Should We Pay Students to Go to School?

Think back to when you were a high school student. Remember all that time you spent slaving away, studying for those stress-inducing examinations, attending those tedious classes, and writing those ill-informed essays?

There must have been some days where your motivation was seriously waning—and for good reason. School can be extremely difficult, especially for those of us who are less academically gifted, and studying can take away much of our free time. Focusing on academics is even more difficult when you need a job outside of school to support yourself, and your family too.

Difficulties such as these can lead some students to drop out of school altogether. Although these students may see dropping out of high school as a good idea, dropping out typically has drastic socioeconomic consequences in the long-term. When compared with high school graduates, high school dropouts are more likely to earn substantially lower wages, be unemployed, suffer adverse health issues, and generate higher social costs for taxpayers through criminal activity and public assistance.[1] Despite these long-term consequences, in 2017, over 500,000 students dropped out of high school in the U.S., while an even greater number were not enrolled in school at all.2

Explanations?

Why, then, do students drop out of school if the long-term consequences are so negative? Often, students are not necessarily choosing to drop out of school, but rather, they are forced into it. Researchers classify school dropouts in three ways: Students may be “pushed” out of school due to poor discipline or bad grades, “pulled” out of school for reasons such as family or financial issues, or they may “fall out” of school due to a disillusionment with the education system.3

However, while these explanations are the typical reasons why students drop out, standard economic theory would suggest that students are being myopic if they drop out. From this perspective, it is irrational to choose the short-term benefits of dropping out over the lifetime gains of persevering and obtaining a diploma. Perhaps students are underestimating the higher returns from education, or experiencing survivorship bias4—mistakenly focusing only on the successful minority, without considering all those that failed. For example, some students may believe they can emulate highly successful high school dropouts like Richard Branson, not realizing that they are a statistical anomaly.

Paying students: A potential solution?

Despite the economists’ perspective, even if students are foregoing future rewards by dropping out, many students will feel like dropping out is their only option. But because the future benefits of completing a degree are so great, is it worth paying students to go to school?

This is not a particularly new idea, and some Nordic countries already provide financial incentives to go to school. Incentivizing students could allow them to put more effort into attending school and to care more about their studies, at least for long enough that they can complete their degree. This could particularly offset the challenges faced by students who come from financially disadvantaged backgrounds, as monetary incentives would allow these students to focus on their studies and not require an outside job, therefore reducing the probability of dropping out.

Of course, you might be thinking: shouldn’t attaining an education be enough motivation to stay in school? Wouldn’t paying students only make them care about the money, and not the education? These are common critiques of financial incentives for education, particularly since the literature has shown that monetary incentives (especially small ones) can sometimes crowd out the intrinsic motivation to do something.5,6 In other words, students may be only motivated to study for the money, while insufficient payments may diminish a student’s willingness to learn. And in fact, some studies have found that financial incentives override the desire to learn, at least in the short-term.7

However, the counter-argument to these concerns is that these monetary incentives would be most effective for preventing high-risk students from dropping out, such as those from highly disadvantaged backgrounds or those with poor academic performance. Since they are already at a high risk to drop out and are likely to be unmotivated anyway, by providing this financial motivation to stay in school, they would at least have some sort of incentive to complete their degree. Additionally, the money could also be given to parents rather than to students themselves, which would remove the possibility of money crowding out students’ intrinsic motivation to study hard. Instead, the monetary compensation may motivate parents to be more forceful in ensuring their kids attend school, while simultaneously alleviating some of their financial burdens.

Monetary incentives and dropout rates

As it turns out, financial incentives are remarkably effective in reducing dropout rates. For instance, in the initial phase of the PROGRESA program in Mexico, 506 rural villages were randomly assigned to participate in the program or serve as controls.8 Participating parents received financial incentives averaging $55 per month, approximately 1/5 of the average monthly income in Mexico—quite a substantial amount! The money was delivered on the condition that their children were enrolled in and attended school frequently.

The program was very successful, having a large effect on several educational outcomes such as reducing the dropout rate and increasing the school enrolment rate. Interestingly, the program also created peer effects, where siblings of students in the program were also less likely to drop out, even after the incentives disappeared. These results showed not only that financially incentivizing parents works to reduce dropouts, but it also leads to more forward-thinking behavior. Similar studies have been conducted in countries such as Colombia, and have also found similar results.9

Monetary incentives and academic achievement

Although financial incentives have proven to be very effective in reducing dropout rates, paying students to do well in exams might not be as effective, as various studies have shown non-existent or only modest improvements in academic performance when financial incentives are introduced.10

Does this mean that monetary rewards cannot motivate students enough to study harder? Not necessarily. One alternative explanation could be that students are sufficiently motivated by money, but they simply do not know how to study effectively. Unlike attending classes, success in improving academic achievement depends on many factors. Even if students are motivated to do well in school, they might not know how to translate their efforts into better grades.

This is what Fryer (2011) found with a large-scale study that involved conducting randomized field experiments in over 200 schools in the cities of Dallas, New York, and Chicago, with over $6.3 million paid out in incentives.11 One finding from this large-scale study was that financial incentives for attaining better grades were less effective than incentives for educational inputs which had easily achievable gradients for success, such as attendance, good behavior, or wearing uniforms.

Other studies have examined which groups of students benefit most from monetary incentives, and have found that financial incentives might not be effective at improving the grades of the best and worst-performing students, but can be very important in improving the performance of those in the middle of the pack—specifically, those whose existing performance is only slightly below the threshold for the monetary reward (on average a GPA on 2.96).12 Money therefore can be a motivating force for these students who just need that extra push to get to an acceptable standard of academic achievement.

However, these effects typically do not correspond to permanent changes in performance, as many of these students revert to their previous level once the incentives are removed. This suggests that there was a crowding-out effect where students were more motivated by the money rather than by the intrinsic motivation to do well, suggesting that persistent financial incentives are required to establish consistent improvement in academic performance. Interesting, financial incentives have also been shown to be much more effective at improving academic performance for girls than for boys.13, 14

Implications?

Overall, the main takeaway from this research is that financial incentives can create positive short-run benefits for various educational outcomes. Paying students might not lead to them attaining better grades or create any permanent changes in philosophy when it comes to studying, but it can lead to them staying in school and finishing their high school diploma. This would at least allow students, particularly those who are already struggling, to gain valuable credentials and experience better future outcomes than most dropouts would. However, financial incentives have been shown to less effective at improving students’ grades. It may be that students don’t know how to achieve this goal, lacking appropriate study methods or feeling they’re unable to keep up with the materials. If this is the case, other solutions to improving academic performance, such as providing students with resources or mentors, would be more effective at improving grades than money would.

Of course, it’s very costly to impose financial incentives to improve educational outcomes, and other cheaper solutions might be preferred by policymakers. For instance, the U.K.’s Behavioural Insights Team has found that supportive text messages from a nominated support person (e.g. teacher, parent, friend) can improve school attendance,15 which could be a significantly cheaper way to solve these issues. More research is needed to gauge the effectiveness of different policies to improve educational outcomes, and how they compare with financial incentives in terms of cost-effectiveness.

Why It’s So Hard to Choose Who Gets the COVID-19 Vaccinations First

This article originally appeared on the Global News website, where TDL has a monthly column analyzing current events through the lens of behavioral science. You can find the original here, or listen to Dr. Struck’s interview on Global News Radio here.

