, it's sort of like playing the piccolo in an orchestra where you do a lot of sort of regular day-to-day stuff, mundane, you don't really get noticed that much.
	Most of the stuff is, you know, pretty healthy people.
	And then every so often there's this piercing, life-threatening event that in a matter of seconds can go from great to horrific.
	So it's sort of, and I do play the piccolo, so I feel like there's some connection there where, you know, we, for the most part, we take care of healthy people and everybody smiles and it's pretty much You know, an enjoyable time.
	But because I take care of tiny infants, and we as a specialty are the last resort when it comes to an airway problem.
	So if somebody can't breathe, and if that somebody happens to weigh two or three pounds, we're the ones that are called.
	So every so often we have this excruciating, life-threatening moment.
	And that just keeps us on our toes, and we lose a little bit of sleep because of that.
	Also, you're dealing with people's kids, which has to raise the stakes.
	I can tell you just from the side of being a parent that it definitely does.
	I'm way more stressed out dealing with the uncertainty around my kids' health than my own.
	So I can imagine you are seeing parents at their most stressed out, where the news is seeming bad.
	It is, yeah.
	And we joke that the kids are the easy part, the parents are the hard part.
	Because kids are actually, for the most part, a lot more resilient than adults, and they're healthier than adults.
	But rightly so.
	Parents are very, very stressed about anything related to their kids.
	And again, rightly so.
	But taking care of kids, we have a little bit of a different perspective because we know how much they can handle.
	Just a lot.
	A lot more than we can handle, that's for sure.
	Yeah, well, so say more about that because I think a lot of the parental stress is predicated on not being in touch with that fact.
	When you've gone onto Google and read the fine print on whatever this scary diagnosis is, and you see all of the horrific possibilities, you sort of transfer that knowledge or pseudo-knowledge.
	We'll talk about the problems with Google.
	Onto your kid, I think, just tacitly, where you're just assuming that, you know, this dark cloud hanging over your life now is casting the same amount of shade in your kid's mind, or at least could be.
	And, of course, your kid, depending on the age, I mean, if your kid is, in fact, a kid, your kid knows nothing of these possibilities unless you tell them.
	And it's very likely that your concerns are out of proportion to the actual probabilities, and now speaking of me and many of our listeners, you not being a doctor are not weighing these possibilities intelligently, and so tell me a little more about how you perceive the experience of a child dealing with significant health adventures.
	So, you know, I hear a lot of concerns from parents and some of these concerns are very, very well founded.
	You know, for instance, if they're concerned about anesthesia or concerned about medications, you know, there's a lot of solid information about that that they can find.
	You know, as you mentioned, Google, and that's what most people, doctors included, actually use when we're looking something up or, you know, we're questioning something, is set to find the most extreme, most exaggerated information.
	That, you know, it's devastating and all it does for the most part is create some confusion and panic.
	And we love to panic.
	We love to sort of find the most extreme whatever it is, certainly when it comes to our health or our child's health.
	And it will be easily found if you do a search.
	So, you know, a lot of what I do day to day is calming people down and trying to put things into perspective.
	And what often people think about is the risk of an intervention, whether it's a medicine or a surgery, but few people are really thinking about the risk of not intervening.
	And they think of that always as less invasive, when oftentimes, and certainly in my practice, Being less invasive or less proactive can actually be higher risk and more dangerous to a child, but a parent obviously just thinks of it as protecting their child from something.
	But that something could actually be much more beneficial than the risk of not doing something.
	It is an interesting view of human health you get working only on kids, because I think as you say, kids are, for the most part, the healthiest people on earth, but obviously there are the rarer cases where there's something very serious going wrong.
	The stakes are that much higher.
	Is there more to say about the resiliency of kids with respect to adults?
	I mean, in terms of just recuperating from procedures that work out or just, you know, most conditions being self-limiting?
	I mean, how do you think about the resiliency of a kid versus the resiliency of someone our age?
	So, for the vast majority of kids, they are much more resilient than most adults.
	Their hearts are stronger, their lungs are stronger.
	When they have an infection, they recover more quickly.
	When they have any sort of surgery, they recover more quickly.
	And, you know, it's astounding as some, you know, kids will go home the same day or the next day after a small heart surgery.
