Gladwell on Doctors' Prescriptions, Carbon Copies and the Opioid Crisis.

Published Jul 8, 2022, 4:01 AM

What if a little bit of extra paperwork could saves lives and perhaps end an epidemic? Enjoy a cautionary tale from our friend and fellow Pushkin host, Malcolm Gladwell. The new season of Revisionist History begins with a half-baked idea of an obscure bureaucrat in the 1930’s and ends with one of the worst public health disasters in American history - the opioid crisis. 

Stick around to hear Tim and Malcolm discuss the episode and the importance of admitting you're wrong.

Pushkin. Nobody likes paperwork, nobody likes bureaucracy, nobody likes a fussy government. Except what if a particular bit of paperwork could save a life, or a hundred lives, or a hundred thousand lives. You might want to try to figure that out, right. I'm Tim Harford and I present a cautionary tale with a difference. This week, The Mighty Malcolm Gladwell is your storyteller. As you may know, Malcolm hosts the blockbuster nerd storytelling podcast of our time, Revisionist History, and he is back with an amazing new season. And not only is he back with an amazing new season to which you should all subscribe immediately, he is also sitting in front of his microphone with me right now. Hello Malcolm, Hello Tim, thank you for those kind words of all deserved. And we're going to listen to one of the episodes from the new season of Revisionist History in a second. But just lay out what was it about this story in Triplica that caught your attention? I read this the big book on the Sacklers, the people who created who owned the company that created OxyContin, and on sort of page it's one of those. I'm sure you read the book books the same way. You know, in the footnotes on page five, you know, four hundred, five hundred and forty eight, there is this reference to a study, and I was just like, wait, what, I didn't one of those kind of things that didn't make any sense. So I looked at the study, and I read the study and say, this is astonishing. That was a little acorn from which the oak grew. And then I just sort of puzzled over how to tell a story around you were about to listen to the episode, so we don't even say how it begins, because we're going to listen to it right now and then, and please stay where you are, and because I want to ask you lots of questions immediately afterwards. It's a remarkable story, as you will hear, and so Cautionary Tails presents from the new season of Revisionist History, to which you should all subscribe in all the usual places, I present Malcolm Gardwell with in triplicate. When I was in my twenties, many years ago, I was a reporter for the Washington Post. A newsroom the size of a football field, phones ringing, keyboards, clattering, the glory days of print journalism. I want you to describe what is the status in position of a Washington Post reporter in Washington, d C. In nineteen eighty nine. Well, in general, godlike, because the whole city ran on politics in news, and there weren't many organizations that produced it excellently. In the Post was sort of the place that everyone cared about. That's my friend Michael Specter. He and I were both on the health and science beat for the Post. If somebody cured something, discovered something, solve something, or screwed something up, we were on it. In those days, it seemed like everyone read everything we wrote. Well they did. I mean there is an exception, which is we were in the science pod, and at least at the Post that was considered like why would smart people write about science when they could write about the White House and wear yellow ties? But in general we had big readerships, particularly in the when we wrote about science policy, we sat at the center of a giant ecosystem of lobbyists, lawmakers, aids, bureaucrats, policy walks who tried to get us to see the world their way. If you called someone and said you were from the Washington Post, they called you back. I used to us into Michael every day on the phone with a source on Capitol Hill. That individual had access to everything, but he didn't mind ratting people out. It was like Heaven. I had a couple of people like that. It was Heaven. I remember once where you get the plain brown rappers with stuff inside of it. Because nothing, of course was digital in those years. You would get the mysterious phone call and you had to decide whether to return it. So there's one member of this ecosystem that I'm most interested in, ready, Sid Wolf. Sid Wolf. I love Sid. I loved him then, I love him now. But you know, yeah, he is a particular kind of guy. I think I was the most skeptical of Sid. Yeah, because you were like a right wing lunatic. I was a right wing lunatic, and it was a right wing time Sidney M Wolf m d versus me thirty years when I was a right wing lunatic. I was different then, which I offer as at least a small explanation from my behavior in the story. I'm about to tell you my name is Malcolm Gladwell. You're listening to Revisionist History, my podcast about things overlooked and misunderstood. This season is devoted entirely to experiments, and this episode is about what happens when an experiment teaches us an important lesson and we don't listen. Sidwolf came to Washington, d