TEDMED 2018
David Asch: Why it's so hard to make healthy decisions
大卫·阿施: 为更好的医疗保健，请拥抱非理性
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我们为什么要做出明知道对健康不利的错误决定？在这场坦率且有趣的演讲中，行为经济学家和健康政策专家大卫·阿施（David Asch）解释了为什么我们的行为常常是——以一种高度可预测的方式——非理性的，并且展示了我们如何能掌控这种非理性，从而做出更好的决定，并在整体上改善我们的医疗保健系统。
David Asch - Behavioral economist, health policy expert
David Asch advances individual and population health by improving the way physicians and patients make decisions in health care and in everyday life. Full bio
David Asch advances individual and population health by improving the way physicians and patients make decisions in health care and in everyday life. Full bio
Double-click the English transcript below to play the video.
那是 2007 年的 4 月，
00:12
It's April of 2007,
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新泽西州的州长，
荣·科赞（Jon Corzine），
荣·科赞（Jon Corzine），
00:15
and Jon Corzine,
the Governor of New Jersey,
the Governor of New Jersey,
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陷入了一场可怕的车祸。
00:18
is in this horrific car accident.
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当他乘坐的那辆 SUV
在花园州高速公路撞毁的时候，
在花园州高速公路撞毁的时候，
00:21
He's in the right front
passenger seat of this SUV
passenger seat of this SUV
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他正坐在副驾驶的座位上。
00:23
when it crashes on
the Garden State Parkway.
the Garden State Parkway.
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他被转移到一家新泽西的
创伤治疗中心，
创伤治疗中心，
00:26
He's transported
to a New Jersey trauma center
to a New Jersey trauma center
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身上伴有多处骨折和撕裂。
00:28
with multiple broken bones
and multiple lacerations.
and multiple lacerations.
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他需要立即接受手术、
7 品脱的输血、
7 品脱的输血、
00:31
He needs immediate surgery,
seven units of blood,
seven units of blood,
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一个帮助他呼吸的呼吸机，
00:34
a mechanical ventilator
to help him breathe
to help him breathe
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以及即将面临的又几场手术。
00:36
and several more operations along the way.
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他能活下来真的令人震惊。
00:39
It's amazing he survived.
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但可能更令人震惊的是，
00:41
But perhaps even more amazing,
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他当时在车里根本没系安全带。
00:43
he was not wearing a seat belt.
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事实上，他之前从来不系安全带，
00:45
And, in fact, he never wore a seat belt,
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曾经开车载过科赞州长的
新泽西州巡逻队员
新泽西州巡逻队员
00:47
and the New Jersey state troopers
who used to drive Governor Corzine around
who used to drive Governor Corzine around
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曾求着他系上安全带，
00:51
used to beg him to wear a seat belt,
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但是他从来没系过。
00:53
but he didn't do it.
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其实，在科赞当上
新泽西州州长之前，
新泽西州州长之前，
00:55
Now, before Corzine
was Governor of New Jersey,
was Governor of New Jersey,
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曾是新泽西州的联邦参议员，
00:57
he was the US Senator from New Jersey,
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再之前，是高盛投资公司的 CEO ，
01:00
and before that, he was
the CEO of Goldman Sachs,
the CEO of Goldman Sachs,
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负责高盛的上市，
01:02
responsible for taking
Goldman Sachs public,
Goldman Sachs public,
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并为其赚取了上亿美元。
01:05
making hundreds of millions of dollars.
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不论你从政治上
还是挣钱方式上
还是挣钱方式上
01:07
Now, no matter what you think
of Jon Corzine politically
of Jon Corzine politically
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是如何看待荣·科赞这个人的，
01:10
or how he made his money,
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没人会说他是个蠢人。
01:12
nobody would say that he was stupid.
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但是你瞧他，
01:14
But there he was,
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在每一个美国人都知道
安全带能救命的时候，
安全带能救命的时候，
01:15
an unrestrained passenger
in a car accident,
in a car accident,
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他就是那个车祸现场中
不系安全带的人。
不系安全带的人。
01:18
at a time when every American knows
that seat belts save lives.
that seat belts save lives.
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这个简单的故事反映出
01:23
This single story reflects
a fundamental weakness
a fundamental weakness
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我们在改善健康行为的方法中
的一个基本的弱点。
的一个基本的弱点。
01:26
in our approach
to improving health behavior.
to improving health behavior.
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我们告诉医生和病人的
一切东西几乎
一切东西几乎
01:29
Nearly everything we tell doctors
and everything we tell patients
and everything we tell patients
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都是基于“人类行为是理性的”观点。
01:33
is based on the idea
that we behave rationally.
that we behave rationally.
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如果你给我信息，
我会在脑袋里分析那个信息，
我会在脑袋里分析那个信息，
01:36
If you give me information, I will process
that information in my head,
that information in my head,
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然后我的行为会随之改变。
01:40
and my behavior will change as a result.
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你觉得荣·科赞
不知道安全带能救命吗？
不知道安全带能救命吗？
01:43
Do you think Jon Corzine didn't know
that seat belts save lives?
that seat belts save lives?
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你觉得他只是没收到提示便笺吗？
01:47
Do you think he, like,
just didn't get the memo?
just didn't get the memo?
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（笑声）
01:49
(Laughter)
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荣·科赞没有知识缺失，
01:50
Jon Corzine did not have
a knowledge deficit,
a knowledge deficit,
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他有的是行为上的缺失。
01:53
he had a behavior deficit.
