Dan Gorenstein: As humans, our brains love a good shortcut: rounding numbers, following a crowd, jumping to conclusions. It’s how we get by in a world that overwhelms us with choices,  which chips to buy, what TV show to stream. But for doctors and nurses, these shortcuts — also known as cognitive biases — can lead to mistakes, a missed diagnosis, even death.

Bapu Jena, MD, PhD, Professor of Health Care Policy, Harvard Medical School; Physician, Massachusetts General Hospital (Credit: Steven Lipofsky)

Today, friend of the show Bapu Jena returns to explain how these mental leaps, fate and unseen forces shape more of our care than patients and providers realize. From the studio at the Leonard Davis Institute at the University of Pennsylvania. I’m Dan Gorenstein. This is Tradeoffs.

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DG: Longtime Tradeoffs listeners will remember Bapu Jena as the cohost of some of our first episodes. 

[Archival tape from old Tradeoffs episode: 

Bapu Jena: What are those areas where we need to be doing more? And where are those areas where we can get away with doing less?

DG: Bapu, it sounds like you’ve got to get busy. Gotta start researching this question.

BJ: I’ve got to start researching this question. You’re absolutely right.

DG: What are you doing? Why are you talking to us? Get out of here.

BJ: I’ll see you later.]

DG: As the rare doctor-economist dual threat, Bapu, who’s based at Harvard, loves to design clever studies taking advantage of what are called natural experiments, where there’s no intentional test — just studying the randomness of everyday life to reveal provocative insights.

Bapu Jena: Instances in which the real world generates these experiments, these chance occurrences that can teach us something about how health care works.

DG: In a new book “Random Acts of Medicine,” Bapu and his coauthor Chris Worsham curate the kind of greatest hits of these natural experiments. One goal, the pair writes, is to point out that clinicians like to think the decisions they make for patients are “based only on science and carefully considered data, not on simple chance.” But as Bapu and Chris make clear, medicine is a lot more messy and uncertain than that.

BJ: The same sorts of ways we think about decisions to buy Doritos versus a different bag of chips could affect something as monumental as whether or not I’m offered cardiac bypass surgery. We think that the factors that drive those decisions are so different. Turns out they’re not that different.

DG: Bapu, it is so great to have you back. It is so wonderful to actually see you again. 

BJ: You’re looking younger than I remember you.

DG: Well, you know, I have some lost weight since we last saw each other in person,

[Laughter]

DG: So Bapu, I want you to start by having you tell us a story that I think captures one of the big ideas from book. This idea that, if we harness it right, the randomness of everyday life can actually reveal a lot about why we get the health care that we do. And the story comes from a chapter called “What Happens When All the Cardiologists Leave Town.” It’s based on a study that you did. What was the idea behind it, Bapu?

BJ: So like most ideas I have, they came from something that I saw or experienced. And in this case, I was a resident at Massachusetts General Hospital almost 10 years ago now, and I was working in the cardiac care unit.

And it happened to be around the dates of one of these big meetings that cardiologists go to, and the unit just felt different to me and I couldn’t put my finger on it. And that got me thinking, “Gee, I wonder what happens when patients are hospitalized with cardiac conditions when all the cardiologists are out of town?”

DG: What was your assumption?

BJ: My assumption was that patients would do worse, because I thought staffing would be lower and/or the types of cardiologists who remained behind may not be as good in providing cardiac care. And I thought, alright, this gives us a way to see how some random factor — which is you had a heart attack during the specific dates of these meetings — how that could tell us something about the importance of adequate staffing or adequate expertise. That’s where I thought it was going to go.

DG: Go on…

BJ: So it didn’t go in the direction I thought. We found that mortality went down, not up.

Now a cardiac arrest is when your heart literally stops. So at any other point in the year, out of 100 people who have a cardiac arrest, 70% of them are dead within 30 days of having that cardiac arrest. Now if you happen to have a cardiac arrest during the dates of the American Heart Association or American College of Cardiology meetings, that number falls to 60 out of 100. So that’s a ten percentage point reduction in mortality, if by chance…

DG: So wait, you’re saying it is better to have this near fatal condition when more heart docs are at their meetings?

BJ: It’s not only better; it’s way better. It’s better than the benefits of beta blockers, statin drugs to treat cholesterol, stenting of the heart. You put all those things together [and] they don’t generate the magnitude of improvement in mortality that we see when patients just, again, by chance happen to have a cardiac arrest during these specific dates.