c. In the nineteen sixties as a young doctor. He went to work as a postgraduate fellow at the National Institutes of Health, part of the same class as Tony Fauci. One day in nineteen seventy one, someone told him that half of the saline solution being supplied to American hospitals was contaminated with bacteria. And Sid said, Oh, where are they going to take it off the market? And the person said they aren't because if we do, hospitals will run out of ivy fluid and we'll have a disaster on our hands. And Sid said, that can't be right. There have to be other sources of ivy fluid. He did his research, found out there were other sources, and went public, called the press, got his friend, the political crusader, Ralph Nader, to hold a press conference, and the bad ivy fluid was pulled from the market. Sid had found his calling as a consumer advocate. I am sick and part of the patronizing attitude of the American Medical Association towards American patients. Patient SID was unstoppable door He started something called the Public Citizens Health Research Group and became one of the angriest voices in Washington. As many of you know, our organization has now for twenty five years, been the most outspoken critic of the FDA. More than fifty times we've submitted petitions, sometimes resulting in lawsuits against the agency to try and get them to do what we think the law requires them. Example, in the c SPAN archives, there's practically a SID division. Sit against the drug companies, sit against the doctors, sit against the FDA. It is clear that of the seventeen years since we have been running the Health Research Group and washing the FDA, this is by far the worst period of time ever. SID didn't like anyone except those who were willing to join him on the lonely ice flow of his sixties radicalism. Okay, that's not fair. It's not that SID disliked people. It was never personal for him. Sid's battle was with institutions. SID believed that bureaucracies and companies and legislatures would behave better only when constrained by the right laws, the right regulations, and the right kind of relentless nudging from people like Sid. He was the nudge of Washington, DC. Sid's very smart and very colorful and a great quote. But there's only one way in that Sid's way. You don't have like a deep, meaningful conversation on both sides of was Sid. But some people, and he was one. We're just excellent at knowing what we needed and what we wanted and how to package it, and that was Sid. I hadn't thought of Sidwolf in years, but then I started reading about someone named Paul Madden, one of those forgotten figures in the mid century. If you lived in California in the nineteen forties, you would hear Madden from time to time on the radio. Good Evening, Ladies and gentlemen. There may be harder jobs than breaking up a narcotic brain. I don't know. I've never seen one. Especially difficult is a job of rounding up a band of narcotic pedley, including the brains of the game. Madden was a progressive that progressives believed that government could fix things, that systems and regulations and rules properly written could make the world a fairer place. Progressives were activists full of zeal. In nineteen thirty nine, Paul Madden was appointed to run the California Bureau of Narcotic Enforcement. He was the man responsible for stopping the use of illegal drugs in the state of California, a job he tackled with enthusiasm and his customary hyperbole. Let me quote directly from his writing on the effects of marijuana, Madden wrote that the user might quote believe himself so small that he is afraid to step off the kerbstone into the street. Or he may feel himself of enormous size and of superhuman strength and passion, and in that condition commit crimes altogether foreign to his nature. But because Paul Madden was a progressive, he didn't just fulminate against a problem. He had a whole, carefully thought out scheme for using the enlightened power of government to fix it. Consider the great fear of anti drug crusaders of that era, which was that doctors might be driving drug addiction. What if the person gets the script from the doctor and goes down and keeps some of the drugs for himself, and then sell some of the drugs on the street. Then you're going to have the problem of the initiation of new addicts potentially if that happens. David Courtwright, who is America's leading historian at the Drug Trade, says that people were worried that patients could walk into the doctor's office asking for an addictive drug like morphine and the doctor would just give it to them. So steady were as small number of doctors who are relatively unscrupulous, who are simply writing prescriptions for maintenance, and much of that drug may end up being diverted. How would I identify the doctor who's doing that. So one of the things you might do is send an informer to the doctor and he would try to persuade Typically it was a he. He would try to persuade the doctor to write a prescription. In California, Paul Madden looks at that practice of running sting operations against shady doctors and says that's a crude and inefficient way of dealing with the problem. Remember, he's a good progressive, a man who believes in systems and procedures. So Madden decides