EP. 94: RANDOM ACTS OF MEDICINE

WITH ANUPAM JENA

Jan 10

WITH ANUPAM JENA, MD, PHD

A health economist and host of the popular Freakonomics, MD podcast shares the hidden drivers behind healthcare and how random chance affects our health outcomes.

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Episode Summary

What happens to the mortality rates of cardiac arrest patients on days when there is a marathon happening in the city? What happens to surgical complication rates when it's the surgeon's birthday? Why do patients of younger doctors seem to have better health outcomes?

These and other quirky questions are what preoccupy health economist, Dr. Anupam Jena. Dr. Jena is a professor of health care policy at Harvard Medical School, professor of medicine at Massachusetts General Hospital, host of the popular Freakonomics, MD podcast, and, together with Dr. Christopher Worsham, co-author of the 2023 book Random Acts of Medicine.

Over the course of our conversation, we discuss the often-unintuitive role that random chance plays in our health outcomes, the hidden drivers of medical decision-making, misconceptions about physician burnout, and more. As we'll see, through tackling what can be amusing questions about why physicians and patients behave the way they do, Dr. Jena encourages us to reconsider our own ways of thinking and imagine how we can do better and be better.

Anupam B. Jena, MD, PhD, is the Joseph P. Newhouse Professor of Health Care Policy at Harvard Medical School and a physician in the Department of Medicine at Massachusetts General Hospital. He is also a faculty research associate at the National Bureau of Economic Research. As an economist and physician, Dr. Jena’s research involves several areas of health economics and policy including the use of natural experiments in health care, the economics of physician behavior and the physician workforce, medical malpractice, the economics of health care productivity, and the economics of medical innovation. Dr. Jena graduated Phi Beta Kappa from the Massachusetts Institute of Technology. He received his MD and PhD in Economics from the University of Chicago and completed his residency in internal medicine at Massachusetts General Hospital. He is the host of the Freakonomics, MD podcast, which explores the “hidden side of health care.”
In this episode, you will hear about:
• 2:18 - The path that took Dr. Jena to the intersection of medicine and economics
• 8:54 - How Dr. Jena discovers topics for research
• 12:12 - Unexpected and important findings that Dr. Jena has learned over the course of his work
• 19:18 - Dr. Jena’s focus on “natural experiments”
• 22:02 - Thinking about physician burnout from an economist’s perspective
• 36:42 - The mission Dr Jena had when he set out to write Random Acts of Medicine
• 44:08 - Dr. Jena’s advice for medical trainees on how to understand the hidden forces of the medical system
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] What happens to the mortality rates of cardiac arrest patients in the city on days when there is a marathon happening? What happens to surgical complication rates when it's the surgeon's birthday? Why do patients of younger doctors seem to have better health outcomes? These and other quirky questions are what preoccupy health economists Dr. Anupam Jena. Dr. Jena is a professor of health care policy at Harvard Medical School, professor of medicine at Massachusetts General Hospital, host of the popular Freakonomics MD podcast, and together with Doctor Christopher Worsham, coauthor of the 2023 book Random Acts of Medicine. Over the course of our conversation, we discussed the often unintuitive role that random chance plays in our health outcomes, the hidden drivers of medical decision making, misconceptions about physician burnout, and more. As we'll see through tackling what can be amusing questions about why physicians and patients behave the way they do, Dr. Jena encourages us to reconsider our own ways of thinking and imagine how we can do better and be better.
Henry Bair: [00:02:12] Bapu, thank you so much for taking the time to join us and welcome to the show.
Dr. Anupam Jena: [00:02:16] Thank you for having me.
Henry Bair: [00:02:18] Before we dive into your fascinating explorations of health and behavioral economics, can you tell us what brought you to medicine initially?
Dr. Anupam Jena: [00:02:27] You know, when I was two years old, I knew I wanted to be a doctor. No. My mom was a doctor, and she... She's still alive, but she's retired now. And, uh, my dad is a physicist, a university professor. And so I always had this interest in medicine and research, in part because of just who my parents were. I had gone to study college at MIT and did econ and biology, and the only reason I did econ at that time, this is late 1990s, was I thought I should study a humanity to help me get into medical school. This was sort of my thinking back in the day. Turns out MIT econ is considered a humanity, even though it's far from it. But that's why. That's why I studied economics and I worked in the lab, though, doing basic science research in the summers and applied to MD PhD programs. This had been around 1999, thinking that I wanted to do an MD and a PhD in the basic sciences, and when I went to the University of Chicago for an interview, the director of the program at the time said, oh, I noticed you studied economics. We have a good economics department. Would you want to do your PhD in economics instead? And I was like, wait, is this guy saying that I shouldn't do a PhD in immunology? What's he trying to suggest here? Uh, so I took him up on it. I tried it out, and I and I knew that if I couldn't do it or if I didn't like it, then I would have gone back to the path I had initially thought. And so that's how I found myself in medicine and economics. It was a, you know, quite a bit by chance, just, you know, this this person happened to suggest it to me. I happened to be of the mindset that I could try it out. It worked out well and the rest is history.
