Bob Nease received his doctorate from Stanford University, where he studied methods to improve medical decisions made by doctors and patients. Before joining Express Scripts in 2001, he was an associate professor of internal medicine at Washington University in St. Louis and an assistant professor at the Dartmouth Medical School. He recently retired as the Chief Scientist at Express Scripts, a Fortune 25 healthcare company dedicated to making the use of prescription medications safer and more affordable. As a leader in the convergence of consumer behavior and healthcare, he was responsible for advancing the Express Scripts behavior-centric approach to the pharmacy benefit. He is the author of more than 70 peer-reviewed scientific articles, and inventor on six US patents.
Over the past several years, Bob has emerged as the nation’s expert on the application of behavioral sciences to health care. He has now turned his attention to equipping others to make practical use of those insights in applications beyond health care — at work, at home, and in the community. His book, The Power of Fifty Bits: The New Science of Turning Good Intentions into Positive Results, was published by HarperBusiness/An Imprint of HarperCollins (January 2016). He and his wife Gina split their time between Phoenix, Austin, and their farm in rural Italy.
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Morris: When and why did you decide to write The Power of Fifty Bits?
Nease: The book is a practical field guide for improving the behaviors of our customers, our colleagues, our loved ones, and especially ourselves. I started writing it after I’d gotten a good sense of the true nature of the problem, the limitations of other approaches to behavior change, and a working understanding of the seven strategies in the book. As chief scientist at Express Scripts, I was giving a lot of presentations, and people were always asking me where they could find a practical “how to” resource for applying the behavioral sciences.
Morris: Were there any head-snapping revelations while writing it? Please explain.
Nease: Once I decided to write it, I became pretty obsessed with the project. I am still surprised that my wife put up with it.
Morris: To what extent (if any) does the book in final form differ significantly from what you originally envisioned?
Nease: It started as a reference guide, something someone could pull from the shelf when they were thinking about solving a specific type of behavior change challenge. My editor at HarperCollins reminded me that most people don’t read reference guides, so I focused more on storytelling to get the main ideas across. It’s still a reference guide, but now it’s one that sort of sneaks up on you via engaging examples.
Morris: When and how did you formulate the Fifty Bits concept?
Nease: I realized that most of our bad behaviors are due to inattention or just letting the status quo slide. The bulk of non-adherence to prescription medications is due to forgetting or procrastinating, for example. Then I stumbled across this startling finding: of the 10 million bits our brains each process every second, only 50 bits are dedicated to conscious thought. Understanding that cognitive chokepoint is critical; it tells us that our brains are pretty much wired for inattention and inertia. If you don’t understand that and you’re trying to improve behaviors, you wind up barking up the wrong tree.
Morris: What are the core principles of fifty bits design?
Nease: The main idea is that we are wired for inattention and inertia, and that over time, these lead to a gap between our good intentions and our actual behaviors. Other approaches assume that bad behaviors stem from bad intentions, and so they focus on changing peoples’ underlying desires. In contrast, fifty bits design takes good intentions as a given, and focuses on activating those good desires. The book describes seven different strategies for activating pre-existing good intentions, and uses lots of examples to show how to use each of the strategies in practice.
Morris: Presumably at some point, you connected some of those proverbial “dots” and realized that fifty bits design has almost unlimited applications. Which application excites you most? Why?
Nease: Behavior is mission critical to every human endeavor. Representative democracies depend on us getting up off the couch and voting. Better health depends on us exercising more, eating and sleeping better, and using medical interventions in an effective and sustainable way. Our kids and their kids are counting on us to be good stewards of both the environment and the economy. Our communities and organizations need us to be more plugged in and participatory. Fifty bits design holds the promise to unlock better behaviors across these domains, and that’s incredibly exciting. The thing that excites me the most is that these strategies aren’t rocket science. You don’t need to be a scientist to make a difference. This book is for everyone.
Morris: In the book, you note that much of the time our brains are on autopilot. Fifty bits out of ten million isn’t much to work with. Do you find this disturbing?
