A Randomized Trial of Niceness in the ER and Other Stories

One of the great joys of a life in academic medicine is the opportunity to work with lots of very smart people. But one regret is that there is something about academia that tends to homogenize – faculty learn that, when it comes to competing for the next grant or promotion, it pays to be clever but relatively conventional. Sure, innovation is the coin of the realm, but out-of-the-box, quirky thinkers generally need not apply.

With one exception. I’d like to introduce you to the mind of Don Redelmeier, Professor of Medicine at the University of Toronto, and, to me, the most creative researcher in healthcare, perhaps all of science, today.

I came to know Don when we were both Robert Wood Johnson Clinical Scholars at Stanford University in the late 1980s, and we became fast friends. His eccentricities were obvious even then. Take, for example, Don’s algorithm for analyzing his dates, using a complex formula that assigned point values for intelligence, looks, humor, and tennis playing ability (bonus points). It wasn’t very romantic, but it was hilarious (we all looked forward to Monday recaps of the weekend’s events) and generally accurate. Or the time Don accepted my invite to come to UCSF as visiting professor, about 5 years ago. My colleagues still marvel over the scene at a fancy downtown Asian restaurant, where our group decided to order family style. After listening to a few minutes of good-natured negotiation over who would be ordering what, Don led us through a formal decision-analysis to optimize the chances that each of us would be satisfied with the results of our orders. (We each used a secret ballot to choose our top 3 items; Don’s algorithm was designed to maximize the chances that individuals would receive one of their top selections while minimizing the possibility that the vegetarian would get the tenderloin.)

While these examples give you a sense of Don’s one-of-a-kind personality, it is his body of work I’d like to focus on, work that highlights his brilliance, creativity, and impeccable training in decision-analysis and cognitive psychology (he studied under the legendary Amos Tversky at Stanford). Here are some Redelmeier classics – you’ll probably recall many of them, either because you read the original article or saw it discussed in the popular press or on Oprah:

1)    Do Academy Award Winners Live Longer Than Runner-ups? In this Annals of Internal Medicine study, Don, noting that most research examining the correlation between social status and health focused on society’s lower rungs, decided to use the Academy Awards to examine the relationship among the glitterati. In a study whose genius was Don’s decision to isolate the impact of success by largely controlling for income and profession, he found that Academy Award winners live an average of 4 years longer than runner-ups, an astounding survival advantage. In the article, Don attempted to explain the remarkable finding:

Movie stars are often subjected to a personal scrutiny that far exceeds their dramatic achievements. They often need to preserve their image by continually avoiding disgraceful behaviors and maintaining exemplary conduct… They have personal chefs, trainers, nannies, or other staff that make it easy to follow the ideals of lifestyle. Furthermore, a movie star may have more control, ability to avoid stress, self-efficacy, resources, admirers, motivation, and access to special privileges than others in society. The full mechanism of the apparent survival benefit among successful actors and actresses is not known. Untangling the explanations is further complicated because some stars also engage in superstitious and deleterious behaviors.

2)    Death Rates of Medical School Class Presidents: Sticking with the theme of longevity and success but finding an opposite result, Don compared medical school class presidents to a control group comprised of those who appeared alphabetically before or after the president in the medical school class photo (again note the cleverness of Don’s choice of control group, a defining characteristic of his work). While the presidents made more societal and professional contributions (as judged byWho’s Who listings and alumni notices), they died about 2.5 years earlier. “We suggest that the type of medical professional who sacrifices themselves for this type of professional prestige may also be the type who fails to look after their health or is otherwise prone to early mortality,” he wrote.

3)    The Individual-Aggregate Discrepancy: In a NEJM study conducted when we were fellows, Don demonstrated that simply framing a decision as being about an individual patient (you are considering doing X for your patient) vs. about a population of patients (you are considering doing X for a group of patients) leads physicians to favor more expensive decisions in the individual frame, a key insight for health policy.

4)    A Randomized Trial of Niceness in the Emergency Department: EDs are extraordinary social and medical laboratories. Don noticed that homeless patients were often treated poorly in EDs, partly because docs and nurses worried that patients would keep returning for medically inappropriate reasons if they were treated kindly. To discover the truth, Don randomized patients at a Toronto hospital to their usual (generally unsatisfying) care, or to receive additional niceness: student volunteers “explained their role, established rapport, and spent time listening attentively, typically starting by sharing opinions on common experiences (eg, television).” The volunteers sometimes brought food to the patients (average cost $1.75). Clinical care was the same in the two groups. The findings in this Lancetstudy: not only were the homeless patients randomized to “compassionate care” more satisfied, but they were also one-third less likely to return to the ED, probably because they felt their needs were met.

