If you've read Malcolm Gladwell's 'Blink', you might be familiar with this case study. I was particularly fascinated with it, so I've tried to take a look at it from a behavioral perspective, enjoy!
In 1996, Dr. Brendan Reilly arrived in Chicago to become the chairman of the Cook County Hospital's Department of Medicine. The hospital, an equally cavernous and ornate early 20th century structure, was once at the cutting edge of innovation in medicine. It was here that the world's first blood bank opened, where cobalt-beam therapy was pioneered, and where the Emergency Department attained such acclaim that it inspired the television series ER (1).
What Dr. Reilly inherited was a world apart from the Cook County Hospital of the past. As the Chicago's principle public hospital, Cook County had become a last resort for Chicagoans lacking health insurance. As a result, the hospital was routinely inundated with patients, stretching the hospital's already-slim resources to their limit. While Dr. Reilly had a myriad of problems to deal with, the Emergency Department (ED) was in need of particular attention, primarily because it was the bottleneck through which all uninsured patients had to flow through. The challenge was balancing the patients' needs with the hospital's constrained resources. Dr. Reilly faced this unenviable balancing act; he had to determine how to direct resources to the appropriate patients, a daunting proposition in an ED that receives 250,000 patients a year.
Cardiology patients were amongst the resource-intensive patients, and therefore, their management in the ED was a starting point in improving hospital resource management. The treatment protocol for cardiology patients was elaborate, lengthy, and worst of all, often indeterminate. To demonstrate this, Dr. Reilly gave 20 typical case histories to a group of doctors from varying backgrounds and asked them to make a determination on whether or not the patient was having a heart attack. There was almost no consistency in the doctors' recommendations, the same case may be sent home by one doctor and be taken into intensive care by another. The doctors thought they were making informed decisions, but in reality they were making educated guesses. In the actual ED, this uncertainty left doctors vulnerable to Action Bias. Action Bias is our tendency to favor action over inaction, even when there is no justification for taking action. In the ED, doctors typically responded to uncertain heart-attack cases by ordering more tests, or admitting the patient to the hospital. After all, if there is even a slight chance that someone may be having a heart attack, why take the risk of letting them leave the hospital? Action Bias is extremely common in medicine, not just in Cook County Hospital, and in most hospitals, it isn't necessarily a negative bias, after all, doctors can gain more information and patients have their concerns validated through excess action (2). But with the shoestring budget of Cook County Hospital, excess action meant excess dollars used inefficiently. A single bed in Cook County Hospital's cardiology unit cost roughly $2000 a night, and a typical chest pain patient would be admitted for several nights. Yet, this patient might find themselves in the cardiology unit with nothing particularly wrong with them due to the Action Bias.
In an attempt to solve this problem, Dr. Reilly reallocated hospital resources to open an intermediate coronary care unit and an observation unit. These were less-resource intensive options for chest pain patients, where they could be monitored for a period of time without occupying the volume of resources allocated to patients in the cardiology unit. While the idea behind having lower-level options for admission was well-reasoned, it didn't have the effect Dr. Reilly had hoped for. Instead, doctors began arguing about who gets into the observational unit. From a behavioral perspective, this response of the doctors' to the observational unit may have been predictable. Without knowing it, Dr. Reilly had added a new bias - Choice Overload - while not addressing the Action Bias that doctors were vulnerable to before. Choice Overload is a behavioral phenomenon that occurs when people get overwhelmed when there is a large number of options to choose from. You've probably experienced this when staring at a menu in an unfamiliar café. Similarly, the doctors of Cook Country Hospital now had double the options to choose from when working with chest-pain patients. Before, it was either the cardiology ward or send them home. Now, it was cardiology ward, intermediate coronary care unit, observational unit, or send them home. The increased number of options likely taxed the doctors' already-extended decision-making facilities, leading to even more reliance towards action bias. Without knowing, Dr. Reilly's addition of the observation unit had made doctors even less inclined to 'do nothing' by sending the patients home.
It became readily apparent that the cognitive biases of the doctors had to be minimized if Dr. Reilly was going to properly allocate resources to cardiology patients in Cook County Hospital, even if he wasn't explicitly aware of it. He accomplished this by incorporating Dr. Lee Goldman's algorithm for managing heart attack patients. In the 1970s, Dr. Goldman worked with a group of mathematicians who were interested in developing statistical rules for telling apart atoms. While he wasn't particularly interested in subparticle physics, he thought that mathematic principles may be useful in deciding whether someone had a heart attack. Dr. Goldman eventually created and refined a decision-tree for treating chest-pain in the ED. However, he couldn't get an institution to test his decision tree in a clinical context. That is, until Dr. Reilly decided to implement his algorithm in the Cook County ED. Over the course of two years doctors systematically shifted between using Goldman's algorithm and their own judgement when treating chest pain patients. When the data was analyzed, it wasn't particularly close, Goldman's decision tree was 70 percent more effective in recognizing patients that weren't having a heart attack. The decision tree was also safer, accurately identifying serious chest-pain 95 percent of the time. The decision tree removed action bias and choice overload from the doctors' decision making process, as the decision tree told them what action to take and what choice to select. Without knowing it, Dr. Reilly had taken the cognitive biases of the doctors out of the clinical decision-making equation, saving the hospital thousands of dollars a year, and most importantly, improving patient care.
Without knowing it, Dr. Reilly worked around cognitive biases to better allocate resources in Chicago's largest public hospital. Indeed, by all accounts his administration of the ED, and incorporation of the Goldman algorithm, was a pioneering success, now added to the rich history of medical innovation at Cook County Hospital. However, with the explicit application of behavioral science, its entirely possible that issues which plagued the Cook County ED could've been identified and resolved sooner.
(If this story sounds somewhat familiar, it is because Malcolm Gladwell used the same case study in his book 'Blink', though he didn't incorporate a behavioural focus in his writing).
1. https://en.wikipedia.org/wiki/John_H._Stroger_Jr._Hospital_of_Cook_County
2. Kiderman A, Ilan U, Gur I, Bdolah-Abram T, Brezis M. (2013). “Unexplained complaints in primary care: evidence of action bias”. Journal of Family Practice. 62(8), 408-413.
3. Chernev, A., Böckenholt, U., & Goodman, J. (2015). Choice overload: A conceptual review and meta-analysis. Journal of Consumer Psychology, 25(2), 333-358. https://doi.org/10.1016/j.jcps.2014.08.002
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