As Canada prepares to ramp up its vaccine rollout, one question looms: Who should be first in line to get the jab? This much is uncontroversial: The elderly living in care homes and front-line healthcare workers should be the first in Canada to get vaccinated. Throughout the pandemic, we’ve heard a lot about the increased risk these groups face, the strain that the medical system would face if many of them were to get infected, and the psychological toll that the pandemic has taken on them. 

There are two reasons why this early consensus has come so easily. The first is that there isn’t any serious doubt about whether these statements are true. The second is that there isn’t any serious disagreement about whether these constitute goodreasons for vaccine prioritization. And because these reasons point towards prioritizing the same people, we get to enjoy the luxury of agreement.

But that won’t last forever. We haven’t been faced yet with having to figure out exactly what we mean when we say some group or other “should be prioritized” for vaccination. “Should” can mean a lot of different things. And that makes it hard to answer the question.

As behavioral scientists have been showing for decades, we react quite predictably when faced with a hard or ambiguous question. Instead of answering it, our mind will reach for another question to answer instead, one that’s in the same neighborhood but is much easier for us to answer. This is called “question substitution,” and it’s subconscious.

For example, I don’t know how frequently shark attacks occur. If you ask me, I’ll probably answer a different question: How easily I can bring to mind an example of a shark attack. So, if there’s been a shark attack recently that’s all over the news, I’ll bring this example to mind with ease. I’ll estimate that shark attacks are very frequent. If I’m on my Twitter feed 24/7 reading the latest news about the case, I’ll rate attacks as even more frequent than somebody who just glances at the newspaper casually here and there. This whole process happens subconsciously.

Coming back to vaccine prioritization, figuring out who “should” be prioritized for vaccination is very difficult. Naturally, we’ll reach for other, similar questions we feel more confident about. Some of us will think of whoever is most exposed to the virus. Some of us will think of those who face the most serious outcomes, or whose infection creates the largest challenges for the healthcare system. And some of us think about moral worthiness.

The first signs of disagreement are already visible. Question substitution can help us to understand these disagreements. For instance, Erin O’Toole, the leader of Canada’s federal Conservative Party, criticized the Liberal government for listing some federal inmates among prioritized vaccine recipients. This was not because he disagreed with Justin Trudeau’s assertion that prisoners have a heightened risk of contracting or falling severely ill with COVID. His disagreement was based not on facts, but on values: As he tweeted, it is his opinion that “[n]ot one criminal should be vaccinated ahead of any vulnerable Canadian or frontline health worker.” He’s arguing that a different metric should be applied: moral worth (which, in his view, inmates do not seem to have).

In other words, O’Toole wasn’t saying that Trudeau was wrong about who faces higher exposure risk and vulnerability. He’s saying that Trudeau is answering the wrong question. In this instance, the question substitution is obvious.

Perhaps this kind of analysis could also help us to make headway in discussions about whether racialized Canadians should be offered priority in the vaccine campaign. Some people are critical of prioritization based on race. Is that because they don’t believe that racialized Canadians face higher exposure risks and vulnerability? Or are these critics arguing that exposure and vulnerability are not the relevant questions to be addressing?

Similarly, through the pandemic, we have talked at length about those members of society who have braved great challenges to help us all keep trucking along. They include front-line healthcare workers, long-term care workers, teachers, and early childhood educators. While “the rest of us” have had our normal routines torn to shreds, they have battled on in the face of great adversity. We, meanwhile, have stayed home and had our groceries delivered.

But who is delivering those groceries? Did they just magically appear at our door? Did they collect and bag themselves, coming off self-stocking shelves? Of course not. Somebody had to keep producing, preparing, and packaging the food. It had to be delivered to distribution centres and stores. Shelves had to be stocked. Orders had to be received. Food had to be plucked from the shelves, bagged, queued up for delivery. A driver had to pick it up and bring it to your front door.

Most of this labor is invisible. It matters which stories we tell (and which ones we don’t). This has an impact on what jobs we understand to be “essential,” which workers are viewed as heroic, and, ultimately, who we believe needs to get a spot towards the front of the line. And vaccine prioritization has elements of both practicality as well as justice to consider.

It will be difficult to reach the same solution if we can’t even agree on what question we’re trying to answer. We need to have an open, transparent conversation clarifying precisely what our goals are; we need to ask probing questions. “Are you saying you’re not sure the evidence shows that inoculating teachers (for example) would decrease community transmission? Or are you saying that community transmission is less important than, say, healthcare burden?”

Those are not the kinds of questions we hear in Parliament. They aren’t the kinds of questions that emerge when our politicians telegraph barbs at each other through the media. They aren’t even the kinds of questions that many media representatives ask during the Q&A after a politician provides an update.

We need clarity on what question we’re looking to answer. Currently, there doesn’t seem to be much progress on that front. As a result, question substitution will continue mostly unchecked. We’ll talk right past each other without realizing we’re talking about different things. And social cohesion around vaccination (and the wider pandemic response) will continue to be a point of friction—at a time when we all need to stick together.

Why We’re Numb to the Toll of COVID

“There were not six million Jews murdered: there was one murder, six million times.”

Abel Hertzberg, Holocaust survivor 1

The year was 1998. The tiny town of Whitwell, Tennessee, with less than 2,000 residents, was about to become known for something no one had ever expected. 

It all started when Linda Hooper, the principal of the Whitwell Middle School, wanted to give the students of this largely white and Christian town a broader world view. She asked the language arts teacher, Sandra Roberts, and the associate principal, David Smith, to start an after-school program on Holocaust education, a topic that wasn’t yet part of the school’s curriculum.2

So they went about explaining to their students the horrors of the Holocaust, readings books such as Anne Frank’s The Diary of a Young Girl (1947) and Elie Wiesel’s Night (1956). Eventually, they touched on the massive number of lives lost during this time. But when the teachers stated that 6 million Jewish people had died in the Holocaust, a young student remarked, “What is 6 million? I have never seen 6 million.”

The teachers realized this was a valid concern. How could they help students understand something on such a large scale? They soon came up with the idea of collecting 6 million objects, in order to visualize the deaths. Through research, the students learned that Norwegians had worn paperclips on their clothing during World War II as a silent protest against Nazi atrocities. 

And so began the famous Paperclip Project: a quest to collect 6 million paperclips.

At first, it was just the students, looking for paperclips everywhere they could find. Then they expanded the search. They set up a website, they wrote to people, and they spread the word. Gradually, paperclips started trickling in from around the world. From Holocaust survivors to celebrities such as Bill Clinton and Tom Hanks, everyone started sending in paperclips. Some came with little notes, featuring dedications, names, and stories of family members who had lost their lives to the atrocity. One letter read, “Today, I am sending 71 paperclips to commemorate the 71 Jews who were deported from Bueckeburg.”3

Over the next few years, more than 30 million paperclips were collected. The school then converted this into an exhibition. They acquired a German cattle car that had been used to transport people to concentration camps, and filled it with 11 million clips: 6 million to represent the Jewish lives lost, and 5 million to represent victims from other persecuted groups.

It still exists today as the Children’s Holocaust Memorial.

