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Understanding barriers to patient behavioral change

Posted May 17 2012 9:58am

by Kent Bottles

Healthcare, wellness, hospital care and post-acute care all depend on relationships between providers and patients. The gap between health care professionals and the public that has been documented in Kaiser Family Foundation polls indicates that these relationships are not working perfectly.

For example, professionals believe 30 percent of healthcare services are not necessary, but 67 percent of the public say they do not get all the care they need. Professionals state there is wide variation in quality of providers, but 70 percent of the public believes there is not much difference in quality of physicians in their area.

Much of the discussion about both the cost and quality of American healthcare centers around the lack of responsibility that patients exhibit when they smoke, lead sedentary lives and eat an unhealthy diet. And yet most attempts at behavior change have been disappointing, to say the least. It has been frustrating for physicians and public health officials that we do not really know how to effectively influence lifestyle behavior.

A new book by a Nobel Prize winner summarizes how he established the new field of behavioral economics, which sheds light on how human beings make decisions and what works (and doesn't) in trying to get people to change behaviors. Anyone interested in the transformation of the American healthcare delivery system needs to read Daniel Kahneman's "Thinking Fast and Slow" (New York: Farrah, Straus, and Giroux, 2011).

Kahneman describes the two ways we humans interact with our world: the largely unconscious, always on, fast system that depends on intuition and the conscious; and the lazy slow system that depends on critical examination of the evidence. Humans are consciously aware of only 40 of the 11,000,000 pieces of information that are influencing their behavior at any one moment. The 10,999,960 pieces of information coming in through the five senses that unconsciously affect us do so largely through the fast system that is always monitoring our environment for danger and making up causal interpretations of what is happening in our world.

The fast system, under conditions of time pressure and uncertainty, uses shortcuts (heuristics) to make judgments that can lead to a predictable pattern of cognitive illusions and errors. Kahneman received the Nobel Prize because his work with Amos Tversky established that we humans overestimate how much we understand about the world and underestimate the role of chance in events. "We can be blind to the obvious, and we are blind to our blindness."

A study of the incidence of kidney cancer in the 3,141 U.S. counties revealed the occurrence is lowest in rural, sparsely populated, traditionally Republican states in the Midwest, the South and the West. When most are asked about this finding, their fast system comes up with a plausible cause associated with clean living, little pollution and access to fresh food.

When it is revealed that the same study also showed the incidence is highest in the same counties, the fast system comes up another believable cause associated with rural poverty, limited access to medical care, and poor diet and smoking habits. Our human fast system is inept when faced with statistical facts, which change the probability of disease outcomes but do not cause them. Extreme outcomes--in this case high and low incidences--are always more likely to be found in small rather than large samples. Kahneman calls this cognitive illusion the law of small numbers.

The affect heuristic shows that our predictions of frequency of events are distorted by the prevalence and emotional intensity of messages we are exposed to in the 24/7 news cycle. Although strokes cause twice as many deaths as accidents, 80 percent of the public judged accidents more likely. Although asthma causes 20 times more deaths than tornadoes, the dramatic news reporting of tornadoes contributes to the public thinking this weather event is more deadly than the respiratory disease.

It turns out that humans, physicians and patients, are not good intuitive statisticians. If it takes five machines five minutes to make five widgets, how long will it take 100 machines to make 100 widgets? When given the choice of 100 minutes or five minutes as the answer, the majority of humans will pick the wrong answer of 100 minutes because the fast system intuitively thinks it makes sense.

The well-documented difficulty of physicians and patients to understand statistics when they attempt shared-decision making now makes more sense. Our intuition often leads us astray because human beings are not good intuitive statisticians. Kahneman makes it clear that statisticians are Homo sapiens, and they too often get tripped up by their fast system of thinking. The new field of behavioral economics has much to teach all of us concerned with decreasing the per-capita cost and increasing the quality of American medicine.

Dr. Kent Bottles is a Senior Fellow at the Thomas Jefferson University School of Population Health and Chief Medical Officer at Verilogue/

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