What Behavioral Science Can Teach Healthcare About Patient Follow-Through — A Conversation with Sarah Waters, PhD
Download MP3Well, hi, everyone. I'm Daniel Williams, senior editor at MGMA, host of the
Daniel Williams:MGMA Podcast Network. Today, I've got a guest, Sarah Waters. Now Sarah has a PhD in behavioral science from, of all places, the London School of Economics. I am definitely gonna ask her about that. She's led patient programs that cut avoidable hospital and ER visits.
Daniel Williams:She now runs fifty West, a consultancy, so we're going to ask her about that as well. Sarah, I'm so glad we connected. I believe it was on LinkedIn, if I remember correctly. Welcome to the show.
Sarah Watters:Yeah. I believe so. Thanks so much, Danielle. I'm really happy to be here and chatting with you.
Daniel Williams:Yeah. We had fun, chatting, just getting to know each other. I guess it was a few weeks ago. The time has elastic and elusive recently, so I think it was a few weeks ago. So, anyway, good to see you again.
Sarah Watters:Yeah. Likewise. I agree. That's a human behavior thing. Time seems to move faster and faster.
Daniel Williams:It does. It well, you and I were just talking about, sports injuries and other injuries and thinking we're invincible, and then suddenly going, I don't think so. So I am you were telling me about something. I I am so sore right now. I I go to the gym.
Daniel Williams:I kinda have a routine where I go there's usually a class at 06:15 every morning, except for there's one day a week, Tuesdays, that's not available, but it's every other day. And I've been trying to go every day and not let I'm finding out at a certain point I'm needing a a break, you know, a little bit more downtime, rest time. So Yep. Working on that. Working on that.
Daniel Williams:We'll see. So I hope you're feeling better. I know we had to reschedule. You're getting everything sorted out there.
Sarah Watters:Yeah. All good. And I'm sure we'll touch on this today. There is something to the art of of showing up for yourself every single day, though, that if you have to go six out of seven days, that
Daniel Williams:That's it.
Sarah Watters:Something isn't quite right.
Daniel Williams:I know. Yeah. I know. It is. I I I definitely wanna touch on that with you.
Daniel Williams:So let's talk about this. I have let me say this, the London School of Economics, I used to listen to the LSE Podcasts, where they'd have distinguished guests, and you're actually the first person I've ever spoken to who is a graduate of the program. Tell me, what is it like? What what how did you how did you even matriculate to this place over across the pond or so?
Sarah Watters:Yeah. Absolutely. I think, like like so many of us, I I I thought I was destined for medical school originally, and I spent kind of the first part of my education kind of running down that path. And at some point, I came across this ability to combine my interest in health care and and clinical aspects with this element of psychology, which I also really loved. And since then, I really have been incessantly obsessed with kind of why people make certain decisions, why do we act and behave in certain ways, and especially when it comes to health care, of thinking about, well, these things are almost inherently good for us.
Sarah Watters:Why are we not doing them? Why are we not, to your point, exercising or eating well or taking our medication when we know these things are gonna benefit us? So I yes. I would I would qualify myself as obsessed when I think about these things all the time.
Daniel Williams:Okay. So let's break this down because all of our listeners I mean, behavioral science has become one of these really popular topics, and you see it in popular books. In a lot of spaces, but you do have the degree from London School of Economics. Help us, educate us on where's the intersection between psychology and then economics. Is it something that you gravitated Where did that happen, and where is that intersection?
Sarah Watters:Yeah. I think a lot of kind of what exists in behavioral science today was has a number of kind of originations. One of them being in kind of marketing science is one area that for a long time, many decades now, the the marketers have been saying, yeah, we kinda knew this all along, this human behavior element. But kind of more recently over the last few decades, there's also been this kind of other school of thought around the economic side of things. So leaning into kind of why do people behave in certain ways when it comes to making financial decisions and and things like that.
Sarah Watters:And, certainly, there have been Nobel Prizes awarded for those types of things. Better understanding, yeah, how do we when we're considering numbers, which truly applies to health care as well, how do we perceive numbers and perceive risk and and those sorts of things as well, which have important kind of ramifications in various different aspects of our lives.
