Gary Oftedahl: Homer Simpson and me...Really!

I have to confess, Homer Simpson and I have something in common.  It is potentially a trait which will have significant impact on how we design health care.  It is an area of focus which we’ll have to deal with if we are ever to succeed.  Despite the fact that I’ve had more than seven years of post graduate education, more than 30 years of experience in caring for patients, Homer and I have something in common which will potentially be an area of challenge in our work in engaging patients in actively managing their health.  Oh, by the way, I think most of you are closer to Homer than you think.  That is, if you’re human (OK, he’s a cartoon character, but play along with the analogy), because it is that trait which unfortunately will complicate our best efforts.

Let me explain, lest you leave this blog in a huff of incredibility, questioning if I’ve lost my mind.  What Homer and I, along with all of you have in common to some degree, is the challenge of making decisions, changing behavior, and altering our course in life.  In my readings which I’ve highlighted before (Nudge, Sway, Predictably Irrational, Drive, Switch, Made to Stick, Outliers, Blink, The Drunkard’s Walk, Counterclockwise, etc—you get the picture), a common theme arises. While perhaps labeled differently, it is a constant across almost all models which address the capacity and ability of humans to change, and make decisions which are in their best interest.

When we are distant from making a decision (let’s call it a “cold” state as Thaler and Sunstein do in Nudge), we are able to analyze the options, objectively consider what the impact of our decision might be, and contemplate a logical approach.  This is a reflective state.  When in this mode, I’m more likely to compare my intellectual and decision-making capacity to that of Albert Einstein, as he crafted his thinking on the theory of relativity.

Unfortunately, there’s another level of thinking which is referred to by Thaler as the automatic state.  It is this state, when in the heat of the moment, or enticed by the pile of donuts lying nearby, that the “lizard” part of our brain sneaks up, clubs the reflective portion into submission, and causes us to proceed in a manner abhorrent to our reflective contemplations, but for the most part very pleasing to our more primitive needs.  Yes, there goes that donut, and what was I thinking?

It is this part of the brain that we see most often reflected in the wisdom and thoughts of Homer Simpson.   Interestingly enough, we find these often humorous, and occasionally causing deep laughter.  When purchasing a gun, and being told there was a five-day waiting period before he could take possession,  Homer responded “but I’m mad now.”  Certainly this is a demonstration of the triumph of the automatic over the reflective state—and a good argument for the rationale of the waiting period.

While I’m considered by many to be a fairly intelligent guy, it is primarily demonstrated when I’m in a reflective, cold state, thinking logically, abstractly, and not under any immediate duress.  Unfortunately, I’m totally capable of demonstrating the lack of “intelligence” often manifested by my automatic state.  How else could I explain my ongoing upgraded time share, reflectively a ridiculous expense, but in the sun, sand, and Corona of Mexico, with well-trained sales representatives whispering in my ear, subject to the automatic “lizard” desire to have “more, more, more.”

As we consider how to engage our patients in partnering in their health, and addressing the behaviors which will need to change for us all, there are many challenges.  But as we consider our course, it is useful to consider the impact of the reflective/automatic (neocortex/limbic) nature of decision making.  How quickly that care plan addressing the need to eat healthier foods, exercise regularly, and lose weight (thoughtfully constructed) can be overwhelmed by the aroma of the Cinnabon shop in the mall, the smell of French fries at a ball game, or the lure of another hour of sleep instead of that elliptical machine.  I’m just saying—we all have a bit of Homer Simpson in us.  So do our patients.  It will be a part of the challenge we face.

Excuse me, I see a bowl of cashews……Doh!!!