Tuesday, October 11, 2016

Persuasive Factors in Politics

In my previous posts, I was describing some of Cialdini's factors which affect decision-making and persuasion.

It is interesting to look at some of these factors playing out in current news events:

Why do people adhere to a particular political choice?

Many people insist that they support a particular political candidate, simply because that candidate has the best policies, or has the best leadership skills.  Or they support an ideological position, or a whole system of values, because they believe, and feel, that they are the best.

But are there other factors at play?  Let's look at some of Cialdini's persuasion factors to consider how they affect candidate or political choice:

1) Consistency & Commitment.  If a person has already supported a candidate, a political party, or a position, then that person is more likely to maintain their choice, even if circumstances change.  We form loyal attachments to our previous choices, even if the attachment is shown to be irrational or harmful.   It may seem humiliating, embarrassing, or weak, to bail out on a previous choice.   It might feel similar to abandoning a marriage, a job, or a responsibility, just because things are going through a rough patch.

This consistency factor is especially strong if the person has grown up in a culture where consistency or commitments are considered strong points of honour.   This culture of honour is to be respected.  Loyalty is to be respected!  But unfortunately, this loyalty can cause people to keep supporting, for too long,  something that is harmful...it can cause people to overlook negatives in their position, and to go along with things that they would never have rationally supported were it not for their previous commitment.

A related cognitive bias is the "sunk cost fallacy":  if you have already invested a lot of time, energy, or money into something, you are more likely to continue pursuing it, even if it is irrational to do so, and even if the project is failing disastrously.   It may feel humiliating or shameful to change your mind, even if changing your mind could save you from bankruptcy!  It can take courage to let a previous commitment go!

Commitment and consistency are bolstered by community and family factors:  if most people among your cultural group, family, or coworkers have all been supporting a particular group, idea, or candidate, then it could seem intensely disloyal to disavow your own support or commitment.  You might even fear that your peers or family could reject you if you changed your mind.

So, commitment and consistency are powerful, noble forces in decision-making, and in life, but we must not be enslaved by these factors...it is a sign of a much greater character strength to sometimes over-ride this, and to make a deeply moral choice to let go of a previously held commitment.  

There are many tragic stories in history, where massive segments of the population of great societies follow disastrous ideas and leaders, partly due to the persuasive force of consistency.

2) Social pressure.  If many people continue to support a particular thing, then it is easier to keep supporting it yourself, even when this is irrational.  We all have a tendency to follow a trend...sometimes we follow these trends, along with an excited, passionate crowd, even when the crowd is rushing towards the edge of a cliff!  Beware of  "GroupThink!"

3) Liking & Authority.  We form positive emotional connections with candidates or positions we support, and we may also respect their authority...trust and admiration grows with any ongoing relationship, and we may continue to make decisions influenced by this.  If we "like" a political candidate, we may support that person long after it makes rational sense to do so.  Conversely, it may be difficult to support a candidate we do not personally "like," even if this candidate may offer the best leadership.   Some of these factors can be incredibly irrational, such as supporting a person whom we find better-looking or more entertaining!

When these factors have been at play, and we support something, we are likely to invest our time, attention, energy, and money...we may even suffer and struggle for these causes.  Our struggles and suffering usually intensify our attachment, and make us even more resistant to letting it go when it is morally right to do so.   If you have fought for something, you are much more likely to keep fighting for it, even if your cause is proven to be unjust.

It is our duty as citizens, or as participants in any community,  to make wise choices, and to be willing to change our minds after thinking carefully.  You need a great strength of character to take an honest, balanced look at both sides of every major issue or position.   You are not just born with character strength--you must work at it, and develop it as an essential life skill!  In politics, it is important to give sincere attention to multiple sources of information, and not to rely only on a single news source which happens to support your pre-existing point of view.

I am very alarmed about situations--which we see across the world today--in which there is restricted freedom of speech and expression.   Many news sources are overtly supporting only one position.  In some countries, the government is restricting free debate in the media.  Even closer to home, individual news sources are focusing on telling only one side of many stories...  We must protect our freedom of expression!  It is not only a matter of taking care of our freedoms, it is also a matter of making wise, unbiased decisions!  Wise decision-making is impossible unless we fairly attend to multiple points of view, and unless we are willing to challenge our own individual biases.

