>> why does your head hurt? this is the first day i've been close to you and you smell like you've been smoking. or like someone around you has been smoking. >> probably, i don't know, i haven't been smoking though. >> has somebody around you been smoking today? >> i don't know. i've been at school all day. >> i've never smelled any smoke on you before ever during class. but when i was over here working with you, i was like, it smells kind of like weed. and i'm not trying to insult you, i'm just saying i haven't seen you, and then you're saying i don't feel well, and you're late to class. i'm like, what is going on? >> nah, it ain't no smoke. >> okay. >> the fact that she smells very strongly of marijuana, i'm going to follow up with that. i don't believe what she said about, "no, i've been at school! no, no one around me was smoking." uh-uh, there's no way. >> i'm not nervous. if i get in trouble, i just get in trouble. (laughs)

>> i just went to get her from grad lab and ms. sharpe told me that she said, "i don't want to work, i have a headache, i'm hung over." so. >> sparkleontinues to be a project. we have continually reached out, provided, provided and provided, for her to try to accommodate her needs. >> she's good. probably just hung over. >> she's got a great mind. she's not a stupid kid. but those life things weigh on her. i don't know how resilient i could be and if i could be able to get to school either. that's not an excuse. no excuses, but gosh, that's pretty tough stuff. you can't do school the way you are right now. >> i don't know, it just made me forget about it and go to sleep. >> and i understand. i get it that there's a lot of pain but they just put a little mask over the pain for a little bit. and when the mask comes off today, you feel worse and the

pain's still there. >> yes, sir. >> okay. you don't want to say, "hey, you're not even in our district, we don't have to do this," but at some point, we have to say, "we've done everything humanly possible to help you and you don't want that help." and she's about at that point. >> there's only so much we can do. in order to be effective at what we're doing and to help as many students as we can, you've got to be able to let go of some of them. i feel like it's gotten to a point where, with sparkle and lawerance both, i think i'm starting to feel like they may not make it.

>> what time did you get to school today? >> uh, like, 1:00. that's kind of late. >> the deadline is may 1 for all seniors to get all classes completed. >> i know it wasn't the best aspect to come in at one. but at least i still made it to come. at least i didn't stay at home and sit here and have nothing completed for the day. >> he's not doing or finishing what he needs to finish. it doesn't seem like he's taking it seriously. >> let me see. i want to see what you're doing. >> lawerance doesn't have adults in his life. >> i triple donut dare you all to do that. >> right now, he's a kid that's on his own and nobody's telling him what to do, so i feel like he still needs high school, not just for the academics but for the structure. >> come on, lawerance. >> he's on a list that's put out that says, okay, these are

the seniors in grad lab that at this point are not getting credit for their classes so they won't walk and they won't graduate. >> it's not really bad, but it's what you need to take care of. you have english 4a. chemistry a. health. spanish 2b. he has seven classes that he needs to get credit for. he's on the fast track to do it, but he needs to work harder and come more often to get it completed. >> if i get all them completed by spring break, what's that mean? >> then that means you will be able to graduate in may. if we don't get these completed, then that means august. >> it's no... none of that. it's going to be completed. >> if i can get him here, he can do it. we just need him here every day. if you have a problem and you can't get some of this stuff done, then what we're going to have to do is just kind of double up, okay? >> gotcha. >> you need to come to school on time! if he doesn't follow suit to what i was telling him today, he will not graduate, because he needs those classes

in order to graduate. >> it made me kind of scared a little bit. like i have all this to do in a little bit of time, but it's going to help me. either i'm going to put up or shut up. that's how i do. (bell ringing) >> what were your goals? >> goals. i got six. >> come to school on time every day, right? that's fine. check. raise spanish grade from a 22 to a 65. did you do that? >> it's up to a 70. >> the stars have aligned for marcus. nobody expects him to be perfect but, you know, brandi hasn't been having to take him to school, he's been here early, checks in like he's supposed to, so we're in a better place than we were when he was in jail two weeks ago. >> okay, marcus, you're going to go ahead and read your essay. will you stand at the front for me? >> yes, ma'am. it's been real hard, you know.

but i'm making it work. i done brought every one of my grades up. came to school every day on time. basically following the plan. i'm making it happen, though. it's going good. but it's hard, though. it's hard. i want to quit. but i'm not a quitter so, you know. >> as we start to write the goals for next week, the first one, what shouldt be? what's something right now that you're not doing that you should be doing? >> i don't know. >> i'm looking for something specific. something that you know that you're doing that you shouldn't be doing. >> smoking? >> mm-hmm. >> 'cause i've been smoking for so long. like so long, every day. i can't remember the last day i didn't smoke. when i go home i go straight to the weed, man. i'm so used to it, it's like a daily routine. >> so you're telling me

you can't do something to try to stop? >> i didn't say that. i'm gonna try. i'm gonna give it my all, like i've been doing. and hopefully i come out on top like i want to. (bell rings) (dance music playing) (bell rings) >> we'll do whatever it takes for you to come to school. whatever you need, you can ask us, we'll help you. >> sparkle had connected with yosef workenh, our business manager. >> all we need you to do is just come to school. not only you're helping yourself, you're helping your family. >> she can relate to his background because he was orphaned at a very young age, came to this country with no family, and i think that she saw traits in him that she could relate to and aspire to be. >> so there's no excuse then? i want you to promise me that you'll come to school from now

on. >> i honestly thought she was on the path to dropping out, and then we kind of hooked her back in at the last minute when we saw her teetering at that precipice of, "i'm about to throw everything away." where have you been since the last time we talked a few weeks ago in my office? >> home. >> doing what? when we had all met mr. yosef, myself, and sparkle, she didn't go into deep specifics, but she had to leave where she was living, she had to move away, she couldn't trust anyone. i mean really a lot of drama. >> what was the thing that i told that changed your perception about your wanting to stay in school? (sniffles) >> 'cause i see that success can come from anybody. anybody can be successful. >> we met with her, gosh, i don't know, for maybe an hour,

and then she and i came in here and talked some more and she just really let a lot of stuff out. so i felt like maybe this was the moment we were really going to turn the corner with her. and then she was withdrawn. >> what happened was, she promised that she was going to come to school on saturdays, on regular days. but she never did. finally, mr. gasparello has decided that they have given her so many chances and they can't, you know, they can't keep doing this. >> we said, sparkle, we're doing all the giving, and you're not. and that's got to be understood that you've got to reciprocate. and if you can't do that, then you can't be here, and then she said okay. i don't want to be here. >> she withdrew on march 2.

i'm printing here a withdrawal form. mr. leiva, can i get you to withdraw, sign the withdrawal for taunika? she's been in and out of so many schools. so i really believe this won't be her last. she has two more years to go. and she's 17 at the moment. i don't know, a lot of them do give up at 18. >> i feel like this was a special situation, a student with extremely challenging life circumstances, and we then missed the opportunity to follow through and actually support her in the ways we said we would. >> sparkle was given lots of opportunities to come back and was given support. she got the sense of almost entitlement, where we were going to do whatever we needed to do to help her, but she didn't buy

in enough to do the things she needed to do. >> as a matter of fact, she called me yesterday. i can show you the text message that she sent. "i have nowhere to go. it's raining and all my stuff is outside. can you please just reply back?" and i said, "please call me." and it really... i mean, it really hurt me last night. it just hurt me so bad. i said, how can somebody can live like this? so i was going to call her today. (dial tone) (number tones beeping) (phone ringing on other end) >> the cricket number you have called has been temporarily disconnected. message 22, h-o-u. >> that means her phone is disconnected since last night. (fast busy signal) >> everyone does all jobs. counselor, social worker, parent. all of that.

but ultimately we're not equipped to deal with these kinds of circumstances that the students either find themselves in or put themselves in. >> and yet do you feel like the world expects you guys to solve these problems? >> absolutely. you know, the famous phrase i hear from folks over and over is, "oh, my goodness, god bless you all. your work is so noble. i could never do it." i'm thinking, you're right. most people cannot do this work, but you want us to be miracle workers. like, you guys take care of it. i'm going to stay over here in my comfortable job that i leave at work when i go home. but yeah, i think we're definitely held to a higher standard. >> iyou increase the pressure, what happens to the solubility of a gas? >> it increases. >> it increases. >> you got to have quality teachers in all of your classrooms. having said that, we already know if we balance this year's budget, this coming year's budget, cut $45 million out... we already know now the following year we're going to have to cut $52 million more.

the thing about improving schools, we know what to do. it's whether or not we have the courage to do what we know. but i just don't understand ethically how you can walk away and, year after year after year after year, see these kinds of schools when you know what to do to fix them. and it's just, to me, i don't understand it. i get angry when i think about it. these are our kids. they're all our kids. >> by and large, if you are a school dropout, good jobs are no longer available to you. and so you're destined to probably a lot of unemployment over the course of a lifetime. and then we see these large numbers of high school dropouts that really start filling our prisons. and that's when you become a significant burden on society.

