Patient Support & Advocacy

Doctor’s career path offers economic insight on patient choices

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As a physician, a portion of your patients will smoke, avoid seatbelts or skip doses of medication. In those instances, patients are doing things that are not in their own best interest.

Rather than ask the obvious question—why do patients act against their own interests?—one physician is taking a different tack when it comes to such self-defeating behaviors.

“We will 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,” said David Asch, MD, MBA. “When it comes to health care, understanding our irrationality is just another tool in our tool box. And harnessing that irrationality, that maybe the most rational move of all.”

Dr. Asch recently spoke at TEDMED 2018—the annual health and medicine edition of the world-renowned TED Talks—about his work. He also will be featured in an upcoming episode of “AMA Doc Talk,” a lively, informative, conversation between physicians, ethicists, patients and academics, focused on relevant topics in medicine and packaged for quick consumption. “AMA Doc Talk” is just one of the podcasts produced by the AMA.

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As a general internist, behavioral economist and professor at both the Perelman School of Medicine and the Wharton School at the University of Pennsylvania, Dr. Asch works to improve how physicians and patients make decisions in health care and in everyday life, including in the use of medical interventions and in personal health behaviors. He also is executive director of the Penn Medicine Center for Health Care Innovation.

Here is Dr. Asch’s look at some common irrational behaviors that your patients may exhibit, along with some potential responses.

Living for today

The irrational behavior: People can live in the moment, to their own detriment. Dr. Asch describes this phenomenon as present bias.

“The personal example I might use is this: I'm always on a diet and if someone offers me a piece of chocolate cake, I know I shouldn't eat that chocolate cake,” he said. “The chocolate cake is going to land on that part of my body where chocolate cake permanently settles.

“But the chocolate cake is right in front of me, it looks so good and the diet can wait till tomorrow. And it's the same kind of bias that explains why almost no one saves enough for retirement. Or even if you desperately would like to avoid a stroke and you have hypertension, you might not take your medicine today.”

How to combat it: There are some effective examples of motivating people to make the better long-term decision by offering a measure of short-term gratification. That could include giving a financial incentive for patients to take their own medication and offering them an accelerated benefit in the short term.

No regrets

The irrational behavior: People have a fear of missing out, or “regret aversion,” as Dr. Asch calls it. This is one reason why state lotteries are so popular. Despite the odds being stacked overwhelmingly against gamblers, many play the same number over and over and hate the idea that the one day they don’t play their number, it wins.

How to combat it: Studies have looked at how to make regret aversion work for the patient’s good in the context of medication adherence, Dr. Asch said.

“We've given patients these electronic pill bottles that allow us to tell whether they're taking their medication or not and we reward them with a lottery. If their number comes up, they get a prize, but only if they had taken their medication the day before.  If not, they get a message like, ‘You would have won $100, but because you didn't take your medication yesterday, you don't get it.’

“And really people hate that kind of message and because they can anticipate that, they are much more likely to take their medication.”

Peer pressure

The irrational behavior: People model their behaviors on what they see others do.

How to combat it: Use peer pressure as a positive. Dr. Asch noted that assigning patients to peer mentors can help them improve their health.

“Social interactions are essentially costless and maybe they will solve some other problems, like the epidemic of loneliness that we have—who knows?” he said. “But the point is that our social engagements are important to each of us and we all know that we're motivated by what our friends and family and co-workers and idols do. Why not harness that tendency to help people’s health?”