Cialdini tells an interesting story about the decline of tobacco use in the U.S., associated with a policy called the "Fairness Doctrine" which required equal time to be given to opposing viewpoints.  If tobacco ads were always followed by other ads trying to show the harms of smoking, it led the viewer to make a more balanced decision (which, in this case, led to a decline in smoking).  Ironically, once tobacco advertising disappeared entirely, smoking rates did not decline as much.  Part of an explanation is that tobacco advertising could then occur in more covert forms, perhaps marketed more exclusively to existing smokers, without equal time given to opposing viewpoints.  The best decision-making occurs not when issues are suppressed, but when powerful counter-arguments can be presented in a free society, by a free press, where opposing positions can always be clearly shown, side by side.  

It takes a great strength of character to be willing to change our minds,  and to make an intelligent, morally-guided choice, in the face of powerful persuasive factors such as consistency, social pressure, liking, and authority.  We can all improve this character strength, if we are willing to challenge ourselves, and if we are willing to work hard!

The Psychology of Language Use: Big Words & Zombie Nouns

I'm very interested in the use of language, as a joy of life, and as a factor in psychological health.

Poetry and rhetoric are beautiful and powerful forms of self-expression,  and of beginning a dialog with others in an effort to solve problems.

It is therapeutic to have a forum to express yourself.    Journaling can be a part of psychological well-being, as a way to process past adversity or trauma, and  as a way to manage anxiety.  One of the most meaningful aspects of psychotherapy can be to share your story out loud with a supportive, respectful therapist.

One of the problems with some new  brief styles of mental health care can be that there is very little comfortable space given for  expressing yourself in this way.    Instead, care is guided by questionnaires, symptom reviews, and mechanical treatment algorithms.

This blog has been enjoyable for me to write.  I had always wanted to do some writing.  It has been good for my own health, in many ways.  It has been my own self-expression!

I do enjoy writing...but I'm quite conscious that my style of writing may not actually be that enjoyable for many readers.   The way I speak, and write, often can sound really formal and wordy...I would like to work on this, but it can be hard to change these habits.  Also, I want to use my actual, authentic voice, which actually is a bit formal and wordy!

During the past year, I have come across many examples of language use which have bothered me...in fact, this is one of the big reasons I am writing this post today.

To explain, there are two authors I'd like to refer to...

Daniel Oppenheimer: Using Long Words Needlessly

The first is Princeton Professor Daniel Oppenheimer, who in 2006 published an amusing article called "Consequences of Erudite Vernacular Utilized Irrespective of Necessity: Problems with Using Long Words Needlessly."

He showed, quite simply, from 5 experiments, that if you use bigger, longer words, people will form an impression that you are less intelligent!   In his words, "needless complexity leads to negative evaluations."   The use of jargon and complex vocabulary can sometimes be an indication of being part of an "in-group."  But especially in mental health discussions, it is vitally important that the therapeutic community not be an "in group" separate from the community of clients!   This is one extremely important reason to avoid such jargon!

Here is another useful quote from his discussion:

Pennebaker and Lay (2002) have shown that people are more likely to use big words when they are feeling the most insecure...leaders facing crucial decisions might use more complex vocabulary and end up undermining others’ confidence in their leadership ability. Thus it may be worthwhile to investigate ways of either preventing the tendency to use needless complexity, or look at ways that fluency biases might be overcome.
In the interim, we can conclude one thing...write clearly and
simply if you can, and you’ll be more likely to be thought of as intelligent.
In discussions about health care and wellness, as in other communications from daily life, it is good to strive towards beauty and clarity in language.  Beauty and clarity are intrinsically healthy and comforting.  Awkward language, jargon, and rambling, confused text induce anxiety, stress, and irritation in the reader or listener.

Steven Pinker:  Zombie Nouns 

The second author is the famous linguist and psychologist Steven Pinker, who recently published a  book called The Sense of Style: The Thinking Person's Guide to Writing in the 21st Century (Penguin, 2014).

Pinker has a refreshing approach to looking at writing style and grammar use, with an interesting focus on the history and background of stylistic rules.  Many grammar and style rules are cultural variants, and are often held more strictly than is appropriate, especially given their often arbitrary nature.  Many of our greatest authors have often violated various style or grammar "rules."

