The Power of Fifty Bits

Bob Nease

• Publisher: Harper Business
• Year: 2016
• ISBN:
  9780062407467
• Topic: Business
• Subtopic: Marketing
• Index: Business

Going beyond the bestsellers Predictably Irrational and Thinking, Fast and Slow, the first "how to" guide that shows you how to help customers, employees, coworkers, and clients make better choices to get what they truly want.

Of the ten million bits of information our brains process each second, only fifty bits are devoted to conscious thought. Because our brains are wired to be inattentive, we often choose without thinking, acting against our own interests—what we truly want. As the former Chief Scientist of Express Scripts, a Fortune 25 healthcare company dedicated to making the use of prescription medications safer and more affordable, Bob Nease is an expert on applying behavioral sciences to health care. Now, he applies his knowledge to the wider world, providing important practical solutions marketers, human resources professionals, teachers, and even parents can use to improve the behavior of others around them, and get the positive results they want.

Nease offers a set of powerful and effective strategies to change behavior, including:

• Require Choice—compel people to deliberately choose among options
• Lock in Good Intentions—allow people to make decisions today about choices they will face in the future
• Let It Ride—set the default to the desired option and let people opt out if they wish
• Get in the Flow—go to where peoples' attention is likely to be naturally
• Reframe the Choices—set the framework people use to consider options and choices
• Piggyback It—connect the desired choice or behavior with something they already like or are engaged in
• Simplify... Wisely—make right choices frictionless and easy, make wrong choices more difficult
• And more.

CHAPTER 1

Wired for Inattention and Inertia

In the week before Easter of 1889, President Benjamin Harrison appointed Robert P. Porter to the post of supervisor of the census. Porter immediately faced a nightmare of constitutional proportions. Normally, such an appointment would be an honor, but Mr. Porter found himself with an immediate headache. Article 1, Section 2 of the US Constitution mandates that a census be taken every ten years. Unfortunately, the previous census of 1880 had taken nearly a decade to complete and was just barely rolling off the presses when Porter took on his new job. Because the population of the United States had continued its upward climb, the best guess at the time was that the 1890 census would take thirteen years to complete—which would obviously create a big complication come time for the 1900 census. Mr. Porter was in a pickle.

Fortunately, an electromechanical whiz kid named Herman Hollerith was already all over the problem. At age nineteen, Hollerith had worked on the 1880 census and had a firsthand appreciation of both the size and the nature of the challenge. In fact, Hollerith had anticipated the problem years earlier and had developed a system that he believed would dramatically shorten the time required to complete the census.

Hollerith’s key insight was that the choke point for the US census was not the collection of the data—done by enumerators going door to door—but the speed at which the data they’d collected could be processed. Prior approaches involved tabulating and sorting data by hand, tracking counts with tally sheets and a series of hash marks (in groups of five).

Hollerith cracked the nut by employing punch cards that could be quickly “read” using an electromechanical system of metal pins that poked through the punched holes and into wells filled with mercury. This completed a circuit and incremented a series of forty counters that kept track of age, household status, employment, race, and a number of other variables captured for the census. Hollerith’s automated system was far faster than the approaches that came before; the rough population count was complete in a matter of months, and the full tabulation (which was far more robust than previous analyses) was completed with plenty of time to spare. Hollerith’s machine served as a launching point for applications in other areas, and the company he founded eventually became International Business Machines—known today as IBM.

The human brain has its own processing choke point. Each second, your brain devours about ten million bits of information. This is the equivalent of having the original Ethernet cable running at full capacity plugged directly into your brain. The hang-up is that the conscious part of your brain (and mine as well)—the part of the brain of which we’re aware when we’re using it—can only process about fifty bits per second.

This is a stunning pair of information-processing rates, because it shows us just how scarce human attention is. If you doubt how limited your attention really is, try simultaneously singing “The Star-Spangled Banner” and counting backward from 100. Or make yourself aware of the way the chair feels on your rump, and the sound of whatever is going on around you, and then spell “cantaloupe” backward . . . all at the same time. Most of us can’t, and we shouldn’t take it personally.

I’m not sure what’s more difficult: to appreciate how fast ten million bits per second is, or how slow fifty bits per second is. But here’s a way of wrapping your mind around how slow your mind is wrapping itself around things. Let’s assume that a cup of sugar represents all the information entering your brain each second. In this scenario, the part your conscious mind is aware of is about ten grains—an almost undetectable amount. In short, 99.9995 percent of our bandwidth is beyond the reach of our awareness.

THE INTENT-BEHAVIOR GAP

The fundamental idea of The Power of Fifty Bits is that for better or worse our brains are wired for inattention and inertia, not for attention and choice. This point is critical for those of us who are trying to improve behavior, because most of the time we act as though people have an infinite appetite for information and a boundless willingness to make decisions. Nothing could be further from the truth.

