Random Acts of Medicine: The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health

by Anupam B. Jena, Christopher Worsham

A groundbreaking book at the intersection of health and economics, revealing why doctors make mistakes, how we often get too much care or too little, and how unexpected--but predictable--events can profoundly affect our health. Why do kids born in the summer get diagnosed more often with ADHD ? How are marathons harmful for your health, even when you're not running? What do surgeons and salesmen have in common? Which annual event made people 30 percent more likely to contract COVID-19? As a University of Chicago-trained economist and Harvard medical school professor and doctor, Anupam Jena is uniquely equipped to answer these questions. And as a critical care doctor at Massachusetts General who researches health care policy, Christopher Worsham confronts its impact on the hospital's sickest patients. In this singular work of science and medicine, Jena and Worsham work together to reveal the hidden side of medicine, and its effect on everyone that touches the health care system. Relying on ingeniously devised natural experiments--random events that unknowingly turn us into experimental subjects--Jena and Worsham do more than offer readers colorful stories. They help us see the way our health is shaped by forces invisible to the untrained eye. Do you choose the veteran doctor or the rookie? Do you take the appointment on Monday or on Friday? Do you get the procedure now or wait a week? These questions are rife with significance; their impact can be life changing. In a style that's animated and enlightening, this book empowers you to see past the white coat and find out what really makes medicine work--and how it could work better.

Genres: Nonfiction, Medicine, Science, Medical, Health, Audiobook, Economics

Audiobook

First published July 11, 2023

Reviews

[Laura · Rating 1 out of 5]

I thought reading this might give me an insider's view on how to navigate the randomness of medicine when experiencing a chronic and pervasive illness. Wrong. So, I wasted time not money as it's a library borrow.

[Bam cooks the books · Rating 4 out of 5]

Anupam Jena, a Harvard medical school professor and doctor and an economist and Christopher Worsham, a critical care doctor at Massachusetts General, address how medicine really works and its effect on all of us is this groundbreaking book. First of all, there's chance: say having an accident, then what doctor treats you in the hospital, what treatment you are given, depending on your age, your gender, your race...even whether it's the doctor's birthday!

The authors, both doctors, rely on 'natural experiments' to answer certain questions; such as: Are children who enter kindergarten at a younger age more likely to be diagnosed with ADHD? Does the age or sex of a physician or surgeon influence successful results? Is the age of a patient a factor in what treatment they are likely to receive? Do politics affect medical care? The answers to all these and more is fascinating reading. Something to think about the next time you schedule an appointment.

I received an arc of this new book from the authors and publisher via NetGalley. Many thanks! My review is voluntary and the opinions expressed are my own.

[✨️ Jessica's Bookshelf ✨️ · Rating 4 out of 5]

Random Acts of Medicine was an interesting read. It was so informative and really gets you thinking in depth. This is a book that you'd definitely want to keep and refer back to at different times in your life or pull out to read to a friend. Having 4 boys, I know I'll skim through this book as they grow up. Random Acts of Medicine is thought provoking. I loved how this book was backed up by data and science.

I'd like to thank the publisher and Netgalley for the ARC.

[Kendra · Rating 1 out of 5]

This is Freakonomics: Medical Version. It replicates some of the problems with the Freakonomics approach, hedges its bets in presenting case studies, and is boring. The cases are cherry-picked, the data-mining is questionable on various levels, and the authors make claims based on speculation. I'm appalled that the Freakonomics effect has continued, and that people read this kind of work without fully understanding what's being studied and analyzed.

[Tyler Critchfield · Rating 4 out of 5]

Fascinating stuff. This is basically Freakonomics for the healthcare system. The authors do a great job explaining their research processes (including how created counterfactuals, how they avoided confounding variables, how they ensured they could or could not make certain conclusions, etc. It was very clear what could and couldn't be taken away from their studies, which was refreshing.

[Karen Renee · Rating 4 out of 5]

I learned so much about conducting experiments! The authors were great about explaining the details without getting too technical. They focus mostly on natural experiments and uncover some very interesting finds. Some of the explanations of the findings are assumptions but that is understandable. Those assumptions can be tested or refuted with other data in the future. I loved that where they could, they suggested ways doctors or the health care system could make improvements based on the data found.

The story telling makes this a fun read!