Pinker describes a particular style problem, which is prevalent among academics and bureaucrats.  This type of talk is common in politics and in corporate lingo and jargon.  He calls this "bureaucratese, corporatese, legalese, medicalese, or officialese."  

...as I browse through Pinker's book again, I find myself  self-conscious about my own writing style, right now...here's a quote attributed to Mark Twain, which shows that I'm not following good style advice right now myself:
substitute damn every time you're inclined to write very [or quite, or especially, or particularly, etc.]; your editor will delete it and the writing will be just as it should be.
Anyway, I think Pinker is so right about the need to work on better style, to make language more beautiful, expressive, and enjoyable...

A lot of Pinker's illustrations are quite funny.  I had a good laugh when he referred to the word "model" as "a verbal coffin,"   There is a lot of "model" talk in health care planning--too much talk about "models" and too little time taking care of patients or clients in need!    

 Another term Pinker uses is "zombie nouns."  This is the confusing, pedantic use of words which are almost neologisms, where a noun is turned into a new verb, or perhaps back into a noun again with extra suffixes.   This language use imposes a sort of "in group" status upon those engaging in it...which could be useful for a team working on a narrow project, but not healthy for a team hoping to serve and interact with the community in a sensitive and empathic way.

Here are some variations of this:

noun into verb into noun again:  "languaging"
adjective into noun: "the collaborative,"  "competencies"
noun into verb: "effectualizing"
noun into adjective into verb: "operationalize"

Applications for Healthy Living

I encourage you to practice using your voice!  I mean this literally, in terms of speaking out loud!  I also mean it figuratively, in terms of writing and expressing yourself in other media.

If you do some writing, such as in a journal, pay attention both to the content (which could be writing about painful life experiences, about things you feel gratitude for, or about musings of your imagination), but also to the process.   Enjoy language, and form a style which is sincere, expressive, and beautiful!  If you are writing or speaking for other people, then be sure to empathize with your audience, and to consider ways to make your communication understandable and engaging.

Oppenheimer, DM (2006).  Consequences of erudite vernacular utilized irrespective of necessity:  Problems with using long words needlessly.  Applied Cognitive Psychology, 20(20), 139-156.

Pinker, S. (2015).  The sense of style:  The thinking person's guide to writing in the 21st century. Penguin Books.

Thursday, October 6, 2016


One of my favourite areas of psychology has to do with the study of persuasion, and of the cognitive biases involved with this.

There are two very important researchers who have written extensively about this:  Robert Cialdini (an expert in the psychology of persuasion), and Daniel Kahneman (an expert in the psychology of cognitive biases).   

Cialdini: Persuasion
I highly recommend that everyone be familiar with Cialdini's work, because it relates to making good decisions in the modern world.  Cialdini has spent decades studying the persuasive techniques which are used in sales and marketing, with the rigorous and thoughtful eye of a scientist and experimental social psychologist.  A problem with Cialdini, however, is that his books seem too focused on an audience of business people and marketers. 

Kahneman: Cognitive Biases
Kahneman's work focuses more on the cognitive mechanisms that affect judgment, and this area is an important complement to Cialdini.   Kahneman is the only psychologist to have won the Nobel prize!  His psychological work is very relevant to economics--it is a quantitative look at how human cognitive biases affect all decision making, including small and large economic or financial decisions.  
Why is this Important?
Cialdini -- and probably Kahneman too -- are most appreciated by people in the business community, especially marketers, since their ideas are likely to help any business earn more profit.  But I think these ideas should be part of everyone's knowledge base, since they will help us all to protect ourselves from being influenced by marketing in an unwelcome way.   Not just obvious marketing, such as commercial advertising, but also subtler forms of "marketing," such as experiencing persuasive forces in the workplace, in the media, in politics, and even in our personal or social lives.  

