Thinking Beyond First Order Effects

The pandemic teaches many lessons. Complexity of a single decision is surely one.

Heart disease statistics can be mundane. But not this one. This one makes me Stop and Think.

Off the main stage, at the American Heart Association meeting last month, Dr. Rebecca Woodruff, a scientist from CDC, presented a study that found a spike in deaths due to heart disease in 2020. Journalist Marlene Busko covered the abstract.

Two factors make this observation notable. One is that that there had been a steady decline in yearly heart disease deaths in the previous decade. The spike in 2020 essentially wiped out the previous five years of progress. Another factor was that the uptick in deaths was greater in non-Hispanic Black people and younger adults.

Woodruff speculated about causal factors:

“Non-Hispanic Black patients and younger adults may have had more exposure to COVID-19 at their workplace, less financial stability, greater stress, and more limited access to healthcare.”

That’s all true. The question for this column is what we can learn from these observations.

It’s a story about the complexity of healthcare interventions. Things like second and third order effects from one decision.

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When I was a young doctor, I didn’t appreciate that one decision had so many possible downstream effects.

Two examples:

If you order a coronary calcium scan (I wouldn’t, but doctors do), the first order effect is the presence or absence of calcium in the coronary arteries.

But there are second order effects. Let’s say a scan detects a hunk of calcium in the left anterior descending coronary. You’ve now created a patient who was previously a well person. A Google search of LAD disease is likely to induce anxiety. This person may limit vigorous exercise—a second order effect that is harmful in the long run.

Now think about the societal effects of coronary artery calcium scans. When you (or your hospital or professional society) promote these scans, over time, you may create a societal or cultural feeling of healthism.

My friend Saurabh Jha simplified healthism:

Healthism is not the promotion of health but the medicalization of everyday life in the pursuit of perfect health.

Said another way: you should get this test, or you are an irresponsible person.

Another example:

The push to do early ablation for atrial fibrillation. Some recent studies have suggested that early is better. These are imperfect studies. I ablate AF, but I am not convinced that early AF ablation is always a great idea.

When you decide to ablate AF, the first order effects are simple: did you electrically isolate the pulmonary veins and did you avoid a complication?

But there are second and third order effects. A second order effect might be the creation of the false idea that AF is a focal disease--like supra-ventricular tachycardia (SVT)—that is amenable to a procedure rather than lifestyle modification. This person may now tell his friends or post on an internet forum—”just get your AF fixed by ablation.”

The third order effect comes when enough of these decisions create an erroneous norm in society that AF can be treated with a catheter rather than healthy living.

The moral hazard is obvious. Wrong think about AF is highly profitable for doctors, hospitals, and the makers of ablation catheters.

I hope you are getting the idea. Seemingly simple decisions--say, ordering a stress test for low-risk chest pain, or a colonoscopy at age 50, or basic lab tests during a yearly checkup—all come with layers of complexity.

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Now let’s go back to 2020 and the decision to shut down the world.

SARS-CoV-2 was bad. I saw it in our ICUs. I don’t mean to minimize it. But now that the pneumonias have nearly disappeared, it’s time to learn.

The first order effect of shutting down the world was to minimize the spread of one pathogen.

The study that found a spike in deaths from heart disease in 2020 shows a second order effect. An especially bad one because the way in which our lockdowns crushed the young and those with less means.

The irony is that the AHA meeting included many sessions on reducing disparities in health outcomes.

Yet, voices in 2020 that attempted to warn about the complexities of these decisions, and the likelihood that it would increase disparities, were…let’s just say…not welcomed.

And more heart disease deaths were only one of the second order effects of the decision to lockdown. A crisis in childhood mental illness, learning losses in kids, inhumane care of the dying and reduced immunity to other serious respiratory viruses are four others. This list is long.

There were also third order effects on society and culture: big-picture things, such as the spread of misunderstanding of science and a major loss of trust in the healthcare profession.

The weird thing is that these third order effects are likely worse in the US. During my visits this year, I did not get the sense that Denmark, Italy, or Poland suffered the same societal effects as we did in the US. I wonder about Sweden.

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The concluding lesson is simple: healthcare and healthcare decisions are complex. It’s wise to think beyond first order effects. Embrace nuance and always allow debate.

Surely this is one of the main lessons from the pandemic.