5)    Driving Fatalities on US Presidential Election Days: About 25 more people die in auto crashes on US election days than might be expected to die on an average day, Don found in this JAMA paper. His explanations highlight the obvious possiblilties (increased traffic or rushed drivers) and the less obvious: “distraction (driver inattention), rerouting (unfamiliar pathways), enforcement (decreased police presence), and demographics (mobilizing unfit drivers).”

6)    Mortality Among Patients Admitted to Hospital on Weekends vs. Weekdays: In this NEJM paper, Don and his disciple Chaim Bell found that seriously ill patients admitted to hospitals on weekends were significantly more likely to die. This study catalyzed important discussions about weekend staffing patterns in hospitals around the world.

7)    Why the Other Lane Seems to Move Faster: “The temptation to change lanes on a motorway may be prompted by an illusion,” begins Don’s article in Nature. By using computer traffic simulations, and having driving students review videos of drivers’ perspective scenes in moving traffic, Don and colleague Robert Tibshirani found that the other lane appears to be moving faster but usually isn’t. The perception, they wrote, “occurs because vehicles spread out when moving quickly and pack together when moving slowly,” causing drivers to notice when they are being overtaken far more than when they are passing other cars themselves.

8)    On the Belief that Arthritis Pain is Related to the Weather: Like the “Other Lane” paper, another example of perception trumping reality. After following 18 arthritis patients for a year, Don found no relationship between weather and pain. It’s just that people tend to notice the weather more when their joints are aching, and that humans like to find patterns and explanations (particularly for unpleasant phenomena), even when none exist.

9)    The Risk of Talking on Cell Phones While Driving: This is a now-familiar tale, but Don’s 1997 NEJM paper was the first to prove the association (he found a four-fold increased risk). This is also the only time I can recall a medical paper’s methodology (Don correlated cell phone billing records with crash reports, using as a control group the same driver’s cell phone bill from the week before the crash) being called out for special praise in a Page 1 New York Times articleWrote the Times’ Gina Kolata:

The study pleased some statisticians because, they said, it so cleverly answered a seemingly unanswerable question. That is, how to determine what looks like truth is true: driving while talking on a cellular phone is dangerous. Dr. Bradley Efron, a professor of statistics at Stanford University… thought at first that the deciding whether cellular phones are a hazard to drivers ”looked like an impossible thing to prove, even it was true.” The problems were several: any study would have to determine whether phones were being used at or near the time of car accidents, and whether the confluence of phone use and car crashes was more than coincidence. Dr. Efron said he changed his mind when he read the paper. ”It was pretty ingenious,” he said. ”When I saw the evidence, I had to admit it was pretty darn good.”

Finally, I’ll add one more article to my Top Ten list of Redelmeier classics. In this month’s issue of the Canadian Medical Association Journal, Don examined University of Toronto medical school admission interview reports from 2004-2009. After correlating the interview scores with each day’s weather archives, he determined that candidates who interviewed on rainy or snowy days received interviewer ratings that were significantly lower than those of candidates who were lucky enough to visit on a sunny day, a difference that could not be explained by demographic factors or by grades and test scores. In fact, the impact of the bad weather on applicants was the equivalent of a 10% lower score on the MCAT, easily enough to influence acceptance and rejection in many cases. About 25 years ago, I visited Yosemite National Park with my oldest friend, Larry Levy. We were at Tunnel View, the jaw-dropping overlook made famous by Ansel Adams. The assembled crowd was oohing and ahhing, snapping photos. Larry, another quirky and unusual guy (perhaps I gravitate to such types), said, “Wouldn’t it be great if somebody put together a book of photos that looked in the other direction.” In other words, go to the world’s most famous vistas – the Grand Canyon, the Statue of Liberty, Notre Dame Cathedral – and photograph what you’d see if you turned around. That thought comes to mind when I review Don’s research – he is looking at healthcare, and life, through a mental lens pointed in the opposite direction of everybody else’s. When I’m mentoring young researchers about innovation and creativity, I have them review Don’s body of work for inspiration. I don’t exactly know how one trains them to do what Don does, but we’d undoubtedly understand our world a lot better if we could.

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”