Persuasive Factors
In his initial work, Cialdini described 6 factors contributing to persuasion:
1) Reciprocity.  If someone gives you something, you will be more apt to give something back, including your approval or support!   If you are treated to lunch, you will be more likely to comply with someone's request afterwards!  This is a normal, natural thing, and even part of good social skills...but be careful about this, because sometimes the person giving you a free lunch may have an agenda to change your mind about something that you would otherwise not want to change.  A very troubling example of this in current events is of extremist groups providing free food, shelter, and other care to people in need...while helping people in need is wonderful, it also leads the people receiving this help to be more likely to join the extremist group!   We can address this problem politically by making a big effort to help people in need long before an extremist group does, rather than focusing only on military solutions to such problems!  

2) Consistency. Once you have done a certain action, or agreed to a certain thing, or committed in a small way to a certain thing, you are more likely to go further with that same thing in the future.  If you once joined a particular political party, you will be much more likely to keep supporting it in the future, even if you would otherwise disagree.  If your parents and grandparents have always supported a certain political or religious group, you will be more likely to also support the same group, since it could seem inconsistent, or even a "betrayal," to change your mind or your actions.  This consistency can be a great thing--it is part of maintaining a personal or community culture.  But it can also cause people to be "stuck" with ideas or behaviours which are unhealthy or harmful, yet with a resistance to change.   Marketers use this phenomenon all the time, by encouraging you to become a "member" of a points plan for a particular business, to have consumer "loyalty" programs, by having you formally endorse one of their products, which leads to a long-term tendency to choose the same products again.   
Be careful about this one!  Consistency is good, but not if it prevents us from changing our mind when change is needed.  Some of the most disastrous events in world history happened when people's consistency and commitment led them down a dark path...

3) Social Pressure, or Social Proof.  If you see that something is becoming more popular, you are more apt to support it.  Suppose you are starving in the woods, and you see bushes with berries on them.  You are not sure whether they are poisonous or safe.  If you see other people happily eating those same berries, you will obviously be reassured that they are safe, and you will happily pick some berries for yourself!  In this case, social proof is very useful and protective.  But marketers routinely use information about social proof to push us to support things or buy things.  Even the polls that we see in the media can have this effect:  if someone claims that a particular candidate is soaring in popularity, many people will be more likely to join in and support that person as well.  This effect is especially pronounced if the social proof comes from people who are similar to us in some way.  For example, if you are shown that most people who are around your age, and who come from a similar ethnic background, and who share similar cultural interests, are all supporting a particular political candidate, you will be more likely to be persuaded to support this candidate as well.  
Once again, this is a normal and often efficient way to make decisions in life, by assessing the decisions that similar people are making already.  It is what Kahneman calls a "cognitive short-cut."  

But marketers use this factor all the time, to push us to support things, or to buy things, that we otherwise would not want.   

4) Liking.  If someone you really like asks you to do something, or to change your mind, you are more likely to comply!  This is again a completely normal, understandable, and often useful human behaviour.  But be careful with this one!  Marketers, politicians, and even people in your social circle could sometimes push you to make decisions you otherwise would not make, just by being nice, and by being "likeable."  The stereotype of a "con man" usually includes being physically attractive, charming, and superficially likeable.  Be careful not to let these factors affect your judgment more than you want!  

5) Authority.  This is a huge factor, both in the marketplace and in a professional work environment.  It is another very useful cognitive short-cut to assume that an "expert" has good advice.  Often the expert or authority (such as a famous doctor or researcher) really does have useful advice and wisdom!  But people are easily prone to shutting off their critical judgment if they are told something by an expert.  In many cases, an expert may have a particular agenda for change which is not directly related to their expertise.  And in many cases, a speaker may be granted more "authority" or expert status than is reasonably warranted.  For example, it is a tradition for speakers at a meeting or conference to be introduced with a glowing biographical vignette, summarizing a list of very impressive credentials, degrees, awards, and a publication record.  These facts may be completely accurate, but it is important to know that this introduction will increase the speaker's persuasive influence over the audience...While this is often useful and reasonable, it could also often give the speaker license to influence the audience about all sorts of things that are outside of their expertise!  

I have seen this in my work very often:  a speaker with impressive credentials is greatly respected by the audience.  The speaker's ideas about treatment strategies (e.g. medication or therapy approaches for treating depression) or about health care policy (e.g. how to set up an efficient medical system) are accepted by the audience in a much more uncritical way, with much less reasoned debate, than would be the case if the same ideas were shared without the introductory eulogy about credentials!  