Henry Bair: [00:04:10] I personally haven't heard of an MD PhD candidate doing their PhD in anything that is not like a laboratory science personally.
Dr. Anupam Jena: [00:04:19] They exist. They're not a lot, but they are out there.
Tyler Johnson: [00:04:21] Yeah, yeah. So I have known a few. They are very rare. I've known a couple of people who've gotten a PhD in anthropology or related fields, or sometimes in other so-called softer sciences, but they are quite rare. So can you walk us through Bapu, then from that point forward, where did you go from there?
Dr. Anupam Jena: [00:04:37] So I finished in 2009 from the University of Chicago and then moved to Boston. I did internal medicine at Mass General Hospital. Why did I do internal medicine? Well, it's what everybody else had done. All the MD PhDs who came before me, who were economists, I think almost all of them had studied internal medicine. And even though I, I like surgery, I liked working with my hands. I thought to myself, you know, could I really be a surgeon working on totally random topics at the intersection of medicine and economics? And at that time I thought, no, that wasn't going to work. It might be a different story nowadays, but back then I said it wouldn't work. And so I went into internal medicine and I, you know, I had appreciation for it in medical school, but it's not necessarily what I would have picked otherwise.
Tyler Johnson: [00:05:24] Also, with apologies to ophthalmology and all of those other lesser disciplines, it's also just the right answer. So there's that's.
Dr. Anupam Jena: [00:05:30] True. That's true. Yeah. Exactly. That's exactly it.
Henry Bair: [00:05:33] Okay, okay, I get it. I've made the wrong career decision for life. I will regret it forever. But anyway, so Bapu, you finish internal medicine residency and then what happens next?
Dr. Anupam Jena: [00:05:46] Well, it actually starts a little bit before that. So I was an intern and, uh, was thinking about what the job market would look like for me in a, in a few years. And in economics, the job market is very different than what you see in medicine. The job market is that you finish your PhD, and in your last year of your PhD, you go in this very organized market, which is really strange. You send applications through this sort of common platform to all of these places, many universities, they decide whether to interview you. And that first interview typically happens at the American Economic Association meetings. And it used to be the case that PhD students would go to hotel rooms, and a group of professors would be sitting in the hotel room doing an initial interview of somebody. So that's what the econ world looked like. I didn't really know where I was going to go and what I was going to do, but it just so happened that in my intern year, the department where I am now, which I've been in since since I finished residency, it's called health care policy, and it's at Harvard Medical School. They were looking to hire a junior faculty. They asked me to come out there and give a job talk. I gave a job talk, met with a lot of the faculty. They extended me an offer and decided to hold it until I finished my residency, which is about a year and a half, two years later. So it was a it was kind of an interesting feeling, being in residency, knowing where my first job would be right after I finished. So I didn't actually go on a formal job market. I didn't search around the country for different jobs. I didn't try to leverage one job offer against another. I just kind of stayed. And and I've been at Harvard ever since.
Tyler Johnson: [00:07:23] So in my world, in medical oncology or academic medical oncology, people tend to split their time often between clinical work and research. So they might say they're a 90/10 person or an 80/20 person or what have you. I feel like among health economists that I've known, more of them tend to be more heavily focused on research, though I suppose the split could be, you know, whatever you want it to be. So do you maintain a clinical footprint now? And did you have one when you first came out of your training, or are you almost exclusively focused on your health economics research?
Dr. Anupam Jena: [00:07:54] I would say I have a not just a footprint, but a full boot in the ground now. Yeah, well it depends. It's all relative compared to economists. I've got like 17 boots on the ground compared to you. Probably not. When I first finished I used to work as a as a hospitalist. And so I would work every Thursday night in the hospital from 7 p.m. to 7 a.m. and I think I did probably six weeks on service on our general medicine teaching service. We call it Bigelow at Mass General. And so that was my clinical footprint for the first few years. And then over time, after we had kids and as the research started to grow, I started giving up the the nighttime work. And now I only do inpatient work with residents. So I still do that. It's certainly not as much as my full time colleagues, but I still enjoy it and still feel like I've got something to to add. And, and I definitely learn a lot when I'm on service. But most of my time is spent doing research and and I teach as well.
Henry Bair: [00:08:54] So when it comes to your research, what are some of the big questions that you find yourself exploring these days?
Dr. Anupam Jena: [00:09:01] I would say. You know, Henry, I'd like to answer a lot of small questions. I'm not guided by a large interest in answering one big question. So if I think about my basic science, or if you think about your basic science friends, they think they're studying a particular large cancer pathway, and they want to understand everything about that pathway and how it leads to disease and how treatments can prevent the progression of disease. I'm more of an opportunist in the sense that because of my background and because the setup costs are much lower than they are in a basic science lab, I have the ability to say, all right, here's just a totally random question that came into my mind. I want to know what the answer is to that question. And it could be something as absolutely ridiculous as which types of doctors spend more time on the golf course, which we've looked at. Or it could be something, you know, a little bit less ridiculous, like what happens to people who have heart attacks when a marathon is going through their city? They're more likely to die because they can't get to the hospital in time. And then I've done some other stuff which I think, you know, you would say is more conventional in terms of the types of topics. But I'm I'm always interested in just individual questions. There's not some overarching theme, I guess you might say that I like natural experiments, so I tend to focus on things where there is some experiment that's happened in nature, but it's not always the case. You know, if it's a really interesting descriptive question and I want to know the answer, I'll do it.
