For better health care, embrace irrationality
-
0:01 - 0:03It's April of 2007,
-
0:03 - 0:07and Jon Corzine,
the Governor of New Jersey, -
0:07 - 0:09is in this horrific car accident.
-
0:09 - 0:12He's in the right front
passenger seat of this SUV -
0:12 - 0:14when it crashes on
the Garden State Parkway. -
0:14 - 0:17He's transported
to a New Jersey trauma center -
0:17 - 0:19with multiple broken bones
and multiple lacerations. -
0:20 - 0:23He needs immediate surgery,
seven units of blood, -
0:23 - 0:25a mechanical ventilator
to help him breathe -
0:25 - 0:27and several more operations along the way.
-
0:28 - 0:29It's amazing he survived.
-
0:30 - 0:32But perhaps even more amazing,
-
0:32 - 0:34he was not wearing a seat belt.
-
0:34 - 0:36And, in fact, he never wore a seat belt,
-
0:36 - 0:40and the New Jersey state troopers
who used to drive Governor Corzine around -
0:40 - 0:42used to beg him to wear a seat belt,
-
0:42 - 0:43but he didn't do it.
-
0:43 - 0:45Now, before Corzine
was Governor of New Jersey, -
0:45 - 0:48he was the US Senator from New Jersey,
-
0:48 - 0:51and before that, he was
the CEO of Goldman Sachs, -
0:51 - 0:53responsible for taking
Goldman Sachs public, -
0:53 - 0:56making hundreds of millions of dollars.
-
0:56 - 0:59Now, no matter what you think
of Jon Corzine politically -
0:59 - 1:00or how he made his money,
-
1:00 - 1:02nobody would say that he was stupid.
-
1:02 - 1:04But there he was,
-
1:04 - 1:06an unrestrained passenger
in a car accident, -
1:06 - 1:11at a time when every American knows
that seat belts save lives. -
1:12 - 1:15This single story reflects
a fundamental weakness -
1:15 - 1:18in our approach
to improving health behavior. -
1:18 - 1:21Nearly everything we tell doctors
and everything we tell patients -
1:21 - 1:25is based on the idea
that we behave rationally. -
1:25 - 1:29If you give me information, I will process
that information in my head, -
1:29 - 1:31and my behavior will change as a result.
-
1:32 - 1:35Do you think Jon Corzine didn't know
that seat belts save lives? -
1:35 - 1:37Do you think he, like,
just didn't get the memo? -
1:37 - 1:38(Laughter)
-
1:38 - 1:41Jon Corzine did not have
a knowledge deficit, -
1:41 - 1:43he had a behavior deficit.
-
1:43 - 1:45It's not that he didn't know better.
-
1:45 - 1:46He knew better.
-
1:46 - 1:49It's that he didn't do better.
-
1:50 - 1:55Instead, I think the mind
is a high-resistance pathway. -
1:56 - 1:59Changing someone's mind
with information is hard enough. -
1:59 - 2:02Changing their behavior with information
-
2:02 - 2:03is harder still.
-
2:04 - 2:07The only way we're going to make
substantial improvements -
2:07 - 2:08in health and health care
-
2:08 - 2:13is to make substantial improvements
in the behavior of health and health care. -
2:14 - 2:17If you hit my patellar tendon
with a reflex hammer, -
2:17 - 2:19my leg is going to jerk forward,
-
2:19 - 2:23and it's going to jerk forward
a lot faster and a lot more predictably -
2:23 - 2:25than if I had to think about it myself.
-
2:25 - 2:27It's a reflex.
-
2:27 - 2:30We need to look for the equivalent
behavioral reflexes -
2:30 - 2:33and hitch our health care wagon to those.
-
2:34 - 2:35Turns out, though,
-
2:35 - 2:38that most conventional approaches
to human motivation -
2:38 - 2:41are based on the idea of education.
-
2:42 - 2:44We assume that if people
don't behave as they should, -
2:44 - 2:46it's because they didn't know any better.
