Why it's so hard to make healthy decisions | David Asch

406,485 views ・ 2019-12-19

TED


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00:12
It's April of 2007,
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and Jon Corzine, the Governor of New Jersey,
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is in this horrific car accident.
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He's in the right front passenger seat of this SUV
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when it crashes on the Garden State Parkway.
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He's transported to a New Jersey trauma center
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with multiple broken bones and multiple lacerations.
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He needs immediate surgery, seven units of blood,
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a mechanical ventilator to help him breathe
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and several more operations along the way.
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It's amazing he survived.
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But perhaps even more amazing,
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he was not wearing a seat belt.
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And, in fact, he never wore a seat belt,
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and the New Jersey state troopers who used to drive Governor Corzine around
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used to beg him to wear a seat belt,
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but he didn't do it.
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Now, before Corzine was Governor of New Jersey,
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he was the US Senator from New Jersey,
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and before that, he was the CEO of Goldman Sachs,
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responsible for taking Goldman Sachs public,
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making hundreds of millions of dollars.
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Now, no matter what you think of Jon Corzine politically
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or how he made his money,
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nobody would say that he was stupid.
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But there he was,
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an unrestrained passenger in a car accident,
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at a time when every American knows that seat belts save lives.
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This single story reflects a fundamental weakness
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in our approach to improving health behavior.
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Nearly everything we tell doctors and everything we tell patients
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is based on the idea that we behave rationally.
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If you give me information, I will process that information in my head,
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and my behavior will change as a result.
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Do you think Jon Corzine didn't know that seat belts save lives?
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Do you think he, like, just didn't get the memo?
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(Laughter)
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Jon Corzine did not have a knowledge deficit,
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he had a behavior deficit.
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It's not that he didn't know better.
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He knew better.
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It's that he didn't do better.
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Instead, I think the mind is a high-resistance pathway.
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Changing someone's mind with information is hard enough.
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Changing their behavior with information
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is harder still.
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The only way we're going to make substantial improvements
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in health and health care
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is to make substantial improvements in the behavior of health and health care.
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If you hit my patellar tendon with a reflex hammer,
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my leg is going to jerk forward,
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and it's going to jerk forward a lot faster and a lot more predictably
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than if I had to think about it myself.
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It's a reflex.
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We need to look for the equivalent behavioral reflexes
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and hitch our health care wagon to those.
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Turns out, though,
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that most conventional approaches to human motivation
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are based on the idea of education.
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We assume that if people don't behave as they should,
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it's because they didn't know any better.
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"If only people knew that smoking was dangerous, they wouldn't smoke."
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Or, we think about economics.
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The assumption there is that we're all constantly calculating
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the costs and benefits of every one of our actions
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and optimizing that to make the perfectly right, rational decision.
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If that were true, then all we need to do
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is to find the perfect payment system for doctors
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or the perfect co-payments and deductibles for patients,
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and everything would work out.
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A better approach lies in behavioral economics.
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Behavioral economists recognize that we are irrational.
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Our decisions are based on emotion,
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or they're sensitive to framing or to social context.
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We don't always do what's in our own long-term best interests.
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But the key contribution to behavioral economics
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is not in recognizing that we are irrational;
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it's recognizing that we are irrational in highly predictable ways.
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In fact, it's the predictability of our psychological foibles
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that allows us to design strategies to overcome them.
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Forewarned is forearmed.
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In fact, behavioral economists often use
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precisely the same behavioral reflexes that get us into trouble
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and turn them around to help us,
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rather than to hurt us.
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We see irrationality play out in something called "present bias,"
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where the outcomes in front of us are much more motivating
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than even more important outcomes far in the future.
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If I'm on a diet -- and I'm always on a diet --
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(Laughter)
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and someone offers me a luscious-looking piece of chocolate cake,
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I know I should not eat that chocolate cake.
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That chocolate cake will land on that part of my body -- permanently --
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where that kind of food naturally settles.
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But the chocolate cake looks so good and delicious,
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and it's right in front of me,
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and the diet can wait 'til tomorrow.
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I used to love the comedian Steven Wright.
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He would have these Zen-like quips.
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My favorite one was this:
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"Hard work pays off in the future,
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but laziness pays off right now."
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(Laughter)
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And patients also have present bias.
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If you have high blood pressure,
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even if you would desperately like to avoid a stroke,
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and you know that taking your antihypertensive medications
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is one of the best ways to reduce that risk,
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the stroke you avoid is far in the future and taking medications is right now.
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Almost half of the patients who are prescribed high blood pressure pills
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stop taking them within a year.
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Think of how many lives we could save
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if we could solve just that one problem.
