Contributor: Emily Azari – Senior Health Writer, Emmi Solutions

In my last post, we began exploring the cognitive biases (unconscious errors in thinking) that come into play when choosing whether or not to pursue prenatal genetic screening for conditions like Down syndrome. Today I’ll cover two more biases we considered as we developed a decision aid to help women wrestle with that choice.

Present focus bias
We have a hard time imagining and planning for our future selves. This is, of course, why hangovers and credit card debt exist. This “present focus bias” gets in the way of all sorts of responsible health behaviors that have long-term benefits with short-term cost (think exercise, eating salads, and getting check-ups).

What does this have to do with the decision to pursue prenatal genetic testing? Well, you might be pretty good at anticipating how your decision will affect you in the near term, but most people won’t be able to imagine what it would actually be like in the future to raise a child with Down syndrome. This could cut two ways:

  • You might figure there’s just no way that you could cope with a child with special needs, when in fact people are extraordinarily resilient, time and time again displaying a capacity to rise to unexpected life challenges
  • In contrast, you might assume that raising a child with special needs is not terribly burdensome. But you might not be fully grasping the lifelong issues involved, and it’s hard to imagine yourself in those shoes 30 years from now

Our decision aid tries to help women break out of this present focus tunnel vision. We encourage them to take the time to learn what life is like for families of children with special needs. When thinking through her options, we ask her to consider how the decision would affect the child, herself, and other family members over the long-term — emotionally, physically, and financially.

Representative thinking
Part of the reason it’s so hard to imagine different future scenarios is something called “representative thinking,” where we assume what we know is reflective of an entire category. Continue Reading »

Contributor: Emily Azari – Senior Health Writer, Emmi Solutions

The mind works in mysterious ways. We like to think we’re highly rational, in control of our opinions and decisions. In reality, we’re susceptible to a slew of cognitive biases that lead us to think and act in perfectly irrational ways. And as the field of behavioral economics shows, we’re predictable creatures, falling into the same traps over and over.

Marketers have long known this. For instance, “buy now, pay later” was born out of our attraction to immediate rewards and our extreme aversion to losing. Now, other fields are using these insights to structure information and interventions so it becomes easier to make more advantageous, or at least better-reasoned, decisions.

How does this apply to health?
For anyone working in health behavior change or medical decision making, it’s helpful to understand the psychological forces at play. For example, we recently incorporated these principles into a decision aid to help women choose whether or not they want to pursue prenatal screening for conditions like Down syndrome. (A decision aid is a tool to help people understand all their options, including the pros and cons and how those options fit in with their values and preferences.)

The decision to pursue or decline prenatal screening is not easy. False positives, caveats, and ever-changing tests muddy the waters. In addition to communicating the basics about screening, we wanted to help balance out the knee-jerk reactions and mental mistakes that could plague someone making this decision.

I’ll cover these cognitive biases topic in two posts. Today, I’ll talk about risk and defaults. (By the way, that’s the closest I’ll ever get to sounding like I know something about finance — but don’t worry, I’m not talking about market collapse.) And next time, I’ll go over present focus bias and representative thinking.

Overestimating risk
Turns out, we’re not great at estimating risk. That was a good thing from an evolutionary perspective: when a predator comes your way, you’re not going to want to sit there and ponder how likely it is that he’s already had lunch. These days, our brains still process risk the same way our ancestors did. We make snap judgments and overestimate risk for emotional and scary things. Continue Reading »

Contributor: Emily Azari – Senior Health Writer, Emmi Solutions

Emily Azari

Emily Azari

The heart of shared decision making (SDM) is providing people with balanced information about all their options for a medical issue. For something like breast or prostate cancer treatment options, this makes good intuitive sense. Who wouldn’t want to learn about each possibility and weigh the good, the bad, and the ugly?

But as I began thinking about SDM for a new prenatal genetic testing program we’re developing, I wondered: how much information is too much, especially if someone wasn’t even aware they had a decision to make? When many women find out they’re pregnant, they’re skipping along on Cloud 9. Then… pow!… they’re confronting this incredibly weighty decision. That innocent stroll just morphed into a muddy slog under the threat of a severe thunderstorm.

Prenatal testing: a changing landscape
The decision to pursue genetic testing for chromosomal conditions like Down syndrome is a relatively recent one. Just a couple decades ago, there wasn’t much screening aside from a red flag for women of advanced maternal age. Testing consisted mainly of amniocentesis, an invasive procedure that comes with a small risk of miscarriage, so it was only done for high-risk pregnancies.