to create a bureaucratic solution. First, Madden makes a list of all the prescription painkillers that he considers dangerously addictive morphine, opium coding chloral hydrate, and then he convinces the state legislature to create a new regulation for doctors Chapter three, Article one, Section one one six six six of the California Narcotics Act, the Madden Amendment of nineteen thirty nine. The prescription blanks shall be printed on distinctive paper, serial number of the book being shown on each form, and also each form being serially numbered. Each prescription blank shall be printed in triplicate, with one blank attached to the book in such a manner that it will be readily removed, while two of the blanks shall be perforated for removal. Meaning every time a physician prescribes one of the listed pain killers, they have to use a special state issued prescription pad where every prescription page comes equipped with two additional carbon copies. To use a contemporary turn of phrase, he wants to create a back up of every narcotic prescription in the state. The first copy was to be kept at the office of the prescribing physician for a minimum of two years, available for scrutiny at any time by one of Madden's team of inspectors. Copy number two had to be kept by the pharmacist for two years. A number three had to be mailed by the pharmacist to the Bureau of Narcotic's head office in San Francisco. A record of physician and pharmacist behavior in triplicate, A textbook example a progressive big brother in action. Now, why did I think of Sid Wolf when I heard about Paul Madden? Because Madden seemed to me like Sid one point zero the nineteen thirties edition. Different context and emphasis, of course, but the same playbook, the same urgency, the same relentlessness. The government needs to fix things. And here is my twenty nine point plan to accomplish that, which I'm forwarding over to you right now. Call me when you get it right away. This is too big to wait. So you know, Sid was his hair was always on fire about something. My memories of Sid is you would never know when you would get off the phone. That's true, that's true. I mean I've even talked to him recently about some stuff I've done, and he'll not just talk to you. Then the information starts flowing. In those days, the facts started to churn, because that's how we got stuff. But Sid was like I would go out to lunch and if there was a pile of fax paper in my desk, it would be like Sid struck. How many forests were sacrificed to feed Sid's fax machine? God only knows. In any case, I moved on. I left the Washington Post and forgot all about Sid and his fixations. And then I heard about an experiment, and it all came flooding back. Once you've found the right doctor and have told him or her about your pain, don't be afraid to take what they give you. Often it will be an opioid medication. Beginning in the late nineteen nineties, a catastrophe unfolded in cities and towns around the United States. Opioid overdoses people suffering a cascade of terrifying effects, pinpoint pupils, labored breathing, respiratory arrest, choking, purple lips, loss of consciousness, and, in what has now been over eight hundred thousand cases, death. There's no question that our best, strongest pain medicines are the opioids. They don't wear out, they go on working, They do not have serious medical side effects. And so these drugs, which I repeat are our best, strongest pain medications should be used much more than they are for patients and pain. At the heart of the crisis was a class of new, powerful pain killers that came on the market in the ninety especially OxyContin, launched in nineteen ninety six by the Purdue Pharmaceutical Company. OxyContin is highly addictive, and Purdue promoted it to doctors more heavily than any other pain color in history. By two thousand and two, Purdue had thousands of salespeople around the country pushing OxyContin. This went on for more than a decade until doctors were prescribing three billion dollars worth of OxyContin a year. But even after twenty years of the opioid epidemic, there were all kinds of questions like was OxyContin the cause of the overdose epidemic or just a symptom of something deeper and even more puzzling, why didn't opioids cause the same level of devastation everywhere? Take Massachusetts in New York, two states side by side. If you run every significant fact about Massachusetts and New York through an algorithm, you'll find there are almost no two states more alike, same population profile, same basic economy, same levels of poverty, very similar rural urban mix. You'd think they would have had similar experiences with overdoses. They didn't. Massachusetts has had a bloodbath, New York not so much. Same thing with New York and New Jersey. Super similar states by any measure, So why did New Jersey suffer so much more than its neighbor. Purdue would end up in bankruptcy court as a result of multiple lawsuits launched against them for misleading marketing practices, and not long ago, for economists Abbey Albert, William Evans, Ethan Lieber, and David Powell realized that the mountains of internal Purdue documents unearthed in those lawsuits might hold some answers. I mean, so there are hundreds and hundreds