-
2:46 - 2:49"If only people knew that smoking
was dangerous, they wouldn't smoke." -
2:50 - 2:52Or, we think about economics.
-
2:52 - 2:55The assumption there is that
we're all constantly calculating -
2:55 - 2:57the costs and benefits
of every one of our actions -
2:57 - 3:01and optimizing that to make
the perfectly right, rational decision. -
3:02 - 3:04If that were true, then all we need to do
-
3:04 - 3:06is to find the perfect
payment system for doctors -
3:06 - 3:09or the perfect co-payments
and deductibles for patients, -
3:09 - 3:10and everything would work out.
-
3:10 - 3:14A better approach lies
in behavioral economics. -
3:14 - 3:17Behavioral economists recognize
that we are irrational. -
3:18 - 3:19Our decisions are based on emotion,
-
3:20 - 3:22or they're sensitive to framing
or to social context. -
3:22 - 3:26We don't always do what's in our own
long-term best interests. -
3:27 - 3:29But the key contribution
to behavioral economics -
3:29 - 3:32is not in recognizing
that we are irrational; -
3:32 - 3:37it's recognizing that we are irrational
in highly predictable ways. -
3:37 - 3:40In fact, it's the predictability
of our psychological foibles -
3:40 - 3:43that allows us to design
strategies to overcome them. -
3:43 - 3:46Forewarned is forearmed.
-
3:46 - 3:48In fact, behavioral economists often use
-
3:48 - 3:52precisely the same behavioral
reflexes that get us into trouble -
3:52 - 3:54and turn them around to help us,
-
3:54 - 3:56rather than to hurt us.
-
3:57 - 4:01We see irrationality play out
in something called "present bias," -
4:01 - 4:05where the outcomes in front of us
are much more motivating -
4:05 - 4:09than even more important outcomes
far in the future. -
4:10 - 4:13If I'm on a diet --
and I'm always on a diet -- -
4:13 - 4:14(Laughter)
-
4:14 - 4:19and someone offers me a luscious-looking
piece of chocolate cake, -
4:19 - 4:22I know I should not
eat that chocolate cake. -
4:22 - 4:27That chocolate cake will land
on that part of my body -- permanently -- -
4:27 - 4:30where that kind of food naturally settles.
-
4:30 - 4:32But the chocolate cake
looks so good and delicious, -
4:32 - 4:33and it's right in front of me,
-
4:34 - 4:36and the diet can wait 'til tomorrow.
-
4:36 - 4:38I used to love the comedian Steven Wright.
-
4:38 - 4:40He would have these Zen-like quips.
-
4:40 - 4:42My favorite one was this:
-
4:42 - 4:44"Hard work pays off in the future,
-
4:44 - 4:47but laziness pays off right now."
-
4:47 - 4:48(Laughter)
-
4:48 - 4:51And patients also have present bias.
-
4:51 - 4:53If you have high blood pressure,
-
4:53 - 4:55even if you would desperately
like to avoid a stroke, -
4:55 - 4:58and you know that taking
your antihypertensive medications -
4:59 - 5:01is one of the best ways
to reduce that risk, -
5:01 - 5:06the stroke you avoid is far in the future
and taking medications is right now. -
5:06 - 5:11Almost half of the patients who are
prescribed high blood pressure pills -
5:11 - 5:12stop taking them within a year.
-
5:13 - 5:15Think of how many lives we could save
-
5:15 - 5:18if we could solve just that one problem.
-
5:20 - 5:24We also tend to overestimate
the value of small probabilities. -
5:24 - 5:27This actually explains
why state lotteries are so popular, -
5:27 - 5:30even though they return
pennies on the dollar. -
5:30 - 5:32Now, some of you
may buy lottery tickets -- -
5:32 - 5:35it's fun, there's the chance
you might strike it rich ... -
5:35 - 5:36But let's face it:
-
5:36 - 5:39this would be a horrible way
to invest your retirement savings. -
5:40 - 5:43I once saw a bumper sticker --
I am not making this up -- that said, -
5:43 - 5:48"State lotteries are a special tax
on people who can't do math." -
5:48 - 5:50(Laughter)
-
5:50 - 5:52It's not that we can't do the math,
-
5:52 - 5:54it's that we can't feel the math.
