News| Volume 22, ISSUE 8, P14, November 2021

Behavioral Change in Clinical Practice: Hard But Not Hopeless

      “It’s hard to change habits,” said Leslie Eber, MD, CMD, at the start of a program on “Changing Provider Behavior: Beyond the ‘Just Do It’ Mentality” at PALTC21, the Virtual Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine. She recalled how she would often come back from Society meetings bursting with ideas and plans, and then she was faced with “how challenging it is to change behaviors and habits.” But she stressed that there is hope.

      Start with System 1 and System 2

      To start, Dr. Eber talked about economist Daniel Kahneman’s systems of decision-making. System 1 is fast and intuitive, and uses past experiences and immediately available facts. System 2 is a deliberate process that uses questioning and further investigation.
      “It feels really good to use System 1. It makes us feel comfortable and secure,” she said. “But it also is correlated with predictable mistakes. System 1 decisions are famous for jumping to conclusions if we don’t have all the facts.” That is, she said, “If it looks like a duck and quacks like a duck, it’s a duck.” System 1 also relies on expert intuition, the recognition of past patterns. This can be useful, Dr. Eber suggested, “but in medicine, as we learn more and fine-tune best practices, it can be a pitfall.” System 1, she said, does not allow for the possibility that evidence critical to our decisions is missing. “We often use heuristics, a shortcut for solving a problem or making a decision.” This is where people revert to something they know to do from experience and habit.
      System 2 is more time consuming and less comfortable, Dr. Eber explained. However, she said, “When we are measured and deliberate, we divert from our habits and make much better decisions.” When we do this, she said, we have to address our cognitive ease — that confidence and trusting of intuition that makes mistakes more likely. At the same time, the focus must be on cognitive strain, which relies on vigilance, suspicion, and an investment of time and effort. This decision-making process may take practitioners out of their comfort zone, but the result is likely to be fewer mistakes.

      Beliefs: Boost or Bust?

      Our beliefs help shape our decisions, and in medicine, Dr. Eber said, “our beliefs are deeply engrained.” That isn’t surprising; human reasoning is belief based, and often it is built on experience. Unfortunately, experience also can lead to inaccurate medical beliefs. Along with our beliefs, Dr. Eber noted, we all have biases. “We need to recognize and address them,” she stressed.
      Base rate neglect — the gap between statistical evidence and best practices and the practitioner’s thinking about an individual patient — is a sort of bias that is common in geriatrics, Dr. Eber suggested. This is when the evidence and clinical knowledge point to one decision, yet the practitioner makes a different one because “I know Mrs. Jones.” Compelling statistics, she said, “will not change long-held beliefs or beliefs rooted in personal experience.” COVID-19 vaccine hesitancy is an example of this, Dr. Eber offered, as many people dismiss the scientific evidence because of their own personal experience with vaccinations.
      So how do we make better decisions? First, Dr. Eber said, “We have to overcome inertia. We have to embrace cognitive strain and consider alternatives and what is possible.”

      Give a Little Nudge

      In recent years, “nudges,” described as effective ways to influence behaviors, have become a popular strategy, said Sing Palat, MD, CMD. These, she noted, “are used to alter behavior, but they don’t forbid options or remove freedom of choice.”
      There are different types of nudges. Among them is the default option, “which creates a path of least resistance,” Dr. Palat said. This type of nudge is designed with the expectation that biases are natural. One popular and common example of a default option is the organ donor opt-out for consent, which has resulted in a high percentage of donors across all states. She said, “Removing small obstacles rather than shoving people in one direction has more impact.”
      Mapping is a nudge where information about various options is explicitly laid out and made easy to understand and choose from, observed Dr. Palat. “Clinical algorithms can put the idea of mapping on paper. Algorithms give providers the necessary cues to take appropriate sequential actions.” These algorithms are common in medicine, and they are used in resources such as the Society’s Clinical Practice Guidelines.
      “Giving feedback, especially in real time, is a nudge that improves performance,” said Dr. Palat. Another nudge is the spotlight effect: “When people think everyone is watching, they tend to conform to social norms,” said Dr. Palat. For instance, one facility posted a commitment letter signed by physicians to decrease inappropriate antibiotic prescriptions. That public declaration of intent led to a reduction in the behavior.
      Framing, another type of nudge, refers to focusing on the way choices are presented. In medicine, this most often involves scripted communication — giving providers specific words or phrases to use. Other types of nudges include priming with effective education and the herd effect, where peer comparisons create social norms.
      To create a nudge, it is important to first identify the opportunities and determine measurable outcomes. The nudge must be implemented strategically and pragmatically — it won’t work if it’s not practical. You align the stakeholders, including leadership and frontline clinicians, compare effectiveness, and translate the findings to scale. Not every situation can or should be addressed with a nudge. As Dr. Palat said, “Sometimes it makes sense to use a nudge, and sometimes it doesn’t.”
      Lea Watson, MD, MPH, described how she has used psych-pharma meetings to nudge changes. Nudging for a successful meeting, she said, requires being efficient and on time, focusing on the process and not persons, and respecting all voices, but keeping the tone light, making it fun, and learning together.