Henry Bair: [00:10:28] How do you find these questions?
Dr. Anupam Jena: [00:10:32] There's totally randomly, someone else just actually before this podcast asked me the same question, I said my answer was because I just do it all the time. You know, if you think about a comedian, right, a comedians, they may or may not be funny at baseline. I don't actually know whether or not they are funny people, but that's their job is to be funny, and they get good at being funny and making people laugh. And because they do it all the time, they probably see things out there in the environment that you or Tyler or I would never, you know, make note of. But that becomes, you know, a semblance of a skit. And what I told the person earlier was I was literally at Whole Foods the other day. I was using my phone to try and pay, use Apple Pay, and I've got my device and I'm waving it all around. This thing like this, whatever, wherever it's whatever it's supposed to detect your phone for, like, 30s just waving around. I'm turning my phone vertical, 45 degrees upside down, and some comedian behind me makes a joke about it. And I was like, oh, that's actually kind of funny. And then I use my credit card. But you can see how a comedian would take that, like really simple observation and make a six minute skit out of it. And that's what I do in my research. It's like I, you know, I see things because I study these kinds of quirky questions all the time, and that's the way my mind works now.
Tyler Johnson: [00:11:50] Yeah. When you describe trying to get your phone to pay, you know, by near-field transaction for your groceries or whatever, it reminds me of when we used to try to get old fashioned Nintendo games to work where it was like, hold it upside down, shake it a few times, blow into the cartridge, etc. yeah.
Dr. Anupam Jena: [00:12:06] The blow blowing in them was great until then. Then you're like, oh wait, is it, is it making it worse now?
Tyler Johnson: [00:12:12] Right. So what I hear you saying is that you just sort of as you move through the world, these research questions just kind of almost come upon you. So that being the case, can you tell us about a time when you felt like you had a research question that just kind of popped into your head or something? You know, it came from something that you were confronted with in your everyday living. And then you looked into the research question, and in the act of looking into it, you were presented with a novel insight or a novel way of understanding things that was not something that you had expected. That came as a surprise.
Dr. Anupam Jena: [00:12:45] Yes. Yeah. Every single study that I do, it starts off in a quirky place. But then, you know, this is the doctor's art. But part of the art of the researcher is to take the finding and to try to frame it out as big and as broad as you can. And so that's a lot of what I try to do is say, all right, here's like this little quirky finding, but maybe it tells me something more than I than I thought it did. And probably one of my most favorite ones is this study that we had about cardiologists. We found that when cardiologists have these meetings, like the American Heart Association meeting or American College of Cardiology meeting, during the dates of these meetings, if people patients have a heart attack or cardiac arrest during the dates of the meetings, they have, uh, lower mortality during the dates of the meetings, they are more likely to survive. I had that idea thinking the opposite would occur. Like I thought, all right, the staffing is going to be lower during the dates of these meetings because the cardiologists are out of town at the big teaching hospitals, a patient shows up with a heart attack or some, you know, acute cardiac emergency because the staffing is lower, they're going to do worse. But I found that they did better.
Dr. Anupam Jena: [00:13:54] The other data point is that I found that rates of certain procedures like, uh, PCI stenting of the heart. Those fall by about 30% on the days of those meetings. And probably what's happening is the types of proceduralists who perform them just aren't there, or there is less staffing. So the people are less likely to want to do invasive procedures. And to me, I did the question because it was like it was cute. It was sexy. All right. Okay, cardiologists go out of town, mortality falls. Patients do better. How could that be? But there is. Then you just ask me, what did you did? I walk into an insight that's more important. And I think cardiologists would probably disagree with me. But I would say, yes, you know, we did, right. We talk a lot in medicine and, you know, oncology. You live and breathe this sort of line of thinking, which is everything that you do has a consequence, positive and negative. And some things are black and white, many things are gray. And in the case of PCI or, you know, interventions for people who are coming with acute cardiac problems, you kind of think, all right, if I do more, they will do better. But it turns out to be the case that sometimes when you do less, people do better. And the reason why is because you're not exposing them to risks in a situation where the risk to that person are going to outweigh the benefits.
Dr. Anupam Jena: [00:15:17] The thought experiment, I would say, is, imagine you've got a 45 year old guy who's a construction worker and he has chest pain and he comes into the hospital. He has no other medical problems, and the doctors figure out that he has a heart attack. So he gets a stent placed. He leaves the hospital in a couple of days, and he lives a long, healthy life. That is kind of a black and white decision right there. You know, for everybody who looks like that person, they should have that procedure performed. The other story is a nine year old woman who has the exact same chest pain at her nursing home. She comes into the hospital. She has the same findings on the EKG. She has a heart attack and she's got 12 other medical problems. She's on 13 other medications, but they still decide to do the same procedure. Why? Because she has a quote unquote heart attack, but then she dies within two weeks of the procedure because of complications and that sort of story. I think anybody who's in medicine, or even if you're not in medicine, you've heard or could appreciate why that might occur. And the thing that happened was that we thought it was a black and white decision for this woman, but it probably wasn't. It was probably a more gray decision, or it could have been black and white in the other direction. Maybe she shouldn't clearly have gotten it, but that is sort of the challenge in medicine. The art of medicine is to understand when it is, and for whom the benefit of a decision outweighs the risks.