it would be so much less expensive if we were less shortsighted and started saying, "what can we do with our public schools to truly make that investment now, um, and really make more of our children successful?" i think one of the interesting things about sharpstown is that they're part of this larger apollo 2 sort of this experiment within the houston independent school district to turn around schools. and it's an experiment that everyone in public education really should be watching, because at some point if as a public we want to turn around the worst of our schools, and if we now have the formula, we're going to need to come up with the dollars. >> good morning, apollos. welcome to day 137. it's tuesday, march 20, 2012.

it's an s.a.t. day at sharpstown high school. >> have you already taken the s.a.t.? >> no. >> you haven't? you haven't taken the s.a.t. but you've already applied for college. >> i guess i gotta take my s.a.t. >> so do i need to take him to his room to take his s.a.t.? he's saying he hasn't taken the s.a.t. how do you want to handle this? >> all right, take, uh... >> nah, you ain't got to worry about it. >> no, i am worried about it. >> lawerance? >> lawerance. what are you doing? just take it and find out where you're at, then you can plan from it. >> high school is getting tiresome. it's like a big amusement park. it's full of ups and downs, but after a while you get tired of riding the ride, right? >> if i don't get you in there, once they get started, you won't be able to do this. >> then we won't be able to do it. >> but that's a bad choice. >> i'll take it in the summer.

>> you just don't... that's not the way it works. you said you're focusing on wanting to be here. >> you're wanting me to take a test i have no idea i had to take. >> it's not a test that you pass or fail, it's a test that you take and gives you a score. >> go get it and i'll take it. >> you can't do it on your terms. >> you're getting mad because i don't want to take a test. >> i'm not mad, i'm just... >> then i won't take the test. >> that's fine, okay, but you can't just go where you want to go because we are testing up there. sit in the office. >> i'm not going to sit in your office. i'm going to grad lab. >> we just have kids that deal with so much more than what a typical 16- or 17-year-old should be dealing with. 70% of the time more of the issues that we deal with on a daily basis have to do with things outside of academics and instruction. you know, it's the baggage that these kids bring to school every day. come here. lawerance. stop. stop.

okay. so are you gonna go take this test? that's it. do you want to take it or not? i'm not forcing you. walk away from me again and you're out of here. this is rude and disrespectful. okay, that's it, you made that choice. everything i do for you. and i sit there and i try to talk to you and you turn your back on me and walk away? you can't act like that. you can't act like that. i don't care what's going on. you can't act like that. >> how am i supposed to act? >> you look at me. you show me the respect of looking at me and talking to me. >> so y'all are supposed to just voice your opinion, and your opinion's supposed to matter. it's supposed to matter to me. >> no. but you have to be respectful, and you're not. >> y'all ain't... and i'm trying to tell you something... >> i'm not respectful to you? say it again. i'm not respectful to you? is that what you're telling me?

you're kidding me? you call me because you're locked out of your apartment. seven o'clock at night. i'm cooking dinner with my family, and what do i do? >> bring me money. >> okay. and i'm disrespectful to you? that action means that you have the right to turn your back on me and walk away? why do i do anything for you? you are rude and disrespectful. i mean, lawerance, are you kidding me? i bend over backwards. my time with my family... do you know how often, at night, with my family, you text me and call me and say, "can you order me a pizza? can you do this?" i have three kids at home that i never see because i'm up here all the time. and you don't even appreciate it! you turn your back on me. you don't even appreciate what i do for you. >> i do everybody like everybody do me. >> i've never done you that way! i've never turned my back on you! >> in due time, that's all you're going to do. >> okay, so that's why you're doing it.

okay, so do you want to withdraw? because you obviously don't want to be here. >> how i don't want to be here? >> because you're disrespectful and rude. and we cannot... >> i don't want to take this test. you keep trying to force it like i have to take this test. >> no, i said you don't have to take the test. >> and i said okay. >> he's disrespectful and rude to everybody. after everything that i've done for him and the support that i've given him, it just pisses me off. he just has so much drama. it's frustrating me. 'cause i feel like he's got this chip on his shoulder and we can't rebuild any of it. >> are you giving up on him? >> no, i'm just frustrated right now. he has no one. his mom has been in and out of prison and i think that's kind of worn on him a lot. >> sit down. >> for what? >> because i need to finish talking with you. >> can you please leave? >> yeah. >> i'm trying to figure out a way to make it work for you, and every time we turn

around, we're babysitting or there's drama. >> you don't know nothing in my life. you don't know nothing what i go through. and you just keep saying, "oh, you know..." the same old three line stuff. >> and you don't like to hear that. >> no, it don't... >> okay. >> but all you hear is what everybody else say, so, (bleep) it! just you been sayin' (bleep) it to me, man, (bleep) it. i don't care no more. bye. >> okay. he thinks the world can just revolve around what his moods and stuff are. and i can't, we can't do that. tomorrow when you come back, you'll deal with officer ruffin. he's got too much other conflicts going on, so, we'll see. to be continued. we'll see. (phone rings) >> sharpstown high school. this is mindy. how may i assist you?

>> we're gonna have kids drop out. there's no way around it. but hopefully, they go somewhere else and we know where they went to. that's the goal. this is the room where we keep the files for the students who are leaving, or who have left sharpstown. when a student leaves, i get a folder, and my job is to find proof that the student, where they are, get an acceptable code for the state so that they don't become a dropout. >> why is it important for you to have the numbers in order? >> the state requires it, our whole rating system for being acceptable as a school depends on it, which means our money. it's all about money, it's all about being an acceptable school. >> unfortunately, the education system has sort of created this culture of wanting to make itself look good-- and i think that's all well and good, but any time performance is judged on the numbers you give me, we know that we need to double

check those numbers. when we look at sharpstown high school, there was an expectation of 343 kids graduating in the class of 2011. the actual number that they had was 177. what happened to the other 166? 45 were marked as dropouts. 38 of those kids stayed in school-- still, maybe fifth or sixth year they'll graduate from high school. 34 were said to be going to other states, 18 going back to home country. but i think this is a key thing. they said 32 going to texas private schools and, you know, that is highly improbable. what are the chances that lots of kids from a high-poverty high school are moving to a private school? >> the private school numbers are high. i try to steer them away from

the private schools. most people, when they think about private school, they think $2,000 tuition a month type of private school. but these private schools, what they are is you go in and you pay a certain set amount-- $300 to whatever it is-- and you take a packet home, you check off the answers and you give the packet back and you get a diploma. >> just like that? >> mm-hmm. >> like, how quickly? >> from what i can tell, you can get it within a day. we've had a student, he wasn't coming to school, the language i think was a barrier from where he came from. so the mom said that she was going to send him to a private school. they withdrew one day. they came back the next day with their diploma. on the same day that they withdrew. >> was he even a senior when he

withdrew? >> no, he was not a senior. >> but as far as the state of texas is concerned, that kid's not a dropout? >> no, because it's a good code. that school is a private school. >> it's not necessarily bad for sharpstown high school? it doesn't affect your... >> it doesn't affect our number, but it affects my morals. >> we have to have something to prove where they are. if i can't prove any of that, that they're in an educational setting or they've got their degree, they're a dropout in texas. only acceptable excuse you can use is to say, "i'm going back to my home country," and then we don't require any proof. just a statement. >> is that one easy to abuse, then? >> probably, but i don't think it's abused as much as what you think. >> i was supposedly in mexico. i dropped out for a whole semester and i didn't have

to prove nothing, you know. they were just like okay, he's going to mexico, that's it. and that was it. like, i was gone. like, supposedly, i was gone. >> yeah, it showed that he left and went home to mexico a couple of times and then he came back to the states to go ahead and finish his education. >> so you were never gonna go to mexico? >> no. i don't even plan on going there. i don't plan on going to mexico ever in my life. >> hmm. maybe there-- we've had some situations like that, that they say that they're gonna go back home, and then they don't, but there's no way of us covering that. so we just go on their word that they're actually going back home. but, i mean, by the looks of it, he probably didn't because, since he came back here. yeah. >> there's plenty of kids out here that do that. especially at this school, yeah.

i think there's a lot. >> marcus in march was doing really well, and it lasted for two or three weeks and then he ended up disappearing. >> it's been a rollercoaster. two and a half weeks, there's been little to no contact. he hasn't been on campus. sometimes you just have to be persistent. i text him almost every day, and just say where are you, you should be here. a lot of kids, if they stay in the environment that they're in, no matter what we do, that environment will take them and chew them up and spit them out. so he's out on the streets, doing who-knows-what. >> i been gettin' money. hustling. just getting it.

