“Imagining the Future to Enhance Prevention Today”


The American College of Preventive Medicine’s annual meeting was held the last week of February in Atlanta, GA.  I’m copying below the article I wrote for the American Journal of Preventive Medicine (in the March, 2015 issue:  http://dx.doi.org/10.1016/j.amepre.2014.12.012; volume 48(3):A5–A9) about the theme of the conference.  Note that the small numbers sometimes in the midst of a sentence refer to the references at the end of the article.

 

“Imagining the Future to Enhance Prevention Today”

Halley S. Faust, MD, MPH, MA, FACPM

President, American College of Preventive Medicine

“Just the facts, ma’am,” Joe Friday would intone using his signature phrase on the radio and TV series, Dragnet.  This is what we believe we practice: evidence-based preventive medicine (EBM) based on “just the facts.” The American College of Preventive Medicine’s (ACPM’s) mission states that we “improve the health of individuals and populations through evidence-based health promotion, disease prevention, and system-based approaches to improving health and health care.”1

In EBM and science as a whole, we seem to be striving for the concept that Goldenberg2 defines as objectivity:  “an epistemic virtue … that stands for an aperspectival ‘view from nowhere,’ certainty, and freedom from bias, values, interpretation, and prejudice. Even if objectivity cannot be achieved, it is perceived to be an ideal worth striving for.”

Though there are controversies surrounding EBM regarding its definition,3 the philosophical base,4,5  definitions of underlying objectivity,2 causal inferences,6 value of magnitude of the effect of proven interventions,7 and balance between evidence and experience in recommending clinical interventions,8 all seem to agree that the evidence is clearly where we need to start.

Ultimately, we want to know if an intervention likely will enhance well-being for an individual or a population.  To simply suggest clinical or population-based interventions without examining the effectiveness, safety, and costs of health-promoting or disease-preventing interventions, and without knowing what works and what doesn’t, would be irresponsible.

Yet, even assuming we could agree on what the evidence implies for clinical or population interventions, evidence alone usually does not lead to health-promoting behaviors in individuals,9 or prioritization of health-promoting policies by policymakers.10 Nor is health care always on top of the list for voters.11 We even have trouble convincing our own healthcare workers (HCWs):  During the 2012–2013 influenza season, the influenza vaccination coverage was only 75.2% for all HCWs, and only 81% among hospital-based HCWs.12

And, as we may often lament, lack of evidence in “alternative” medicine does not prevent individuals from partaking in unproven clinical interventions or prevent policymakers from passing unwise or half-baked laws or regulations.

Why do people or policymakers avoid health-promoting behaviors or pursue unproven, and perhaps even potentially dangerous, behaviors that they believe to be beneficial?

One of many reasons is because we as prevention specialists believe that “just the facts, ma’am” is enough.  In our zeal to be accurate with data, we often ignore methods that would be more effective than simply presenting the facts. We fail to incorporate into our practices lessons learned from non-medical disciplines that could help us persuade patients to increase prevention’s priority in their personal lives, or in policymakers’ work in resource allocation and regulation development.

Why Do We Prioritize Treatment Over Prevention?

In the U.S., we spend about 8.5% of the healthcare dollar on prevention.13  Most of us in prevention still believe that this is a lot less than we should spend. Dee Edington, the Katherine Boucot Sturgis plenary speaker at the ACPM annual meeting in 2009, claimed that 20% of the healthcare dollar on prevention would be a better allocation. Miller and colleagues,14 in a brilliant paper that has received little recognition in the preventive medicine community, found that the marginal benefits of prevention and treatment for cardiovascular disease (CVD) would be reached at 37% spent on known effective prevention and 63% on effective treatment, requiring a reallocation of 9% of spending from their current spending estimate of 28% of the CVD dollar on prevention.

Why this seeming over-prioritization of treatment, or neglect of prevention? As the philosopher David Hume15 wrote, “Reason is, and ought only to be the slave of the passions.” Although we may believe that this is (or ought to be) backwards, the reality is that modern studies in the social sciences, neurosciences, and policy decisionmaking disciplines ratify Hume’s description of human nature. As stated in a recent Wall Street Journal article, “Most of us assume that when we try to solve problems, we’re drawing on the logical parts of our brains. But, in fact, great strategists seem to draw on the emotional and intuitive parts of their brain much more.”16

An appeal to the rational mind is not nearly as motivating as an appeal to the passions.17,18   It is very difficult to ignite the passions for any kind of changes of habit or policy when we are not responding to immediate needs—when we don’t have evidence in front of us of vivid suffering.