of pages of documents, some of which was not very t that's Abby Alpert, lead author of the paper. The four of them ended up publishing origins of the opioid crisis and its enduring impacts. But then when we happened upon the focus group research especially and the launch plan, that really was the basis for a lot of what we talked about in this paper. Buried in that mountain of documents was an internal Perdue report on a series of focus groups that the company held with physicians. This was in the spring of nineteen ninety five, right before the launch of oxycontent. The focus group report runs to almost sixty pages, and in that long buried document, one phrase kept popping up again and again. The phrase coined by Paul Madden half a century earlier, triplicate prescriptions. So I had never heard of a triplicate program, and it's not something that was being discussed in the research on opioids. I mean, why would it be. Nobody really liked triplicates. For decades, no one followed California's lead in imposing this special requirement for prescribing pain killers. Drug makers, of course, hated the idea, so did doctors and state lawmakers. In the early nineteen eighties, the state of Texas did start a Triplica program, and the State Narcotics Division in Austin had to hire thirty three data entry clerks, who in the first year mailed out twenty seven thousand, eight hundred Tripica prescription pads to doctors around the state. The doctors then had to write a check for seven dollars for every pad they used mail The check back to Austin. Use the special pad every time they prescribe anything off the restricted list, keep the pink copy in their office for two years, send the green and the blue copy with the patient to the pharmacist et et I mean triplicate was the kind of bureaucratic nit pickiness that drives people in the medical world crazy. The few states that did triotriplica pro usually dropped them. By the early nineteen nineties, there were just five states with triplicate programs in place, California, the Pioneer Texas, which somehow managed to stick it out, and then Illinois, Idaho, and New York. Five states with warehouses full of carbon copies of doctors prescriptions. Every time you pick up that prescription pad, it was like, boy, I'm prescribing in someone's watching me. And that's what a lot of folks call the chilling effect. Linda was Stilla, who teaches at the University of Maryland School of Pharmacy. She did her dissertation on triplicate programs. The chilling effect she's talking about was the knowledge that physicians in those states had that their behavior was being watched, that there was a permanent record of every prescription they wrote in three places on paper, not in some abstract invisible computer file up in the cloud. Presumably each physician has got a filing cabinet in his or her office just full of prescription forms which they're holding onto for years. So it is a powerful psychological reminder of the way you have handled this specific kind of medication exactly. And the doctor knows that there's a corresponding filing cabinet somewhere in the state capital with a team of investigators attached who can look at every prescription and see the name of the patient, the name of the pharmacist, and the name of which doctor has the biggest bulging file, a file that says, just by its size, something fishy may be going on. This is exactly what Purdue Pharmaceutical discovered when it did its focus group with doctors in nineteen ninety five, just prior to the launch of OxyContin. One of their sessions was in a triplicate state in Houston, Texas, and produced takeaway after meeting with a group of Houston doctors was clear quote the triplicate laws seemed to have a dramatic effect on the product usage behavior of the physicians. It went on the mere thought of the government questioning their judgment created a high level of anxiety in the focus group room among the doctors. Purdue looked at that high level of anxiety and asked, is it even worth marketing OxyContin in triplicate states at all? Years later, Abby Albert's group of economists finds this long forgotten focus group report, and they realized they'd stumbled on a beautiful example of a natural experiment. Natural experiments are the economist's dream. You don't have to create a treatment group and a control group, then laboriously compare what happens to the two groups. Someone else has created the experiment for you. In this case, the someone else was Purdue. A third of the American population lived in the triplicate states. Those states got passed over by the Purdue marketing squads. The rest of the American population lived in states without Big Brother looking over their doctor's shoulders. They got the full Purdue treatment. If you wanted to know how much of the opioid crisis was caused by OxyContin, all you had to do was compare what happened to the triplicate states with everywhere else. So that's what Alpert did, and what she and her colleagues found was that the triplicate rule was everything. What we found was that, in fact, the non triplicate states had much more oxycon use per capita than the triplicate states, almost twice as much. In most years, more OxyContin means more OxyContin overdoses, and not