Reading Room

Nudge — to give (someone) a gentle reminder or encouragement.
Webster’s Dictionary

Improving Decisions about Health, Wealth, and Happiness
by Richard H. Thaler & Cass R. Sunstein | Yale University Press

Few people will be surprised to learn that the setting in which individuals make decisions often influences the choices they make.

How much we eat depends on what’s served on our plate, what foods we pick from the cafeteria line depends on whether the salads or the desserts are placed at eye level (although I can argue that no matter where desert is I will find it), and what magazines we buy depends on which ones are on display at the supermarket checkout line.

But the same tendency also affects decisions with more significant consequences: how much families save and how they invest; what kind of mortgage they take out; which medical insurance they choose; what cars they drive.

Behavioral economics, a new area of research combining economics and psychology, has repeatedly documented how our apparently free choices are affected by the way options are presented to us.

This practice of structuring choices is called “choice architecture” and Richard Thaler and Cass Sunstein’s book “Nudge,” is an insightful journey through the emerging evidence about how human beings make decisions and how that evidence can help individuals and policy makers reach better decisions.

Thaler and Sunstein apply the principles of choice architecture to a few problems in healthcare:

  • How could Medicare part D be improved?
  • How can organ donation rates be increased?
  • Why shouldn’t patients be allowed to waive their right to sue for medical negligence in return for cheaper health care?

But the concepts in the book go well beyond their specific examples and could prove very useful to practicing clinicians, who, the authors note, are often in the position of being choice architects for their patients.

Although there is still a lot of work to be accomplished (a lot) — some of the principles of choice architecture are beginning to find their way into projects to promote better care, ensure better health outcomes and lower costs — such as Accountable Care Organizations (ACO) and Patient Centered Medical Homes (PCMH). These include (but are not limited to):

  • Alignment of incentives with desired and measurable outcomes (e.g. improved provider reimbursement for the active and measurable care coordination of diabetic patients).
  • Default care options that support better health practices (e.g. childhood immunizations).
  • Communication about care and treatment choices and their associated outcomes in patient friendly formats (e.g. structure and well supported informed decision making programs).
  • Systems that expect and therefore are designed to prevent, detect, and minimize errors and improve patient compliance (e.g., pill cases and inhalers with dosage counters, alerts and reminders).

I enjoyed Nudge — the examples are interesting and fun to read. But be fair-warned, some of the theory can be a bit of a slog (just a tad). That said, the information in this book absolutely has the potential to change the way you think about healthcare systems and the delivery of patient care.

And if nothing else, I am quite certain that Thaler and Sunstein’s work about “choice architecture” will be the source of an excellent debate in the coming decades.

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