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

by TED · 2,741 words · 350 segments · language en · Watch on YouTube

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0:12It's April of 2007,
0:15and Jon Corzine, the Governor of New Jersey,
0:18is in this horrific car accident.
0:21He's in the right front passenger seat of this SUV
0:23when it crashes on the Garden State Parkway.
0:26He's transported to a New Jersey trauma center
0:28with multiple broken bones and multiple lacerations.
0:31He needs immediate surgery, seven units of blood,
0:34a mechanical ventilator to help him breathe
0:36and several more operations along the way.
0:39It's amazing he survived.
0:41But perhaps even more amazing,
0:43he was not wearing a seat belt.
0:45And, in fact, he never wore a seat belt,
0:47and the New Jersey state troopers who used to drive Governor Corzine around
0:51used to beg him to wear a seat belt,
0:53but he didn't do it.
0:55Now, before Corzine was Governor of New Jersey,
0:57he was the US Senator from New Jersey,
1:00and before that, he was the CEO of Goldman Sachs,
1:02responsible for taking Goldman Sachs public,
1:05making hundreds of millions of dollars.
1:07Now, no matter what you think of Jon Corzine politically
1:10or how he made his money,
1:12nobody would say that he was stupid.
1:14But there he was,
1:15an unrestrained passenger in a car accident,
1:18at a time when every American knows that seat belts save lives.
1:23This single story reflects a fundamental weakness
1:26in our approach to improving health behavior.
1:29Nearly everything we tell doctors and everything we tell patients
1:33is based on the idea that we behave rationally.
1:36If you give me information, I will process that information in my head,
1:40and my behavior will change as a result.
1:43Do you think Jon Corzine didn't know that seat belts save lives?
1:47Do you think he, like, just didn't get the memo?
1:49(Laughter)
1:50Jon Corzine did not have a knowledge deficit,
1:53he had a behavior deficit.
1:55It's not that he didn't know better.
1:57He knew better.
1:58It's that he didn't do better.
2:02Instead, I think the mind is a high-resistance pathway.
2:07Changing someone's mind with information is hard enough.
2:11Changing their behavior with information
2:13is harder still.
2:15The only way we're going to make substantial improvements
2:18in health and health care
2:20is to make substantial improvements in the behavior of health and health care.
2:26If you hit my patellar tendon with a reflex hammer,
2:29my leg is going to jerk forward,
2:31and it's going to jerk forward a lot faster and a lot more predictably
2:34than if I had to think about it myself.
2:37It's a reflex.
2:38We need to look for the equivalent behavioral reflexes
2:42and hitch our health care wagon to those.
2:45Turns out, though,
2:47that most conventional approaches to human motivation
2:50are based on the idea of education.
2:53We assume that if people don't behave as they should,
2:56it's because they didn't know any better.
2:58"If only people knew that smoking was dangerous, they wouldn't smoke."
3:02Or, we think about economics.
3:03The assumption there is that we're all constantly calculating
3:06the costs and benefits of every one of our actions
3:09and optimizing that to make the perfectly right, rational decision.
3:13If that were true, then all we need to do
3:15is to find the perfect payment system for doctors
3:17or the perfect co-payments and deductibles for patients,
3:20and everything would work out.
3:22A better approach lies in behavioral economics.
3:25Behavioral economists recognize that we are irrational.
3:29Our decisions are based on emotion,
3:31or they're sensitive to framing or to social context.
3:34We don't always do what's in our own long-term best interests.
3:38But the key contribution to behavioral economics
3:41is not in recognizing that we are irrational;
3:44it's recognizing that we are irrational in highly predictable ways.
3:48In fact, it's the predictability of our psychological foibles
3:52that allows us to design strategies to overcome them.
3:55Forewarned is forearmed.
3:57In fact, behavioral economists often use
3:59precisely the same behavioral reflexes that get us into trouble
4:03and turn them around to help us,
4:06rather than to hurt us.