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We also tend to overestimate the value of small probabilities.
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This actually explains why state lotteries are so popular,
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even though they return pennies on the dollar.
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Now, some of you may buy lottery tickets --
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it's fun, there's the chance you might strike it rich ...
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But let's face it:
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this would be a horrible way to invest your retirement savings.
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I once saw a bumper sticker -- I am not making this up -- that said,
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"State lotteries are a special tax on people who can't do math."
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(Laughter)
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It's not that we can't do the math,
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it's that we can't feel the math.
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And we also pay much too much attention to regret.
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We all hate the feeling of missing out.
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So, actually, there was this recent lottery,
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a mega-jackpot lottery,
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that had a huge payoff, something like over a billion dollars.
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And everyone in my office is pooling money to buy lottery tickets,
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and I'm not having any of this.
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There I am, like, swaggering around the office,
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"Lotteries are a special tax on people who can't do math."
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(Laughter)
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And then it hits me:
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uh oh.
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What if they win?
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(Laughter)
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I'm the only one who shows up at work the next day.
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(Laughter)
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Now, it's not that I didn't want my colleagues to win.
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I just didn't want them to win without me.
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Now, it would have been easier if I had just taken my 20-dollar bill
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and put it into the office shredder,
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and the results would have been the same.
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Even though I knew I shouldn't participate,
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I handed over my $20 bill,
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and I never saw it again.
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(Laughter)
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We've done a bunch of experiments with patients
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in which we give them these electronic pill bottles
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so we can tell whether they're taking their medication or not.
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And we reward them with a lottery.
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They get prizes.
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But they only get prizes
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if they had taken their medication the day before.
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If not, they get a message that says something like,
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"You would have won a hundred dollars,
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but you didn't take your medicine yesterday, so you don't get it."
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Well, it turns out, patients hate that.
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They hate the sense of missing out,
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and because they can anticipate that feeling of regret
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and they'd like to avoid it,
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they're much more likely to take their medications.
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Harnessing that sense of hating regret works.
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And it leads to the more general point,
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which is: once you recognize how people are irrational,
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you're in a much better position to help them.
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Now, this kind of irrationality works out even in men's restrooms.
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So, for those of you who don't frequent urinals,
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let me break this down for you.
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(Laughter)
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There is pee all over the floor.
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(Laughter)
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And it turns out that you can solve this problem
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by etching the image of a fly in the back of the urinal.
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(Laughter) (Applause)
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And it makes perfect sense.
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(Laughter)
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If I see a fly,
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I'm gonna get that fly.
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(Laughter)
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That fly is going down.
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(Laughter)
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Now, this naturally begs the question that if men can aim,
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why were they peeing on the floor in the first place?
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In fact, if they were going to pee on the floor,
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why pee in front of the urinal?
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You could pee anywhere.
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(Laughter)
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And the same thing works in health care.
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We had a problem in our hospital
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in which the physicians were prescribing brand-name drugs
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when a generic drug was available.
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Each one of the lines on this graph represents a different drug.
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And they're listed according to how often they're prescribed as generic medications.
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Those are the top are prescribed as generics 100 percent of the time.
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Those down at the bottom are prescribed as generics
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less than 20 percent of the time.
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And we'd have meetings with clinicians and all sorts of education sessions,
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and nothing worked --
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all the lines are pretty much horizontal.
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Until, someone installed a little piece of software
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in the electronic health record
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that defaulted the prescriptions to generic medications
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instead of the brand-name drugs.
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Now, it doesn't take a statistician
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to see that this problem was solved overnight,
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and it has stayed solved ever since.
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In fact, in the two and a half years since this program started,
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our hospital has saved 32 million dollars.
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Let me say that again: 32 million dollars.
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And all we did was make it easier
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for the doctors to do what they fundamentally wanted to do all along.
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It also works to play into people's notions of loss.
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We did this with a contest to help people walk more.
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We wanted everyone to walk at least 7,000 steps,
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and we measured their step count
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with the accelerometer on their cell phone.
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Group A, the control group, just got told whether they had walked
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7,000 steps or not.
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Group B got a financial incentive.
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We gave them $1.40 for every day they walked 7,000 steps.
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Group C got the same financial incentive,
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but it was framed as a loss rather than a gain:
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$1.40 a day is 42 dollars a month,
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so we gave these participants 42 dollars at the beginning of each month
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in a virtual account that they could see,
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and we took away $1.40 for every day they didn't walk 7,000 steps.
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Now, an economist would say that those two financial incentives
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are the same.
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For every day you walk 7,000 steps, you're $1.40 richer.
