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The Elephant, The Rider, and the Path to Change in Health Care
Drawing from psychologist Jonathan Haidt’s Elephant and the Rider metaphor, Utah's Chief Medical Quality Officer Bob Pendleton explains why emotions are critical to motivating change in health care. Behavioral economics, it appears, may provide the direction we need.

health care, we over-intellectualize everything. We say that research and data changes practice. We tell ourselves, “If I just show them data, people will understand they need to change direction.” Not the case. What really motivates change is emotion.

Psychologists tell us there are two systems in our brains—the emotional and the rational. Jonathan Haidt, an NYU psychologist, illustrated these systems as the elephant and the rider. The elephant is our emotional being, our comfort with the status quo, the part of us that doesn't really want to change. The rider is our intellectual understanding of the need to change. The rider looks at the data and says, "That's really good data, let me consider the ways I can change my practice." And then there’s the elephant. When we think about change, the hardest part is getting the elephant—our emotions—to move.

Luckily, there are ways to move the elephant borrowed from the field of behavioral economics that leverage self-fulfilling intrinsic motivators as opposed to traditional, short-lived, external motivators such as pursuit of more money or fear of retribution. At University of Utah Health, we’re already using many of these principles to motivate change in ways that feel respectful and connected to who we are. We’ve improved quality and patient experience by setting attainable targets, leveraging peer comparison, using benchmarks and then challenging people to get just a little better.

Set attainable targets

If a goal is too far out in front of us, we have a normal tendency to give up. For example, I need to lose about 30 pounds. When I think about losing 30 pounds, I go back to ordering pizza. But my goal is to actually lose one pound this week. The immediacy and the benchmark right in front of me is actually much more intrinsically motivating. I know what success looks like, I know how to measure it, and it feels achievable.

This principle has driven our patient experience performance from average to nationally-recognized. When you look at our weekly patient experience scorecard, you can see this principle in action. Each area or unit has a goal based on previous performance and the goal requires a bit of stretching. We don’t expect a 20th %ile area to meet an 80th%ile goal. That would be like me and that 30-pound weight loss goal–it feels insurmountable. Creating visible short term wins and celebrating them have powerful motivational effects. These non-financial motivators create positivity and engagement.

Compare me to my peers

Peer to peer comparison is highly effective in motivating change. We all want to be A+ students.

My most recent favorite study is a review of inappropriate antibiotic prescribing in a clinic. The team wanted to reduce unnecessary antibiotic use. They started traditionally by educating providers about the problems with increased antibiotic prescription. Then they did something interesting.

They randomized the providers into three groups.

  1. The first cohort was asked to justify every time they prescribed an antibiotic against the recommended guidelines. The research team called this “accountable justification.”
  2. The second cohort used peer to peer comparison. The research team displayed the individual prescribing habits of each provider in the cohort.
  3. The third cohort implemented an EMR workflow change.

I was surprised at the results. When the team looked at which group had actually improved antibiotic rates, it was the peer to peer comparison group. A close second was the “accountable justification” group. I would have guessed that decision-making embedded in the EMR workflow would have created the most change, but that wasn’t the case. It was the elephant that changed behavior!

When we fail to incorporate behavioral economic principles in leading individual divisions, sections, and teams, we're losing a powerful motivator. The value-driven outcomes (VDO) program is a visible example of this thinking. Borrowing from the lessons learned from our exceptional patient experience, VDO incorporated benchmarks, threshold effects and local cohort comparisons. Another great example is the Hospitalist group’s work to reduce inappropriate laboratory ordering, led initially by Dr. Peter Yarborough and now by Dr. Claire Ciarkowski. The primary intervention is peer to peer comparison. Very little of the intervention depends on adjusting the EHR. Using behavioral economics, the team has measurably reduced unnecessary lab re-testing for hospitalized patients.

What's Next?

A meaningful research opportunity exists to study the impact of behavioral economics. Are certain interventions more effective than others? What is the impact of combinations of interventions? What is the sustainability of these interventions? How do these interventions affect our resiliency and sense of joy and purpose in our work? We have an opportunity to start asking and answering these kinds of questions to advance the field.



Bob Pendleton

Founder and Chief Sponsor, Accelerate

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