The Children’s Holocaust Memorial, Whitwell (Image Courtesy: Education Week)
The memorial, based in a German cattle car (Image courtesy: Alchetron)

Why COVID-19 is a reminder about the value of life

The somber story above is important because we are once again on the verge of losing sight of the value of life. We, like that young student whose comment kicked off the Paperclip Project, are now grappling with the weight of millions of deaths.

When COVID-19 first emerged, the number of deaths caused by the virus impacted us immensely. Across the world, we all refreshed our news feeds obsessively to keep track. We were all scared when the number hit 1,000 deaths. After 10,000 deaths, we got more scared. But as we marched towards 100,000 deaths, we somehow cared less than before. Now, with more than two million deaths caused by COVID-19 globally, we are going about our daily lives as if nothing happened. 

This becomes even scarier if we take young people into account. Imagine growing up thinking that losing two million people in less than a year is just normal news. For many, the inconvenience of online learning may stand out more in their memories than the toll of the coronavirus.

Why do large numbers of deaths make us feel so numb? Why do we care less when many people die, compared to when we lose just one person?

The value of life, and how we perceive it

I had first read about Paul Slovic and Daniel Västfjäll’s work on this topic when I was doing my Master’s dissertation on a similar subject. I remember reading about examples of mass death, from the Holocaust to the Syrian War. It never occurred to me for a moment that I would live through something comparable.

Slovic and Västfjäll’s groundbreaking work teaches us a lot about how we value life.5 To put it simply, in an ideal world, every life is equal and holds the same value. So if, say, you were to donate money to save lives, where the number of victims is N and X is the dollar amount it takes to save one person, then the total response that should be expected, R would be quantifiable as R = X times N. This gives us a linear graph, as seen below on the left.

The second form of normative value of life is when the number of lives crosses a threshold, beyond which the sustainability of the group is threatened, and as a result, every additional life saved is perceived to have much more value. For example, when an animal is on the verge of extinction, every animal of that species becomes more “valuable.”

Both of these ideal forms of valuing life can be depicted as below:

As I said, all of this is in an ideal world. But we don’t live in an ideal world—and the way we actually respond is very different. Experimental evidence is clear that we do not feel more moved by larger groups, regardless of the group in question. 

In one study, Slovic and Västfjäll show that increasing the number of victims in a donation appeal drastically decreases donations.7 Similarly, Small, Loewenstein, & Slovic showed that a single identifiable victim gets more donations than a larger statistic.8

Even when we’re given information about the people who make up larger groups, it doesn’t make a difference: Kogut & Ritov showed that a single identifiable victim still gets more donations than a group of identifiable victims.9

Two models have been put forward to explain this decrease in empathy. The first is the psychological model, where our compassion initially increases with the number of victims, but then hits a plateau. Imagine if I told you 6 million Jews died in the Holocaust, and then corrected myself to say, actually, it was 6,000,653 people who died. Those 653 additional deaths do not make you feel any worse.

The second model is even scarier. This model, called the collapse of compassion, tells a different story: it says that our compassion drops progressively as we add more victims, even as we move from 1 victim to 2. According to this model, as we move further away from a single victim, our compassion continually drops until it hits zero.

These 2 models are represented below:6

So far, it’s not clear which of these models is correct. But no matter what angle we take, unfortunately, we hit the same problem—that we are not capable of feeling compassionate for large numbers of people.

Why we feel numb, and what to do about it

There are several possible explanations for this. Maybe people doubt the efficacy of their actions when the number of victims is large: If 100,000 children are in need of help, what good will my $10 donation do? Or perhaps people regulate their feelings so as not to feel compassionate when they know a donation has to be made because, at the end of the day, we are selfish, and no one wants to part with their money. Or maybe we feel psychologically distant from large numbers in general; they are abstractions to us, rather than concrete concepts.

Charity is one thing—but now, it’s about how we go about our day-to-day lives. At this point in the pandemic, these large numbers are being thrown around in conversation like any other news item, and we are reacting to them in an equanimous manner, as if it does not affect us. But they do affect us—and we all have a role to play in containing the virus.

Visualization: A possible solution

All is not lost, though. The children of the Whitwell Middle School taught us an important lesson: The ability to visualize large numbers is what is missing, and if we can find innovative ways to do that, we might still be able to salvage some of this compassion. And we have seen this happen.

In May 2020, The New York Timesdedicated the front page of the newspaper to names of 100,000 Americans who had (at that point) died in the pandemic. Each name was followed by a line from the obituary. It was meant as a reminder to people that behind the statistics are the lives of real people, with families. They were a part of someone’s memories and they deserved to be remembered for who they were, and not merely as a number.10

Image courtesy: New York Times

Another stark representation of this loss came in October 2020, when 20,000 empty chairs were laid out at the grounds facing the White House. Each chair represented 10 deaths. This was then followed by similar installations in various states across the U.S.11

Image courtesy: PBS

Final takeaways

In order to counter these effects, there are things we can do. Visualization is one of them. The other is to tell people about the importance of small efforts. Technology, especially, helps us do this through features such as real-time updates about donations. Many crowdfunding websites allow donors to track projects long after they have contributed to them, in order to see the impact of their actions. This could be one way to tell people that every bit matters.

Whether this helps change how we value life might still be a question for researchers, but in the current context, it might just help us understand and assimilate large numbers. This in itself is a move in the right direction. The least we can do at this point is ensure our children don’t grow up thinking that it’s normal to lose millions of lives to a virus within a single year. We owe them that much.

TDL Brief: The Stock Market

The link between behavioral science and the stock market is always relevant, but the conversation surrounding it becomes increasingly important in times of uncertainty, as seen in the early stages of the coronavirus pandemic. The increased volatility of the market and the feelings of anxiety that come with it can further impact our decisions. Without knowledge of behavioral science principles, such as the cognitive biases that can lead us astray and how to go about overcoming them, we may wind up making the wrong choices for all the wrong reasons.

Of course, our decision-making is not always based solely on logic even in the best of times. There are many factors that can influence the choices we make, often without us even realizing it. As an investor, checking your portfolio frequently might seem like a good way to stay on top of things. Yet, it has been shown to result in hasty, irrational decisions. By understanding the factors that can influence our decisions for the worse, we can learn how to avoid them. When it comes to the stock market, this enables us to make sound choices regarding our investments. Better choices mean better performance, and better performance means less anxiety, which in turn allows us to make better choices … and the cycle continues. 

1. The power of biases

By: “Behavioral Guidance During Market Volatility: Why Managing Our Emotions May Lead To Better Investment Outcomes”, PIMCO

Just like how our physical energy becomes depleted after working our bodies, our minds can only do so much before needing a break. Although our mental resources are dedicated to important tasks, like processing the stimuli around us and making important decisions, it is not available in infinite supply. For that reason, our brain takes shortcuts that allow us to conserve that mental energy for the truly important tasks. In decision-making, these shortcuts are referred to as cognitive biases and heuristics. These are useful tools for efficient decision-making when there is not a lot at stake – for example, when deciding what to wear – but trouble may arise when we rely on biases and heuristics to make important decisions – such as how to invest our money. 

One bias that can influence investors’ behavior is the recency bias. This bias refers to how we tend to remember recent events more vividly than events that occurred longer ago. As our memories of these events are more salient, we may feel that they are likely to occur again. This may cause us to change our investment behavior to align with market trends from our recent memories which are actually unrelated to future outcomes.

