Becoming Mindful Of Medical Decision Making

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BECOMING MINDFUL OF MEDICAL DECISION MAKING

TERRY GROSS, host: This is FRESH AIR. I'm Terry Gross. You've probably been there, I know I have. You're prescribed a medication, and then you have to decide whether you want to look at the long list of possible side effects or if you'd rather not know.

Medical decisions are often hard to make. There are so many benefits and risks to be weighed with medications, treatments and procedures. Some people want as much information as possible. Others prefer not to know too much.

My guests think that making the right medical choice requires understanding your own comfort level and making sure your doctor understands it too. My guests, Drs. Jerome Groopman and Pamela Hartzband, have written a new book about making medical decisions called "Your Medical Mind." You may be familiar with Dr. Groopman from his medical essays in the New Yorker.

Groopman and Hartzband are on the faculty of Harvard Medical School and the staff of Beth Israel Deaconess Medical Center. Dr. Groopman is an oncologist, Dr. Hartzband an endocrinologist. They're married and have collaborated on many medical articles. Dr. Jerome Groopman, Dr. Pamela Hartzband, welcome to FRESH AIR.

You've tried to describe what some of the different approaches patients have to dealing with decision-making and to dealing with medication and what they're going to be comfortable with. Let's start with maximalists versus minimalists.

PAMELA HARTZBAND: Well, maximalists are the people who want to be very proactive, ahead of the curve, to do everything possible to prevent or treat an illness. And then on the other hand you have minimalists, and to them less is more.

GROSS: So the fewer drugs I'm taking, the better.

HARTZBAND: Exactly.

JEROME GROOPMAN: Well, then you have people who are more oriented towards natural approaches. We call this a naturalism orientation. And then there are people who are very oriented towards technology, and they believe that the answers are in procedures, technology, scientific, laboratory-based products.

GROSS: And you also talk about believers versus doubters.

HARTZBAND: Believers are convinced that there's a good solution for their problem, and they just want to go for it. Sometimes they are believers in technology, sometimes believers in more natural remedies, but they believe. And then the doubters are the people who are always skeptical, worrying about side effects, worried about risks, and that maybe the treatment will be worse than the disease.

GROSS: Well, let's take examples from your life. Dr. Groopman, you were diagnosed with high cholesterol, and you had to figure out whether you wanted to take a statin drug. And you write about statin drugs and their side effects in the book and the difficulty patients have in deciding whether they want to take the drug and deal with the side effects, or at least possibly deal with the side effects, or take the risks of high cholesterol or find some alternative therapy.

So faced with that yourself, what did you do, and what was your process of thought?

GROOPMAN: Well, my starting point was two-fold. First, I was raised and until recently approached most medical decisions as a maximalist, as a believer and a maximalist.

GROSS: So to translate, you believed there was going to be a way to fix it, and you would do whatever it took and do the maximum therapy.

GROOPMAN: And more.

GROSS: Okay.

(SOUNDBITE OF LAUGHTER)

GROOPMAN: Exactly. So, you know...

GROSS: Give me the intervention, yeah.

GROOPMAN: Intervention, proactive, ahead of the curve, get out there and do it. And my father, at a young age, in his early 50s, had a massive heart attack and died, and he had high cholesterol. But I had reached a point in my life where I was having back pain and problems and I was concerned about side effects, much more concerned about side effects than most maximalists and believers typically are.

And I also was profoundly affected by a story. I was in the hospital parking lot, and a colleague, one of the other doctors, was hobbling from his car. And I thought, oh my God, he must have some terrible neurological disease. But it turned out he had taken a statin and developed severe muscle inflammation, which did not resolve.

So I backed off, and I took a natural approach, maximal natural approach. I lost weight. I exercised like a fiend. I cut out any foods that might increase cholesterol. I ate garlic. And it had almost no effect.

So I went to my internist and my primary care doctor, and he said here's a prescription for the statin. And I said wait a minute, why don't we try half a dose - because I had become very risk-averse, both because of my own muscle pain from my back problems and also because of this story. And it turned out within a month my cholesterol was in a very normal, healthy range.

And so that was an example of going through a process in a very different way than I had ever made a medical decision before.

GROSS: So you took a half-dose first so that you could see how your body responded to it, and maybe you'd only get half the side effects, if you had side effects.

(SOUNDBITE OF LAUGHTER)

GROOPMAN: Exactly. The side effects are dose-related. So you know, in the old days I would have jumped to the full dose or, you know, there are believers who believe you should take higher doses of statins and try to maximally reduce the cholesterol.

You know, so this is an example of two things, I think. One is that each of us is an individual in terms of our biology, our physiology and certainly in terms of our choices, and also that you have a spectrum of expert physicians who can look at the information that exists about statin treatment and cholesterol and come out with a very wide range of different recommendations looking at the same numbers.

GROSS: Now, so you opted for the half-dose. Did you up it to the full dose when you realized your body could handle the medication?

GROOPMAN: No.

