Factually! with Adam Conover - The Hidden Factors Controlling Your Health with Bapu Jena and Chris Worsham

Episode Date: August 16, 2023

While we commonly credit genetics, fitness, and access to healthcare for our well-being, a more complex reality exists – our lives are influenced by unseen elements that deeply impact our health. From birth months to local traffic patterns, these inconspicuous factors exert unforeseen effects. In this episode, Adam welcomes Dr. Bapu Jena and Dr. Chris Worsham, authors of "Random Acts of Medicine: The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health," to decode how to recognize and understand these hidden forces shaping our well-being. Find Dr. Jena and Dr. Worsham's book at factuallypod.com/booksSUPPORT THE SHOW ON PATREON: https://www.patreon.com/adamconoverSEE ADAM ON TOUR: https://www.adamconover.net/tourdates/SUBSCRIBE to and RATE Factually! on:» Apple Podcasts: https://podcasts.apple.com/us/podcast/factually-with-adam-conover/id1463460577» Spotify: https://open.spotify.com/show/0fK8WJw4ffMc2NWydBlDyJAboutHeadgum: Headgum is an LA & NY-based podcast network creatingpremium podcasts with the funniest, most engaging voices in comedy toachieve one goal: Making our audience and ourselves laugh. Listen to ourshows at https://www.headgum.com.» SUBSCRIBE to Headgum: https://www.youtube.com/c/HeadGum?sub_confirmation=1» FOLLOW us on Twitter: http://twitter.com/headgum» FOLLOW us on Instagram: https://instagram.com/headgum/» FOLLOW us on TikTok: https://www.tiktok.com/@headgumSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

This is a HeadGum Podcast. why I am so thrilled that Bokksu, a Japanese snack subscription box, chose to sponsor this episode. What's gotten me so excited about Bokksu is that these aren't just your run-of-the-mill grocery store finds. Each box comes packed with 20 unique snacks that you can only find in Japan itself. Plus, they throw in a handy guide filled with info about each snack and about Japanese culture. And let me tell you something, you are going to need that guide because this box comes with a lot of snacks. I just got this one today direct from Bokksu. And look at all of these things. We got some sort of seaweed snack here. We've got a buttercream cookie.

We've got a dolce. I don't I'm going to have to read the guide to figure out what this one is. It looks like some sort of sponge cake. Oh, my gosh. This one is I think it's some kind of maybe fried banana chip. Let's try it out and see. Is that what it is? Nope. It's not banana. Maybe it's a cassava potato chip. I should have read the guide. Ah, here they are. Iburigako smoky chips. Potato chips made with rice flour, providing a lighter texture and satisfying crunch. Oh my gosh, this is so much fun. You got to get one of these for themselves and get this for the

month of March. Bokksu has a limited edition cherry blossom box and 12 month subscribers get a free kimono style robe and get this while you're wearing your new duds, learning fascinating things about your tasty snacks. You can also rest assured that you have helped to support small family run businesses in Japan because Bokksu works with 200 plus small makers to get their snacks delivered straight to your door. So if all of that sounds good, if you want a big box of delicious snacks like this for yourself, use the code factually for $15 off your first order at Bokksu.com. That's code factually for $15 off your first order on Boxu.com. I don't know the truth.

I don't know the way. I don't know what to think. I don't know what to say. Yeah, but that's all right. That's okay. I don't know anything. Hello and welcome to Factually. I'm Adam Conover. Thank you so much for joining me once again as I talk to an incredible expert

about all the amazing things that they know that I don't know and that you might not know. This week, we're talking about medicine. We give a lot of credit to doctors, don't we? And there's good reasons for that. You know, our bodies are fragile and it's good to have someone who kind of knows what to do when things go wrong with our health, which eventually it will. You know, I'm not going to YouTube when I break my ankle. I'm going to talk to the MDs. But doctors also seem special because they get to wear those nice coats and because our health care system makes it

very hard to access them in the first place. The doctor brand is just straight up strong. But you know, when it comes to our health, doctors are actually just a piece of a much larger story. A huge amount of what makes us healthy or not, what determines how long we live and when we die, has nothing to do with treatment by doctors at all. For many of us, there's a good chance that no doctor's visit in our entire life has been as important as having access to clean water or the nutritional education to know that it's bad to live on a diet of hamburgers and cigarettes. When it comes to our health, public health interventions like these are vastly underrated.

But the factors that affect our health, our well-being, do not stop there. As our guests today show in their new book, there are totally chance factors like the month you were born, what specific doctors are or aren't in town when you're sick, and even the amount of highway congestion where you live that can have a major impact on your health and the health of those around you. So how do we take account of all the factors that affect our health and how do we deal with the faulty explanations that are given to us? And most importantly, how do we navigate our way through the medical system today? Well, to explain all of that and more, we have two incredible guests on the show today. Their names are Dr. Bapu Jena, an economist and professor

at Harvard Medical School who hosts the Freakonomics MD podcast, and Dr. Christopher Worsham, a critical care doctor and public health researcher. Their new book is called Random Acts of Medicine, The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health. I know you're going to love this interview, but before we get to it, I just want to remind you that if you want to support this show, you can do so on Patreon. Head to patreon.com slash Adam Conover. Just five bucks a month gets you every episode of this show ad-free and helps keep the podcast free to everyone. We'll really appreciate it if we see you there. And if you love stand-up comedy, just want to remind you I am on tour. Head to

adamconover.net for tickets and tour dates. And now let's get to my interview with Drs. Bapu Jenna and Chris Worsham. Bapu and Chris, thank you so much for being on the show. Thank you for having us. So your new book is all about the hidden forces that sway doctors, impact our health care, you know, all of these ways that, you know, we think of medicine as being a very scientific rules based, you know, rational discipline. And yet you guys have a whole book full of hidden forces that affect our health. What what are they and why? Who what are these invisible forces that are that are making us sick and or well?

There's so many. Can I give you just one example, please? All right. So my wife was running this race a few years ago in Boston, and it started in the Seaport area. And it was her first time running this kind of race. And she wanted to wanted me to watch her on the race route. And it happened to go by the hospital where I work.

And so I was like, all right, I'm going to go park at the hospital. As I'm driving to the hospital, I've got to turn around because the roads were closed and they were closed because of the race. So I come back home and hours later, I see my wife and I tell her what happened. And she says, well, what happened to everybody that needed to get to the hospital that day? So it was a totally offhand comment. And then it was interesting because what we did is we looked at that. So we looked at 10 years worth of data, lots of different cities, and we looked at marathons. And what we found was that if someone by chance, totally randomly happens to have a heart attack on the day of a marathon, and this is like a 70, 80 year old person. They're more likely to die

because the roads are closed and they can't get there. So that's a random act of medicine. Totally random. Yeah. You wouldn't expect to see that. You know, a lot, I've run a couple of marathons in my life.

A lot of people like talk shit about marathons and how they're, you know, oh, there's too many cups and it's bad for the environment or whatever. This is an impact of marathons I hadn't even thought about. And this is just the beginning that there's all of these various there must be a million factors like that that affect if you get sick, how likely you are to recover.

