Hello. I’m Kelly Thomas. I am the director of scientific content at TEDMED, and I am joined today by Baku Jenna. Babu, please, share a bit about your background and the exciting things you’ve been working on since we last saw you for your TEDMED talk a few years ago.

Yes. It’s been a long time. My name is Babu Jena. I’m an economist and a physician.

I’m a professor at Harvard Medical School, and I see patients at Massachusetts General Hospital.

And I host a podcast called Freakonomics MD and wrote a book with Christopher Worsham called Random Acts of Medicine.

I’d love to dive into some of your natural experiments. And one of the studies that I found intriguing was you look at analyzing left digit bias and how it applies to car salesmen and cardiac surgeons.

How is it that this one little number can have such a large impact on the care we receive?

Yeah. Also, a few things that you probably would not put together in in your mind. The way I describe it is if you go to the grocery store and you see a bag of Doritos and it’s, let’s say, a dollar ninety nine, you might wonder why is it a dollar ninety nine instead of two dollars? And the reason why is because the mind tends to focus on the leftmost digit in a string of numbers.

So the mind focuses on the one instead of the two. And because one is less than two, that one dollar ninety nine item feels cheaper than it really is. It is technically cheaper. It’s a penny cheaper, but it feels more than a penny cheaper, which is why stores for many, many, many years have priced products in this sort of way.

Now what does that have to do with health care? Oh, you would think probably nothing. But it turns out there’s a few examples now where people have shown that this bias, what we call left digit bias, also affects the decisions that physicians make. And the particular example that we talk about in the book and that we research was looking at people who have a heart attack and who come to the hospital just before their eightieth birthday or just after their eightieth birthday.

So someone who’s seventy nine years old and fifty one weeks who happens to come to the emergency department with chest pain just before their eightieth birthday, they are more likely to be offered a cardiac bypass surgery than someone who, by chance, happens to have a heart attack a week after their eightieth birthday. And the reason why is because the older you are, the less likely doctors are to want to intervene upon you. So they see these two different types of patients. The first one is seventy nine years old and fifty one weeks.

And the doctor says, okay, this person looks like they’re in their quote unquote seventies. And they see the second type of patient who’s eighty years old and one week, alright, this patient is in their quote unquote eighties. And the older patients are, the less likely doctors are to want to intervene.

And it to me, it was surprising because I wouldn’t think that a grocery store pricing tactic or something that might work on a used car sales lot would apply to such a high stakes decision like cardiac bypass surgery. But it kinda speaks to how our brain is is wired.

Mhmm.

Are there other ways that these kind of discontinuities impact physicians?

Yeah. So this is a particular one, left digit bias. We’ve done some other work which is sort of similar thematically, but it doesn’t focus on the left digit, but it focuses on this sort of categorization that people do of of things. So for example, when you turn eighteen, you become an adult in the eyes of society.

But is there really a difference between someone who’s seventeen years old and fifty one weeks versus eighteen years old? In one week, are they any more mature right when they turn eighteen? Is the physiology of their body any different? Is the way that they think any different?

Probably not. And yet, from from society’s perspective, we view that individual as now being a, quote, unquote, adult and no longer a, quote, unquote, child. Now what does that have to do with medicine? Well, we have seen, Christopher Worsham, who was a co author of mine of of our book, Chris and I and and a couple of others did this study where we looked at what happens to kids really who are seen in the emergency department right around their eighteenth birthday for a condition that might be painful like a a fracture or something like that.

And what we show is that when someone turns eighteen, they are more likely to be prescribed an opioid in the emergency department than someone who happened to go to the ED when they are seventeen years old and let’s say eleven months. So two groups of people who are basically identical, they’re only separated by this feature that we call adult versus childhood. And as a result, when a doctor sees a quote unquote adult, they might feel more comfortable prescribing an opioid to that person.

And the second thing is that if you look at these people longer term, they do have more problems with longer term opioid use really because of this chance phenomenon that they happen to show up in the ED when they were a quote unquote adult versus a quote, unquote kid.

Is there a way to change the system so that it can help doctors kind of make choices that consider this left digit bias and reduce the gap that you see in the prescription?

I think that, you know, probably the most important thing is to make people aware of it. Right? I mean, biases happen in part because they’re operating in the background of our mind in a very autonomous way, and we’re not aware that it’s happening. So the first thing is to make people aware that this sort of thing does exist.

But even beyond that, I think even if you make people aware, they they probably will still make this error maybe less often, but still, substantively so. And one idea might be in medicine, for example, we use electronic health records and computerized order entry. So if you’re in the emergency department and you’re about to prescribe a medication in the computer system, there could be alert that says, you know, you are about to prescribe this person an opioid and and the system would know that this person just turned eighteen.

Are you aware of this piece of information?

And so then doctors could say, alright. Oh, wow. I I wasn’t aware of that. Maybe this person does or does not need to be prescribed an opioid. Same thing could be true for cardiac bypass surgery. When someone is making a decision to pursue that treatment path, they could be made aware of this sort of bias, the left digit bias in that case. And all that stuff can happen in the background because now we have these electronic order systems, computerized order entry, and so that allows us to be able to sort of enter into the mind of the physician at the time that they’re making a decision.

Mhmm.

Absolutely. And that kind of helps someone take a little pause for a moment and just think about it one more time. I’m so glad that you’re exploring these types of experiments and and, teaching everyone else to think about them as well. And I really appreciate you sitting down with TEDMED today, and we hope to speak to you again.

Thank you.