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他不是知道的少，
01:55
It's not that he didn't know better.
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他知道的并不少。
01:57
He knew better.
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而他，没能做好。
01:58
It's that he didn't do better.
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另外，我认为人的思想
是个抵御性很强的东西。
是个抵御性很强的东西。
02:02
Instead, I think the mind
is a high-resistance pathway.
is a high-resistance pathway.
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用信息改变一个人的思想
已经够难的了，
已经够难的了，
02:07
Changing someone's mind
with information is hard enough.
with information is hard enough.
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用信息改变他们的行为
02:11
Changing their behavior with information
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更是难上加难。
02:13
is harder still.
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我们能在健康和医疗保健方面
02:15
The only way we're going to make
substantial improvements
substantial improvements
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02:18
in health and health care
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做出较大改善的唯一方法，
02:20
is to make substantial improvements
in the behavior of health and health care.
in the behavior of health and health care.
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就是尽可能改善人们
在健康和医疗保健方面的行为方式。
在健康和医疗保健方面的行为方式。
如果你用一个反射锤
敲击我的膑腱，
敲击我的膑腱，
02:26
If you hit my patellar tendon
with a reflex hammer,
with a reflex hammer,
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我的腿会向前弹起，
02:29
my leg is going to jerk forward,
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而且会比我自己
想着让它弹起的时候
想着让它弹起的时候
02:31
and it's going to jerk forward
a lot faster and a lot more predictably
a lot faster and a lot more predictably
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弹得更快，更具可预测性。
02:34
than if I had to think about it myself.
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这是一种反射行为。
02:37
It's a reflex.
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我们得找到相似的反射行为，
02:38
We need to look for the equivalent
behavioral reflexes
behavioral reflexes
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并把我们的医疗保健
都靠到这些反射行为上来。
都靠到这些反射行为上来。
02:42
and hitch our health care wagon to those.
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但实际上，
02:45
Turns out, though,
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最常规的激励人们的举措
02:47
that most conventional approaches
to human motivation
to human motivation
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却是建立在“教育”这一理念上的。
02:50
are based on the idea of education.
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我们假定如果人们
没有做出他们应有的行为
没有做出他们应有的行为
02:53
We assume that if people
don't behave as they should,
don't behave as they should,
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是因为他们缺乏知识。
02:56
it's because they didn't know any better.
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“如果人们知道抽烟很危险，
他们就不会抽烟了。”
他们就不会抽烟了。”
02:58
"If only people knew that smoking
was dangerous, they wouldn't smoke."
was dangerous, they wouldn't smoke."
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或者，我们会从经济的角度思考。
03:02
Or, we think about economics.
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我们假定自己会不断地计算
03:03
The assumption there is that
we're all constantly calculating
we're all constantly calculating
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我们每一个行为蕴含的
成本和收益，
成本和收益，
03:06
the costs and benefits
of every one of our actions
of every one of our actions
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以及为了收益最大化，
我们会做出完全正确且理性的决定。
我们会做出完全正确且理性的决定。
03:09
and optimizing that to make
the perfectly right, rational decision.
the perfectly right, rational decision.
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03:13
If that were true, then all we need to do
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如果这是真的，所有我们需要的
仅仅是给医生找到
一个完美的付费系统，
一个完美的付费系统，
03:15
is to find the perfect
payment system for doctors
payment system for doctors
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或是能给患者完美计算出
部分承担费用和免赔额，
部分承担费用和免赔额，
03:17
or the perfect co-payments
and deductibles for patients,
and deductibles for patients,
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然后一切就自然解决了。
03:20
and everything would work out.
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行为经济学中
有一个更好的方法。
有一个更好的方法。
03:22
A better approach lies
in behavioral economics.
in behavioral economics.
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行为经济学家意识到
我们其实是非理性的。
我们其实是非理性的。
03:25
Behavioral economists recognize
that we are irrational.
that we are irrational.
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我们的决定是建立在情绪上的，
03:29
Our decisions are based on emotion,
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或是被社会环境
或规则框架所影响的。
或规则框架所影响的。
03:31
or they're sensitive to framing
or to social context.
or to social context.
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我们不总是会做出
有利于我们长远利益的行为。
有利于我们长远利益的行为。
03:34
We don't always do what's in our own
long-term best interests.
long-term best interests.
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但是，对行为经济学最主要的贡献
03:38
But the key contribution
to behavioral economics
to behavioral economics
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不是对“人类是非理性的”认识，
03:41
is not in recognizing
that we are irrational;
that we are irrational;
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而是意识到
“人类的非理性行为是高度可预测的”。
“人类的非理性行为是高度可预测的”。
03:44
it's recognizing that we are irrational
in highly predictable ways.
in highly predictable ways.
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事实上，正是我们心理上
那些小缺陷的可预测性
那些小缺陷的可预测性
03:48
In fact, it's the predictability
of our psychological foibles
of our psychological foibles
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使我们能设计出策略来攻克它们。
03:52
that allows us to design
strategies to overcome them.
strategies to overcome them.
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预先警告就宛如事先武装。
03:55
Forewarned is forearmed.
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事实上，行为经济学家
经常精准利用
经常精准利用
03:57
In fact, behavioral economists often use
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那些让我们陷入麻烦的
行为反射，
行为反射，
03:59
precisely the same behavioral
reflexes that get us into trouble
reflexes that get us into trouble
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转而让它们来帮助我们，
04:03
and turn them around to help us,
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而不是伤害我们。
04:06
rather than to hurt us.