That's right. And there's a whole bunch of them. And we don't quite go through a million of them in the book, but we do hit a good number of them. Let's just take another example would be the month you happen to be born in. That's essentially random, right? But the month you're born in can have all kinds of impacts on your life. So we both have kids, for example, who are born in August. When we take them in for their checkup, for their annual checkup, they can't get their flu shot. The doctor says, you know what? Flu shot's not quite ready. You got to come back in a couple of weeks. But if they had just happened to have been born in September, just a couple of weeks later, the flu shot would have been there at the doctor and we wouldn't have had to make that extra visit. And it turns out in an analysis

that we did, that little inconvenience caused just by what month that child happens to be born in can lead to a 15 percentage point difference in vaccination the sign, that corresponds to your vaccination rate. And guess what? If you get the flu more often as a kid, maybe that makes you a little bit more irritable. And therefore, I don't know, you end up a stubborn Taurus or whatever it is. Like there are birth months do affect things. Can I tell you something that wasn't in the book, though? Please. We looked at this.

It turns out that divorce records in this country are available publicly. And so we look to see whether or not that divorce rates were more common based on certain month pairings of like, you know, an August born person versus a December born person. Are they more likely to show up in the divorce records than two other month pairings? And it's totally random. So the horoscopes might work for this, but they don't seem to work for divorce oh that's really interesting so that's not in the book because you didn't get an interesting result uh but so okay i thought you were gonna tell me that like oh marches and september is never get along uh but okay so it's astrology is real but only for medicine not for personalities. Yeah, that's right.

So it doesn't make for particularly exciting horoscopes to learn about the chances of you getting a flu shot that year, but I would love a horoscope that just says you're more likely to get a flu shot. Taurus, you're going to get the flu. Pisces, you're not. OK, well, what I find fascinating about this is that we are bombarded so often by health science information, right? That like open any newspaper, open any news website, and it'll say such and such a thing has been linked to such and such a thing. And you don't even know how to take it because, you know, there's so much of this. It seems like,

does that really have an effect? Especially as it comes to nutrition, which you two wrote an incredible piece on for the New York Times about how nutrition science, not just the way it's communicated in the press, but the science itself has really failed us. I'd love to dig into that a little bit, because to me, it's one of the most contentious and confusing pieces of health science is nutrition science. Why is that? I mean, I think the core problem is that, you know, if you want to know whether or not eating a certain type of food or drinking alcohol or eating chocolate or exercising more or less, if that has an effect on your health, the only way to figure that out is to take a bunch of people and randomize some of them to do the behavior

and others not to, and then to study the health outcome that you care about. In reality, what most of these studies do and the studies that we hear about in the news, what they do is they look at people who actually partake of that behavior and people who don't. So if you look at people who exercise a lot and you compare them to people who don't exercise that much and you see that the first group has better health outcomes, how do you know it's because of the exercise itself versus everything else that is different about those people? Maybe they are genetically predisposed to have better health. Maybe they eat differently. Maybe they have better access to health care. Right. The red wine story that we've heard forever is such a good example of this because, oh, red wine is good for your heart. Well, could it just be that red wine is something that's often drank by richer people who have access to better health outcomes for a myriad of reasons, better health care, better food, better ability to exercise, less stress in their lives, etc.

exercise, you know, less stress in their lives, et cetera. There's a million things that could correlate with drinking red wine that might not be caused by the beverage itself. Is that the, did I basically have it right? Yeah. Let me just say, can I make one joke? You can't write the paper, being wealthy is good for your heart. I think you can write that paper. I want to see that paper.

But that doesn't get in the news, right? Like, like people don't want to read that over their cup of coffee in the morning. That's right. And the challenge with that is, well, really to get to the bottom of this, what you need is randomization, right? And when you randomize people to one treatment or another, it gets rid of all of those complicating factors or confounding factors, as we might call them. And that's easy to do with randomization, except that randomization isn't always easy to do. So let's take the diet, for example. We're usually not interested in the effect of someone going on a diet for a couple of weeks or a couple of months, even we want to know what would be the effect of you being on the paleo diet for 10 years, but try going to anybody and saying, all right,

this scientist is going to flip a coin and that's going to determine what you're going to eat for the next 10 years. That's not, not going to go over well. Yeah. You don't want to be on the wrong side of the double blind study. They've been, they've been giving you food and they're like, they're telling you is pizza. You're like, I'm enrolled in the pizza study, but maybe you got the control group and you, you get the stuff that looks like pizza, but guess what? It's styrofoam. I don't know what it is. It's quinoa based. That's what you make. Fuck. Now I'm eating, I'm eating the cauliflower pizza for the next 10 years. Cause I got on the wrong side of the study, but it's all natural. But, but yeah, you see why you see why studies like a randomized trial for things

like diet is are next to impossible. Yeah. But that randomization, we can find that in other ways. So to go back to your red wine example, and this is where we start getting into this idea of a natural experiment. So a natural experiment happens when patients are randomized to one thing or another, not because a doctor flipped a coin or they were assigned a treatment by a researcher, but by accident, by a random act of medicine, if you will. So with red wine, there have been some interesting studies that have come out of China looking at genetic variants in how people process alcohol. And so your genetics are randomly determined, right? For a given gene, you kind of get that 50-50 chance of getting it from your mom or dad. And so we get randomization. And if you inherit a gene that makes you process alcohol differently and makes it kind of unpleasant, they call it sort of this flushing that people can get. You tend to drink less alcohol because it doesn't feel good.

So what we have there are people who are otherwise similar, but they get randomized to drinking more alcohol or drinking less alcohol because of their genetics. to drinking more alcohol or drinking less alcohol because of their genetics. And so that has been, those types of studies have been one way to look at this. Well, it's not exactly red wine, but alcohol in general question is, is, is there a level of alcohol that's okay to drink? And really what they show is that this idea that like, it's a good thing to have a little bit of alcohol every day, doesn't hold much water. Even small amounts of alcohol can be harmful. And that's a much better data point to have because of that randomization that that genetics

gave us. Let me tell you something. I hung on to that factoid about it's healthy to drink a little bit of alcohol so long. You know, I was like, it's healthy. They said in the news, you one drink a day is good for you. People like you're having, you're on your fifth whiskey. It's good for you. You know, it was, uh, when you want to believe it, it's a very easy to believe a false study, but, but so what you're saying is, um, most nutrition science is faulty because it's not randomized at all. They're just looking

at the population of people who drink wine versus people who don't. And there's all these other factors. And you can't design a random trial to say like, hey, randomly, either you drink or you don't write for the next 10 years. But if you can find this natural bit of randomness in the real world that resembles the, okay, now we have two populations that are separated by nothing but essentially a genetic, genetic coin flip. We got rich people, we got poor people, we got all types of different people from all, all walks of life. So it's hopefully averaging out.

