A more holistic view of people’s decision-making can help us better help our patients
by Austin Perlmutter, MD April 18, 2021
The patient sat down in the exam chair. It had been two months since I saw him last. At that time, we had discussed his rising blood sugar and blood pressure. I had explained to him that unless he changed his diet and started to exercise, things would get worse, and he’d be putting himself at higher risk for things like stroke and heart attack. In response, he had agreed to work on drinking less soda and walking more. When he came in today I said, “So, how did the plan go?” He sighed. “Not good.” As we concluded the visit, I typed “noncompliant with lifestyle modification recommendations” into the chart, and made a note to discuss starting medications at the next visit.
Over the course of a single day in the clinic, this story played out over and over again. I’d recommend exercise and dietary modification, and patients would nod and then fail to follow through. My experience was shockingly consistent with that of other providers. In fact, some reports show rates of “non-adherence” to preventive regimens over 80% of the time. This is, of course, a much bigger problem than healthcare behavior change. Why, despite knowing what is needed for better health, do most of us have such a hard time aligning our present actions with our future goals? Is blame — of others and ourselves — the best we can do when things go wrong?
The world of medicine has seen unbelievable advancement and innovation in the last several decades. Yet, when it comes to eliciting behavior change, we largely remain trapped in an outdated psychological model of willpower and volitional control.
Learning From Economic Models
One of the best insights into better frameworks around decision-making comes from the world of economics. Until relatively recently, economic models focused on rational choice theory. This framework models the outcomes of human behavior as the result of rational decision-making that weighs the pros and cons of a given choice before making a selection. Humans were thus “rational agents,” making choices which synced with their self-determined optimal plan of action. In the second half of the twentieth century, psychologists and economists started to challenge this framework, arguing that psychological, cognitive, emotional, and environmental factors, among others, significantly influenced the way real humans make choices. This alternative perspective became known as behavioral economics, and proposes that the rationality of humans is bounded.
Behavioral economics provides a host of ways in which human decisions can be biased or otherwise influenced. These include mental shortcuts (heuristics), cognitive biases, and the role of environmental cues (nudging). As a whole, the field helps us to see that humans display consistent errors in “rational” conscious thinking. Work by behavioral economist and Nobel recipient Daniel Kahneman additionally proposed a working model of the brain broken into two systems. These include a system one, which operates unconsciously/automatically, and system two, which engages in more effortful, deliberative decision-making. The basic idea: our choices in real life are a reflection of much more than our conscious desires.
Insights from Habit Research
System one in Kahneman’s two-system model helps contextualize research on habits, which has more recently gained popularity in scientific and lay publications. Habits are defined as subconscious context-dependent actions. By their nature, they are automatic, and not subject to the higher-level reflective thinking characterizing the “rational agent.” Research from research psychologist Wendy Wood and her colleagues has demonstrated that around 40% of our daily actions can be classified as habit-driven. This was a major hit for the idea of the conscious decision-maker as the only determinant in our outcomes.
The combined insights from behavioral economics and habit research cast serious doubt on the idea of decisions as a singular outgrowth of a conscious, rational brain. It compromises the rationale for castigating “bad” decisions. It’s far easier to blame a conscious “self” for an action than it is to discuss the major role of unconscious programming in our choices. And yet, it is medicine itself that may provide the biggest reason to abandon the “rational agent” model altogether.
Translation Into Medicine
When a person develops shortness of breath, and testing reveals the likely cause to be heart disease, we work to support the heart for better function. This may include medications, lifestyle interventions and in some cases, medical procedures. Yet, when a person is making low-quality decisions, we generally don’t ask what’s happening in the brain or try to support healthier brain function to bring about better decisions. We are instead likely to ascribe poor choices to variables like “lack of willpower” or other vague psychological deficits. Science shows us that we can do so much better.
Research in the fields of immunology, endocrinology, and neuroscience has convincingly demonstrated that our choices are biological. For example, levels of the hormone ghrelin correlate with appetite, and giving ghrelin to humans significantly increases food intake. Changes in estrogen levels during the menstrual cycle predict impulsive thinking, and testosterone and cortisol are thought to affect financial decisions in men. The state of our immune function has also been found to affect our thoughts and actions. Higher levels of inflammation, for example, are associated with more present-focused thinking as opposed to future-orientation, and induction of inflammation in volunteers predicts more impulsive thinking.
Decision-making patterns can also be linked to patterns of brain activation and structure. In imaging studies, the quality of our decisions reflects activation and interactions between parts of the brain including the prefrontal cortex and the basal ganglia, and when researchers activate the lateral prefrontal cortex using magnetic stimulation, impulsive thinking decreases. This research makes it readily apparent that the quality of our decisions reflects the state of our brains.
A Holistic View of Decision-Making
Reconceptualizing choices as an outgrowth of our biological systems invites empathy and curiosity in place of blame. Biological variables like hormones, immune markers, and activation states of the brain provide windows to help us understand why we do what we do, instead of simply chalking poor decisions up to an unhelpful character trait or defect in psychology. But better understanding the variables is only the first step. Modern science has also shown us how we can influence them through lifestyle modifications to improve our decision-making.
Engaging with nature may help to offset the effects of stress and improve future-oriented decision-making. One study showed that compared to photos of buildings, even short exposures to nature photographs could help decrease impulsive thinking. Getting restful sleep may help us to make healthier food choices, while poor sleep may predispose us to eating more food, especially foods that lead to weight gain, potentially by way of increasing the hormone ghrelin. Exercise may also represent a pragmatic intervention for strengthening executive functions, the brain functions needed for good decision-making. Meditation and mindfulness similarly may affect the parts of the brain most implicated in healthy choices and enhance executive functions. And of course, dietary quality plays a role here as well, with consumption of more fruits and vegetables correlated with improved executive functions.
The takeaway is very simple: we need a more holistic, biologically informed view of decision-making. The blame-based model just perpetuates poor choices by increasing stress. It’s not working in healthcare or in the general public. It’s high time we take a deeper look at the biological substrate that underlies our thinking, and move away from snap judgments based on limited and faulty data. Behavioral economics and habit research opened the door to new models of understanding human behavior, and it’s time for the medical community to take the next step.
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