GROSS: So you stayed at the half-dose. Now, I think it's only fair that we - like it's necessary that we say you can't do this with all medications. Some medications, you have to take the full dose, period.

GROOPMAN: Absolutely.

HARTZBAND: But actually it's a very common thing for patients to take half-dose and then come back and tell you, eventually, as a doctor, that they've done that.

GROSS: Do we need to warn people not to do that with antibiotics?

GROOPMAN: Absolutely.

HARTZBAND: Absolutely. There are many situations where that's not a good idea. We're not recommending it.

GROSS: Okay, okay. And I think the doubters often have really good reasons to be doubters. Like, people know if they're allergic to a lot of stuff, and if they are, they're the ones likely to get the side effects. So I think a lot of people are scared to take drugs for good reason.

HARTZBAND: I agree.

GROOPMAN: If you look at information about prescriptions, about a third of all people will not fill a prescription.

HARTZBAND: I think it's even higher. It's half.

GROOPMAN: It's even higher in certain things, half in certain...

HARTZBAND: Half the patients either won't fill the prescription, or they stop it after a short time of being on it.

GROSS: Well, that leads to an interesting question. If you are a doubter, if you feel like you're the kind of person who's likely to get the side effects, and you worry about side effects - that leaves you somewhere between cautious and afraid when it comes to taking new medications - do you think it's wise or unwise to read all the side effects? Because everything, absolutely every drug on the market, has this like long list of possible side effects.

And it doesn't tell you how likely any of them are. You're just reading this list and feeling absolutely vulnerable to, you know, like two dozen complications, from headache to death.

HARTZBAND: You're right. I think it is very helpful to have an idea of the numbers in that situation, what things are common, what things are uncommon, and to try and put your fears into context based on that. And when you read the insert you may not be able to figure that out. You may need to ask a doctor or another medical professional to help you.

GROSS: Do you know what I sometimes do?

(SOUNDBITE OF LAUGHTER)

HARTZBAND: What?

GROSS: I say to my husband: You read the side effects for me. If I tell you I have one of these problems, you tell me if it's on the list. Because I don't know - I feel so impressionable, like I don't want to know. I just feel like I'll imagine it's all happening.

HARTZBAND: I think that's one way to handle it. I think, you know, some people like to handle it by knowing everything, and other people say this is - you know, I know I'm just going to get a little crazy here, so don't tell me unless I have a problem. I think both are reasonable approaches.

GROSS: So how do you deal with that with your patients? Do you caution them about all the side effects? What's the difference to you between advising your patients and scaring them when it comes to new treatments?

GROOPMAN: What I try to do is to lay out the most important and common potential risks, because I want to make sure that if the patient's feeling something that he or she tells me about it and is alert to it so that I can intervene as early as possible to prevent it from spiraling out of control.

And again, you know, as a blood specialist and a cancer specialist, the side effects of some of the medications really are life-threatening. So when someone says, you know, I don't want to know anything, just give me the drugs, I say, well, let's backtrack a minute and see what's important for you to know because I want to make sure you're getting the best and safest care.

And you know, some of the insights, I think, that we gained from looking at ourselves, as you're doing with us now and also from talking to so many patients, is that if you show people that you want to understand their mind and you want to understand their thinking, either their fears, or in my case being a maximalist and a believer, sort of some of their impulsive decisions, that they can step back and say, okay, I know where I am now, and it makes sense for me to move a little in a different direction and to maybe learn a little about the side effects and complications, or a maximalist, no, I don't have to go to the extreme, I can back off and maybe do something in a more moderate way.

GROSS: If you're just joining us, my guests are Dr. Jerome Groopman and Dr. Pamela Hartzband. They're married. They're both doctors. They both teach at Harvard. Dr. Groopman writes for the New Yorker. They've also co-authored a lot of articles together in various other places. They have a new book called "Your Medical Mind: How to Decide What's Right For You." Let's take a short break, then we'll talk some more. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: If you're just joining us, my guests are Dr. Jerome Groopman and Dr. Pamela Hartzband. They're a married couple who are both doctors. They both teach at Harvard. You might know Dr. Groopman's byline from the New Yorker. Their new book is called "Your Medical Mind: How to Decide What Is Right For You."

Now, you're parents, right?

HARTZBAND: We are parents, yes.

GROSS: Okay, and Dr. Groopman, you describe yourself as having been a maximalist when it comes to treatment, although you've changed a little bit on that. And Dr. Hartzband, you describe yourself as being a minimalist. So when your child got sick, how did you reach an agreement about whether to go for the maximum or the minimum amount of intervention?

HARTZBAND: I'll describe an episode with one of our children. Our youngest child, our daughter, was ill with a fever and a cough and then became extremely ill. And I took her to the pediatrician, and the pediatrician said: I think this is a cold and maybe some asthma, and we're going to give her some inhalers, and then we'll see if she gets better, and if she doesn't get better, give us a call.

And I wasn't happy with that. I felt that she was much sicker than they thought. And I wanted to her have a chest X-ray to see if she had pneumonia and antibiotics. So as I think back on this story, I guess I was acting as somewhat of a maximalist here.

