This American Life devoted a whole hour this weekend -- and plans another hour next weekend -- to the health care crisis, more than it's ever spent on a single topic. Host Ira Glass, who immersed himself in health policy 101, sounded just as amazed and outraged each time he repeated some variant of the following statement: "Rising health care costs are driving everything in the economy. Half of our incomes are going to be going to health care very soon.  Unless somebody does something." (I haven't seen Ira in maybe 10 years, but half his charm was that he always sounded amazed.)

The theme of the first segment, "Dartmouth Atlas Shrugged" may be familiar to our readers, but the story was told with a punch, going back to the Jack Wennberg research that eventually gave rise to the atlas. He discovered the extraordinarily high hysterectomy rates in one Maine community in the 1970s -- a rate so high that 7 in 10 women would have the surgery by age 70, nearly three times the rate of a similar community with similar demographics in the same state.

As Wennberg's researchers found more and more of these variations in care, doctors were motivated to study the phenomenon and to recommend changes. But they didn't follow their own recommendations. Partly because of fear of lawsuits. Partly because some were more "action-oriented" than others. Partly because of local medical culture or habits. And partly because, the great unspeakable truth, restraint was not in their own economic interest. The result, as Dartmouth's Elliott Fisher summed it up, is that "doctors and hospitals (are) doing things to you and me that we don't need" in a system "that pushes doctors to do more when less is probably better."

The second segment,  "Every CAT Scan Has Nine Lives," explored how difficult it is for doctors to practice less is better, when patients are convinced that more is never enough. A California ER doctor named Jerome Hoffman recalled how he examined a teenager who was in a very minor car accident; her mother was relieved to learn she was fine, that she didn't even need an X-ray. But her father went ballistic, demanding not an X-Ray but a CAT scan and implying that he'd sue if she didn't get it.  A CAT scan that wasn't going to aid her recovery from the minor crash, but could increase her chance of cancer from the radiation in the future.

Hoffman finally got fed up and explained that it would be easier (and more lucrative -- insurers pay him more for "complex" patients) to do the test, but that he had sworn to do no harm to the patient. The father finally went away.

Or another physician, Dan Merenstein, (whose children, completely coincidentally, I carpooled to the school bus this morning) a family medicine physician at Georgetown, retold the painful story of how in his residency he and a 53 year old patient discussed -- together -- the pros and cons of a PSA test. Merenstein didn't withhold the prostate test, or tell the patient not to take it. The patient chose not to take it. A year later, another doctor ran the test (without the patient's knowledge) and found a rare and highly aggressive form of  prostate cancer. He sued, with expert witnesses making the extremely dubious assertion that if the patient had the test a year earlier he would have lived "a long and productive life."  The jury basically decided they didn't want to hear about "evidence-based medicine" (or even about rare and incurable forms of cancer). They wanted doctors to do everything, evidence be damned. Merenstein (who later wrote in JAMA about his ordeal and how it changed his practice of medicine and his relationships with his patients) wasn't held liable, but his residency program was. The experience left its mark. He practiced "more is more" for a while, sending more patients to specialists for more follow up and scopes and procedures. But "it didn't feel right"  and he re-found his center. Although when it comes to PSA testing, he gives his patients a little "nudge." Most get the test.