When to Rob a Bank: ...And 131 More Warped Suggestions and Well-Intended Rants

by Steven D. Levitt

  No one is told that my daughter is ill other than her two siblings and my division director (to explain my absences) and an old friend who covers for me as a ward attending. This secrecy is attributable to my paranoia concerning public discussion of family health problems as well as the knowledge that my lacrimal glands are out of control. I know I will cry if anyone asks me about my daughter. An elderly doctor should not walk the halls of a hospital with tears streaming down his cheeks. In contrast, my wonderful, brilliant daughter is a model of self-control. No tears, no complaints. I suspect she has accepted the probable lethal outcome of her tumor and tolerates all the medical gyrations whirling about her to please her husband, son, and father. Is this the result of information from the Internet or have I non-verbally communicated my pessimism to her?

  Six days after leaving the referral center in superficially good health, she returns in a wheelchair, short of breath at rest, and speaking in a whisper. Her oxygen saturation is 90 percent on room air. Since she has no stridor, the breathing problem apparently reflects tumor invasion of the lungs. Following the adrenal biopsy, her husband returns from the post-procedure observation room with the information that she has a rapid pulse. Until now I have remained the passive observer, but now am moved to intervene. I feel her pulse and her heart rate of about 145 is obviously irregular. I tell the nurse that I suspect atrial fibrillation and suggest that an EKG be obtained and the rapid intravenous infusion of saline be discontinued. To obtain an EKG, the Rapid Response Team must be called. This team arrives, an EKG shows atrial fibrillation, and her rate is slowed with beta and calcium channel blockers. Her blood oxygen saturation now is only 86 percent on five liters of oxygen. Her pulmonary function has deteriorated over eight hours. Can the monster tumor be expanding at this rate? To me, the rate-controlled atrial fibrillation is only a small problem on the rapid downhill progression of her malignant condition; to the young members of the Rapid Response Team, new-onset atrial fibrillation is the disease. I want to obtain a pulmonary arteriogram to rule out pulmonary emboli and sufficient oxygen to get her home, but both require transfer to the emergency room. I know this transfer is going to drag my exhausted daughter even deeper into the medical vortex of repeat histories, examinations, venesections, etc., but we acquiesce. A pulmonary arteriogram shows a massive tumor in the lung and no pulmonary emboli. The endocrine-oncologist visits her in the emergency room and patiently explains the need for determining the differentiation of the adrenal tumor to guide treatment. The response to my son-in-law’s query if some treatment can be started immediately is that no treatment is better than misdirected treatment. She is scheduled to return to the referral center in four days to begin chemotherapy. I fear there will be no return visit.

  Overnight admission to the hospital is recommended for “observation” and rest prior to the trip home. Fifty years of experience have taught me that admission to an academic hospital is not restful. I have stopped counting the patients who want to be discharged to get some rest. However, I fear she will not survive the trip home without supplemental oxygen, which only can be obtained via hospitalization.

  She receives very little rest due to everything that happens on admission to a hospital—histories and physical exams by several residents, more blood tests, vital-sign checks seemingly every thirty minutes. I try to run interference—no echocardiogram, no anticoagulation, no cardiology consult, limit the vital-sign measurements, etc.—but by 8 A.M. she and her husband, who stayed in her room overnight, are exhausted.

  My daughter and son want immediate discharge, but discharge requires an attending physician visit. I intercept the attending physician at about 10 A.M. and explain that my daughter has extensive metastatic carcinoma and all that is desired is rapid discharge with home oxygen. We are assured that this oxygen and discharge meds will be provided as rapidly as possible. Three hours later, we are still at the hospital. It is difficult to set up home oxygen on the weekend, and the pharmacy apparently has difficulty filling a prescription for a common drug. On my third visit to the hospital pharmacy, about 1.5 hours after they have received the prescription, I am informed it will be another thirty minutes until the medication will be ready. I insult the entire world of pharmacy with my query as to how hard can it be to put thirty tablets in a bottle.

  At about 2 P.M., the oxygen and medications are ready. The only hurdle standing in the way of our departure is that my daughter fears she will be incontinent on the trip home. She needs an incontinence diaper. I then become an actor in a scene that must be played out many times each day in hospitals. At the nursing station, I explain the situation. The nurse says she will get the diaper, but she first makes a phone call that seems to go on forever (in reality, probably about three or four minutes). When she then begins to do some paperwork, I gently remind her that we need the diaper. She responds, “I have more patients to care for than just your daughter, Dr. Levitt.” Of course she does, but I am only interested in the welfare of my daughter. We finally depart the hospital, no doubt with a well-deserved reputation for being a very difficult family.

  Her condition continues to deteriorate at home, and it becomes apparent that she cannot tolerate a return trip to the referral center. Arrangements are made such that the local oncologist will administer the chemotherapy recommended by the endocrine-oncologist. My daughter can no longer speak and we exchange daily texts. On the day before she is to receive her first dose of chemotherapy (only eighteen days after the initial MRI), we exchange the following messages.