GROSS: That's what it sounds like to me.

HARTZBAND: Yup, so that I think your point of view can change depending on circumstances.

GROOPMAN: But there were also two aspects to that story. First of all, it wasn't our regular pediatrician.

HARTZBAND: True.

GROOPMAN: It was a covering pediatrician. And what you said, as I recall, to the doctor was think about her as an individual and think about the story, that this is not just a typical cold or a typical fever. That's what she had at the start. But something's different.

And this is an example where often now some physicians feel constrained that they're following an algorithm and they're following a formula, which is that, you know, if you have a cold and a fever and you're a kid, it's usually a virus, and that's true.

But what a good doctor does is to be alert to what's different, what's not typical. And by saying something changed, something's different, she's much sicker and she had this lead-in, which was probably a virus, but now she needs a chest X-ray - and indeed she proved to have a full-blown pneumonia.

GROSS: And she wouldn't have been treated for it if you didn't push.

HARTZBAND: Correct.

GROSS: So this maybe leads us to best practices.

GROOPMAN: It does.

GROSS: Describe what best practices is and why it's so in the news now.

GROOPMAN: Best practices involve a group of experts who come together and designate how they think medicine should be provided to patients with a certain condition and so on. Now, we distinguish between two dimensions or two aspects of medicine.

The first aspect is safety or emergency, so having a procedure done in a hospital so that the surgeon doesn't leave instruments in your belly, or someone comes into the emergency room in the midst of a major heart attack and should be given an aspirin.

And that kind of medicine, that kind of treatment, is very amenable to standardization and best practices because it really doesn't involve patient choice and it's not within the gray zone, generally, of medicine. But what's happened, we believe, is that many of these expert committees have overreached, and they're trying to make it one-size-fits-all and dictate that every diabetic is treated in this way, or every woman with breast cancer should be treated this way, or mammograms are only really beneficial for women older than 50 but not less than 50.

But if you step back, you see that you can have different groups of experts coming out with different best practices, and what that tells you is there is no one right answer when you move into this gray zone of medicine.

GROSS: So is best practices written into the new health care plan?

GROOPMAN: It is, and there are many advisors who want to have report cards, where physicians who might try to customize or individualize treatment and deviate from what one group says is best practices, that they will be designated as not delivering quality care and also in some cases being financially penalized.

And what we note is that in the past 10 years, time and time and time again, what was put forth as best practices to apply to everyone have been shown to be wrong or contradicted.

HARTZBAND: And for example, you can think about the estrogen question. There was a period when estrogen was being prescribed so widely, it was like it should have been in the water for post-menopausal women. It was supposed to prevent heart disease and stroke and dementia.

And the WHI trial...

GROSS: Also hoping to keep you physically younger.

HARTZBAND: Yes, that too, of course, forever young. So when the WHI trial results came out, the position reversed dramatically, and all of a sudden everyone was taken off estrogen. And now there's a move back towards looking at sub-groups that might be benefitted by estrogen, different preparations of estrogen. So it's a controversy still.

GROSS: So how is best practices affecting you as doctors?

GROOPMAN: Well, it's difficult because, for example, insurance companies now are saying you must have a patient's blood sugar at this level, or you must have their cholesterol at this level.

HARTZBAND: Or a diabetic must be on a particular blood pressure medication, an ace inhibitor.

GROOPMAN: And you know, first of all, it may not apply to every patient. There are patients like the one we describe in the book, who is a woman with a high cholesterol, where her chance of a non-fatal heart attack in the next 10 years is one in 100, that means 99 out of 100 have no problem, and she's worried about side effects, she's a doubter and a minimalist.

And she doesn't want to take the pill. Well, that then sort of pivots me not as the advocate of the patient or someone who's trying to work with her to find out what's right for her as an individual, but to pressure her to do something which she doesn't want to do and frankly she can justify.

GROSS: You mean, the best practices makes you do that.

GROOPMAN: Exactly, because they're being linked now to public reporting in terms of physician practice. They get a report card, as well as money.

HARTZBAND: So that if your patient refuses to take the medicine, you are a bad doctor, you didn't give her the proper treatment that was recommended by these best practices.

GROOPMAN: You know, one of the things we discovered in terms of best practice, there was an analysis made of 100 best practices put together by top expert committees in internal medicine. Within one year, 14 percent were contradicted, two years about a quarter...

HARTZBAND: And by five years, almost half had been overturned. So the American College of Physicians actually came out with a recommendation that all guidelines should be either updated by five years or discarded.

GROSS: So you're basically approaching medicine as the art of medicine and the science of medicine and that there's a lot of gray area in which decision-making, taking into account an individual's unique body and unique frame of mind are very important.

Best practices, I think, is designed to make sure that there's a modicum of good medicine being practiced, you know, to make sure that everybody is cognizant, all the doctors know what standard procedures are because, as you point out in the book, that's not always true.

