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