Daniel Williams:Yeah. We're gonna get into how this is intersecting with health care in just one second, but let's wonk out for one more second. What is your PhD previously when we talked. It's in behavioral science, but let's hear what's the thesis. What is what is it?
Sarah Watters:Yeah. Definitely. So my PhD is in behavioral science. What I was particularly looking at was how do people make trade offs between quantity and and quality of life. So longevity versus quality of life.
Sarah Watters:So when we think about giving certain decision or treatments to patients at certain junctures during their clinical pathway, These are the types of decisions that do need to be made, which is, well, hey. You could live for kind of this many more years, or you're gonna have these kind of quality of life effects. So how do people kind of manage those cognitively in in their brain? And, ultimately, what are the different types of, like, patterns and trends that emerge. And I think the only other piece I'll say here is we can ask those questions in different ways, which is kind of a batch, you know, behavioral science, which is how you ask the question is ultimately gonna affect the answer that you get.
Sarah Watters:So I tested a few different ways of asking those questions in different ways to see if the responses were different.
Daniel Williams:It does seem like you'd have to massage and nuance the question a little bit, because if you ask a direct question, would you like to live a hundred and ten years and twenty five of those years are not fun physically or health wise? Or you get eighty five years, but eighty three of those are amazing. I mean, I just if I'm thinking of that, I'd think, unless advances in science happen somewhere between when I give you the answer and then we get there, I would think I'm gonna I'd love eighty three quality years versus twenty years of not great health and that sort of thing. You help me understand that question better, though.
Sarah Watters:Yeah. I mean, you're you're spot on, and there are other implications to think about. Like, will technology improve? What's gonna happen over the course of the time horizon you're giving me? But even something as simple as giving you twenty more years and framing it like that versus saying, hey, Daniel.
Sarah Watters:You could live to your 98. And even those subtle framing effects can can emerge as well. So that's also something that I I considered.
Daniel Williams:Okay. Let's talk about fifty West real quick. How does it tell us about the organization, and then how does it intersect with or engage with health care? Our listeners I shared this with you when we talked previously, but MGMA MGMA is the Medical Group Management Association. Our listeners are healthcare leaders.
Daniel Williams:They are practice administrators. Some are nurse leaders. Some are physician leaders. But they are those decision makers on some level at different healthcare organizations. So where do you intersect or engage with those people?
Sarah Watters:Mhmm. Definitely. I think a lot of what happens is when people approach fifty West or my my consultancy is they're they're looking in and around things having to do with engagement, So patient engagement and things like that. And, ultimately, a lot of the the work that I do with those types of stakeholders is figuring out what are what are you trying to engage? What is the specific behavior that you're trying to adjust?
Sarah Watters:Is it something having to do with messaging? It's often it's often not. I often end up talking to stakeholders like practice owners and things like that about the fact that their systems think there's in all areas of their own lives when it comes to affecting behavior change, decreasing no shows, increasing access, and things like that, they need to think about their patients' lives from a systematic perspective as well to to get closer to the sun, so to speak, and more effective messaging and behavior change.
Daniel Williams:Okay. What are some of I the mean, the patient engagement, patient access is one of the things we talk about a lot at MGMA that can involve the patient engagement side of it. Some of the people I've talked to previously on the show, and just in general through MGMA, they talk about meeting patients where they are. We saw that a lot during the pandemic initially. There was overnight practices transformed where they could offer telehealth, where they weren't even set up for that, and they did it over the weekend.
Daniel Williams:That March 2020, I believe, somewhere in that span, we were putting on webinars and just live events wherever we could to share with people, this is how you set it up. Now you've got it set up. This is how you have better practices. So when we're talking about meeting patients where they are, what are you seeing from that behavioral science side of things? What is really clicking?
Daniel Williams:Where are there some real gaps right now that still need to be connected for practices and patients?