just that, because many of those who got addicted to opi with OxyContin went on to get addicted to heroin and fentanyl. We see very quick increase in overdose deaths in the non triplicate states and much slower growth in the triplicate states. And these trends continue even twenty years after the launch. Let's go back to comparing outcomes in New York and Massachusetts. New York was triplicate, Massachusetts was not. So how much of a difference to death single requirement make the two extra carbon copies on the New York prescription pad. Well, if New York had Massachusetts opioid overdose rate between the years two thousand and twenty nineteen, an additional twenty five thousand New Yorkers would have died of overdoses twenty five thousand. Not only that, it turns out that economic growth is higher in triplicate states than non triplicate states. Health outcomes of babies are better, and violent crime is lower in triplicate states, astonishingly lower, as much as twenty five percent. Exactly eighty years after Paul Madden wrote his amendment to the Californian Narcotics Act, his bureaucratic nitpicking gets vindicated by social science and who else gets vindicated? Sydney M. Wolf, MD. In the early nineteen nineties, someone in the White House wondered what was known about the value of triplicate programs. The request got kicked over to the National Institute of Drug Abuse NIDA, and NAIDA rounded up everyone who might know something about triplicates and invited them to a conference at a hotel near its headquarters in Rockville, Maryland. So you attended the symposium, Yes, Linda was Stilla, who had done her dissertation on triplicates was one of the attendees. I do remember the venue, and I do remember. This is really ridiculous. We couldn't have coffee. NITA was very hardcore about these kinds of things. They wouldn't sponsor anything that had an addiction potential, including caffeine. So did he right? What I remember about that was sort of the excitement of this is the first big thing we've had about trying to control opioid use in the United States. This is nineteen ninety one. OxyContin will be introduced in nineteen ninety six, five years later. But opioid overdoses were still high enough in those years that people were starting to get worried about the problem. I was a pharmacist with a PhD. There weren't many pharmacists with PhDs, so it was like, Wow, this is it, and I believed in a lot of these policies. The pain specialist Russell Portnoy was at the NIA symposium. He would later do as much as anyone to promote the aggressive use of OxyContin. He talked about the problem of under prescribing opioids. Someone from the American Pharmaceutical Association was there to say how strongly the industry's biggest trade group was opposed to any kind of federally mandated triplicate requirement. After all, this was nineteen ninety one. Why were we promoting some half baked idea from nineteen thirty nine. But here and there there were other voices. An African American doctor who worked in a tough neighborhood in Brooklyn. Gerald D's said this, I wish that anyone who opposes triplicate prescription programs could walk with me into the real world where these regulations are saving lives. And then at the end of the meeting, who gets up to speak? Sid Wolf? Of course, because what is Sid's great cause in the late eighties and early nineties, it's triplicates. SID has decided that what American needs is a national version of Chapter three, Article one, Section six six of the California Narcotics Act. Sid, how are you. It's been a long time. So when I see Sid's name in the conference proceedings, I realized I had to talk to Sid again after all these years, so I called him up. Sid always answers his phone, and right away he reminds me of how we used to run into each other in the Adams Morgan neighborhood of Washington, DC. We once played pool together Dan's pool room. The last time wanted to Dan's, you couldn't walk in there because there were about ten people changed smoking. So I've never been in there again. I think it's no longer round at all. Just hearing that voice again, that low rumble, the eyebrow raised at Dan's pool room brought back all kinds of memories. I think I was nervous. Thank you for joining me. I would like to take a walk down memory lane with you, and I want to talk about triplicate prescriptions. I know this has been an issue that occupied you with various points in your career, but I just wanted you I want to start at the beginning. When did the subject of tic prescriptions first come to your attention. I became aware of it, I would say in the early eighties, late seventies, something like that. Even back in the nineteen eighties. You are concerned about the problems being caused by opioids, thirty years before the current oid epidemic. This is something that's very much a matter of concern for you, which a matter of concern for several reasons. I would attend FDA Advisory Committee means and not a small number of them had to do with opioids. And there were already some problems with opioids in those days, and sid like Paul Madden two generations before him, had become convinced that focusing on doctors was a big part of the solution. Let them know they were being watched with a few file