	You'd never see that in an adult.
	Kids have these devastating illnesses or a devastating event, and they bounce back.
	It's really, they are almost a different, obviously not a different species, but they're really a different type of being than adults.
	And because they seem so much more fragile and helpless, we rightly want to protect them more.
	But their resilience is so much better, stronger, and quicker Than any adult resilience that, you know, we who take care of kids have, you know, sort of a different view on what they can tolerate.
	And it's a lot more than than what most adults can tolerate.
	Yeah, I once saw my daughter fall down the stairs from a distance.
	I mean, I'm still horrified by this sight.
	I still have PTSD, I think, from seeing this.
	And this was a fall that would have absolutely paralyzed a stuntman.
	I mean, everything was wrong about this fall.
	It looked like her attempt to break her own neck, and she was completely fine.
	So you sort of lose sight of that when you're being dragged through this labyrinth of medical uncertainty with your child.
	And yeah, some of, you know, kids, if you, if you look at a little child, and you know, we always say, oh, children are not just small adults, they're built to withstand stuff like that.
	Their, their necks are smaller, their heads are kind of puffier and more, you know, kind of cushioned than ours are.
	So, you know, a lot of just physiologically and physically, kids are physically built to tolerate falls.
	They're babies.
	They're even like something as simple as a baby's vocal cords.
	What do babies do when they're not sleeping?
	They're crying, but they don't develop hoarseness or nodules or, you know, vocal issues from crying for 10 hours per day because they're built to withstand that.
	So, you know, it's some sort of evolutionary ability for kids to withstand a lot of the trauma that we as adults, you know, if we fell down the stairs, we'd crack our necks or break our skulls.
	But kids, you know, literally, we say they bounce.
	And, and it's great.
	You know, that's that's why they can go on to adulthood and then get hurt.
	Yeah, yeah.
	I want your doctor's eye view of being a patient, essentially, or the parent of a child who's a patient, and I want to know how you go through these experiences of getting sick or having people in your life get sick and just, you know, how it is you would navigate a hospital and, you know, how you think about Second opinions and all of that.
	We've touched a couple of these issues already.
	You get a diagnosis that sounds scary from one doctor.
	You go home and Google it and get properly terrified by what is, in many cases, a very low probability risk.
	And then, it's certainly standard procedure to get a second opinion, certainly if there's any significant intervention on the menu, like a surgery.
	At this point, I have gone down this path enough that all this is anecdotal, obviously, but if you're judging from my experience, both when I'm the patient and when my kids have been, it's fairly alarming how often I've gotten a false diagnosis, you know, that is overturned by a second opinion.
	And in some cases, the first diagnosis came with A very strong recommendation for treatment that was a significant intervention.
	I once left a doctor's office where, I forget, this is now 10-15 years ago, I was having some problem.
	I think I had pain in my hands or something.
	I was a martial artist.
	There were plausible reasons why I might have pain in my hands, but I wound up in the care of a rheumatologist who diagnosed me with, I think it was psoriatic arthritis, and sent me out of the office with a month's supply of methotrexate and Humira, which are significant medications, and basically was, you know, putting me on these drugs for the rest of my life.
	And, you know, it seemed quite crazy at the time, and I went and got a second opinion, and Another rheumatologist said, well, you don't have psoriatic arthritis.
	You probably just did something to your hands.
	But that kind of thing has happened with my daughters.
	It's fairly startling.
	And in fact, I met you in this context, or at least I met you professionally in this context, where I think my daughter had been diagnosed with a cholestiotoma by a pediatrician.
	And this is very much in your wheelhouse.
	I had never even heard of a cholestiotoma.
	And I brought her into you and you took one look in her ear and said, well, she doesn't have a cholesteatoma.
	But, you know, I had spent 24 hours previously having Googled a cholesteatoma and realized how much I didn't want her to have one.
	And, you know, it was a fairly stressful day.
	So how do you think about second opinions and what advice do you have for people?
	Because doctors obviously can quite confidently represent some state of affairs that isn't true.
	Yeah, second opinions are, you know, surprisingly a luxury.
	A lot of people don't have the wherewithal or the means to obtain second opinions, unfortunately.
	So a lot of people, you know, just are lucky and feel lucky that they can just get in to see a doctor.