A second bias that investors should keep in mind is loss aversion, which describes how we tend to feel losses more acutely than gains and, as such, prefer avoiding losses to acquiring gains of equal value. As a result, investors may let their fear of losing money drive their decision-making, which can lead us to make maladaptive choices.

Another example of a bias that can influence investment behavior is the framing effect, which refers to how the manner in which information is presented to us can affect the way we evaluate that information. For example, if an investment option is presented negatively, or in terms of losses, we may be hesitant to select it. However, if an equivalent option is presented positively, or in terms of gains, we may be more willing to go for it. The way information is framed can completely change our perception of it, significantly impacting our subsequent actions.

When it comes to the decisions that matter, like choosing how to invest your money, it is important to take the time to make effortful decisions based on logic and reason, instead of taking a shortcut and risking an unfavorable outcome.

2. How to avoid emotional investing

By: Russ Wiles, “Emotions Can Mess Up An Investment Plan. Beware of 6 Irrational Ways To Make Decisions”, AZCentral, September 2020

Behavioral economists are particularly interested in why people make irrational decisions, which has led to research into the effects of different biases. It is clear that biases can lead us to make poor decisions, which raises the question of how we can avoid relying on them in decision-making – especially when it comes to major decisions, such as what to do with our money.

One simple piece of advice for avoiding succumbing to the various biases that can influence our decision-making is to be aware of them. Reading up on the factors that can sway the decisions we make about our investments can help us be more conscious about how we go about making choices in the future. For example, combining knowledge of loss aversion with research into what normal market fluctuations look like can prevent us from scrambling to avoid losses and instead allow us to make rational decisions based on the big picture.

Something else you may find useful is to write yourself a letter detailing your goals and values pertaining to your investments. When the market gets turbulent, reviewing this letter can help remind us of what’s important to us in the long-term, which can keep us grounded and prevent us from taking actions we may later regret.

A third recommendation to promote rational investment decisions is to avoid impulsivity whenever possible. If we make decisions in the heat of the moment, we are more likely to rely on biases and heuristics to guide us. Instead, take a breather and allow yourself to cool down before deciding what actions to take. This way, you will be able to use logic to make a decision, rather than succumbing to biased thinking.

3. The consequences of frequent checking

By: Mark Hulbert, “This is a sure way to make costly investing mistakes in the coronavirus crash”, Market Watch, March 2020

The plunge the stock market took as a result of the coronavirus pandemic was enough to make even the most confident investors uncertain. A common consequence of the heightened anxiety that resulted was for many investors to begin checking their portfolios far more than usual. Frequent checking feels reassuring and it can even lead us to think that we are doing ourselves a favor by being more cautious. However, all it really accomplishes is increasing our anxiety about the state of our investments.

A 1995 paper by renowned behavioral economists, Shlomo Benartzi and Richard Thaler, which was published in the Quarterly Journal of Economics, provides empirical evidence to support the theory that frequent checking is a path to poor investing. They did so by comparing a group of investors who checked their portfolios on a regular basis to a group of investors who checked their portfolios only every so often. The group of “frequent checkers” tended to have more conservative portfolios and ultimately had significantly worse performance than the “infrequent checkers” in the long-run. Thaler and Benartzi dubbed this effect “myopic loss aversion”, because it represents a metaphorical nearsightedness, or inability to look at the big picture, on the part of the investors who check their portfolios frequently. 

Benartzi and Thaler’s research was conducted in the 1980s and 1990s – before the Internet gave us instant access to information on our portfolios’ performance. In fact, the people they refer to as “frequent checkers” in their paper only checked their portfolios every few months. While the ease of access to information we experience today certainly has changed things, the principle of the matter still holds. A more recent study from the National Bureau of Economic Research compared the performance of investors who check their portfolios almost constantly to the performance of those who checked once every four hours. Like Benartzi and Thaler, they uncovered the steep cost of frequent checking. Investors who checked their portfolios less frequently were significantly more likely to make risky investments and brought in profits 53% greater than those yielded by investors who constantly monitored their portfolios.

Benartzi and Thaler suggest that myopic loss aversion results from the fact that when we focus on the short-term, we experience more loss than we do when we look at the long-term. According to the theory of loss aversion, losses affect us more than gains, so we are motivated to avoid them at all costs. This can cause us to react to even the smallest fluctuations in the stock market. Their recommendation? You can probably guess – check your portfolio less often. It can stop you from making choices you will come to regret and has the potential to reduce your stress about your investments, which can make you a better investor in the long run. 

4. Economic bubbles … and what happens when they burst

By: Emily Graffeo, “A majority of investors believe the stock market is in a bubble – and many fear a recession, according to an E*Trade survey”, Business Insider, January 2021.

When it comes to the stock market, the term “bubble” refers to the rapid inflation of the market value of a good or service, with its price surpassing its intrinsic value. At first, a financial bubble is exciting, and may even be accompanied by a state of euphoria. As prices start to climb higher and higher, some investors feel that things are about to come to an end and sell their shares before the bubble bursts. Ultimately, prices get so high that no one is willing to buy anymore and other investors notice that some of their peers have begun to pull out. A state of panic sets in as investors scramble to sell as quickly as possible, while prices plummet. This crash is referred to as the bubble bursting. At the extreme, financial bubbles can give way to recessions, as was seen in the early 2000s when the real estate bubble burst. 

Examples of this pattern of behavior can be found throughout history. Now, people are starting to wonder whether it is happening again. At the start of 2021, a group of E*Trade surveyed a sample of 904 active investors, 66% of whom stated that they feel that the stock market has achieved bubble status. On top of that, another 26% of the investors surveyed responded that, while they felt that the market is not yet in a bubble, it is on its way there. The market as a whole is above average, but the Tesla stock in particular increased at an astronomical rate over the past year. Concerns over a financial bubble are accompanied by worries about entering another recession – something that 32% of investors surveyed listed as the main risk to their portfolio at the moment. 

Gold Stars for Staying Home: Rewards and COVID-19

The COVID-19 pandemic led to a 2020 characterized by fear, loss, and a whole lot of changes in the way we live. As the disease continues to wreak havoc around the globe, many governments have imposed measures to curb the virus’s spread, from curfews and the closure of non-essential businesses to nation-wide lockdowns and stay-at-home orders. We’re accustomed to seeing litanies of “don’t’s” disseminated online and plastered throughout public spaces. As a result, many countries are now contending with irate citizens who demand their pre-pandemic liberties,1 while alarming case numbers leave many of us wondering what it will take to slow the spread as we await our vaccines.