  “When the chemotherapy does not work, you will have to finish the job.”

  “Be optimistic, I’ll do whatever is necessary.”

  “Is that a yes?”

  “Yes.”

  Exactly what I am going to do is not clear, but I intend to keep my promise.

  The following morning, my son-in-law tells me she cannot get out of bed and coughs and gasps each time she tries to eat or drink. The “monster” now has destroyed her swallowing mechanism. It is apparent that she will not benefit from or tolerate chemotherapy. I talk with her local oncologist, who agrees to admission to the hospital via ambulance, presumably for comfort care. However, the ambulance driver has determined that her condition requires that she must be taken to the emergency room of the nearest hospital (less than ten minutes closer than the metropolitan hospital). I know she will not get comfort care at the local emergency room. I speak with the ambulance driver and forcefully tell him where I want my daughter/patient taken. The next thing I hear is that she is in the emergency room of the nearest hospital. When I arrive, she again has been through a series of tests, and yet another CT angiogram shows massive tumor invasion of the lung and no pulmonary emboli. She now is short of breath, on bi-pap and 100 percent oxygen. She is then transferred to the metropolitan hospital. Immediately upon arrival, my daughter asks for something which, with difficulty, I determine to be ice chips. I ask the nurse for ice chips. Her response is that nothing can be “administered” until ordered by the doctor. I tell her I am the doctor, and I want the patient to have ice chips. I am told I am not the admitting physician and cannot give orders. She ignores my request to show me the location of the ice machine.

  Her oncologist arrives in a few minutes. Comparison of chest CTs shows that the undifferentiated tumor in her lung has doubled in size in less than three weeks. The hopelessness of the situation is discussed with her husband, and a decision is made with the assistance of a hospice physician to provide comfort care. She receives ice chips, and morphine is administered. About four hours later, she enters a peaceful coma and dies at 6:30 A.M. on August 29, just twenty days after the initial MRI demonstrated the brain tumors.

  The purpose of this brief chronicle is not to criticize the practice of medicine. While I had several disagreements with non-physicians, the physicians who cared for my daughter, without exception, were very understanding and gave freely of their time. Each did everything possible to deal with her enormously aggressive malignancy. Rather, I
have attempted to relate the experiences of a father/physician as he watches his daughter die of cancer. Her course was a testament to the limitations of medical care. In this era of molecular biology, the most valuable medication was morphine, a drug that has been available for almost two hundred years.

  Although painful, I am capable of describing the events of my daughter’s illness. When I try to describe my despair and grief, words fail.

  Linda Levitt Jines, 1962–2012

  (SDL)

  It is with great sorrow that I share the news that my dear sister Linda Levitt Jines passed away last month after a short but valiant battle with cancer. She was fifty years old.

  My very first instinct, as I sat down to try to eulogize Linda, was to call her to ask her to write it for me. Pretty much all my life, when faced with something that called for just the right words, that is what I’ve always done.

  Most famously this happened when Dubner and I were halfway through writing a book that meandered from one topic to another and had no theme. Between the publisher, Dubner, and me, we had generated a list of perhaps fifteen terrible titles before we ran out of ideas. I knew with complete confidence that Linda would have the answer.

  Indeed, it was just a matter of hours before she responded with a potential title: “Freakonomics.” I liked it. Dubner wasn’t sure. The publishers hated it. Our editor told us, “We gave you way too big of a book contract to call this thing Freakonomics!” In the end, though, Freakonomics won out, and it’s a good thing it did. Without Linda’s brilliant name, I doubt that anyone would have ever read the book. The name was a miracle.

  Freakonomics wasn’t the first time, or the last time, that I benefited from Linda’s genius.

  The first time I remember was when I was in seventh grade and she was in twelfth grade. I was the nerdiest, most socially awkward kid imaginable. She decided to take me on as a project. Then, as now, I was smart enough to know to listen to her. We became like best friends, and she gave me a complete makeover. She changed my clothes. She explained to me (nicely) how terrible and unlikable my personality was, and she helped me work on a new one. She introduced me to “cool” music—the first album I bought with my own money that year was U2’s album Boy. After a few years of her tutelage, I was unrecognizable. I still couldn’t get a date for another four or five years, but I was a lot more fun to be around. Looking through old scrapbooks, I stumbled upon an example of a note she had written to me that year, which pretty well captures the way her brain worked:

  Dear Oink-baby,

  The year is more than half over and it seems to me that you aren’t yet hitched with a charming little sample of 7th grade womanhood. How do you resist their insidious allure? They’re like the Sirens or the Lorelei! Doesn’t your heart go all aflutter when you see those tempestuous maidens in repose (i.e. math class), natural patches of cochineal flitting across their cheeks as they contemplate various virtues of the opposite sex? Well, keep trying.