But the only thing that differs from them is this genetic coin flip that now you basically have an experiment. And so that's something that might be a little bit more reliable. Is that the idea? You got it. And so we've got a co-author here, Chris. Yeah, I don't think let's not go that far, although if you if you're eligible for any prizes, though, you can put my name on the paper. How about that? A lot of the jokes in the book could really use some some some lifting up a lot of them are bapus and and they're they're strange i gotta i'm not a professional i don't purport to be a professional you guys should stay in your lane all right nobody wants nobody likes a funny doctor okay i literally went to a doctor once

and i was just getting a checkup and the my doctor opened with literally five minutes of Trump jokes. And I was like, I don't, I don't need, I don't need stand up. I'm a standup comedian. I don't need to be at a show tonight. Just, just please put the cuff around my arm. Well, I hope he checked your blood pressure before the jokes. Yeah. Yeah. He was like, oh my God, you're going to have a heart attack. There was a vein popping out of my forehead. So look, what are some of the, just in nutrition, right? Do you have any examples of, you know, faulty nutrition studies that people ended up believing or remarkable new discoveries we've made through this natural experiment method? So we talk about a couple examples in the op-ed. And so let me give one that has not been studied. Then Chris will maybe talk about a couple examples in the op-ed. And so let me give one that has not been studied. Then Crystal may talk about a really interesting one about sugar, which has been looked at.

So I'll just give a personal example. When I went to my PCP not too long ago, she checked my cholesterol. And it's a little bit high. And it's right at the level where you may want to do something about it. And had it been a little bit lower, meaning better, I would have said, all right, my cholesterol is fine. And if it was just a little bit higher, I'd say, all right, I got to do something about it. I got to change my diet. Now, there's millions and millions of people who are just like me who have a cholesterol level that's right around this level,

kind of arbitrary, some threshold where maybe you want to change your diet or all of a sudden you don't have to do anything. So just because of that, I've been drinking whole milk lattes for the last 10 years. And overnight, I switched to oat milk lattes. So I cut the whole milk out of my diet. So you can imagine that there are scenarios where because of where we in medicine place thresholds for something that is quote unquote appropriate or not, or good or bad in terms of your health or lab value, that that randomizes people above or below that threshold to perhaps all of a sudden start changing their behavior. So if you had access to data, you could see that you could see where the behaviors change, health behaviors, exercise behaviors, somewhat randomly based on where they, they lie on that cutoff and then measure outcomes. So that's something like, is it, is it a way that you could get at this question in a more causal way

without doing an actual randomized trial? Yeah. Is there a specific example of a study like that that you're amazed by? Well, so Chris, tell them about the sugar one. I think that's interesting. It's not quite the same because part of the problem is that this way of thinking of using experiments in the wild, it's just not that pervasive at all in that field of nutritional science. And part of the reason for that op-ed is to say, look, open up your eyes. We've got to do things a little bit differently. But Chris, the sugar example is terrific. Yeah, this is a really cool study that they did over in the UK. So during World War Two, they had to ration sugar to the citizens of England, and the, I guess, the rest of the UK as well. But that meant that children who were born sort of during the war,

and in the years following the war, while sugar was still rationed, they grew up with less sugar because there was rationing. The sugar rations lifted, I want to say in 1953. And so all of a sudden, children who are growing up after 1953 can now have as much sugar as they want. And what happens is you have children, you know, some of them even in the same home who some of them are going to grow up being exposed to significantly less sugar than their siblings simply by chance because of when that rationing happened to get lifted. Can I just say, yeah, this is the plot of Charlie and the Chocolate Factory. Post-war England and these poor, deprived children don't have any sugar. And then suddenly they get to go to a candy factory. This is I feel like something was in the air there in the UK time of when these children happen to be born. Yeah. And not I think there's theories that fan theories, I think that the golden tickets were

not actually random that that Wonka wanted. Anyway, so maybe Wonka was conducting an experiment on the kids and he was trying to he was it was he was randomly doling out golden tickets in order to conduct an experiment of sugar on their bodies. There you go. You don't have to look far on the internet to find this stuff. But anyway, so going back to the UK sugar rationing. So they followed these people for decades, all the way out until I think the early 2000s. And they could look at these long-term outcomes that we were saying are so hard to look at in nutrition science.

look at these long-term outcomes that we were saying are so hard to look at in nutrition science. And what they found was that the kids, I guess they were adults now, but that who happened to be born before rationing was lifted. So the ones who got less sugar in their diet, they had lower rates of, they had better cholesterol, they had less diabetes, they had less fewer health complications. And over the course of their lives, they actually consumed less sugar, even though the sugar rationing was lifted simply because of the way they grew up and in that environment. fascinating look at how you can get those long-term studies by using data that's out there. I think they just used existing medical records for people who happen to be in their like 60s when they did the study. Wow. And was, so let me just ask, everything was just better because they had less access to sugar as kids. This is a devastating result. Right. Some of the complications that we attribute to excess sugar intake, they were less than people

who grew up as young children with less sugar and then went on to eat less sugar as adults. Yeah. Well, and the fact that they went on to eat less, that they didn't, they didn't have a sweet tooth as a result of not having it as kids is, is fascinating as well. So, I mean, but again, this is not how nutrition science is normally done. Normally it is what, just comparing people in a, in a much looser, goosier way. Does this have negative impacts on what we eat and what we tell each other to eat because nutrition science has this fundamental flaw in it the way it's normally done? Yeah. I mean, I think that the challenge is in this case right here, if you look at people who grew up in households where there's a lot of sugar that's available to them and versus not, again, there's so many things that are different about those. It's like saying being poor causes diabetes. No, it's not. There's things, there's

risk factors for that, but we don't know what they are. Different people have different diets. So I think it is, and it's challenging, right? Because it's one thing that is under our control. We somewhat, like we can choose what we eat. People, you know, that's one of the core things that we do in society is we, you know, organize around food. It's the thing that people look forward to. So it's not surprising that people are attracted to that kind of information. The problem is, is that most people, I think it's hard to be able to figure out what's reliable versus not. And to your point earlier, if something conforms to what you want, like, I mean, I like pino coladas and I like Ben and Jerry's ice cream.

So if a study comes out that says those two things are good, maybe I'm more likely to believe it. Probably not because I know a little bit more about it. But if you didn't know, you'd be attracted to that finding because it might sort of confirm with confirm your belief already. I mean, turn on the TV any day and you'll see a talk show going like, oh, they say chocolate is good for you. Yum, yum, yum. Like it's it's even though it's one of the fields of science that is least reliable, it's one of the ones that we want to hear about the most where we seek out the information. It's probably one of the most published, if you look at the mainstream news types of scientific news out there, far more than, I don't know, physics or chemistry or something like that. I mean, it definitely feeds back on itself because people we eat every day,

obviously, and people want to be healthy. So they're thinking about it constantly. So they want to read about it. And the media covers these studies and that incentivizes more of them. And we get this sort of feedback loop of study after study, after study that doesn't actually tell us all that much. And it kind of means that we have to look through the noise there to try to see toward the better studies that give us a better insight into what might actually be going on.

Yeah. So how would we do that? I mean, how would you fix nutrition research if you could, and the way that we talk about it as a society? Oh, it's hard. I mean, I think it requires a few things. Well, the first thing it requires is an understanding of the problem, mostly by the people who are doing the research. For me, it's not on the media. It's not on consumers of media to be able to suss out what's a good study versus a bad study. We just shouldn't be doing those kinds of studies. Let's say that you want to figure out whether or not eating red meat is bad for you. Cardiovascular.