[Brian Pond · Rating 4 out of 5]

This is an interesting book filled with “Who’d have thought…?” information regarding healthcare and medicine gleaned mostly from one or both of the authors’ research into social phenomena via “natural experiments”, i.e. naturally occurring events where the variables are effectively randomized on their own accord, like when a large swath of children are born or when heart attacks occur in a specific region.
The authors do a great job laying out the data and findings as well as explaining their methodology without letting the details get too confusing. I have to admit though that I had a little trouble staying engaged. While this sort of healthcare trivia treasure trove is right up my alley as a medical professional, it’s an admittedly tough job making a compendium of research findings ”can’t put it down” enthralling. The writing style might contribute a little bit to this as well. There are popular science authors who are good at, say, injecting a little humor here and there to break up the sense of tedium a little. But in the same breath, I also have to say that I found a lot of the findings described in the book really interesting and thought-provoking. I found myself prattling on a bit to my wife about something I’d read (to which she nodded politely before asking me to get on with draining the pasta) and texting physician friends to ask what they thought or have experienced apropos this or that.
Overall, this book is definitely worth a read if you work in patient care and/or really enjoyed Freakonomics or the Freakonomics/Freakonomics MD podcasts.

And as always, thank you to NetGalley for the ARC 🙂🙏

[Katlyn Calia · Rating 3 out of 5]

Too much overlap with the podcast so a bit repetitive

[CatReader · Rating 4 out of 5]

In Random Acts of Medicine, Drs. Jena and Worsham (Dr. Jena being an internist and PhD economist, and Dr. Worsham being a critical care doctor) discuss their research into hidden factors that influence patient, doctor, and overall health system behavior. The other reviews compare this book to Freakonomics: A Rogue Economist Explores the Hidden Side of Everything, and I agree. As a fellow physician, I found this book interesting and honestly not that surprising, particularly with the example that involved my specialty (pathologists whose opinions on consult cases are swayed by the initial pathologist's report). My only critique is that some of the hypotheses Drs. Jena and Worsham sought to prove, while creative and logical-seeming, may fall into the "correlation does not necessarily equal causation" trap (for example, that the patients who receive operations on their surgeon's birthday have higher mortality rates than patients whose surgeons are not celebrating their birthday).

Further reading:
When We Do Harm: A Doctor Confronts Medical Error by Danielle Ofri, MD
The Checklist Manifesto: How to Get Things Right by Atul Gawande, MD (as well as his other books on the quality of healthcare)
The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age by Robert Wachter, MD (specifically about how healthcare providers interface with electronic medical records)
Rigor Mortis: How Sloppy Science Creates Worthless Cures, Crushes Hope, and Wastes Billions by Richard Harris

[Lucy Bruemmer · Rating 3 out of 5]

Lots of super interesting ideas, but this book is not really what it claims to be. The so-called chance events in this book are not really the kind of randomness I wanted to explore. But still interesting experiments and the use of natural experiments to study things that can’t be studied in controlled lab settings is worth mentioning in my book. More about bias and happenstance than randomness and chance. More human causes bureaucratic differences than truly random ones. Still, some experiments I Will think about for a long time afterwards. Important reading for doctors or other professionals where bias plays a strong role in treatment.

[Ryan · Rating 4 out of 5]

someone else said it's Freakanomics for medicine, and the book itself even references that.
That isn't a bad thing, and the book is really interesting, but if I hear 'Natural Experiment' one more time...!

[Ariyani Challapalli · Rating 4 out of 5]

Great as an audiobook! It was thought provoking with some fun stories and studies (especially loved the one about why kids with summer birthdays might be more likely to get the flu)

[River · Rating 4 out of 5]

Everything is a science experiment

[Ardon · Rating 4 out of 5]

A really cool compendium of how little things can produce significant outcomes in medicine and surgery. Jena and Worsham very elegantly present their various studies, making sure to spend a fair amount of time on their methodology, which I really liked. However, a lot of the research they share in the book is quite popularised as is, and almost every chapter has been covered on Freakonomics MD podcasts.

As a result, I’m not very sure I walked away with any brand new insights into the world of medicine. That said, there is a nice smattering of fun facts dispersed throughout the book, particularly in the footnotes, e.g. psychiatrists represent the bulk of doctors who get ticketed for extreme speeding.

If you listen to Freakonomics MD regularly, I’d give this book a pass. At most, I would recommend just reading the chapter on ADHD and the relative age effect.

[Sameera Nanayakkara · Rating 5 out of 5]

Flirting with the impossible is simply what human beings do.

Research is one of the most important tools we have for the advancement of science. We are moving in the direction of knowledge innovation and the best place to gather new knowledge in a foolproof manner is research.