-
5:55 - 5:57And we also pay much too much
attention to regret. -
5:58 - 6:01We all hate the feeling of missing out.
-
6:01 - 6:03So, actually, there was
this recent lottery, -
6:03 - 6:04a mega-jackpot lottery,
-
6:04 - 6:07that had a huge payoff,
something like over a billion dollars. -
6:07 - 6:10And everyone in my office
is pooling money to buy lottery tickets, -
6:10 - 6:12and I'm not having any of this.
-
6:12 - 6:14There I am, like, swaggering
around the office, -
6:14 - 6:17"Lotteries are a special tax
on people who can't do math." -
6:17 - 6:18(Laughter)
-
6:18 - 6:20And then it hits me:
-
6:20 - 6:21uh oh.
-
6:21 - 6:23What if they win?
-
6:23 - 6:25(Laughter)
-
6:25 - 6:27I'm the only one who shows up
at work the next day. -
6:27 - 6:28(Laughter)
-
6:28 - 6:31Now, it's not that I didn't want
my colleagues to win. -
6:31 - 6:33I just didn't want them to win without me.
-
6:34 - 6:37Now, it would have been easier
if I had just taken my 20-dollar bill -
6:37 - 6:39and put it into the office shredder,
-
6:39 - 6:41and the results would have been the same.
-
6:41 - 6:43Even though I knew
I shouldn't participate, -
6:43 - 6:46I handed over my $20 bill,
-
6:46 - 6:48and I never saw it again.
-
6:48 - 6:49(Laughter)
-
6:49 - 6:53We've done a bunch
of experiments with patients -
6:53 - 6:56in which we give them
these electronic pill bottles -
6:56 - 6:59so we can tell whether
they're taking their medication or not. -
6:59 - 7:00And we reward them with a lottery.
-
7:02 - 7:03They get prizes.
-
7:03 - 7:06But they only get prizes
-
7:06 - 7:08if they had taken
their medication the day before. -
7:08 - 7:11If not, they get a message
that says something like, -
7:11 - 7:13"You would have won a hundred dollars,
-
7:13 - 7:16but you didn't take your medicine
yesterday, so you don't get it." -
7:16 - 7:18Well, it turns out, patients hate that.
-
7:19 - 7:21They hate the sense of missing out,
-
7:21 - 7:23and because they can anticipate
that feeling of regret -
7:23 - 7:25and they'd like to avoid it,
-
7:25 - 7:28they're much more likely
to take their medications. -
7:28 - 7:32Harnessing that sense
of hating regret works. -
7:32 - 7:35And it leads to the more general point,
-
7:35 - 7:38which is: once you recognize
how people are irrational, -
7:38 - 7:42you're in a much better
position to help them. -
7:42 - 7:47Now, this kind of irrationality works out
even in men's restrooms. -
7:47 - 7:52So, for those of you
who don't frequent urinals, -
7:52 - 7:54let me break this down for you.
-
7:54 - 7:55(Laughter)
-
7:55 - 7:56There is pee all over the floor.
-
7:56 - 7:59(Laughter)
-
7:59 - 8:02And it turns out that you
can solve this problem -
8:02 - 8:05by etching the image of a fly
in the back of the urinal. -
8:06 - 8:09(Laughter) (Applause)
-
8:09 - 8:11And it makes perfect sense.
-
8:11 - 8:12(Laughter)
-
8:12 - 8:14If I see a fly,
-
8:14 - 8:15I'm gonna get that fly.
-
8:15 - 8:19(Laughter)
-
8:19 - 8:21That fly is going down.
-
8:21 - 8:23(Laughter)
-
8:23 - 8:26Now, this naturally begs the question
that if men can aim, -
8:26 - 8:29why were they peeing
on the floor in the first place? -
8:29 - 8:31In fact, if they were going
to pee on the floor, -
8:31 - 8:33why pee in front of the urinal?