I mean, Dr. Groopman, you write about when your father had his heart attack years ago, he was in a hospital where they did an outdated procedure. If there had been best practices then, and if this hospital had been following it, your father might have lived.

GROOPMAN: Absolutely. So we very strongly advocate best practices in situations where, again, you're dealing with safety or protecting the patient against complication and unnecessary infection, or in an emergency situation where there's clear information that giving an aspirin or intervening for a heart attack, absolutely.

But what's happened, Terry, in the past few years is that the committees that have formulated best practices have overreached, and sometimes this overreaching, with one-size-fits-all, has hurt patients.

GROSS: Drs. Jerome Groopman and Pamela Hartzband will be back in the second half of the show. Their new book is called "Your Medical Mind: How to Decide What's Right For You." They're both on the faculty of Harvard Medical School. I'm Terry Gross, and this is FRESH AIR.

This is FRESH AIR. I'm Terry Gross, back with doctors Jerome Groopman and Pamela Hartzband. There new book, "Your Medical Mind," offers advice on how to make difficult medical decisions and how to understand your medical mind. For instance, are you a maximalist who wants to go for the maximum intervention? Or a minimalist who prefers to proceed as slowly and cautiously as possible, concerned about side effects and complications? Groopman is an oncologist; Hartzband, an endocrinologist. They're both on the faculty of Harvard Medical School. Groopman also writes about medical issues for The New Yorker.

Dr. Groopman, you've described yourself as a maximalist who has kind of pulled back a little bit because you...

JEROME GROOPMAN}, ONCOLOGIST, HARVARD MEDICAL SCHOOL: In recovery.

(SOUNDBITE OF LAUGHTER)

GROSS: Recovery. Exactly. When you were a medical student, you were at UCLA for a while, and this is a period when UCLA was...

SCHOOL: I was a fellow, Terry. I was, right, yeah.

GROSS: Yeah, was a fellow. Okay. Thank you. Yeah. And there were at the time doing pioneering work on bone marrow transplants. And as you've pointed out, this was a period when bone marrow transplants were still pretty experimental and it was a far riskier procedure than it is now. It's basically a procedure in which your stem cells are transplanted. Can you describe it in two sentences?

SCHOOL: Sure. Bone marrow transplant involves taking marrow stem cells – the cells that give rise to all of the different blood cells from a compatible donor, usually a brother or a sister - and transplanting them into you after your entire blood system has been wiped out by radiation treatment and chemotherapy treatment. So you're basically being resurrected in terms of your immune system and your entire blood-forming system, using the stem cells from a donor.

GROSS: So when you are working with this procedure back when you were a fellow at UCLA, the mortality rate I think was pretty high, because the procedure was new. It's been improved a lot since then. But how did you feel as a maximalist, as somebody who wanted, you know, the ultimate intervention for things, seeing the ultimate intervention sometimes killing people?

SCHOOL: It is very painful, very difficult and at times caused serious doubt and concern. You know, as you say, Donnall Thomas, who pioneered bone marrow transplant and won the Nobel Prize for it, the first 11 people who were transplanted all died within weeks. And as you indicate, you know, the treatment is so harsh that it's an unpleasant, miserable kind of therapy with a real suffering. But it required to some degree being a believer - that to eradicate leukemia, or eradicate lymphoma, these deadly diseases that occur from childhood all the way up into late adulthood - necessitated this treatment and that it was important to persevere.

And, you know, there were a whole group of people who said that Donnall Thomas was like a war criminal. You know, that how could he be doing this work. And now every year hundreds of thousands of people are saved because of that treatment. And as you say Terry, it's been refined. So, you know, medicine is not simple.

HARTZBAND: And sometimes being a believer is important...

SCHOOL: Yeah.

HARTZBAND: ...for progress. Even a doubter can say that.

GROSS: One more thing. And I'm not sure you bring this up in the book, but I think the medical mind can also be subdivided into two other categories. And that is one, the people who absolutely obsess on their medical problem or their symptoms. And two, the people who say yeah, I have that. I'm ignoring it. You know, it's there. I don't pay attention.

HARTZBAND: That's a good point, a very good point.

SCHOOL: I think, you know, being an obsessor(ph) - what a friend of mine once called psychosemitic(ph) - being a nice neurotic, Jewish guy.

(SOUNDBITE OF LAUGHTER)

SCHOOL: And you can decide if, you know, that's a new term in psychology. That is another real divide in terms of – but to a degree I think, Terry, it moves towards the believer kind of, you know...

HARTZBAND: I agree, the believer-doubter - that the doubters tend to dismiss their symptoms because they really don't want to pursue any treatment unless they absolutely have to. And the people who are obsessing about their symptoms are more likely to be a believer. They want to do something about it.

SCHOOL: Right.

HARTZBAND: So they're thinking about it, thinking about it, thinking about it all the time, what can they do.

GROSS: Can we just say that the worst thing is to be a believer and a doubter at the same time? In other words...