  Your sister,

  Linda

  At my middle school, every student was required to memorize a short story or poem and recite it standing in front of the class. Two winners were chosen from each class, and they “got” to do their speech in front of a packed auditorium. I was a kid who almost never spoke. Nothing terrified me more than public speaking. I asked for Linda’s advice. She told me she would take care of everything. She picked out a witty, lighthearted story for me. She practiced with me, coaching me on every line’s delivery. But she knew it wouldn’t be enough. The piece she had chosen was told by a girl. So she dug out one of her old dresses that would fit me. Then she grabbed one of my mom’s blond wigs and put it on me. She taught me how to curtsy. She declared me ready. It says a lot about my faith in her that I dutifully dressed as a girl and delivered my speech just as she wanted it. I was selected to present in the packed auditorium. Against all odds, the shyest kid in the class, dressed in drag, took home the trophy. After that I never doubted her—I just did what she told me to.

  When she wasn’t busy pulling the puppet strings on my life, she was doing impressive things on her own behalf. After college she got a degree in journalism from Medill at Northwestern. She went into the creative side of advertising, landing a job at one of the top Chicago ad agencies. Amused by the goings-on at the shoot for the first commercial she wrote, she wrote a satirical piece about it for Advertising Age. She got fired the next day, which turned out to be a great career move. She got hired within days by a cross-town rival with a big salary increase.

  Eventually she tired of advertising. In 1995, she called to tell me she was going to start an Internet business. Her idea: she was going to buy big jugs of fragrance oils used in soap-making, pour the oil into little bottles with fancy labels, and resell them online. This sounded like the worst idea I had ever heard. First, no one was making money selling things over the Internet in 1995. Second, how could there possibly be enough soapmakers around to make good money? We all screamed at her not to waste her time. Seventeen years later, www.sweetcakes.com remains a thriving, highly profitable business. It never ceases to amaze me. Later, she started a second online business, www.yarnzilla.com. After Freakonomics, I started a little consulting company which eventually grew into the Greatest Good. Linda was the chief creative officer, her unique spirit imbuing everything we did.

  And she did all this while she and her husband, Doug, raised the nicest, best-adjusted, most likable seventeen-year-old boy you could ever imagine, their son Riley. (Linda’s expertise at turning boys into men clearly improved with practice over time, because even after her middle-school recrafting of me, I was nothing compared to Riley.) In addition to Doug and Riley, she leaves behind her parents Shirley and Michael, her sister Janet, and me, as well as many nieces and nephews who could never get enough of Auntie Lin.

  Every time Linda entered the room, without even trying, she became the center of gravity. One of the people at the Greatest Good had never met Linda before. He walked into a conference room and all his co-workers were “grinning ear to ear.” He wondered why. The answer was that Linda was there holding court.

  The massiveness of her genius and creativity make the gaping hole of her absence all the greater.

  Linda, we all miss you so much.

  CHAPTER 12

  When You’re a Jet . . .

  ©iStock.com/doodlemachine

  When you’re a Freakonomist, you’re a Freakonomist all the way. At least that is true for the two of us. We see economics everywhere we look, whether the subject is animated movies, baby formula, women’s happiness, or pirates.

  How Many Chinese Workers Does It Take to Sell a Can of Baby Formula?

  (SDL)

  On a recent trip to China, I found that there were typically five people doing the job that one American would typically do. At our hotel, for instance, there was a floor monitor, whose main job, it seemed, was to press the button for the elevator. Maybe she also did other tasks I didn’t notice, but she could always be relied on to hit that elevator button. In restaurants as well, servers were everywhere, seemingly one per table.

  On the main street in Nanchang, there were perhaps two hundred people standing around with handwritten cardboard signs. I guessed maybe they were unemployed and looking for work. It turns out they actually were working, but I didn’t realize it. Their job was to stand on the corner all day with a sign saying that they will buy used cell phones. Unfortunately for them, I saw perhaps three cell phones get sold in my week wandering up and down that street. It was the most competitive market I’ve ever seen. They must have been earning what they thought was a fair wage, though, or they wouldn’t have been out there.

  When I went to a large grocery store to buy a can of formula for my daughter Sophie, I thought I had observed the most extreme case of excess labor. As I searched the aisle for the exact type of formula she had been using in her orphanage, four young women very eagerly attempted to help me. At first I thought they were just shoppers trying to aid me. Event
ually (they didn’t speak English and I knew about fifty words of Mandarin) I realized they were working. Four of them huddled around me for roughly ten minutes before I finally purchased four dollars’ worth of formula. It made absolutely no sense to me.

  Only later, back at the hotel, did my Chinese guide explain what was going on. These women weren’t employees of the grocery store; they were hired by rival formula companies to try to direct customers to their particular brand of formula! Which explains why they were all so cheerfully and persistently suggesting so many different kinds of formula to me. The store didn’t care what kind of formula I bought—a sale was a sale. But to the formula manufacturers, stealing business from the rival brands was worth paying an employee to do.