Bob Nease on eliminating the “intention/behavior gap”: Part 2 of an interview by Bob Morris

Nease (M)Bob Nease received his doctorate from Stanford University, where he studied methods to improve medical decisions made by doctors and patients. Before joining Express Scripts in 2001, he was an associate professor of internal medicine at Washington University in St. Louis and an assistant professor at the Dartmouth Medical School. He recently retired as the Chief Scientist at Express Scripts, a Fortune 25 healthcare company dedicated to making the use of prescription medications safer and more affordable. As a leader in the convergence of consumer behavior and healthcare, he was responsible for advancing the Express Scripts behavior-centric approach to the pharmacy benefit. He is the author of more than 70 peer-reviewed scientific articles, and inventor on six US patents.

Over the past several years, Bob has emerged as the nation’s expert on the application of behavioral sciences to health care. He has now turned his attention to equipping others to make practical use of those insights in applications beyond health care — at work, at home, and in the community. His book, The Power of Fifty Bits: The New Science of Turning Good Intentions into Positive Results, was published by HarperBusiness/An Imprint of HarperCollins (January 2016). He and his wife Gina split their time between Phoenix, Austin, and their farm in rural Italy.

Here is an excerpt from Part 2 of my interview of Bob.

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Morris: < When and why did you decide to write em>The Power of Fifty Bits.?

Nease: The book is a practical field guide for improving the behaviors of our customers, our colleagues, our loved ones, and especially ourselves. I started writing it after I’d gotten a good sense of the true nature of the problem, the limitations of other approaches to behavior change, and a working understanding of the seven strategies in the book. As chief scientist at Express Scripts, I was giving a lot of presentations, and people were always asking me where they could find a practical “how to” resource for applying the behavioral sciences.

Morris: Were there any head-snapping revelations while writing it? Please explain.

Nease: Once I decided to write it, I became pretty obsessed with the project. I am still surprised that my wife put up with it.

Morris: To what extent (if any) does the book in final form differ [begin italics] significantly [end italics] from what you originally envisioned?

It started as a reference guide, something someone could pull from the shelf when they were thinking about solving a specific type of behavior change challenge. My editor at HarperCollins reminded me that most people don’t read reference guides, so I focused more on storytelling to get the main ideas across. It’s still a reference guide, but now it’s one that sort of sneaks up on you via engaging examples.

Morris: When and how did you formulate the Fifty Bits concept?

Nease: I realized that most of our bad behaviors are due to inattention or just letting the status quo slide. The bulk of non-adherence to prescription medications is due to forgetting or procrastinating, for example. Then I stumbled across this startling finding: of the 10 million bits our brains each process every second, only 50 bits are dedicated to conscious thought. Understanding that cognitive chokepoint is critical; it tells us that our brains are pretty much wired for inattention and inertia. If you don’t understand that and you’re trying to improve behaviors, you wind up barking up the wrong tree.

Morris: What are the core principles of fifty bits design?

Nease: The main idea is that we are wired for inattention and inertia, and that over time, these lead to a gap between our good intentions and our actual behaviors. Other approaches assume that bad behaviors stem from bad intentions, and so they focus on changing peoples’ underlying desires. In contrast, fifty bits design takes good intentions as a given, and focuses on activating those good desires. The book describes seven different strategies for activating pre-existing good intentions, and uses lots of examples to show how to use each of the strategies in practice.

Morris: Presumably at some point, you connected some of those proverbial “dots” and realized that fifty bits design has almost unlimited applications. Which application excites you most? Why?

Nease: Behavior is mission critical to every human endeavor. Representative democracies depend on us getting up off the couch and voting. Better health depends on us exercising more, eating and sleeping better, and using medical interventions in an effective and sustainable way. Our kids and their kids are counting on us to be good stewards of both the environment and the economy. Our communities and organizations need us to be more plugged in and participatory. Fifty bits design holds the promise to unlock better behaviors across these domains, and that’s incredibly exciting. The thing that excites me the most is that these strategies aren’t rocket science. You don’t need to be a scientist to make a difference. This book is for everyone.

Morris: In the book, you note that much of the time our brains are on autopilot. Fifty bits out of ten million isn’t much to work with. Do you find this disturbing?

Nease: The first reaction a lot of people have when they hear about the “fifty bits” statistic is disappointment at how little of what our brains do is focused on deliberate behavior. I don’t see it that way, and I’m happy that we can do so much without having to deliberately think about it. Take driving a car: when we first learn how to drive, we are using only our fifty bits, and it takes every last one of them. We have to deliberately think about where to place our feet, how hard to push on the gas or brake pedal, how far to turn the steering wheel to the right or the left, how to work the turn signals, when to check the mirrors. There’s a lot going on cognitively, and that’s why new drivers are at a higher risk of having an accident. As with lots of other behaviors that we do repetitively, however, those tasks get handed over to the automatic system, and when that happens we get our fifty bits back and can use it for something else.

Morris: You elevate three shortcuts that people use to navigate through the world. What are they and why are they important to fifty bits design?

Nease: Psychology and behavioral science have identified lots of heuristics and biases that people use and are burdened with. Because I was focused on helping a large group of non-scientists apply the insights in a business setting every day, I settled on a small number of powerful shortcuts.

The first is fitting in: people will make an extra effort to stay part of the group and to meet expectations. There’s a fun example in the book about which hybrid cars people buy and why. It turns out that in towns that “lean green” not only are hybrids more popular, but those that are obviously hybrids (e.g., the Prius) are more popular. In other words, when the prevailing group value is to be eco-friendly, people will go out of their way not just to be eco-friendly but to be conspicuously eco-friendly.

The second shortcut that we often use is loss aversion: people work harder to avoid losses than to pursue gains. Losses are usually seen as deviations “down” from the status quo. That’s how the “endowment” effect works; once I see something as mine, I am more attached to it (i.e., I work harder not to lose it). But losses can also be seen as deviations down from what’s expected. That’s why it feels worse to miss a flight by two minutes than it does to miss it by two hours. It’s a lot easier to envision another reality in which you’d made a flight that you barely missed than one you missed by a mile.

The third shortcut that we use is to focus on the present. To some degree, this is due to the limbic system in our brain; it weighs pleasure and pain in the here and now, but pays no attention to the future. The neocortex area seems more capable of weighing benefits against cost regardless of timing, so for many behaviors these two part of the brain can come into conflict. Exercise, for example, is good for us in the longer term but typically unpleasant in the present. When we make plans to exercise, the limbic system is “offline” – everything about which we’re thinking happens later. When it comes time to exercise, however, the limbic system only perceives the effort involved and none of the costs. If the limbic system wins over the neocortex, we fail to follow through on our plans.

Understanding these shortcuts sets the stage for identifying strategies to effectively change behavior. They are three key psychological forces that often – to one degree or another – contribute to our behavioral hiccups and which can be leveraged to advantage better behaviors.

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Here is a direct link to the complete Part 2.

Please click here to check out Part 1.

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Bob cordially invites you to check out the resources at these websites:

For more information about Fifty Bits design, please click here.

For more information about the book and where to buy it, visit HarperBusiness by clicking here.

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