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我们可以在一种叫做“即时偏误”的
现象中看见非理性的作用，
现象中看见非理性的作用，
04:08
We see irrationality play out
in something called "present bias,"
in something called "present bias,"
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这种现象，是我们正在面对的结果
04:13
where the outcomes in front of us
are much more motivating
are much more motivating
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比将来会出现的更重要的结果
更能调动我们的积极性。
更能调动我们的积极性。
04:16
than even more important outcomes
far in the future.
far in the future.
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如果我在节食——
其实我一直在节食——
其实我一直在节食——
04:22
If I'm on a diet --
and I'm always on a diet --
and I'm always on a diet --
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（笑声）
04:24
(Laughter)
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这时有人给了我一个
看上去很美味的巧克力蛋糕，
看上去很美味的巧克力蛋糕，
04:26
and someone offers me a luscious-looking
piece of chocolate cake,
piece of chocolate cake,
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我知道我不应该吃那个蛋糕。
04:30
I know I should not
eat that chocolate cake.
eat that chocolate cake.
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那块巧克力蛋糕会沉积在
我身体中——永远——
我身体中——永远——
04:34
That chocolate cake will land
on that part of my body -- permanently --
on that part of my body -- permanently --
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就在这类食物会自然沉积
的身体部位上。
的身体部位上。
04:38
where that kind of food naturally settles.
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但是那块巧克力蛋糕
看起来如此美味，
看起来如此美味，
04:41
But the chocolate cake
looks so good and delicious,
looks so good and delicious,
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而且它就在我的眼前，
04:44
and it's right in front of me,
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那节食可以明天再说了。
04:45
and the diet can wait 'til tomorrow.
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我曾经很喜欢一个喜剧演员，
史蒂文·赖特。
史蒂文·赖特。
04:47
I used to love the comedian Steven Wright.
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他经常说些很有禅意的玩笑话。
04:49
He would have these Zen-like quips.
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我最喜欢的是这个：
04:52
My favorite one was this:
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“努力了将来会有回报，
04:54
"Hard work pays off in the future,
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但是懒惰了现在就会有回报。”
04:56
but laziness pays off right now."
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（笑声）
04:58
(Laughter)
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患者也有即时偏误。
05:00
And patients also have present bias.
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如果你有高血压，
05:03
If you have high blood pressure,
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即使你极度想避免中风，
05:04
even if you would desperately
like to avoid a stroke,
like to avoid a stroke,
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而且你知道吃降血压药
05:07
and you know that taking
your antihypertensive medications
your antihypertensive medications
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是降低这种风险最有效的方式之一，
05:10
is one of the best ways
to reduce that risk,
to reduce that risk,
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然而，中风是很久以后可能发生的事，
而吃药则是现在要做的。
而吃药则是现在要做的。
05:13
the stroke you avoid is far in the future
and taking medications is right now.
and taking medications is right now.
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几乎有一半开了降血压药的患者
05:18
Almost half of the patients who are
prescribed high blood pressure pills
prescribed high blood pressure pills
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在一年内就停止了服药。
05:22
stop taking them within a year.
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想想如果我们单单解决这一个问题
05:25
Think of how many lives we could save
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就能拯救多少生命。
05:27
if we could solve just that one problem.
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05:31
We also tend to overestimate
the value of small probabilities.
the value of small probabilities.
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我们也容易高估小概率事件的价值。
这也许能解释为什么国营彩票
即使回报极小，
即使回报极小，
05:36
This actually explains
why state lotteries are so popular,
why state lotteries are so popular,
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却依旧这么受欢迎。
05:39
even though they return
pennies on the dollar.
pennies on the dollar.
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在座的一些人可能会买彩票——
05:41
Now, some of you
may buy lottery tickets --
may buy lottery tickets --
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买彩票挺有意思的，
你有可能中大奖、变富有——
你有可能中大奖、变富有——
05:43
it's fun, there's the chance
you might strike it rich ...
you might strike it rich ...
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但是咱们清醒一点吧：
05:46
But let's face it:
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这可能是个花掉你养老金的
很糟糕的方式。
很糟糕的方式。
05:47
this would be a horrible way
to invest your retirement savings.
to invest your retirement savings.
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我曾经看到过一张车尾贴——
这不是我编的——写着，
这不是我编的——写着，
05:51
I once saw a bumper sticker --
I am not making this up -- that said,
I am not making this up -- that said,
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“国营彩票是向不会
数学计算的人征收的智商税”。
数学计算的人征收的智商税”。
05:55
"State lotteries are a special tax
on people who can't do math."
on people who can't do math."
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（笑声）
06:00
(Laughter)
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我们并不是不会做数学计算，
06:01
It's not that we can't do the math,
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我们是感受不到这种计算。
06:03
it's that we can't feel the math.
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而且我们花太多精力在后悔上。
06:06
And we also pay much too much
attention to regret.
attention to regret.
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我们都痛恨错过机会的感觉。
06:09
We all hate the feeling of missing out.
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所以，事实上，最近有个彩票，
06:12
So, actually, there was
this recent lottery,
this recent lottery,
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大乐透彩票，
06:14
a mega-jackpot lottery,
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回报超高，大概超过 10 亿美元。
06:16
that had a huge payoff,
something like over a billion dollars.
something like over a billion dollars.