Nease: The first reaction a lot of people have when they hear about the “fifty bits” statistic is disappointment at how little of what our brains do is focused on deliberate behavior. I don’t see it that way, and I’m happy that we can do so much without having to deliberately think about it. Take driving a car: when we first learn how to drive, we are using only our fifty bits, and it takes every last one of them. We have to deliberately think about where to place our feet, how hard to push on the gas or brake pedal, how far to turn the steering wheel to the right or the left, how to work the turn signals, when to check the mirrors. There’s a lot going on cognitively, and that’s why new drivers are at a higher risk of having an accident. As with lots of other behaviors that we do repetitively, however, those tasks get handed over to the automatic system, and when that happens we get our fifty bits back and can use it for something else.
Morris: You elevate three shortcuts that people use to navigate through the world. What are they and why are they important to fifty bits design?
Nease: Psychology and behavioral science have identified lots of heuristics and biases that people use and are burdened with. Because I was focused on helping a large group of non-scientists apply the insights in a business setting every day, I settled on a small number of powerful shortcuts.
The first is fitting in: people will make an extra effort to stay part of the group and to meet expectations. There’s a fun example in the book about which hybrid cars people buy and why. It turns out that in towns that “lean green” not only are hybrids more popular, but those that are obviously hybrids (e.g., the Prius) are more popular. In other words, when the prevailing group value is to be eco-friendly, people will go out of their way not just to be eco-friendly but to be conspicuously eco-friendly.
The second shortcut that we often use is loss aversion: people work harder to avoid losses than to pursue gains. Losses are usually seen as deviations “down” from the status quo. That’s how the “endowment” effect works; once I see something as mine, I am more attached to it (i.e., I work harder not to lose it). But losses can also be seen as deviations down from what’s expected. That’s why it feels worse to miss a flight by two minutes than it does to miss it by two hours. It’s a lot easier to envision another reality in which you’d made a flight that you barely missed than one you missed by a mile.
The third shortcut that we use is to focus on the present. To some degree, this is due to the limbic system in our brain; it weighs pleasure and pain in the here and now, but pays no attention to the future. The neocortex area seems more capable of weighing benefits against cost regardless of timing, so for many behaviors these two part of the brain can come into conflict. Exercise, for example, is good for us in the longer term but typically unpleasant in the present. When we make plans to exercise, the limbic system is “offline” – everything about which we’re thinking happens later. When it comes time to exercise, however, the limbic system only perceives the effort involved and none of the costs. If the limbic system wins over the neocortex, we fail to follow through on our plans.
Understanding these shortcuts sets the stage for identifying strategies to effectively change behavior. They are three key psychological forces that often – to one degree or another – contribute to our behavioral hiccups and which can be leveraged to advantage better behaviors.
Morris: Can you give an overview of the seven strategies of fifty bits design?
Nease: Each of the seven strategies is designed to activate the good intentions that most people already have. That’s the main idea of the book: our fifty bits “chokepoint” means that much of the time we’re wired for inattention and inertia, and that over time this causes our actions to diverge from our intentions. This insight is critical because without it we mistakenly chalk bad behavior up to bad intentions, and then pursue strategies to try to change what people want to do. The results of these kinds of strategies almost always disappoint because they’re tackling the wrong problem.
People are wired for inattention and inertia, so the strategies fall into one of those two buckets: they either demand attention, or leverage inertia. In addition, some of the strategies have a better track record in terms of performance. I refer to these as the “power” strategies. The three power strategies are:
o Require Choice: mandate that people stop and deliberately make a choice
o Lock in Good Intentions: allow people to make decisions today that make tempting but undesirable behaviors in the future costly or impossible
o Let It Ride: set the default to the desired behavior and let people opt out if they want
Three other strategies are usually more modest in terms of effectiveness, and I call these “enhancing” strategies. The three enhancing strategies are:
o Get In the Flow: put a call to action where peoples’ attention is likely to naturally be
o Reframe the Choices: set the framework that people use to think about and react to choices they face
o Piggyback It: attach the desired behavior or choice to one that is inherently pleasing
And then there is the “über” strategy; it’s the overarching idea for all of the other strategies: Simplify…Wisely. Wise simplification means making things smooth, frictionless, and easy if the person is headed the right direction, but slowing them down considerably if they are headed the wrong way. This seems a little obvious but the idea is subtle and important. The “Require Choice” strategy, for example, is the ultimate in slowing someone down; the “Let It Ride” strategy puts people on the right path and then removes every obstacle so they remain on that path.