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But a behavioral economist would say that they're different,
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because we're much more motivated to avoid a $1.40 loss
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than we are motivated to achieve a $1.40 gain.
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And that's exactly what happened.
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Those in the group that received $1.40 for every day they walked 7,000 steps
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were no more likely to meet their goal than the control group.
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The financial incentive didn't work.
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But those who had a loss-framed incentive
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met their goal 50 percent more of the time.
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It doesn't make economic sense, but it makes psychological sense,
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because losses loom larger than gains.
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And now we're using loss-framed incentives to help patients walk more,
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lose weight
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and take their medications.
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Money can be a motivator.
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We all know that.
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But it's far more influential when it's paired with psychology.
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And money, of course, has its own disadvantages.
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My favorite example of this involves a daycare program.
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The greatest sin you can commit in daycare is picking up your kids late.
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No one is happy.
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Your kids are crying because you don't love them.
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(Laughter)
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The teachers are unhappy because they leave work late.
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And you feel terribly guilty.
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This daycare program in Israel decided they wanted to stop this problem,
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and they did something that many daycare programs in the US do,
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which is they installed a fine for late pickups.
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And the fine they chose was 10 shekels,
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which is about three bucks.
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And guess what happened?
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Late pickups increased.
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And if you think about it, it makes perfect sense.
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What a deal!
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For 10 shekels --
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(Laughter)
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you can keep my kids all night!
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(Laughter)
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They took a perfectly strong intrinsic motivation not to be late,
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and they cheapened it.
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What's worse, when they realized their mistake
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and they took away the financial incentive,
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the late pickups still stayed at the high level.
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They had already poisoned the social contract.
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Health care is full of strong intrinsic motivations.
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We have doctors and patients who already want to do the right thing.
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Financial incentives can help,
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but we shouldn't expect money in health care
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to do all of the heavy lifting.
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Instead, perhaps the most powerful influencers of health behavior
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are our social interactions.
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Social engagement works in health care,
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and it works in two directions.
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First, we fundamentally care what others think of us.
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And so one of the most powerful ways to change our behavior
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is to make our activities witnessable to others.
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We behave differently when we're being observed
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than when we're not.
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I've been to some restaurants that don't have sinks in the bathrooms.
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Instead, when you step out, the sink is outside
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in the main part of the restaurant,
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where everyone can see whether you wash your hands or not.
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Now, I don't know for sure,
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but I am convinced that handwashing is much greater
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in those particular settings.
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We are always on our best behavior when we're being observed.
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In fact, there was this amazing study
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that was done in an intensive care unit in a Florida hospital.
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The handwashing rates were very low, which is dangerous, of course,
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because it can spread infection.
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And so some researchers pasted a picture of someone's eyes over the sink.
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It wasn't a real person, it was just a photograph.
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In fact, it wasn't even their whole face, it was just their eyes looking at you.
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(Laughter)
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Handwashing rates more than doubled.
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It seems we care so much what other people think of us
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that our behavior improves
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even if we merely imagine that we're being observed.
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And not only do we care what others think of us,
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we fundamentally model our behaviors on what we see other people do.
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And it all comes back to seat belts.
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When I was a kid, I used to love the "Batman" TV series with Adam West.
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Everything that Batman and Robin did was so cool,
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and, of course, the Batmobile was the coolest thing of all.
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Now, that show aired from 1966 to 1968,
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and at that time, seat belts were optional accessories in cars.
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But the producers of that show did something really important.
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When Batman and Robin got in the Batmobile,
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the camera would focus on their laps,
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and you would see Batman and Robin put on their seat belts.
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Now, if Batman and Robin put on their seat belts,
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you can bet that I was going to wear my seat belt, too.
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I bet that show saved thousands of lives.
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And again, it works in health care, too.
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Doctors use antibiotics more appropriately when they see how other doctors use them.
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So many activities in health care are hidden, they're unwitnessed,
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but doctors are social animals,
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and they perform better when they see what other doctors do.
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So social influence works in health care.
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So does tying it to notions of regret or to loss aversion.
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We would never think of using these tools if we thought that everyone was rational
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all the time.
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Now, just to be clear: I am not condemning rationality.
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I mean, that really would be irrational.
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But we all know that it's the nonrational parts of our minds
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where we get courage, creativity, inspiration
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and everything else that sparks passion.
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And we know something else, too.
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We know that we can be much more effective at improving health behavior
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if we work with the irrational parts of our nature
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instead of ignoring them or fighting against them.
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When it comes to health care,
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understanding our irrationality is just another tool in our toolbox.
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And harnessing that irrationality --
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that may be the most rational move of all.
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Thank you.
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(Applause)
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About this website

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