Technology advanced rapidly. In 2007, the American Congress of Obstetricians and Gynecologists (ACOG) recommended that ALL women be given the option to screen for chromosomal problems. As recently as 2012, ACOG began recommending a newer form of screening, cell-free fetal DNA testing, to high-risk women. This test is more sensitive and has fewer false positives — in fact, experts believe it will be extended to all women once it has been validated among lower risk populations.

In short, screening options have multiplied, yet clinicians often don’t have time to explain the accuracy, risks, benefits, and cascading decisions involved with this extremely sensitive topic. Continue Reading »

Contributor: Geri Lynn Baumblatt – Executive Director of Patient Engagement, Emmi Solutions (Originally published for the Association of Patient Experience)

Geri Lynn Baumblatt

Geri Lynn Baumblatt

The old adage ends “…but words will never hurt me.” And most of us agree words may hurt feelings but not cause physical pain. However, we also know the emotional and physical are not completely discrete and separate experiences. We’ve all experienced how language or even a friendly text message can affect our mood and emotions. But more evidence points to language having an impact on at least some physical experiences.

This year, at the International Conference on Communication in Healthcare, a symposium on communication and pain discussed recent research showing that while words, themselves, may not literally hurt people, language, tone, or just avoiding the word “pain” can have an impact.

For example, women recovering from a C-section were either asked: “How are you feeling?” or “Do you have pain?” Did the phrasing of the question change reported pain? It did.

  • When asked “How are you feeling?” only 24% of women reported pain.
  • And when asked, “Do you have pain?” that percentage more than doubled, with 54% reporting pain.

A similar study asking women to rate “pain” vs. “comfort” on a 0-10 point scale also found the women who were explicitly asked about pain had higher pain scores.

As psychometricians and political pollsters know, how we ask questions matters. And that’s not always a bad thing. In this case, asking a more open-ended question may improve the experience or perception of pain.

Geri Lynn Baumblatt is the Executive Director of Patient Engagement at Emmi Solutions. She is on the board of the Journal of Patient Experience, a contributor to the Association for Patient Experience, and regularly participates in health literacy and shared decision making conferences and panels for organizations like AHRQ, the Institute for Healthcare Advancement, the Society for Medical Decision Making, Health Literacy Missouri, Stanford Medicine X, the Health Sector Advisory Council at Duke, and the Center for Plain Language. You can follow her on Twitter at @GeriLynn

Contributor: Courtney Hummel – Senior Client Services Specialist, Emmi Solutions

Courtney Hummel

Courtney Hummel

In his TEDtalk, “The Riddle of Experience vs. Memory”, behavioral economist Daniel Kahneman tells a short story about a man listening to a symphony. The man experiences such joy throughout the entire performance , intensely feeling and relating to the music. As the recording meandered to its finale, the music suddenly stopped, replaced by a horrible screeching sound. This ruined the entire symphony, the man solemnly remembered. But, had it? He experienced 20 minutes of glorious music, jarred by a few seconds of madness. But those 20 minutes were now irrelevant; the experience was ruined, replaced with a marred memory.

One key takeaway from this scenario is the human memory is significantly and consistently biased. We must understand that a memory is merely the end result of an experience and the processing of that experience. It’s helpful to think of each person as two selves: an experiencing self (the one that is fully present in the moment and experiences every sight, sound, smell, taste, and feeling) and a remembering self (the one which sifts through the detritus of that entire experience, retains a few key nuggets, and forms a “memory” of it).

And these aren’t just random nuggets. We form memories based on very specific aspects of an experience: the most extreme aspect (the highest high or the lowest low) and the final moments. Shakespeare must have unknowingly donned his behavioral economist cap when he wrote “All’s Well That Ends Well.”

