Random Acts of Medicine

June 1, 2023
Jena and Worsham, doctors who work at Harvard Medical School, open this unusual inquiry by considering serendipity, such as when a couple meets in an airport after a blizzard cancels their flights, or a retiree collapses from a heart attack and dies because road closures delay the ambulance. Jena, an economist who hosts the Freakonomics, MD podcast, and Worsham, his former student, are fascinated by so-called natural experiments, used when randomized, controlled studies aren't possible. As an example, they wonder if heads of government, who seem, like Barack Obama, to go gray rapidly in office, really age faster and die earlier than they would have had they not been the top dogs. Yes, they do. They observe that with COVID-19 vaccinations, ""sticks,"" like job mandates to get a shot, seem to motivate people more than ""carrots,"" like special lottery drawings. Doctors wondered if organ donations spiked during major motorcycle rallies; they did. As Worsham notes, Jena taught him to think creatively about research and to practice and hone this skill and to share it, which they both do here, admirably and intriguingly.

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Starred review from May 15, 2023
An ingenious exploration of "natural experiments" that influence medical care. Physicians and researchers at Harvard, Jena and Worsham open with a teaser claiming that children born in summer suffer influenza more often than those born in autumn. Readers may be confused until they reveal the results of millions of insurance claims. Parents tend to follow pediatric guidelines for yearly checkups, and they recommend using a child's birthday as a reminder. Flu shots become available in the fall, so some children are immunized during their yearly checkup. The vaccine isn't available during the summer so those parents are told to make a fall appointment; many don't follow up, so their children get sick. The text is full of such intriguing and surprising facts and trends. When cardiologists go on vacation, their patients' death rates drop significantly, likely because the substitutes are less aggressive in treatments. Most doctors prefer action over inaction, and so do those they care for. Sick patients want their doctor to "do something." Hearing that waiting is the best course is often greeted as bad news. In a parallel study, patients with metastatic lung cancer were either given standard cancer treatment or simple palliative care. The palliative care patients were more comfortable--and also lived longer. Few readers will ignore the long section on who makes the best doctor. Backed by millions of records, mostly of hospital discharges and deaths, the authors determine that graduating from the best medical school makes no difference. Experience matters for surgeons, who improve with age, but not for internists. Women doctors perform as well as men in most specialties and a little better as internists, and doctors trained internationally are just as effective. Pandemic politics provides a concluding shock. Republicans and Democrats died in equal numbers early in the pandemic, and with the vaccine came a highly politicized anti-vaccine movement, after which excess deaths among registered Republicans jumped to over 150% higher than those of Democrats. A well-documented, unnerving, fascinating study for anyone adrift in the American health care system.

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