Be careful when you see a commercial featuring an esteemed expert or authority endorsing a product.  The information you hear should be considered seriously, but remind yourself that you may exaggerate the validity of this information, simply because you respect the expert's authority.  Always question authority!  Don't reject it outright, but always question it!  

6) Scarcity.  If you know that something is rare, or disappearing, you are more likely to desire it more.  This factor is routinely used in sales and marketing:  if a particular product is "disappearing fast,"  or if you are told it is your "last chance" then you are more likely to be interested in it.  If you are guided to believe that you have some kind of rare, special, personalized knowledge about something, then you are more likely to act on it. 
In marketing and politics, the fear of loss can have an exaggerated influence on people's decision making.  The fear of loss of security or safety can lead to a greatly increased focus on policies addressing this (e.g. military or policing issues).  While it is reasonable to focus on such things, ironically the fear involved can distract attention away from other policy factors which would ultimately have a much better chance of improving safety (such as enhancing diplomacy, improving education, focusing resources on eliminating poverty, etc.) 

In Cialdini's more recent work, we could add another factor, one which Kahneman has talked about extensively as well.  It is something which all the other 6 factors incorporate to some degree as well:  

7) Guided Attention & the Focusing Illusion
If our attention is guided towards something, we are much more likely to assume that this thing is important, and that it has some causal influence.  A magician or illusionist routinely makes use of this...most magic tricks involve carefully guided attention, so that we don't notice the magician fooling us, right in front of our eyes!   I encourage you to look at some YouTube videos showing clever illusionists using this phenomenon; here's a good example: https://www.youtube.com/watch?v=GZGY0wPAnus

This factor is arguably the most powerful of all persuasive influences.   When a person or a group is focusing on something, we will be guided into thinking that this focus is more important and causal than it really is, and it will prevent the person or group from asking other important questions!  

Cialdini gives a good example of this, having to do with the journalists who were allowed to cover a recent war.  The journalists were given unique, unprecedented "embedded" access to soldiers in their daily lives.  On the one hand, this allowed a valuable transparency about the goings on in the war.  It led to a focus upon the daily dramas in the life of a soldier:  the harsh climate, the food, the camaraderie and bonding with fellow soldiers, and especially the heroism, bravery, and self-sacrifice involved in the battles.   As a result of this focus, the viewers would form an understandable and healthy attachment to the human stories on the battleground, and would form a completely normal and healthy admiration for the bravery and nobility of the soldiers.  But--because of this, the viewer would be less likely to question the strategy of the war itself!   

The manner in which a story is focused upon can distract us from asking other questions about the story, which may need to be asked!  

In a work environment, there could be a new policy scheme, which in some ways could be similar to the example above...it could involve honourable, devoted, intensive efforts from many warm-hearted people, all of whom nobly striving towards making things better.  But once such a plan is in action, the attention of the group becomes focused upon the daily "battles" and human dramas associated with enacting the plan.   The group is much less likely to question the strategy of the plan itself, even if the plan is unhealthy or harmful.  

One can see this in political movements:  supporters of a particular political party or candidate are working very hard, are forming strong social and emotional bonds with the cause...they are motivated honourably, often with strong wishes to make the country better.  There are daily struggles with polls, with debates, with interviews, with criticisms from opponents...these struggles are analogous to a battlefield.  The stories involved with the battles are dramatic and engaging, and the media on both sides of the battle are eager to focus on them.   But because of this, supporters are likely to simply focus on continuing the battle they started, rather than pausing, reflecting, thinking deeply, and being willing to change their strategy or beliefs if necessary and morally right.   


So, this is what I mean by "GroupThink."  It is going along with what other people are thinking...due to reciprocity, consistency, social pressure, liking, authority, and the focusing illusion...we then risk getting caught up in things that aren't good for us.  

"GroupThink" can often be efficient, to get certain tasks done.  If everyone in a group is constantly stopping, reflecting, and questioning themselves, then the group's actions could be frozen...but we must always at least be aware of how powerful "GroupThink" is, and how it affects all of us.  The antidote for this, the way to keep this force balanced, is to always be willing to question things!  

Be willing to question others, even authorities, even people whom you really like!  Be willing to question yourself!  Just because you have thought, felt, or done a certain thing for a long time doesn't mean you can't change your mind, your feelings, or your actions!   