DG: What was your reaction to this research? Were you kind of like rubbing your eyes, like running the numbers twice, three, five times?

BJ: First of all, I’m like, okay, who programmed this and what did they do wrong? No. I was surprised by it because I was expecting to see the opposite, and then a couple of more things really started to fall into line that helped make clear why it was that we were seeing what we were seeing.

DG: And what was that, Bapu?

BJ: What we find is that the level of care that patients receive in the hospital during the day of these meetings, it falls. It’s lower.

DG: They’re getting less stuff.

BJ: Less stuff, less aggressive care. Well, why is it that less might be more in this setting? So let me just tell you two stories. 

The first is a guy who’s, let’s say, 45 years old. He’s a construction worker. He smokes. No other medical problems. And he’s got chest pain. He gets rushed to the hospital and they do some testing. He has a heart attack and they take him to the cardiac catheterization lab. Someone puts in a stent and he’s discharged in two days and lives a long happy life.  

The second story is a 90-year-old woman who lives in a nursing home. She’s got 10 different medical problems. She’s on 12 different medications, and she has the exact same chest pain. She gets rushed to the emergency department — same one actually — and she has the exact same findings. So she gets taken to the cardiac catheterization lab. She gets a stent but she has a complication from the procedure and she passes away in two weeks.

And I think that’s what’s happening here is that sometimes there’s a black and white decision to be made. But in situations like this, it’s actually kind of gray. You know, we think we know what we need to know for the 90-year-old woman based on the experience of the 45-year-old guy. But that might not actually be true.

DG: And the point you make in your book, Bapu, is that it’s in these gray areas where doctors most often take these cognitive shortcuts — maybe assume what worked for your last patient will work for the next, or err on the side of doing something rather than nothing. Is that what you think is going on here in the case of the cardiologists?

BJ: Yeah, so anybody who has either practiced medicine or has medicine literally practiced on them knows there’s always this pressure to do something right. If you walk into a room and a patient’s doing poorly, the answer is almost never: Let’s just watch and see what happens and see if this gets better on its own. The answer is what’s going on? And then what do I do about it? And I think that’s true for people who provide care, and that’s also true for people who are in need of care. That desire to do something is very strong.

DG: And I know Bapu, when I was reading this story I was wondering, “Why would some cardiologists do more risky procedures than others? Aren’t they all looking at the same data?”

And in the book you give a couple of hypotheses, like maybe the doctors who stay behind are just more cautious ‘cause they’re short on staff or taking care of patients that aren’t theirs, bu, as you write, “For all their power, natural experiments have their limits.” What do you mean by that, Bapu?

BJ: Yeah, I mean the natural experiments that Chris and I look at in the book, they show us that things are affecting mortality and they give us a window into what those types of things might be but they’re not precise in the same way that we can do a controlled laboratory experiment where we’re randomizing mice or we’re studying cellular pathways — things like that that are used to design treatments. A limitation of this kind of work is that I can tell you, I think it’s probably causal — something different is happening in the hospital — but what that specific something is, elucidating that mechanism of action is a harder task.

DG: When we come back from the break, what Bapu’s learned about the art of medicine and what might happen when the country’s health economists leave town.

MIDROLL

DG: We’re back with Bapu Jena, author of a new book called “Random Acts of Medicine.” One of the book’s key takeaways is that doctors, they’re just like us. When pressed for time, faced with complex decisions, clinicians cut mental corners. And that can be good, but it can also lead to errors — some small, some big. 

OBGYNs, for example, are more likely to deliver a baby by c-section if the baby just beforehand was delivered vaginally but had complications. And kids who are the youngest in their class are much more likely to be prescribed ADHD medication — a product of clinicians overlooking age as a reason for their behavior. 

BJ: So we talk about kids, we talk about adults in the book. It’s everywhere, you know? It’s everywhere. I mean, this is medicine, right? I mean, high stakes, tons of uncertainty. Often decisions have to be made quickly and with great cost, financial and health. So all of these are a recipe for these sorts of things to emerge and to have profound effects on people.

DG: In some ways, Bapu, this book can read like a catalog of missteps that doctors can and often do make. What advice do you have for your fellow clinicians? How can they guard themselves against making these kinds of mistakes?