Like there's a lot of epidemiologic work out there that suggests that it might be, but again, it's not randomized. So you don't know whether it's the red meat consumption versus other things. So it is hard. I mean, it requires creativity to find a situation in the real world where some people by chance are more or less likely to eat red meat. And maybe it's something like alpha-gal that people are talking about now, or you remember the mad cow disease that was, this is like 10, 15 years ago. So imagine you grew up around that time in areas that were affected

by mad cow. You probably would be less likely to be interested in eating, you know, cow products compared to people who lived in a different area where that wasn't an issue. And you look before and after. So I think that there are creative ways that we can get at these questions, but the field just isn't isn't there yet. And it's a bummer because it's a it's a form of science that people have such an intense interest in that matters so much to people. Everyone is obsessed with what they're putting in their bodies. Everyone is, am I eating the right thing? Is this right? Or is it wrong? You know, or they're jaded on that. Anything they tell you what's right or wrong is bullshit. Who

gives a shit, right? Um, people have such an emotional connection to this form of science. It's a bummer that it's not actually more reliable. And so it's very cool that you, that you folks are, uh, finding ways to do the science that science that we can be more certain about. And those studies that you cite are really cool. Let's get back to medicine more generally, though. Like, what are some of the other surprising findings that you found of ways that, you know, hidden forces affect medical outcomes? What should, Chris, should I talk about the cardiologists?

That's a good one. I would love to hear about the cardiologists. Actually, before I get to the cardiologist story, there's a lot of funny stuff in the, we think it's funny. I'll be the judge of whether it's funny. You'll be the judge. Tell me if you think this is funny. Well, first let me ask you, what type of doctors, specialists do you think drive the fastest? Let's put it this way way get the most speeding tickets yeah what kind of doctors get the most speeding tickets okay it's gonna be um okay it could be doctors who need to uh uh get somewhere in an emergency so i i would think maybe a kind of doctor who gets a call from

the hospital i gotta go someone's gonna die. And I think it would be doctors who would be kind of, you know, cocky, the highest paid, the cowboys of the hospital. You know, the guys, I'm going to buy a fancy car. I'm flashy. So I'm going to say definitely surgeons of some kind. And because you said cardiologist, I'm going to have to say a heart surgeon because A, And because you said cardiologist, I'm going to have to say a heart surgeon because, A, that's an emergency. And B, I don't know. I just feel like the heart surgeon, that's the guy who's the star of the medical drama. That's the heartbreaker. That's the guy who's like, I want to be the alpha dog of the hospital.

So I'm going to say heart surgeon. Okay, two things. One, it turns out that the alpha dog is actually a psychiatrist. So psychiatrists what yeah psychiatrists uh are caught for speeding the most and what because they're crazy that's why they're crazy motherfuckers yeah they think that they can talk the officer through the they're like sit down no you that you didn't work you didn't see that you didn't see what you thought you saw. A lot of people think that they see a lot of people speeding, but let's examine that.

And you're right. Your intuition was right. Cardiologists do drive the fanciest cars, but yeah, sorry. Here's the study. A few years ago when I was in training, I happened to be working in something called the Cardiac Intensive Care Unit, where all the sick cardiac patients go. And it was, it happened to be around the time when one of the major cardiology conferences that cardiologists go to was being held. So there's two big ones, American Heart Association and American College of Cardiology. And these are just big conventions where a lot of cardiologists and cardiology researchers, they go to these meetings. And so I was wondering, you know, what happens to people who happen by chance to have a cardiac

problem during the dates of these exact, you know, these meetings, right? People don't know when the AHA meeting is being held and they don't choose to have a heart attack. It just happens naturally and randomly. So we looked at what happens during the dates of these meetings, and I think, Chris, our intuition would have been that people would do worse because the staffing might be lower because cardiologists are not in the hospital. It turns out, and this is surprising to us, is that outcomes are actually better. People are less likely to die if they happen to be admitted to the hospital when the cardiologists are out of town.

OK, that's yeah, that's weird. Why that might be true. I'm just curious. I mean, OK, I could make a joke, but I think my first guess is that it's some sort of over treatment problem that, that there's, it reduces the risk of if the cardiologists aren't around, it reduces the risk of someone getting a surgery that they maybe don't need because a cardiologist who's like, I want to kind of want to buy a fancier car this year. I think you need open heart surgery so I can, uh, I can get that new Ferrari or whatever. Uh, and the person didn't need the surgery in the first place. I'm a little bit scared of that prediction because I, I, I don't want to make people think that you shouldn't,

you shouldn't trust what a doctor says, but, but I know that over-treatment is a problem. You know what, Babu? I think we have our co-author. We've got a bunch of people we work with. Chris, we've got a, what is this? The phrase you've got to squash the zeros and go with the heroes. Oh my God. Wow. Guys, I have, I have a bachelor's in philosophy, but you know, you know what? Hand me a scalpel. Let me, let me do some studies. They told you it would never come in handy and look at you now. Yeah, but you're right. That's the exact point. You're right. That's what has happened is that we show the other data point, which I didn't reveal to you, was that rates of certain procedures, they fall by about a third during the dates of the meeting. So what we think is going on is in the rest of the year, there's a lot of things that we do in medicine and cardiology.

We're going to kind of constrain ourselves a little bit because the staffing is lower. The backup might be lower. We pull back on certain things. And sometimes that might actually be beneficial to people if they were being harmed otherwise. But that's a little bit worrying because, look, if I have a heart problem, I go to the hospital, right? And and the cardio, I talk to the cardiologist and they say, you need surgery. I'm the sort of person I want to trust that cardiologist. I don't want to have read your book and say, hold on a second.

Outcomes are better when, if the cardiologist was literally in a different state, like, could I come back when you're not here? And I think I might do better. Like that's that I worry about that undermining my my trust in the medical system. And look, you should be skeptical at all times. But you also need to be able to trust, you know, the doctor who you're speaking to in order to, you know, interact with the medical system at all. Otherwise, because you can't you can't be going, you know, second guessing every step of the way saying, hold on a second. Like you guys are overtreating me. How do we so how do we deal with this information? I mean, I wouldn't say you can't

second guess your doctor. I think that's that's, you know, and you can do it politely, of course. But we talk about this in the book where we show findings like this and some other ones where they might make you think like, oh, does this guy know what he's doing? And the answer to this is that we have to recognize that human doctors are human beings too, right? And what happens is, you know, we fall subject to various biases or things that are just, you know, this is the way we typically do things. And one of the ways we can not fall into traps is to sort of hit the brakes. Our brains work on, you might call it sort of this highway where doctors are going around the hospital. They're seeing potentially dozens of patients every day. They have to work quickly and efficiently and their brains take shortcuts.