Morris: When I read your book, I noticed that each of the chapters describing a strategy ended with some practical considerations. Why did you feel the need to structure the book that way?
Nease: There have been a lot of interesting and really good books on behavioral economics and behavioral science. What was missing was a practical field guide to help everyday people apply the science in a nuts-and-bolts way. At Express Scripts, our mission was to make things better for our patients – to make the use of prescription medications safer and more affordable. We learned a lot about the challenges and workarounds needed to make the strategies work, and I wanted to close out each chapter with some very practical advice and caveats. My hope is that this approach will help the readers get a really good sense about how to proceed when they tackle their own applications.
Morris: What are one or two of your favorite examples of how the fifty bits design strategies are applied?
Nease: I am so impressed with what PetSmart Charities has done with the “Require Choice” strategy. PetSmart Charities is the not-for-profit arm of PetSmart, a pet supply retailer. When you’re checking out at PetSmart, something really interesting happens. After the checker has scanned all of your goods, after you’ve swiped your credit or debit card, but right before you approve the charges, everything comes to a dead stop. You can’t proceed until you answer a question that pops up on the point-of-sale monitor: “Donate to help save homeless pets?” There’s no sales pitch (although the phrase “homeless pets” is a really strong way to frame the donation). You just have to say yes or no.
From 2007 to 2011, the US went through a rough time in terms of the economy. Nationally, individual charitable contributions were down 3%. During the same time, however, individual contributions to PetSmart Charities went up 85%. PetSmart Charities understood the gap between intentions and actions. They didn’t spend a second trying to educate or incentivize donations among their clientele. Instead, they realized that there are a lot of PetSmart shoppers who are willing to donate but don’t get around to doing it. The Require Choice strategy grabs people briefly and demands their fifty bits long enough to tap that latent interest in doing the right thing. It’s exceptionally powerful.
The other really impressive example is the CHOICE Project at Washington University in St. Louis. Their goal was to decrease unintended pregnancies by increasing the use of the most effective methods of contraception. It turns out that one of the most popular methods, oral contraceptives (also called the “Pill”) works great in theory but has a high failure rate in practice… and that’s due to inattention and inertia. Other methods only require women to make a decision once, and after that the methods protect against unintended pregnancy even if the woman forgets. These long-acting reversible methods (or LARC) have a failure rate of less than 1% per year. That’s an example of the “Lock In Good Intentions” strategy.
My wife, Gina, was the project director so she had the chance to put the fifty bits design strategies to work. The project recruited nearly 10,000 women in the St. Louis area. Participants in the project were counseled about all their options, and those options were framed around effectiveness. That put the LARC methods front and center, and reminded participants of the importance of effectiveness (rather than, say, familiarity) when selecting a contraceptive method. They made it possible for participants to immediately get the method they selected, which is a softened type of requiring choice. They took to heart the design ethos of simplifying wisely, making every right behavior as simple as possible. For example, instead of requiring women to return to the project clinic for their annual testing, they developed an in-home version of the test that women could use instead. A randomized controlled trial showed that this version of the test worked better than the one in the clinic.
The result of all of this fifty bits design is nothing short of remarkable: the use of LARC methods rose from less than 10% to 75%, and unintended pregnancies among the study participants dropped dramatically. This effect was so large that it showed up at a population level in the St. Louis area. Groups from across the country are now working to emulate the CHOICE model of care.
Morris: One of the seven strategies is something you call “piggybacking.” What does that mean?
Nease: Piggybacking is one way of making something that’s good in the long run more attractive in the here and now. With piggybacking you attach the good behavior to something that’s pleasant or engaging in the present. Tooth brushing really took off in the US after mint was added to the formulation. All of a sudden, people started brushing their teeth because it was immediately pleasurable; your mouth felt clean and fresh. Clean teeth and the prevention of cavities was a side effect.
My wife, Gina, is a big fan of piggybacking. She wanted to do more vigorous workouts but was struggling to stick to her routine. Then she found videos in which a ballet instructor does these tough workouts. Gina always wanted to be a ballerina, so for her working out is now a side effect of pretending to be one. It sounds a little strange but it works for her, and I suspect that when done right piggybacking can be very useful for a lot of people.