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我办公室里的每个人都在
掏钱集资买彩票，
掏钱集资买彩票，
06:19
And everyone in my office
is pooling money to buy lottery tickets,
is pooling money to buy lottery tickets,
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我一点都不理解。
06:22
and I'm not having any of this.
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我在办公室里转悠，嚷嚷着：
06:23
There I am, like, swaggering
around the office,
around the office,
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“彩票是向不会数学计算的人
征收的智商税。”
征收的智商税。”
06:26
"Lotteries are a special tax
on people who can't do math."
on people who can't do math."
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（笑声）
06:29
(Laughter)
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然后一个想法击中了我：
06:30
And then it hits me:
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啊呀，
06:31
uh oh.
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万一他们中奖了呢？
06:33
What if they win?
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（笑声）
06:34
(Laughter)
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我就成了第二天唯一来上班的人了。
06:36
I'm the only one who shows up
at work the next day.
at work the next day.
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（笑声）
06:39
(Laughter)
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不是我不想让我的同事中奖。
06:40
Now, it's not that I didn't want
my colleagues to win.
my colleagues to win.
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我只是不想让他们丢下我，自己中奖。
06:42
I just didn't want them to win without me.
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如果我当初拿出一张 20 美元钞票
直接塞进办公室的碎纸机里，
直接塞进办公室的碎纸机里，
06:45
Now, it would have been easier
if I had just taken my 20-dollar bill
if I had just taken my 20-dollar bill
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06:49
and put it into the office shredder,
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事情本会简单很多，
而且结果也会是一样的。
06:51
and the results would have been the same.
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即使我知道我不应该参与，
06:53
Even though I knew
I shouldn't participate,
I shouldn't participate,
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我还是递出了 20 美元钞票，
06:55
I handed over my 20-dollar bill,
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之后我再也没见过它。
06:58
and I never saw it again.
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（笑声）
07:00
(Laughter)
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我们和患者做过一些实验。
07:01
We've done a bunch
of experiments with patients
of experiments with patients
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我们给患者们电子药瓶，
07:04
in which we give them
these electronic pill bottles
these electronic pill bottles
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以便于知道他们是否在吃药。
07:07
so we can tell whether
they're taking their medication or not.
they're taking their medication or not.
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我们用彩票奖励他们。
07:10
And we reward them with a lottery.
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他们能得到奖品。
07:13
They get prizes.
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但他们只有在前一天吃药的情况下
07:15
But they only get prizes
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07:17
if they had taken
their medication the day before.
their medication the day before.
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才能得到奖品。
如果没吃，他们会收到
一条诸如此类的信息：
一条诸如此类的信息：
07:20
If not, they get a message
that says something like,
that says something like,
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“你本来能赢 100 美金，
07:23
"You would have won a hundred dollars,
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但是你昨天没吃药，
所以你没法得到这笔钱。”
所以你没法得到这笔钱。”
07:25
but you didn't take your medicine
yesterday, so you don't get it."
yesterday, so you don't get it."
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事实证明，患者们痛恨那种感觉。
07:28
Well, it turns out, patients hate that.
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2007
他们痛恨错过的感觉，
07:30
They hate the sense of missing out,
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而且因为他们能预判到
那种悔恨的感觉，
那种悔恨的感觉，
07:32
and because they can anticipate
that feeling of regret
that feeling of regret
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于是想要尽量避开它，
07:35
and they'd like to avoid it,
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所以他们更有可能会吃药了。
07:37
they're much more likely
to take their medications.
to take their medications.
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掌控那种痛恨后悔的感觉是有用的。
07:40
Harnessing that sense
of hating regret works.
of hating regret works.
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它引出了更一般化的观点，
07:43
And it leads to the more general point,
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即：一旦你认识到人是非理性的，
07:46
which is: once you recognize
how people are irrational,
how people are irrational,
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你就会处于一个
能够更好地帮助他们的位置。
能够更好地帮助他们的位置。
07:50
you're in a much better
position to help them.
position to help them.
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这种非理性
甚至在男厕所也能用得上。
甚至在男厕所也能用得上。
07:54
Now, this kind of irrationality works out
even in men's restrooms.
even in men's restrooms.
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在座的不常光顾小便池的人，
07:59
So, for those of you
who don't frequent urinals,
who don't frequent urinals,
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让我给你们解析一下。
08:03
let me break this down for you.
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（笑声）
08:05
(Laughter)
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地板上全是尿。
08:06
There is pee all over the floor.
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（笑声）
08:08
(Laughter)
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事实证明，你只要在小便池上
蚀刻一个苍蝇的形象，
蚀刻一个苍蝇的形象，
08:11
And it turns out that you
can solve this problem
can solve this problem
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08:13
by etching the image of a fly
in the back of the urinal.
in the back of the urinal.
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就能解决这个问题。
（笑声）
（掌声）
（掌声）
08:17
(Laughter) (Applause)
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这完全说得通。
08:21
And it makes perfect sense.
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1336
（笑声）
08:22
(Laughter)
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如果我看见一只苍蝇，
08:24
If I see a fly,
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我一定要射中那只苍蝇。
08:26
I'm gonna get that fly.
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08:27
(Laughter)
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（笑声）
那只苍蝇会被冲入下水道。
08:31
That fly is going down.
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（笑声）
08:33
(Laughter)
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这自然地引出了一个问题：
如果男人们上厕所时能瞄准，
如果男人们上厕所时能瞄准，
08:34
Now, this naturally begs the question
that if men can aim,
that if men can aim,
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他们一开始为什么要尿到地上？
08:38
why were they peeing
on the floor in the first place?
on the floor in the first place?