BJ: Well, ask yourself why. What happens if I do this and what happens if I don’t do this? And how good is the information that’s available to me to be making that determination? 

I used to be one of these people who would be sort of — how would I put it — leery of someone who talks about the art of medicine, and I’d say, look, it’s just evidence-based medicine. Well, it turns out that evidence-based medicine is actually really difficult to implement in practice, and you need to know something about the art of medicine to actually do that. 

DG: And you do talk a bit about that art in the book, Bapu — something you call diagnostic reasoning – basically the art of how providers arrive at the clinical decisions that they make. And you quote this other doctor, Gurpreet Dhaliwal, who says the only way for clinicians to improve that art is to view it like any other skill worthy of mastery. But I guess, Bapu, I’m wondering if there’s a role here for hospital executives. Like, if you ran a cardiology department, what would you do differently tomorrow?

BJ: Yeah, here’s a situation where the real world has offered us an opportunity to understand something that has a really dramatic effect on mortality, but what are the specific things that are done differently? I couldn’t tell you. The way to figure that out would actually be to have someone be in the hospital during the dates of these meetings and really measure precisely what exactly is being done differently. And that is more of almost an anthropologic exercise. It’s something that’s not in, in my expertise. But I think it’s important because it highlights an area where we could be doing something differently and we just need to figure out what that thing is.

DG: So it sounds like Bapu, you’re really putting in a plug for research, for hospital executives and even government to invest more in understanding how and why doctors practice differently — the kinds of differences that literally, can kill people.

Bapu, why do you think improving the practice of medicine — how docs do their jobs, which could save lives and money — gets so much less attention and funding than say, studying a new drug or disease?

BJ: Oh, this is like a million dollar question. You might ask me the meaning of life first. I’ll take that easier question than answering this one. 

Dan, I don’t know. I think part of it is inertia. I mean, people have thought about health care quality issues in this framework of incentives, and financial incentives in particular, for such a long time. It’s hard to walk away from that. It’s hard to walk back from that. So that probably is a big issue.

The last thing though, I would say is think about the types of decisions we as a society had to make during the pandemic that were not based on the highest quality evidence.

News clips: Tonight for the first time ever the subway will be shut down for cleaning and sanitizing. // Pick a bandana and you make a nonmedical cloth boundary. // Wipe down the orange juice. Wipe down any canned products before you put them away.

BJ: But I do know because of randomized controlled trials whether dexamethasone is better than not for COVID. I do know whether or not this vaccine is better than not. And the reason why is because there is an incentive for people to generate that information, that evidence financially. Where is the incentive to generate information on the quality of particular masks? Who’s going to do that? There’s no, sort of, private entity that has that incentive. So I think a lot of what we have in terms of health care problems stems from a lack of incentives to figure out the right answer. Not because the implications aren’t great — they are great — but because the rewards are so decentralized and there’s no one who can sort of take ownership of that information and benefit from it. 

DG: It seems like the only potential entity there that has that sort of collective best interest would be the federal government. 

BJ: That’s right. That’s right. 

DG: Last question: Our team is going to the American Society of Health Economists’ conference, as you know, called ASHEcon. For people who don’t know, that’s the big gathering of the country’s health economists. You just told us what happens when all the doctors go to a conference. Patients fare better. What do you expect is gonna happen when all the country’s health economists head to St. Louis?

BJ: I guess it depends on whether you think they’re useful or not. Probably nothing. [Laughter] Maybe some spouses will be happier. Maybe there will be fewer kid injuries because now mom or dad economist is not taking care of the kids. I think the kids will be better off. That’s what I think.

DG: Very good, Bapu. Thank you very much for being here. And how can folks find you and your book? 

BJ: Well, thank you for asking. The book is being published by Doubleday on July 11th and it’s available for preorder right now. And, I think people will like it. It’s a fun book. 

DG: And again, it is called “Random Acts of Medicine.” Bapu, it’s really nice to talk to you. 

BJ: Likewise. I had fun, as always. 

DG: As always. Thanks so much.

For more information on Bapu’s book check out our website tradeoffs.org. I’m Dan Gorenstein. This is Tradeoffs.

Tradeoffs’ coverage of diagnostic excellence is funded in part by the Gordon and Betty Moore Foundation.