(SOUNDBITE OF LAUGHTER)

GROSS: ...the worst thing is somebody who obsesses on their symptoms and then doubt...

(SOUNDBITE OF CROSSTALK)

GROSS: ...that there's anything that they could do to do to fix it.

(SOUNDBITE OF LAUGHTER)

HARTZBAND: Absolutely. You are so right.

SCHOOL: Right. It's much easier to have even two people like us; one a believer and the other a doubter, live with each other and be married for 32 years, then to have it in the same person.

(SOUNDBITE OF LAUGHTER)

GROSS: Okay. Well, I want to thank you so much for talking with us. Thank you, Dr. Groopman, Dr. Hartzband.

HARTZBAND: Thank you very much for having us.

SCHOOL: It's a pleasure. Thank you.

GROSS: Doctors Jerome Groopman and Pamela Hartzband are the authors of the new book "Your Medical Mind." You can read an excerpt on our website, freshair.npr.org.

Coming up, former "Jeopardy!" champ Ken Jennings talks about his new book "Maphead." It's about weird geography and geography wonks. And I'll hear about his post-traumatic game show stress disorder. This is FRESH AIR.

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LOVE LONGITUDE? 'MAPHEAD' LOCATES GEOGRAPHY BUFFS

TERRY GROSS, host: Our next guest, Ken Jennings, appeared as a contestant on "Jeopardy!" in 2004 and discovered he was pretty good at it. In fact, he became the longest-running champion the show ever had, winning 74 games and two-and-a-half million dollars, an American game show record. That led to TV appearances and a book called "Brainiac," about trivia in American culture.

In his new book, Jennings reveals that since he was a kid he's been fascinated with maps and geographical curiosities, like how the shapes of Wisconsin and Tanzania are practically the same. And where towns like Scotsguard and Saskatchewan got there names. The book explores the history of mapmaking in many ways map lovers and geographers affect our lives and indulge their obsessions. It's called "Maphead: Charting the Wide, Weird World of Geography Wonks." Ken Jennings spoke with FRESH AIR contributor Dave Davies.

DAVE DAVIES: Well, Ken Jennings, welcome to FRESH AIR. I have to say, I was drawn to the book in part because I like being geographically oriented. Whenever I go visit some place, even if I'm driving around with a friend, I like a map to know where I am. And whenever I read a book especially a nonfiction book, in which the author starts referring to places, you know, cities, shorelines, rivers, other features, and there's no map to tell me where they are, I get really annoyed. So, am I one of you guys?

KEN JENNINGS: I think so. That sounds like, I don't want to diagnose you here on the air...

(SOUNDBITE OF LAUGHTER)

JENNINGS: ...but that sounds like the symptoms to me. It almost seems like a form of OCD, where I'm the same way. If I go to a new city I sort of need to know which way is north. I need to get that crappy map they always have in the hotel room magazine to tell me, you know, which way I'm walking. Otherwise, it just sort of nags at me. And as recently as last night, I was reading my son, we were reading the "Lord of the Rings" as a bedtime story, and we kept flipping back and forth between the map and the narrative just because that's the best way to do it, you know, if your brain is wired like that, I guess.

DAVIES: You visit some interesting places in the book. One of them is the map division of the Library of Congress. You want to describe this place?

JENNINGS: It's a vast basement. It's the lowest possible floor on what I believe is the largest building of the Library of Congress. And the librarian there told me that it had to be in the basement because the holdings were so heavy that, you know, if you tried to put the maps and atlases on the top floor, they would fall through to the basement anyway. It's a library straight out of Jorge Luis Borges. It's, you know, a football field's worth of shelves just as far as the eye can see - full of maps and atlases - and it seemed like at any point the librarian could open any of them and just pull out some amazing historical treasure. You know, some surveying map of Virginia hand drawn by George Washington or the maps from the Versailles conference at the end of World War I or maps that Teddy Roosevelt drew when he was exploring South America after his presidency. It's just amazing. It's just like a walk through history to look at these maps.

DAVIES: Now in this book you introduce us to many different species of geography nerds, for a lack of a better term.

(SOUNDBITE OF LAUGHTER)

DAVIES: One of them...

JENNINGS: I'm not offended.

DAVIES: One of them are road geeks. Tell us about them.

JENNINGS: Road geeks are obsessed with roads of all kinds, and specifically the interstate system. This seems to be the catalog by which they organize their love of place and maps. They like to clinch roads, which means to drive on every, you know, inch of a certain highway. They're interested in minutia as far down as the kind of the company that makes the streetlamps on a certain length of road, or the typefaces on the signs. They notice when the government changes fonts to a new typeface called Clearview, which the government's rolled out for the interstate system. They're scholars - they drive around on these roads, taking pictures of nothing but road signs and hoping to find mistakes to write their congressman about - or taking pictures of road construction projects as they develop. This is their life.

DAVIES: I want you to tell the story of this character Richard Ankrom and what he did on this particular highway.

