Why it's so hard to make healthy decisions

[Music] 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 seatbelts 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 seatbelts save lives do you think you'd like just didn't get the memo 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 with our 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 interest but the key contribution of 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 that even more important outcomes far in the future if I'm on a diet and I'm always on a diet 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 till tomorrow I used to love the comedian Steven Wright he would have the zen-like quips and my favorite one was this hard work pays off in the future but laziness pays off right now 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 her 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 chances 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'm not making this up that said state lotteries are a special tax on people who can't do math 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

that had mega jackpot lottery that had a huge payoff something like over a billion dollars and every one of 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 or a special tax when people can't do math and then it hits me Oh what if they win I'm the only one who's just up at work the next day 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 just taken my twenty 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 hand it over my twenty dollar bill and I never saw it again we've done a bunch of experiments with patients 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 $100 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 restaurants so for those of you who haven't don't frequent urinals let me break this down for you there is pee all over the floor and it turns out that you can solve this problem by etching the image of a fly in the back of the urinal and it makes and it makes perfect sense if I see a fly I'm gonna get that slide that fly is going down 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 gonna pee on the floor why pee in front of the urinal you could pee anywhere 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 now each one of the lines on this graph represents a different drug and they're listed according to how often they were prescribed as generic medication so those at the top are prescribed as generics 100% of the time those down at the bottom are prescribed as generics less than 20% 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 thirty two million dollars let me say that again thirty two 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 to 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 7000 steps or not Group B got a financial incentive we gave them a dollar 40 for every day they walk 7000 steps Group C got the

same financial incentive but it was framed as a loss rather than a game a dollar 40 a day is $42 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 a dollar 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 a dollar 40 richer but a behavioral economist would say that they're different because we're much more motivated to avoid

a dollar 40 loss than we are motivated to achieve a dollar 40 game and that's exactly what happened those in the group that received a dollar 40 for every day they walk 7,000 steps were no more likely to meet their goal in the control group the financial incentive didn't work but those who had a loss framed incentive met their goal 50% 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 lost 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 right your kids are crying because you don't love them 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 they did something that many daycare programs in

the u.s. do which is they installed a fine for Lake pickups and the fine they chose was 10 shekels which is about 3 bucks and guess what happened late pickups increased and if you think about it it makes perfect sense what a deal for ten shekels you can keep my kids all night they took a perfectly strong intrinsic motivation not to be late and they cheapened it what's worse when they realize their mistake and they took away the financial incentive the late pickup 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 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 witness Abul 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'm convinced that hand-washing 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 hand-washing rates were very low

which is dangerous of course because we 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 hand-washing 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 be a views on what we

see other people do and it all comes back to seatbelts when I was a kid I used to love the Batman TV series with Adam West everything the 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 seatbelts were optional accessories and 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 gonna wear my seat belt ooh 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 healthcare are hidden their 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 in 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'm not condemning rationality I mean that really would be irrational but we all know that it's the non-rational 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] [Music]