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Smart Thinking blog

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Drug of choice

Can patients make the right decisions?
Drug of choice

It seems rather obvious to me that the choices one makes are limited and governed by the choices one has. Or at least the choices one is presented with. In fact, much of my thinking on this subject is based on the groundbreaking work of Richard Thaler who wrote the book Nudge and which I am now re-reading for the third time.

As the field of behavioural health economics continues to grow and gain influence over policy design, it should not escape us that the manner in which information is presented to patients has a tremendous influence on their decisions and actions. The prototypical example that Thaler uses in Nudge is that of the director of food services for a large inner-city school system who, by virtue of her own school cafeteria design, can influence the eating habits of thousands of school children. Population-level changes are tantalising and possible, with the right design, commitment and political will. But changes on a smaller level are also tantalising, because they afford us the opportunity to pilot ideas and test theories before committing to large-scale change.

So why aren't we doing more to work on 'choice architecture'? Because we believe that healthcare is a System 1 ecosystem. System 1 thinking can be imagined as 'automatic' thinking and, its counterpart, System 2 can be imagined as conscious thinking. A large degree of medicine has to be about System 1 thinking. No argument. It has to be about doing things in an automatic and subconscious way, about 'muscle memory'. But, more than ever, System 2 thinking is critical in medicine. It is critical in patient counselling and education. The manner and order in which we present information to patients, and even the extent to which we use group behaviour as an example to 'nudge' patients can greatly influence choice and action. Provider and patient interactions cannot be System 1 interactions. So error number one is that we treat all medicine as though it were a System 1 process.

The second fundamental error is that we assume individuals always make decisions in their best interest or, as Thaler points out, at least better than the choices that others would make for them. And then, to make matters worse, we discount the role of experience in decision-making (error number three). We don't take into account that in order to make decisions that are in one's best interest, one must have some plausible degree of experience in order to be able to determine what to do in a given scenario. Not many people have experience with AIDS or cancer or Type 2 diabetes. Hence they make questionable decisions. Anyone who is a parent would immediately recognise the lunacy of this approach to healthcare. We don't let six year-olds decide what to do precisely because they have no experience and we all agree that they cannot make decisions in their best interests without someone else's intervention. So why do we let sick people decide what's in their best interest when they have no prior experience of being sick?

The list of fundamental errors does not end with the two I have presented here. But to be sure, they aggregate and roll up into the larger issue of choice architecture as Thaler describes it.

[How] information is presented to patients has a tremendous influence on their decisions and actions

Who knows best?
We are all products of the choices we are given. The difference between telling a patient about the efficacy of a new therapy and then the side effects versus the side effects first and then the efficacy is staggeringly important. We pay so much attention to the education curriculum (with good reason) that our children are taught. We obsess over teaching kids the basics 'the right way' and 'in the right order'. We don't stop and think that a patient learning about a new disease or medication is equivalent to a child learning his ABCs or mathematics for the first time.

Medicine is changing. We are not. Deliberate, controlled, conscious and deductive thinking are required more than ever. Incentives geared towards spending more time educating patients and 'nudging' them towards decisions and actions that increase compliance, adherence and lifestyle modifications are required. The framing of choices and ordering of information is probably the least expensive way with the highest probability of success that we can focus our efforts on. We need to spend time with those at the front lines of patient care teaching, reminding and rewarding them for implementing more System 2 thinking, especially in their patient interactions. We need to recalibrate our view that people know what's best for them and that without experience they can make the right decisions. To be truthful, we have no other choice.

Article by
Rohit Khanna

4th August 2016

From: Healthcare



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