PMNR physicians improve the quality of life for their patients and advance the specialty through groundbreaking research, innovative care, advocacy, public service, and volunteerism. The American Academy of Physical Medicine and Rehabilitation and the Foundation for PMNR offer our deepest gratitude to those with an exceptional commitment to excellence and advancement in physiatry. The Foundation for Physical Medicine and Rehabilitation's mission is investing in the scientific foundation and advancement of physiatric care through research. Year over year, the number of grant applications has greatly increased, as has the level of scientific sophistication, making these awards competitive and prestigious. Congratulations to the following Foundation for PMNR grant recipients. Each year, the Foundation provides Richard Matterson ERF New Investigator Grants to support career development for physiatric investigators five years or less out of training. This year's recipients include Dr. Alexandra Behling, Spalding Rehabilitation Hospital, Harvard Medical School, Relationship of Tibial Bone Perfusion to Stress Fracture Healing Outcomes, Dr. Nicholas Reitz, University of Pittsburgh Medical Center, Social Relationship Status and Serotonergic Dysregulation Contributions to Unhealthy Social Behavior and Impaired Stress Management After TBI, Dr. Elliott Block, Casa Colina, EEG Biomarkers of Motor and Cognitive Recovery Following Transcutaneous Auricular Vagus Nerve Stimulation in Acute Stroke Patients, a Preliminary Study. The Encompass Mid-Career Investigator Research Grant provides pilot funding to an established investigator with a proven track record who wants to explore a new line of research. Dr. Adrienne Richard-Denis, Hospital du Sacre-Coeur de Montréal, using a point-of-care electrophysiological method to accelerate the detection of neurogenic bladder dysfunction and improve prognosis of neurofunctional recovery after acute spinal cord injury. The Nadler-Passor Musculoskeletal Research Grant supports an established physiatric investigator who proposes an outstanding, innovative musculoskeletal rehabilitation research study. Dr. Daniel Herman, University of California, Davis, Effect of COVID-19 Infection on Neuromuscular Control Factors Related to Musculoskeletal Function, a Pilot Study. The Pain Management and Spine Care Research Grant supports physiatric research in these vital areas. Dr. Roger Luo, Rutgers New Jersey Medical School PM&R Program, Phenol Neurolysis for the Treatment of Osteoarthritic Knee Pain. The Gabriela Molnar Pediatric PM&R Lifetime Achievement Award recognizes the extraordinary contributions to patient care, training, and research in pediatric physiatry. Dr. Maureen Nelson, Baylor College of Medicine and San Antonio Children's Hospital. Dr. Nelson is a professor of pediatrics and PM&R at Baylor College of Medicine and medical director of Pediatric Physical Medicine and Rehabilitation at Seton Healthcare Network. For more than three decades, she has contributed to our knowledge of brachial plexus injury and recovery in children. Her research and publications also include important work in adaptive sports and recreation, as well as electrodiagnosis. Dr. Nelson has also taught more than 600 residents in PM&R. She was selected for this award to recognize her strong leadership and mentorship abilities, as well as her tireless quest to better the lives of children with disability. Foundation for PM&R Research Grants are made possible by the generosity of donors like you. Your support is appreciated by these grant recipients and awardees who are the future of our field. Congratulations, Foundation for PM&R grant recipients. Thank you to this year's award committee for their time and diligence in selecting the following 2023 AAPM&R award recipients. Dr. William F. Macheo, Frank H. Kruzan Lifetime Achievement Award. Dr. Macheo is chairman, professor, and sports medicine fellowship director in the Department of Physical Medicine, Rehabilitation, and Sports Medicine at the University of Puerto Rico School of Medicine. He is a founding partner of Grupo Fisiátrico, a PM&R specialty group practice that has provided outpatient services in Puerto Rico for the last 37 years. Dr. Macheo is director of the Sports Injuries Unit of the Center for Sports Health and Exercise Sciences of the Olympic Training Center and is currently the medical director for the Puerto Rican delegations that participate in this Olympic cycle. He was president of AAPM&R in 2009, the Puerto Rico Physical Medicine and Rehabilitation Association, the Puerto Rico Sports