Sarah Watters:Mhmm. Definitely. And I love the example of kind of the pandemic being almost that we talk about in behavior change a lot of times, you need activation energy to change behavior. And we we talk about that in reference to patients a lot, but that was really the activation energy needed for a lot of clinics and practices to stand up those capabilities to to meet patients where they are. When I think about meeting patients where they are, a lot of people think about that personalization piece, which is like, oh, I know there's these characteristics about you, but I spend a lot of time talking to to my clients and other people about identifying barriers.
Sarah Watters:We we get so caught up in kind of how do we message people? How do we send more reminders and and things like that? But these every message you send is kind of decreasing. People start to tune you out more and more. So I think something which we'll also probably talk about today is that kind of knowing versus doing gap.
Sarah Watters:We all know there are things that are good for us to do, but we don't execute on them. So instead of telling patients over and over again that knowing side of things, how about we figure out what's that big blocker or that often very small blocker in the middle? I talk about kind of moguls turning into mountains in people's brains, and often we we don't fully appreciate that something as small as kind of not knowing what something entails or being nervous, some sort of emotional barrier is is really going to prevent us from doing something we very well know that we should do.
Daniel Williams:Yeah. Let's elaborate that then. That was a question I had here. You have actually made the case that knowing isn't half the battle. And I'm okay.
Daniel Williams:My head's trying to wrap around that, so help us understand that. What do you mean by that?
Sarah Watters:Yeah. I think as we've been talking about, we we all know there are things that we should do and that we just we don't end up executing on them. Whether you think about from a health behavior perspective, as we talked about earlier, kind of getting more exercise or eating well. Or even there are things when you woke up this morning that you were like, Daniel, you know you need to do this later today. And I was like, Sarah, you know you have to do this by noon or this by five, and and we don't execute on them.
Sarah Watters:So there's this big kind of cavernous gap between knowing and doing. And though we can't kind of manufacture our willpower in the future, so I know, Sarah, by 4PM, you need to do this, There are things you can do around designing the environment and kind of limiting choices and automations and things like that that can help bridge that knowing doing gap. But knowing again, going back to your original question is, in my opinion, it's not half the battle. We all walk around with a million things we know we should do, and here we are
Daniel Williams:I know.
Sarah Watters:Always having that list of things we should do that gets longer and longer.
Daniel Williams:Well, from the behavioral side, why do humans inherently do that then? If we know we have a checklist or a list of something, and then we don't activate or we don't act on it. No, every time I go on LinkedIn, somebody's putting some new hack or some other thing that goes, Well, this will help you get from here to there, and this to that. I'm going, I appreciate it, and why don't we just do it? I because I have two dogs and a cat, and they kind of just do what they do.
Daniel Williams:They don't go, My stomach's growling, but I'm not gonna eat right now. No. They come walk right up to me and just stare at me until I go, okay. I'm getting up now even though I'm super comfortable, and I'm almost finished with this chapter I'm reading or whatever. I'm getting up because I see those eyes, and you're, like, hypnotizing me.
Daniel Williams:So what what is it of why do animals behave in a certain way? And then we get to humans where this more advanced level of thinking, and then we don't do it. What's going on?
Sarah Watters:Right. I think there are a number of different kind of valuabilities our brains have when we think about planning for the for the future. And a lot of the things that are good for us don't necessarily have quick enough feedback loops for us to be compelled to do them in the moment, truthfully. To the point you made about LinkedIn, I mean, we live in a time of rapid, rapid, rapid feedback loops, hacks, those sorts of things. We want to get rich quick is essentially how you would think about truly everything at this point in time.
Sarah Watters:I wanna get healthy quick. I wanna be productive quickly. But I think it comes back to basics almost all the time, which is unfortunately, though there are kind of ways to to manage this, it's compounding. There are small behaviors do you do repeatedly over time. And we know this from the greats in truly every field, which is you have to kind of have these small compounding behaviors over time, which certainly can be wrapped in things like quicker feedback loops that are kind of designed.