Tyler Johnson: [00:16:41] Yeah. You know, it's interesting because I have enough friends who are cardiologists and from my own internal medicine training, and then following some of the debate on Twitter, to know that if you put five cardiologists in a room and I'll ask them to outline their approach of when to put a stent into a patient who's having stable or stable ish angina, you're probably going to get seven answers, right, which is and all of the cardiologists will have very good clinical and trial and anecdotal evidence to back up what they're saying. It reminds me a little bit of when you're training to become an oncologist. One of the hardest things to learn is how to give chemotherapy, right? Because chemotherapy can be very toxic in some very extreme cases. It can even have side effects that are fatal. It really amounts basically to poison. And it's very strange to have to figure out how to both sort of feel okay, I guess morally or ethically giving something that, you know, may hurt someone, and then also having to then learn when is the right time to give it and how much and how aggressively and all the rest of it.
Tyler Johnson: [00:17:44] For the first number of years of being an oncologist, I felt like the main thing that I was doing was just figuring out how to be comfortable giving chemotherapy. But then the thing that's so counterintuitive about it is that on the flip side of that equation, as I have gotten more comfortable being an oncologist and more comfortable giving chemotherapy, now, I have had to learn a sort of a almost a counter reflex to that, in the sense that I have had to learn when the right thing is to not give chemotherapy. And I can think of a number of examples where there were people who we were treating who were getting chemotherapy. They seem to be getting sicker. My initial thought was maybe they need something more aggressive, but then with greater wisdom and experience, I eventually learned that sometimes the right thing to do was actually to pull back or to not give chemotherapy at all. And in some of these cases, it's very clear in retrospect that stopping chemotherapy or giving something less aggressive was the thing that ultimately helped the person the most.
Dr. Anupam Jena: [00:18:37] Yeah, I totally agree. And you know, it's very challenging because it is the case that if you don't get treatment, there's no hope, almost no hope, I would say for a long terme remission or, you know, you might even use the word cure depending on how you define it. I mean, that's for sure the case, right? But it could also be that if you give someone treatment, you are going to shorten their life relative to them not getting treatment. And so in either case, are you going to live the full life that you would have hoped to live had you not been diagnosed with cancer? But you're sort of choosing between two less desirable options, which is a very difficult thing, I think, as you know, more than me and most to kind of think through.
Henry Bair: [00:19:18] One of the things that you mentioned before, when you were describing your overall approach to your work, is that you tend to focus on questions where there are natural experiments involved. Can you tell us more about what you mean by that? Sure.
Dr. Anupam Jena: [00:19:30] So when we do in medicine, um, a randomized trial, you take a bunch of people with a disease and you randomized some of them to get a treatment, and you randomize the other group to get a different treatment, or maybe no treatment at all, like a placebo. And that allows you to figure out what is the effect of that treatment on the outcome that you care about. And that is in contrast to what we might call a real world observational study, where you simply look at people who received the treatment and people who don't receive the treatment and study their outcomes. So sort of a tongue in cheek example might be if you look at people who get cancer medications, they tend to live shorter than people who don't get cancer medications. But of course, it's not because the cancer medications are necessarily leading them to die earlier. It's because one group has cancer, and that's why they're getting cancer medications and the other group doesn't. And the way that we try to deal with that kind of obvious issue is we try to account for as many factors as we can that might be different between these two groups, but the short of it is that you can't account for everything when you see things that are observable, that are different between two groups, that typically means that there are things that are unobservable, that are going to be different between those two groups, and you can only account for what you observe.
Dr. Anupam Jena: [00:20:51] And that's where natural experiments or randomized trials come in. They randomize people to one group or another. A randomized trial does that at the hands of an investigator. In a natural experiment, you have a situation where one group of people is by chance exposed to one treatment versus another. And in the cancer example, it might be something like an oncologist might be less likely to give an aggressive chemotherapy to someone who is 80 years old versus 79 years old because of a trick that is played on the mind called left digit bias. The older we are, the less likely you are to want to do aggressive things as doctors for our patients. And someone who is 80 years old feels like they're in their quote unquote 80s, and someone who is 79 years old feels like they're in their quote unquote, 70s. And so something as simple as where a person sits relative to their 80th birthday at the time of diagnosis, where a treatment decision would be made, that could be it is arbitrary and could affect their likelihood of getting on one treatment versus another. And that's a natural experiment that would allow you to study the effect of being on that treatment versus not.