>> this doesn't sound legal. >> it's not. it's not. >> we're trying to figure out if he's going to choose to drop out. it's very likely at this point. it's kind of the hardest one on me because i feel like this one should make it. he's got football, which it should be a motivation. but now i'm starting to realize that... in his case, all of that stuff may not matter. >> because people at the school, they expect so much from me and like i'm not this little just preppy school kid. i ain't never been that. and it's hard trying to become that. man, pooh! i know i have to go to school and graduate. like i know this in my heart. but like, it's just everything

in my body, like my mind, like do not want to. but i know i need to. so it's like that's why i'm there sometimes, then i'd be away, then i come back, then i go back away. >> i was supposed to battle some nigga the other day, bro. the next day that boy got killed. >> 'cause sometimes i could be feeling like, "forget all of the other bull crap, i'm coming to school and doing my work. everyday. i'm not going to play no more." but then like my old mind says, just, "let's go grind, let's go get it. you need some money in your pocket." i know it's temporary. but it's like everybody around you, they know too. so it's like they tell me all the time, "go to school, fool! stop being stupid." >> i really can't tell him (bleep). because that's what the game is. >> 'cause like all my older partners and stuff, most of them dropped out. yeah, cliff... >> man, they said i (bleep) his life up. >> but, they know i'm gonna end up if i drop out. i'll be just like them and they don't want to see me like that.

my momma tell me, that's all she want me to do is graduate. but there's so many things that just jump in the way of it like these streets. that's a big part of it, right. i don't know. it's hard. >> come here, come here... >> unfortunately, i was supposed to attend sharpstown still, but my actions got me kicked out. it just seemed like sharpstown wasn't a fit for me. i was not supposed to be there for that long. i'm surprised i lasted this long. >> what happened with lawerance, it was just a series of things. i don't think there was one thing that broke the camel's back, but he just became so unmanageable. and angry. so at that point we just needed to part ways.

some kids can't do school. >> yeah. i've been hearing that story my whole life. like you are very smart and intelligent, but you don't want to fit the rules. you don't want to obey our rules. in a sense, i don't. i'm gonna do it my way because that's how it's been for so long. (girl laughing) >> it was really hard for a while. it hurt that i couldn't get him to change and fix things, or take things differently or make better choices or, you know, appreciate what was being offered to him. >> all the stuff she did for me, she didn't deserve that. she didn't deserve me going off on her like that. i feel like a complete (bleep). the first two weeks, i was like, i'm done with school. sat home. chilled. play basketball. blew off my day. thought i had fun, like, in my mind, like, "oh, this is a fun experience, dah-dah-dah." but when i really sat down and thought about it, it wasn't.

it's like, man, do i want to live like this? do i want to keep doing the same stuff over and over and over? this is boring, this is dumb. so i decided i want my diploma still. >> lawerance enrolled in twilight, which is considered a separate school. it's on our grounds. >> glad you made it. >> and it's kind of hisd's way of trying to help kids that may have dropped out because they can't attend school from 8:00 to 3:00 or 8:00 to 4:00. they need something more flexible. >> so now, just go to hisd and officially enroll you. >> i think it really helps us. not as many kids are dropping out, because they have another way to finish school and get their degree. >> so, where are we starting? >> i think it's very possible for him to graduate by august. >> twilight be better for me

because i can be by myself. so there's not distractions, no nothing. just me, my work, and the time i got to do it. i can come from 4:00 to 8:00. it's not long, couple of hours, do my work i can get out of there quicker. more me time, the more i be focused. and just try a new step towards a better life. >> i started my career at a school that... it was more of an affluent neighborhood, kids that had a lot of good home support, that kind of stuff and, you know, i hate to say it, but i felt like i really wasn't needed. i feel like that's why i'm doing this. to make a difference. and so i enjoy being at schools like this where there are kids that really do need an adult to help them. parker, did you get everything in your backpack? >> yes. >> brandi thinks outside

the box. i have a tremendous amount of respect for her. she's a very good high school teacher working with kids that no one else wanted to work with and making a difference for them. >> are you ready? >> i don't know how she balances. she's got little kids. her husband is a saint. it's like that person who takes in strays. every time she sees a stray, she takes them in. >> marcus! marcus asked if for the remainder of the year he could stay with me. >> marcus! >> he's been staying with me for two and a half, maybe three weeks now. go see if marcus is ready. >> okay. >> he felt like part of his struggle getting to school every day was his self-discipline at home at night. i think he just needed someone to provide a little bit more structure and get him there.

>> marcus, are you ready? >> i'm almost ready. >> okay. >> football season is coming, so i knew i had to come back. i can't miss football season. never. i got to be here. i know for sure i was gonna come every day, like, for sure, and i have. i actually got a chance to go to college. i might as well take it. you know, the streets are going to be there forever and i always come back to them. but college, that's pretty much the only opportunity i got is right now. might as well try, try something new. >> what are you going to take to eat? obviously this scenario is not one that could be done for tons of kids. it's unconventional, unrealistic. i love you! this is a very unique situation where i just had a connection with a student that i felt like really needed support. i mean, i also feel guilty, because i know there's lots of

kids out there, and how do you pick and choose who to provide this much support for? (dance music playing) >> marco came in this year. we sat down and we completed his graduation plan together, and as we were looking at his transcript, i'm, like, "oh, marco, i don't know." it was pretty bleak. he just said, "ms. church, i want to graduate this year," and i said, "i want you to graduate as well." i said, "however, you know, right now i need for you to accomplish in one year what it takes most students to accomplish in two years." i am elated to say that through all of marco's hard work and his dedication, as well as commitment to get the job done, marco is now ready and

able to graduate on time. >> on sunday, you need to be there at 3:00. that's when you are going to put on your cap and gown, get yourself together. we need to line you up. this is a serious ceremony to acknowledge you for your success. >> well, my mom, she thought i was going to be graduating in august. now she knows it's june, she's, like, happy. this morning i texted her and she told me, "how much would the cap and gown be?" and i was, like, "$50," and she was, like, "do you want me to buy it?" i was, like, "no, i got money saved up, i'll buy it." >> you will practice the way you perform for sunday. stand tall. hands to your side. looking forward. >> she even told me, "what do you want me to give you that day, a party or something somewhere?" and i told her, "no, i don't know yet." but most likely, she's going to just take me out to eat at olive

garden and that's it. >> he's gonna graduate and he's gonna go in the army because he couldn't afford college, and he's gonna hopefully have a decent life. >> make sure you're with your... >> i have something planned to do after high school now. you know how they say, "you may be strong but then there's army strong?" and that's what i want to be and it's just like a different opportunity for me just to experience more. >> the issue is marching in properly. you are going to come down the center aisle. turn with your partner, and go to the end of your row to your teacher. >> i'm proud to be born in the u.s. my parents wasn't. i think i'm blessed to be born here, because i get to do more than them. >> stand up, straight, smile. >> now i can be a role model to my sisters and cousins, 'cause now they are looking up to me too. and my aunts, they respect me. when i go over sometimes they be, like, "look at the soldier, look at the soldier." i'm, like, "calm down. i'm still the same person.

i'm still your cousin. i'm still family. just because i'm in the army, doesn't mean i'm gonna change," so... i guess it's my year now. >> i need y'all to smile. (music playing) >> i am pleased to announce your 2012 prom king and queen. (cheers) >> good morning, apollos, and welcome to the last day of school. it is thursday, may 31, 2012. >> the algebra end-of-course exam test results had come back. so we had a meeting to talk about the scores. this is the results based on met minimum for 2012 and 2013.

so if you see, we are at 79% for satisfactory. notice that our advanced is the highest in the district. you know, i'm not going to show the biology and the world geography and everything else. but math is by far the best. our students are the top students in hisd comprehensive high schools. (applause and cheers) this is preliminary, but when you look at our algebra scores, they are amazing. our kids performed at a higher level than most other comprehensive high schools in hisd. this is proof right here. part of that accomplishment was due to the fellows and the math lab and the tutorials and the apollo 20 program. it's paid off because our kids are doing better than, you know, most of the other schools in the district. it shows. it shows. because when you look at that and you consider where our kids are coming in... you know, you guys grew them

huge. and this is very exciting. >> initially a lot of things look very good about apollo 20. we're seeing good data from sharpstown high school. we're seeing good data from some schools. but we're not seeing in all 20 of the schools, you know, all 20 of them are not being turned around. but i think it's very early to draw broad conclusions. while all the indicators look good, i think time will be able to help us in terms of determining whether this is the answer to our dropout problems. >> have we fixed it? no, no way. but i think we're improving it. i want people to see, okay, they are obviously doing something right over there. congratulations. it's awesome. (enthusiastic applause) so while i was having a celebration with the math fellows, across the hall, marcus punched a student in his class. >> that's what i thought, man.