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2492
实际上，如果他们
本来就打算尿到地上，
本来就打算尿到地上，
08:40
In fact, if they were going
to pee on the floor,
to pee on the floor,
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又为什么要跑到小便池前面去尿？
08:43
why pee in front of the urinal?
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你可以在任何地方尿。
08:44
You could pee anywhere.
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1153
（笑声）
08:45
(Laughter)
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1038
同样的道理也适用于医疗保健。
08:46
And the same thing works in health care.
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我们医院当时有个这样的问题：
08:50
We had a problem in our hospital
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2292
当普通药可供选择的时，
08:52
in which the physicians
were prescribing brand-name drugs
were prescribing brand-name drugs
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医生们却一直在开品牌药。
08:57
when a generic drug was available.
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这张图上的每条线
代表一种不同的药物。
代表一种不同的药物。
08:59
Each one of the lines on this graph
represents a different drug.
represents a different drug.
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这些药根据被当做普通药开
的频率被列了出来。
的频率被列了出来。
09:03
And they're listed according to how often
they're prescribed as generic medications.
they're prescribed as generic medications.
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位于顶部的，
是一直都被当做普通药开的。
是一直都被当做普通药开的。
09:07
Those are the top are prescribed
as generics 100 percent of the time.
as generics 100 percent of the time.
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下面那些，
不到 20% 的机率
不到 20% 的机率
09:11
Those down at the bottom
are prescribed as generics
are prescribed as generics
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是被当做普通药开的。
09:13
less than 20 percent of the time.
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1585
我们跟临床医师们开过会，
也办过各种教学会议，
也办过各种教学会议，
09:15
And we'd have meetings with clinicians
and all sorts of education sessions,
and all sorts of education sessions,
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但是都没用——
09:18
and nothing worked --
201
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1166
所有的这些线，几乎都没变。
09:19
all the lines are pretty much horizontal.
202
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直到，有个人在电子健康记录表里
09:22
Until, someone installed
a little piece of software
a little piece of software
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3213
安装了一个小软件，
09:26
in the electronic health record
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把处方设置为默认开普通药，
09:27
that defaulted the prescriptions
to generic medications
to generic medications
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而非品牌药。
09:31
instead of the brand-name drugs.
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现在，不用统计分析员
09:34
Now, it doesn't take a statistician
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1745
也能看出来，
问题一夜之间就解决了，
问题一夜之间就解决了，
09:35
to see that this problem
was solved overnight,
was solved overnight,
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3053
而且之后再没有出现此类问题。
09:38
and it has stayed solved ever since.
209
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2513
事实上，
在这个项目上线的两年半内，
在这个项目上线的两年半内，
09:41
In fact, in the two and a half years
since this program started,
since this program started,
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我们医院
已经省下了 3200 万美元。
已经省下了 3200 万美元。
09:44
our hospital has saved 32 million dollars.
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3010
让我再说一遍：
3200 万美元。
3200 万美元。
09:47
Let me say that again: 32 million dollars.
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3463
我们所做的，只不过是
把医生们一直以来想做的事
把医生们一直以来想做的事
09:51
And all we did was make it easier
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2957
09:54
for the doctors to do what they
fundamentally wanted to do all along.
fundamentally wanted to do all along.
214
582396
5191
变得容易做了而已。
利用人们对损失的概念也有用。
10:00
It also works to play into
people's notions of loss.
people's notions of loss.
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4414
我们办了场比赛
来帮助人们走更多路。
来帮助人们走更多路。
10:06
We did this with a contest
to help people walk more.
to help people walk more.
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3410
我们想让每个人至少走 7 千步，
10:10
We wanted everyone to walk
at least 7,000 steps,
at least 7,000 steps,
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3880
我们也用他们手机上的计步器
10:14
and we measured their step count
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1564
10:16
with the accelerometer
on their cell phone.
on their cell phone.
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604209
2276
以记录他们行走的步数。
A 组，控制变量组，
仅被告知他们
仅被告知他们
10:19
Group A, the control group,
just got told whether they had walked
just got told whether they had walked
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3285
是否走够 7 千步。
10:22
7,000 steps or not.
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B 组，有金钱刺激。
10:25
Group B got a financial incentive.
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每天如果他们走了 7 千步，
我们就奖励他们 1.4 美金。
我们就奖励他们 1.4 美金。
10:28
We gave them $1.40 for every day
they walked 7,000 steps.
they walked 7,000 steps.
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4491
C组，有相同的金钱刺激，
10:33
Group C got the same financial incentive,
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2140
但这种刺激被包装成损失
而不是收益：
而不是收益：
10:35
but it was framed as a loss
rather than a gain:
rather than a gain:
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每天 1.4 美金
即 42 美金一个月，
即 42 美金一个月，
10:38
$1.40 a day is 42 dollars a month,
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所以在每个月的头一天
我们给这些参与者 42 美金，
我们给这些参与者 42 美金，
10:41
so we gave these participants 42 dollars
at the beginning of each month
at the beginning of each month
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就放在他们能看见的虚拟账户里，
10:45
in a virtual account that they could see,
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2180
然后如果他们每天没走够 7 千步，
我们就从账户里取走 1.4 美金。
我们就从账户里取走 1.4 美金。
10:48
and we took away $1.40 for every day
they didn't walk 7,000 steps.
they didn't walk 7,000 steps.
