He was talking on his mobile phone even as I ushered him along the corridor to the consulting room. He kept up the conversation even as we sat down. I took it all in as he raised his nicotine stained finger signaling he was nearly finished- the worn baseball cap perched atop his dirty hair. The missing incisor, the thread bare tee shirt and torn jeans. A pair of filthy unlaced trainers completed the look of someone who might have been sleeping on the streets for a week.

As a doctor I’m in the ‘people’ business. All whose life I hope to influence for the better are people. That’s a challenge because people come in all shapes and sizes, not to say ways of being and there is no question that their interactions with me are likely to influence my behaviour as much as mine does them.

The usual route to behaviour change in economics and psychology has been to attempt to ‘change minds’ by influencing the way people think through information and incentives. There is, however, increasing evidence to suggest that ‘changing contexts’ by influencing the environments within which people act (in largely automatic ways) can have important effects on behaviour. 

Dolan et al

How I choose to react in a meeting with someone else is an opportunity to exercise supreme agency. Nobody likes to think that their ‘buttons’ can be pushed without being aware and able to override and automatic responses.

Dolan and colleagues used the pneumonic MINDSPACE to summarise how this happens.

M: Messenger- we are heavily influenced by who communicates information to us. In healthcare information drives the action. That means that we take into account all manner of information within milliseconds of meeting a person. Size, shape, accent, smell, colour and draw conclusions that may or may not be valid.

I: Incentives: our response to incentives are shaped by predictable mental shortcuts such as strongly avoiding losses. What kind of losses are relevant to you- loss of time, loss of income, loss of control?

N: Norms we are strongly influenced by what others do. Entire books have been written about this in medicine but the paper I like to quote most is by Gabbay and le May. Yikes! who have I been talking to lately in the coffee room?

Clinicians rarely accessed and used explicit evidence from research or other sources directly, but relied on “mindlines”—collectively reinforced, internalised, tacit guidelines. These were informed by brief reading but mainly by their own and their colleagues’ experience, their interactions with each other and with opinion leaders, patients, and pharmaceutical representatives, and other sources of largely tacit knowledge. Mediated by organisational demands and constraints, mindlines were iteratively negotiated with a variety of key actors, often through a range of informal interactions in fluid “communities of practice,” resulting in socially constructed “knowledge in practice

Gabbay and le May

D: Defaults- we ‘go with the flow’ of preset options. In this situation I always do these tests or I don’t consider that option or that ‘type of person’ always responds to this treatment. Are you aware of your default mode?

S: Salience- our attention is drawn to what is novel and seems relevant to us. The challenge is that whilst that might alert us to something of interest it might also send us down the proverbial rabbit hole. ‘Common things are common’ as medical educators like to tell us. There may be something novel about almost anyone we meet but that does not mean it is the reason why they need our help on this occasion.

P: Priming – our acts are often influenced by subconscious cues. Markham Heid alerts us to some of these prejudices. Gender and racial bias are the most problematic but one you don’t hear often is prejudice founded on bad teeth. I imagine tattoos and body piercings might have found their way on this list.

A: Affect- our emotional associations can powerfully shape our actions. This is one to watch- how are you feeling today? What did that person say or do to put you in this mood? What impact might that have on your interactions with people who are going to need you to explain their situation?

C: Commitments- we seek to be consistent with our public promises and reciprocate acts. Perhaps that’s a good thing but it still implies ‘automatic’ behaviours and that can go awry.

E: Ego- we act in ways that make us feel better about ourselves. Having trained in a competitive environment for all of their career health professionals need to be aware when the need for validation impinges on their encounters with people who need help. There are no medals for lifelong selfless service of others.

Photo by Nathan Dumlao on Unsplash