>> go away. >> all right. >> go. go. >> didn't even hurt. >> so we don't know where marcus is? >> i'm calling. >> (on phone): hello. >> where are you? (indistinct) why? (indistinct) why? (indistinct) >> okay, i hope it was worth it. because you're done. you're done. you're done. i hope it was worth it. you're done. you're done with sharpstown, you're done with football, it's over. >> he needs to get back here, and we're gonna deal with it. >> marcus, you need to get back up here to school and sit down with mr. gasparello.

now. i was shocked. i mean, and i was very disappointed. bye. because here it was, we were literally two hours from the end of the year. >> all right, got it covered. >> okay, what happened? >> i wanted to fight the dude a long time ago, but it was too much stuff i would've lost. >> this isn't the streets. this isn't how we settle things. so if you had an issue with him, don't you think there could have been a better way of dealing with this? >> yeah. >> now he wants to press charges right now. you, you... what's gonna happen when you go to court again? i can't put you on a football team representing this school. if that's the mentality you have, that, "well, i'm not gonna fight him here, i'm gonna fight him at school." what do you think coach blacklock is gonna say? >> i don't know. i wasn't trying to jeopardize all that, i really...

>> but you... but you did. it is everything. >> i just can't even imagine what you were thinking in the middle of class. you just decided to start punching him. you talk about how good you been doing for the last month. but have you changed the way you think about what's important and priorit...? no, you haven't. >> i have with a lotta stuff, but... >> but not that. i mean, that doesn't make sense. >> there are no throwaway kids. even that kid that disappointed you and frustrated you and not held up their end of the bargain and what have you, they don't want to do that. i don't think you can go into it saying, "oh, we won one, we lost one." you just... you take everyone for as long as you can go and give them as many opportunities as you can, knowing full well that you're not going to be able to save every one of them.

but you have a moral obligation to try. you just sort of plug away each day, and then in the end some have made it, some haven't, and some will be in between. otherwise you go crazy. i think you really, really would. (cheering) >> we will be able to keep track of those students that are potential dropouts, because they're going to have to enroll in school. >> when it comes to the data and the numbers, this is a ongoing, day-to-day, week-to- week, month-to-month, yearly process. it never stops. so when daniela came, she supplied the private school that she was at. as long as we have good code

to know where they are going and where they are at, so they don't count as far as our dropout rate. >> deguerro... >> i think he was... he's a '98 dropout. in 2012, we have 18 students that i'm currently counting as dropouts. two of those may or may not be. we're talking an official definition of dropout for the state records and the way they define it. but no, i'm sure many, many more did not get a diploma somewhere. >> the pattern is always the same: the ninth grade always seems to be about 450 kids, and by the time they're 12th graders, it's like 275. where do they all go? >> well, i can't tell you where all they went, but they go, is all i can say. the ninth grade is the largest, granted, and you're right that it's about a little more than half-- 60%, something like

that-- end up in the 12th grade. but they just... slow attrition, and it happens. i think it happens at every school. >> i think we lose track of a lot of kids-- i mean, that's one thing. but you also got to realize that we have a transient population. our kids come, they go, they come back. we try to document, at least in the two years we've been here, as many of those kids as we can. that's a full-time job. i don't know that we do it better than any other schools. there's a lot of schools that do it better than we do, but that's a hard thing. what we are seeing is more of our kids over the last two years have stayed here. >> in a sense, the system sets up these really well-intentioned people at these schools to have to record this data in these particular ways that raises lots of suspicion from people like us.

but when you see these numbers that don't make a lot of sense around homeschooling, returning to home country, going to private school, all of us should really just say, "a lot of kids who should be finishing school are not finishing school. a lot of kids who should be graduating are not graduating and what are we going to do about it?" >> no, la negra. >> el cap y gown en el bano...

>> i got my name on there. i put "i made it." and i actually put my name on it because i'll throw it in the air. yeah, i'm going to have it so... it's really exciting. >> yeah. >> i asked my brother, my older brother, because he's a dropout, and i asked him, "are you going to come see me?" he said no. like, he just literally said, "no, i'm not going to go watch you walk a stage." and to me, i was like, okay, i'm not going to worry about it. i know i'm doing better than him. and that's just what i want her to do, my little sister, to be something. i know i'm going to be gone, but i told her she better pass all her classes and, you know, behave because i don't want her growing up like he did.

she don't want me to leave. >> what's the matter? >> she don't want me to go to the army but, yeah, it's like a lot of people are telling me not to go, but i'm still sticking to the plan and i'm going to go. >> you're going to miss him? ("pomp and circumstance" playing) (applause and cheers) >> we get caught up in kids that struggle. if that's the only thing you see, then i don't know that

you'd get up and come to work the next day. but we can't lose sight of the fact that at the other end and in the middle and in the continuum there's a lot of good things going on. that's the joy that keeps you going. >> graduating with highest honors. class valedictorian. quyen le. (applause and cheers) >> i'm graduating, you know. like, officially from high school, not a ged or anything like that. >> daniel peña. (cheers) >> i actually thought i was never coming back to school, too. before i came, i was like, "high school's not for me. i'm not going to school." i didn't think i would be graduating at all. >> marco antonio donavan servin. (cheers)

>> yeah, i'm proud of myself. >> never doubt, never doubt. >> he made it! i'm so proud of him! yes, he had a rough start, but his ending, his ending was like he was going for the gold. >> the silver lining in some of these struggles is it does make some of these kids tougher, resilient and flexible in dealing with life's issues so that they can move forward. i ask the class to stand. (loud cheers) one of my last directives to you. take your hand and put it on your tassel. by the power vested in me, i now pronounce you as graduates of sharpstown high school!

(wild cheers and applause) move that tassel! parents and friends, the graduating class of 2012! >> i don't think we've overcome the dropout problem, by any means. we don't always get it right, we don't always make the best decisions, but i think we're doing a better job with it, and we're keeping more kids in school. it's unbelievably hard, but it's doable if you don't let numbers define who and what your school is about. the kids are the reason we're here.

>> i got my start as a community organizer. >> i know how the private sector works. >> they've told us their stories, but this october, there's more. frontlineaward-winning political team takes you behind the headlines and spin. >> what unites both of these characters is this sense that there was a destiny that they had. >> "the choice 2012," a frontline exclusive. >> frontline continues online. find out what happens next for marcus. >> i wanna just go to college,

period. >> learn more about how the apollo program got started, and read more on houston's last-chance schools. follow up on texas's quick fix degree programs. find out the real economic value of a high school diploma. plus, watch the film online and follfrontline on facebook and twitter, or tell us what you think at pbs.org/frontline. >> frontline is made possible by contributions to your pbs station from viewers like you. thank you. and by the corporation for public broadcasting. major funding is provided by the john d. and catherine t. macarthur foundation, committed to building a more just, verdant and peaceful world. and by reva and david logan, committed to investigative journalism as the guardian of the public interest.

additional funding is provided by the park foundation, dedicated to heightening public awareness of critical issues. and by tfrontline journalism fund, with grantsa1 from susan hunter and douglas watson, and scott nathan and laura debonis. major funding for "dropout nation" is provided by american graduate: let's make it happen, a public media initiative made possible by the corporation for public broadcasting. captioned by media access group at wgbh access.wgbh.org >> for more on this and other frontline programs, visit our website at pbs.org/frontline.

frontline"dropout nation" is available on dvd. to order, visit shoppbs.org or call 1-800-play-pbs. frontline is also available for download on itunes. [ female announcer ] they can be enlightening.

hey, bro. or engaging. conversations help us learn and grow. at wells fargo, we believe you can never underestimate the power of a conversation. it's this exchange of ideas that helps you move ahead with confidence. because an open dialogue is what opens doors. if you need anything else, let me know. [ female announcer ] wells fargo. together we'll go far.