“We too like to think that the decisions we make for our patients—whether to prescribe them a drug, perform surgery, order a diagnostic test—are based only on science and carefully considered data, not on simple chance. The reality, though, is that medicine can be messy, complicated, and uncertain. There are many opportunities for randomness to affect the medical care we give and receive.”

This book gives a dozen or so examples of natural experiments in medicine. This is indeed a novel concept in medicine. Previous practice in medicine was to conduct operational research where the researcher moved forward in time following an intervention.

“Randomized controlled trials—the gold standard of science, where researchers randomly assign subjects to either a treatment or a control group and then follow them into the future—are our most powerful and preferred tool for studying cause and effect. They are our best way of knowing whether an intervention really works.”

Natural research is looking back to identify patterns that shed light on knowledge that lay obscured in the past.

“Economists, epidemiologists, and social scientists sometimes talk about “natural experiments.” Natural experiments are “natural” because they occur without the influence of any manipulating hand.”

The authors talk of stuff they themselves were involved with and as a result the content sounds and feels genuine. They do not seem to self-loath or boast, which some medical books tend to do. How the chapters are divided and how they in cooperate natural experiments into their discussion is smooth and progressive so that the reader will not get bored with the precious data.

As a clinician I thoroughly enjoyed all the concepts in the book except for some part of the last chapter where they talk of how politics might influence the way we practice medicine. I doubt America’s politics in medicine has a global appeal.

Anybody with a basic understanding of health, statistics and the fundamentals of research can relate to the content and surely can enjoy the book irrespective of their involvement in medicine. The content sure was insightful and some of the biases that shape our decisions sure did shed some new light into my own thinking.

The book was so absorbing. Without any effort it carried my thoughts to my medical school days and freshened up some old but sweet memories.

“WHILE IN MEDICAL school, doctors in training are expected to absorb a daunting amount of information, encompassing all that’s known about the human body, its normal function, and its disease states. The process was often likened by our instructors to drinking water from a fire hose and having been on the business end of the spray, we can say the analogy rings true.”

My favourite chapter of the book was the one where they talk of the gender inequality and the unfair challenges faced by women doctors. As a male doctor working in Obstetrics & Gynaecology and with a teenage daughter dreaming of a future position in the same field I firsthand know and fear that these are to be true. Every day I try to be better at my job and I do believe (without bias) that I am indeed one of the best in my unit. At the same time, I know that me being a male doctor relating to women’s reproductive complaints will always leave a gap between my patients and me. I strongly believe Sri Lankan health care system needs more women Obstetricians and the males in this male dominant specialty do hinder that becoming a reality.

“One small study of obstetricians seeing pregnant patients at their prenatal visits showed that it was male obstetricians who spent more time with their patients, spent more time making sure they understood their patients, and expressed more concern for their patients. Nonetheless, pregnant patients reported higher satisfaction with women obstetricians, who, despite spending less time with their patients, were found to spend more of their visits connecting with them emotionally.

It’s quite possible that for pregnant patients, there may be something that’s important, but difficult to measure, about having a doctor who shares your gender—who, if they haven’t experienced pregnancy themselves, may be more likely to relate to your experience. Studies of gender concordance (doctors and patients being the same gender) have found that it can play a role in other aspects of medicine.”

The mental stimulation I got from this book was worth every minute I spent with it. This was indeed a medical book that was not tedious to go through. I do strongly recommend this book to anyone who is welcoming new knowledge.

But what we do know is that women physicians face a host of challenges that men do not, and yet the evidence shows that in many settings they’re getting better outcomes for their patients. This makes solving gender inequities in medicine all the more urgent.

LET US PRAY AND HOPE THIS TO BECOME A REALITY IN NEAR FUTURE.

[Ronald J. · Rating 4 out of 5]

This book is the spirit of Freakonomics, and indeed one of the authors hosts Freakonomics, M.D. podcast. MD stands for “make diagnoses,” (a line I like since House M.D.). It studies randomness in medicine that can affect the medical care we receive. The authors goal is to learn from randomness so we don’t become victims of chance. Rather than conducting random controlled trials (RCT), the supposed gold-standard of science (this is debatable), the authors rely on natural experiments. It’s creative and well thought-through, but you can decide for yourself how much weight you should give these studies. The authors want you to be skeptical, and think critically. Both are doctors, and one is also an economist. One of the first natural experiments was conducted by Dr. John Snow in 1854, studying an outbreak of cholera in London. Some people died, others didn’t, a great natural experiment. He traced it back to a specific water pump that only some folks used. Some of the more interesting conclusions from the studies recounted in this book:

• Elected leaders in government live an average of 2.7 fewer years than the runner-up. They do age faster in office.
• Kids born in October have a higher vaccination rate for influenza, since the vaccine by their annual checkup appointment. Kids born in summer have to book another appointment, since the vaccine isn’t out when they visit the doctor. The latter vaccination rate is 55%, the former 40%. Thus, kids born in summer months are more likely to be diagnosed with influenza. Nearly half of cases of influenza among the elderly may be due to interactions with young children.
• Younger kids in school are diagnosed more frequently with ADHD. But a year’s difference in Kindergarten or first grade is a big difference in maturity and behavior. Perhaps parents should “redshirt” their kindergartners—hold them back a year.
• In cities that conduct marathons, among patients hospitalized with cardiac arrests, 28.2% died within 30 days of admission, compared with only 24.9% of patients admitted on surrounding non-marathon days. Due to roads being crowded and ambulances not being able to get to hospital quickly on marathon days. As they say in emergency medicine, time is tissue.
• If a bystander performs CPR, chance of survival is 11.2%, compared with 7% when no CPR is performed.
• When physicians go on strike in various countries, mortality either stays the same or even goes down. For high risk patients, mortality also went down when cardiologists were attending national meetings (these findings really make you think). Doctors are biased for action over inaction.
• 30-day mortality rates go from 7.21% to 7.03% during the week of government inspections of hospitals (“Code J” is announced, and everyone knows the inspectors are in the building).
• Could a surgeon’s birthday be distracting enough to affect the outcome of patients they operate on? 30-day mortality was 7% on birthday compared with 5.6% on other days. The culprit seems to be distractions (text messages, dinner that night, etc.).
• Hitting certain milestones in age, such as 18, 40, 80, etc. can greatly affect care, diagnostic tests ordered, drugs prescribed, etc. It’s the left digit bias (39 vs. 40), and it’s worth being aware of!
• As doctors get older, their patients had higher mortality rates. Why do younger doctors get better outcomes? Older doctors overly confident? Or, they do things differently because they were educated at different times (authors think is more likely). Older surgeons however, have lower mortality rates as they age, unless they operate on a low volume of patients. There were no differences between male and female surgeons mortality rates.
• Organ donations increase four weeks after a major motorcycle rally, increasing by 21% (think Sturgis), and transplant recipients increase 26% (since one recipient can receive multiple organs).


The report, To Err Is Human: Building a Safer Health System, estimated that preventable medical errors lead to the deaths of between 44,000 and 98,000 patients every year in the United States. “Every system is perfectly designed to get the results it gets,” is attributed to W. Edwards Deming, but more likely originated with the inventor Arthur Jones. The authors conclude that the public health response to COVID-19 was a “successful failure,” a term borrowed from astronaut James Lovell, commander of Apollo 13. Interesting conclusion, and in hindsight one I disagree with.

Overall, this was an interesting read—it certainly makes you aware that randomness plays a role in our lives more than we might think.

[Jake · Rating 2 out of 5]

Didn't finish. Put it down pretty early and didn't pick it back up. So take only a pinch of salt.

From the bits I read, it's an eh kinda decent book. Easy to follow along with. I like that this book forces readers to acknowledge the chaotic behavior of medical treatment efficacy. But it isn't true to its title - it doesn't describe THE hidden forces in medicine. If it did, it'd be a book about the Eli Lily marketing department. It picks several case studies of curious medical outcomes and natural experiments w nuisance parameters, and then explains them. Then addresses them, often relating it to his (and the other author's) personal lives and experiences.

Reading this felt like the first few lecture slides where you get some interesting examples of what you're gonna learn and delve deeper into, but then the lecture just ends. It feels like a "We could get into that, but it's outside of the scope of this book" type of energy throughout. Which is why it was hard to connect with - It's not a "put your head down and read", but more like a walkthrough of "ohh look at that ride...now this one" without ever jumping into the ride.

Picking just a couple rides, and zoning in on all their nitty gritty details and histories, would be more thought provoking, and provide the reader greater reason to consider chaotic behavior in their own and those around them's medical lives.

It's a fine book. But we have limited time on this planet - Let's look for something better, something more visceral, more scathing and raw. This book is buttoned up like Young Sheldon.

[Jessie · Rating 3 out of 5]

This was good! The stories were random but that was the point.