cabinets of carbon copies. I mean, the data which you've seen showing what happens in a very short period of time after some of these states implement these prescription programs is astounding. At the night A meeting in nineteen ninety one, SID stood up and made the case for a national triplicate program. He said, in effect, California started an experiment. New York and Illinois and others have joined, and the results of the experiment are clear. It works. In a perfect world, had everyone listened to what nightA was saying in ninety one, what all you guys were saying back in we would have had a very different and much less damaging opioid epidemic in the last twenty years. Right, There's no question about that, because it's a clear public health problem. He's right. A national triplicate program would clearly have slowed the advance of OxyContin. Eight hundred and forty one thousand people have died of drug overdoses since the nineteen nineties. How many of those would now be alive. In nineteen ninety three, SID published a monograph reiterating the need to get serious about opioid prescriptions. It almost certainly made its way to the Health and Science desk at the Washington Post. Did anyone take you up on it? No? Why? I don't know why. I bring this up only because I and one of the reasons this issue interested me so much was that, in the early nineties, when you were thinking very seriously about the importance of triplicates, the person covering the FDA, the Health bureaucracy and science, all those kinds of medical science and for the Washington Post was me. That's how we met. We met. But back then my sympathies did not lie with the sid Wolves of the world. I didn't share Sid's belief that government could fix everything. I thought medicine was full of trustworthy, judicious professionals who did not need Big Brother looking over their shoulder. In my time on the Health and Science desk at the Washington Post, I was in my twenties, a kid too young for nuances. Sid was just the guy who called me up and wouldn't let you off the phone and sent you so many papers and reports and polemics that you gave up and just threw them in the trash. Sid Wolf was so alert to the frailty of institutions, that he seemed to me like chicken little. I'll be candid. At the time, I thought you were way off to the left. I thought you were you know, my position was much more sympathetic to big pharma that I thought you were just a kind of crazy sixties radical who was always who didn't believe in drugs. Now I realized no one was more wrong than me on this issue. I mean, hundreds of thousands of people have died in this country because we didn't pay attention to what you were saying in nineteen ninety one. Well, all I can say is I certainly have been thought by a number of other people that I'm sort of a sixties radical. So I do not blame you or anyone else that thought that I was some wildlife, but said I blame myself. It is almost certainly the case that that monograph you wrote about triplica prescriptions was sent to me at the Washington Post. It is almost certainly the case that I did not read it, And it is almost certainly the case that had I read it, and had I taken it seriously, and had I called you up, and had I educated myself, and had I written a story about it in the Washington Post that maybe it would have made some small difference, or even a book about it, or even a book about it. I didn't do any of those things. In the nineteen thirties, the rest of America dismissed what Paul Madden was saying because they thought Paul Madden was overbearing and hysterical. In the nineteen nineties, I dismissed what sid Wulf was saying because we thought sid Wulf was overbearing and hysterical. We violated all of us the first rule of learning from experiments, which is to judge the message, not the messenger. Once you've found the right doctor and have told him or her about your pain, don't be afraid to take what they give you. Sid Wulf said the sky was falling back in nineteen ninety one, and guess what the sky fell, Malcolm. That is an amazing story. And I wanted to begin by asking you about something you said, which is that no one was more wrong than me. I don't hear people saying that very often. Oh yeah, well I was wrong. I find it's very I actually I don't understand people's reluctance to admit that they were wrong, because once you're in the habit of doing it, it it makes your life so much easier. Yeah, so much work is done. Cognitive dissonance is the you know, the psychological phrase to describe the enormous lengths of human beings go to reconcile contradictions in their own thinking. You can avoid cognitive dissonance just by saying, well, I was wrong about X, so I do no longer have to square with my world view. My world view has moved on right. Well, yeah, and this is all what twenty five years ago, nearly thirty years ago? So I mean, is there a time horizon at which point you're willing to you admit you were wrong five minutes ago or six months a bit, I was wrong all the time. I think it's useful to practice this as much as possible, just because, like I said, I don't think it. You know, it's easy to admit about you were wrong about something that happened long ago, but there are usually a few consequences