Sarah Watters:But ultimately, yes, that's what it comes down to is the behaviors that we we do want to do and we plan to do in the moment among kind of the constellation to far more appealing things to do in that moment. Keep getting reprioritized and shuffled to the bottom of the list.
Daniel Williams:Cognitively, what's going on when, and I'm referring back to something you said earlier, if a practice is doing what they believe is the best behavior to engage with the patient, and they text them, and then they text them again. Then there's another update, now only twenty four hours until your appointment, and now twelve, and now an hour. You were saying you're tuning out and tuning what's going on in the brain? Is it like when we get in a car that and we drive in a direction we've driven a lot and we go into autopilot, or what what is happening cognitively in that situation?
Sarah Watters:I mean, it's could almost consider it, and certainly this probably has a more negative connotation than I wish it would, but corporate nagging in a way, which is the sense of someone knows they need to do something. And if we keep sending that over and over again versus understanding why they're not doing it, then at that moment, the moment we understand why it flips the script, we can start to help them. Maybe they don't have a ride to their appointment, or maybe they don't have someone who's gonna come with them. The moment we can understand that, the messaging changes, and then we are actually that's what meeting patients where they are ultimately stands for. It at least in my brain is understanding not only what they need to do, but why aren't they doing it.
Daniel Williams:Okay. You and I talked about this. So you get contacted or you make have engagement with health care organizations. When they're coming to fifty West, what what are they looking for? What is the friction point, the challenge, the problem often that they're having that they want your help with?
Sarah Watters:Yeah. Definitely. So I worked with a lot of companies on appointment no shows is is always a big one because it has such a a linchpin effect on the bottom line. And then also things like a lot of care gap closures. So why aren't people kind of completing their care gaps, quality measure, HEDIS screenings, things like that?
Sarah Watters:And then thirdly, I think people don't take their medication. Medication only works in people that take it is between this line. Yet yet people struggle to to do that, and there are a whole myriad of reasons and decades worth of research, but there are effective strategies.
Daniel Williams:Okay. So what are some of those? Not to give away everything, but, I mean, just let's go to no shows for a moment because that we have put on webinars. We have had workshops on no shows. Is one of the biggest challenges that practices have.
Daniel Williams:People make appointments, and then they don't follow through on it, and myriad reasons. We were talking offline before we went live here, and I had a podcast interview earlier this week where the power went out right before the interview, and the production team here texted me. They could still use their cellular data, but no, they had no power. And so they said, if you can get in contact with the guests because, we're out for hours. So that's an extreme example.
Daniel Williams:But what's going on there with no shows when you've studied that? And what's some of the very basic advice that you provide your your clients and those health care organizations?
Sarah Watters:Mhmm. Certainly. I'm glad the power did not go out today.
Daniel Williams:I know. I know.
Sarah Watters:I think there are there are a few things to consider, and certainly going back to that kind of knowing versus doing gap, one thing that should be considered is how far in advance are are we allowing patients to book appointments. I think that is one of the biggest things that has emerged in research, which is kind of the longer time horizon that emerges, the more likely something is gonna come up. So, Daniel, if you're scheduled for an appointment in August and we're here in June, who knows what August looks like? That is a date that we are not considering, but it feels good to have it on the calendar. What will come to fruition at that moment?
Sarah Watters:We we don't know. You're gonna be faced with that same present Daniel. Oh, no. I have three other things to do that day. The appointment gets completely lost.
Sarah Watters:When I talk to clients about no shows and how to navigate them more specifically, I think there are a bunch of things that can be done throughout the process from booking the appointment all the way to kind of the date and time of the appointment. The first one being when you have kind of the front desk people even book it if you're on the phone booking with them. Even kind of subtle tweaking around the wording, which is less so when might you be free for an appointment? Almost taking the reverse approach and asking what days don't work for you and better having the patient think through from that perspective almost, well, what doesn't work? I think when you force people to think in slightly different mental models, all of a sudden, it forces them to think a little bit more critically about potential barriers and blockers.
