Why it's 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 frontpassenger seat of this SUV when it crashes onthe Garden State Parkway.

He's transportedto a New Jersey trauma center with multiple broken bonesand multiple lacerations.

He needs immediate surgery, seven units of blood, a mechanical ventilatorto 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 trooperswho used to drive Governor Corzine around used to beg him to wear a seat belt, but he didn't do it.

Now, before Corzinewas Governor of New Jersey, he was the US Senator from New Jersey, and before that, he wasthe CEO of Goldman Sachs, responsible for takingGoldman Sachs public, making hundreds of millions of dollars.

Now, no matter what you thinkof Jon Corzine politically or how he made his money, nobody would say that he was stupid.

But there he was, an unrestrained passengerin a car accident, at a time when every American knowsthat seat belts save lives.

This single story reflectsa fundamental weakness in our approachto improving health behavior.

Nearly everything we tell doctorsand everything we tell patients is based on the ideathat we behave rationally.

If you give me information, I will processthat information in my head, and my behavior will change as a result.

Do you think Jon Corzine didn't knowthat seat belts save lives? Do you think he, like, just didn't get the memo? (Laughter) Jon Corzine did not havea 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 mindis a high-resistance pathway.

Changing someone's mindwith information is hard enough.

Changing their behavior with information is harder still.

The only way we're going to makesubstantial improvements in health and health care is to make substantial improvementsin the behavior of health and health care.

If you hit my patellar tendonwith a reflex hammer, my leg is going to jerk forward, and it's going to jerk forwarda 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 equivalentbehavioral reflexes and hitch our health care wagon to those.

Turns out, though, that most conventional approachesto human motivation are based on the idea of education.

We assume that if peopledon't behave as they should, it's because they didn't know any better.

“If only people knew that smokingwas dangerous, they wouldn't smoke.

” Or, we think about economics.

The assumption there is thatwe're all constantly calculating the costs and benefitsof every one of our actions and optimizing that to makethe perfectly right, rational decision.

If that were true, then all we need to do is to find the perfectpayment system for doctors or the perfect co-paymentsand deductibles for patients, and everything would work out.

A better approach liesin behavioral economics.

Behavioral economists recognizethat we are irrational.

Our decisions are based on emotion, or they're sensitive to framingor to social context.

We don't always do what's in our ownlong-term best interests.

But the key contributionto behavioral economics is not in recognizingthat we are irrational; it's recognizing that we are irrationalin highly predictable ways.

In fact, it's the predictabilityof our psychological foibles that allows us to designstrategies to overcome them.

Forewarned is forearmed.

In fact, behavioral economists often use precisely the same behavioralreflexes that get us into trouble and turn them around to help us, rather than to hurt us.

We see irrationality play outin something called “present bias, ” where the outcomes in front of usare much more motivating than even more important outcomesfar in the future.

If I'm on a diet –and I'm always on a diet — (Laughter) and someone offers me a luscious-lookingpiece of chocolate cake, I know I should noteat that chocolate cake.

That chocolate cake will landon that part of my body — permanently — where that kind of food naturally settles.

But the chocolate cakelooks 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 desperatelylike to avoid a stroke, and you know that takingyour antihypertensive medications is one of the best waysto reduce that risk, the stroke you avoid is far in the futureand taking medications is right now.

Almost half of the patients who areprescribed 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 overestimatethe value of small probabilities.

This actually explainswhy state lotteries are so popular, even though they returnpennies on the dollar.

Now, some of youmay buy lottery tickets — it's fun, there's the chanceyou might strike it rich .

.

.

But let's face it: this would be a horrible wayto invest your retirement savings.

I once saw a bumper sticker –I am not making this up — that said, “State lotteries are a special taxon 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 muchattention to regret.

We all hate the feeling of missing out.

So, actually, there wasthis recent lottery, a mega-jackpot lottery, that had a huge payoff, something like over a billion dollars.

And everyone in my officeis pooling money to buy lottery tickets, and I'm not having any of this.

There I am, like, swaggeringaround the office, “Lotteries are a special taxon 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 upat work the next day.

(Laughter) Now, it's not that I didn't wantmy colleagues to win.

I just didn't want them to win without me.

Now, it would have been easierif 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 knewI shouldn't participate, I handed over my $20 bill, and I never saw it again.

(Laughter) We've done a bunchof experiments with patients in which we give themthese electronic pill bottles so we can tell whetherthey're taking their medication or not.

And we reward them with a lottery.

They get prizes.

But they only get prizes if they had takentheir medication the day before.

If not, they get a messagethat says something like, “You would have won a hundred dollars, but you didn't take your medicineyesterday, so you don't get it.

” Well, it turns out, patients hate that.

They hate the sense of missing out, and because they can anticipatethat feeling of regret and they'd like to avoid it, they're much more likelyto take their medications.

Harnessing that senseof hating regret works.

And it leads to the more general point, which is: once you recognizehow people are irrational, you're in a much betterposition to help them.

Now, this kind of irrationality works outeven in men's restrooms.

