Dr. Kit Delgado’s eureka moment came when he was a new attending in the emergency room at Stanford University School of Medicine a decade ago.
Resident physicians were required to get attendings to sign off on controlled medications like opioid painkillers. Delgado noticed prescriptions were always for 30 pills, the ordering system’s default number of pills per script. Thirty pills is too many for most cases requiring short-term pain relief.
For Delgado, now at the Hospital of the University of Pennsylvania, it was a critical insight. He showed that when Penn’s ER default order changed to 10 pills, his colleagues prescribed fewer opioids. “From working in the ER to realizing that, is a pretty powerful approach,” he says. It’s also behavioral economics, the basis for Delgado’s groundbreaking research at the University of Pennsylvania. Using behavioral economics, he and his team are working to change the way we understand and address problems from addiction and firearm injuries to distracted driving.
Delgado’s work profile is extensive: Co-Chair, Penn Medicine Opioid Task Force; Associate Director, Center for Health Incentives and Behavioral Economics; Director, Behavioral Science & Analytics For Injury Reduction (BeSAFIR) Lab; Assistant Professor of Emergency Medicine … fellowships, associate fellowships … Attending Physician, Department of Emergency Medicine, Penn Presbyterian Medical Center.
A physician-scientist who bridges the gap between the front lines of healthcare and behavioral research, Delgado is a Generation Change Philly Fellow, a partnership with the nonprofit Keepers of the Commons highlighting the city’s innovators and changemakers.
Studying how and why people behave how they behave
So, what does picking up a dropped cell phone while you’re on a highway have in common with opioid addiction, gun violence, or Covid?
Behavioral economics studies how and why people behave the way they do. We assume people make decisions based on rational cost-benefit analysis and will act in their own self-interest. In reality, people are “predictably irrational.” “We have these certain situations of lapses of self-control that are really hard to prevent,” Delgado explains. “And it can be because there’s a certain value in the short term, [there are] rewards — not thinking about long-term benefits — there’s some emotional thing that’s overriding the rational thing to do.”
“Kit’s a genius because he’s finding the obvious thing that you never knew” says Kaufman. “And it seems really obvious once someone really smart like Kit has totally reframed it the way that you should be thinking about it.”
Behavioral economics examines emotional reactions and biases such as status quo bias, present bias, overconfidence, loss aversion, and selective perception, to name a few. It leverages psychology to overcome “decision errors.” Delgado established the Behavioral Science & Analytics For Injury Reduction (BeSAFIR) lab in 2017 to develop injury prevention interventions. (He’s proud of the acronym “because it sounds cool.”)
Take distracted driving, for example. BeSAFIR’s work used smartphones themselves as a valuable source of real-time data and intervention. Distracted driving accidents usually result from two decision errors: the desire for instant gratification and overconfidence. The lab worked with Progressive Insurance and True Motion (now called Cambridge Mobile Telematics) on a series of studies testing ways to reduce handheld phone use while driving.
Together, they enrolled volunteer customers in Progressive’s Snapshot Mobile program which uses an app to collect data on driving behaviors, including handheld phone use, to provide a personalized price on insurance based on actual driving behavior. The studies tested different ways to frame financial incentives for good driving , providing a “social comparison” between drivers in the app, where participants could see their safety performance relative to others, and for building habits to make it easier to keep hands off the phone.
What they learned is that public service campaigns and the threat of tickets are not enough to overcome a driver’s impulsivity or overconfidence — but pairing reframing rewards and discounts on car insurance with feedback and gamification can. “And so,” he says, “to look at what the most effective strategies are to get people not to use drugs or to stay off their phone while driving, it’s actually redesigning things so that it makes it easier to do without having to rely on willpower.”
The ER as a window to the community
Delgado, originally from the Washington, D.C. area, entered Princeton in 1997 knowing he wanted to do something to improve people’s lives. But his interest in biology and microbiology was quelled by a summer internship that left him unenthusiastic; he realized he didn’t want to sit in a lab all day or wait 20 years for breakthroughs. He pivoted to public policy, where his coursework included a task force on children’s mental health. “I thought, This is really cool, because we get to combine research with actually doing something,” he says.
After graduation he spent a year lobbying legislators for community mental health and substance use treatment centers in New Jersey. “I got to learn about how stuff actually gets done, and it’s not very scientific,” Delgado recalls. “It’s lining up coalitions and developing relationships. But what I missed was seeing what’s actually happening at the patient level.”
He decided he could do both by becoming a physician. It was at medical school at Columbia University that he fell in love with emergency medicine. Emergency rooms see car accidents, heart attacks — and people who can’t get an appointment for months with a doctor or don’t engage in care. They see people actively using drugs, mentally ill, unable to fill out paperwork, the uninsured, the undocumented.
“The emergency room is really the window into the community,” Delgado says. “All the people who have unmet health needs show up in the emergency department.”
In 2013, after his residency and fellowship at Stanford, Delgado came to Penn because of its reputation as a premier research university, including in emergency medicine, then a less robust field. He also liked Philly, not just for its lifestyle, but for the patients he’d see — those who needed care most and were likely the least cared for. He felt that here, he could make the biggest impact.
Trauma surgeon Elinore Kaufman works in, teaches, and researches traumatic injury at Penn’s Perelman School of Medicine. Delgado met Kaufman shortly after he arrived at Penn and describes her as a badass and his “partner in crime” in firearms injury research.