Medicine Federation, and the Physiatric Association for Spine, Sports, and Occupational Rehabilitation. His areas of academic and research interest include epidemiology of sports injuries, rehabilitation and prevention of sports injuries and management, rehabilitation and return to play following anterior cruciate ligament injury. His most important achievement is his family. He has been married to Dr. Vanessa Marcial for the last 41 years and has two sons, both lawyers, Javier and Francisco. Dr. Macheo's countless achievements have evolved the specialty and it is with great honor that we recognize his extraordinary impact on PM&R. The Distinguished Member Award was established to honor AAPM&R members who have provided invaluable service to the specialty of PM&R. Dr. Joanne Borgstein, Distinguished Member Award. Dr. Borgstein is a physiatrist in Wellesley, Massachusetts and is affiliated with multiple hospitals in the area, including Massachusetts General Hospital, Spaulding Rehabilitation, and Newton Wellesley Hospitals. She is currently Chief Division of Sports and Musculoskeletal Rehabilitation at Spaulding Rehabilitation Hospital Network and the Harvard Department of PM&R. She is the Director of Regenerative Medicine for Mass General Brigham Health Care. Dr. Michael Fredrickson, Distinguished Member Award. Dr. Fredrickson is the Director of PM&R Sports Medicine in the Department of Orthopedic Surgery and Co-Director of the Stanford Center on Longevity and Founder of Lifestyle Medicine. He is also the Head Team Physician for the Stanford Track and Field and Swimming Teams, the Medical Director for Stanford Club Sports, and a WUSI Human Performance Alliance Member. He has volunteered at both national and international levels with USA Track and Field in the International Olympic Committee. Dr. Aslan Tariq, Distinguished Member Award. Dr. Tariq is a physician executive with more than 11 years of experience in a variety of leadership roles. He is presently Chief Clinical Officer at Optimal Health Medical Fitness in Madrina. A first-generation immigrant from Pakistan, Dr. Tariq completed his undergraduate studies at Stony Brook University Medical School at Lake Erie College of Osteopathic Medicine and residency at Marion Joy Rehabilitation Hospital. The Public Service Award has been renamed to the PM&R Public Service Health Equity and Advocacy Award to underscore our members in these areas. Dr. Talia Fleming, PM&R Public Service Health Equity and Advocacy Award. Dr. Fleming is an accomplished academic physiatrist who advocates for health care policies and practices to improve access to care for individuals with disabilities in under-resourced communities. She serves as the Medical Director of the Stroke Recovery Program, Post-COVID Rehabilitation Program and Aftercare Programs at JFK Johnson Rehabilitation Institute in Edison, New Jersey. Dr. Brenda Waller, PM&R Public Service Health Equity and Advocacy Award. Dr. Waller has enjoyed a career in PM&R for 34 years. She received her early education in rural Virginia, attended Howard University, obtaining a BS in chemistry, and went on to the University of Pittsburgh for her medical degree. Dr. Waller maintains her sole proprietor, private practice, PRIS, PLC, Physical Rehabilitation and Interventional Spine, and has been recognized for her many years of service as teaching faculty or paraprofessional medical staff. Rehabilitation and Services Volunteer Project, PM&R Public Service Health Equity and Advocacy Award. RSVP is an all-volunteer, non-profit organization that provides rehabilitation services and durable medical equipment to uninsured and underinsured individuals with disabilities that lack access to the services that we provide. Their volunteer team is made up of multidisciplinary health care professionals and other individuals committed to providing high-quality rehabilitative care that is comprehensive, compassionate, and community-oriented. This new award is presented to Academy members who have made an impact on the future of PM&R through distinction in innovation, advocacy, leadership, service, or clinical practice within 10 or fewer years of practice. Dr. Daniel C. Herman, Early PM&R Career Award. Dr. Herman is an accomplished sports medicine physiatrist, researcher, and educator in the Department of Physical Medicine and Rehabilitation at the University of California at Davis, where he has been an associate professor since 2021. He is the director of sports medicine research for his department and maintains an active interdisciplinary research program. Dr. Prakash S. Jayabalan, Early