Star Wars, Behavioral Economics, Geriatrics, and Palliative Care

Obi-Wan: “These are not the droids you’re looking for.”

Stormtrooper: “These are not the droids we’re looking for.”

Obi-Wan: “He can go about his business.”

Stormtrooper: “You can go about your business.”

Obi-Wan: “Move along.”

Stormtrooper: “Move along….move along.”

What if there was a tool, or set of tools that could influence our behavior in ways that we didn’t recognize, or even denied?  Would you call it The Force?

Well it turns out there is such a force, and it’s called behavioral economics.  I recently finished reading a  book by Daniel Kahneman called Thinking, Fast and Slow.  Kahneman won the Nobel Prize for his landmark research that led to the field of behavioral economics.  The idea is that you can alter the context in which decisions are made. You can take advantage of the irrational (fast) way in which humans are hardwired to make decisions.

My question is, how can we harness this force for the good of geriatrics and palliative care?

Here is a brief primer on the methods of behavioral economics, the mnemonic MINDSPACE courtesy of some folks from the UK:

• Messenger: We are heavily influenced by who communicates information
• Incentives: Our response to incentives is shaped by predictable mental shortcuts such as strongly avoiding losses
• Norms: We are strongly influenced by what others do
• Defaults: We “go with the flow” of pre-set options
• Salience: Our attention is drawn to what is novel and seems relevant to us
• Priming: Our acts are often influenced by subconscious cues
• Affect: Our emotional associations can powerfully shape our actions
• Commitments: We seek to be consistent with our public promises, and reciprocate acts
• Ego: We act in ways that make us feel better about ourselves

This is not coercion.  There is a perfectly ethical way to use behavioral economics.  I’m returning from a Greenwall conference where some very prominent bioethicists are thinking about how to use these tools for the good.  The context is already there, we just need to do a better job of attending to the message and subconscious cues the context is sending.

Here are some examples to prime the pump of ideas:

• Default of full code.  Consequently, most hospitalized patients and nursing home residents (I think) are full code
• The Choosing Wisely Campaign: Re-setting medical norms around ordering tests and treatments.  It’s just not OK to be slathering on that ABH gel!  Everyone else has stopped doing it! (or at least I hope AAHPM wisely chooses ABH gel as verboten)
• Paying hospitals a bonus up front, then taking away money if patients develop urinary tract infections in the hospital.  Hospital administrators value losses (taking away money) more than gains (a bonus at the end). (In this example, the paper says no difference was found after the up-front incentive was started.  More likely hospitals started changing their behavior the moment they heard the payment incentives were going to start, before folks in this study started measuring outcomes).

I look forward to your thoughts on how we can use behavioral economics to improve the quality of geriatrics and palliative care for older adults.

And now I have to run, I feel a tremor in the force…I have not felt that since…

by: Alex Smith @alexsmithMD