The Cost of Not Doing: The Neuroscience of Engagement

This week we’ll do a very basic overview of how underlying brain structures and biochemistry shape the way we behave to better understand why we don’t always do the things we should do, related to our health, even when we know we’re making suboptimal choices.

I know you’ve been there.  You have the choice between an apple or a slice of apple pie.  You choose the pie.  You tell yourself, you’ll walk the dogs an extra 30 minutes or you’ll choose the apple next time.  It all cancels out then, right? Wrong.

Neurobiologists like David Eagleman of Baylor University suggest that our unconscious brain does most of our decision making, that there is a gap between what information is available to our subconscious and our conscious selves. I find the idea that we use only a small proportion of our brain and available information a hard concept to wrap my head around.  It seems a little overwhelming!

To understand this a little better, our brain activity was framed up as the following: Imagine that you were trying to process every single piece of news that is happening in the United States on one given day. Every story. It would be impossible to process all that information, and so we read newspapers and watch the news to get headlines that summarize and categorize what is most important. (OK, the most important part is debatable these days.) Mr. Eagleman suggests that we consciously act on ‘headlines’ from our brain’s subconscious.

Because the human subconscious drives our actions, instead of making decisions in a completely rational way that delays gratification, ignores emotion and is unswayed by influence, we often make suboptimal choices.  We are flawed. Humans love immediate gratification, we ignore consequences, we are swayed by emotion, we are influenced by branding and cultural norms, and we can’t be counted on to behave consistently.  Given all these facts, it’s a wonder we make it through the day.


We spent some time on the idea of making ‘Deals with the Devil.’ This is the concept of getting something now knowing there will be consequences later.  In these situations the consequences are so far down the road, so delayed, that you don’t really care about them right now.  The official term for this scenario is a Ulysses Contract. In a Ulysses contract, we make a deal with ourselves to constrain our future behaviors. patient engagement neurobiology medx

Here is a great example of the present me trying to hold the future me accountable to do something good for my health. Remember that 30 day Abs challenge that was posted to Facebook a few months ago? It seemed doable.  The challenge was a finite amount of time, someone had already laid out the exercises for you to do, and there were videos explaining each move.  What more could I need?  I had really good intentions to do the challenge and said to my husband, “I’m doing this, no wait- WE’RE doing this. Make sure I do this with you every night after the baby goes to bed. Don’t let me say no.”  Well, 5 days in and I was too exhausted, or I had work to do, or I just didn’t feel like it, or I figured I could just make it up tomorrow.

This type of scenario is all too common, and yet, I would consider myself an engaged patient.  I take active steps to ensure my family and I eat healthy and live an active lifestyle.  I’ve even been accused to being too over zealous about my need to shop at Whole Foods even though our closest store is 25 minutes away.  (That, by the way is a great example of being engaged and committed.)  When it came to this ab workout situation, however, I wasn’t engaged.  There was no consequence of not doing the challenge in the near future.  Nothing to hold me accountable in the public eye, nothing online the line.


Our beautifully flawed existence can make it difficult to choose the ‘right’ decision, and is the very reason that patients frequently just do not engage. Having good intentions is simply not enough to ensure that you’ll do the right thing.  Mr. Eagleman provided five strategies to decrease the likelihood of non-engagement .

MINIMIZE TEMPTATION. Examples of this might be alcoholics who do not keep alcohol in the house or healthy families that don’t keep processed foods in their cupboards.

PUT MONEY ON THE LINE. Make a cost associated with not doing.  We all know that there are thousands of people around the US that have paid gym memberships that go unused. (Good intentions, bad decisions.)  Some gym companies are betting on you to make bad decisions and offering to pay for your gym membership if you use it ‘X’ number of times per month.

Another really neat health initiative that’s knocking it out of the park with patient engagement is Stickk.  Stickk lets its users make contracts with themselves and build support networks to reach personal health goals. Users sign up for Stickk and choose any goal they want: lose 10 lbs, stop smoking, run 3 miles every day, etc. Stickk incorporates social networking so its users have a community of participants to cheer them on and hold them accountable. In addition, Stickk makes users put some cash on the line that will be charged if the goal is not completed.  Now here’s the really cool part.  You choose how much money you want to put on the line and you choose a charity or cause that the money will be donated to if you do not complete your goal.  When I looked today there was $19 million dollars on the line from over 268,000 goals.

RECRUIT SOCIAL PRESSURE. Stickk is a great example of recruiting social pressure to help patients reach their health goals.  It’s harder to back out of a workout when you have a giant online community waiting to hear about your results.

INVOLVE EMOTION. Well, this one is a no brainer.  Emotional investment into any cause will help drive engagement and action. Healthcare marketers, providers and institutions must tap into this for successful patient engagement.  As I mentioned in my post last week on design thinking for patient engagement, deep understanding and empathy for the patient journey is critical to creating products and services that truly engage patients.  For more on this, head back to last week and take a look.

ESTABLISH RULES.  I think this one kind of goes along with the social pressure.  Setting rules is easy to do, but they are not always easy to follow when it comes to health because of the complicated, intricately designed human brain.

I found this week to be a very interesting, new perspective on patient engagement.  I had some flashbacks to my psychology classes at Bucknell, and it also was a stark reminder of how much we have left to learn about the human brain.  As we wrap up here today, can you think of one way that you could incorporate the five strategies for engagement?


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