Be aware that there are powerful persuasive factors in our lives, all around us...we don't have to be afraid of them, but we do need to know that it can be easy to follow these factors passively.  We can live healthier, happier, more satisfying lives if we take some time to step back, think carefully about our decisions, and be willing to speak up!  

Friday, September 16, 2016

Mental Health Care Triage

What is Triage?

"Triage" is a term used in medicine, referring to the process of deciding the order in which patients should be seen and attended to, if many are waiting.

If you are waiting for something, such as for a table at a restaurant,  the first person to arrive is served first.  An even higher priority is also given to people who have made "reservations," or who have arranged their appointments in advance.

In an emergency room, a different system is needed.  Even if you have been in the waiting room for several hours with a broken ankle, a person just arriving with a heart attack must be seen right away, before you!   It generally would not work to make "reservations" at the emergency room, except maybe if you are on your way in an ambulance.

Triage involves not only deciding what order in which patients should be seen, it also involves deciding what type of service should be provided to each person.

If everyone with abdominal pain was sent to a surgeon, it would be inefficient...most cases of abdominal pain do not need surgical treatment.  If these non-surgical cases were all seen by the surgeon, then the surgeon would be too busy to deal with the true surgical emergencies!

In mental health care, it can be efficient to have a triage process.  But how to do this?


The most common strategy is to offer some form of "assessment" which then could guide a triage decision.  This usually would involve an interview.  It could involve filling out questionnaires.  Based on the results of the interview and the questionnaire results, a decision could be made about whether some form of counseling might be needed, or perhaps a visit to a physician, a referral to a psychiatrist, or even an urgent trip to the hospital.   In other cases, a bit of simple reassurance, simple lifestyle or self-care advice might be really helpful.

The benefits of an efficient triage process would be that others in the system could then see clients or patients whose particular problems or levels of severity were well-matched to the skills of the particular caregiver.  All caregivers in the system would spend less time dealing with situations that were outside their scope of experience or expertise.

Potential Problems 

What are some of the potential problems of a mental health triage process?

1) The first issue has to do with the reliance on a single interview, and on questionnaire data.  In a great many cases, this is an efficient, helpful process.  But in some cases, an ongoing relationship is needed to understand mental health issues.  People may not be willing to share sensitive issues with someone who will only be seeing them once.  People may not be willing to divulge sensitive information in a questionnaire, which will then be handed in to a stranger.   Some people may have a very clear reason to desire a therapeutic relationship of a particular type, without wanting to explain their reasons in detail to a stranger who would only be seeing them once.

So the triage system, involving interviews and questionnaires, must have the flexibility to accommodate situations of this type.  Basically, it should have strong consideration for patients' or clients' wishes for privacy, discretion, confidentiality, and therapeutic resources, while not being rigidly adherent to questionnaire or interview data.

A simple remedy for this problem can be for individual patients or clients to have the ability to make a direct request for a particular type of care, without having to "jump through the hoop" of a triage assessment visit.  Many people who desire a therapeutic relationship will not benefit from going over their history with a stranger who will not be seeing them in the future.  In fact, the triage step will just add to their stress, and could lead to a feeling of having to negotiate yet another bureaucracy.

2) The second issue has to do with the quality of life of people working in the system.  In my experience, emergency psychiatry is a very stressful area of mental health care.  Practitioners in this area can often become burned out or even cynical over time, if this is the only type of work that they are doing.  The reasons for this are not simply related to the severity of the problems seen in the emergency room:  it is also because emergency workers usually do not follow the patients or clients after their emergency visits.  Therefore, they do not get to see their patients or clients recover!  They may not have the satisfaction or enjoyment of working with someone over a period of time, and seeing their progress.    Furthermore, if they are only doing emergency or triage tasks, their clinical skills for doing other types of ongoing health care will weaken or atrophy.  

I believe that a big part of the joy of being a therapist or a physician, involves getting to know your clients and patients on an ongoing basis, sometimes for long periods of time.  It can be demoralizing and stressful to only be seeing people a single time, or only be seeing people who are severely ill.