And one of the best ways to get around some of these things is just to slow down a little bit. And if you're being told, you know, you should, we recommend that you get this procedure. It is absolutely worth it to say, can we hold off and for a second and just talk about what would it look like if I didn't? What are the risks here? What are the benefits? And a lot of times just slowing down is enough to overcome some of these problems. You know, is that something that happens? And maybe the doctors are actually, yeah, that is something that people are taught because maybe they read your book or they read whatever other journal article and they say, yeah, I mean, that is a risk factor. And now you're weighing that along with everything else and maybe having a more informed decision. I think that's right.

You know, and so the core question is, is it possible for a doctor? I mean, let's reflect on the problem. The problem is that there are a lot of things in medicine that are black and white. You know, if you've, if you're coming in and you're bleeding profusely because of a major leg injury, we know what to do and you have to act on it, black and white. But there are other medical decisions like the one that we're talking about with, you know, heart attack patients, where it can be a little bit more gray you know, heart attack patients, where it can be a little bit more gray. And our tendency is to do more than to do less in medicine. And what we do talk about in the book, and I think we can show through in a different way, that if cardiologists, if push came to shove, and they sort of had to

reflect, who are these people that are at the margin for whom we might be better off not doing something? I think they can actually identify those people. But there's nothing in the real world that constrains their mind to have to do that. You know, to put it a different way, if a cardiologist had 300 people in front of them, they could probably figure out who are the 50 that absolutely needed that procedure, and they would get it right. But then as you start to march down 50 to 100, 100 to 150, it becomes a little bit more vague about who's going to benefit versus not, but they can probably get the ordering generally correct. And the key is to figure out, well, where's that threshold where the benefit is now outweighed by the risk to the person?

And I think they can figure it out. But we also have the problem that we haven't gotten into yet is that, you know, we have a corporate medical system, a for-profit medical system where, you know, folks, the system makes money from fees for services, right? As opposed to, it's not like they get a big bonus if they didn't do the service in your well, right? And so there's also that pressure like that, that doctor, yes, in a vacuum could maybe look at the person and see who's on the threshold and who isn't, but they're operating within a system that is,

you know, pressuring always do more because that's how we make more money. Is that an issue at all? I think it is, but I think it's maybe not as big. And I mean, maybe Chris would disagree, but my own intuition is it's not as big an issue as we, as we make it out to be. Cause like you're absolutely right. And there's like the way that many doctors are paid is they're paid to do more. Um, but there's a lot of studies that look at how, if you pay doctors differently, do they change their behavior radically? For example, if you pay doctors by salary, do they all of a sudden start doing much,

much less of things? And the answer is no. And the reason why is because, you know, the first five things that drive a decision by a physician to do something is do they think that this person is going to benefit? Now, on the margins, does how they get paid nudge them in one direction or the other? Yeah, I think absolutely that can happen. But it's not like the first order thing. The first order thing is, this is a person in front of me. I think that what I want to offer this person will help them. I don't know for sure, but I think it will. And if I don't do it, what am I risking? And most of the time they're thinking, if I don't do it, they could be harmed. Maybe they worry about malpractice sometimes, but the tendency is

always to try to do more rather than to do less. And that's a really hard instinct to run away from. And on the very big, on the larger scale, the data back this up that we have sort of experimental payment models that various areas around the country are using, where financial incentives are a little bit more aligned, where people are incentivized to make sure that the patient gets exactly the right care. They don't get too much care, but they also don't get too little care such that they experience a complication of too little care. And there are small changes here and there. But when we align financial incentives more, it doesn't lead to dramatic differences in the quality of care for patients. So it's a piece of the puzzle, but it's not all of it.

Well, look, and I don't think that doctors are sitting there thinking, oh, well, some maybe are. But I think the majority cardiologists are not sitting there going, oh, you know, I want to make a little extra scratch. Let me let me do an unnecessary surgery. I do think we live under an overall system of capitalism that that causes a lot of distortions in our medical system. But that's maybe a different episode. There's so much I want to more. I want to ask you guys about your work, though.

We have to take a really quick break. We'll be right back with Dr. Bapu Jena and Chris Worsham. Okay, we're back with Drs. Bapu Jena and Chris Worsham talking about all the hidden factors that affect your health outcome when you go to a hospital or go see a doctor. your health outcome when you go to a hospital or go see a doctor. I know that in your book, you wrote about talking about birth months, how this can affect your chances of getting an ADHD diagnosis as an ADD kid who was born in March. I have to know what is the effect and does this explain my entire childhood? I can't answer that last question. I can answer something about the birth month, though. We can take that as a kind of stepping off point. So a lot of states, in fact, every state has a cutoff for when you have to be five to enter kindergarten. So in the state that

Chris and I live in Massachusetts, it's September 1. So if you're five by September 1, you go to kindergarten. If you turn five on September 3rd, you wait a year. And what that means is that in any kindergarten class, the August born children's in this state are going to be the youngest kids in their class. And then the September born kids are going to be the oldest kids in their class. Right. And there could be, it could be like almost a year's difference. Could be 360 days separating separating those kids that's a huge difference when you're talking about five-year-olds yeah it's like 20 chris wrote 20 on planet earth between these two kids and so yeah huge huge maturity difference and the

interesting thing is if you look at the data the august born children are about 30 percent more likely to be diagnosed and also medically treated with a medication for ADHD to the September born kids. And the intuition is just that, right? Like a kid is a little bit more inattentive. They're more fidgety in class. The diagnosis of ADHD is being considered because of that. And ultimately that leads to a diagnosis. And maybe what would have happened is if you just gave that kid a few months to mature, you would see a different child. And so it's sort of an interesting way to talk about how medical diagnoses, decisions we make are sometimes subjective because you wouldn't see that same pattern with diabetes because it's a lab

test that makes that diagnosis, not sort of a subjective assessment by different people, doctors, therapists, parents, teachers, et cetera. It's interesting because on the other hand, I think there's a disadvantage in life to starting school almost a year later than your peers. You're missing out on a year of schooling and you're getting the same instruction, but much, much later than other kids. I imagine that would have problems as well that come with it. When you put it that way, it's such a bizarre way to figure out who should be in which school year. It's like some kids are kids are getting radically different school experiences. Right. And what this study shows

exactly what Bobby said, that difference between the August and September born kids and basically highlights where when we're making this diagnosis of ADHD, where that subjectivity could be causing some problems. But the study doesn't necessarily tell us what we should do about it or what a parent should do about it. what a parent should do about it. So it does not say that a parent should necessarily hold their kid back a year if they have that option and start them later. Because like you were just saying, Adam, you don't know, is that year of their life where they're doing not school? Is that going to be good for them in the long run? We don't know the answer to that. But what it does tell us, at least for us on the medical side of things, is that this is a really important diagnosis. It affects a lot of things for a lot of kids. I think it's something like 8% of kids in the US are looking at diagnoses of ADHD. So it means we have to be careful when we say,

okay, this is a kindergartner. How is a kindergartner supposed to behave? And we shouldn't ask that question because kindergartner represents some kids who are an entire year older than others. So we need to be mindful of what we would call the relative age within that class. So there's a kindergartner who's old for his class year. There's a kindergartner who's young for her class year. There's a kindergartner who's young for her class year. And we shouldn't we shouldn't have the same expectations for those people. Yeah. And they give you I mean, the medical intervention can be strong. I mean, they give you amphetamines, right, as a as a kid, often as a treatment.