Sarah Watters:So that's an example at the at the front end of the system. And then certainly as well at the front end of the system asking what we've been talking about, which is you do you have a ride? You have to prepare for twelve hours before this appointment. You have to come fasted to that appointment. Making sure that you're addressing that up front, but then also through these reminders as you get closer and closer to the appointment.
Sarah Watters:And then I'll say one more thing before on this appointment no show piece, which is it should be data driven. I'm sure when companies look at, and as I've looked out with my clients, some of the no show patterns, there is some predictability there. So understanding what dates and times, what parts of the week do people tend not to show up, what characteristics of patients tend not to show up when you bump that up against times and dates of the week. And then from there, you can build more effective strategies to to helping people follow through on those appointments or nudging them towards appointment slots in the future that that will be more amenable to their schedules.
Daniel Williams:Okay. Another pattern that you've described is where people avoid procedures that are life altering, life saving, colonoscopies, mammograms, and they may have a tendency to avoid those because maybe they're perceived as unpleasant, maybe they are unpleasant, whatever the case may be. It could be perception, it could be reality. Help us understand that, and how can practices really look into that when it may be something that they're seeing. It's going back to the data you were talking about.
Daniel Williams:Hey, let's study the numbers. Oh, when we put somebody down for a colonoscopy, the no shows go up here or something, you know? So how do you look at that, and how do you share with healthcare organizations so they can make improvements in navigating that with their patients with these procedures that really are so important.
Sarah Watters:Mhmm. I think a lot of that goes back to what we were talking about, kind of going to the gym six days a week versus seven days a week, which when you're trying to get someone to do something annually, I mean, that's even a much heavier lift. How do you get someone to do one rep per year? There's no kind of regularity to that, so to speak. So I think a big contributor to why people don't engage in the procedures that you named colonoscopies and and mammograms like that is that there are elements of the unknown.
Sarah Watters:People know generally these are good things for me to do. Once again, knowing doing. But they don't necessarily know all the nitty gritty details and some of the unknown. The aspect of the unknown is often what kind of turns us off, so to speak. In in behavioral science, there's this concept called the ostrich effect, which you can just picture.
Sarah Watters:The ostrich sticking its head in the sand saying, nope. Not for me. I don't know what it involves. But I think the more pernicious part of it is the fact that when you when there's an unknown and especially for things that are talked more colloquially about, like colonoscopies and mammograms, we fill in that unknown with usually kind of negative information. We go, that hurts.
Sarah Watters:It's uncomfortable. It's weird. It's embarrassing. And that just kind of decreases the odds that that we actually follow through on these behaviors. I think what what practices can do to help navigate that is for these particular gaps, and we often say we often wanna put stats in front of people.
Sarah Watters:We wanna get them it's a scare tactic sort of thing or information, like, put lightly. But what I the phrase that I usually use is kind of stats sell, but story stick. And, ultimately, patients need to hear kind of stories about what specifically happens during these appointments, maybe for someone like them, giving them a narrative that they can remember versus this that they're unequivocally gonna forget the moment they pick up their phone and start scrolling some sort of app. So thinking about it from that lens is helpful as well.
Daniel Williams:Okay. I wanna make sure I get this next question right. You've led programs that produced real reductions in avoidable different types of patient visits. What changed in how patients behaved that drove the result? What what was going on there?
Daniel Williams:Where did y'all bridge that gap?
Sarah Watters:Yeah. Absolutely. It goes back to what we're talking about before around we all wish there was kind of a get rich quick scheme for avoiding inpatient utilization or ED visits and things like that. But, ultimately, what we worked on with with these patients were we went way upstream. We figured, well, how do we get people to even avoid approaching the decision where they need to use inpatient or they need to use the ED?
Sarah Watters:So we backed all the way up to kind of classic behavior change habit formation strategies, which is taking these largely kind of noncompliant, so to speak, patients. How do we start developing kind of healthier behaviors over time by essentially, I mean, or coming up with the smallest possible behaviors for people to start adopting over time. So we focused on things like if you had for people who who are diabetic, maybe, how do you start taking your blood pressure for the first time? And that goes back to, again, our six out of seven days a week. How do you practice very simply this kind of art of just showing up every single day?
