Friends, colleagues and readers of “Mistreated: Why We Think We’re Getting Good Healthcare—And Why We’re Usually Wrong” know that I’m an avid baseball fan. I can scarcely make it through a meeting or book chapter without referencing our nation’s pastime.
I’m not alone in my obsession, either. I received texts and emails during the World Series this year, asking whether I planned to write something about my favorite sport, similar to the an article I wrote earlier in the summer titled “5 FIFA World Cup Lessons For U.S. Healthcare.”
Truth is I’ve been so preoccupied with the upcoming elections that a blurb on baseball, or any sport, really, seemed too superficial. But when the 2018 season ended last weekend, I realized I was overlooking some powerful lessons.
From my perspective, both baseball and healthcare are (1) striking out too much, (2) relying too much on “relievers,” and (3) ignoring the health of their players.
First, a lesson in fan appreciation
It’s no secret baseball has an emerging “people problem.” Game attendance is down 6.6% compared to last year. That’s the largest such decline since 1995, the year after the league-wide players’ strike, which resulted in the cancellation of the entire World Series.
In recent weeks, sports-talk hosts have offered two interconnected theories about the recent slump in ticket sales: (a) the games are too long with (b) too many lulls in between action. Remember that 18-inning marathon between the Red Sox and the Dodgers two weekends ago? The one that lasted 7 hours and 20 minutes? A little less than a century ago, the Giants beat the Phillies 6-1 in a game that took only 51 minutes to complete.
And if you think baseball fans are frustrated, healthcare consumers are growing equally irritated. There’s good reason for it. In Boston, home of the 2018 world champions, it takes an average of 66 days to see a doctor. Elsewhere, patients suffer all sorts of inconveniences. Most Americans can’t access their medical records digitally, can’t email with their physician, and can’t participate in a simple video visit that would save them a half-a-day travelling to and from the doctor’s office. More often than not, healthcare in the 21st century is striking out.
1-2-3, you’re outta there
This season, for the first time in the history of pro baseball, there were more strikeouts than hits. Though hits per game have held steady since the 1980s, strikeouts have more than doubled. This has a big impact on the fan experience. Routinely, a batter will battle through six, seven, eight or nine pitches only to be sent back to the dugout. Five minutes at the plate and the ball hasn’t been put into play once. As a result, yawns are becoming a big part of the game.
One reason for the uptick in strikeouts is the game’s growing obsession with home runs. Home-run hitters strike out often due to the upward trajectory of their bats, and the need to swing sooner to generate greater bat speed. Thus, as the percentage of strikeouts has increased, so has the percentage of home-run hitters. The Yankees, a club with a storied history of them—from Ruth to Gehrig to Mantle—broke the club’s home-run record in 2018 with 267 dingers, as did the Dodgers with 235.
Like baseball owners, the healthcare industry is enamored with the home run. Hospitals and specialists are paid hundreds of times more for performing heart surgery than for preventing a heart attack in the first place. Patients and the media “ooh” and “ahh” at so-called miracle drugs and technologies that rarely extend life-expectancy by more than a week or two. And yet we universally dismiss “base hits” like exercise, proper nutrition and prevention.
There’s a term in baseball that describes someone who fails to meet minimum standards. The “Mendoza Line” was named after shortstop Mario Mendoza, whose career batting average of .215 became the threshold for incompetent hitting. Nowadays, any player who get a hit just 1 in every 5 at-bats is usually demoted to the minors or cut from the team entirely.
Unfortunately, there’s no “Mendoza Line” in American medicine. In fact, nobody seems to notice poor performance much at all. Independent research has demonstrated that many devices and surgeries, like robots and knee arthroscopies for pain, don’t improve the care or recovery of patients any more than tradition (and far-less expensive) alternatives. But as is true for baseball owners, hospital administrators know that “splash hits” bring in fans and generate major revenue.
Since when did relievers become the heroes?
In addition to the increase in strikeouts, there’s yet another reason for slower games. Baseball has entered the era of relief specialization, when more than a dozen pitchers can share the mound in a single World Series game. In the past, as few as two pitchers could throw an entire game. Now, pitching changes are commonplace. And when they happen in the middle of an inning, the reliever leisurely strolls from the bullpen to the mound and takes his 8 warm-up pitches. And there’s five more minutes of actionless sports.