“He’s amazing,” Kaufman says of Delgado. “He’s a wonderful human, of course, but he’s a really fabulous researcher in specific ways that are unusual. He is excellent at carrying out the research and at all the things you need to keep organized and make that happen. That’s super important, but less special, I think, than the skill that he has for finding really important, relevant, interesting questions that you would think had already been addressed, but haven’t.”
In part, she says, that’s the advantage of being both a doctor and a researcher. “If you’re paying attention anytime you’re working with an individual, you’re going to become aware of the conditions that are outside of the exam room that are contributing to their illness,” Kaufman says. “Every disease condition is a lot more socially and structurally determined than we usually think, but that is nowhere more true than in trauma. We take care all the time of devastating injuries that could absolutely have been prevented.”
Delgado agrees, “In my case, it’s very synergistic,” he says. “A lot of my research interests are around helping clinicians and patients make better decisions, and I think working in the emergency department, it’s kind of like a petri dish for observing decision making all the time under a lot of stress and time pressure.”
From ER to the lab
Delgado refers to emergency rooms as “emerging markets.” They’re where the most pressing patient needs are revealed to those on the frontlines, and enable him to focus his research. “It’s the privilege of on-the-ground, in-the-trenches experience. You see it first,” he says.
Drawing on his experience with opioid prescriptions as a resident, Delgado wanted to address one controllable avenue to opioid addiction: According to a 2020 report published by the American Medical Association, “up to 5.7 million Americans may potentially become persistent opioid users annually after surgery.” BeSAFIR built an automated text messaging program for post-op patients to voluntarily self-report pain and painkiller use for three weeks following their procedure. The result: More than 60 percent of opioid tablets went unused — and usage data gets reported back to physicians at Penn for tailored, procedure-specific prescription recommendations and prompts patients to dispose of unused pills.
When it became clear that Covid was going to stretch hospitals’ capacity, the Center for Health Care Innovation at Penn Medicine designed COVID Watch, an automated text message program that contacts at-risk Covid patients isolating at home to ask about symptoms. If the patient reports a problem, a nurse contacts them within the hour. Dr. Delgado and his team demonstrated the system enabled providers to prioritize patients needing medical intervention and keep healthier patients safe at home, reducing mortality, even among high-risk, low income, and non-white patients.
“The emergency room is really the window into the community,” Delgado says. “All the people who have unmet health needs show up in the emergency department.”
Opioids and distracted driving seem intractable enough. But researching injuries from guns is notoriously more difficult here in the U.S. “Until recently, the CDC was not allowed to even fund research about firearms injury. Think about that,” says Delgado. It’s slowly getting better: In 2018, Congress allowed the CDC to fund firearms research as long as government appropriates weren’t used to “specifically advocate for gun control,” and the 2020 federal budget included the first funding for gun-related deaths and injuries research since 1996.
But, to date, sources on gun-related injuries are limited and fragmented. While gun deaths are easily tracked on death certificates, the best the CDC does on injuries is a database sampling 100 emergency departments across the country to deliver an annual estimate. A more recent non-CDC database draws from all ER visits in 40 states, allowing Kaufman and Delgado’s team to conclude that, on average, 320 people are shot each day in the U.S. Unfortunately, this data stops in 2019; Delgado believes the current number is closer to 400. Without complete, real-time data, it is difficult to say where to focus efforts, let alone what those efforts should be.
There’s also a lack of societal understanding, and, therefore, buy-in, to do this research to begin with. Most Americans don’t know, for example, that while just 1 percent of firearm deaths are accidental, nearly 40 percent of firearm injuries are unintentional, a result of a child finding and handling an unsecured weapon, for example.
“I think that’s why progress has been really slow,” Delgado says. “The media focuses on public mass shooting events, and while they’re very jarring and societal impacts are widespread, and obviously, that gets a whole lot of people motivated, they’re really only a small portion of the overall numbers.”
Knowing and doing
Ultimately, finding a solution via an academic study undertaken under perfect conditions only matters if it can be translated into real-world action. The space between identifying a solution and regulators, policymakers, and those in the field putting that solution into practice is known as the knowledge-implementation gap.
Many of our big societal problems can be addressed through low-cost interventions, making small changes to the environment, and focusing investment where the data indicates. It’s the political and social will that’s often lacking. This reality underpins much of Delgado’s work. “You know, there’s different ways that we hope to get things more broadly implemented, and my team’s approach focuses on testing things that can be broadly implemented,” he says.
“I think it’s a challenge across spheres,” says Kaufman. Philadelphia spent $155 million on anti-violence efforts in fiscal year 2022. For all the urgent violence prevention work happening in Philadelphia right now, Kaufman notes that we have very little information about whether the resources invested in the problem are working. “There are all kinds of things that people think are common sense that don’t turn out to work. And then there are all kinds of things that you haven’t thought of that suddenly make everything clear,” she says. “One of the things that I hope that we bring to the table from the academic side is keeping your eye on the outcomes that matter and measuring them consistently and measuring them in a smart way.”
At least once a week Delgado still works as an attending physician in the Penn Presbyterian ER. His experience and observations inform much of his current research: keeping people out of the ER by making it easier for doctors to care for high-risk patients and for individuals to make better decisions. Many of the solutions his research uncovers appear obvious when you see them, but are invisible until the data is collected and organized into a clear picture.
“That’s why Kit’s a genius,” Kaufman states, “because he’s finding the obvious thing that you never knew. And it seems really obvious once someone really smart like Kit has totally reframed it the way that you should be thinking about it.”
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