How to "Nudge" Patients on Behavior Change

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I just finished listening to Nudge, by Thaler and Sunstein, and I was struck by how many strategies from their book are relevant to helping patients make healthy behavioral changes.

This book highlights principles of behavioral economics and shares many examples of how small things can dramatically influence, or nudge, behavior. Nudge endorses the concept of libertarian paternalism, described as the idea that it is legitimate to try to affect the behavior of others (in ways that make individuals better off), so long as freedom of choice is respected.

Physicians spend a lot of time counseling patients about myriad topics, including being compliant with medications, exercising regularly, eating healthily, quitting smoking, limiting alcohol consumption, and so many other behavioral changes that have been unequivocally proven to have health benefits. We all do differently, and almost all of the time, we receive no feedback about whether our messaging had any impact whatsoever.

Nudge presents many principles that have been shown to be persuasive with respect to influencing decision-making. A few examples are shared below:

Choice architecture

There are few truly neutral designs and many people are content to accept whatever the default setting or the original set up (such as the web browser that is the default on a computer).

For example, states that have an organ donation ‘opt out’ tick box on their driver’s license application forms have significantly higher percentages of organ donors than states where the box is to be checked for ‘opting in’.

Framing

The ways in which an issue is contextualized can dramatically influence choices.

Apparently, if a doctor informs a patient that “97% of patients having operation X will survive,” more will opt to go forward with the surgery compared with those presented with the same information described alternatively, “3% of patients having operation X will die on the table.”

Herd Behavior

Humans generally like to conform and thus can be influenced by what others are doing.

Because of this, I titled this piece, “Most physicians sit down at the bedside when entering a patient’s room”; I actually have a hunch that this may not be true but I’m hoping that those who do not read these comments will succumb to social influence and begin sitting down when visiting hospitalized patients.

As it relates to counseling patients, I will sometimes inform a patient after collecting details about their diet, “You’re eating more red meat than most of my other patients.” Some have told me at follow-up visits that this information nudged them to start eating more fish and chicken.

Feedback

Precise and timely feedback helps to nudge behaviors in the desirable direction.

Examples from the book include the unpleasant side effects that disulfiram causes when alcohol is consumed (in the treatment of alcoholism), and how “SUPERNAILS Bite No More” can effectively break this compulsive habit. Evidence suggests that physicians that marry feedback with their patient education and counseling may see be better results.

Scott Wright, MD, Johns Hopkins University School of Medicine, divides his time between caring for patients, teaching, and research. He leads the division of General Internal Medicine at Johns Hopkins Bayview Medical Campus and directs the Johns Hopkins Miller Coulson Academy of Clinical Excellence. He has no conflicts of interest to declare. Dr. Wright manages a free and open-access medical education website, closler.org, where this piece originally appeared.

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