JENNINGS: This is a remarkable story. I don't know if he would consider himself a road geek, but he's sort of a patron saint for many road geeks, I think. He got so annoyed by this signage in downtown L.A. that did make it clear where to get from one freeway to another that he decided he would do a little bit of performance art. And one night he and some friends dressed up in orange jumpsuits and clipboards, you know, in case they were caught so it looks plausibly like a road crew, and they broke into the, they broke onto the sign, climbed out onto it and replaced the confusing sign with a new entirely convincing sign of their own devising, which actually labels the lanes and the exits correctly.

And the great thing is the California Transit Authority didn't notice for months and months. You know, hundreds of thousands of travelers were able to navigate to the leftmost lane and get the right off-ramp without anyone noticing. It wasn't until a local alt-weekly broke the news that the California Transit Authority, you know, issued a stern public statement about the dangers of vandalizing public signage. But the guy is a hero. He's like a Robin Hood of the 405 or whatever it is.

DAVIES: And even after the authorities reacted it stayed that way for years, right?

JENNINGS: That's right. The sign stayed that way for years. And when they finally replaced it a few years ago, they replaced it with a sign that looked essentially just like Ankrom's illegal performance art sign.

DAVIES: One of the interesting things about maps is that they connect us to places that we haven't been. I mean, you know, we can show a connection between my house, my street, my city to faraway places that I could only imagine. And one of the interesting things you point out in the book is that maps in past centuries included places whose existence we couldn't even be sure of, imaginary places right?

JENNINGS: Yeah, and they often turned out to be imaginary. You look at these old mapa mundi from the 14th, 15th century whatever it is, maybe even earlier, and you'll see real explored places just side-by-side with the Garden of Eden, for example. If they drew a map of Turkey, they would draw of Noah's Ark still sitting on a mountain. If they were drawing the Middle East they'd find a way to squeeze in the Land of Gog and Magog from the "Book of Revelations," including a - and they would draw a wall - which according to legend, Alexander the great built a wall around the land of Gog and Magog. And, of course, these places don't exist, but old habits die hard.

You know, once something is on a map it gets that sheen of authority. I know that, you know, as late as this decade in the mid, you know, around 2005 or so, the latest edition of Goode's World Atlas included in the Ivory Coast a mountain range called the Mountains of Kong, which do not exist at all. They've just been passed down on maps through the century. And as time goes on these nonexistent islands sort of get swept farther and farther towards the edges as, you know, actual explorers find out they don't exist and they finally disappear altogether. And it's sort of sad, you know. It's like, you know, all these wonderful imaginary places swept to the dustbin and then gone.

DAVIES: One of the wonderful stories that you tell in here is how we got numbered highways. It was really because of mapheads at Rand McNally. Is this right?

JENNINGS: Yeah. You know, we don't realize how hard it was to drive anywhere outside the major cities just less than a century ago. After World War I, the U.S. government ordered a tank convoy or a, you know, an armored vehicle convoy of jeeps and whatnot across the country, and it took them months. You know, there were casualties. You know, there were injuries and, you know, a huge percentage of the jeeps that set out couldn't make it across the country because the roads were so terrible. And, you know, Rand McNally, looking for a way to map these roads, you know, all they - there was no signage, there was no numbering system, all they could do was give you directions, you know, turn left at the barn, or turn right at the stand of poplar trees, or whatever. And this was not working out. So...

DAVIES: So if you wanted a map back then you would get in effect a booklet of narrative descriptions of what to do when you...

JENNINGS: Often they'd be photographs taken from the hood of a car. It would be like a Google Street View 100 years ago, you know. You'd get these street auto guides that would show you this is what it's going to look like from, you know, from the road when you need to turn left, so it would be like a flipbook. And wanting to have easier-to-read maps, Rand McNally held this in-house contest for suggestions. How can we do this? And I guess one of their designers said, there is no way to make the maps match the territory. We need to make the territory match the maps. So Rand McNally decided to just unilaterally create their own numbering system for roads in the U.S., and then they sent out groups to paint their numbers alongside every highway that needed one. They called it the, I think they called it the Blazed Trail System. They were blazing a trail just like frontiersmen and explorers.

DAVIES: So they paid them to put out signs with numbers on them or?

JENNINGS: Yeah. They would actually paint little flags with colors and numbers all along these highways. So that the roads would actually match the road atlas. The road atlas came first, and they had to change the roads to match it. It's a remarkable story of, you know, the mountain coming to Mohammed.

DAVIES: And eventually the government picked up on the idea and...

JENNINGS: Yeah. It became a hit, states started to do it, and finally the government imposed the system we have today.

DAVIES: If you're just joining us, we're speaking with a writer Ken Jennings. He is the longest running champion on "Jeopardy!"" and he's written several books. His latest is "Maphead: Charting the Wide, Weird World of Geography Wonks."

Well, you became a celebrity in 2004 when you appeared on the show, "Jeopardy,!" and won 74 straight times - an all-time record, winning, was it $2.4 million? Is that right?