-
8:33 - 8:34You could pee anywhere.
-
8:34 - 8:35(Laughter)
-
8:35 - 8:38And the same thing works in health care.
-
8:39 - 8:41We had a problem in our hospital
-
8:41 - 8:45in which the physicians
were prescribing brand-name drugs -
8:45 - 8:48when a generic drug was available.
-
8:48 - 8:51Each one of the lines on this graph
represents a different drug. -
8:51 - 8:56And they're listed according to how often
they're prescribed as generic medications. -
8:56 - 8:59Those are the top are prescribed
as generics 100 percent of the time. -
8:59 - 9:02Those down at the bottom
are prescribed as generics -
9:02 - 9:03less than 20 percent of the time.
-
9:03 - 9:07And we'd have meetings with clinicians
and all sorts of education sessions, -
9:07 - 9:08and nothing worked --
-
9:08 - 9:10all the lines are pretty much horizontal.
-
9:11 - 9:14Until, someone installed
a little piece of software -
9:14 - 9:16in the electronic health record
-
9:16 - 9:20that defaulted the prescriptions
to generic medications -
9:20 - 9:22instead of the brand-name drugs.
-
9:22 - 9:24Now, it doesn't take a statistician
-
9:24 - 9:27to see that this problem
was solved overnight, -
9:27 - 9:29and it has stayed solved ever since.
-
9:29 - 9:33In fact, in the two and a half years
since this program started, -
9:33 - 9:36our hospital has saved 32 million dollars.
-
9:36 - 9:39Let me say that again: 32 million dollars.
-
9:39 - 9:42And all we did was make it easier
-
9:42 - 9:48for the doctors to do what they
fundamentally wanted to do all along. -
9:49 - 9:53It also works to play into
people's notions of loss. -
9:54 - 9:58We did this with a contest
to help people walk more. -
9:59 - 10:03We wanted everyone to walk
at least 7,000 steps, -
10:03 - 10:04and we measured their step count
-
10:04 - 10:06with the accelerometer
on their cell phone. -
10:07 - 10:11Group A, the control group,
just got told whether they had walked -
10:11 - 10:127,000 steps or not.
-
10:13 - 10:16Group B got a financial incentive.
-
10:16 - 10:21We gave them $1.40 for every day
they walked 7,000 steps. -
10:21 - 10:23Group C got the same financial incentive,
-
10:23 - 10:27but it was framed as a loss
rather than a gain: -
10:27 - 10:30$1.40 a day is 42 dollars a month,
-
10:30 - 10:34so we gave these participants 42 dollars
at the beginning of each month -
10:34 - 10:36in a virtual account that they could see,
-
10:36 - 10:40and we took away $1.40 for every day
they didn't walk 7,000 steps. -
10:41 - 10:44Now, an economist would say
that those two financial incentives -
10:44 - 10:45are the same.
-
10:45 - 10:49For every day you walk 7,000 steps,
you're $1.40 richer. -
10:50 - 10:53But a behavioral economist
would say that they're different, -
10:53 - 10:57because we're much more motivated
to avoid a $1.40 loss -
10:57 - 11:00than we are motivated
to achieve a $1.40 gain. -
11:00 - 11:02And that's exactly what happened.
-
11:03 - 11:07Those in the group that received $1.40
for every day they walked 7,000 steps -
11:07 - 11:10were no more likely to meet their goal
than the control group. -
11:10 - 11:12The financial incentive didn't work.
-
11:12 - 11:15But those who had a loss-framed incentive
-
11:15 - 11:18met their goal 50 percent
more of the time. -
11:18 - 11:21It doesn't make economic sense,
but it makes psychological sense, -
11:21 - 11:24because losses loom larger than gains.
-
11:24 - 11:28And now we're using loss-framed incentives
to help patients walk more, -
11:28 - 11:29lose weight
-
11:29 - 11:31and take their medications.