In a prior publication, I argued that the priority of treatment over prevention, or alleviating harm over preventing harm, is “a function of our compassion, which is animated by spatial and temporal vividness.”19  This claim is based on what Slovic et al.20 describe as the affect heuristic:

Representations of objects and events in people’s minds are tagged to varying degrees with affect. In the process of making a judgment or decision, people consult or refer to an “affect pool” containing all the positive and negative tags consciously or unconsciously associated with the representations.… Using an overall, readily available affective impression can be far easier—more efficient—than weighing the pros and cons or retrieving from memory many relevant examples, especially when the required judgment or decision is complex or mental resources are limited.

The affect heuristic can be evoked in many ways.

Think of the infant Jessica McClure, who fell down a well in 1987. Millions of dollars of previously unallocated resources were mobilized to save her.21 This is an example of Jonsen’s22 well-known rule of rescue.  [Jonsen22 explores this rule as a deontological imperative when we also need to be considering utilitarian consequences. He asks, “Should the rule of rescue set a limit to rational calculation of the efficacy of technology?  Should we force ourselves to expunge the rule of rescue from our collective moral conscience?”]

Think of James Foley and Steven Sotloff—their beheadings by Islamic State for Iraq and Syria (ISIS) in vivid video evoked outrage in the American public, mobilizing Congress to pass the bill giving authority for the Obama Administration to arm Syrian rebels. The Associated Press’s take on this?

We only respond if there’s video.… Time and again, we are informed of outrages … but only grow outraged and force action when video or audio or images emerge.… “Seeing things provides more information and puts a human face on whatever the situation is, and helps people relate on a much more personal level to what’s going on.”23

Video gives us vividness, an essential ingredient to mobilizing resources.

Think of the way Americans give to charity. As recently discussed on a National Public Radio Planet Money podcast,24  90% of all money is given within 90 days of a disaster—a clear-cut event that is a “galvanizing moment” that focuses world attention by evoking affect tags. Slowly moving, deadly disasters like the Ebola outbreak go on without a clear, defining moment in the mind of the general public. Further, prevention requires giving to currently normal individuals or populations.  Prevention occurs before suffering or disaster.

When vividness of suffering is not evident, affect tags are not evoked and the affect heuristic is not in play. Yet, we know there will be unnecessary suffering in the future because patients and policymakers are not taking health-promoting action today. How can we find ways to evoke affect tags associated with future suffering so patients and policymakers will take action today?

Somehow, we need to capture the imagination—get people vividly to imagine the reality of the future. This is our challenge.  This is the theme of the American College of Preventive Medicine’s annual meeting to be held in Atlanta, Preventive Medicine 2015 (PM2015), February 25–28.

Making the Future Vivid Through Imagination

How might we stoke the imagination to enhance prevention today?

There are many ways we can stoke the imagination.  These methods have been used by non-scientific disciplines for ages working with the needs and desires of individuals. Data, information interpretation, and EBM are still important, of course. Proposing courses of action without evidence that they are meaningful would be irresponsible, and PM2015 will continue its strong emphasis on scientifically based information skill building and dissemination. At the same time, we will explore ways that we can harness the imagination through non-science, yet evidence-based, tools by looking at ways that elicit the affect heuristic imaginatively.

To do this, we will tap experts from outside of traditional preventive medicine in some of the following disciplines:

1. Sound business techniques. Companies use marketing and sales methods to encourage needs fulfillment through purchasing of goods and services. They use persuasion techniques that convince the consumer or customer that their product or service is just what customers need to fulfill desires that they may not even know they had. Of course, from the preventive medicine perspective, sometimes these techniques result in encouragement of poor health habits— excessive calories intake, smoking, stress-producing anxieties, inappropriate use of medications, sedentary lifestyles, among others. And from an ethical perspective, we need to ensure against coercion or manipulation.  However, these techniques can also be used to encourage health-promoting behaviors—to evoke images of future happiness and well-being because of actions we take today.

