"Benevolent" Social Engineering for Behavior Change!

The health care industry is heavily regulated and health care workers need to be aware of these rules and regulations that relate to personal and patient safety, security of data, etc.

The big question is whether the training leads to changes in behavior.  Of course, being aware of the information is necessary; no one would dispute that.  But education alone is in most cases a weak intervention for behavior change unless it is accompanied by something I call "benevolent social engineering".  The phrase social engineering has evil connotations and thus the modifier "benevolent".  

What do I mean by this?  Lets take the story of recycling.  

Say, someone crawls out from under a rock and sees a blue recycle bin somewhere.  He would have no clue what to do with it.  He would benefit from a brief training on importance of recycling and how to do it.  Suppose after the training, he decides he wants to recycle his can of soda   If the nearest recycle bin is 250 meters away, but there are 3 trash cans within 10 meters, he is  somewhat unlikely to recycle the can.  On the other hand if there were recycle bins within easier reach, a fewer trash cans, we could change behavior relatively easily.

What implications does this have for health care?  

The IDSA and ATS guidelines for community acquired pneumonia recommend either a fluoroquinolone or macrolide+beta lactam for inpatient cases.  For some hypothetical reason (like local susceptibility patterns), your institution guideline is to not use fluoroquinolone alone for community acquired pneumonia (CAP).  What if you notice that the residents in your hospital are using inappropriate antibiotics to treat patients admitted CAP.  You educate them about the guidelines, formulary, costs and susceptibility patterns and advise them to use azithromycin + ceftriaxone unless there are contraindications like allergies.  You study the effect of your intervention and notice no change in behavior.  You do a focus group of residents to see why they still use a fluoroquinolone alone.  It is possible that you may find that there is an order set in the electronic health record that makes it easier to order a fluoroquinolone rather than the preferred combination.  You change the order set and it is quite possible that you will see a big change in behavior.

Besides making things easier or more convenient, benevolent social engineering sends a message that something is more important.  Otherwise the hidden curriculum of the education intervention is, "We are just paying lip service to this.  Keep doing whatever you were doing."  Seeing the old order set for fluoroquinolone sends the same message as the multiple trash cans - "We don't think recycling is important".  When an institution backs up its educational efforts with the measures that make action easier, it tells the health care worker that it is a priority!  Its like putting your money where your mouth is!

3 Case Studies for managing information and staying organized

At a several recent meetings, colleagues have mentioned how they are finding it increasingly difficult managing information in various different settings.

Some examples:

1.  One colleague needs to have regularly scheduled meetings with a group of physicians.  They need to share and collaboratively author documents.  Not everyone can attend these meetings consistently.
2.  Another colleague finds it difficult to keep up with literature in his specialty.  He gets a lot of print journals, but does not have a streamlined way of recalling recent studies and finding them quickly when needed.
3.  A third colleague finds that she is getting disorganized, gets distracted and is unable to complete elective but high stake tasks.

Three very common problems and here are the solutions I proposed to them.  One criteria I used was to use  tools that were free.

1.  I suggested that he start using Google+ and Google Docs.  It is very surprising how many people do NOT know about these tools.  Sure there are other ways to do this but the sheer simplicity of Google Docs is a winner for any group with members that might be technically challenged.  The commonest question I get is, "How do I save the document?" Some other questions are, "How do I share this document?" or "Does it track versions?" 

I suggested he set up a Google circle with the participants.  He could then start a Google document and set it up to be editable by anyone with a link.  He could then copy the link and share it with the Google circle.  He could also start a Hangout at the next meeting to discuss the document and those who could not attend live, could participate via the Hangout.  Using Google Hangout with extras they could collaboratively edit the document.  

The part he loved was that at the end of the Hangout, the document was finalized and he did not have to send it to anyone.  They could all see it on Google Docs.  

2.  This conversation started when the colleague was complaining about the flood of lab results, copied charts, refill requests etc in his EHR inbox.  I mentioned a recent Archives article where they found that 50% of such messages and alerts are not important.  Even in the important messages 80% of the text is irrelevant to the critical message.  He was surprised I was able recall the article and pull it up quickly on my laptop.  

I described how I use Google Reader to subscribe to key journals in my area of interest.  In addition I have set up RSS feeds on specific key words from PubMed.  As I scan through the articles, I tag and organize them by specialty.  I share some of these articles with colleagues on Twitter or Google+ which leads to some interesting discussions and helps ingrain the article in my memory.  

The part that really works is finding the article that you have scanned/read/shared.  Google reader has an excellent search function and quickly pulls up any article in your set of journals whether you have read it or not.  

If you can spend some time each week scanning through your journals of interest on Google reader, you can generally recall studies that got published and can retrieve the article very quickly.

To get him started, I gave him a link to a bundle of medicine journals I follow.  He was able to get started with these with 1 click!

3.  The last case prompted me to suggest something that I have just started using.  One of my medical students recommended Workflowy to me.  This tool is another case of things being so simple that they just work.  Workflowy lets you create a bulleted hierarchical list.  The web page can be opened in any browser including on mobile devices.  You start off by creating a high level list like

• Personal
• Family
• Work

and then create sub-items.  You can add notes to the items and strike through items that you have completed.  I am planning a trip to Peru and the amount of stuff that needed to be done e.g. flights, train tickets, forms for the consulate, Machu Picchu entrance tickets, hotels, SIM card etc. all needed to be completed.  Putting it together in one list and then adding notes of web sites, phone numbers, confirmation numbers etc made the whole process very organized.  I was able to share the list with my wife who could also complete and cross off certain items.  Being able to spend a few minutes to complete elective tasks takes a huge burden off ones shoulders and is very stress relieving.  If still need more help, you can use the Pomodoro extension on your browser (Chrome) to block off all distractions for a specified amount of time till you complete the task.

I will be first to admit that I am not the most organized of people and am constantly trying to find solutions for this.  Still these are tools I use regularly (except the Pomodoro) and they help immensely.