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One of the principal areas to be understood and developed as we expand participatory medicine is decision making. As patients become “responsible drivers of their care, and providers welcome and value them as full partners,” patients participate in decisions – and inevitably start to understand the decision process that used to be the domain of the clinician. So we’ve written often about shared medical decision making.

And whether you’re the clinician or the patient, it turns out illusions are a real challenge. The thing is, even when you know it’s an illusion, the illusion’s still there. And it’s really hard to persuade people that they’re not seeing something they know they’re seeing. Example:

If you can’t see the presentation below, view it here: Optical illusion examples
If that doesn’t work, try the no-animations Slideshare version.

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Update 1/4/2014: Be sure also to see the new videos in the comment below.

The three books cited here – Nudge, Switch, and Thinking, Fast and Slow – have earned popularity in health circles. Thinking is heavier than the others, literally and metaphorically; together, they make the case that it’s not too useful to overcome an illusion by presenting the brain with facts.

And that’s really hard to accept if, like most clinicians, you’ve been trained to respond only to facts. In this case though, the ultimate fact is that it’s not that simple: information doesn’t change behavior.

Thinking, Fast & Slow (Oct. 2011) is by Nobel-winning economist Daniel Kahneman. It’s hefty and chewy, all full of 30+ years of research into the usual quick-thinking mind (fast, which he calls “system 1”) and the methodical “stop & think” mind (slower, “system 2”).  The decades of evidence are pretty compelling that System 2 isn’t involved in nearly as many wants and decisions as we’d like to think: System 1 runs almost everything, and is quite prone to illusions and mirages. Even when System 2 knows it.

The other two books are at a much more popular level. At first they struck me as potentially air-headed or light (“oy, another trendy one-word title”), so I didn’t read them. But Kahneman took me to school and I get it.

And here’s the problem: clinicians and policy people alike try to persuade using facts and rationale, but it doesn’t work. That approach speaks to “system 2,” which is often overruled by what system 1 swears is actually important or actually happening.  And it’s an illusion of the worst kind: the rational mind swears it’s thinking, but other factors are more compelling.

So what do we do?

2010’s Switch describes this as “the elephant, the rider and the path.” The rider is the rational one, but the elephant has all the power. You can talk logic all you want, but if the elephant gets spooked or excited, it does what it wants. So there’s more leverage, Switch says, by shaping the path that the elephant walks – the environment, the way choices are presented, and so on.

2008’s Nudge (with elephants on the cover!) is along similar lines and talks particularly about presenting choices in ways that “nudge” us to better decisions, which Switch would call “shaping the path.” For a good quick understanding of Nudge, I recommend this Amazon review.

For cross-discipline subjects like this, I always try to ask, “What are the takeaways for e-patients? For participatory clinicians?” This time that’s a rich question, because we’re changing the culture of medicine, which cares a lot about what’s true, what’s valid, etc. Plus, we’re asking clinicians to make wrenching changes in how they do their jobs and run their businesses; we try to persuade with information, when the real challenge may be people’s beliefs and expectations – the elephant’s home.

(If you get irked by this, have another look at those slides. This is a human issue, not an individual one.)

Some suggested takeaways:

  • Information is not a sure path to behavior change.
  • Don’t be surprised if information isn’t persuasive
  • Don’t try to solve it with more of the same.
  • Don’t interpret resistance as a moral failure.
  • Look for ways to relate to the elephant.

Others, anyone?

A good example arose today on the SPM member listserv. Our member Peter Elias MD, who wrote January’s terrific post Empowerment and collaboration, was discussing physician acceptance of electronic medical records. No amount of factual persuasion swings some docs’ attitudes, even though they’re intellectually skilled and well trained … but when their patients commented about how useful it was, and asked about changing doctors, they came around.



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