to that. It's harder to admit you were wrong about something that happened that just happened, But it's really useful to do that. You can you can just say you know what. I sent this nasty email, And if you said another email that says actually more what I shouldn't. I don't think that. I'm sorry, I didn't mean that, then you've just kind of cleared away. But intellectually it's what allows you. It's a kind of condition of curiosity. So the only way for curiosity really to work is if you open up all of your own received wisdom to re examination. The minute you say I'm willing to renounce my previous belief because someone else I've learned something new, that is what permits your curiosity to go forward in an unfattered way. Well, I think that curiosity. Really the foundation of curiosity is humility. It's it's that acknowledgement that there's something you don't know. I mean, if you think you know everything about a subject, there's no there's no possibility for curiosity, there's no space for curiosity. But the moment you say, oh, I don't know, then the space to ask the question opens up. And I suppose the next step is not only do I not know, but that thing that I thought I did know I didn't know that either. It is easier for journalists to be have humility and change their mind than it is for you know, a scientist who has spent a career developing a certain position. For them to renounce their life's work is really an you know, a big deal, really hard to do. And so you often see people who will academics or intellectuals who will defend previous positions they've held, maybe past the point where those positions are worthy of defense. And I understand psychologically why they're doing that, because it would be really hard for them to say I wasted my life. But a journalist, we are different. We're just reporting what other people say. So if we say, oh, I actually got it wrong, it's fine. We are Repetition is not at stake, by the way, and also we're you know, because we're skimming over the surface putting out so much more stuff that to admit one thing we did out of twenty is wrong is actually it's without consequence. Yes, And there's a particular kind of mistake as well. As a journalist, you want to always get the facts right. The quotes need to be right, you know, the numbers need to be right, and of course they aren't a waste, but you try. But the mistake that you were facing up to in that episode was of a mistake of priorities, which is, and that's always imponderable, like what should I have been paying attention to? Should I've spent more time on some other thing? And that's that's not the same kind of error as I spelled this guy's name wrong. Yeah, although I would actually phrase the mistake I made slightly different. The reason the core error was that I was blinded by my ideology. And it's a reminder of how dangerous having kind of ideological convictions is to a journalist that I I was particularly compared to today, just far more. I was a kind of conservative activist at that time, and I had very strong convictions about drug companies and why I thought they were unfairly maligned, particularly by a journalist, and very strong feelings that a lot of what passed for consumer activism was kind of nonsensical or even harmful, and as opposed to simply being I shouldn't be an agnostic on those questions. Sometimes farmer does good things, sometimes I don't. Sometimes, you know, but I was an agnostic, That's what I'm getting at. Yeah, I had failed my journalistic duty to keep my mind open. And one of the things that we're supposed to do when we're not sure is instead of relying on ideology, we run an experiment, I mean, go out and collect some information, or we pay attention to an experiment that someone else has run. And the whole season of revisionist history is about experiments. And one detail though, that that struck me as interesting about the intriplicate story is that herd you didn't seem to need to run an experiment to understand the effect of the triplicate form filling requirement. So while while you were of the opinion that it was probably but what was the phrase he used at bureaucratic nitpickiness? You know, you you have this preconception that it's it's probably just a bunch of unnecessary paperwork, and there's this genuine debate out there as to whether this is going to help or it's not going to help. But you have no doubt they were sure that it was going to be really bad for their business, and that's why they just decided to ignore the marketing push in these in these states. So they knew, or at least they thought they knew well. They had done so, they had done focus group research, I mean the crucial. I think they would have considered the focus group research in their world to be an experiment. It's not really an experiment, but they did gather data on the question. They were i think legitimately surprised at the extent to which triplicate legislation would make doctors hostile to to oxyconton. That did shock them and m but you're right. What's interesting is they didn't come back at it another way, or they just kind of walked away from New York and California, in Texas and Illinois, which are big places, it's a lot of people to ignore it. Third, I think it's it comes out