Increasingly, businesses are using behavioral economics to motivate employees and customers as well.  They are using “nudges” to “alter people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives.”2527

2. Spiritual/religious heuristics. “Effective ethical arguments and policy making are not made in sealed chambers of rationality—in the real world they reach people imbued with traditions and cultures.  Traditions inform our ethical premises and reasoning, and certainly impact on health policy decision making.”28  Theological reasoning is directly relevant to both imagining and analyzing our personal actions and how we believe we should treat communities. How do we assess the question of “do not stand idly by thy neighbor” with the resource-competing “build a parapet around your roof?” How do we account for (and work with) the influence of religious leaders in times of calm to strengthen relationships so we can get them to deliver health-promoting messages?29,30

3. Experimental psychology and health behavior.  There are a number of behavioral “models” of why we behave the way we do in health care31 and broader pursuits.32  Psychologists and sociologists have been studying these areas for many years, yet we rarely have these specialists present in preventive medicine meetings.  This may be very relevant to how we treat risk factors through lifestyle medicine,33,34 and how consumers consider the value of first dollar prevention coverage that could backfire.35 For example, Segar and Richardson36 recently opined on how autonomy and intrinsic experiences such as pleasure motivate regular walking better than emphases on healthy outcomes:

…affect drives people’s daily decisions, and regular walking is determined by whether people consistently decide to walk…messages featuring affective benefits consistently resulted in higher participation than the health-related ones…larger delayed rewards for walking, like preventing illness, will not be as motivating as smaller, immediate rewards, like experiencing pleasure (i.e., delay discounting).

Segar and Richardson suggest that we eliminate health as the driving motivator for physical activity, and emphasize the core needs such as the inherent pleasure and meaning it brings to our lives.

Further, how individuals understand and react to risk is a complex and critical topic for how we can promote healthy lifestyles,36 appropriate use of prevention screening methods,37 and policies.38

Food psychologists are helping us understand how doing exercise or taking risk-reducing medications can cause health-adverse compensatory responses in people by their feeling they have been given license to consume more calories or eat less-healthy foods.34,39

4. The arts. In music, “the emotions accompanying expectations are intended to reinforce accurate predictions, promote appropriate event-readiness, and increase the likelihood of future positive outcomes.”40  Music is a way of evoking the “imagination response,” which is a way of imagining “different possible outcomes and vicariously experienc[ing] some of the feelings that would be expected for each outcome… provid[ing] an important mechanism for motivating an individual to take courses of action that increase the likelihood of a positive outcome.”41

Music is known to help us express basic emotions.41  Paradoxically, even sad music is known to induce pleasant emotions.42 Music can alter customer purchasing patterns in restaurants,43 and influence consumer choices during wine purchases.44  Music is used to evoke emotions in advertising, film-making, military campaigns, and even to manipulate our emotions.  It’s also used to soothe us; since the dawn of civilization, mothers “have used soft singing to soothe their babies to sleep, or to distract them from something that has made them cry.”45

We all have unlived lives that enhance our lived ones.46  Sometimes literature can evoke imaginative responses to fictional circumstances, or relate personal experience to health-promoting behaviors. Eula Biss47 uses personal narrative to illustrate how metaphors in medicine, risk, health, and motherhood inform our understanding of immunization and willingness to take acceptable medical preventive actions to protect our children. Among many useful insights, Biss suggests that many alternative practitioners may be successfully convincing mothers to use “alternative” therapies (and avoid vaccinations) because they avoid war metaphors commonly evoked in clinical medicine.

Films evoke responses as well. For example, watching films can cause short-term action desires on smokers.48

In other words, using non-prevention traditional disciplines may help us in our difficult work of eliciting affect heuristics in a positive way to enhance the effectiveness of our clinical and policy work.

It’s not uncommon for preventive medicine specialists to eschew these types of techniques for high-minded reasons. We may be turned off by the assumption that advertising and marketing are manipulative tools. We may be turned off by religion or the idea that religious precepts are not as important as secular human rights statements or codes of ethics. We may feel that emotional appeals are somehow unfair. And we are right to be cautious that persuasion does not veer into coercion or manipulation.  We always want to be aware that our actions are ethical; at the same time, being too “virtucratic” diminishes our effectiveness as clinicians or policy advocates.49

As Epstein49 reminds us related to the 2014 midterm elections, “Political arguments at the level of ideology are seldom won. As Jonathan Swift wrote, ‘it is useless to attempt to reason a man out of a thing he wasn’t reasoned into.’”

The way we behave related to health, our imagination, and the future often has more to do with our passions, our affect tags, and our imagination than “just the facts, ma’am.” Come to Preventive Medicine 2015 in Atlanta and find out more about how you can better influence and persuade your patients and policymakers by stoking the imagination of the future for better health today.

References

1. ACPM. Who we are. American College of Preventive Medicine 2014.  www.acpm.org/?WhoWeAre.

2. Goldenberg MJ. Iconoclast or creed? Objectivism, pragmatism, and the hierarchy of evidence. Perspect Biol Med. 2009;52(2):168–187, http://dx.doi.org/10.1353/pbm.0.0080.