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一个经济学家可能会说，
这两种金钱刺激的结果
这两种金钱刺激的结果
10:52
Now, an economist would say
that those two financial incentives
that those two financial incentives
230
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3125
是一样的。
10:55
are the same.
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1327
因为每天你走够 7 千步的话，
你都能赚 1.4 美金。
你都能赚 1.4 美金。
10:57
For every day you walk 7,000 steps,
you're $1.40 richer.
you're $1.40 richer.
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但是一个行为经济学家会说，
它们的结果是不同的，
它们的结果是不同的，
11:01
But a behavioral economist
would say that they're different,
would say that they're different,
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2945
因为我们为避免损失 1.4 美金
会比赚取 1.4 美金
会比赚取 1.4 美金
11:04
because we're much more motivated
to avoid a $1.40 loss
to avoid a $1.40 loss
234
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4177
11:08
than we are motivated
to achieve a $1.40 gain.
to achieve a $1.40 gain.
235
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3250
来得更有动力。
实验结果也确实如此。
11:12
And that's exactly what happened.
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1878
那些每天因为走 7 千步
而收到 1.4 美金的人
而收到 1.4 美金的人
11:14
Those in the group that received $1.40
for every day they walked 7,000 steps
for every day they walked 7,000 steps
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并不比控制变量组（没有金钱激励）
更能达到目标。
更能达到目标。
11:18
were no more likely to meet their goal
than the control group.
than the control group.
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3107
金钱刺激没能起作用。
11:21
The financial incentive didn't work.
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2087
而那些受到损失刺激的人
11:24
But those who had a loss-framed incentive
240
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2557
则有 50% 更高的可能
完成目标。
完成目标。
11:26
met their goal 50 percent
more of the time.
more of the time.
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3160
这在经济学上说不通，
但在心理学上是说得通的，
但在心理学上是说得通的，
11:29
It doesn't make economic sense,
but it makes psychological sense,
but it makes psychological sense,
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3502
因为损失比收益带来的刺激更大。
11:33
because losses loom larger than gains.
243
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2609
现在我们已经在用这种损失刺激法
去帮助患者走更多路、
去帮助患者走更多路、
11:35
And now we're using loss-framed incentives
to help patients walk more,
to help patients walk more,
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4164
减肥，
11:40
lose weight
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1268
以及吃药了。
11:41
and take their medications.
246
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1748
钱可以是一个激励因素，
11:43
Money can be a motivator.
247
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1644
我们都知道这一点。
11:46
We all know that.
248
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1165
但当它与心理学配对使用时
更具有影响力。
更具有影响力。
11:47
But it's far more influential
when it's paired with psychology.
when it's paired with psychology.
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4572
当然，金钱有其自身缺点。
11:52
And money, of course,
has its own disadvantages.
has its own disadvantages.
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2290
我最喜欢的例子，
说的是一个日托项目。
说的是一个日托项目。
11:55
My favorite example of this
involves a daycare program.
involves a daycare program.
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3557
你能在日托中犯下的最大的罪孽
就是接孩子接晚了。
就是接孩子接晚了。
11:59
The greatest sin you can commit in daycare
is picking up your kids late.
is picking up your kids late.
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4646
没人开心。
12:04
No one is happy.
253
712390
1484
你的孩子在哭，因为你不爱他们。
12:05
Your kids are crying
because you don't love them.
because you don't love them.
254
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2363
（笑声）
12:08
(Laughter)
255
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1166
老师不开心，因为他们下班晚了。
12:09
The teachers are unhappy
because they leave work late.
because they leave work late.
256
717475
2663
你也觉得极其内疚。
12:12
And you feel terribly guilty.
257
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1731
以色列的这个日托项目
就想解决这个问题，
就想解决这个问题，
12:14
This daycare program in Israel
decided they wanted to stop this problem,
decided they wanted to stop this problem,
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而且他们做的，
是许多美国日托项目也在做的事，
是许多美国日托项目也在做的事，
12:18
and they did something that many
daycare programs in the US do,
daycare programs in the US do,
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3009
就是给晚接孩子的人设置罚款。
12:21
which is they installed
a fine for late pickups.
a fine for late pickups.
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2530
他们把罚款定为
10 谢克尔（以色列货币单位），
10 谢克尔（以色列货币单位），
12:23
And the fine they chose was 10 shekels,
261
731801
3076
大概相当于 3 美元。
12:26
which is about three bucks.
262
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1620
猜猜然后发生了什么？
12:29
And guess what happened?
263
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1272
晚接孩子的情况恶化了。
12:31
Late pickups increased.
264
739191
1921
如果你仔细想想的话，
这完全说得通。
这完全说得通。
12:34
And if you think about it,
it makes perfect sense.
it makes perfect sense.
265
742200
2603
多合适的买卖啊！
12:37
What a deal!
266
745200
1152
10 谢克尔——
12:38
For 10 shekels --
267
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1167
（笑声）
12:39
(Laughter)
268
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1282
你就能一晚上不用接孩子！
12:40
you can keep my kids all night!
269
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1744
（笑声）
12:42
(Laughter)
270
750641
2548
家长们卯足了内在动机，
准时接孩子，
准时接孩子，
12:45
They took a perfectly strong
intrinsic motivation not to be late,
intrinsic motivation not to be late,
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结果日托机构
把这个动机因素变得廉价了。
把这个动机因素变得廉价了。
12:49
and they cheapened it.