	And unfortunately, a lot of people are misdiagnosed or You know, receiving overly aggressive or underly aggressive treatment.
	And this is a big problem.
	You know, I, as you, you know, you've had the experience with your daughter, you know, I, I see patients and I, you know, sometimes they're a bit disappointed when I say, Nope, there's not the problem.
	And your child doesn't need surgery.
	And the family actually leaves a little bit frustrated because they, they almost wanted there to be something.
	And I tell them, you will find a surgeon who will operate on your child, you know, guaranteed.
	Um, so it is...
	It is a problem and there isn't really the why this is happening, why people in different medical centers recommend different treatments, unless it's something that's, you know, has several pathways.
	For instance, if you have a cancer patient, there are several different ways to approach it, whether it's surgery, chemotherapy, surgery, chemo radiation, you know, there are some variations to those sorts of paths and a lot of that depends on The medical status of the patient, how healthy they are, their age, what they can tolerate.
	But, you know, this sort of stuff where somebody doesn't have something and then they end up getting a surgery, that is not good medical care, unfortunately.
	I think, you know, if you have a new problem and you have the wherewithal to obtain two or even three opinions and it's not something urgent, I think I do encourage people to do that.
	And for the most part, you will find, you know, for instance, if it's a surgical issue and you see two surgeons, you may find some minor variations in how they do the surgery or exactly what type of surgery.
	But if one surgeon says operate and the other surgeon says absolutely don't operate, then you need a third opinion to sort of break the tie.
	But, you know, it's a problem.
	What about bias built into the disciplines?
	Surgeons have the tool of surgery, and I think it's a common concern, and maybe a valid one, that if you go to a surgeon for advice, really his or her choice will always be, well, to operate or not.
	And that could bias you in the direction of getting surgery that perhaps you don't need.
	I mean, I guess this is somewhat linked to the question of whether or not to get certain kinds of tests.
	I remember once, again, this is back to my own personal martial arts-generated problems, but I was having some back pain, and I asked my doctor whether he thought I should get an MRI of my back, and he said, well, you know, you're, whatever it was at the time, 40 years old, I can guarantee you, you have at least one bulging disc.
	It'd be a miracle not to have something that we can image there.
	And seeing it in your scan is not going to tell you whether it really is the source of your symptoms.
	And then you're going to want to have a conversation with a surgeon, and you will find one who will say, yeah, we could shave that off for you.
	This is something that we can talk about and, you know, why start that process at all when what I'm going to recommend you do, whatever we see on that film, is, you know, do physical therapy back off the martial arts and avoid surgery at, you know, at almost any cost for a problem of this scale.
	There's this problem of too much information and maybe there's this problem of talking to the wrong specialty too early.
	Well, hopefully not.
	I like to tell people that their child doesn't need surgery.
	And I think we have to sort of wonder if it's that much of a concern if people are feeling that you can't go to a surgeon for an evaluation because they are a hammer and they're just looking for a nail.
	That's a pretty negative feeling or concern about medicine in general, that if you go to a certain specialty, they will find a problem related to their specialty.
	I think that's what's created a lot of mistrust of medicine, and rightly so, because people are You know, known to over-operate as you said, you know, you have a small disc problem that could probably be remedied just by taking, you know, some physical therapy or resting or doing different exercises as opposed to, oh, you know, you have a disc bulge, we need to operate on it.
	And, you know, unfortunately, there are a lot of doctors out there, a lot of surgeons out there who are sort of cutting, you know, recklessly or unnecessarily.
	And, you know, with the same result as not doing surgery.
	But, you know, it's unfortunate that that's how it's become, that people feel that if they go to a rheumatologist, you're going to leave the office with a rheumatologic disease.
	Or if you go to a spine surgeon, you're going to leave, you know, scheduled for spine surgery.
	And, you know, I think that's, I don't know how to sort of purify medicine or how we can sort of get back to, well, if you go to a surgeon and the surgeon tells you you don't need surgery, actually, some people are disappointed with that recommendation and they'll go find someone else who will recommend surgery.
	But I think if there is something so drastic that's recommended, then you do need to get a second or a third opinion.
	Does this all just fall into the bin of there being a normal distribution in the talent and knowledge and ethics and any other relevant variable among doctors as there is in almost anything else?