3. Luce BR, Drummond M, Jonsson B, et al. EBM, HTA, and CER: Clearing the Confusion. Milbank Q.  2010;88(2):256–276, http://dx.doi.org/10.1111/j.1468-0009.2010.00598.x.

4. Karanicolas PJ, Kunz R, Guyatt GH. Point: evidence-based medicine has a sound scientific base. Chest. 2008;133(5):1067–1071, http://dx.doi.org/10.1378/chest.08-0068.

5. Upshur R. Making the grade: assuring trustworthiness in evidence. Perspect Biol Med. 2009;52(2):264–275, http://dx.doi.org/10.1353/pbm.0.0079.

6. Faust HS. A cause without an effect? Primary prevention and causation. J Med Philos. 2013;38(5):539–558, http://dx.doi.org/10.1093/jmp/jht039.

7. Greenhalgh T, Howrick J, Maskrey N. Evidence-based medicine: a movement in crisis? BMJ. 2014;348:g3725, http://dx.doi.org/10.1136/bmj.g3725.

8. Williams BA. Perils of evidence-based medicine. Perspect Biol Med. 2010;53(1):106–120, http://dx.doi.org/10.1353/pbm.0.0132.

9. Montori VM, Brito J, Murad M. The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines.  JAMA. 2013;310(23):2503–2504, http://dx.doi.org/10.1001/jama.2013.281422.

10. Haas M, Ashton T, Blum K, et al. Drugs, sex, money and power: an HPV vaccine case study. Health Policy. 2009;92(2–3):288–295, http://dx.doi.org/10.1016/j.healthpol.2009.05.002.

11. Polling Report I. Problems and priorities. 2014 http://www.pollingreport.com/.

12. Black CL, Yue X, Ball SW, et al. Influenza vaccination coverage among health care personnel—United States, 2013–14 influenza season.  MMWR Morb Mortal Wkly Rep. 2014;63(37):805–811.

13. Miller G, Roehrig C, Hughes-Cromwick P, Turner A. What is currently spent on prevention as compared to treatment? In: Faust HS, Menzel PT, eds. Prevention vs. Treatment: What’s the Right Balance?. New York: Oxford University Press, 2012:37–55.

14. Miller G, Daly M, Roehrig C. Tradeoffs in cardiovascular disease prevention, treatment, and research. Health Care Manag Sci. 2013;16(2):87–100http://dx.doi.org/10.1007/s10729-012-9215-x.

15. Hume D. A Treatise of Human Nature. New York: Oxford University Press, 1740.

16. Blastland M, Spiegelhalter D. Risk is never a strict numbers game. Wall Street Journal. 2014.

17. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux, 2011.

18. Kahneman D, Slovic P, Tversky A. Judgment Under Uncertainty:

Heuristics and Biases. New York: Cambridge University Press, 1982.  http://dx.doi.org/10.1017/CBO9780511809477.

19. Faust HS. Our Alleviation Bias: Why Do We Value Alleviating Harm More than Preventing Harm? In: Faust HS, Menzel PT, eds. Prevention vs. Treatment: What’s the Right Balance? New York: Oxford University Press, 2012:139–175.

20. Slovic P, Finucane M, Peters E, MacGregor DG. The affect heuristic. Eur J Operational Res. 2007;177(3):1333–1352, http://dx.doi.org/10.1016/j.ejor.2005.04.006.

21. Small DA, Loewenstein G. Helping a victim or helping the victim:  altruism and identifiability. J Risk Uncertain. 2003;26(1):5–16, http://dx.doi.org/10.1023/A:1022299422219.

22. Jonsen AR. Bentham in a box: technology assessment and health care allocation. Law Med Health Care. 1986;14(3–4):172–174.

23. Washington J. Where’s the tape? America cares when there’s video.  Santa Fe New Mexican. September 14, 2014.

24. Chase Z, Smith R. Planet Money. In: Chase Z, Smith R, eds. Why Raising Money for Ebola Is Hard. New York: National Public Radio, 2014.

25. Thaler RH, Sunstein CR. Nudge—Improving Decisions About Health, Wealth, and Happiness. New York: Penguin Books, 2009.

26. Rice T. The behavioral economics of health and health care. Annu Rev Public Health. 2013;34:431–447, http://dx.doi.org/10.1146/annurev-publhealth-031912-114353.

27. Rogers T, Milkman KL, Volpp KG. Commitment devices—using initiatives to change behavior. JAMA. 2014;311(20):2065–2066, http://dx.doi.org/10.1001/jama.2014.3485.

