Q & A with Anupam B. Jena

2020 TEDMED Speaker Anupam B. Jena shares the power of creative observations in his Talk The profound difference between seeing and looking.” In response to his Talk and his segment on TED Radio Hour, TEDMED spoke with Anupam about observing the changing world during COVID-19.

TEDMED: Given the rise of COVID-19, what questions that are “hidden in plain sight” have you been most intrigued by?

Anupam B. Jena: I’ve been intrigued by a few questions. In some respects, the COVID-19 pandemic is The Great Natural Experiment. Medical procedures, including screening tests for cancer, have been deferred. Can this inform as to how necessary those tests really were by studying the impact of those delays on patient outcomes? For some procedures, like cardiac bypass surgery in patients with severe heart disease, we’ll be able to better understand in a large-scale way what the impact of several month delays are on outcomes. The list is endless. I also wonder about the impact of forcing people to stay close together for longer periods of time than they do normally. There’s already evidence of domestic strain. It may also be the case that in families that have at least one smoking member, second hand smoke exposure (especially among kids) could rise. Remember, kids normally spend their days at school not all day at home. I mentioned in my NPR TED Radio Hour episode that I thought that outcomes of individuals with alcohol dependence might worsen because of the stress of pandemic and the lack of availability of resources like AA for those who use it.

TM: How do you balance correlations and coincidences? How do you differentiate the two if the observed event is a unique instance?

ABJ: My main approach, and that of economists, is only to take seriously those correlations that arise from individuals being exposed to an event for an essentially random reason. If we want to study the impact of the malaria drug hydroxychloroquine on COVID-19 outcomes – something that’s been in the news – what you quickly see is that patients who receive the drug tend to be different, on average, than those who do not. They are often sicker. A simple comparison may falsely lead you to conclude that the drug harms people. In the end, it may, but the right approach is to find people who were otherwise similar but by chance were exposed to the group. For example, patients who happened to be hospitalized after President Trump’s advocacy of the drug may be more likely to have been prescribed it. That might serve as a natural experiment because patients hospitalized before and after that first presidential announcement obviously were unaware that announcement was going to occur.

TM: How might the current pandemic inspire creative thinking and macro-level change to the US health system?

ABJ: The current pandemic has forced a lot of people who don’t think about health care issues to now put those issues front and center in their mind. Having talked a lot to people recently who are completely removed from health care, the ideas they come up with about testing, about the impacts of social distancing on their lives, etc., are fascinating. In many instances, what they are describing are the outcomes of this huge experiment but they just aren’t thinking about it in that way.

TM: Do you consider this pandemic a natural experiment?

ABJ: Yes and No. A natural experiment has to satisfy an important criteria – the impact of the event, in this case the pandemic, has to exact its effect on people’s lives in a single way, otherwise it becomes difficult to study. For example, suppose we find that the pandemic led people to not fill prescriptions for their essential medications and we wanted to use that transient disruption to study the ‘effect’ that medicines have on health outcomes in a real world setting. It is true that the medication disruption was caused by an unforeseen event, the pandemic. But if people’s health worsens, was it because of the lack of medication use or because of the stress and other changes to life induced by the pandemic. In that example, the natural experiment assumption fails.

TM: While everyone is looking at the health care system being overloaded, what are you seeing in the world of health?

ABJ: I am struck by the resilience of health care systems and health care professionals. In my own health care system, which is not alone, the organization is taking active steps to improve housing, social distancing measures, and testing in hard hit, historically underserved areas. That doesn’t help their ‘bottom line’ and as an economist who first thinks of the non-altruistic reasons that individuals and organizations do what they do, it highlights what we can do together when we have incredibly challenging problems to solve. At the end, the pandemic will take fewer lives than heart disease and cancer. It would if we were able to dedicate this amount of effort to reducing the burden of those diseases, the impacts to society would be large.

TM: Where do you anticipate seeing the most unexpected change in creative thinking?

ABJ: There has been a huge increase in interdisciplinary thinking around the pandemic. For example, economists are weighing in on issues that epidemiologists have studied for decades, in some cases offering new insights and in other cases re-discovering the wheel. A tangible area of interdisciplinary work is estimating the effectiveness of policies to stem the tide of the pandemic. At their core, these are statistical or econometric issues – what was the observed effect of a policy on disease spread, using state-to-state or county-to-county variation in the timing of policy implementation – not issues that are best addressed by mathematical epidemiologic models.

Four Thought Leaders Shaping the Future of Health Care

By guest contributor and TEDMED 2015 speaker Thomas H. Lee, MD

For years now, experts have said health care should move “from volume to value,” and the good news is that it’s finally happening. Even within the past few months, the pace of change has accelerated. More and more payments to providers are tied to quality and efficiency, and increasing amounts of data on their performance are being published online.
Empathy suffering health careIn my TEDMED talk, I spoke about how the reduction of suffering was becoming the focus for health care. Today, many health care providers are starting to compete on how well they meet patients’ needs.
As this competition increases, health care providers can look to four key thought leaders whose work influences my own every day: Michael Porter, Leemore Dafny, Ronald Burt, and Nicholas Christakis. Individually and collectively, their contributions provide clarity on what we need to do in health care, why we need to do it, and how to get it done.
Over the last few decades, Michael Porter of Harvard Business School has defined the meaning of strategy for business in general. His work on health care clarifies why an overarching strategic goal is important for every organization, and why that goal should be to create value for patients. He and his colleagues have described how multidisciplinary teams should look, and what kind of information and incentives those teams need to drive improvement.
If Porter’s work describes the “recipe” for what we need to serve in health care, Leemore Dafny helps us understand the heat that is necessary to start things cooking. She is the Harvard economist who has studied payer and provider consolidation and shown how it leads to weaker competition and higher prices. I have long been leery of thinking about health care as a marketplace, concerned about unintended consequences if patients have to act like consumers and make tradeoffs in quality and price. But Dafny and her colleagues are persuasive when they argue that competition in a value-driven market has greater potential to drive improvements in quality and efficiency than the alternatives – and that providers like me should embrace competition and learn to trust market forces.
Porter and Dafny’s work tell us what we have to do, and why we have to do it. But how do we get that work done? Part of the answer is to strive for the creation of social capital.
For the last several years, I have given a book to virtually every new close colleague: Brokerage and Closure: An Introduction to Social Capital by University of Chicago sociologist Ronald Burt. We all know about financial capital (the funds that enable organizations to do things they otherwise could not do), and about human capital (hiring good people). Social capital is about how those people work together. If they are reliable in their coordination, the organization can make leaps in quality and efficiency. Burt provides a clear and useful structure for learning (increasing variation in what is done by brokering ideas) and then converging on best practices (closure).
Then there is the challenge of how do we make collaboration and compassion the norm in health care. Financial incentives cannot get the job done. That is why I think so often of Nicholas Christakis, the Yale social network scientist who has shown how epidemics of values and emotions can spread from person to person. While the work of Porter, Dafny, and Burt define the big picture, Christakis characterizes the nature of the work that needs to be done on the ground.
There are, of course, many more colleagues whose work I respect and learn from, but these four constitute a “package” that I think can accelerate the transition to a new and better health care system.
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TEDMED Speaker Tom Lee, on addressing patient suffering in health careIn his TEDMED talk, quality care pioneer and Chief Medical Officer of Press Ganey, Tom Lee reveals his passionate quest to define empathy as a business asset and patient suffering as an outcome.