There is a simple remedy for this problem:  in any triage system, or emergency care system, it can be valuable for different staff to take turns doing triage tasks.  Each staff person should also have the opportunity, at other times,  to follow some patients or clients for ongoing care.   This would help staff to maintain better morale, and to maintain better clinical skills beyond "assessment."

3) A third issue has to do with the risks of a supposedly "efficient" system becoming more and more like a mechanical or impersonal bureaucracy.   As questionnaire-based systems become more and more prevalent, we may start talking more and more about "PHQ-9" scores, and less and less about a person's story.   Furthermore, score-based assessments in mental health may lead to false conclusions about what is truly helpful.  For example, a person in great distress may enter an emergency room on a Friday night with an extremely high score.  That person might have an unpleasant experience on a stretcher in a noisy hallway on Friday night, then a frightening experience on a busy emergency ward for the next day.  On Sunday afternoon, the symptom questionnaire may be repeated, yielding a greatly reduced score.  The conclusion may be that the emergency room experience was profoundly helpful!   In this case, the symptom score diminished because of the passage of time, and perhaps because of a physical place that was safe in some ways.  Other types of harms may well have been done because of this experience (for example, the person may dread ever having to go to the hospital again), but this harm would not be detected on a cross-sectional symptom scoresheet.   The harm would be apparent, however, if we were to have a conversation with this person rather than just give them a questionnaire.

Symptom questionnaires are very imperfect guides, and should never be the foundation of any type of health care, especially in mental health  (see my previous post about questionnaires: http://garthkroeker.blogspot.ca/2015/11/the-business-of-psychological.html).  I do think they have their role, and people could be invited to use them, but there is a risk of both the patient or client, and the caregiver, paying too much attention to questionnaires, and too little attention to other aspects of care or need.

4) A fourth issue has to do with allocation of health care resources.  While triage could improve efficiency, and allow more people to get the help they need, it could also in some cases be an unnecessary bureaucratic hurdle.  The same money and resources spent on a triage system could instead be spent simply hiring more counselors, who could manage their own triage.  In many private counseling regimes, a person seeking a counseling relationship is already "self-triaging" and can inquire on their own with the therapist about the possible types of care available or needed.  

This issue is similar to the Electronic Health Records (EHR) issue:  an innovative device, triage system, or "model" may be useful in some ways, but it must always be in service of a higher value, which is to provide personal, empathic, attentive, ongoing care to those who desire it, and to allow a healthy, balanced, meaningful work environment for therapists.

Wednesday, September 14, 2016

Electronic Health Records (EHR)

Electronic health records allow for a variety of improvements in medical practice and health care:

Communication between physicians can be improved.

Lab results can be coordinated and exchanged efficiently, with a reduction in the chance of results being overlooked.

Patients or clients of a health care service can become more directly involved in perusing their own health records, and therefore could have a more empowered, active role in their health care.

Some systems can also allow prescriptions, other treatments, and symptoms to be tracked efficiently over time.

Patients could also contribute information (such as providing a history, filling out questionnaires about symptoms, etc.) directly into the system, which could make the clinical time with a health care provider more efficient and more personal, less focused on "data gathering."

Problems with EHR

Yet, there are a variety of problems associated with the use of computerized health record systems.  

Impact on Rapport

I think the worst problem is the potential impact on rapport during a health care visit.  If your physician or therapist is fumbling with a keyboard, and staring at a screen, instead of paying attention to you, this is poor quality of care, and threatens the therapeutic relationship.  This is potentially harmful to clients or patients, and is also potentially harmful to the well-being of the physician or therapist.  

You could compare this to having an "appointment" with a friend...if your friend is busy checking a cell phone or typing on a computer keyboard during dinner, or during a forest walk, the technology will harm your friendship!  When such behaviour becomes more frequent, more of a norm, more trendy, people tend to simply go along with such things, rather than insist that the device or gadget be turned off.  I think it would be better to complain to your friend about it instead, and to insist on having a conversation, or to insist on just walking quietly through the forest together!  

In some of the meetings I have attended over the past few years, I have seen people enthusiastically talking about new apps and gadgets in therapeutic settings (such as collaborating with clients using an ipad), yet part of the irony of these meetings was that the presenters or audience members were themselves so engrossed with their laptops or with their other gadgets that they had very little eye contact or social connection with those around them, and perhaps not a lot of awareness that their gadget-preoccupation was even a bit of an annoyance to their neighbours.  