And that's like a that's a pretty drastic thing to give to a kid who's maybe just a little bit more fidgety or a little bit younger than the other kids. A lot of people are helped by it as well, but there's a real risk factor there. Yeah. And the honest truth is that we're probably looking in this case of instances where people are being quote unquote overdiagnosed, but we know that underdiagnosis is also a problem as well. Very real. Sort of two parts of the same coin that we've got to be kind of be mindful of. But that's sort of the takeaway for me is that if, again, if you're entertaining that diagnosis, if you think it's at play, then it is worth saying if a child has an August

birthday, you know, you might have a little bit more latitude to say, let's wait six months and see what happens. Well, so staying on children's birthdays, I know you also write about how it has to you might have a little bit more latitude to say, let's wait six months and see what happens. Well, so staying on children's birthdays, I know you also write about how it has to do with the risk of getting COVID. I'm very curious to hear about this. Okay. All right. So these are all family stories. You're getting like a window into our lives. So Chris and I both have two kids and they're similar ages. And a few years ago, our daughter was turning five and it was in the middle of the pandemic. And we were trying to figure out whether or not we should do a Zoom birthday or a in-person birthday and kind of hammed and hawed about it.

We ultimately went the Zoom route. And there is a guy named I think his name is Tricky Tim, who's like a Zoom magician. He's I'm not I'm not a paid advertiser for him, but he was quite good. He's a Zoom magician named Tricky Tim. Yeah. I feel like that's the beginning of a really bad first date story. Exactly. Exactly, yeah.

I went on a date with a Zoom magician named Tricky Tim. Yeah. Or a Dateline special, one or the other. It's not going in the right direction. But anyway, so we thought about it. Yeah. Or a Dateline special, one or the other, not going in the right direction. But anyway, so we thought about it. Okay. Tell me all about it. All right. So that was a setup. And then it was like, huh, you know, one question that people had thought a lot about at the beginning of the pandemic was how does the disease spread? Is it these big super spreader events? Is it people going to bars and restaurants with people that they don't know very well? Or might it even be occurring in these small social gatherings with people that you know and

trust? Fundamentally, it's a hard question to study because what do you need? You need data on lots of people. You need to know whether or not they were gathering. You need to know whether or not they ultimately got COVID-19. And then you got to sort out the problem of, well, is the reason they got COVID-19 because they were gathering or because of all sorts of other things that they might have been doing differently? And that's where the birthdays come in. So the insight was that birthdays are a natural time for people to want to gather. And birthdays tend to be recorded in the types of data that people like Chris and I work with, insurance data. Chris and I work with insurance data. So all we did is we looked at hundreds of thousands of families and we looked at instances in the same city where a bunch of families either have a

household member with a birthday, the insurance company knows that, versus other households in that same city in that same week where nobody in that household has a birthday. Not a birthday party, a birthday. That's recording the data. And what you see is that in households where there is someone with a birthday, that household is 30% more likely to have a COVID-19 diagnosis two weeks after that date compared to households in which in that same city in that same week, no one had a birthday. And not surprisingly, the effect is the birthday effect, the COVID-19 birthday effect, as we might call it, is larger in households where there's a child who has a birthday. Right. Because we can we're adults.

We can get away without celebrating our birthday, perhaps. But for a kid, it's a big deal. This was so many parents are like, we've been so good the whole time. And like, oh, but our little kid just wants a birthday. So we can't we got. OK, we'll just have two people over and do it on the porch, you know, or whatever. It's a hard decision for a lot of candles, not and not with a vigorous breath. We'll get a fan and we'll wave it out.

Hopefully it'll be fine. And then it's fine for some, but not for all. Yeah. Yeah. And another interesting insight from that paper that Bapu did was they, they also looked at the, um, the area that the patients lived in as far as the political leanings of that County. And if we can think back to, um, 2020, where we kind of attached a lot of these COVID-19 infection control behaviors, got attached to various political leanings. Without getting into too many details there,

there was sort of this idea that, well, maybe people living in Democratic areas might behave differently than people living in Republican areas. And it turned out in that study that there weren't any real differences between right and left-leaning areas, which the question is, well, what does that mean? And it kind of means one of two things. One, that then this, this is what I think it probably means is, is that Democrats and Republicans were probably actually not behaving all that differently. They probably they signaled that they were doing different things, but probably were doing similar things at home. Or alternatively, that the measures that people were taking weren't doing all that much. But but the birthday study really shows that everybody, regardless of their leanings, was still getting together.

everybody, regardless of their leanings, was still getting together. Yeah, that's really fascinating because there was so much in the press about, oh, people on the right act like this, people on the left act like that. It became like this sort of signifier of political belief. But then if you look at and I'd hear people say, oh, you go here and you go to this area and no one's wearing masks or whatever. But and they would sort of use that as a proxy for political affiliation, except that even in the most polarized parts of the country. I mean, you go to California. Most of it is still 60, 40. It's a blue state, still 60, 40. And then also same thing in Texas. Right. 60, 40 the other way. And then also what people do socially, like whether they wear a mask in the grocery store, I'm not thinking about what Joe Biden or Donald Trump said. I'm wearing a mask in the grocery store. If there's other people wearing a mask in the

grocery store that I feel like that's how a lot of people, uh, behave is they look for the social cues of everybody in their area. Um, and, uh, for better or for worse for worse, for worse in a lot of cases. And that's not necessarily as directly linked to who you might vote for in November, as people think. It's more of a general sort of cultural vibe. Yeah. I mean, you mentioned you're a philosophy major. I won't get too philosophical here, but in the pandemic, we did a really good job of maximizing perceptions of differences across people. I mean, we did a stellar job and I'm being a little bit sarcastic there, but- Yeah. Yeah. Did too good of a job. Yeah.

Exactly. Yeah. Who didn't pay a price? Everybody paid a price. Right. Even if you didn't want to mask, you were still being required to or it was harder for you to live the life that you were living just months earlier. sort of emphasize the ways in which people, you know, either were or may have been different rather than sort of maximizing the fact that everybody was being affected by this. And sort of, you know, I think we view that as a bit of a loss in terms of how we thought about the dynamics of the pandemic. Yeah. I mean, even even folks who I think felt that they were following the best public health guidelines and et cetera, et cetera, and were doing it in a very science-based way, were often making very political judgments of other people and their behavior and say, oh, this person did X, Y, Z because of their political beliefs and that's why they died or that's why they suffered. And there was a lot of people

jumping to that conclusion, whereas in your view, it was maybe had less of an impact on health outcomes than many thought. Yeah. I mean, it's a little bit hokey, but at the end of the day, we're a lot more similar than we are different. And just one statistic, if you were to log on to the CDC's website and look at the percentage of American adults who have had at least one covid vaccine, I think a lot of people would be surprised to find out that that number is higher than 90 percent. Really? Yeah. That for one dose, all Americans overall. Right. So, you know, we have some room to make up still with people completing the series. But if you think about just the vitriol and the and the, you know, the screaming and all of this about vaccines. got off their couch, drove somewhere, got a vaccine, knowing that it was new, knowing that it might have some unpleasant side effects. And they did it and they did it because they were

doing it for their neighbors, for themselves. Yes, but for their country. And it's really easy to lose sight of how much we actually have in common because our differences get so inflamed. But vaccines are just one piece of that. And you're blowing my mind. Yeah, it sounds like a, you know, after school special, but but it's true. Wait, Chris, didn't you looked I remember when we talked about this a while ago, you looked at these two statistics. One was like, what proportion of Americans, what percentage of Americans like apple pie? Yeah. And like, the point was, like, getting back to it was more American than than. Yeah. Yeah. The only thing that people agreed on more than getting at least one dose of the vaccine was that they don't like Congress.