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更糟的是，
当日托机构意识到自己的错误，
当日托机构意识到自己的错误，
12:50
What's worse, when they
realized their mistake
realized their mistake
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把迟到罚款的规则撤回时，
12:53
and they took away
the financial incentive,
the financial incentive,
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晚接孩子的情况丝毫没有改观。
12:56
the late pickups still stayed
at the high level.
at the high level.
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他们已经毒害了社会契约。
12:58
They had already poisoned
the social contract.
the social contract.
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医疗保健充满了强大的内在动机。
13:02
Health care is full
of strong intrinsic motivations.
of strong intrinsic motivations.
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医生和患者本身就想做正确的事。
13:05
We have doctors and patients
who already want to do the right thing.
who already want to do the right thing.
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金钱刺激也有正面作用。
13:09
Financial incentives can help,
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但是我们不能盼着
13:12
but we shouldn't expect
money in health care
money in health care
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金钱能在医疗保健中
承担全部的重任。
承担全部的重任。
13:15
to do all of the heavy lifting.
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相反，对健康行为
最有效的影响因素
最有效的影响因素
13:18
Instead, perhaps the most powerful
influencers of health behavior
influencers of health behavior
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可能是我们的社会互动。
13:22
are our social interactions.
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社会参与在医疗保健中是起作用的，
13:24
Social engagement works in health care,
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主要体现在两个方面。
13:27
and it works in two directions.
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第一，我们本能地在意
别人对我们的看法。
别人对我们的看法。
13:29
First, we fundamentally care
what others think of us.
what others think of us.
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所以改变我们行为
最有效的方法之一
最有效的方法之一
13:34
And so one of the most powerful ways
to change our behavior
to change our behavior
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就是让我们的行为能被别人看见。
13:38
is to make our activities
witnessable to others.
witnessable to others.
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我们在被观察，
和不在被观察时候的行为表现
和不在被观察时候的行为表现
13:41
We behave differently
when we're being observed
when we're being observed
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13:44
than when we're not.
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是不同的。
我去过几个饭店，
它们厕所里没有水槽，
它们厕所里没有水槽，
13:45
I've been to some restaurants
that don't have sinks in the bathrooms.
that don't have sinks in the bathrooms.
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但当你走出来，水槽在外面，
13:48
Instead, when you step out,
the sink is outside
the sink is outside
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在饭店的主要位置，
13:51
in the main part of the restaurant,
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这时候所有人都能看见
你洗没洗手。
你洗没洗手。
13:52
where everyone can see
whether you wash your hands or not.
whether you wash your hands or not.
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我不是很确定，
13:55
Now, I don't know for sure,
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但我敢保证在那些特定环境下
13:56
but I am convinced
that handwashing is much greater
that handwashing is much greater
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洗手的人变多了。
13:59
in those particular settings.
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我们在被观察的时候，
总能表现出最好的行为。
总能表现出最好的行为。
14:00
We are always on our best behavior
when we're being observed.
when we're being observed.
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事实上，在佛罗里达一家医院
14:04
In fact, there was this amazing study
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的重症监护室里，
进行了一项很棒的研究。
进行了一项很棒的研究。
14:06
that was done in an intensive care unit
in a Florida hospital.
in a Florida hospital.
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这里的洗手率非常低，
当然，这很危险，
当然，这很危险，
14:09
The handwashing rates were very low,
which is dangerous, of course,
which is dangerous, of course,
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因为该行为
会传播疾病，导致感染。
会传播疾病，导致感染。
14:12
because it can spread infection.
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所以一些研究员在水槽上
贴了一张人眼的照片。
贴了一张人眼的照片。
14:15
And so some researchers pasted
a picture of someone's eyes over the sink.
a picture of someone's eyes over the sink.
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那不是一个真人，只是一张照片。
14:20
It wasn't a real person,
it was just a photograph.
it was just a photograph.
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实际上，那甚至都不是一整张脸，
只是一双眼睛看着你。
只是一双眼睛看着你。
14:22
In fact, it wasn't even their whole face,
it was just their eyes looking at you.
it was just their eyes looking at you.
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（笑声）
14:26
(Laughter)
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洗手率翻了不止一倍。
14:27
Handwashing rates more than doubled.
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1737
我们似乎是如此在意
别人对我们的看法，
别人对我们的看法，
14:29
It seems we care so much
what other people think of us
what other people think of us
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2940
以至于我们的行为会就此改进，
14:32
that our behavior improves
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1452
14:33
even if we merely imagine
that we're being observed.
that we're being observed.
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3186
即使我们仅仅只是
想象我们在被别人观察着。
想象我们在被别人观察着。
而且我们不只是在意
别人怎么看我们，
别人怎么看我们，
14:37
And not only do we care
what others think of us,
what others think of us,
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3162
我们还会本能地模仿他人行为。
14:40
we fundamentally model our behaviors
on what we see other people do.
on what we see other people do.
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4549
这一切又回到安全带上来了。
14:45
And it all comes back to seat belts.
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1806
我小的时候，喜欢看亚当·韦斯特
演的电视剧《蝙蝠侠》。
演的电视剧《蝙蝠侠》。
14:48
When I was a kid, I used to love
the "Batman" TV series with Adam West.
the "Batman" TV series with Adam West.