4:08We see irrationality play out in something called "present bias,"
4:13where the outcomes in front of us are much more motivating
4:16than even more important outcomes far in the future.
4:22If I'm on a diet -- and I'm always on a diet --
4:24(Laughter)
4:26and someone offers me a luscious-looking piece of chocolate cake,
4:30I know I should not eat that chocolate cake.
4:34That chocolate cake will land on that part of my body -- permanently --
4:38where that kind of food naturally settles.
4:41But the chocolate cake looks so good and delicious,
4:44and it's right in front of me,
4:45and the diet can wait 'til tomorrow.
4:47I used to love the comedian Steven Wright.
4:49He would have these Zen-like quips.
4:52My favorite one was this:
4:54"Hard work pays off in the future,
4:56but laziness pays off right now."
4:58(Laughter)
5:00And patients also have present bias.
5:03If you have high blood pressure,
5:04even if you would desperately like to avoid a stroke,
5:07and you know that taking your antihypertensive medications
5:10is one of the best ways to reduce that risk,
5:13the stroke you avoid is far in the future and taking medications is right now.
5:18Almost half of the patients who are prescribed high blood pressure pills
5:22stop taking them within a year.
5:25Think of how many lives we could save
5:27if we could solve just that one problem.
5:31We also tend to overestimate the value of small probabilities.
5:36This actually explains why state lotteries are so popular,
5:39even though they return pennies on the dollar.
5:41Now, some of you may buy lottery tickets --
5:43it's fun, there's the chance you might strike it rich ...
5:46But let's face it:
5:47this would be a horrible way to invest your retirement savings.
5:51I once saw a bumper sticker -- I am not making this up -- that said,
5:55"State lotteries are a special tax on people who can't do math."
6:00(Laughter)
6:01It's not that we can't do the math,
6:03it's that we can't feel the math.
6:06And we also pay much too much attention to regret.
6:09We all hate the feeling of missing out.
6:12So, actually, there was this recent lottery,
6:14a mega-jackpot lottery,
6:16that had a huge payoff, something like over a billion dollars.
6:19And everyone in my office is pooling money to buy lottery tickets,
6:22and I'm not having any of this.
6:24There I am, like, swaggering around the office,
6:26"Lotteries are a special tax on people who can't do math."
6:29(Laughter)
6:30And then it hits me:
6:31uh oh.
6:33What if they win?
6:34(Laughter)
6:36I'm the only one who shows up at work the next day.
6:39(Laughter)
6:40Now, it's not that I didn't want my colleagues to win.
6:42I just didn't want them to win without me.
6:45Now, it would have been easier if I had just taken my 20-dollar bill
6:49and put it into the office shredder,
6:51and the results would have been the same.
6:53Even though I knew I shouldn't participate,
6:55I handed over my $20 bill,
6:58and I never saw it again.
7:00(Laughter)
7:01We've done a bunch of experiments with patients
7:04in which we give them these electronic pill bottles
7:07so we can tell whether they're taking their medication or not.
7:10And we reward them with a lottery.
7:13They get prizes.
7:15But they only get prizes
7:17if they had taken their medication the day before.
7:20If not, they get a message that says something like,
7:23"You would have won a hundred dollars,
7:25but you didn't take your medicine yesterday, so you don't get it."
7:28Well, it turns out, patients hate that.
7:30They hate the sense of missing out,
7:32and because they can anticipate that feeling of regret
7:35and they'd like to avoid it,
7:37they're much more likely to take their medications.
7:40Harnessing that sense of hating regret works.
7:43And it leads to the more general point,
7:46which is: once you recognize how people are irrational,
7:50you're in a much better position to help them.
7:54Now, this kind of irrationality works out even in men's restrooms.
7:59So, for those of you who don't frequent urinals,
8:03let me break this down for you.
8:05(Laughter)
8:06There is pee all over the floor.