Tyler Johnson: [00:22:02] So there's a section in one of Malcolm Gladwell's books, and I know that economists have varying takes on how much to trust Malcolm Gladwell, but nonetheless, there's a take in one of Malcolm Gladwell's books where he talks about there was a time where there was a sharp decline in the average US crime rate or violent crime rate, or something to that effect. And economists were casting about trying to figure out what it might have been that had caused this dramatic decrease. And there were a bunch of hypotheses put forward, none of which really worked. And then someone recognized that the sharp decline came right about the time that people would have become adults who were born around the time that abortion was largely legalized in the United States. Which is to say that, according to Gladwell, that was the sort of secret key to understanding this was that the legalization of abortion 20 years or whatever earlier, may have led to the decrease in the crime rate that nobody else could otherwise figure out why that had happened. I bring that up as an example. He sort of touts it in the book as a sort of an aha moment where it's like, well, see, nobody could figure it out.
Tyler Johnson: [00:23:04] But then there's this hidden connection. And once you know this one statistic and look at the appropriate timeline, then you can understand that this is what's going on. So I bring that up in this setting to say the main impetus for this podcast is that Henry and I recognize that there is an epidemic of burnout among health care workers, certainly in the US, and I think also in Western Europe and similarly situated places. And, you know, I was just looking there was a Jama Open access journal article that was published in the last week or so that showed that something like half of us. Us health care workers are thinking of leaving the institution where they currently work, and something like a third are considering leaving the field altogether. And so all of that is to say that if you were to use your best economist powers of discernment to try to look at that problem of worsening burnout, do you see some not obvious to the rest of us roots of that problem? Like, do you see some things that need to be addressed that maybe we are not even recognizing, let alone addressing?
Dr. Anupam Jena: [00:24:05] So I think there's a couple of things. Burnout is incredibly subjective, right? When we talk about burnout, we're talking about how people respond to surveys like you described. And there might be valid, quote unquote, validated survey metrics that are used. And I used the word quotes because ultimately, as an economist, what I care about is behavior, right? So if more people are going into medicine and fewer people are exiting medicine, that to me, says Hmm'hmm, is that burnout? Because I'm seeing more people entering and fewer people leaving. Maybe it's burnout, but you know that those two data points don't coincide. So I am a little bit cautious about interpreting surveys at any given point in time and across time. The second thing is then the perception of burnout in work is got to be a function of two things. It's got to be a function of one's own sort of barometer for what they consider to be burned out, and a function of the environment that they're practicing in, like obvious things that would lead them to be burned out. So, for example, if you're in a workplace where you are being forced to work 90 hours a week, if there's discrimination or bias that's very explicitly laid out against you, anybody's going to be upset about that. And no surprise then that people would say that they're burned out. But with all due respect, I'm sure we will have some colleagues who are listening to this show who might be dermatologists, who are working 40 to 45 hours per week and doing quite well.
Dr. Anupam Jena: [00:25:40] I think if you look at surveys of dermatologists, a large number of them will report being burned out, less so than perhaps other specialties which compensate less and for which the hours work would be greater. But that isn't the data point that I would focus on. I'd say, well, you know, why is it that 40 to 50% of dermatologists report being burned out? And the reason I mentioned that is because it's hard to separate what is a function of the system versus what is a function of the people who are in the system. Medicine attracts a very unique group of people. They're different than the types of people who go into law, that go into business, that go into education, that go into art. And I do wonder whether or not how much of what we kind of talk about as burnout potentially changing over time is just a function of the types of people who are coming into medicine over time. And that's not to say that it's good or bad, but sort of as an explanatory factor for why we are seeing things changing over time. You do need to understand whether the system is changing and getting worse, or whether or not the people who are entering it have different set points, or whether both of those things are occurring. The third thing I would say is burnout is an interesting terme.
Dr. Anupam Jena: [00:26:51] You know, when you go into the hospital, you see there's a lot of people who are involved in the care of any given patient. We talk about doctors a lot because we are doctors. But you think about nurse practitioners, nurses, lab techs, people who are involved in environmental services, the person who is bringing food to and from the patient's room. We don't have surveys of burnout in those groups as well, but the work that they do certainly pays less, for the most part, than physicians. They are probably not viewed in the same light, I think, inappropriately so in a lot of respects by other health care workers and patients. And yet we don't talk about burnout there. So what is it that's special about medicine that we can talk about burnout, that we don't talk about that in any other walk of life. The last thing I'll say, one area that we've we've done a lot of work in is gender differences in promotion and pay. And one observation that we have seen is if you look at physicians over time, if you look at male physicians, you look at female physicians. My recollection from our work is something like 10% of male doctors are married to a female doctor, whereas for female doctors, something like 30% of female doctors are married to a male doctor. So who men in medicine tend to marry is different than who women in medicine tend to marry.
Tyler Johnson: [00:28:18] That statistic is really breaking my brain for a minute, but I guess in order to make that work, the denominator would have to be really different. Is that right?
Dr. Anupam Jena: [00:28:25] Yes. That's right. Yeah. The denominator is different. Yeah. But the point I think that's important is that we know that there are gender differences in burnout. And one factor that I think is hard to escape is like when we think about burnout, we think about what's happening in the health care system. And the point that I would make is burnout is not just a reflection of what the system is doing to you, but what happens outside the walls of that system. So, for example, if you're a female surgeon and your husband is also a surgeon, your life, your ability to sort of divide between work and non-work responsibilities is going to be very different than if we're talking about a male surgeon. Who was married to someone who, in that point in time is not in the formal labor market. And so the stresses, the pressures that they will feel, the burnout that they'll experience from work. Those two things are very different. And I think the insight from that literature that we've contributed to is to say, look, burnout is probably happening, but it's not only going to be driven by what's happening inside the walls of the health care system, it might be outside of it. So I don't know. Those are just some amorphous thoughts. Take them as you will or respond. I'm curious to see what you think.