And another one was if you the Rotten Tomatoes for the movie Geely has about the same amount of hate as the percentage of people who got vaccinated. Okay. You guys got jokes in your medical science book, and I appreciate that from you. That's an incredible statistic. And if you had asked me to guess what percentage of Americans had at least one dose, I would have probably said 60%, something like that, 65. My expectations would have been low because I ingested all the news about how slow the rollout was. We did not do as good a job as we should have of making the vaccine accessible to people and just knocking on doors and making sure that folks got it.

So 90% at this time is wild to me. I mean, especially given the vitriol and the quote debate and all of that, that was slung back and forth. Incredible what happens when you actually look at the data. I want to get to one more, one or two more pieces of data because I have some really cool ones in my notes here. I see that you wrote about the difference between a rookie doctor and a veteran doctor. I think that a lot of people have that concern. They go to the hospital. They're like, oh, my God, my doctor was in braces right out of medical school.

What what effect does this have on our medical coverage? First of all, now it's called Invisalign. OK, and you can't tell who has braces anymore. And that's reducing my ability to know how experienced my doctor is. I have a problem with that. Well, both Chris and I, we, I don't know if we look young or look old, but we're getting older. So it's something that we think about. So a few years ago, we had done a lot of work trying to figure out whether or not older or younger doctors have better outcomes, male or female doctors, Harvard or non Harvard. Did you train this country or

another country? And the age one is a particularly interesting one because, you know, here's why it's hard to study. If you think that older doctors are more seasoned, more experienced, then if you look at patients who are treated by older doctors, they select those older doctors. And if they select them because they think that they have a medical problem that needs that attention, if you look at the outcomes of patients who are treated by older doctors versus younger doctors, you might find that the patients do worse. But you couldn't infer from that that it was the age of the doctor that led them as a patient to have worse outcomes. They chose that doctor because something was going on that was medically complex.

And here's where we enter back into that discussion of natural experiments. It turns out that in American hospitals, most of the time when you're hospitalized, it's totally random who the doctor is who happens to get assigned to you. So if you go on Monday, you get me. If you go on Tuesday, you get Chris. If you go on Wednesday, you get Adam. If you go on Thursday, you get Lisa. It's totally random. And so what that allows you to do is figure out, well, what happens if some people by chance are admitted to the hospital and cared for by an older doctor versus a younger doctor? And what we find is that the mortality rate is actually lower for patients when they by

chance happen to be admitted to the hospital and cared for by a younger doctor. And the reason why I think that's the case is because even though the older you are, you get more experience, you see more stuff, it's also true that the younger doctors are fresh out of training, and they are sort of closest to the current medical guidelines and information and knowledge. And so that factor might be more influential. But they're really worried about fucking up. They really they're like, oh, my God, this is like if I lose my first patient, I'm done. Chris, there's a wrinkle that Chris thought a lot about as well.

Yes. So there's another twist here is that. So if we go with this idea that these younger doctors are the most up to date because they just went through training, they just took their board exams, they've studied all the literature, that's the idea that your average patient, as long as they're getting that guideline recommended therapy, on average, they're going to do better. So the question is, what's happening with these older doctors? Are they not keeping up with the literature? And when you look at this study, when they drill down into specific age groups, if we look at doctors like in their 30s and 40s, 40s, 50s, 60s, et cetera, if you looked at the number of patients that those doctors treated, as long as the older

doctors were still taking care of as many patients as their younger colleagues, there was no difference in mortality. And what that said to us is that it's sort of this use it or lose it kind of phenomenon, where in the course of taking care of patients, and Bapu and I deal with this all the time, let's say someone comes in with a condition that we haven't treated in a while, we go and we read what's the latest on this condition. And as we see patients, we stay up to date. But if we get older and maybe we start seeing fewer patients back off on the intensity of our practice, we just don't get as much experiencing patients. And that means we probably spend less time staying on top of the latest treatments. And so the question you should

be asking when you see that sort of salt and pepper hair, or in my case, the no hair, that doctor coming into you is not how old are you, but what are you doing to stay on top of the literature? How often how many patients do you see? Those might be better questions than just looking at an older doctor. Yeah. Yeah. I went to see a doctor a couple of years ago. My primary care physician was a very eminent doctor in Los Angeles. You know, I went into his office and he had all photos and certificates on the wall. This guy was like, you know, on the board of of all these institutions. He was an important doctor right in L.A. And I went and a beautiful office and all this vintage like medical equipment.

And this is the same guy who when he sat down, he told me five minutes of Trump jokes. Right. And he was very nice. He had a wonderful bedside manner. I was like like i'm starting to pass out when i stand up it's happened not pass out but i'm getting light head when i stand up and he was like you need to eat more salt and i was like okay i mean i'll happily eat more salt but i was like i don't really feel like i got uh you know what i mean it was it was a little bit of a this guy's on a victory lap you know what i? Like he likes going in a couple days a week and, and, and keeping up the old practice, but you know, this is a, and I'm sure

he was a, I'm sure he's got a great medical mind, but I didn't feel that I was getting the person who was really in still mentally in the game. You know, um, I experienced what you're talking about, I think. Well, it sounds Adam, like your physician is a lovely guy, albeit not a stand-up comedian. I haven't seen him in years. But I think, sure, there is still that sort of benefit to experience. And, you know, as I'm still going to call myself a bit of a younger doctor, there are older doctors who have been practicing for decades who if I come up to them with a I'm seeing this patient, it's kind of a challenging case. Here's the details. I wasn't 100 percent sure what was going on. They will from 10 miles away just say, I know what that is.

Check for this. And inevitably they'll be right. So sometimes it's with these like really rare conditions or really challenging diagnoses that I personally think that that experience is still important. But those very rare conditions are not what make up the data, right? What make up the data and what speaks to the average patient is common things like pneumonia and hip fractures and heart attacks, right? And so those are a little bit more straightforward,

but there is still that role for that sort of elder statesperson doctor who's kind of seen it all. And we still really look up to them when, especially when we're in a challenging situation. I mean, if you're getting a heart surgery, do you want it from the person who's done a hundred thousand heart surgeries and can do them with their eyes closed? Or do you want the person who's like, they're very good at it, but they're also thinking about here's the new things that we know about, about it. They're thinking, I don't want to fuck

up. They're thinking, et don't want to fuck up. They're thinking, et cetera. There's there's a bit of a tradeoff there, right? Yeah. Between experience. Exactly. With surgeons, the follow up study that Bobby did, they they found exactly what you said. So it's a little bit different as surgeons get older and they just rack up those case

numbers. They get better because they're they're developing their muscle memory. They know, you know, when I get it, when it seems like this, if I'm in this tight spot, this is what I should be doing. They have a better sense maybe of which patients they should and shouldn't take for a given surgery. So for surgeons, as they get older, they tend to age like a fine wine as long as they're continuing to do lots and lots of procedures. They just get more and more fancy cars in the garage. Yeah. Let me ask one. I feel remiss if we didn't bring it up because we've talked about all these biases.