8:08(Laughter)
8:11And it turns out that you can solve this problem
8:13by etching the image of a fly in the back of the urinal.
8:17(Laughter) (Applause)
8:21And it makes perfect sense.
8:22(Laughter)
8:24If I see a fly,
8:26I'm gonna get that fly.
8:27(Laughter)
8:31That fly is going down.
8:33(Laughter)
8:34Now, this naturally begs the question that if men can aim,
8:38why were they peeing on the floor in the first place?
8:40In fact, if they were going to pee on the floor,
8:43why pee in front of the urinal?
8:44You could pee anywhere.
8:45(Laughter)
8:46And the same thing works in health care.
8:50We had a problem in our hospital
8:52in which the physicians were prescribing brand-name drugs
8:57when a generic drug was available.
8:59Each one of the lines on this graph represents a different drug.
9:03And they're listed according to how often they're prescribed as generic medications.
9:07Those are the top are prescribed as generics 100 percent of the time.
9:11Those down at the bottom are prescribed as generics
9:13less than 20 percent of the time.
9:15And we'd have meetings with clinicians and all sorts of education sessions,
9:18and nothing worked --
9:19all the lines are pretty much horizontal.
9:22Until, someone installed a little piece of software
9:26in the electronic health record
9:27that defaulted the prescriptions to generic medications
9:31instead of the brand-name drugs.
9:34Now, it doesn't take a statistician
9:35to see that this problem was solved overnight,
9:38and it has stayed solved ever since.
9:41In fact, in the two and a half years since this program started,
9:44our hospital has saved 32 million dollars.
9:47Let me say that again: 32 million dollars.
9:51And all we did was make it easier
9:54for the doctors to do what they fundamentally wanted to do all along.
10:00It also works to play into people's notions of loss.
10:06We did this with a contest to help people walk more.
10:10We wanted everyone to walk at least 7,000 steps,
10:14and we measured their step count
10:16with the accelerometer on their cell phone.
10:19Group A, the control group, just got told whether they had walked
10:227,000 steps or not.
10:25Group B got a financial incentive.
10:28We gave them $1.40 for every day they walked 7,000 steps.
10:33Group C got the same financial incentive,
10:35but it was framed as a loss rather than a gain:
10:38$1.40 a day is 42 dollars a month,
10:41so we gave these participants 42 dollars at the beginning of each month
10:45in a virtual account that they could see,
10:48and we took away $1.40 for every day they didn't walk 7,000 steps.
10:52Now, an economist would say that those two financial incentives
10:55are the same.
10:57For every day you walk 7,000 steps, you're $1.40 richer.
11:01But a behavioral economist would say that they're different,
11:04because we're much more motivated to avoid a $1.40 loss
11:08than we are motivated to achieve a $1.40 gain.
11:12And that's exactly what happened.
11:14Those in the group that received $1.40 for every day they walked 7,000 steps
11:18were no more likely to meet their goal than the control group.
11:21The financial incentive didn't work.
11:24But those who had a loss-framed incentive
11:26met their goal 50 percent more of the time.
11:29It doesn't make economic sense, but it makes psychological sense,
11:33because losses loom larger than gains.
11:35And now we're using loss-framed incentives to help patients walk more,
11:40lose weight
11:41and take their medications.
11:43Money can be a motivator.
11:46We all know that.
11:47But it's far more influential when it's paired with psychology.
11:52And money, of course, has its own disadvantages.
11:55My favorite example of this involves a daycare program.
11:59The greatest sin you can commit in daycare is picking up your kids late.
12:04No one is happy.
12:05Your kids are crying because you don't love them.
12:08(Laughter)
12:09The teachers are unhappy because they leave work late.
12:12And you feel terribly guilty.
12:14This daycare program in Israel decided they wanted to stop this problem,
12:18and they did something that many daycare programs in the US do,
12:21which is they installed a fine for late pickups.
12:23And the fine they chose was 10 shekels,
12:26which is about three bucks.