-
11:32 - 11:33Money can be a motivator.
-
11:34 - 11:35We all know that.
-
11:35 - 11:40But it's far more influential
when it's paired with psychology. -
11:41 - 11:43And money, of course,
has its own disadvantages. -
11:43 - 11:47My favorite example of this
involves a daycare program. -
11:47 - 11:52The greatest sin you can commit in daycare
is picking up your kids late. -
11:52 - 11:54No one is happy.
-
11:54 - 11:56Your kids are crying
because you don't love them. -
11:56 - 11:57(Laughter)
-
11:57 - 12:00The teachers are unhappy
because they leave work late. -
12:00 - 12:02And you feel terribly guilty.
-
12:02 - 12:06This daycare program in Israel
decided they wanted to stop this problem, -
12:06 - 12:09and they did something that many
daycare programs in the US do, -
12:09 - 12:12which is they installed
a fine for late pickups. -
12:12 - 12:15And the fine they chose was 10 shekels,
-
12:15 - 12:17which is about three bucks.
-
12:17 - 12:19And guess what happened?
-
12:19 - 12:21Late pickups increased.
-
12:22 - 12:25And if you think about it,
it makes perfect sense. -
12:25 - 12:26What a deal!
-
12:26 - 12:28For 10 shekels --
-
12:28 - 12:29(Laughter)
-
12:29 - 12:31you can keep my kids all night!
-
12:31 - 12:33(Laughter)
-
12:33 - 12:37They took a perfectly strong
intrinsic motivation not to be late, -
12:37 - 12:39and they cheapened it.
-
12:39 - 12:42What's worse, when they
realized their mistake -
12:42 - 12:44and they took away
the financial incentive, -
12:44 - 12:47the late pickups still stayed
at the high level. -
12:47 - 12:50They had already poisoned
the social contract. -
12:50 - 12:54Health care is full
of strong intrinsic motivations. -
12:54 - 12:58We have doctors and patients
who already want to do the right thing. -
12:58 - 13:01Financial incentives can help,
-
13:01 - 13:03but we shouldn't expect
money in health care -
13:03 - 13:05to do all of the heavy lifting.
-
13:06 - 13:11Instead, perhaps the most powerful
influencers of health behavior -
13:11 - 13:12are our social interactions.
-
13:13 - 13:15Social engagement works in health care,
-
13:15 - 13:17and it works in two directions.
-
13:18 - 13:23First, we fundamentally care
what others think of us. -
13:23 - 13:26And so one of the most powerful ways
to change our behavior -
13:26 - 13:29is to make our activities
witnessable to others. -
13:30 - 13:32We behave differently
when we're being observed -
13:32 - 13:34than when we're not.
-
13:34 - 13:37I've been to some restaurants
that don't have sinks in the bathrooms. -
13:37 - 13:39Instead, when you step out,
the sink is outside -
13:39 - 13:41in the main part of the restaurant,
-
13:41 - 13:44where everyone can see
whether you wash your hands or not. -
13:44 - 13:45Now, I don't know for sure,
-
13:45 - 13:47but I am convinced
that handwashing is much greater -
13:47 - 13:49in those particular settings.
-
13:49 - 13:52We are always on our best behavior
when we're being observed. -
13:52 - 13:54In fact, there was this amazing study
-
13:54 - 13:57that was done in an intensive care unit
in a Florida hospital. -
13:58 - 14:01The handwashing rates were very low,
which is dangerous, of course, -
14:01 - 14:03because it can spread infection.
-
14:03 - 14:08And so some researchers pasted
a picture of someone's eyes over the sink. -
14:08 - 14:11It wasn't a real person,
it was just a photograph. -
14:11 - 14:14In fact, it wasn't even their whole face,
it was just their eyes looking at you. -
14:14 - 14:16(Laughter)
-
14:16 - 14:17Handwashing rates more than doubled.