There's plenty of issues of discrimination in the medical system where, you know, people from different backgrounds had different outcomes because they're treated differently in the medical system. Are those issues that you cover at all? Yeah, we do. And I mean, and the biases come in a lot of different flavors. I mean, there's biases against patients. And that's something we think a lot about. But there's also biases against physicians. And there's there's a paper I'll mention really quickly. It's really it's clever. And it's also concerning. It's by an economist named Heather Sarsen. She's a Canadian economist. And basically what she did is she looked at male

surgeons and female surgeons. And she looked at instances in which either one of those two groups of surgeons had a bad outcome. So a person had surgery and they died on the day of surgery. That's a bad outcome. And what she found was that when male surgeons had a bad outcome like that, the physicians who refer patients to that surgeon, they don't stop really referring patients to that surgeon, even though they had a bad outcome. Whereas when a female surgeon has a bad outcome, referring physicians reduce their referrals to that female surgeon. Wow. And the intuition, I think, is the following, is that when a male surgeon has a bad outcome, it's the cost of doing business. Right?

When you do a surgery, things happen that are complicated or complications. Whereas when a female surgeon has a bad outcome, oh, it reflects something about the quality of her skill and the quality of her as a surgeon. And, you know, to me, that was like a fascinating and illuminating study. And it just showed how you can use data to try to get at questions that people might have some intuition about, but that matter. And it speaks to how you might do things differently. There's a lot of female surgeons that they're going, I knew it. I knew it. This is like you've proved that there is sexism in this case.

Yeah. Unfortunately, there's not enough female surgeons, but yeah, the ones who were there, they're probably thinking that. Yeah. And when it comes to patients, it's really challenging because a lot of the data that we use for research, we don't even have race as sort of the variable in the data set that we can even study it. So really, yeah, sometimes it's available, sometimes it's not.

And then there's just so many really complex factors that build into racial biases. And they range from a lot of the stuff we're obviously all familiar with, sort of the history of this country, and the way it seeps into medicine, there's a lot of mistrust in the healthcare system. And so even if you come from a certain background, and you come into the doctor, you have access to the doctor, you have good insurance, you can afford your medications, all of that stuff. If the doctor you see, you don't trust them. Are you going to take that medication they want you to take every day for the rest of your life? Are you going to let them near you with a scalpel while you're unconscious? So there's a lot, what it seems like, at least from the data that's out there and from

research that many, many people are doing, that trust and building relationships with patients is really important. And that's probably one area we should be exploring when it comes to closing sort of racial disparities in health care. Unfortunately, we don't have any really great natural experiments about that, but we are looking for some. Yeah. Um, and, uh, but we, we know that bias exists in, in these systems and that, you know, it's something that, that doctors do perpetrate to a certain extent and, and taking care of those biases is like a, an important way to, to build that trust, I think, you know, because you hear, you know, so many stories about people of color being treated differently by the medical system, et cetera, that that leads to the problem that you're talking about. Well, look,

this has been an incredible conversation. But when, you know, people are looking at, you know, medical science news or interacting, you know, with the medical system, how do you suggest they comport themselves to take some of these biases into account to not fall for bad medical science, et cetera? Is there any sort of healthy skepticism we're able to breed or any way to sort of keep all these issues in mind? Yeah, I think the short answer is, and I apologize, it's not very sexy, but it's simple,

which is look for the randomization. So if you hear a study in the news and the people weren't randomized to that thing that they're studying, whether it's chocolate or a new medication or a new surgery, I would immediately be skeptical. And if you do see that there's randomization one way or the other, I'd put more trust in it. Yeah. And in Random Acts of Medicine, you know, throughout the book, we sort of teach in an entertaining and approachable way. You don't really need to have known anything coming into it. We teach the reader to recognize, start recognizing randomization, right? And so when they do read that news article, they should be able to spot the difference between a study that carries a little bit more weight than another one.

And the other thing is, you know, usually a single study is not something that should change our practice, that we should change our lives about. So I'll give you an example. I'm still drinking Diet Coke, even though there's been all these headlines about aspartame. Even though he has a growth on the back of his head. Right. Immediately after he started drinking Diet Coke.

It throbs every time I drink a Diet Coke, but I just can't stop it. Because you're waiting for more information or because what? Well, it's all of this, the same issues we talked about with, um, the studies into nutrition is that first of all, the, the WHO saying that, that something may be a carcinogen, the list of things on that list is like everything around your house. So we shouldn't get too excited about that. So, so yeah, I'm still consuming aspartame. I'm not too worried about it. But we should,

we could come back to that conversation about when that, when that recommendation came out, there are probably a bunch of people out there who stopped drinking certain diet sodas, right. And that actually created a natural experiment where all of a sudden people kind of in a randomly timed fashion might have switched to whatever, sodas containing stevia or something because they read that headline. And that actually creates an opportunity for us to study the effects of aspartame maybe a couple of years down the road. Well, I hope we're able to study that because it's fascinating, as is all the work that you're doing. The name of the book is Random Acts of Medicine. You can get it at our special bookshop at factuallypod.com slash books. And

where can people find you on the internet? Well, you just Google it, but we also have a sub stack. It's called Random Acts of Medicine, where we talk about all the same types of topics in the book and new ideas that we have, like whether or not cicadas lead people to lose sleep. What? They do, because I grew up with them, and they absolutely do. They do, but they don't. Case closed, they do. We got to end the interview right there. Papu and Chris, thank you so much for coming on the show. Thank you. Thanks for having us, Adam. Well, thank you once again to Chris and Bapu for coming on the show. If you want to pick up their book, you can do so at factuallypod.com slash books. If you want to support this show directly, you can do so at patreon.com slash Adam Conover.

Five bucks a month gets you every episode of this podcast ad free. Fifteen bucks a month gets your name read on this very show. Specifically, I want to thank John McAvee, Scott Kaler, Doug Arley, Sean McBeath, Samuel Aaron Foster, Quinn M. Enochs, Alferia, James Sinclair, and Jack Nelson. Thank you so much for your support. You help keep this show possible and make it free for everyone. We thank you so much for your support. You help keep this show possible and make it free for everyone. We thank you so much for your support. I want to thank my producers, Sam Roudman and Tony Wilson, everybody here at HeadGum for helping make this show happen. You can find me online at adamconover.net. All my standup tickets and tour dates are there as well. I'm on at Adam Conover, wherever you get your social media. Thank you so much for listening and we will see you next time on Factually.