to a third of the country that they decided to kind of um but it's you know, it's a you know, one one interpretation of that is it's a reminder of just how much market research influences decisions by companies. Those of us who are not within large corporations I think underestimate these guys. You know, movie companies care a lot about what the what the audience in you know, Waterloo, Ohio thinks of their latest release in a way that would strike the rest of us is weird. But they really they place a huge amount of emphasis on that kind of stuff. But one of the things that struck me stepping back from this story is, huh, well, in a digital age, all of this oversight of doctors and what they're prescribing and where it's going, this is a solved problem. Right. It's now incredibly easy, or should be incredibly easy, to keep track of everything, and not only that, to learn from you know, the side effects. You know what's happening. Is this drug working, is it leading to problems? Is it doing what was promised? All of this stuff in principle, it's all solved by digitization. In practice, have we made any progress on that? So the argument with with Tripliker prescriptions is, yes, you can duplicate the Triplica prescription digitally, but all of the evidence suggests that that is not as strong a break on physician behavior as the paper form. Something about that. Forcing the doctor to fill out an actual paper prescription and then mail off the paper prescriptions that have piled up in his office every month to the government makes the doctor start thinking about their prescribing behavior in a way that having a silent digital kind of record of what they're doing does not. So what we're really interested in doing here is it's not about the regulatory function, the bit of information that is given to the regulator that allows the regulator to check on what doctors are doing. That's not what's crucial here. What we want to do is we want to change the doctor's thinking in the moment when the patient is in front of them. What drug am I choosing? And something about paper makes is salient for a doctor in a way that digital's not. I'm completely persuaded by your argument that the paper forms were essential in changing what the doctors did in this particular case. But I can't help but think of one of the cautionary tails we released last year about Harold Shipman, who was a British doctor who murdered maybe two hundred and fifty of his patients. I mean, it was just extraordinary. He's, by some measures, the most prolific serial killer who ever lived, and a lot of that was because he had certain privileges as a doctor. He would sign the death certificates himself and tell the police it was all fine, He'd checked and everything was fine. But if there had been some centralized collection, wouldn't have had to be very sophisticated. Some centralized collection of the death rates and are very very simple monitoring rule that would have been flagged up. Something very very strange is happening in this little town of Hyde, near Manchester in the northwest of England. It may be nothing, but somebody should go and have a look. And that you don't get from the paper that you need this cheat somewhere. Agreed. I think we're talking about two different phenomenon. One is a kind of micro level behavioral nudge and one is a macro level analytic capacity. And I think you're absolutely right, Malcolm. We've we've heard the interpreticate story. It is one of one of many experiments that you tell stories about in the new season of Revisionist History, so it give us a sense of what other experiments you're looking at over the course of the season we have. The first two episodes are about what I call magic Wand experiments and term I think I made up, although onever knows. A magic wand experiment is an experiment that you would do if you could, if the scientists could wave a magic wand and wave away all logistical, practical, ethical, laws of nature constraints. So a thoughts experiment. But it's more than that. Because sometimes with the experiment, you're still grounded in the real world. What I wanted to do was to take people entirely out of the real world into the realm of fantasy. It's your fantasy experiment. And my gut was that every scientist has a magic wand in the back of their head and it's out of pointless to talk about it because it can never be done, or they feel ashamed because it's a little bit questionable. Right, So I call on all these people and just said, what's your magic wand? And everyone? I was absolutely right everyone, I every every scientist, thinker and whatever that I call it up and said, what's your magic wand? Day immediately like not even oh yeah, here it is, Malcolm. That was delightful, occasionally dark, wonderful. The season is of course on the Revisionist History podcast feed. Everybody must be subscribed by now, but for those who aren't, how many episodes in the new season? Ten? Ten new stories on Revisionist History. Malcolm Bradwell, it's been a pleasure. Thank you, Thank you, Tim. It's been so much fun.

Cautionary Tales with Tim Harford

We tell our children unsettling fairy tales to teach them valuable life lessons, but these Cautionar 
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