So, for those of youwho 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 youcan solve this problem by etching the image of a flyin 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 questionthat if men can aim, why were they peeingon the floor in the first place? In fact, if they were goingto 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 physicianswere prescribing brand-name drugs when a generic drug was available.

Each one of the lines on this graphrepresents a different drug.

And they're listed according to how oftenthey're prescribed as generic medications.

Those are the top are prescribedas generics 100 percent of the time.

Those down at the bottomare prescribed as generics less than 20 percent of the time.

And we'd have meetings with cliniciansand all sorts of education sessions, and nothing worked — all the lines are pretty much horizontal.

Until, someone installeda little piece of software in the electronic health record that defaulted the prescriptionsto generic medications instead of the brand-name drugs.

Now, it doesn't take a statistician to see that this problemwas solved overnight, and it has stayed solved ever since.

In fact, in the two and a half yearssince 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 theyfundamentally wanted to do all along.

It also works to play intopeople's notions of loss.

We did this with a contestto help people walk more.

We wanted everyone to walkat least 7, 000 steps, and we measured their step count with the accelerometeron 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 daythey walked 7, 000 steps.

Group C got the same financial incentive, but it was framed as a lossrather than a gain: $1.

40 a day is 42 dollars a month, so we gave these participants 42 dollarsat the beginning of each month in a virtual account that they could see, and we took away $1.

40 for every daythey didn't walk 7, 000 steps.

Now, an economist would saythat those two financial incentives are the same.

For every day you walk 7, 000 steps, you're $1.

40 richer.

But a behavioral economistwould say that they're different, because we're much more motivatedto avoid a $1.

40 loss than we are motivatedto achieve a $1.

40 gain.

And that's exactly what happened.

Those in the group that received $1.

40for every day they walked 7, 000 steps were no more likely to meet their goalthan the control group.

The financial incentive didn't work.

But those who had a loss-framed incentive met their goal 50 percentmore 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 incentivesto help patients walk more, lose weight and take their medications.

Money can be a motivator.

We all know that.

But it's far more influentialwhen it's paired with psychology.

And money, of course, has its own disadvantages.

My favorite example of thisinvolves a daycare program.

The greatest sin you can commit in daycareis picking up your kids late.

No one is happy.

Your kids are cryingbecause you don't love them.

(Laughter) The teachers are unhappybecause they leave work late.

And you feel terribly guilty.

This daycare program in Israeldecided they wanted to stop this problem, and they did something that manydaycare programs in the US do, which is they installeda 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 strongintrinsic motivation not to be late, and they cheapened it.

What's worse, when theyrealized their mistake and they took awaythe financial incentive, the late pickups still stayedat the high level.

They had already poisonedthe social contract.

Health care is fullof strong intrinsic motivations.

We have doctors and patientswho already want to do the right thing.

Financial incentives can help, but we shouldn't expectmoney in health care to do all of the heavy lifting.

Instead, perhaps the most powerfulinfluencers of health behavior are our social interactions.

Social engagement works in health care, and it works in two directions.

First, we fundamentally carewhat others think of us.

And so one of the most powerful waysto change our behavior is to make our activitieswitnessable to others.

We behave differentlywhen we're being observed than when we're not.

I've been to some restaurantsthat 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 seewhether you wash your hands or not.

Now, I don't know for sure, but I am convincedthat handwashing is much greater in those particular settings.

We are always on our best behaviorwhen we're being observed.

In fact, there was this amazing study that was done in an intensive care unitin a Florida hospital.

The handwashing rates were very low, which is dangerous, of course, because it can spread infection.

And so some researchers pasteda 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 muchwhat other people think of us that our behavior improves even if we merely imaginethat we're being observed.

And not only do we carewhat others think of us, we fundamentally model our behaviorson what we see other people do.

And it all comes back to seat belts.

When I was a kid, I used to lovethe “Batman” TV series with Adam West.

Everything that Batmanand Robin did was so cool, and, of course, the Batmobilewas the coolest thing of all.

Now, that show aired from 1966 to 1968, and at that time, seat beltswere optional accessories in cars.

But the producers of that showdid something really important.

When Batman and Robingot in the Batmobile, the camera would focus on their laps, and you would see Batman and Robinput on their seat belts.

Now, if Batman and Robinput on their seat belts, you can bet that I was going to wearmy seat belt, too.

I bet that show saved thousands of lives.

And again, it works in health care, too.

Doctors use antibiotics more appropriatelywhen they see how other doctors use them.

So many activities in health careare hidden, they're unwitnessed, but doctors are social animals, and they perform betterwhen they see what other doctors do.

So social influence works in health care.

So does tying it to notions of regretor to loss aversion.

We would never think of using these toolsif 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'sthe 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 effectiveat improving health behavior if we work with the irrationalparts of our nature instead of ignoring themor fighting against them.

When it comes to health care, understanding our irrationalityis just another tool in our toolbox.

And harnessing that irrationality — that may be the most rational move of all.

Thank you.

(Applause).