Choice Architecture

Freedom of choice. I suspect that your gut instinct suggests that more options are always better.  But, do we recognize that sometimes numerous options are actually more cumbersome than a limited choice?

Consider the vast array of toothpaste in your local pharmacy. How do you choose? Think of all the assessment instruments with unique variations. Which is the right one for your program? The first one that shows up in your lit search?  The one that a colleague champions?

We’d like to think that our decisions are bias-free…but are they really?

In reality, we all respond to influences – some good, some poor. Product advertising is based on profit, so you aren’t necessarily making a good choice if choose a toothpaste because of a great commercial. Studies have shown that most people choose the product that is in the middle rack at eye level.  Advice from a colleague can be helpful, but maybe they are uninformed or biased, and their needs are likely different than yours.

In the book Nudge: Improving Decisions about Health, Wealth and Happiness,  Thaler and Sunstein argue that by understanding how people think, we can design environments that make it easier for people to make a better choice. By nudging people in a certain direction, choice architecture looks to affect outcomes through the manner in which a person or organization is presented a decision. For example, nations that require citizens to opt-out of organ donation have a significantly higher donation rate than nations where the citizens must choose to take part (opt-in).< Johnson, E. J. & Goldstein, D. G. (2003). Do defaults save lives? Science, 302, 1338-1339.>

At this point you are asking yourself…how does this relate to medical education?  What if we designed a direct observation assessment instrument that “nudged” faculty to assess a learner according to best practices.  A neutral architecture would have a single blank box that asked for comments.  The typical input would be “Good job, read more.”  What if the choice architecture had a series of boxes like this:

  1. Choose one patient interaction that you witnessed your trainee performed today.  Provide enough description for a second clinician to understand the interaction.
  2. Describe the part(s) of the interaction that the trainee needs to work on.  Provide enough description for a second clinician to understand the issue.
  3. Provide the trainee with a strategy to address this area of need.  You cannot input “read more.”

Suddenly, we have choice architecture for a FIELD NOTE. (See here for the origin of field
notes. Field notes are becoming an increasingly popular qualitative direct observation assessment instrument, especially in Family Medicine in Canada.)  Choice architecture has prompted a shared mental model among faculty about the use of this field note.  In place of tens of hours of faculty development to reach all of your clinician teachers at multiple distributed sites, choice architecture has both improved these qualitative assessments and limited the required faculty development.

Thaler comments, “If anything you do influences the way people choose, then you are a choice architect… You have to meddle.”

While there is a reek of paternalism within this theory (which Thaler readily admits), choice architecture is already unconsciously employed in our personal lives. (i.e. Parents never ask a child what they want to eat, they give them a choice between the 2 (or 1!) items you are able to prepare.) Is it time for us to consciously employ choice architecture in our professional (education) lives?

Image 2 courtesy of Creative Commons