12:29And guess what happened?
12:31Late pickups increased.
12:34And if you think about it, it makes perfect sense.
12:37What a deal!
12:38For 10 shekels --
12:39(Laughter)
12:40you can keep my kids all night!
12:42(Laughter)
12:45They took a perfectly strong intrinsic motivation not to be late,
12:49and they cheapened it.
12:51What's worse, when they realized their mistake
12:53and they took away the financial incentive,
12:56the late pickups still stayed at the high level.
12:59They had already poisoned the social contract.
13:02Health care is full of strong intrinsic motivations.
13:05We have doctors and patients who already want to do the right thing.
13:09Financial incentives can help,
13:12but we shouldn't expect money in health care
13:15to do all of the heavy lifting.
13:18Instead, perhaps the most powerful influencers of health behavior
13:22are our social interactions.
13:24Social engagement works in health care,
13:27and it works in two directions.
13:29First, we fundamentally care what others think of us.
13:34And so one of the most powerful ways to change our behavior
13:38is to make our activities witnessable to others.
13:41We behave differently when we're being observed
13:44than when we're not.
13:45I've been to some restaurants that don't have sinks in the bathrooms.
13:48Instead, when you step out, the sink is outside
13:51in the main part of the restaurant,
13:52where everyone can see whether you wash your hands or not.
13:55Now, I don't know for sure,
13:56but I am convinced that handwashing is much greater
13:59in those particular settings.
14:00We are always on our best behavior when we're being observed.
14:04In fact, there was this amazing study
14:06that was done in an intensive care unit in a Florida hospital.
14:09The handwashing rates were very low, which is dangerous, of course,
14:12because it can spread infection.
14:15And so some researchers pasted a picture of someone's eyes over the sink.
14:20It wasn't a real person, it was just a photograph.
14:22In fact, it wasn't even their whole face, it was just their eyes looking at you.
14:26(Laughter)
14:27Handwashing rates more than doubled.
14:29It seems we care so much what other people think of us
14:32that our behavior improves
14:33even if we merely imagine that we're being observed.
14:37And not only do we care what others think of us,
14:40we fundamentally model our behaviors on what we see other people do.
14:45And it all comes back to seat belts.
14:48When I was a kid, I used to love the "Batman" TV series with Adam West.
14:54Everything that Batman and Robin did was so cool,
14:57and, of course, the Batmobile was the coolest thing of all.
15:00Now, that show aired from 1966 to 1968,
15:04and at that time, seat belts were optional accessories in cars.
15:08But the producers of that show did something really important.
15:11When Batman and Robin got in the Batmobile,
15:14the camera would focus on their laps,
15:16and you would see Batman and Robin put on their seat belts.
15:19Now, if Batman and Robin put on their seat belts,
15:21you can bet that I was going to wear my seat belt, too.
15:24I bet that show saved thousands of lives.
15:26And again, it works in health care, too.
15:29Doctors use antibiotics more appropriately when they see how other doctors use them.
15:35So many activities in health care are hidden, they're unwitnessed,
15:40but doctors are social animals,
15:42and they perform better when they see what other doctors do.
15:47So social influence works in health care.
15:49So does tying it to notions of regret or to loss aversion.
15:53We would never think of using these tools if we thought that everyone was rational
15:59all the time.
16:00Now, just to be clear: I am not condemning rationality.
16:03I mean, that really would be irrational.
16:06But we all know that it's the nonrational parts of our minds
16:11where we get courage, creativity, inspiration
16:14and everything else that sparks passion.
16:17And we know something else, too.
16:19We know that we can be much more effective at improving health behavior
16:24if we work with the irrational parts of our nature
16:27instead of ignoring them or fighting against them.
16:30When it comes to health care,
16:32understanding our irrationality is just another tool in our toolbox.
16:38And harnessing that irrationality --
16:40that may be the most rational move of all.
16:44Thank you.
16:45(Applause)

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