Corporate Influence: 20 Billion Dollars!

Another problem with electronic records has to do with economic factors.   The EHR market is worth about $15-20 billion dollars globally, and is growing rapidly! *   This is enough money to fund 400 000 therapists, each earning $50 000 per year.

The corporations producing EHR software and machinery profit financially from sales. Clinics or hospitals using EHR will need educational sessions with representatives of the tech companies.  This is a potential conflict of interest issue:  it is similar to having medical education sessions organized and led by pharmaceutical reps.  The educational sessions are marketing opportunities for representatives of the EHR software company to consolidate adherence to a product.  Much of this education is sincerely useful for staff and beneficial for clients or patients, and the educational sessions may come with sincerely positive intentions.   But there are biases favouring a continuing business relationship with the software corporation, separate from considerations of patient or client care.  

Literature Review of EHR Problems

What does the academic literature have to say about this?  We have a pertinent article just published:  Susan Hingle, in Annals of Internal Medicine (Sep 6, 2016, doi 10:7326/M16-1757), reviews the use of electronic health records. Here is a quote from this article: 

Sinsky and colleagues confirm what many practicing physicians have claimed: Electronic health records (EHRs), in their current state, occupy a lot of physicians' time and draw attention away from their direct interactions with patients and from their personal lives. Observers documented that for every hour of direct clinical time with patients, physicians spent 2 additional hours on EHR and desk work, and physicians reported spending up to an additional 1 to 2 hours of after-hours personal time completing documentation and EHR tasks. These observations have important implications for patient care and outcomes...A recent study found that physicians who use EHRs and computerized physician order entry have decreased satisfaction and a higher risk for professional burnout. Physicians who burn out are at a significantly greater risk for depression and suicidal ideation, and there is also concern that they are more likely than satisfied colleagues to provide lower-quality patient care and to leave clinical practice early, although this is difficult to fully measure...Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the health care system that will redirect our focus from the computer screen to our patients and help us rediscover the joy of medicine.

Here is another article, expressing similar concerns, from the Washington Examiner, published in October 2014 by Richard Pollock: 

Another critical article, from the point of view of nursing staff in a hospital:

Here's a good article published in 2016 by Suzanne Coven, in Stat:

Despite these concerns, I do acknowledge the potentially useful role of computers, electronic records systems, therapeutic apps, etc.  But I think this gadgetry must never be focused on at the expense of highly personalized care for each client or patient.  As I have said elsewhere, I think these innovations can be truly great advances, but they can be a bit like giving children gifts at Christmas or birthdays:  children may get excited about a new toy, and may even become conditioned to expect more and more expensive toys as time goes by.  The toys may be great toys!  They could even be "educational"!

But the "gift" that children (and all the rest of us) really want and need is care and attention from loved ones.  Without this, the toys are worthless, and may even cause the children to have a deteriorating, materialistic quality of life.  

The impact of gadgetry and computers in health care affects not only clients or patients, but also caregivers, clinicians, therapists, and office staff.  It is important to consider staff quality of life, and staff satisfaction with work, as essential components in choosing health care strategies.  "Efficiency" and "optimal data collection" may seem to be desirable goals, but such efficiency is insidiously negative if it does not allow for a healthy workplace environment.  This is similar to managing a nation's economy:  a bottom-line view of maximizing economic efficiency may lead to increased overall financial wealth in a society; this is easy to measure, and therefore could be irresistible for policy-makers to follow.   But such optimization of efficiency and wealth can often lead to a decline in the morale and well-being of the population, if it is not balanced by other factors.  A reduction in efficiency, if it means more time for family, and better care of the environment, can sometimes lead to far greater wealth than anything money can buy.  

So in order to move forward with this issue, I do not suggest that we abandon EHR technology.  It is a potentially useful and innovative tool.  But we must never let our tools or toys distract us from providing a caring, empathic, human interaction.  We must never let a pursuit of efficiency or the acquisition of data have a higher order of importance  than caring, empathic, personalized health care. And we must be wary of corporate influences on health care policy, especially when large amounts of money are involved.

If you are affected by this issue, I encourage you to offer constructive feedback to your health care provider.