[ female announcer ] wells fargo. announcer: the following is a pbs election 2012

special presentation. man: this program was made possible by the charles a. frueauff foundation, the w.k. kellogg foundation, the missouri foundation for health, the silverweed foundation, the park foundation, the odyssey fund, the spunk fund, the trull foundation and the fledgling fund. brownlee: we have this idea in this country that when it comes to healthcare, more is better. you can't be too thin or too rich, and you can't get enough healthcare. fisher: we all come to a similar conclusion that about 30% of u.s. healthcare spending is devoted to unnecessary services, and that's, you know, $800 billion a year. you don't have a significant blockage. james: one person's waste is nearly always another person's income, and income turns into strong political defenses of areas that are classic waste. brownlee: we spend 2 1/2 times more per capita

than the average western european country spends, but the part that i'm most worried about is the waste that actually hurts patients. hill: there's a lot of unnecessary treatment that people undergo. hoffman: i see it every day in real human beings who get enormous amounts of unnecessary testing and enormous amounts of unnecessary treatments, and then the irony, of course, is that when we look at the health olympics and how we come out in the world in terms of health outcomes, we end up doing terribly. you know, we're just below slovenia or next to costa rica. life is so unfair. james: everything we do in healthcare is innately dangerous. it's sometimes extremely difficult to walk that thin line between health and harm, and you step over it fairly routinely. i have cancer, and life as we have known it is over.

brownlee: if you add up medical errors, drug interactions and hospital-acquired infections, medicine itself is the third leading cause of death in this country. of course i don't want to die. i'm paid more when i harm my patients. i'm paid more when i do more, even if it's not beneficial. brownlee: when payment incentives are aligned towards more care, when their worries about defensive medicine are aligned towards giving more care, when their patients seem to want more care, it keeps driving in the same direction towards more, more, more. you do everything you can to preserve life. james: the big entitlement programs-- medicaid, medicare, social security, with the vast majority being medicaid and medicare-- they're on autopilot. they automatically increase year by year. by 2050, they'll be consuming over 70% of the total federal budget. oh, wait a minute. so will interest on the debt. we can't afford it.

if healthcare costs keep rising at the rate they've been rising for the last few years, we will bankrupt this country. everybody clear, please. [flatline tone] james: we'll create a financial crisis of a size sufficient to destroy the united states of america. we have no choice. we will solve the problem. captioning made possible by friends of nci fisher: when we compare ucla and intermountain in terms of use of care, what we saw is that similar patients in that similar patients in los angeles were spending 60% more time in the hospital. they were having 75% more frequent office visits. and of course, if you're seeing more specialists,

by golly, you're going to get a lot more diagnostic tests and minor procedures. that led to the question of are they getting much better health outcomes as a consequence of all this extra time in the hospital and all the additional procedures? and we found that they were not. feinberg: i would put our quality rankings against anybody, 'cause to me i think the most important quality ranking is patient satisfaction. if we look at that measure, we're the number one academic medical center in the united states. fisher: ucla is a very high-quality hospital, and i'd want to be taken care of there if i had an acute catastrophe. but they also provide a lot of care that i believe is unnecessary. i'm certain that we provide care, not intentionally, that isn't needed, and we have to work on decreasing those inefficiencies that don't add value to care. [siren wailing] fisher: the secret to places like intermountain healthcare

is that they are designing into care the best possible science, and they have shown that it's possible to improve care and by improving care, reduce the overall cost of care. james: we deliver about 34,000 children a year. it turns out we have the ability to start labor artificially. it's called elective induction. now, sometimes you have to get that baby delivered because the mom's health or the baby health will be affected. an elective induction is purely for convenience. the direct consequence of inappropriate elective induction is cesarean section deliveries. we've seen huge differences in rates of cesarean section across the country, and the evidence is increasingly clear that the higher rates are not necessarily good for patients.

the national c-section rate today is running about 34%. intermountain as a system is running at about 20%. some hospitals in this country have c-section rates as high as 45%. feinberg: our rates of c-section in santa monica are high. we really want to do not one more c-section than necessary, but in all of these improvements, it's changing behaviors of patients, it's changing behaviors of providers, and trained as a psychiatrist, changing behaviors is a very, very difficult thing to achieve. so, our big day today. here you are, 39 weeks. can you believe it? it's been a long pregnancy. well, as we talked before, we have kind of a couple options about how to get this baby out, and option "a" was to try for a vaginal birth,

and option "b" is to do a c-section. mm-hmm. you had a c-section last time. and as we talked about, we have kind of some risks either way. mm-hmm. if we went for a vaginal delivery, the main risk would be something called a uterine rupture. so my understanding is that we've decided not to go with the vaginal delivery and we'd like to do the c-section, right? ok. that's for sure. tell me how you really feel. yeah. let's do this. let's get this baby here. we worked to reduce elective induction. as a consequence, we took down our c-section rates. oh, my goodness. hello. happy birthday! [laughter] what we did was build a little protocol that any time a woman appeared at the hospital saying, "my obstetrician sent me for an elective induction," we first carefully tracked the data. turns out that 28% of our patients were not good candidates when we started.

it was a phone call back to their physician saying, "doctor, your patient doesn't meet professional criteria "for elective induction. "we need a consult from a high-risk pregnancy specialist or the department chair." it went down to under 3%. we decided to go after the highest risk group in our preventive measures, and that's the people that have had the cesarean. the time in the hospital may actually decrease a little bit. yeah. we might... james: it's team-based care. we sometimes call it organized care. and that's the shift that's happening in medicine right now, is from each physician as a stand-alone expert in their own right, kind of a little law unto themselves, god-like in their powers, to a team of physicians managing the complex knowledge necessary to deliver best care to a patient. [crying] james: we have a massive drop in unplanned c-section rates. it was associated with about $50 million per year in savings to the people of utah. oh, by the way, we were punished financially.

we make more money when we do an unplanned c-section. we get basically screwed by the payment system, but patients come first. here's your boy. oh. there you go. james: turns out that our criteria for appropriate elective induction, if you violate the criteria, more children end up in the newborn icu. [monitor beeping] i had a c-section and basically, i had 2 7--babies that were over 7 1/2 pounds apiece, so they were pretty big babies. i kind of chose to do the c-section. people come from literally all over the world for complicated deliveries, and that by definition drives up our c-section rate because of the complications. but i would still say that i think our c-section rate can be improved. we left our newborn icu basically a ghost town. what a wonderful thing

if the rest of the nation had the same cesarean section rate that intermountain does, an overall rate of 20% versus 34%. it would save the country about $3.5 billion per year. now, that's waste. the variation in how we care for patients i think has real meaning for patients' lives, especially when you talk about what happens to patients as they near the end of life. fisher: places like los angeles that have more hospital beds on a per capita basis or have more physicians on a per capita basis, will have patients spending more time in the hospital and having them seeing their physicians more often. hoffman: we all know, you build it and they will come. if we have a whole bunch of things that are profitable and we could use them, well, we use them.

fisher: in the last 2 years of life for patients with serious illness at the university of california, los angeles, the average patient spends 29 days in the hospital, whereas those at intermountain spend 16 days. how many physician visits do they have in the last 2 years of life? 92 at ucla, 48 at intermountain healthcare. startling difference. almost two-fold differences. and patients at ucla spend 3 times as many days in the intensive care unit. as a consequence, in the last 2 years of life, patients at intermountain spend about $54,000, whereas patients at ucla spend about $98,000. [siren chirping] [indistinct] aysola: mr. toston suffered multiple strokes. he's had a profound injury to the brain from what's happened most recently.

the prognosis for mr. toston is extremely poor. there is--as far as what most of us would consider recovery to meaningful neurologic status-- ability to express themselves, recognize family, communicate in a way that most people would be able to understand-- that's essentially zero. i'm dr. aysola. i'm the icu doctor. i've gone through his chart in detail and i've seen what he's been through. how much is he able to interact with you? not that much. not much at all. i can tell you that in patients who have this much support, where the machine is doing all the breathing, if the heart stops in those circumstances to the point where we have to do cpr, compression of the chest, or shock the heart, typically the chance for recovery to functioning neurologic status is less than 1%. if he could be here and see the situation he was in, what would he want? ok. that's what you really have to focus on. there are many times that i ask him

if he still want to be with us, and he nodded. he said he wanted to live. if his heart stops, you want us to shock his heart and do cpr if that's needed? well, if-- when that's needed, yeah. ok. ok. are you ok with that, mom? hmm? i want him to live. whatever you can do, sir, to help him. man: ok. ok. all rightythen. thank you, mom. [alarm sounding] aysola: essentially, to provide adequate cpr, one must essentially have the full weight pressing upon someone's chest, and that is likely to crack ribs, potentially cause bleeding and result in significant trauma. hi, edgar, honey. do you know that we are here and that we love you so much. and i'll be right here beside you.

i will always love you. i would characterize his state certainly now as a vegetative state and potentially even worse. it is enormously troubling to focus our resources on patients in his condition, who really have no reasonable chance for recovery to a level of function which most of us would find acceptable. the family wants everything done. the way the system is set up currentl is that spouse, that child, that parent can really demand a full-court press regardless of what the odds are. he was in the icu for 6 days. i think the patient's wife was actually asking about diagnostic test results, asking the results of the eeg, asking results of the ct scans.