PM&R Career Award. Dr. Jayabalan is the physician-scientist director of the Nancy W. Knowles Strength and Endurance Lab at the Shirley Ryan Ability Lab and an associate professor in the Department of Physical Medicine and Rehabilitation at Northwestern University Feinberg School of Medicine. He focuses his clinical practice on the prevention, diagnosis, and treatment of sports injuries and degenerative joint disease. Dr. Matthew J. McLaughlin, Early PM&R Career Award. Dr. McLaughlin serves as an associate professor and division director at Children's Mercy in Kansas City, Missouri. He is a duly trained pediatric physiatrist and clinical pharmacologist whose primary research encompasses the concepts of precision medicine and pharmacogenomics. Dr. McLaughlin's passions include cycling and adaptive sports, serving as an international and national level paracycling classifier. This new award recognizes individuals whose efforts have significantly elevated the understanding and value of physiatry across healthcare. Dr. Lori Grafton, PM&R Awareness and Value Award. Dr. Grafton's areas of clinical expertise involve the specialized care of individuals with traumatic brain injury through a comprehensive and multidisciplinary approach. She continues to work towards establishing a continuum of care for brain injured patients who receive their care at Penn State Health, with an ongoing focus on early consultation and intervention. Dr. David Rosenblum, PM&R Awareness and Value Award. Board certified in physical medicine and rehabilitation, spinal cord injury medicine, and brain injury medicine, he joined Gaylord Specialty Healthcare in 1992 and now serves as medical director of the Milne Institute for Healthcare Innovation, director of medical education, and director of the spinal cord injury program, and the research site director of the model systems SCI program. Dr. Lauren Shapiro, PM&R Awareness and Value Award. Dr. Shapiro is an associate professor of clinical physical medicine and rehabilitation at the University of Miami Miller School of Medicine, where she serves as the vice chair of quality, safety and compliance for the PM&R department. She also serves as the medical director of the stroke rehabilitation service at the Christine E. Lim Rehabilitation Center for the Miami Project Cure Paralysis. The Passore Legacy Award and Lectureship is meant to recognize an individual in mid-career who has advanced musculoskeletal physiatry through clinical care, education, service, or scholarship. Dr. Nitin Jain, Passore Legacy Award and Lectureship. Dr. Jain is a tenured professor of physical medicine and rehabilitation and orthopedic surgery. He serves as vice chair of the Department of Physical Medicine and Rehabilitation, and chief of the section of musculoskeletal medicine and research. In his role as UT Southwestern's co-director of musculoskeletal and sports medicine, he leads the UTSW sports and musculoskeletal clinic and educational programs. Thank you to the 2023 award recipients for advancing our specialty and the work we do on behalf of our patients. Please join us in congratulating all of the distinguished AAPMNR and Foundation for PMNR 2023 award winners. Good afternoon, everyone. I am Scott Laker, chair of the AAPMNR Awards Committee and president-elect of the academy. I'd like to ask our 2023 award winners to join me on the stage. As they do, please join me in congratulating them. How about yours? That's the way I like it and I've never been bored. Hey now, you're an all-star, get your game on, go play. Hey now, you're an all-star, get the show on, get paid. All that glitters is gold. Only shooting stars break the mold. Only shooting stars break the mold. It is inspiring to see all the amazing work you are accomplishing. Now I'd like to ask you, ask our Cruise and Lifetime Achievement Award winner, Dr. William Macheo, to step up to the front and say a few words. Thank you. I brought my own fan club right here, good. I'd like to start by thanking the AAPMNR, its awards committee and its members for this prestigious award. I am humbled and honored to be recognized by the professional society that I consider my medical home for the past 40 years and one that has contributed greatly to my personal, professional and academic growth. I would like to thank God for all the blessings that me and my family have had over the years and for him to allowing me to practice in the beautiful island of Puerto Rico. Second, I would like to thank my family, my wife Vanessa of 41 years. She stood by my side, ran her home and was the general at home, yes. And our