With few exceptions, the starting pitcher has become less relevant to baseball. In fact, relief pitchers actually started two games in the 2018 World Series. Prior to that, in the divisional playoffs, the Brewers yanked their starter after five pitches.
The same evolutionary idea is playing out in medicine, too.
Primary care physicians who “start the game” as their patient’s first point of contact have become relatively insignificant in healthcare’s hierarchy. Decades ago, family doctors played a starring role. Today, Americans overlook the importance of preventive care until there’s a major complication. That’s when the starter is replaced by a relief specialist: a cardiologist, an oncologist or a neurosurgeon. Suddenly the crowd pays attention.
Even the need for primary care physicians is being questioned amid the rise of retail clinics and new telemedicine offerings. We’re seeing primary care doctors spending more and more time “on the bench” (doing data entry on their computers) and getting paid a fraction of their specialist teammates.
Playing through injury
Relievers used to be pitchers who were past their prime. They were called “firemen,” indicative of their role: mitigating the disaster caused by a struggling starter. All of that changed in the 1990s when “closers” became all the rage. For the first time, there was a specialty created for the sole purpose of getting three outs. Over the past decade, this concept flourished so that there are now seventh-, eighth- and ninth-inning specialists, each brought in to pitch a single inning.
The result has been two-fold. First, the starter’s role has shrunk, and with few exceptions doesn’t exceed the five innings required to earn a statistical victory. Second, when you’re only expected to pitch one inning, you throw every ball as hard as you can (sometimes reaching speeds over 100 mph). More and more, this type of velocity is causing major ligament damage, requiring pitchers to undergo “Tommy John” surgery, named after the first pitcher to get the procedure.
In medicine, the growing demands of clinical practice and ever-greater productivity requirements are putting a strain on doctors’ time and mental well-being. One in three physicians are experiencing depression, more than half say they would discourage their children from becoming a doctor, and more than 400 physicians take their lives each year.
Can baseball or healthcare survive?
MLB owners understand what’s happening to the sport and they know die-hard fans don’t like it. But owners also know that home runs and hard-throwing relievers win games and boost ticket prices, especially for the most expensive luxury seats. Therefore, despite the growing tedium of each at-bat and the increasing impatience of your average fan, the value of baseball franchises is on the rise.
Over the past 10 years, revenues have doubled, despite dwindling attendance. Fifteen years ago, the average ball club was worth $295 million. Today it’s valued at $1.65 billion.
That’s why owners are unwilling to make the improvements needed in the short-run, despite the long-term threats. The same mentality is hurting American healthcare.
Healthcare, as an industry, has taken its eye off the ball. It’s swinging for the fences and striking out more often than ever. Medical practice has lost sight of what really helps patients improve their health and life expectancy. Healthcare leaders understand it is better to avoid cardiac disease than treat it when “the game is out-of-hand.” But they also know prevention isn’t nearly as lucrative.
“When you come to a fork in the road, take it”
Baseball’s general managers have figured out that a slugger who can clear the fences is more reliable (and more profitable) than three players who can string together base hits. They know it’s harder to hit a blazing fastball, so they fill their bullpens with hot-shot relievers, confident that there are dozens of 20-year-olds waiting to throw at 98 mph until their arms turn to mush.
Unfortunately, healthcare is trapped in the same economic reality as major league baseball, but with more painful consequences.
When healthcare’s biggest players try to clear the fences—with high-priced medications that are no better than generic alternatives, with medical devices that generate massive reimbursements but only marginal improvements, with complex end-of-life interventions that shorten rather than extend life—we ought to remember that medicine isn’t a game. And when we hear about the next set of doctors ending their lives, we should think about the impact on their families and patients.
As a physician and a baseball fan, I worry that both of my passions won’t change until it’s too late. For baseball, this might spell the end of a glorious and storied tradition. For healthcare, this will produce irreversible harm for all of us in the future.
Dr. Robert Pearl is the former CEO of The Permanente Medical Group, the nation’s largest physician group. He’s the bestselling author of “Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong” and a Stanford University professor. Follow him on Twitter @RobertPearlMD.