when she was basically told that nothing i could do could help him recover to any degree, she then was also willing to accept the outcome. what we did is start a drip of morphine and disconnected the ventilator and stopped all other medicines and fluids, stopped diagnostic testing, stopped monitoring, and then, within a matter of hours in his case, approximately 4 or 5 hours, he died. icus were initially designed to help someone recover to the point where they can leave the intensive care unit. oftentimes the icu now is the last stop before someone dies. i at one point was an icu patient and survived and-- due to the exceptional care i received. i felt it was my obligation, my duty to continue to provide that care, but i don't think it's a failure on my part

to say there's nothing i can do to cure your loved one. what i can do is make sure that your loved one is comfortable, they don't suffer. i think when we keep trying to find interventions, procedures, drugs and give false hope to families that we propagate this mythology that we can somehow stave off death indefinitely. woman: ms. stonum? how are you? ms. stonum, can you see me? [machine beeps] are you in pain? i don't know what's going on inside the mind. she's non-verbal, but she's able to respond to pain and noise and stuff like that. this has been a long journey for you... yes, it has. that began with her stroke, that it required a breathing machine, feeding tube and dialysis.

i feel like my mom is my baby, so to speak, so i want to nurture and care for her in any way that i can. if there's something that can sustain her medically, she would want that. if the nurses were doing their rounds and such and they found that, you know, her heart had stopped, at that point, would you want us to try to do something to try to restart her heart? one of the things that she would want is every opportunity to live and to enjoy life. as i look at how she's doing now, i'm glad that i didn't make the decision to let nature take its course. you know, miracles happen if you believe in miracles. we do run out of miracles, and there is a time for everyone. i don't know what that time frame would be. that i feel or some family member feels, you know, she's really not here with us now.

i suppose something like that, something spiritual. this is not something that i would want. it would be torturing me. on the other hand, other people feel very differently. you do everything you can to preserve life. that's what my mother would want. ok, let's find your favorite picture again. she likes to be talked to while looking at the photographs. this is your first baby way back in the times. ok, here's your favorite picture. this is when you were very young. always very glamorous, huh? reuben: what hasn't happened in the past 10 months is she hasn't left the hospital. in the meantime, basically our hospital has become her home. ucla, through their ethics committee, put in place a do-not-resuscitate order which, as her durable power of attorney, i am against.

and i believe my mother would be against. if she gets any new infections, for example, they will not treat them. in other words, they will not do heroic efforts to save her life. if a patient is very unlikely to survive but the physicians feel that there's some chance by using all the available resources they might be able to pull them through, they appropriately will use all of those treatments. yet they may recognize that a further deterioration would mean that that goal is unattainable, and under those circumstances, it would be inappropriate for them to further escalate care. yes. you're doing good. hang in there. every day is a miracle. why all of a sudden am i not in a position to make decisions about her life-ending choices? aysola: i think there is a disconnect between what we can do

and what we can do that helps. nurse: i'm going to visit you back again later. we're in a situation where we have very powerful technology, medications and tools and expertise in caring for people in critical illness, but i think we've approached a point where we're almost abusing that power. wenger: it's under those extremely unusual circumstances where the goals of medicine are being tested by the use of technology that physicians need to begin to pull back, have intensive conversations with families, and sometimes consider overriding them. essentially, they're pulling the plug. i call it a medical execution. it is essentially a death panel. aysola: it's difficult when we are put in an adversarial position, where we have to tell patients' families that "i don't think this will help." this is exacerbated by discussions in the general media and in politics, unfortunately,

with statements like "death panels" and really politicizing a deeply personal issue. stonum: it is euthanasia, and i feel that the decision was made because she basically wouldn't go away. we do not practice euthanasia under any circumstances. euthanasia is the active promotion of death with that intent. going to suction you again, ok? we use machines to be able to protect patients from dying from an underlying condition. just a little bit. and it's possible to use these advanced tools that we have to not help patients but to actually prolong a death or to actually produce more suffering or less comfort, and under those circumstances, physicians may very well say no. we have to be able to save lives, perform miracles,

and we also need to figure out the best way to allow people to pass with dignity. but that's a discussion that really doesn't take place when you show up to our emergency room in extremis. that decision has to take place with a trusted primary care provider that's been your family doc for years, ideally, because when you come to us with multi-organ failure, we do what we know how to do, and america has not focused on that particular discussion in advance enough. and we're not talking about death squads. we're talking about having real discussions about the end of your life and how do you want it to be? we have to start being able to talk about it, and not just because we're spending a huge amount of money on it but because a medicalized death is not what most people want.

so, why don't you tell me your understanding of your heart and kidneys, what's going on. well, i'm in congestive heart failure, and it's gotten to a terminal point. there's nothing anyone can do to cure it. ok. they were at first talking going to the icu, but i don't want to be kept alive by machines. when it's time, it's time. my goal is to honor what he wants. sorry. going out kicking and screaming doesn't change the going out. i realize that i'm going to need hospice at home,

i'm only 6 feet from a nice place to sit in the sun in the front yard, and i love that more than anything else. those sound like good goals. i think you've made a lot of peace, and you're going to show your family how to do this last part of life. yes. i'm going to do my best. i see that. we often recommend going out of the hospital with what's called a physician order for life sustaining treatment. yes. so, it's your wishes turned into in an order that can be followed in the community. it would tell them what limited interventions you're willing to have and what you don't want. i'm going to fill this out like we talked about. we'll be watching to see how you can get out maybe by monday. he can get home, get in that sunshine. that's what i'm hoping for.

when you start to focus on the real needs of your patients, you find that very often they don't want this over-the-top rescue care. they want dignity. i need to say in passing nobody's getting out of here alive. it's going to happen to all of us sometime. you get a choice about how it happens to you, and a good physician will support you in that choice. there's a study that just came out that looked at cancer patients who had standard treatment, fairly aggressive treatment, versus palliative care. so, palliative care simply meant that nobody was going for cures, and comfort was paramount, and the question was what happened to those patients? and lo and behold, the palliative care patients lived longer. now, some patients will want that aggressive approach, and if they ask for it, they will get it in this system here in utah.

the difference is is many of them won't. they'll have lived a full and satisfying life. the last thing they want to do is to die in an icu. they know they're going to die. they want to die in the arms of their family at the close of a wonderful life, you see? we have built a system that accommodates that view. breathing ok? not just the other technological view. we are done. you did good. good job. he was in a motor vehicle accident. we ordered both a ct of the head as well as a ct of the cervical spine. ok, excellent. well, you can see here are the ct images, and this is a nice young person's brain. he's 24 years old. if someone is worried about the possibility that he's sustained an important injury to his head,

the only way to know for sure is to do a cat scan. seems reasonable. and then it comes out normal and we all feel better. it sounds like that's a good deal, but it's not a good deal, actually, for anybody and most particularly not for that patient. why is that? well, there are many, many reasons. one is that most of the time, almost always, i can tell clinically whether he has an important head injury. the right test is usually putting the eyes of an experienced physician on a patient. we would call this normal, so we're going to give his head a clean bill of health. the cat scan itself is not benign, and we know for sure that doing a cat scan, which is about 200 to 500 chest x-rays in terms of radiation-- it's a lot of radiation-- will cause cancer. the estimate is that tens of thousands of cancer deaths are being caused each year by medical radiation.

feinberg: not doing the scan and missing that one out of 1,000 is a big problem, and the medical legal responsibility of now experts saying, "well, in this case, "you should have certainly done a scan. why didn't you do one?" gets you into this sort of defensive medicine mode, and i'm a parent of 2 teenagers. "i want a clean bill of health. that's my little girl. are you sure there's nothing you're missing?" "well, i can't be 100% sure. "i can tell you the neurologic exam was normal, "but there's a 1-in-5,000 chance there could be a small bleed that i'm missing." "well, yeah, i want the test." hoffman: when i do all sorts of tests that i don't really think are abnormal, some of them are going to look abnormal just by chance. that's just how it is. and when they do look abnormal, i'm forced to do things to you that many times will cause you harm and only rarely will do any benefit. james: imaging or testing

in inappropriate circumstances just exposes you to the risks of false positives, and working up those false positives kills people. sometimes. not often, thank heavens. there's this, oh, deeply embedded belief that it's all upside. no. ok, relax. ok. all finished. all done? so, melissa, you had your big birthday this year where you turned 40. i did. and from age 40 on, little present that we like to give you is an order for a mammogram. hoffman: there are many, many things that under the microscope turn out to be cancer, but which actually in real life

if we never looked for them, we'd never find them, and they'd never cause you a problem. once we find them, we don't know which is which. we have to do something about it. so we're going to do an intervention which could cause you harm. it certainly will cause you psychological concern. it'll cause you economic concern. it might interfere with your ability to get insurance. it will change you from a healthy person into a cancer victim, and it turns out in many cases, if we'd never known about it, you would never have known about it. you would have died with it 50 years from now but not ever of it. now, one of the questions that a lot of patients have had recently is in the news in the last couple of years, there's been a little controversy about when should we start doing mammograms. how frequently should we do it? should we be doing them at all? feinberg: when it says, well, we shouldn't do mammography till age 50, that's looking at populations. but now you're an individual patient. now it's my wife, andrea,

who's 46. should she skip her mammography because this new study came out? or should she get her mammography? and that becomes a very, very personal decision. if it picks something up, it could actually save her life despite when we looked at 5,000 women, it didn't statistically improve overall life survival, because there were false negatives or false positives. but now this is my wife, and when you start talking about personal, individual choices and families, the evidence kind of takes a back seat. guess what i'm going to recommend to you, ok? is that we should do that annually. i think it's just worth it. it's the right thing to do. after listening to what you said, i feel a lot more confident. for me, it's--yeah. absolutely i guarantee i'm going to get that done as soon as possible. half of women in 10 years will have one false positive test. one out of every two. now, some of those, the false positive test, they get another test, and everything's ok. it's not that harmful.