JENNINGS: Sounds about right. That's a very minor kind of celebrity. You know, everyone's grandma recognizes me, that's what "Jeopardy!" does for you.

DAVIES: OK. So you get on the show, and one of the things that people watch the show observe is that more than one person often knows the answer. And an important part of the game is being the one who buzzes first. What are the rules and how much of winning is handling the buzzer properly?

JENNINGS: I feel like telling people there's no Santa Claus here. But yeah, the buzzer is huge. The buzzer is as important as knowledge. Because as you say, every player every night has passed the same hard test to be there, so most of the players know most of the answers every single time, and it just becomes a matter of figuring out your timing. You can't buzz as soon as you know it. The button is disactivated(ph) until Alex actually finishes reading the question. And at that point, some human somewhere flips the switch and then you can buzz. But if you buzz too early you lock yourself out for a fraction of a second. So it becomes this very delicate balancing act between what's too early and is going to lock me out, and what's too late and is going to get me beat by the guy next to me? You know, there's one right, you know, fraction of a second and you have to find it. You have to get into a rhythm.

DAVIES: Right. And to do that you can't be listening to Alex read the question because actually you need to read it yourself and then find the answer. But then you have to pay attention to at least the end of his answer. That sounds a little tricky.

JENNINGS: Sure. You sort of have to be multitasking. You've got to be aware of the score, aware of the situation, aware of the category. Then you're reading the clue as fast as you can, you know, hoping to give yourself enough time to come up with an answer. Once you have an answer ready, you've decided whether you are going to buzz, then you're listening to Alex's voice trying to get into the rhythm of it, waiting for that last syllable. There's a little discernible pause and then you're just, you know, your thumb is buzzing as hard as you can. It's amazingly fast paced doing that, you know, 61 times in just 20 minutes of show.

DAVIES: Now you are on the show from June to November of 2004 - 74, well, 75 straight episodes, the last one you lost. And...

JENNINGS: Thanks for rubbing that in, by the way.

(SOUNDBITE OF LAUGHTER)

DAVIES: It happen...

JENNINGS: Lo these seven years later.

DAVIES: Well, since I brought it up, what question did you lose on? Was there a final "Jeopardy!" that you lost?

JENNINGS: It was. I didn't know it. If I had known that I would've won. It was a business and industry question about, I don't know how it was phrased, some company that, some firm that hires most of its white-collar workers for just a few months out of the year. And I had no idea. And I could hear the woman next to me writing away to immediately. And I thought oh, she knows it. And she did. It was H&R Block.

DAVIES: Right. For tax season.

JENNINGS: Tax preparation.

DAVIES: And you are thinking probably the holiday shopping season or something.

JENNINGS: Yeah. I'm sure it had to be some Christmas thing. I wrote FedEx, but unfortunately not true. Although I did get a nice FedEx and an H&R Block endorsement out of it. So if you're going to lose on "Jeopardy,!" lose on the corporate questions, you know?

(SOUNDBITE OF LAUGHTER)

DAVIES: Okay.

JENNINGS: If the answer is who is Isaac Newton and you get that wrong, you know, you don't see a dime.

(SOUNDBITE OF LAUGHTER)

DAVIES: No payoff for Isaac Newton.

JENNINGS: That's right.

DAVIES: Now you were eventually brought back to face off with the IBM computer Watson in a, you know, highly publicized match. I guess it went over three nights, three shows. How did competing against the computer differ from competing against a human contestant?

JENNINGS: The game felt about the same. You don't have a foreboding sense of evil when there is some Hal-like supercomputer standing next to you like I thought you might. But the big difference is the buzzer. The computer has just flawless buzzer time. It receives an electronic signal to tell it when the buzzer is activated. Just like the players, you know, we see a little light that tells us that as well. But the difference is, you know, it has just milliseconds precise reflexes every time which no human can cope with. So, you know, maybe the computer didn't know quite as many answers as a good human player would, but that didn't matter because every time it did it got in first. It was remarkable.

DAVIES: Do you still watch "Jeopardy!"? Is the experience different for you?

You know, I can't relax and just, you know, sink back in the couch and watch "Jeopardy!" the way I used to. That's sort of the one regret I have is that now when I hear that music or I hear Trebek's, you know, Canadian accent, I, you know, I used to get excited and now I just get panicky. It's like an adrenaline rush - I have post-traumatic game show stress disorder or something.

(SOUNDBITE OF LAUGHTER)

JENNINGS: I just cannot relax into "Jeopardy!" the way I used to.

DAVIES: So, what, do you leave the room?

(SOUNDBITE OF LAUGHTER)

JENNINGS: If it's on and, you know, if it's on in a restaurant or a bar or something, you know, the voice will - the Trebek a voice will just cut through everything else like a knife, you know, I'll be hyperaware of it. But I don't leave the room, but it's no longer, you know, sort of pleasurable experience where you can just spit out answers at the screen through a mouthful of Pringles like it used to be.

DAVIES: Well, Ken Jennings, it's been fun. Thanks so much for speaking with us.