The fact of the matter is that we tend to focus our attention on things that are either pressing or pleasurable. Life—what happens, as John Lennon sang, when we are busy making other plans—is loaded with mundane stuff that is neither pressing nor pleasurable. That means we pay little attention to much of what we do. If the status quo isn’t painfully broken, and if an alternative doesn’t tickle our fancy, we are apt to let things ride.

Once you understand it, you begin to see evidence of the intent-behavior gap all around you. When I was at Express Scripts, we partnered with a national survey firm to estimate the size of the intent-behavior gap for key medication behaviors. To do this, in the first half of the survey we asked respondents whether they were using brand-name or generic medications, whether they were using home delivery or retail for their maintenance medications, and which retail pharmacies they were using. (In each of these cases, one option is lower cost and offers equal benefits: using a generic rather than a brand, having long-term medications delivered directly to your home rather than going to a retail pharmacy, and using the lowest-cost retail pharmacies for short-term medications.)

Later in the survey, we presented respondents with realistic pairs of options (e.g., getting their long-term medications by home delivery instead of going to a retail pharmacy). This approach allowed us to determine the fraction of people who were doing one thing (e.g., using retail pharmacy for their long-term medications) but who preferred something different (e.g., home delivery) when they stopped long enough to think about it. Eight of ten users of brand-name drugs would rather be on a generic, seven out of ten people getting their medications in retail would rather be getting their long-term medications in home delivery, and four of ten users were willing to move to a different retail pharmacy if it saved their plan money . . . even if it didn’t save them any money in the near term. (The seven-out-of-ten statistic for home delivery reflected copayments that were very favorable for mail order; it dropped to five out of ten for copayments that are more typical.)

The intent-behavior gap is critical because it radically alters how we approach behavior change. Human resource executives, marketers, and others often infer people’s underlying intentions from observed behaviors (e.g., most patients are getting their maintenance medications from retail pharmacies, so they must prefer retail over home delivery). This leads us to focus on strategies for changing underlying intentions—strategies that focus on persuasion, cajoling, and the like.

The intent-behavior gap tells us that when we use these approaches we are very likely barking up the wrong tree. It’s no wonder that we are routinely disappointed by educational campaigns aimed at extolling the virtues of this behavior or that, or by financial incentive schemes to lure people into the desired behavior. These things have less effect than you’d guess because lots of people already believe in the virtue and value of the behaviors that are being promoted. The problem isn’t that people’s intentions are pointed in the wrong direction. It’s that people are not acting on the good intentions that they already have.

The intent-behavior gap is at the heart of some extremely powerful solutions for changing behavior. We don’t need to change people’s intentions. We don’t need to persuade them or to attempt to change their minds. What we need is to activate their preexisting intentions to do the right thing.

Adherence to medications provides an interesting example of how a “fifty bits” point of view significantly changed our approach. If behavior and intentions move in lockstep, and you observe that patients aren’t taking their medications as prescribed, then you must conclude that their behavior is deliberate: patients aren’t taking their medications because they think the drugs aren’t working, or are causing side effects, or cost too much. As a result, the solutions you design will focus on solving these problems (e.g., lowering the cost of medications).

But when you look at nonadherence through the lens of fifty bits, an entirely different set of causes rises to the top, and these lead to very different solutions. We should expect a lot of forgetting and procrastinating by patients: forgetting to take their medications, delays in getting refills, and delays in getting new prescriptions when they have no more refills left. Fifty bits tells us that nonadherence will be accidental rather than deliberate.

This situation is exactly what my colleagues and I found when we looked at patients taking medications for high blood pressure: nearly 70 percent of nonadherence was completely accidental—patients periodically forgetting or procrastinating on refills and renewals. The remaining causes for nonadherence were equally split between cost concerns and clinical concerns. When you ignore the fifty bits limitation, you risk losing sight of an entire class of causes of suboptimal behavior, and you fail to pursue effective solutions for those problems.

Once you understand and believe in the fifty bits way of looking at the world, a lot changes. You stop focusing on trying to change behavior by changing intentions. Instead, you start focusing on strategies that activate the good intentions that already exist for most people.

OUR LAGGY, LAZY BRAINS

Inattention and inertia reflect the way human brains are wired, and that wiring is a reflection of the way our brains evolved. Like any other organ, our brains are the result of millions of years of evolution. (If you’re the parent of a teenager, you’ll probably want to take evolution aside for a very stern discussion and ask whether this is really the best that could be done with such a generous timeline.)

That our brains are evolved organs leads to two critical and interlocking insights. The first is that they are stuck far in the past. For the vast majority of our evolutionary history, we’ve lived in small groups scraping by, foraging plants and hunting animals. It’s an existence that the evolutionary psychologists Leda Cosmides and John Tooby describe as “a camping trip that lasted an entire lifetime,” and it’s been that way for millions of years.