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5187
蝙蝠侠和罗宾做的所有事都特酷，
14:54
Everything that Batman
and Robin did was so cool,
and Robin did was so cool,
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当然了，蝙蝠车是所有事情里最酷的。
14:57
and, of course, the Batmobile
was the coolest thing of all.
was the coolest thing of all.
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3133
那个电视剧从 1966 年播到 1968 年，
15:00
Now, that show aired from 1966 to 1968,
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4205
在那个年代，安全带
还是车里可有可无的配件。
还是车里可有可无的配件。
15:04
and at that time, seat belts
were optional accessories in cars.
were optional accessories in cars.
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3807
但是那个电视剧的出品人
做了一件非常重要的事。
做了一件非常重要的事。
15:08
But the producers of that show
did something really important.
did something really important.
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2960
当蝙蝠侠和罗宾坐上那辆蝙蝠车时，
15:11
When Batman and Robin
got in the Batmobile,
got in the Batmobile,
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2797
相机会聚焦到他们腿上，
15:14
the camera would focus on their laps,
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1785
然后你会看到蝙蝠侠和罗宾
系上了他们的安全带。
系上了他们的安全带。
15:16
and you would see Batman and Robin
put on their seat belts.
put on their seat belts.
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如果蝙蝠侠和罗宾
系上了安全带，
系上了安全带，
15:19
Now, if Batman and Robin
put on their seat belts,
put on their seat belts,
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2302
你可以打赌
我也会系上我的安全带。
我也会系上我的安全带。
15:21
you can bet that I was going to wear
my seat belt, too.
my seat belt, too.
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2652
我打赌那个电视剧
拯救了上千条生命。
拯救了上千条生命。
15:24
I bet that show saved thousands of lives.
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再次，这在医疗保健中也能起作用。
15:26
And again, it works in health care, too.
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2658
在看见别的医生如何使用抗生素后，
医生自己能更加适当地使用抗生素。
医生自己能更加适当地使用抗生素。
15:29
Doctors use antibiotics more appropriately
when they see how other doctors use them.
when they see how other doctors use them.
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5802
医疗保健中的许多行动
是隐匿的，别人看不见。
是隐匿的，别人看不见。
15:35
So many activities in health care
are hidden, they're unwitnessed,
are hidden, they're unwitnessed,
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4694
但医生是社会动物，
15:40
but doctors are social animals,
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2153
因此当他们能看见其他医生的做法时，
他们自己也能表现得更好。
他们自己也能表现得更好。
15:42
and they perform better
when they see what other doctors do.
when they see what other doctors do.
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4474
所以社会影响在医疗保健中
是有积极作用的，
是有积极作用的，
15:47
So social influence works in health care.
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2423
把它与后悔感和损失规避
联系起来也是大有裨益的。
联系起来也是大有裨益的。
15:49
So does tying it to notions of regret
or to loss aversion.
or to loss aversion.
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3594
15:53
We would never think of using these tools
if we thought that everyone was rational
if we thought that everyone was rational
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5305
如果我们认为每个人
时刻都是理性的，
时刻都是理性的，
那我们永远不会想到
利用这些工具。
利用这些工具。
15:59
all the time.
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947122
1522
这里我要澄清一点：
我不是在指责理性。
我不是在指责理性。
16:00
Now, just to be clear:
I am not condemning rationality.
I am not condemning rationality.
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3171
这才会是真正的不理性。
16:03
I mean, that really would be irrational.
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951863
1978
但我们都知道，
正是我们思想中那些不理性的部分
正是我们思想中那些不理性的部分
16:06
But we all know that it's
the nonrational parts of our minds
the nonrational parts of our minds
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4672
给予我们勇气、创造力、灵感，
16:11
where we get courage,
creativity, inspiration
creativity, inspiration
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以及其他一切能激发激情的东西。
16:14
and everything else that sparks passion.
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我们还知道一些别的。
16:17
And we know something else, too.
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965357
1857
我们知道如果我们能
与天性中不理性的部分合作，
与天性中不理性的部分合作，
16:19
We know that we can be much more effective
at improving health behavior
at improving health behavior
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3715
而不是忽视、或跟它们反着来，
16:24
if we work with the irrational
parts of our nature
parts of our nature
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972111
3711
我们就能更有效地改善
我们的健康行为。
我们的健康行为。
16:27
instead of ignoring them
or fighting against them.
or fighting against them.
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当谈到医疗保健时，
16:30
When it comes to health care,
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理解我们的非理性
只是工具箱中的一个工具。
只是工具箱中的一个工具。
16:32
understanding our irrationality
is just another tool in our toolbox.
is just another tool in our toolbox.
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5233
而掌控这种非理性——
16:38
And harnessing that irrationality --
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或许才是所有行为中最理性的。
16:40
that may be the most rational move of all.
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谢谢。
16:44
Thank you.
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（掌声）
16:45
(Applause)
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ABOUT THE SPEAKER
David Asch - Behavioral economist, health policy expertDavid Asch advances individual and population health by improving the way physicians and patients make decisions in health care and in everyday life.
Why you should listen
David Asch is the executive director of the Penn Medicine Center for Health Care Innovation, which aims to accelerate the transformation of health care for better patient outcomes. He is also a professor at both the Perelman School of Medicine and the Wharton School at the University of Pennsylvania. Asch practices internal medicine at the Philadelphia Veterans Affairs Medical Center, where he created the Center for Health Equity Research and Promotion, a national center that works to support vulnerable populations and reduce health disparities. He is the author of more than 350 published papers.
David Asch | Speaker | TED.com