Ask any parent currently stuck at home with their children: nobody responds well to being told “no.” Whether age five or fifty-five, we tend to bristle when we feel our freedom is threatened. This reactance, so termed by Brehm in 1966,2 means that perceived restrictions on independence are often met with anger, resistance, and attempts to restore one’s autonomy.3 It’s little wonder then that COVID-19 safety rules have been resented, shirked, and in some cases faced outright rebuttal. From resistance to masks in the United States to protests against curfews in the Netherlands,4,5 it is evident that these measures have triggered reactance around the world, particularly in countries characterized by ardent individualism.6

Tempting though it may be to counter transgressors with criticism and shaming—revelers recently apprehended at an illegal London rave were branded “incredibly selfish people”7—this too may have counterproductive results. Shame has been shown to have ambivalent effects on behavior, and can often prompt the rationalization of one’s actions rather than elicit change for the better.8

A 2010 study conducted by de Hooge and colleagues observed that when participants were tasked with reading about the shameful experience of bungling a public speaking event, these individuals expressed a desire to give a subsequent presentation in order to restore their damaged sense of self.9 When considered in the context of COVID, these findings suggest that shame is, at best, a risky tool for behavior change: though it may drive people to amend their ways, it can also leave people utterly focused on their self-image. Fearmongering may not be the way to go, either: too weak a message will likely be ineffective, while too large a dose of fear can be paralyzing.10

The case for rewarding safe behavior during COVID-19

So, how should governments and healthcare professionals encourage pandemic-safe practices? Behavioral science tells us that applauding citizens’ good efforts and utilizing positive framing would be more effective than finger-wagging interdictions or shaming remonstrations. Laboratory experiments have indicated that rewarding cooperation effectively encourages more cooperative behavior.11

Further, positive emotions can be harnessed to maximize the effectiveness of health communication. Pride may motivate individuals to engage in selfless behavior, while hope can focus attention on the future and possible rewards. On top of emotional drivers, extrinsic motivators can also precipitate meaningful change. A 2009 study found that financial incentives effectively motivated regular exercise and that the effects of the rewards outlasted the temporal bounds of the experiment.12

How can this knowledge help us throughout the remainder of the pandemic? While monetary rewards for obeying rules may not be feasible, there are many opportunities for behavioral insights to promote safe practices. The technology already in place to assist with contact tracing could easily be adapted to provide positive feedback. Let’s say you resist temptation and stay at home for three consecutive days: an app on your phone automatically celebrates your achievement with a thank you and a video of a pig romping in a pool to give you a chuckle. Craving some community and encouragement? Make a pact with your friends to be diligent about wearing masks in public and bolster each other with affirming messages and physically-distanced support; after all, humans are highly motivated by social norms.13 Feeling extra proud of your communal efforts? Make a big sign that proclaims your neighborhood’s commitment to protecting everyone’s health.

While most of us typically shy away from advertising our accomplishments, in this case making your good behavior known may actually encourage others to follow suit. Trivial though it may seem, these affirmations can make a big difference in how we approach navigating this challenging era.

As many of us gloomily face more time spent navigating Zoom etiquette and baking our hundredth loaf of banana bread, even the smallest of rewards may be enough to keep us masked and distanced for the foreseeable future. And for those who have been tempted to bend the rules in the past, a dose of appreciation and thanks could prevent future defiance. No matter how old you are, a (virtual) pat on the back and a shiny gold star can be all the motivation you need to keep going in tough times.

“Tell Me More”: Vaccines and the Illusion of Knowledge

The newly minted president has an ambitious goal: vaccinating 300 million Americans by the end of summer or the beginning of fall.1 One obstacle that stands between President Biden and his goal is vaccine hesitancy. As of December 2020, 27% of the public said that they probably or definitely would not get the vaccine, even if it were free and deemed safe by scientists.2

Public opinion on vaccines

Despite findings from large clinical trials demonstrating the safety and effectiveness of the vaccines, misinformation regarding the vaccines has spread like wildfire.3,4 This is problematic, as studies have shown that exposure to vaccine-skeptical websites and blogs significantly reduces intentions to get vaccinated.5,6 Judging from the number of people who are vaccine-hesitant, it seems like many people have fallen prey to the falsehoods shared by people on various social media platforms. 

According to Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, we need to vaccinate at least 75% of Americans in order to achieve herd immunity.7 If vaccination rates are significantly lower than that benchmark by the end of the summer, we may not be able to return to a life resembling pre-pandemic times this year.7 Needless to say, if we don’t reach herd immunity, the death toll will continue to rise. 

Can states require their residents to get vaccinated so that we reach herd immunity as soon as possible? The short answer is yes. The 1905 U.S. Supreme Court case Jacobson v. Massachusetts established a legal precedent giving states the authority to mandate vaccinations.8 However, Lawrence Gostin, a law professor at Georgetown University said, “I think it’s very unlikely that they [states] will exercise that power. They would be fearful of causing a backlash and politicizing the vaccine.”9 His concern is not unfounded: only 57% of workers say they would support a workplace vaccine mandate once the shot becomes available to the public.10

In cases like these, leveraging insights from behavioral science might be the answer. 

Why don’t people listen to experts?

Among experts, support for existing COVID-19 vaccines is overwhelming—but clearly, this is not enough to convince many people. This is in line with previous research, which has found that people do not typically revise their beliefs to be more in line with expert opinion than lay opinion.11

What’s yours is mine: Knowledge and transactive memory

People tend to believe that they store all their knowledge within their own brains. But in actuality, people rely on the knowledge of others to obtain and maintain an accurate model of the world.12 People store their knowledge of the world in others through transactive memory, where instead of remembering the exact details about a subject, they remember the markers for the people who are likely to possess knowledge of it.13,14,15,16 

Sometimes, however, people might fail to distinguish other people’s knowledge from their own.17 Because of this, people often hold an “illusion of explanatory depth,” wherein they overestimate how much they know about inherently complex and ostensibly simple phenomena.18 In the case of COVID-19 vaccines, if people believe that they possess the knowledge of experts, then there is little reason for them to update their beliefs in response to expert opinion. 

Shattering the illusion of knowledge

But what if people were forced to confront their lack of knowledge about how COVID-19 vaccines work? This was the question posed by Ethan Meyers and colleagues in a recent article for the journal Judgment and Decision Making.12 The researchers suggest that by exposing the illusion of knowledge that people hold, people will become more receptive to the opinions of medical professionals than the falsehoods shared by laymen on the internet. 

The following diagram details the procedure of one study used by Meyers and colleagues to answer this question.

The researchers hypothesized that by asking participants to explain the mechanics of a process in detail, the illusion of knowledge would be exposed, and consequently, participants will rely more on expert opinion than lay opinion. In addition, the researchers wanted to examine whether exposing an illusion of knowledge would reduce position extremism on economic issues.

Results showed that participants changed their agreement in response to receiving consensus information, regardless of the source. However, they changed their agreement significantly more when they received consensus information from professional economists than from the general public. However, the results also showed that when participants held more extreme views on the issue, exposing the illusion of knowledge did not cause them to change their minds. 

Implications for COVID-19 vaccines

These findings suggest that public figures and media outlets may be able to persuade some people to receive the COVID-19 vaccine by making them realize how little they know about how vaccinations actually work. For example, news programs can first quiz their audience on COVID-19 vaccines, then proceed to give them the correct answers and advice from medical professionals. 

This intervention achieves two objectives: First, it causes people to reflect on what they actually know and don’t know about COVID-19 vaccines; and second, once the illusion of knowledge is exposed, people may become more receptive to the advice of medical professionals. Although this strategy isn’t likely to work with hardline anti-vaxxers, it could prove very effective among people who are on the fence about vaccine safety.

This intervention is also useful when we want to convince our friends and family who are hesitant to get the shots. We can simply ask them, “Do you know how COVID-19 vaccines work?”

Of course, this intervention alone is not enough to increase vaccination rates to where it needs to be. Ending this pandemic requires a concerted effort by healthcare workers, policy-makers, government officials—and most of all, you. So if you’re given the opportunity, please consider making plans to get vaccinated as soon as possible. 