If you doubt that our brains are stuck in the past, just consider the things that spook us. For example, many of us fear spiders and snakes, and why not? They’re creepy, and as we all know, they can be deadly. But a cool-headed look at the data shows that our fears are wildly overblown. In the United States, snakebites cause five to seven deaths per year, and deaths from spiders are so rare that it’s tough to get a reliable estimate of the risk (there were only two reported deaths from spider bites between 2001 and 2005). In contrast, every year six hundred or so Americans suffer bicycle-associated deaths, and about six hundred thousand Americans die each year from heart disease. If our fear circuits were calibrated to today’s environment, we would be about a hundred times more skittish about ten-speeds than rattlesnakes, and completely petrified of cigarettes and saturated fats.

It’s not just about fear. We’re wired to solve all sorts of problems that we faced way back when and way over there—problems that, for the most part, we no longer face. Conversely, we now face daily tasks (e.g., shopping for food, deciding whether to go to a movie or stay home and read) that were nonexistent for our ancestors.

In other words, evolution has endowed us with a set of mental capabilities and functions that are solutions to key problems—but they are the problems faced by our ancestors over vast periods of time in our long-ago past. Our species spent nearly its entire existence in a relatively stable and harsh environment, and it’s in that environment where natural selection has done the majority of its work. Ten million years is a length of time that’s incomprehensible to most of us, and try as we might, it’s simply impossible to grasp how narrow the time window is in which we’ve made some of our most important advances—including ATMs and microwave popcorn.

But perhaps even more germane is how radically our environment has changed in our very recent past. Our standard of living was stuck in the mud for nearly all of human history. This situation has improved dramatically—at least in developed countries—since the dawn of the industrial revolution only about three hundred years ago. Until that time, we were held in a tight Malthusian, zero-sum grip: the only way for me to do better was for you (or someone else) to do worse; increases in the quality and length of life for some people only occurred by offsetting decreases in the quality and length of life among others. Sadly, wars and plagues improved the lives of those who survived them because a fixed set of resources was available to a smaller number of people.

And then something remarkable happened. The industrial revolution produced a rising tide that for the first time in the history of humankind lifted all boats. No longer were improvements in quality of life in one group dependent on increased misery among another. It was as if, at least among a large chunk of the world’s population, the rules of the game changed dramatically.

Why does this matter? Because this major shift happened in a time frame so recent that evolution has not had a chance to catch up. In a very real sense, our brains—and the instincts, sentiments, and inclinations they produce—are living fossils from a very different environment.

PREDICTABLY IRRATIONAL OR LIVING LOGICALLY?

The realization that human inclinations and instincts are a peek into the past can help resolve the ongoing tension that exists between classical economists and social psychologists. Traditional economists argue that people are mostly rational and that they reliably respond to incentives (often referred to as the Homo economicus model). Psychologists often focus instead on how irrational people are and how they reliably violate the assumptions of classical economics (affectionately referred to as Homer economicus in a nod to the donut-loving father from the television show, The Simpsons).

Economist and journalist Tim Harford, for example, has observed that as the cost of unprotected vaginal sex increases (e.g., by decreasing the availability of abortions or requiring parental notification), rates of sexually transmitted infection among teenagers (relative to those for adults) drop, presumably due to less frequent sex or greater use of condoms. This shift is precisely the effect one would predict if teens were making decisions about sexual behaviors in a rational manner: as costs increase, demand decreases.

Psychologists, on the other hand, have convincingly argued that people reliably deviate from rational decision-making. In the same arena of sexual behavior, for example, social psychologist Dan Ariely notes that people not only make different decisions when they are sexually stimulated than when they are not, but they also incorrectly predict that they will behave the same in both aroused and unaroused states. This “hot state/cool state” effect is difficult to fit squarely within a rational model of decision-making.

Harford celebrates the rationality of people engaging in everyday behaviors (the trick is to understand the incentives to which people are responding), while Ariely relishes the predictable irrationality of those same people. So which is it? Are people reliably rational or predictably irrational?

As interesting as these arguments are, they obscure a more fundamental point. The question isn’t so much whether people are rational or irrational. The fifty bits perspective says that most of the time we’re neither. Instead, a more useful distinction is to think about whether our behaviors are adaptive or maladaptive to the current environment. Those behaviors that are adaptive appear to be rational; those that are not adaptive often appear to be irrational. For example, most of us enjoy eating foods that contain fat or sugar (or both), and we may find that at times we eat a lot more than we should. This behavior doesn’t make a lot of sense, because after engaging in it we experience regret and may even devote additional time and effort to undo the results of our behavior (e.g., diet or exercise). But in the resource-scarce environment in which our brains developed, this sort of behavior would have been very adaptive: eating foods high in calories (i.e., containing fat or sugar) and consuming past the point of comfort would offer evolutionary advantages.

Rationality may simply be a by-product of (mostly automatic) behaviors shaped by past natural selection that still ...