Tyler Johnson: [00:29:37] Yeah. You know, I remember this moment toward the beginning of the pandemic when I, along with, I think most of us who were working in the hospital had become hyper aware of donning and doffing a gown. Right. We had to watch a video about the appropriate way to do that, the appropriate way to wash your hands. Et cetera. Et cetera. And what I realized over time was that while I was taking such great care to do that and to try to, you know, keep myself and my family and whatever from getting infected. I was in a patient's room one day, and I watched as the environmental services worker came in and removed from the plastic trash bin, the plastic bag that had all of the garbage in it, and then had to tie it off and put it in this big sort of a bin with wheels that he could then take it down to, you know, wherever the trash went. Eventually. I just remember being really struck by that image, because when the environmental services worker tied the bag off, it had to create a whoosh of air that presumably caused a sort of a rush of viral particles to go right towards him. And hopefully he was appropriately gowned and masked and whatever. So it didn't matter. But it's just to say that this is a person who may have gone weeks or months without anyone thanking them for their work, or complimenting them on their work or what have you.
Tyler Johnson: [00:30:57] And I just was so struck by this because in the context of talking about the epidemic of burnout, there is one sense in which I think the entire discussion about the epidemic of burnout among health care workers reflects a position of some privilege, because the only reason that we talk about an epidemic of burnout as a surprising and concerning thing is because we have the collective assumption that doctors should not be burnt out. That is to say that they should be finding existential fulfillment in what they're doing. And it's when they don't have that that we then become really distressed. But there are many other occupations, including in the same hospital where the doctors are working, where because there is no expectation of having existential fulfillment. For instance, if you are the person who empties the trash receptacles, there may not be that same expectation in the way that there is. If you go into medicine that because the expectation isn't there, if they don't find that existential fulfillment because it's not surprising, then we don't even end up having the same kind of discussion.
Dr. Anupam Jena: [00:31:56] I have two thoughts. And I think it's actually much broader than the issue of burnout. I mean, I think I mean, we're I'm we have young kids and I think about this issue a lot, which is it's really about perception, meaning like when someone is upset, they're upset because something happened that they weren't expecting to happen. And a lot of what causes us anxiety and makes us upset is when something happens that we just didn't see coming. And I think that's part of medicine, right? Like, I think people have an idea of what a career in medicine will look like, and then they see how that career unfolds. Perhaps they see how the careers of their colleagues unfold. Who didn't spend 7 to 12 years in training, who may or may not be making more money than them. And all of those things start to, you know, say, this is not what I expected. And the question then is, all right, well, do we fix that component of it, or do we fix what the expectations were? And as a parent to a child, it's like, you know, that's a thing that I try to to talk about a lot is like, look, we you know, there's that SNL skit Lowered Expectations. Now, I'm not saying that we should lower expectations about about medicine, but it is difficult to set your expectations. And that's something I struggle with a lot. The other thing that I'd say, Tyler, is that I was just on service. Uh, I was asking the residents how many of them look forward to coming to work, and most of them said that they didn't really look forward to it. They did. You know, there's not something in the day that brought them a lot of, uh, a lot of joy. And I thought to myself, he's kind of interesting because one thing that medicine is supposed to offer people is that sort of warm glow, the warm glow that you get from sitting down with somebody who needs your help and being able to help them. And it happens in a lot of different occupations.
Dr. Anupam Jena: [00:33:50] But that's sort of what medicine is. You know, bread and butter is that that's what it is. And if we're not getting that, then the question is why aren't we getting that? And it struck me that part of the reason is that we just we don't spend as much time with patients at the bedside as probably we used to. And that is a system problem, right? Like, you know, you can't feel good about helping someone unless you see them say thank you and talk to you about why they feel better and how much it means to them. That sort of conversation, which I think is a really important source of energy, is just untapped. It feels untapped to me, and I don't know if that's a systematic problem or not, but one thing that I tried to do when I was on service is to say, all right, we can look at the labs a little bit less, do x, y, z a little bit less, engage more, be a part of the person's life a little bit more. It just feels different. And I think that aspect of medicine, you know, you are in a different breed. You're an oncologist, so you have to do that. It's part of your practice. But I think a lot of places we spend far too little time at the bedside. Yeah.
Henry Bair: [00:34:51] As an intern, definitely. I see that every single day.
Dr. Anupam Jena: [00:34:55] I know you're doing, uh, medication, reconciliation. I know it's much more important. Apparently, that's what I'm told. Uh, by the way, if there's one thing, this is one thing I cannot let go. You asked about burnout. And every December, and I don't know if it's the same for you. I get a series of emails from my hospital asking me to complete something called a health stream module. I don't know if you guys have health stream or something else. You have health stream. Yeah. And I'm thinking to myself, wow, the health care system is so interested in burnout. And yet they're asking me to figure out whether or not I should use a silver canister or a red canister. If there's a fire asking me whether I should first sweep, then pass, then spray. And I'm just thinking like, who is in charge of this stuff? There's like a lot of low hanging fruit that we could do here to make people's lives better.