-
14:17 - 14:20It seems we care so much
what other people think of us -
14:20 - 14:22that our behavior improves
-
14:22 - 14:25even if we merely imagine
that we're being observed. -
14:26 - 14:29And not only do we care
what others think of us, -
14:29 - 14:33we fundamentally model our behaviors
on what we see other people do. -
14:34 - 14:36And it all comes back to seat belts.
-
14:37 - 14:42When I was a kid, I used to love
the "Batman" TV series with Adam West. -
14:42 - 14:45Everything that Batman
and Robin did was so cool, -
14:45 - 14:48and, of course, the Batmobile
was the coolest thing of all. -
14:48 - 14:52Now, that show aired from 1966 to 1968,
-
14:53 - 14:56and at that time, seat belts
were optional accessories in cars. -
14:57 - 15:00But the producers of that show
did something really important. -
15:00 - 15:03When Batman and Robin
got in the Batmobile, -
15:03 - 15:04the camera would focus on their laps,
-
15:05 - 15:07and you would see Batman and Robin
put on their seat belts. -
15:07 - 15:10Now, if Batman and Robin
put on their seat belts, -
15:10 - 15:12you can bet that I was going to wear
my seat belt, too. -
15:12 - 15:15I bet that show saved thousands of lives.
-
15:15 - 15:18And again, it works in health care, too.
-
15:18 - 15:23Doctors use antibiotics more appropriately
when they see how other doctors use them. -
15:23 - 15:28So many activities in health care
are hidden, they're unwitnessed, -
15:28 - 15:30but doctors are social animals,
-
15:30 - 15:35and they perform better
when they see what other doctors do. -
15:35 - 15:38So social influence works in health care.
-
15:38 - 15:41So does tying it to notions of regret
or to loss aversion. -
15:42 - 15:47We would never think of using these tools
if we thought that everyone was rational -
15:47 - 15:49all the time.
-
15:49 - 15:52Now, just to be clear:
I am not condemning rationality. -
15:52 - 15:54I mean, that really would be irrational.
-
15:55 - 15:59But we all know that it's
the nonrational parts of our minds -
15:59 - 16:03where we get courage,
creativity, inspiration -
16:03 - 16:05and everything else that sparks passion.
-
16:05 - 16:07And we know something else, too.
-
16:07 - 16:11We know that we can be much more effective
at improving health behavior -
16:12 - 16:16if we work with the irrational
parts of our nature -
16:16 - 16:19instead of ignoring them
or fighting against them. -
16:19 - 16:21When it comes to health care,
-
16:21 - 16:26understanding our irrationality
is just another tool in our toolbox. -
16:26 - 16:28And harnessing that irrationality --
-
16:29 - 16:32that may be the most rational move of all.
-
16:32 - 16:34Thank you.
-
16:34 - 16:38(Applause)
- Title:
- For better health care, embrace irrationality
- Speaker:
- David Asch
- Description:
-
Why do we make poor decisions that we know are bad for our health? In this frank, funny talk, behavioral economist and health policy expert David Asch explains why our behavior is often irrational -- in highly predictable ways -- and shows how we can harness this irrationality to make better decisions and improve our health care system overall.
- Video Language:
- English
- Team:
- closed TED
- Project:
- TEDTalks
- Duration:
- 16:53
Camille Martínez commented on English subtitles for Why it's so hard to make healthy decisions | ||
Camille Martínez edited English subtitles for Why it's so hard to make healthy decisions | ||
Erin Gregory edited English subtitles for Why it's so hard to make healthy decisions | ||
Oliver Friedman approved English subtitles for Why it's so hard to make healthy decisions | ||
Oliver Friedman edited English subtitles for Why it's so hard to make healthy decisions | ||
Camille Martínez accepted English subtitles for Why it's so hard to make healthy decisions | ||
Camille Martínez edited English subtitles for Why it's so hard to make healthy decisions | ||
Camille Martínez edited English subtitles for Why it's so hard to make healthy decisions |
Camille Martínez
The English transcript was updated on 12/11/19:
06:34
20-dollar bill --> $20 bill
Thank you!