but some of them end up losing a breast, having pain, getting infection, and, yes, there's even a risk of the rare case where, for crazy reasons, a seemingly routine intervention ends up causing death. james: we focus on our ability to detect abnormalities and do something about them. we're very action-oriented. scientifically, it's not a black and white choice at all. it's a massive zone of gray. and then the question is, who decides? after the recent mammogram, they did the stereotactic biopsy, and it showed that there's a breast cancer. yours is a grade 1. it's the least aggressive. and so there are 2 surgical options when we address breast cancer. number one is to do a lumpectomy, or breast preservation, where we just take out the breast lump and sample the lymph nodes. and then the other option is a mastectomy to remove the entire breast to take care of the cancer.

the most important thing that you can hear today is you are not going to make a bad choice. if you preserve the breast or take the breast, the mortality, which is the most important thing, is the same, stage for stage. i would prefer to do the lumpectomy over the mastectomy by far. i want to do everything i can to preserve the breast. cosmetically, it would be a very good option for you, and it's a smaller surgery and a quicker recovery as well. our goal, obviously, is cure. ok, i'm going to give you oxygen to breathe, ok? that's all this is. big breaths in. 4 more deep breaths. you'll be asleep by the time you get to 4. good night. there's this subtle area of calcification. that's the area that they biopsied that showed that she has cancer. so, there's a hotspot in the armpit

identifying a sentinel node. so we'll send this off to pathology to be looked at right now. hey. i don't see anything obvious yet. yeah, there's no evidence of tumor on the frozen section, ok? thanks, michael. appreciate it. now i'm going to scrub back in, and we're going to take care of the cancer itself. we have the abnormality out that we want. i'm going to talk to her family right now. so, things went great. we were able to do everything that we wanted to do. first we go after the lymph nodes. we had the pathologist look at it, and there was no evidence of cancer in it, and then we took out the cancer in the breast and we x-rayed the tissue that we got, and it looks like we got everything out. wow. ok.

it's just-- it's a big relief. woman: yeah. the doctor said things couldn't have gone better, and so we're really happy. wow. that's such an exciting-- i can't believe it. every time someone has a diagnosed cancer, i hope she is in fact the winner of the lottery and did have her life saved by mammography. our estimates are, though, in fact that's relatively uncommon. this compression comes down. imagine screening 2,000 40-year-old women for a course of 10 years. at most, one will avoid a breast cancer death. woman: ok, nicki, just hold still. but somewhere between 500 and 1,000 over the course of 10 years will have one false alarm, and somewhere between 2 and 10 will be over-diagnosed and treated unnecessarily for breast cancer, and in fact that's the harm of cancer screening. now, i hope that's not the case in cindy's case.

i hope she's a winner. i even feel better now that the news is so good. yeah. that's good. it's a big relief. i know you've been worried. my gosh, i know. it's been a roller-coaster of emotions, so it's really good. love you. so, adam, i want to discuss routine psa screening with you. we've talked about this in the past. prostate cancer screening is the poster child for over-diagnosis. with the advent of the psa blood test, which is the prostate-specific antigen, there's evidence that we've treated about 1.3 million american men

for a disease that was never going to bother them. what are your feelings about getting a routine psa test? i have no issues about it. i'd rather know. ok. definitely rather know. it seems like catching it early would be a good thing, but it almost never is, because when you catch it early, you're mostly not catching cancer, you're catching something that looks like cancer, and it isn't. and when it is cancer, it almost never is a cancer that would ever bother you in your life. and so we're finding it and we have to do something about it, but it's trivial. it's only cancer under the microscope. and the flip side is the few others, it's probably too late to do anything, so we haven't found anything that's good for you. on the other hand, the treatments have a very good chance of making you impotent, have a very good chance of making you incontinent, can cause all sorts of other problems as well. welch: it turns out in autopsy studies of men age 50, 60, 70, upwards of 50% to, in the 70-year-old group, closer to 80% have pathologic evidence of the disease.

so if we start to look really hard for prostate cancer, we will find it in over half of older men. litwin: the u.s. preventive services task force said that at the population level, we shouldn't be spending money on screening, 'cause the evidence doesn't support it. researchers look at the outcomes. are the men who were screened regularly for prostate cancer more likely to be alive and not having died from prostate cancer? and the answer was no. for the physician, all the incentives are just to do it. if i don't do it, and you end up with prostate cancer, you're going to be very mad at me and you're going to-- you might sue me, and you're certainly going to think i cost you your life. you're going to be very, very unhappy. if i do it and i do no benefit to you, the test is normal, you'll still think i'm a good, savvy doctor. if i do it and i do worse than that, it gets a false positive and i end up doing all sorts of interventions,

and you end up impotent for something that you had no reason ever to undergo in the first place, you're still going to thank me. you're going to say, "whew. the doctor saved my life. isn't that great? i had prostate cancer, and now i'm better." and i get paid more. unfortunately, that's not always what's best for the patient. i think practitioners will ignore the recommendations, and the reason for that is that psa is as simple as sending a patient for a blood test. it's counterintuitive to patients and to doctors that that could possibly be harmful. i'd rather know now rather than wait till it's late stage and there's nothing i can really do. the central issue is not an issue of screening, even thought that's the discussion. the central issue is being smarter about treatment or choosing not to treat a man whom we do diagnose with prostate cancer. as you know, we have the results in from the biopsy, and as you know, it does show that there's a cancer in the prostate,

as we suspected there would be based on that psa test. let's review the options that we've talked about. there's surgery, which is an operation called radical prostatectomy. it can be done through an open incision, which is the traditional way-- it's been around for decades-- or it can be done the newer way with a robotic assistant. another option is radiation therapy. radiation can be given as an external beam, which we call imrt, or it can be given as radioactive pellets, or brachytherapy, implanted directly into your prostate. another option is active surveillance. you go onto a rigid protocol of regular psa tests and regular repeat biopsies, and if it progresses, then we revisit the idea of considering active therapy. it would be nice for me to be around for the next 10 years without the use of catheters and diapers and other things if it was not necessary to save my life.

you might say, gee, how is a patient possibly going to decide between these therapies with so little evidence to guide us about whether one is better than the other in terms of either cancer control or side effects? so the first question is do i recommend that you be treated? hoffman: people rely on us to help them make decisions. but if it turns out that your doctor doesn't have information about which one is good and which isn't, and your doctor could do a much better job if she knew that, because we studied it, and we said, this treatment's good, this treatment isn't good, that test is good, this one isn't, that would help your doctor help you make a decision. why don't we do the type of research that tells us what actually works and what doesn't work? feinberg: medicine really has been this cottage industry, where each doc learns from an apprentice model and then goes and practices in their own little private practice. if you don't pool that information together and really use evidence as a way to come up with decision-making, you never advance.