The Real Roots of the GameStop Short Squeeze

On paper, Gamestop is not a great investment. In fact, well-established investment firms have been betting against it for some time now. Why, then, are hobbyists buying it up en masse?

Any individual investor should reason that the stock is likely to lose money, considering the moves made by elite investors. But sometimes making money isn’t all that it’s about. Who’s buying GameStop stocks? A lot of people who feel left behind by the markets. Why? Because it’s the only thing they can do that ever seems to get heard.

This kind of economically “irrational” action isn’t unique to Gamestop or even to financial markets. Following Brexit and the election of Donald Trump, many researchers asked themselves how so many voters could support candidates who lied openly in public discussions. In the “rational” model of voting, lying is extremely risky. If the lie is exposed the candidate loses valuable credibility.

But a group of researchers found a circumstance where lying actually improves the candidate’s chances at the polls: crises of legitimacy. When people are ignored, they feel that the system doesn’t represent their interests. The system appears corrupt, run by insiders who only care about their own interests.

In such a legitimacy crisis, voters will support a candidate who lies. Flaunting the most central rules of the system is a diss to institutional norms and a cheap shot at the insiders who run the place. The more flagrant the lie, the more effective it is with disenchanted voters. They begin to view the candidate as a champion for those without a voice.

Their vote for the candidate is an expression of their identity and their anger. It isn’t necessarily an indication of which policy ideas they support. In fact, people will act against their own interests if it means sticking it to their champion.

Let’s bring this discussion back to the present, and see if it helps us to understand what’s going on with GameStop. Institutional investors short the stock; they think the company will do poorly. We should expect investors to follow the herd unless they have an exceptional reason to do otherwise.

What exceptional reasons might investors have? Under normal circumstances, exceptional reasons might include a belief that the company will rally, that it’s currently undervalued, that the sector as a whole is positioned for growth, etc. Those are all economic reasons: reasons to believe that the investment will make money.

But in a crisis of legitimacy, profit-seeking no longer predicts human behavior. Buying a share becomes a statement. Investors can become activists, using their trades as a way to voice their grievances. Historically, though, this logic shows an affinity to conservative ideology. With governments painted as the problem since the 1980s, and free markets as the solution, this kind of investor activism can be interpreted as exactly what one should expect. People will make their voices heard wherever the power is; as power shifts from the ballot box to the marketplace, we should expect their self-expression to follow along with it.

Where do we go from here? If we want investors to only follow “economic” reasons (and cool off the dangers associated with hyper-fluctuating markets), we need to handle the underlying legitimacy crisis. Barring people from trading the stocks actually makes it worse, since it only fuels pent-up energy for further self-expression. And disparaging this kind of trading because it treats stock markets like a casino is unlikely to bring down the temperature among folks who probably felt that way about 2008. 

Whether it is overtly populist politics or rag-tag investors, the discontent is real and there is a lot on the line. Revolution feels necessary when the system is deaf to appeals for peaceful, gradualist change. Crises of legitimacy disrupt the social order and make policy-making (as well as investing, and corporate management) harder than it should be; traditional incentive structures no longer function as they should, and responses become much more volatile and unpredictable. Those fretting about the financial consequences of the GameStop debacle should take a step back and see these expressions of discontent for what they truly are. The lens of social behavior helps a lot in doing exactly that.

“If Only”: The Good and the Bad of Counterfactuals

One of my all-time favorite movie series is Back to the Future. Not only does it provide exciting glimpses into ’80s fashion, ’50s nostalgia, and the American Wild West, it emphasizes how altering a single moment in history can change everything. If it showed me anything as a kid, it was that I, unlike Marty McFly, was not up for the responsibility of time travel.

Although I learned that history is probably best left unchanged, I often think of how past scenarios could have been different, whether it be in my own past, or in history more generally. These thoughts are called “counterfactuals,” and they’re a topic of interest in the scientific literature due to their impact on our mood and on our understandings of the world.

Counterfactuals are “what could have been.” They are the roads not taken, or the alternative realities. Engaging in counterfactual reasoning is a ubiquitous mental process that we develop from ages 6-12. This concept frequently comes up in psychological, economic, and political science research.1,2

I, personally, am a fervid counterfactual-er. I constantly think back to past events imagining how they might have been better, worse, or simply different. Yet, I wondered, is there any benefit to doing so? Or am I just wasting precious mental energy on scenarios that will never occur?

Research provides insight into how our brains make sense of the past, why we rehash what’s already done, and how doing so can help us.

Norm theory, the simulation heuristic, and mutability

One of the earliest theoretical explanations of counterfactual thinking as a mental process is the simulation heuristic and norm theory.3,4,5 The simulation heuristic explains how our brains are likely to believe things that are easy to picture mentally. Similarly, norm theory describes how we tend to have stronger emotional responses to events with abnormal causes, or events that could have been easily changed.

So, first, an example of our mental processes in generating counterfactuals.

In an experiment, participants were informed that a drug-crazed teenager ran a red light and hit Mr. Jones in his car, resulting in a fatal accident.

Participants read one of two scenarios:

On the day of the accident, Mr. Jones left his office at the regular time. He sometimes left early to take care of home chores at his wife’s request, but this was not necessary on that day. Mr. Jones did not drive home by his regular route. The day was exceptionally clear, and Mr. Jones told his friends at the office that he would drive along the shore to enjoy the view.

Or

On the day of the accident, Mr. Jones left the office earlier than usual, to attend to some household chores at his wife’s request. He drove home along his regular route. Mr. Jones occasionally chose to drive along the shore, to enjoy the view on exceptionally clear days, but that day was just average.

One statement emphasizes an abnormal change in route, the other a change in time. While the reader technically could have attributed time and route as causal in both scenarios, participants focused on the exceptional action, not the routine habit, as the cause.

The idea that these events were both caused by abnormal circumstances (and thus could have been avoided) allows us to consider even more possible alternatives. What if he hadn’t left early? What if he had taken a different route? Would the outcome have been different? (At the same time, we neglect to consider other, external, factors, like the teenager who caused the accident.)3,4

Norm theory explains this phenomenon in that certain factors are more likely to lead us to imagine different scenarios than others.3 That is, we believe some events are more easily changed than others. Examples include focusing more on the effect than on the cause, or focusing more on the behavior of an individual victim’s actions than the circumstances in which they were acting.

We also may respond more emotionally to some alternatives than others. For example, suppose two individuals share a cab to the airport, which gets stuck in traffic and delayed for several hours. In that case, we are likely to assume that the individual who just missed their flight by ten minutes would be more upset than the individual whose flight left 2 hours ago.

In moments that are deeply frustrating or traumatic, one might think that we are more likely to blame ourselves for cases in which the event was a cause of our own doing. But research shows this is not the case. In experiments where participants experienced similar losses or gains, yet differed in the degree to which their decisions influenced the outcome, participants had similar feelings of regret regardless of whether or not they were responsible.6 It seems that our feelings may be based more on the outcome and not our involvement.

While it is interesting to understand how our mental processes work, it is important to remember that counterfactual reasoning is “rapid, automatic, and essentially immune to voluntary control after its initiation.”5 It is inevitable, and serves many functional purposes.

Different types of counterfactuals and how they help us

The above examples show how our brain engages in counterfactuals, and what aspects might influence an emotional or irrational response. But counterfactuals are not necessarily bad or irrational. They serve an important purpose.