Morris: People seem to have tough time with procrastination. How can fifty bits design help?
Nease: Behaviors on which we procrastinate all share a specific feature: they are good for us over the long haul but aren’t fun today. People tend to overweight the present and underweight the future, and that’s why we put off those behaviors. Specifically, the hassles and effort are now and loom large; the benefits and gains are in the future and are discounted.
The key to breaking the cycle of procrastination is to make the desirable behavior a little more enjoyable in the present, and the tempting but self-defeating behavior a little less desirable in the present. If any of the hassles or effort associated with the good behavior can be outsourced, consider doing that. For example, if you procrastinate getting your prescription refilled, consider signing up for an automatic refill program.
Sadly, you can’t outsource everything. For example, paying someone to work out for you won’t help you fit into that old pair of really great looking jeans. For those situations, try the “Lock In Good Intentions” or “Piggyback It” strategies. These tilt the present stakes in favor of the behavior that’s good for you in the long term.
Morris: Can these strategies for behavior change be misused? If so, how can that be prevented?
Nease: Designers could certainly use the strategies in the book to advantage behaviors that are in their interest and come at a cost to others. I call this “trickonomics.” There’s no guaranteed way to prevent unscrupulous people from intentionally misusing the strategies. More likely, however, is that well-meaning designers will inadvertently cut corners. The book includes a section offering some “guardrails” that all good fifty bits designers should use to make sure they stay out of trouble. Essentially, if you can look your mother in the eye, explain what you’ve done, and sleep well that night, you’re probably okay.
Morris: You seem to have an optimistic view about people and behavior. Why is that?
Nease: I didn’t start out that way; the research led me there. I do believe that most people want to do the right thing, and there is really wonderful evidence that when you are able to activate those pre-existing intentions, great things happen. That’s why PetSmart Charities has done so well with the “Require Choice” strategy: people who shop at the retail store have a latent interest in making donations. That’s why the CHOICE Project has been so successful: if you can help women act on their intention to avoid unintended pregnancies, it works. The problems we face with behavior don’t stem from bad behaviors on which people are acting. They stem from good intentions that lie dormant. This just one of those great situations in which the facts turn out to be uplifting and inspiring.
Morris: For more than 25 years, it has been my great pleasure as well as privilege to work closely with the owner/CEOs of hundreds of small companies, those with $20-million or less in annual sales. In your opinion, of all the material you provide in The Power of Fifty Bits, which do you think will be of greatest value to leaders in small companies? Please explain.
Nease: The most important message from the book is that there is a large and persistent gap between what people – coworkers, clients, loved ones, ourselves – want to do and what they actually do. If you understand this, you focus behavior change efforts on activating peoples’ pre-existing good intentions. If you get this wrong, you’ll find yourself barking up the wrong tree, spending a lot of time and energy, and having little to show for it.
Morris: Which question had you hoped to be asked during this interview – but weren’t – and what is your response to it?
Nease: “Do all bad behaviors start from good intentions?”
Here’s my response. To be sure, bad intentions can lead to bad behaviors. But I’ve met a lot of people, and most of them are well intentioned. There is just a greater number of well meaning people out there than there are villains. That means that when you run across someone engaged in a suboptimal behavior, chances are that it’s coupled with a good intention that hasn’t been acted upon. The moral is, “Don’t be fooled by the behavior that you observe.” Instead, assume there’s a good intention waiting to be activated.
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Here is a direct link to Part 1.
Bob cordially invites you to check out the resources at these websites:
For more information about Fifty Bits design, please click here.
For more information about the book and where to buy it, please click here.Tags: Annals of Internal Medicine, Bob Nease on eliminating the “intention/behavior gap”: Part 2 of an interview by Bob Morris, Brooke Manville, Dartmouth Medical School, Express Scripts, HarperBusiness/An Imprint of Harper Collins, James O’Toole, Journal of the American Medical Association, Judgment Calls, Lao-Tse, Peter Drucker, Power of Fifty Bits: The New Science of Turning Good Intentions into Positive Results, Stanford University, Tao Te Ching, the Consumerology® Advisory Board, Tom Davenport, Washington University in St. Louis, “the ideology of comfort and the tyranny of custom”