Sarah Watters:And and, ultimately, what that does for a patient who may be kind of, air quotes, noncompliant is you start to create a streak almost, which is almost immaterial of the action that they're managing to accomplish that day or whatever their blood pressure values are that day. There's almost a layer of behavior change that works in on top of it through just patterns showing up every single day.
Daniel Williams:Okay. I want to go to back to something you mentioned earlier, and that's about patients not taking the medicine because it doesn't work if you don't take it. That one can be so challenging. What seems to be going on there, and how do you change that behavior where you get the patients to be sure and take the medication that's prescribed to them?
Sarah Watters:Mhmm. Definitely. I mean, medication is certainly a complicated one, especially at this point in in time, acknowledging there are often cost barriers and and things like that. It does go back to kind of a lot of the behavioral fundamentals, which is understanding beyond the cost barriers, what are those potential behavioral barriers. Forgetfulness is always a high ranking one when it comes to taking your medication.
Sarah Watters:So there are kind of tried and true strategies that exist around things like coming up with implementation intentions. So I, Daniel, I'm gonna take my medication at this time alongside something I do every single day. I brush my teeth. I take my medication. Often with medication, we put things in the in the cabinets or in the in the drawers and things like that.
Sarah Watters:I am a behavioral scientist, and I've been for many, many years now, and I still leave things in the middle of the floor if I know I need to pay attention to it later. Our brains our brains are that kind of forgetful and susceptible to just being distracted. So I think the implementations and kind of coupling, it was something you already do with great regularity is is highly effective, although it seems very simplistic. It works. And then the other piece on the flip side, which is kind of its slightly less talked about cousin is, well, if I have an appointment tomorrow and I'm not doing my regular thing like brushing my teeth, I hope you are though, coming up with some sort of coping mechanism, which is mean what I mean by that is it's an alternative or backup plan.
Sarah Watters:So I know I have this thing tomorrow. Here is my backup plan. And making sure it's not just a kind of a one shot attempt, but you're building out this essentially kind of system for your future self to be compliant versus saying, I'm gonna remember. I hope I remember and so on.
Daniel Williams:Okay. We've talked a lot about behavioral science, how it engages with or interacts with practices and healthcare organizations and the behaviors of those patients. What is something I haven't asked you that you think is really important that our listeners need to hear?
Sarah Watters:Yeah. I think as we've talked about through different health behaviors, a lot of what we've talked about today is patient facing, but the same, a lot of these behaviors are human behaviors. And when we think about within a practice and affecting change within our practices, the same things apply. So whether it's knowing, oh, I should ask this question related to a health outcome survey during my appointments today. Clinicians and and front office folks and physician's assistants and things like that are all just as susceptible to these kind of behavioral anomalies as everyone else.
Sarah Watters:So planning for things that you know your future self should do. So asking that question at the front desk even though it's not part of your usual script or kind of getting those labs done or making sure when you're talking to a patient instead of giving them generic advice, you're saying, hey. When are you gonna take your medication? Hey. When is a good time for you to measure your blood pressure every day?
Sarah Watters:Changing our our own behavior as clinicians and professionals should be looked at through the same lens as changing patient behavior as well.
Daniel Williams:Okay. If people wanna get in touch with fifty West, if they wanna learn more about you, where where would you send them? How can they get in touch with you or the organization?
Sarah Watters:Yeah. Absolutely. I'm always on LinkedIn for better or for worse through our corporate social media that is LinkedIn. And then my email as well and my website, which is just 50-west.com.
Daniel Williams:Okay. Well, Sarah Waters, it has been a pleasure having you on the podcast. Thank you so much for joining us.
Sarah Watters:Yeah. Great to chat with you today, Danielle. Thank you so much for having me.
Daniel Williams:Alright. Everyone, I am gonna put those hyperlinks and those resources into our episode show notes and an article that's gonna accompany this podcast. So until then, thank you so much for being MGMA Podcast listeners.
