How to Overcome Clinicians’ Resistance to Nudges

Executive Summary

Discussions about how behavioral economics can make the world a better place are often framed through the lens of decision makers trying to improve the quality of other people’s decisions. To do so, behavioral economics provides policymakers and managers with a toolkit for serving as “decision architects” and nudging citizens and team members towards better choices. The principle is simple — make the right decision the path of least resistance — and the results are often good. Many nudge interventions seem to work across a wide range of applications. But what if you, a manager or another kind of professional, were on the receiving end of behavioral nudges? Would you feel differently about others trying to nudge you towards specific choices? If so, you are not alone. Nudges aren’t always perceived as helpful. Regardless of the creator’s intentions, nudges can feel patronizing or subtly manipulative and could backfire if recipients perceive them as noodges, a Yiddish term that means “nuisance or pest.” This is a particularly relevant problem for professional employees because three important traits they possess — a strong sense of purpose, a desire for autonomy, and a commitment to mastery — can be barriers to accepting managerial nudges. This article use examples from health care to illustrate the challenges of implementing nudges to drive behavior change among professional employees like physicians and offers principles that can be applied to overcome them.

How to Overcome Clinicians’ Resistance to Nudges 1
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Discussions about how behavioral economics can make the world a better place — through energy conservation, greater employee wellness, increased personal savings — are often framed through the lens of decision makers trying to improve the quality of other people’s decisions. To do so, behavioral economics provides policymakers and managers with a toolkit for serving as “decision architects” and nudging citizens and team members towards better choices. The principle is simple — make the right decision the path of least resistance — and the results are often good. Many nudge interventions seem to work across a wide range of applications.

But what if you are a manager, a physician, or another kind of professional and are on the receiving end of behavioral nudges? Would you feel differently about others trying to nudge you towards specific choices? If so, you are not alone.

Nudges aren’t always perceived as helpful. Regardless of the creator’s intentions, nudges can feel patronizing or subtly manipulative and could backfire if recipients perceive them as noodges, a Yiddish term that means “nuisance or pest.” This is a particularly relevant problem for professional employees because three important traits they possess — a strong sense of purpose, a desire for autonomy, and a commitment to mastery — can be barriers to accepting managerial nudges.

Insight Center

Drawing on our collective insight from clinical practice, health system leadership, and behavioral economics research, we use examples from health care to illustrate the challenges of implementing nudges to change the behavior of professional employees like physicians and offer principles that can be employed to overcome them. The applicability of our approach is not limited to physicians; it can also be used with other skilled workers such as lawyers, engineers, scientists, and professors.

The challenges. Health care organizations have begun using nudges to improve physicians’ clinical decisions. For example, nudges have recently been used to decrease inappropriate antibiotic prescriptions, reduce opioid prescriptions in the emergency room setting, and improve influenza vaccinate rates. However, in our experience implementing change across different institutions, many managers have shared reservations about nudges as things being done to physicians rather than done with them — i.e., a hidden noodge rather than a transparent nudge.

One common fear managers have shared with us is that physicians sometimes perceive nudges as threats to their autonomy or questions about their professional mastery. Physicians are highly skilled and trained to synthesize evidence into clinical decisions. Their strong sense of autonomy is frequently warranted because exceptions are often the rule in medicine, and gaps in medical evidence make it impossible to identify a universal best choice. In fact, the medical community still lacks strong evidence to guide many clinical decisions. Two examples: In the absence of clear guidelines, primary care physicians range widely in how frequently they see patients for follow-up visits; and because of lagging data for new technologies to treat heart valve disease (e.g., trans-catheter aortic valve replacement), current practices are based on expert opinion rather than strong medical evidence.

Because they also worry about oversimplified “cookbook” medicine, physicians may also recoil from the perception that nudges represent a view that leaders, not frontline clinicians, know best, and that choice architecture trumps professional mastery. For example, we worked with leaders at a large hospital system to implement nudges aimed at decreasing opioid prescribing in the emergency room and urgent care clinics. While physician employees acknowledged that they could prescribe fewer opioid pills, some also perceived the proposed nudge as a critique of how they make clinical decisions.

How can managers overcome these perceptions of manipulation and use nudges to improve decisions made by skilled employees? We offer these three principles:

Transparency of purpose. One misconception about behavioral economics strategies is that they must be hidden to be effective. In fact, transparent nudge interventions such as defaults can work just as well as hidden ones. For example, in an online study, researchers asked over 1,000 individuals to complete hypothetical advanced directives, forms detailing their end-of-life health care wishes. Explicitly disclosing the presence of the defaults (i.e., telling individuals they were receiving a form with pre-populated defaults options selected) did not meaningfully diminish the impact of the nudge.