Tyler Johnson: [00:35:50] Yeah. So we've mentioned this before on the podcast, but it still is just the best. And by best I mean worst example. So I have to bring it up again, which is that when I was in residency every year, we had to watch this video module online about the importance of appropriate sleep hygiene. But this was back in the era when the majority of residents, including us, were still like during intern year. The majority of the months of the year, I was working Q4 30 hour call during those entire months, right. But we had to watch the module because there was going to be a question on the Acgme survey about whether we had been appropriately educated as to the importance of good sleep hygiene. And so I just remember pulling up the module and starting to watch it and thinking, what kind of Kafkaesque thing is this? That the very people who you're not allowing to sleep, you then require them to watch a video about how important it is that they get good sleep. Like the whole thing just was, frankly, a little ridiculous.
Henry Bair: [00:36:42] I do want to shift gears slightly and kind of maybe step back a little bit, right? Because we've talked a lot about specific instances when unseen forces end up having profound consequences on the lives of real people. And in many ways, this was a focus of your latest book. Random Acts of Medicine is about like how using case studies of natural experiments, as you've described, you illustrate the many ways that our healthcare outcomes, how patients do and how how doctors think and act is profoundly shaped by things that we don't even think about. I'm wondering if you can share with us what was your mission in writing this book? What did you hope that readers could get out of it?
Dr. Anupam Jena: [00:37:20] So the book, which is written with by my friend and colleague Chris Worsham, Chris is a critical care doctor at MGH. I mean, the first impetus was that over the last ten years, I've been doing a lot of work, which is I would just broadly describe as Freakonomics meets medicine as sort of large data, quirky questions in medicine, usually leveraging some sort of natural experiment. And I thought that the that the findings of those studies would be something that the general public would be interested in. And the challenge for Chris and I was to figure out, how do we take a lot of that work? And then actually some work that Chris and I have done together in more recent years is a communicate that to the public, make it interesting, and then draw out the implications for people in a way that made sense. And so the book is called Random Acts of Medicine because it refers to these instances in our lives in which randomness affects our health, but in a way that we can learn something from. And I think I would draw that distinction because random things happen to people all the time. You could be in a movie theater where a gunman enters. That's random, right? Or you could be struck by a car. You might even be struck by lightning. Literally. You could develop a cancer where you didn't have any known risk factors for that cancer. These are all sort of things that are pretty random. They affect our health, they affect our lives, but they're not things that we might learn from. You know, there's nothing that says now you shouldn't go to a movie theater or you shouldn't drive outside.
Dr. Anupam Jena: [00:38:47] But other things, for example, the cardiology meeting study is a good one. We show how this random event, which is having a heart attack during the dates of the American Heart Association meetings versus any other day of the year, which is random with respect to you as a patient has this effect on your health. But guess what? You can learn something from it about whether more care is more better outcomes, or whether it's worse outcomes. In each chapter in the book goes through a series of these sorts of experiments where it is random. What happens to somebody, you know, earlier I mentioned people who live in a city where there's a marathon. We show that mortality goes up for people who live in the area because if they have heart problems, they can't get to the hospital in time because all the roads are closed. And that's the random thing, you know, random act of medicine. You couldn't get there because the roads were closed. But it tells us something about how we should design prehospital care. It tells us something about how much time matters when it comes to acute medical conditions. So there's things that you can learn something about and do something about as well.
Henry Bair: [00:39:56] And how have these findings affected how you approach your own work or your own health?
Dr. Anupam Jena: [00:40:03] You ask about how it affects my own health? There is a study that we didn't put in there, which maybe will come in the next, which looks at the health care decisions and behaviors of physicians versus non physicians. And guess what? They don't do a lot better. You might think that they do but they're they're not much better. But I would say the following about the the work. One question is all right okay. Bapoo you showed that during marathons people have worse cardiovascular outcomes because they can't get to the hospital. What's your solution? Are you proposing that we cancel marathons? And I would say no, but I will say that more people die because of road closures than died in the Boston Marathon bombings in any given city. And yet that latter event has tremendous salience for people. But I kind of view all of these studies, which, again, are not independently designed to change the health care system. That's not what the book is about. The book, to me, is about sort of the basic science of things, which is why do doctors do what they do? Why do hospitals do what they do? Why do patients do what they do? And how can we make people do things that we think are better? Each one of these studies gives us a little bit of a glimpse into the sort of things that affect the doctor's decision.
