I’ve carried an MD degree proudly for over 40 years. Being of service to those in my community in improving their health has been a badge of pride I’ve worn proudly. But for the 26+ years of practice, and my 11+ years at ICSI, I’ve had the sense we could, and must, do better…. especially as the world around us has changed drastically.
We’ve all heard the term “bucket lists.” The idea of creating a wish list of activities or experiences we’d like to accomplish in our life is often raised, both in the cinema, as well as in daily conversations. I must admit that while I’ve considered this, I’ve been far too focused on my work, and maximizing the impact which I might have in creating a desirable change. Starting with my undergraduate days, and progressing through medical school, residency, and practice, there was always an excuse—too busy, no time, there’s always later, someday when the time is right…. It was a never-ending list of rationalizations, and made sense to one who felt that time would always be there later to relax.
I don’t know about you but I always look for a good deal. The idea of a 2 for 1 or 50% off draws me like a magnet to further investigate what the opportunity might offer. Whether we are purchasing groceries, clothing, books, music, or even an evening meal, our native human behavior seeks out what seems to us to be a great deal. Of course, it may also be we end up purchasing something we either didn’t need or was a marginal desire, but the lure of a “deal” drew us in.
But there is an additional element to the draw of a good deal, that of obtaining a discount. And we as humans innately believe that with our superior intelligence, we have the ability to logically assess whether the discount is worthy of our interest. After all, that’s why we’re the superior race, isn’t it?
But as I continue to expand my interest in behavioral economics, and the intriguingly named “social neuroscience,” I’m becoming acutely aware that there are gaps in my knowledge and defects in my capabilities regarding that assessment capability. For while we harbor a personal bias that we’re able to identify a valuable discount, the reality is that our ability to assess a discount’s value is impacted by many underlying vagaries of human behavior. Not the least of those is whether an immediate discount is of superior value to one which would come due in the future.
But why is this of interest to me in my work in health care? Fundamentally, it’s caused me to appreciate that in addition to all the challenges we already have identified in addressing behavior change, we have evolving knowledge of another attribute that will frustrate our efforts—our personal immediate discount rate.
In a recent book Wait, The Art of Delay, Frank Partnoy addresses many issues important in understanding when delay (which some might label procrastination) is appropriate. Additionally, he addresses our need to understand the impact of an individual’s “discount rate” as it impacts that delay. If I’m given the following offer—would you take $100 today or $110 in a week, which would you take—if you don’t eat that cheeseburger and fries today, you may in the long run live a longer, healthier life, etc., etc. What is our immediate need for gratification, and how is it balanced against what might be a long-term benefit, but not immediately available to me?
Multiple studies have revealed that people often do poorly in balancing the benefit of these discounts. If we have a “high immediate discount rate,” we will take the immediate offer, and not think of the long-term implications. So if imbedded in my brain is a tendency to a satisfy a high immediate need, I’ll take that $100 today, because it’s not worth waiting that 7 days for a larger reward.
Let’s think about that in terms of what we’re often asking our patients to do in addressing their health. We’re often asking them to eat healthy (look past that cheeseburger), exercise regularly (even if you’re tired, and don’t feel you have the time), get adequate rest, drink less alcohol, all in the hope they will live a few years longer in the distant future. While that is laudable, if you examine it in the context of discount rates, if that person we’re asking this behavior of has a high discount rate, despite our strongest urgings and our heartfelt pleas, and perhaps even with their initial agreement, we all too often know what happens—pass me the ketchup for that cheeseburger, and another beer please. That’s what some will call “non-compliance” which appeases our sense of responsibility.
Why does this cause me to pause? Research has shown that there are several attributes associated with high immediate discount rates (driving me to that immediate gratification). Those who are under educated, poor, obese, have job uncertainties, are all prone to high immediate discount rates.
We need to understand and incorporate this into any of our work in improving the health of our citizens. For despite all of our efforts in health care at engaging patients, attempting to involve them as partners in managing their health, we will be challenged by the environment in which they live. If we fail to address the social determinants of health—poverty, education, public health, jobs, etc. I fear our efforts will be limited in success. That high immediate discount rate which impacts our behavior is a big part of our society today. What can we do to address that as we confront the many challenges we face in health care? Is our discounted offering compatible with the world they live in?
A thrilling adventure, a saga of epic proportions, a hero overcoming incredible obstacles to triumph, a chilling tale of horror, a goofy set of cartoons—irrespective of what our individual predilections might be, we all love a good story. Even the most stoic of us will admit to a tug of the heartstrings or a moment of joy and excitement when confronted with a tale well told.
It’s likely not news to anyone, but the world around us is changing at an ever-increasing rate of speed. For one such as myself, who is approaching the December of my career, and hopefully not of my journey on this planet, it’s occasionally daunting to contemplate what lies in front of me.
Often times during the day, unfortunately sometimes while I’m supposed to be focusing on a specific task, I find my thoughts wondering to other things—isn’t that hawk circling in the sky outside my window fascinating, what is it like to soar so freely through the air, I wonder if I could ever write a book, what might it mean if the Mona Lisa actually was the great painting everyone thinks it was, what should I wear to the Twins baseball game tonight (outside of black to mourn their play). Perhaps you’ve done the same, although with different topics, only to be abruptly pulled back into the present.
We’ve all experienced it. Or at least I have, and I was beginning to think it was my advancing age, declining memory, and increasing forgetfulness. You’re sitting in a room, working on a particular project, when you realize there’s something you need to get from another room. Quickly, you rush to the next room to ….. and then it hits you, you’ve forgotten why you came into the room.
The world of health care today is much different than the one I became involved in as a physician over 35 years ago. But why should that surprise me? The world in general is so dramatically changed from that which I knew then, it would seem reasonable and totally understandable that we’ve had to make dramatic changes in how we work with the population in maintaining health. Or have we? For it seems to me that in many cases the volume-based, paternalistic, top down, cottage industry approach which served us generations ago still has a strong presence, at least intellectually and emotionally, in many in the medical profession.
Most of my life has been centered around the concept of the individual genius, using a unique skill and set of talents to create a piece of art, a great round of golf, a unique new device—you name it, I was inspired by the creativity and genius exhibited by such unique people.
Nothing about me, without me.” Perhaps not exactly presented as promoted by Dr. Donald Berwick, previously at CMS (sadly not true for the future, but that’s another story). It was a mantra used by him in his ongoing crusade to advance the patient-centered concept into our health care system. His energy in promoting the needed transformation from the provider-centered world we presently inhabit to one focused on the patient has been unabated.