First, it’s important to distinguish between “upward and downward” counterfactuals. In the scientific literature, upward counterfactuals involve thinking about how the situation could have been better. In the car accident example, an upward counterfactual could be thinking about what would have happened if the driver had left at his usual time, or had taken a different route and dodged the accident entirely.

In contrast, downward counterfactuals are how the situation could have been worse.5,7 In this same example, that might involve thinking about what could have happened had there been more people in the car with Mr. Jones, or if the accident had turned into a multi-vehicle pile-up that caused even more injury and suffering.

Downward counterfactuals can be incredibly useful, especially to soothe ourselves emotionally. In realizing that the situation could have been worse, we find relief in knowing that we dodged a more negative outcome.5 Downward counterfactuals may repair mood functions and are a useful tool in helping us deal with potentially negative information.5

The opposite, upward counterfactuals, also have functional benefits. While thinking about how a situation could have been better may not be particularly enjoyable, those who generate upward counterfactuals are likely to change their behavior in the future.5,7

Yet, what may have a unique effect may not be our upward or downward processes, but how we add or take away from the situation.

Adding and subtracting

In some instances, we use additive or subtractive counterfactuals. An additive counterfactual is adding new information to the scenario—for instance, thinking “I should have studied more.” A subtractive, by contrast, involves removing scenarios: “I should have never taken that class.”

Subtractive counterfactuals are related to more analytical thinking, helping us consider how things work together. Consider the game Jenga, wherein the player must remove a single block each round, risking a collapse. With each subtraction, players must consider how a single block relates to the stability of the entire structure.8

Yet additive thinking has its function as well. When we engage in additive counterfactual thinking, we are more creative, consider more novel options, and make more behavioral improvements.5 Take, for example, social entrepreneurs—such as those of Project Aspire, an innovative effort to end homelessness. By engaging in additive counterfactuals, they were able to think outside the box of existing systems and visualize novel solutions to social problems.9

The role of opportunity in counterfactual thinking

Whether we engage in upward or downward counterfactuals seems to be affected by the opportunities that are available to us. When opportunities exist that we feel we’re not fully taking advantage of, we’re likely to engage in upward counterfactuals, inspiring feelings of regret and spurring us to action. In contrast, when opportunities are taken away—for example, not getting the job you applied for—our main concern is feeling better, leading us to engage in more downward counterfactuals (“I probably wouldn’t have liked that job anyway. I dodged a bullet!”).

Paradoxically, this means that we’re more likely to feel satisfied when certain doors are closed to us than we are when those opportunities remain open.5 This nuance illustrates the different functions of counterfactuals. On the one hand, downward counterfactuals protect us from the emotional pain of rejection and failure. On the other hand, when we experience situations where we can still change the outcome, we can channel our energy and feelings of regret into concrete action.

Moderation is key: the dark side of counterfactual reasoning

While counterfactual reasoning is a helpful mental process and diagnostic tool at our disposal, it is essential to remember that moderation is key. Its absence is a warning sign of the onset of schizophrenia, yet its excess is a core symptom of depression and anxiety.5,10,11,12 As well, in counterfactual thinking, we can fall victim to biases like hindsight bias, self-serving bias, and cognitive dissonance.5,13

Counterfactuals may also influence how we perceive false information. In a 2018 experiment, Daniel Effron gave participants information they were told was untrue, and asked half of the participants to think about ways the information might have been true. In some instances, the untrue information aligned with the beliefs of Trump supporters; and in others, those of Clinton supporters. As a result, the participants who were asked to engage in counterfactual reasoning were less likely to see the lie itself as immoral.14,15 Even though participants knew the claims were false, they were more lenient on individuals who continued to spread the mistruth, especially if the liar aligned with their political beliefs. The danger of counterfactual thinking lies in its potential to make us more willing to accept unacceptable behavior.

Overall, counterfactual reasoning is a common mental process that is unavoidable and natural. It can make us improve our decisions and our mood, yet also increase our susceptibility to bias. Some key takeaways to counterfactual reasoning:

  • We are consistently inconsistent in how we reason: In creating alternative scenarios for past events, we tend to emphasize events that seem easily changed, being influenced by factors like seemingly “abnormal” events, or focal actors.
  • Different directions have different results: Downward counterfactual reasoning (what could have been worse) helps us think positively. In contrast, upward counterfactual reasoning (what could have been better) may be more influential in changing future behavior.
  • How we feel depends on whether the door is “opened” or “closed”: One of the best explanations for whether we use counterfactual reasoning to feel better or to change our behavior depends on the availability of opportunity.
  • With great power comes great responsibility: While a useful process, too little or too much counterfactual reasoning can lead to depression or anxiety and can influence how we perceive those who spread lies.

Moving forward, I know I’ll still probably try to convince myself that a situation could have been worse, or find new ways to make new situations better. But instead of feeling guilty about doing so, feeling that I am shrouded in delusion, I can remind myself that certain events are out of our control, and rest in the knowledge that my mental processing can turn those situations into teachable moments. Plus, I will continue to believe it is for the better that I don’t have access to a time machine.

Overlooked: Implicit Bias in Health Care

In health care, the impact of implicit bias in clinical decision-making is a persistent problem. Although implicit biases are ubiquitous among the general human population, healthcare professionals may be more susceptible, because the healthcare setting—often fast-paced, high-stress, and high-uncertainty—can accentuate cognitive biases.

The clinical setting is fast-paced because clinicians need to juggle numerous patients, administrative tasks, and other responsibilities while staying on a tight schedule. Clinical decision-making can also often be synonymous with uncertainty. Arriving at a diagnosis is like a puzzle; sometimes, a patient’s symptomatology or lab results will not point to a clear diagnosis, requiring the provider to rely on prior experience to make a decision.

This, in conjunction with intense work demands, long hours, and occasionally uncooperative patients, can contribute to the emotional toll and stress that healthcare professionals endure on the job. This is the perfect storm for prejudice to rear its head, as it promotes a shift towards System 1 thinking and increases our reliance on heuristics—mental shortcuts that we take during the decision-making process for the sake of cognitive ease.1 

Healthcare bias: Opening up the discussion

Generally, implicit racial bias tends to draw a disproportionate amount of attention in healthcare research and policy. Rightly so: research has shown that patients of color face receive a lower quality of care than white people, even when socioeconomic status is considered.

However, this has come at the expense of attention to other important factors. In the context of health care, a recent systematic literature review identified 42 articles that measured implicit bias among healthcare professionals in-patient care. While 27 studies examined racial/ethnic bias, only 10 studies focused on gender, age, weight, marital status, or other demographic factors.2

In this article, I use a sociological lens to discuss the existing body of research on implicit biases related to gender, body size, and marital status among healthcare professionals, linking these biases to prevailing social norms. By doing so, I hope to draw attention to the fact that race is not the only implicit bias that we must address in healthcare settings. 

Implicit weight bias in health care

Over 40% of the U.S. adult population is obese,3 and negative attitudes about weight are prevalent throughout the country. In our society, obese and overweight individuals are often perceived as lazy, weak-willed, unsuccessful, unintelligent, and lacking self-discipline. These harmful stereotypes promote widespread prejudice and discrimination. In fact, weight discrimination is nearly just as common in America as racial discrimination.