I do think there was a tendency to run on a bit while discussing particular experiments/case studies. For example, discussing Tom Brady’s likelihood of football fame and success while investigating the link between child birth year and ADHD diagnosis was a bit exasperating. I’m also not entirely sure I follow or agree with the point of “adhd is overdiagnosed” in some students as opposed to under diagnosed in others, but I have minimal knowledge of development psychology and studies pertaining to it.

I will say I’m also a bit disappointed to find out from other reviews that the book is more or less regurgitated from the podcast. If for nothing more than my desire to hear about more natural experiments. But also because I usually think repetitive published material is disappointing.

Still a good read for healthcare workers or anyone else to understand how unseen, unknown, or seemingly completely random factors may impact a level of care.

[Cheryl · Rating 4 out of 5]

This was a very interesting book. It reminded me of Malcolm Gladwell’s books but with more emphasis on data and analysis. The authors address a lot of very interesting questions.

Some examples:

Why are children born during the summer more likely to be diagnosed with ADHD?

What do car salesmen and surgeons have in common?

How is the treatment of cardiology patients in a community affected when the best cardiologists leave town for a convention?

Can a local marathon affect your health even if you are not participating in the marathon?

Why are children with summer birthdays more likely to get the flu?

How do the political views of a doctor affect the treatment of their patients?

Does the treatment you receive for a medical condition differ depending on if you are treated just before or just after a decade birthday ending in zero?

Lots of food for thought here. Entertaining read.

[Derek Jenkins · Rating 3 out of 5]

I was expecting more from this book. It was interesting and while I am glad I read it, I wasn’t blown away. It makes some interesting points and highlights some natural experiments that exemplify what the field of health economics is about, but I wanted more.

Old hospitalists are worse, but old surgeons are better. August birthdays have higher rates of ADHD diagnoses then September birthdays. Marathons in cities increase daily mortality among non-runners…. Etc…

Every chapter was just another case study of what makes a nice natural experiment (able to identify some randomness in the “treatment”) and thus why the question can be answered with standard research methods.

[Fatima Sarder · Rating 3 out of 5]

The authors embarked on a study of nuanced and extremely important questions. At face value, these questions seem nitty-gritty: Does a doctor's political stance affect the care they give to their patients? How often do male surgeons refer their patients to an equally competent female surgeon? How do male gynaecologists fare against their female counterparts and which doctors do the pregnant patients prefer? How are acute heart attack patients handled during a medical seminar when most of their doctors are away?

And so on.

I'm sorry to say this will most probably appeal to economists -I think.- I found the text dry and academic. This one was not for me.

[Danielle · Rating 3 out of 5]

I would have liked this a lot more if I hadn’t listened to every episode of the Freakonomics MD podcast already. A lot of the content was repeated from the podcast so I wasn’t as drawn in as I could have been (though I loved that podcast!). So my rating is biased and would probably be higher if I had just done this book and the content was all new to me. A lot of good insights into how the medical system works.

[Christine Lepird · Rating 3 out of 5]

Loved Bapu's narration after listening to his podcast the past year. He provided some good examples of natural experiments, but the second half of the book was only relying on heart attack data, and it began to drag on. I was so excited for the chapter on the left digit bias... only to learn they tested it on heart attack data 😭. Give us some other conditions, B!

[Abby · Rating 4 out of 5]

3.5 rounded up to 4. Let me preface by saying it’s another one of those books that’s so closely niche to me. Research. Medicine. Changes topic every chapter and during chapters. It’s so good for my adhd dissociative brain and I’ll eat it up every timeeeee

[Martha · Rating 5 out of 5]

The research in this book on the “hidden side” of medicine has captured my attention to the point I just borrowed the written copy of this book so I can reread some of the stats and information that has me interested in knowing more.

Highly recommend!

[Audrey Hyrkas · Rating 4 out of 5]

It was really interesting and statistic heavy. They discuss tons of examples of natural experiments of the sociological implications of medicine. I enjoyed it from the perspective of someone who works in healthcare but it is written for everyone.

[Liza · Rating 3 out of 5]

Very interesting. Sometimes the analogies lost me and I just wanted them to get on with the information. But I did understand that they helped with what might have been complicated material.

[Josie · Rating 4 out of 5]

Audiobook #5 of 2024. Really enjoyed this book, it was very interesting to hear about all these types of natural experiments and the connections between seemingly random events and medicine.

[Chuck Lutz-Priefert · Rating 5 out of 5]

This book is perfect. Love adding to my repertoire of nerdy facts, particularly as it relates to medicine.

[Erin Zeller · Rating 3 out of 5]

Very interesting but long explanations especially if you are a medical professional who doesn’t need the whole story. Definitely thought provoking.