the picture of health
When you think about the phrase “medical research” the image that probably enters your mind is a white-coated scientist, carefully pipetting chemicals, culturing cells or observing something under a microscope. For centuries, research in the basic sciences—chemistry, physics and biology—produced medicine’s most substantive advances. However, a shifting landscape of disease suggests that medicine will have to adopt discoveries from a broader array of disciplines, such as psychology and economics, if it is to effectively address the challenges of the future.
Translational research is the process of transitioning discoveries from “bench to bedside”—leveraging fundamental scientific discoveries into applicable treatments for patients. Take for example the development of cancer therapies. A fundamental understanding of cell division led to the discovery of agents that halt that process. These agents were then developed into medications that target rapidly dividing cancer cells. Similarly, research about human behavior and decision-making can be leveraged to create interventions to treat diseases driven by choices.
In industrialized nations, the landscape of disease is rapidly shifting. Due to medical advances in the treatment of infectious disease and traumatic injury, American mortality is increasingly driven by chronic, and often preventable, disease. In 1900, 23.1 percent of all deaths were attributed to pneumonia, influenza and tuberculosis and just 3.7 percent of deaths were attributed to cancer. However, in 2005, influenza and pneumonia accounted for just 2.6 percent of deaths while cancer contributed 22.8 percent. The discoveries of chemists, biologists and physicists have radically improved the survival of cancer patients. However, research from the behavioral sciences can help craft interventions that lower the risk of developing the disease at all.
Inducing behavioral change could have a major effect on health outcomes. In 2010, it was estimated that 42.7 percent of the cancers in Britain could be attributed to lifestyle factors, such as obesity, smoking and exercise. Psychological studies shed light on the most effective ways to elicit a lifestyle change. For example, motivational interviewing is a technique used to prompt and support patients in making change. This technique seeks to address ambivalence to change by eliciting patient’s own motivation. Using this approach to prompt behavioral change—rather than confronting or persuading patients—results in statistically significant improvements in health. Studies have shown that motivational interviewing results in increased weight loss and exercise, decreased viral load among HIV positive patients, and lower blood pressure and cholesterol values.
Another non-traditional discipline that is particularly suited to crafting health interventions is behavioral economics, which combines the fundamentals of economic theory with insights from psychology. Behavioral economics challenges the assumption that humans behave as fully informed and rational actors and instead understands decision-making as a process with predictable biases. For example, psychological and economic studies have shown that humans overvalue immediate rewards and undervalue delayed rewards. In health terms, this means that the immediate joy of a donut is overvalued against the amorphous increased risk of cardiovascular disease in the future. Similarly, the hassle of taking a medication every day may seem more onerous than the potential progression of future disease. Since these biases are predictable, interventions can be be designed to anticipate and counteract the bias, or use bias to predispose us to healthy, rather than unhealthy behavior.
Investigators at the University of Pennsylvania used findings from behavioral economics to create an intervention to increase adherence to warfarin, an anticoagulant that must be taken consistently to be effective. In the study, a machine recorded each time a dose of the medication was taken and gave the patient with an entry in a lottery with small prizes. The incentive increased adherence to medication, better than a simple reminder message. Given the fact that discontinuation of warfarin has major health risks, and patients who discontinue warfarin typically incur an additional $5,000 in annual healthcare expenditures, this intervention could have significant clinical implications.
Information from psychology about human decision making—and human error—can also be used to help physicians and surgeons provide better care for patients. Industries such as aviation, manufacturing, and nuclear power, have long incorporated research about human error into their systems design. Their systems anticipate and respond to human mistakes, allowing for correction before an error becomes critical. These systems leave nothing to chance or fallible human memory. While medicine has been slower to adopt this mentality, reports suggesting as many as 98,000 die annually as the result of medical errors have spurred action. Simple, evidence-based interventions that anticipate human error can have a major impact—implementing a infection prevention checklist dropped rate of infections in Michigan ICUs by 66 percent.
While translational research has traditionally focused on the hard sciences, human behavior is an increasingly important factor driving morbidity and mortality. In order to address these important challenges, we must widen the focus of translational research to include research that specifically addresses decision-making and behavior. Interventions based on this research can help elicit behavioral change in patients and help protect patients from the inevitable fallibility of medical providers. Just as fundamental discoveries in the hard sciences lead to life saving advances, so too can the discoveries of behavioral sciences.
Lauren Groskaufmanis is a graduate student in the school of medicine. Her column, “the picture of health,” runs on alternate Fridays.