i had a blood test and was a little surprised to get a call from my physician about that. he said that i had not done so well with psa, so at that point it was time to schedule a biopsy. there are a number of different plugs they take out of the prostate, and some of them in my case were cancerous, and being as young as i am at 55, my view is that surgery is the best option for me. just i never envisioned our life together to be possibly shortened, you know? we were looking at cruising off into the sunset. and we're still actively raising children, and here we are, and you have this diagnosis. it's just hard to do. changed my view of my future quite a bit, and i gradually came around to the point of view that i'm actually fortunate that if i had to have a tumor of this sort,

this is an oppor-- this is a much easier one to find at an early stage and to be able to take an aggressive action against it. i'm ready if you are. yeah. all right. so, we've talked a little bit about the advantages and disadvantages of the robotic surgery. at least in our hands here, the chances of actually getting what we call a negative surgical margin-- that is, getting the cancer out without any margins around it-- at least in my hands have been lower with the robotic approach. so, put you to sleep, and we'll go ahead and get started. woman: there's never enough. never enough. no. take care. so, answer your e-mail. don't worry about me. when you get home, you've got chores to do. yeah. yeah, i know. honey-dos. buck up, honey. reiter: no heavy lifting for a while. hill: she'll think of something that doesn't lifting. dishes. dishes. hill: folding laundry.... fisher: there's an assumption on the part of the public, even on the part of many physicians,

that physicians are scientists and that science mediated through my brilliant judgment is somehow going to lead to the correct treatment for you, my patient every time for every patient. nothing could be further from the truth. man: it's a little bright. brownlee: there's so little science behind many of these decisions. the same patient is going to be treated in a different way at one hospital versus another hospital. very highly trained people with great skills and knowledge who've put in a career at being the best at what they do, you put them in one place versus another place, and they act very differently, and that cannot be because of a medical reason. it can't be 'cause it's better in one place to do something and another place, not to do it. if you identify variation that's 10-fold, 15-, 20-fold, like we see in prostate cancer from one area of the country to another, then we know that we're over-treating

men with prostate cancer. i believe that i may be one of the people whose life was saved or at least extended by going in aggressively, but i understand that there's a lot of unnecessary treatment that people undergo. that organ there. we may know from studies that too many or too few people in a population are being treated, but it's hard to look at any one person and say, "yes, mr. jones was over-treated, mrs. smith was undertreated," 'cause we can never be sure whether we're doing some good or doing some harm in an individual case. going into the surgery, i was aware of the potential side effects, that i might be giving up some things that i would rather not give up, and as it's turned out, i did give up something, but prostate cancer kills people,

and i would do it again. you have to remove about 15 prostates to prevent one prostate cancer death. the problem is at the individual level, all 15 of those men will think it was them whose life was saved. one of them is right, 14 are wrong, but we don't know which one. and i may well be one of the 14 for whom this wasn't particularly live-saving or in any way important, but since i can't know that, i'm not comfortable carrying a tumor around if i don't know how lethal it is. i'm cold. you're cold? and i think that the consequences and the side effects are unfortunate, but at least i'm not left with the concern that i could have done more and didn't act. treatments that are powerful enough to heal can also harm. i trained in surgery. to be a good surgeon, you have to believe in what you do.

you really do. and so the advice we give to patients is much too aggressive, more aggressive than they would probably choose if they had a true, fair choice. but maybe i need my counselor who advises the surgery to not be the surgeon. i got a phone call from the urologist that confirmed that i had cancer. i turned to my wife, i got the phone call, and i said, "life as we have known it is over." and that's where i was headed. i did not know about proton treatment at that time. the key to successful cancer treatment is avoiding the normal tissue surrounding the cancer, and protons allows us to miss more normal tissue than we're able to with other forms of radiation.

i call it, instead of a shotgun approach, a .22 approach. when it comes in and stops with all of its energy right at the prostate and doesn't go on through the body, and causing damage to other inner organs. i was able to avoid having surgery, having a catheter for 2 to 3 weeks, having incontinence and impotence. it's the most effective thing on earth. the cost of a proton facility can run up to $150 million, so it is more expensive to build the facility than others, but it really comes down to the cost to the individual patient. i had to sign papers that i'd be responsible for all the costs. it's between 70,000 and 200,000. in american healthcare, the bar to adapt new technology has been relatively low. the bar really is that it's not harmful or not worse,

not that it necessarily needs to be better. and it may be better, but when something costs that much, one would truly like to know it's better if society is going to bear the cost. it has saved my life. i have the satisfaction in my mind that i don't have cancer. in fact, i think of getting all my affairs in order... i bought a new suit. i'm going to live, not die. the suit is for living, not for my funeral. in mr. thompson's case, i hope it changed his outcome, but again, one person's story doesn't tell you whether the treatment really helps. in fact, it's possible that he may not have even needed treatment. you just don't know. it really is a problem that we don't have good, comparative effectiveness studies to show us that particularly the more expensive treatments, things like robotic radical prostatectomy or proton beam therapy,

despite being so much more expensive, are any better, and they could even be worse in terms of cancer-controller side effects. yeah. he's 83 years old with a psa of 117. gleason score 4 plus 3, adenocarcinoma in 9 of 12 cores, but the involved cores were 50% to 100% involved. i'd sure feel a lot more comfortable about just saying intermittent therapy. doing the kitchen-sink approach may be better. he could probably wait a couple years. those results. turns out that when you start to work in an organized-care system, you talk an awful lot about indications, guidelines. it relies on data. when is there a benefit? how do i properly advise the patient? when you start to make this explicit so people can see it, it changes their behavior. even my good, aggressive surgeons. by the way, we won't lose clinical outcomes if we do this. we'll lose a lot of complications, we'll lose a tremendous amount of costs,

we'll probably lose a few deaths. we'll get care that's a lot better, not worse. this isn't withholding necessary care. this is withholding unnecessary injuries. ...which is your nerves. there are surgeons who cut things out. and you're in the favorable group. how are you? good to see you. the good news is that it's very unlikely that it's spread outside your prostate. you know, in years past, certainly we'd treat small amounts of cancer very aggressively, but the real question is, did we really need to do that? did we really need to treat that? and so that's where that whole idea of the watchful waiting is. if i pursue the watchful-waiting approach, is some number excluding one of these 2 main procedures? yes. if you have anything that's rising rapidly, or we get up to where that psa is close to 10, which is where we start worrying about extension outside the prostate or into the lymph nodes, we say, "ok, no more watchful waiting. now we treat."

the clinician needs to fill in the patient on the options, the outcomes, and how likely they are to happen, but there's transfer of information the other way, too. the patient is the expert at what they value, and they need to transmit those preferences and values. and i think matching the best outcomes data from clinical research and evidence-based medicine with the patient preferences is what gets us to the best decision. the good situation is this disease is very unlikely to cause you any harm in the immediate short term. but the upside to immediate treatment is you could eradicate the cancer. it's early, and i don't have to worry about it. ok. or you could say, "you know, doc, treatment has side effects. "i probably don't need the treatment for a while. why don't we just delay things for a while, which is--or forever," which is also not an unreasonable approach in you. so i guess i'm safe for now.

you're safe for now. i might have to make a decision at some point. since my cancer is low grade and early stage, watchful waiting seems like a reasonable approach. i think it's a very reasonable approach. thanks. james: when you give patients a true, fair choice, it typically reduces surgical treatment rates by 40% to 60%. their consumption rate drops. it comes to about the same level that physicians themselves show when we get these conditions. litwin: prostate cancer is an example of a disease where we ought to be smarter about whom to treat and whom to observe. and in that way, there are a lot of dollars to be saved that could be put to better use to improve the health of many, many more people. james: one of the things that we've invested in very heavily at intermountain is data. we can tell what works. that's the first key for being able to innovate. you have to be able to tell if a change was an improvement.

that's how you find best care. we try to build those data right into the flow of work. we try to give our clinicians, our physicians, our nurses a clear picture of what this means to patients. when we've done that, it's been associated with fairly massive improvements in patient results, and the funny thing is, it's nearly always associated with significantly lower healthcare costs. if the rest of the country delivered care to medicare patients the way that we do here in utah, the total cost of care would fall by about 34%, and we would not be in the midst of a national healthcare cost crisis. one of the myths of american medicine is that we have to ration in order to reduce costs. i think our research shows that's absolutely not necessary. that if you look at some of the examples of great care around the country, it is possible to redesign our care in ways that are great for us as patients and great for us as physicians, by the way,

and that reduce the costs of care. this is about redesign, not rationing. brownlee: it's not rationing to get rid of stuff that's bad for you. it's not rationing to get rid of care that won't benefit you. it's rational. man: for more information about "money and medicine," visit pbs.org. "money and medicine" is available on dvd for 29.95, plus shipping. to order, call 1-800-336-1917, or write to the address on your screen. captioning made possible by friends of nci i'm not trying to push. i'm trying to understand you. it's good. diameter of this artery-- maybe it's 20%.

man: this program was made possible by the charles a. frueauff foundation, the w.k. kellogg foundation, the missouri foundation for health, the silverweed foundation, the park foundation, the odyssey fund, the spunk fund, the trull foundation and the fledgling fund. announcer: trusted, in-depth, indepbs.ent--

hey, bro. or engaging. conversations help us learn and grow. at wells fargo, we believe you can never underestimate the power of a conversation. it's this exchange of ideas that helps you move ahead with confidence. because an open dialogue is what opens doors. if you need anything else, let me know. [ female announcer ] wells fargo. together we'll go far.