Dr. Anupam Jena: [00:41:16] I mentioned that left digit bias earlier. We showed that cardiologists and cardiac surgeons are less likely to intervene in someone who's got a heart attack with a cardiac bypass surgery. If that person is 80 years old in one week, versus they're much more likely to do so if that person's 79 years old and 50 weeks. And the reason why is because the older person who's just like a week or two older is quote unquote, in their 80s, the implication of that is, well, look, we are making these decisions all the time that affect patients that are not sort of grounded in, quote unquote, evidence based medicine. That's the first point. And the second point is, well, we can actually learn something about whether or not cardiac bypass surgery is helpful in those groups 80 years old. And we show that it may not be because the people who are 79.9, who are 20% more likely to get the cardiac surgery, they don't live any longer than the person who is 80 years old who didn't get the surgery. So that's the sort of way I think about it. It's like the basic science of all these things.
Tyler Johnson: [00:42:16] Yeah. You know, it's one thing to talk about the fact that there are these sort of systemic forces that are acting like an invisible hand behind the scene that we're not even aware of, that are probably influencing the way that we make some of these judgments. And that's certainly important to recognize. But in a way, it's even more daunting to me, the fact that then, in addition to these systemic factors, there are also internal factors, right? I come to every medical decision that I make with this entire sort of set of biases that may be based on a whole number of things, right? They may be based on a person's age, gender, or their ethnicity or their appearance, or how much money or that looks like they have, or the social connections that they have or whatever. And of course, in a perfect world, I would be able to somehow rid myself of all of those biases, but to the point that you make. If I'm presenting a patient to one of my colleagues and asking their advice about, you know, what should they get in terms of chemotherapy? And I say, here's this one patient with cancer type A who's in their 70s. And then I present another patient who's in their 80s, even though those patients may actually only be separated by a few months in terms of their actual age, those scenarios sound entirely different, right? And I may end up making decisions that seem totally reasonable and justified to me, right. A la that I would give more aggressive chemo to a patient in their 70s than I would to a patient who's in their 80s, even though, in fact, the facts do not bear out the basis on which I think I'm making that decision. But it is this sort of a trick of my brain, right? That and this has come up a lot recently in terms of implicit bias and other things that our brains try to simplify our decision making by sorting people and things and scenarios and whatever into buckets based on relatively simple rules. And sometimes those rules can really get us in trouble.
Dr. Anupam Jena: [00:44:02] Yeah, I couldn't have said it better than you. I won't even try.
Henry Bair: [00:44:08] So after all this is said and done, if, as you say, your book doesn't seek to create change in specific aspects of the health care system since it addresses the fundamental way we think about problems, then what advice do you have for clinicians and trainees about how they can be more cognizant of what drives our practices and behaviors, and how they can provide better care?
Dr. Anupam Jena: [00:44:30] So I don't know that the book will offer great guidelines for how to behave differently. You know, it wasn't intended to be that way, and honestly, I don't even know that I could. There's any way to sort of do that in a in a really evidence based way. What to me is interesting about the book and what I really hope that people would get out of it. And when I give talks about the book, I don't focus so much on any particular finding, but I really focus on the process to how we got there. And so I think what I'd leave a trainee with is, all right. You go throughout your day making hundreds of decisions about all sorts of things, some of which would be very important, many of which will not be. You've got tons of different experiences. Think about how all that stuff you're doing matters. Like what is it that matters? And how could you sort of think a little bit more experimental in your everyday practice? Here's an example of what I mean by that.
Dr. Anupam Jena: [00:45:26] Someone emailed me from the National Health Service not too long ago who wanted to do research, and he's a clinician there, and I didn't have any research opportunities I could give him. But what seemed to really be driving him was this this interest in experiments, doing something and seeing what happens as a result. And I said to him, well, look, you don't have to have an NIH grant. You don't have to get money. You don't have to write a paper to do experiments. You can do experiments on your own. And I said, for example, suppose that, you know, he was a full time clinician, so he's probably seeing 20 patients a day, five days a week, 100 people he sees a week.I said, why don't you just alternate every other patient after you see them in the exam room, you walk out with them to the front door, to the receptionist desk, and you shake their hand and you thank them because normally what what he was doing was the person would see him in the office and then just walk out the office. He'd probably turn back to his computer and start writing his notes. I said, just do that, randomize it, and then look and see whether or not these people were more likely to come back to you at the follow up visit, see whether they're more likely to fill a prescription medication that you recommended at that visit, because there's all sorts of ways in which you could tinker around with how you present information, how you interact with people that could have potential impacts on patient care. You don't have to study it. You don't have to write a paper about it in a journal. You don't have to get a grant for it. If what you know whets your appetite is just this idea of experimentation, you could do that. And so what I would tell students is, just as you go across your day, think about what could be done differently to make things better and just do it and kind of get a sense of whether or not that's working or not. And if it does, then, you know, you may have something you could study actually.
Henry Bair: [00:47:12] Well, with that, we want to thank you so much for taking the time to join us, for sharing your stories and your fascinating insights. I love the way that your work really sheds light on the inherent messiness of life and of medicine, but nonetheless turn that into a compulsion for all of us. Like like a clarion call for all of us, you know, to reflect more carefully about the way that we process information and how we act on that information, how we can consistently, continually look for ways to do better and be better. So thank you so much for your work and for your time.
Dr. Anupam Jena: [00:47:43] Oh, thank you. Thank you both.
Henry Bair: [00:47:49] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:48:08] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor or patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:48:22] I'm Henry Bair.
Tyler Johnson: [00:48:23] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.