	I think this is something that people don't realize or don't want to realize because there's not really a good or obvious remedy for it.
	But we recognize that there's a normal distribution of ability in any I mean, baseball players aren't all the same skill level, and you could extend this to every profession, but I think we all want to assume that doctors are all at the same level, or that the differences between them don't matter.
	How do you as a doctor think about that?
	I mean, when a friend of yours has to get a surgery, and is asking you, you know, how to find a good surgeon.
	Is there a kind of insider knowledge of there being good surgeons and bad surgeons in medicine, or do the bad surgeons magically disappear?
	Bad surgeons never disappear, unfortunately.
	I think there is a little bit of an insider track that we in medicine are privy to.
	Certainly, if you work in a large medical center, we know how to navigate this very complex system internally.
	And then even around the country, you know, for instance, if I get a call from a friend across the country and their child or they need a surgery or have a specific medical problem, you know, it's one of those almost like a six degrees of separation, but it's usually only two or three degrees within a phone call or two, I could find them but it's usually only two or three degrees within a phone call or two, I could find them the right person that is trustworthy, has a good background, has it, you know, has good ethics, as you said, and is not just operating because they
	So, you know, there is, just as with most fields, there is a little bit of an insider tract.
	And one of the benefits of being in medicine is that we have pretty good access to other specialists pretty quickly.
	All right, so we'll give your phone number at the end of this podcast and you'll just get a few calls a day for medical referrals.
	Just my home address would be good, yeah.
	So this just brings me to my wanting your doctor's eye view of getting pushed or dragged into the machine of medical attention.
	And so you are sick or someone close to you is sick and you now have to go to the hospital.
	What do you as a physician know about checking into a hospital that the average patient might not.
	What are your concerns?
	What do you want to avoid at all costs?
	What kind of questions do you ask that might not occur to the average person to ask?
	How do you navigate a hospital?
	So, you know, that really depends on whether it's something that's planned, you know, a scheduled procedure or scheduled admission or surgery versus an emergency situation.
	Obviously, if there's an emergency situation and it's something in my home hospital, whether it's as when I was a resident You know, across the country or now, here in Los Angeles, you know, we do have, there is a little bit of professional courtesy, just as with if you're in any other line of work, you will get a little bit of professional courtesy and perhaps get in the door a little more quickly, get seen by who you want to get seen a little more quickly.
	But what I've found, and you know, certainly living and working in Los Angeles, where we have a very Substantial VIP population.
	You know, as we say, everybody's a VIP, but we have VIPs.
	they often try to create and navigate their own treatment plan.
	And it ends up being creating the worst possible medical care.
	They may ask for somebody who they think is the best anesthesiologist, for instance, but because the person has a high administrative title, but they have no experience with their medical, their family member's medical condition, it may be the absolute wrong person.
	People also have this notion that they want to be the first procedure of the day, you know, for a surgeon's busy schedule.
	Well, that's not always necessarily the best time to have surgery.
	Or, I don't want any, you know, if you're in a teaching hospital, I don't want any residents or medical students around.
	Well, if we're used to a certain way of practicing and then somebody tries to change that routine because they think they'll get better care, it actually just makes for more anxiety on the part of the caregivers and can create actually a worse care situation.
	So, Oftentimes, you know, it's best to just go with the flow of a hospital because they know what they do best.
	They know their routines, how they do them best, and sometimes trying to alter that.
	Even if doctors, we as doctors, try to alter The routine of the caregivers, it can actually backfire and get in the way.
	So, you know, a lot of hospitals, especially the big ones, are very frustrating.
	They feel very inefficient.
	But a lot of that is just the nature of how they work.
	And the care ends up being better, sometimes by not making a big stink about who you are and who you know, and, you know, trying to sort of cut corners.
	Has this been quantified in any way?
	It's hard to see how it would be quantified, but I'm sure there are some famous cases where some, you know, Hollywood celebrity got what was obviously substandard care because the whole machine of the hospital was thrown into disequilibrium by all of his or her demands and all of the starfuckery going on.
	Is that what you're thinking of when you talk about this?
	Yeah, I mean certainly there have been some extreme cases.
	It was, you know, there was, you know, one of the babies in one of the hospitals in Los Angeles.
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