JENNINGS: It's a pleasure. Thanks for having me, Dave.

GROSS: Ken Jennings spoke with FRESH AIR contributor Dave Davies. Jennings new book is called "Maphead: Charting the Wide, Weird World of Geography Wonks." You can read an excerpt on our website, freshair.npr.org.

Coming up, John Powers reviews Roger Ebert's new memoir. This is FRESH AIR.

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ROGER EBERT: A CRITIC REFLECTS ON 'LIFE ITSELF'

TERRY GROSS, host: Roger Ebert is best known for expanding the place of film criticism on TV, for his thumb, of course, and for his cancer - which has left him unable to speak. He remains active as a critic and blogger. Ebert and his wife Chaz has been producing a new version of the show, "At the Movies," with two young critics talking about films like Ebert and the late Gene Siskel once did. Now Roger Ebert has a new memoir called "Life Itself." Are critic-at-large John Powers has a review.

JOHN POWERS: You can divide famous people into two broad categories: Those who find fame a burden and those who take it like a tonic. Roger Ebert is one of the latter. That rarest of creatures - a film critic who everyone knows. He really enjoys being Roger Ebert. This pleasure comes through in his new memoir, "Life Itself." Perhaps goaded into existence by the cancer that has assailed him in recent years, it tells the life story of the man with the most famous thumb in America, pausing along the way to offer the author's views on everything from the glories of black-and-white cinematography to the existence of God to the comedy of being fat.

The book is chatty, upbeat and structurally loose - which is to say that it sounds exactly like Roger Ebert. He was born 69 years ago in Urbana, Illinois, and enjoyed a classic Middle American childhood, idyllic but tinged with darkness. He had an electrician father, Walter, whom he obviously adored; and a mother, Annabel, who treated him kindly but also scared him with her anger, especially once she became an alcoholic, a drinking problem that Ebert himself would share - and eventually conquer.

A lifelong liberal, Ebert had dreamed of being a feisty newspaper columnist like Mike Royko. But his life took a very different turn in 1967 when, much to his surprise, he was named film critic for The Chicago Sun-Times. He was all of 25 years old, and he seized the job like a brass ring. His career took off quickly - he'd won the Pulitzer Prize by age 33 - and he began accumulating a vast storehouse of anecdotes. He gives career advice to the young Oprah Winfrey, hangs out with the old Robert Mitchum, and scripts the movie "Beyond the Valley of the Dolls" for skinflick meister Russ Meyer, whose own account of their collaboration makes you suspect that Ebert is giving us the PG version.

Still, he would have remained a minor local celebrity had it not been for the 1975 creation of the movie review show "Sneak Previews," with fellow Chicago critic Gene Siskel, a competitive man of burning ambition, whom Ebert portrays with surprising generosity. The show wasn't Ebert's idea, but it changed him - and our culture, not always for the best. The trademark feature of "Sneak Previews" was that moment when Ebert and Siskel gave movies thumbs up or thumbs down, a hugely influential shtick that reduced film criticism to a simple-minded consumer guide in which ideas barely matter.

Yet while I know scads of critics who dislike that show, I'm not sure I know any who dislike or blame Ebert. They think, that's just Roger. And Roger has never been one of those critics you read for his analysis. He's a critic you read for his openness and enthusiasm. Because of that enthusiasm, you might almost say that he's the original fanboy - breezy, personal, ready to share.

This may help explain why, after cancer forced him from his TV show, he reinvented himself as a hugely successful blogger, weighing in on everything from movies to politics to what he sees as the ruination of his newspaper by idiots. It's probably the best writing he's ever done. And it's all the more impressive because life dealt him a hard blow with a disease that keeps him from eating, drinking or talking - three things he obviously loved. But rather than sinking into a funk or hiding away, he's gone on with his life, and one of the many admirable features of his new book is its sunny-ness(ph). It's wholly free from the complaining and self-pity so popular in memoirs these days.

That's just what you'd hope for from a guy who was raised, and thrived, in the very heart of the American century. Ebert is anything but provincial. "Life Itself" begins with a reference to Ingmar Bergman's film "Persona," and ends by quoting Tintin's dog, Milou. But reading this book I was struck by how deeply he's inscribed with our national character; the decency and good humor and happy acceptance of other cultures. The recognition that the world has murky depths he'd just as soon not dwell on. Above all, the eagerness to engage with life. You see, unlike a lot of film critics, Roger Ebert knows that there's more to living than just sitting in the dark.

GROSS: John Powers is film critic for Vogue and Vogue.com. He reviewed "Life Itself: A Memoir" by Roger Ebert. You can read an excerpt on our website, freshair.npr.org, where you can also download podcasts of our show.

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GROSS: I'm Terry Gross.

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GROSS: Brad Pitt is starting in the new film "Money Ball." On the next FRESH AIR, we talk with Pitt about some of his movie roles and about his childhood, the religion he was brought up in and why he left, becoming an actor, and dealing with the stalkerazzi that are always lurking around his family. Join us.

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Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.