What does this mean for the patient experience? As healthcare systems constantly monitor patient satisfaction scores in both inpatient and outpatient settings, how do we account for what patients care about? What makes them form happy memories? Kahneman actually studied these phenomena, by comparing ‘experienced’ and ‘remembered’ pain levels during colonoscopy exams. Each patient participating was asked to rate his/her pain intensity every 60 seconds on a scale from 0 to 10, (0=no pain, 10=intolerable pain).* Let’s look specifically at two patients in his study:

pain intensity

Photo Credit: Donald Redelmeier; Daniel Kahneman

 

One would assume by total shaded area that Patient B had more pain than Patient A. Poor guy. However, when the team compared patients’ overall ratings of their pain, they remarkably found the opposite to be true. Patient A and those like him described their experience, both immediately following the procedure and much later, as more painful. Herein lays the difference between the experiencing self and the remembering self. Continue Reading »

gbaumblatt

Geri Lynn Baumblatt

Contributor: Geri Lynn Baumblatt – Executive Director of Patient Engagement, Emmi Solutions

At hospitals across the country, the patient experience is coming into its own. No longer just the healthcare term for customer service, the substance of its goals, to humanize every interaction, are at the heart of medicine.

This year at the Beryl, Cleveland Clinic, and Next Generation Patient Experience conferences one theme kept emerging: engaged and satisfied patients are the result of engaged providers and employees. So before the office of patient experience starts assessing the culture or the processes or the quality of care and implementing changes, how can they ensure clinicians and employees are engaged?

Start by Remembering “The Why”
Everyone wants to feel their work matters. And for most people in healthcare, it’s not just a job it’s a vocation: to care, treat, and heal. So start by helping everyone remember their “why”. Ask everyone to tell the story of why they went into healthcare or a story where they felt they made a difference. As former emergency nurse Liz Jaswiec put it, “One of the biggest crises in healthcare today is that caregivers no longer feel heroic.” People want to go home at the end of the day and know they helped save lives and made a difference. Learn their stories and bring that back into focus.

Once providers and all employees feel the focus is on what really matters (and not on better HCAHPS scores or the hospital’s brand), they feel less threatened because the focus isn’t on criticizing what isn’t working. Instead, it’s about recognizing how changes like spending time with each individual isn’t just a better experience for patients and families, but it’s also more fulfilling for the caregiver or employee on the other side of that interaction.

The term “patient experience” is part of the vernacular now. However, looking closer at the best way to accomplish this means humanizing and improving the experience for everyone, starting with the people providing the care.

Geri Lynn Baumblatt is the Executive Director of Patient Engagement at Emmi Solutions. She is on the board of the Journal of Patient Experience, a contributor to the Association for Patient Experience, and regularly participates in health literacy and shared decision making conferences and panels for organizations like AHRQ, the Institute for Healthcare Advancement, the Society for Medical Decision Making, Health Literacy Missouri, Stanford Medicine X, the Health Sector Advisory Council at Duke, and the Center for Plain Language. You can follow her on Twitter at @GeriLynn

Contributor: Emily Azari – Senior Health Writer, Emmi Solutions

Emily Azari

Emily Azari

Our health care system is complicated. So why don’t we have a way of helping people understand how it works before they find themselves in the hot seat? Instead of trial by fire, wouldn’t it be helpful to have some form of Health Care 101?

Blissful ignorance
If we’re fortunate, we’re blissfully unaware of how the medical system works as we’re growing up. When you get sick, a parent whisks you away to the pediatrician and your only concern is whether to accept the lollipop from the stranger in the white coat. If your luck continues as a young adult, you bump into the health care system rarely, if at all, perhaps relying on Mom’s suggestions or the student health service a few blocks away.

But at some point you find yourself selecting health insurance, choosing a doctor, and making appointments. Maybe you have to help a loved one navigate the system. Or you get sick, injured, or develop a chronic illness. Whatever the reason, many of us are unprepared when circumstances push us into health care’s deep end, and we don’t have a coach to show us how to swim.

Stumbling into a foreign world
When I had to choose insurance the first time, I didn’t understand the lingo, and I didn’t know who to ask. It was kind of like how I didn’t know what a car’s transmission was — even though everyone else in the adult world seemed to know. (To be fair, I didn’t buy my first car until I was 25. But if I’m being honest, years have passed and I still don’t know.)

Lingo is a barrier, but at least we’ve got Google. What if you don’t even know who’s who in health care? It took me years to learn that a gynecologist can double as your primary care physician. And how would anyone know an internal medicine doctor can treat problems in the eyes, ears, and skin (which aren’t “inside” the body)?

Young adults might find themselves moving or switching jobs every couple years, which means finding a new doctor — for many, that’s little more than a shot in the dark. To be a savvy patient, you also need to maintain a list of your medications, articulate your symptoms, and keep your medical records organized (and for that matter, you need to realize that’s your job in the first place).

In other words, there’s a long list of skills and knowledge we need, but we’re left to learn it by high-stakes trial and error. Continue Reading »

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