In contrast to race, however, anti-fat bias is often perceived as more socially acceptable because one’s weight is believed to be under one’s control. In reality, body size is influenced by factors such as an individual’s environment and genetic makeup. Still, our culture promotes that overweight individuals should be blamed for their size.4 Obese individuals often face the consequences of these stigmas in a variety of aspects of their life including, but not limited to, the workplace, educational institutions, and healthcare settings. 

Anti-fat bias is deeply ingrained among healthcare professionals. In one study, physicians indicated that they react to obesity with feelings of discomfort, reluctance, or dislike. Additionally, they associated obesity with poor hygiene, noncompliance, hostility, and dishonesty.5 Similar findings have been demonstrated in other studies on physicians and medical students.6 I do recognize that many of these studies are from over two decades ago. However, these findings should direct future research towards evaluating current anti-fat attitudes. 

Several studies have indicated that anti-fat attitudes among healthcare professionals can negatively impact clinical judgment, diagnosis, and quality of care. For instance, physicians who hold such attitudes indicate that they themselves do not expect treatments will succeed when the patient is overweight.7 Physicians also express that poor patient compliance and motivation is a common frustration during obesity treatments, resulting in a reduced emphasis on communicating information that can promote lifestyle changes.8

This can lead to a self-fulfilling prophecy: physicians may put less effort into treating obese patients or communicating with them, resulting in poorer outcomes and reinforcing the physician’s original attitudes. In one study that used vignettes to assess clinical judgments, it was found that mental health workers tend to associate obese patients with more negative symptoms.9

The negative attitudes of healthcare providers towards obese and overweight patients can also lead to hesitance among these patients to seek health care.10 For example, women who are overweight are significantly less likely to obtain regular pelvic exams due to the negative body image fostered by physicians’ unwillingness to attend to these patients.11

The assumption that obesity leads to worse health outcomes largely goes unquestioned. Going forward, researchers should seek to better understand how much of this is due to physiological characteristics, and how much is from the consequences of discrimination.

Marital status and implicit bias in health care

Social support can be characterized by the emotional, informational, and instrumental resources that people obtain from other people. Social support is strongly correlated with better health and well being.12

It is not uncommon for physicians to consider social support when determining a patient’s ability to handle challenging treatments. However, it is important to note that marital status is not synonymous with social support. Unmarried patients can still have strong support systems through family, friends, etc. In medical decision-making, this creates concern for marital status bias that is founded on cultural narratives, not evidence. 

In a recent article published in the New England Journal of Medicine, it was discussed how unmarried patients are less likely to survive cancer. The authors suggested that this may be due to physicians’ implicit stereotyping of patients based on marital status as an indication of the patient’s support system.13 Physicians are less likely to recommend surgery or radiotherapy as treatment for cancer patients who are unmarried.

Marital status also strongly affects clinical judgment when evaluating patient eligibility for scarce medical resources such as organ transplants.14 Divorced patients, as opposed to married patients, are less likely to receive an organ transplant because they are perceived to be less resilient, have less social support, and be “less deserving.”

Future steps that medical decision-makers can take to minimize this bias is to ask patients questions about their social support system without bringing marital status into the picture. For example, they can ask patients if they have people who will be supporting them throughout their treatment journey, and if they have people they can talk to about important medical decisions. These sorts of questions will draw attention away from marital status and towards social support, which is the true focus.

Implicit gender bias in health care

Implicit gender bias has been shown to affect medical decision-making in the hospital setting. Surprisingly, one study found that women are less likely to receive a knee arthroplasty than men by a factor of 3. This study even accounted for cases where it was clinically appropriate for the women to receive the arthroplasty.15,16,17

This drastic difference may be because men are stereotyped to be stronger and able to withstand more pain while also being more active, therefore benefiting more from the knee replacement than women because their condition is perceived to be worse. This pain stereotype, albeit clinically true, can have adverse consequences because it can inadvertently result in women not receiving the appropriate medications and treatment.18 

This was also observed in another study where male coronary artery disease patients were considered to be at higher risk and thus were prescribed more aspirin and lipid-lowering medication as a mode of secondary prevention than women patients, even when all other factors were controlled for. In fact, the study concluded that while men tended to be prescribed the optimal amount of medication, women did not. This is an indication that gender bias actually contributes to a lower quality of medical care. 

It is important to note that there are many systemic factors that contribute to this gap. For example, there is a large funding gap in medical research concerning woman’s health. These often inevitably feed into individual implicit biases and vice versa.

Future outlook 

How can we combat the effects of implicit bias in healthcare settings? Creating bias education programs for all physicians, as well as nurses, physician assistants, and social workers, can help counteract unconscious bias and stereotypes by making them aware of their disastrous consequences. Teaching people to recognize their biases can make them more aware and apt in attempting to reduce the bias themselves.

A commonly used tool to assess implicit biases is the Implicit Attitudes Test (IAT). While the race-based version of this test is most commonly used, health care workers should also take the tests assessing implicit attitudes towards gender, sexuality, and weight. This exercise will help elucidate the distinction between implicit bias and explicit endorsement.

While awareness does help in reducing the effects of bias, it is not sufficient to fully overcome the automatic activation of stereotypes and the consequential effects. To combat this, there are various strategies that the provider can implement that are low-cost, time-effective, and simple.

Practicing perspective-taking

Providers should be mandated to a perspective-taking strategy in between each patient that a physician sees. This short reflection period can allow the provider to understand the entire situation specifically from the standpoint of potential biases, and correct accordingly. This perspective-taking can involve manipulating a certain perspective through visual or audio guidance, or through a specifically designed form of the IAT. Both of these methods can guide the individual to start understanding what types of bias exist and how their decisions incorporate the bias.19

Focus on the patient’s individuality

Another effective strategy is individuating. Individuating is the practice of consciously focusing only on specific information about an individual that is relevant to medical decision-making while leaving race or gender out of thought.20 This strategy helps physicians avoid filling in gaps and uncertainties in patient information with stereotype-based assumptions, as shown in a study conducted by Chapman et al on gender disparities in COPD.21 However, it is important to note that such a strategy may take away value from the provider-patient relationship as it forces the provider to treat the patient as a set of lab results and symptoms rather than as a human being.

Early education

In addition to training sessions for practicing providers, training should also be implemented into the curricula for medical students. Starting an annual training plan including recurring IAT examinations and a manipulative perspective-taking experience can begin to have these future physicians ready to adjust to the background of any patient they may encounter. A preemptive acknowledgment of the bias issues will allow physicians to combat this issue before it evolves into a problem in the workplace.

Conclusion

The wide array of literature culminates to a crucial conclusion: healthcare professionals are not immune to implicit biases, and these implicit biases extend beyond just race. After all, healthcare practitioners are still members of society, and are privy to society’s social norms and stereotypes. More recent literature will be important to understand the impact of discrimination in healthcare today because, in recent years, there have been great strides towards advocacy and awareness of implicit attitudes and stereotypes. However, the innate challenge of addressing implicit biases is that they differ from explicit attitudes, making it very difficult to achieve tangible results.

Another question worth addressing in the near future is whether or not racial implicit bias can lead to worse outcomes in comparison to other forms of implicit bias. Existing literature does not focus on comparative analyses. Answering this question can better guide future interventions, policies, and where to invest research funding. Till we answer this question, however, I urge that implicit biases concerning body size, marital status, and gender receive the same amount of attention.