28. Faust HS, Menzel PT, eds. Prevention vs. Treatment: What’s the Right Balance? New York: Oxford University Press; 2012.

29. Faust HS, Bensimon CM, Upshur REG. The role of faith-based organizations in the ethical aspects of pandemic flu planning—lessons learned from the Toronto SARS experience. Public Health Ethics. 2009;2(1):105–112, http://dx.doi.org/10.1093/phe/php002.

30. Roberts LF, VanRooyen MJ. Ensuring public health neutrality. N Engl J Med. 2013;368(12):1073–1075, http://dx.doi.org/10.1056/NEJMp1300197.

31. Glanz K, Rimer BK, Viswanath K, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA:  Jossey-Bass; 2008.

32. Schwartz B, Ward A, Monterosso J, Lyubomirsky S, White K, Lehman DR. Maximizing versus satisficing: happiness is a matter of choice. J Pers Soc Psychol. 2002;83(5):1178–1197, http://dx.doi.org/10.1037/0022-3514.83.5.1178.

33. Bolton LE, Cohen JB, Bloom PN. Does marketing products as remedies create “get out of jail free cards”? J Consum Res. 2006;33(1):71–81, http://dx.doi.org/10.1086/504137.

34. Sugiyama T, Tsugawa Y, Tseng C, Kobayashi Y, Shapiro MF.Different time trends of caloric and fat intake between statin users and nonusers among us adults: gluttony in the time of statins? JAMA Intern Med. 2014;174(7):  1038–1045, http://dx.doi.org/10.1001/jamainternmed.2014.1927.

35. Dixon RB, Hertelendy AJ. Interrelation of preventive care benefits and shared costs under the Affordable Care Act (ACA). Int J Health Policy Manag. 2014;3(3):145–148, http://dx.doi.org/10.15171/ijhpm.2014.76.

36. Segar M, Richardson C. Prescribing pleasure and meaning: cultivating walking motivation and maintenance. Am J Prev Med. 2014;47(6): 838–841, http://dx.doi.org/10.1016/j.amepre.2014.07.001.

37. Rosenbaum L. Invisible risks, emotional choices—mammography and medical decision making. N Engl J Med. 2014;371(16): 1549–1552, http://dx.doi.org/10.1056/NEJMms1409003.

38. Miller M, Solomon G. Environmental risk communication for the clinician. Pediatrics. 2003;112:211–217.

39. Werle COC, Wansink B, Payne CR. Is it fun or exercise? The framing of physical activity biases subsequent snacking. Marketing Lett. 2014, http://dx.doi.org/10.1007/s11002-014-9301-6.

40. Huron D. Sweet Anticipation: Music and the Psychology of Expectation. Cambridge, MA: MIT Press, 2006.

41. Juslin PN. What does music express? Basic emotions and beyond. Front Psychol. 2013;4:596, http://dx.doi.org/10.3389/fpsyg.2013.00596.

42. Kawakami A, Furukawa K, Katahira K, Okanoya K. Sad music induces pleasant emotion. Front Psychol. 2013;4:311, http://dx.doi.org/10.3389/fpsyg.2013.00311.

43. North AC, Shilcock A, Hargreaves DJ. The effect of musical style on restaurant customers’ spending. Environ Behav. 2003;35(5):712–718, http://dx.doi.org/10.1177/0013916503254749.

44. North AC, Hargreaves DJ, McKendrick J. In-store music affects product choice. Nature. 1997;390(6656):132, http://dx.doi.org/10.1038/36484.

45. Levitin DJ. This is Your Brain on Music—The Science of a Human Obsession. New York: Penguin Group, 2006.

46. Phillips A. Missing Out: In Praise of the Unlived Life. London: Hamish Hamilton, 2012.

47. Biss E. On Immunity, an Inoculation. Minneapolis, MN: Graywolf Press, 2014.

48. Wagner DD, Cin SD, Sargent JD, Kelley WM, Heatherton TF.  Spontaneous action representation in smokers when watching movie characters smoke. J Neurosci. 2011;31(3):894–898, http://dx.doi.org/10.1523/JNEUROSCI.5174-10.2011.

49. Epstein J. After the midterms, virtucrats still rule. Wall Street Journal. November 4, 2014.

[Note that this was a non-peer reviewed contribution from the American College of Preventive Medicine, which is one of the sponsoring societies of the American Journal of Preventive Medicine.  No financial disclosures were reported by the author of this paper.]

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