In health care, such transparency means that managers must communicate that the purpose of nudges is in sync with the physicians’ sense of purpose and their roles as patient advocates, practitioners of evidence-based medicine, and stewards of societal resources. Managers can acknowledge that nudges are needed not to trump professional purpose or medical evidence but exactly because unwarranted variation in care remains despite these things.

Other nudges, such as pre-commitment contracts in which individuals consciously “sign on” to take accountability for certain behaviors, are transparent by design. For example, Virginia Mason Medical Center instituted an organization-wide “physician compact” that outlines specific expectations and responsibilities for both physician employees and organizational leaders, creating a bridge between physician goals such as autonomy and organizational goals such as efficiency and variation reduction. Transparency helps dispel suspicion around these goals, creating fertile soil for dialogue about specific nudges and their purpose.

Co-creation of content. Another misconception is that nudges must be passively received to change behavior. In reality, the impact of nudges does not depend on their being “done to” people. Co-creating nudges with recipients may be more effective because the process of doing so itself can be helpful in reinforcing mastery of skill, sense of purpose, and autonomy. By respecting employee autonomy, co-creation helps generate shared understanding between manager and employee about key aspects of their work. It also helps prioritize solutions, avoid missteps, and identify situations where additional input is required.

These dynamics are important in settings such as health care, where decisions can be context-specific and the end users’ input is critical. Physicians are influenced not just by patient wishes and medical evidence but also other factors (e.g., time constraints, professional norms, competing tasks, ability to use work tools such as electronic medical records). Nudges can be more effective if co-created by managers and physicians to ensure interventions match “on the ground” insights and the culture of their organization.

Co-creation could be used to create nudges that meet the needs of skilled professionals. For example, managers could borrow principles from companies that have used personalized adaptive defaults — those that update themselves based on the current decisions that a customer has made — to sell computer protection packages based on consumer price sensitivity: Price-sensitive customers are shown defaults for affordable basic packages, while premium features are defaulted for easy purchasing among less-price-sensitive individuals.

In health care, managers could apply similarly adaptive defaults by auto-populating different diagnostic tests based on physicians’ initial assessment of patients — thereby streamlining workflow and increasing efficiency. Consider patients visiting an emergency room with chest pain. For patients whom physicians initially deem to be at high risk of a heart attack, the electronic health record could include a set of auto-populated advanced cardiac tests. For those patients whom physicians initially deem to be low risk, the electronic health record could auto-populate non-cardiac tests.

Co-creation can inspire other process improvements. For example, hospitals and physicians have worked with information technology experts to create software that nudges clinicians towards more appropriate use of imaging — in other words, to order scans only when they are really needed. This process helped harness internal expertise while reducing the risk of erroneous orders, informing clinicians about the financial implications of their decisions, and reducing waiting time for some patients.

Constructive Framing. Early efforts to implement nudges in health care have focused on helping physicians avoid mistakes (e.g., inappropriate antibiotic or opioid prescribing). While this “low hanging fruit” provides a starting point, nudges that champion professional ideals may motivate more positively.

For example, some health care organizations have used the behavioral economics principle of social comparisons to nudge physicians using “dashboards” that provide them with feedback about their performance compared to that of their colleagues. Dashboards can encourage mastery by displaying information about bigger, more complex goals that require more complicated decision-making. A health insurer in Hawaii is using a performance dashboard that it designed together with primary care practices to nudge primary care clinicians to reduce cost while improving quality metrics like better blood glucose control for patients with diabetes.

In another instance, Utah Health started an effort to patients’ health care experiences in 2008 by collecting their feedback and showing it to physicians via peer comparisons (i.e., showing physicians how their ratings compared to those of their peers). By 2012, amid a growing number of commercial websites offering external physician ratings and reviews, Utah Health started publicly posting patient feedback and scores for its physicians directly on its website. As a result, patient satisfaction scores for over half of Utah Health physicians exceeded the 90th percentile while scores for one quarter of physicians exceeded the 99th percentile compared to peers nationwide.

Nudges can be effective management tools for guiding behavior among skilled employees. The trick is to ensure that professionals see them as something positive — and not pesky or manipulative noodges.

The authors would like to thank Katherine Milkman and Jason Doctor for helpful input regarding behavioral science theory and applications.

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