At that first lunch, Redelmeier mainly just watched as Sox and Amos talked. Still, he noticed some things. Amos’s pale blue eyes darted around, and he had a slight speech impediment. His English was fluent but spoken with a thick Israeli accent. “He was a little bit hypervigilant,” said Redelmeier. “He was bouncy. Energetic. He had none of the lassitude of some of the tenured faculty. He did 90 percent of the talking. Every word was worth listening to. I was surprised by how little medicine he knew, because he was already having a big effect on medical decision making.” Amos had all sorts of questions for the two doctors; most of them had to do with probing for illogic in medical behavior. After watching Hal Sox answer or try to answer Amos’s questions, Redelmeier realized that he was learning more about his superior in a single lunch than he’d gathered from the previous three years. “Amos knew exactly what questions to ask,” said Redelmeier. “There were no awkward silences.”
At the end of the lunch, Amos invited Redelmeier to visit him in his office. It didn’t take long before Amos was bouncing ideas about the human mind off Redelmeier, as he had bounced them off Hal Sox, to listen for an echo in medicine. The Samuelson bet, for instance. The Samuelson bet was named for Paul Samuelson, the economist who had cooked it up. As Amos explained it, people offered a single bet in which they have a 50-50 chance either to win $150 or lose $100 usually decline it. But if you offer those same people the chance to make the same bet one hundred times over, most of them accept the bet. Why did they make the expected value calculation—and respond to the odds being in their favor—when they were allowed to make the bet a hundred times, but not when they are offered a single bet? The answer was not entirely obvious. Yes, the more times you play a game with the odds in your favor, the less likely you are to lose; but the more times you play, the greater the total sum of money you stood to lose. Anyway, after Amos finishing explaining the paradox, “He said, ‘Okay, Redelmeier, find me the medical analogy to that!’”
For Redelmeier, medical analogies popped quickly to mind. “Whatever the general example was, I knew a bunch of instantaneous medical examples. It was just astonishing that he would shut up and listen to me.” A medical analogy of Samuelson’s bet, Redelmeier decided, could be found in the duality in the role of the physician. “The physician is meant to be the perfect agent for the patient as well as the protector of society,” he said. “Physicians deal with patients one at a time, whereas health policy makers deal with aggregates.”
But there was a conflict between the two roles. The safest treatment for any one patient, for instance, might be a course of antibiotics; but the larger society suffers when antibiotics are overprescribed and the bacteria they were meant to treat evolved into versions of themselves that were more dangerous and difficult to treat. A doctor who did his job properly really could not just consider the interests of the individual patient; he needed to consider the aggregate of patients with that illness. The issue was even bigger than one of public health policy. Doctors saw the same illness over and again. Treating patients, they weren’t merely making a single bet; they were being asked to make that same bet over and over again. Did doctors behave differently when they were offered a single gamble and when they were offered the same gamble repeatedly?
The paper subsequently written by Amos with Redelmeier* showed that, in treating individual patients, the doctors behaved differently than they did when they designed ideal treatments for groups of patients with the same symptoms. They were likely to order additional tests to avoid raising troubling issues, and less likely to ask if patients wished to donate their organs if they died. In treating individual patients, doctors often did things they would disapprove of if they were creating a public policy to treat groups of patients with the exact same illness. Doctors all agreed that, if required by law, they should report the names of patients diagnosed with a seizure disorder, diabetes, or some other condition that might lead to loss of consciousness while driving a car. In practice, they didn’t do this—which could hardly be in the interest even of the individual patient in question. “This result is not just another manifestation of the conflict between the interests of the patient and the general interests of society,” Tversky and Redelmeier wrote, in a letter to the editor of the New England Journal of Medicine. “The discrepancy between the aggregate and the individual perspectives also exists in the mind of the physician. The discrepancy seems to call for a resolution; it is odd to endorse a treatment in every case and reject it in general, or vice versa.”
The point was not that the doctor was incorrectly or inadequately treating individual patients. The point was that he could not treat his patient one way, and groups of patients suffering from precisely the same problem in another way, and be doing his best in both cases. Both could not be right. And the point was obviously troubling—at least to the doctors who flooded the New England Journal of Medicine with letters written in response to the article. “Most physicians try to maintain this facade of being rational and scientific and logical and it’s a great lie,” said Redelmeier. “A partial lie. What leads us is hopes and dreams and emotion.”
Redelmeier’s first article with Amos led to other ideas. Soon they were meeting not in Amos’s office in the afternoon but at Amos’s home late at night. Working with Amos wasn’t work. “It was pure joy,” said Redelmeier. “Pure fun.” Redelmeier knew at some deep level that he was in the presence of a person who would change his life. Many sentences popped out of Amos’s mouth that Redelmeier knew he would forever remember:
A part of good science is to see what everyone else can see but think what no one else has ever said.
The difference between being very smart and very foolish is often very small.
So many problems occur when people fail to be obedient when they are supposed to be obedient, and fail to be creative when they are supposed to be creative.
The secret to doing good research is always to be a little underemployed. You waste years by not being able to waste hours.
It is sometimes easier to make the world a better place than to prove you have made the world a better place.