two sons, Javier and Francisco, who have always supported me in my professional activities, which included frequent travel to medical meetings, conferences and to cover athletic events all over the world. Without their love and encouragement, I would not be here today. Third, I want to recognize some important mentors in my life. I have a lot of mentors, but I will name a few. From Temple Moss Rehab, where I trained, I recognize especially Dr. Tom Strax, past president of this academy. An exceptional individual who showed me how to fight for things that I wanted, how to be compassionate with those in need, how to lead by example. I never forget a favorite phrase of Tom, which I teach our residences. If there is no wind, row. Dr. Nat Mayer, a brilliant clinician educator who taught me how to think critically and analyze a problem in order to come up with a solution. Nat is a great teacher. From Puerto Rico, in medical school, I met Dr. Walter Frontera when I was a first-year medical student. I have known him for 40 years. He used to be my boss. Now I am his boss. But he can do whatever he wants. Walter has become a model of what a leader in our field should be. Humble, organized, an excellent clinician, and a world-renowned researcher. Eduardo Amin is a special orthopedic surgeon who has worked with me in clinic for 30 years. He taught me medical discipline and how to search for excellence. He always said, if you look for perfection, you will never get it. But in that search, you will find excellence. Finally, Dr. Carmen Lopez, our Program Director for Physical Medicine and Rehabilitation. She has been working with me for the last 31 years. She was part of the staff that recruited me, and she has worked tirelessly in education and highlighting the field of physical medicine and rehabilitation for medical students for over 40 years, and I admire that. Thank you, Carmen. Next, I would like to recognize my peers. First and foremost, Alberto Eskenazi, who traded with me. A brother from another mother that life has gifted me. His excellence has inspired me through my career. There are many others that I could mention here, but I'll mention a few that have excelled in our specialty in our field of musculoskeletal and sports medicine. They include Stan Herring, Joel Press, Mike Fredrickson, who's getting an award today, Jerry Malanga, may he rest in peace, a great individual, and Ben Kibler, who is not a physiatrist, but really influenced the lives of many of us in this specialty. I would not like to end without recognizing the hundreds of medical students, residents, and fellows that have allowed me to be part of their education, personal, and professional development. You certainly bring out the best in me. Finally, I would like to recognize the unwavering support of faculty and staff who work with me at the Physical Medicine Rehabilitation and Sports Medicine Department at the University of Puerto Rico. My partner of 37 years in practice, Dr. Jose Arias, who's probably working at home while I'm traveling, and his support was incredible through me for my career, and the great staff at the AAPMNR. In particular, Dan Leverow, who works with me during my days in the past for leadership, Margaret Keating, who has been great for all of us over the last 15 years, and last but not least, Tom Stotzenbach, who I admire for his dedication and hard work on behalf of our great specialty. We will miss you, Tom. In the words of the great Roberto Clemente, idol of our beautiful island of Puerto Rico, anytime you have an opportunity to make a difference in this earth, and you don't, you're wasting your time. Thank you very much. Thank you, Dr. Macheo. To continue celebrating the work of our peers, we'll be posting the awards video on the Academy's website and on social media. I encourage you to share this video with your friends and your colleagues. Now, Dr. Sarah Wong is going to introduce today's Zeider lecturer. Thank you very much, Dr. Laker. The Walter Zeider Lectureship is an Academy tradition that honors the qualities of statesmanship, scholarship, executive leadership, and comforting friendship of Dr. Walter Zeider, past executive director of AAPM&R and ACRM. The lectureship honors a broader spectrum of leaders who share Dr. Zeider's admirable qualities. I'm excited to introduce this year's Zeider lecturer, Dr. Tali Sherratt. Dr. Sherratt is the director of the Affective Brain Lab. She's a professor of cognitive neuroscience in the Department of Experimental Psychology and the Max Planck UCL Center for Computational Psychiatry at University College London, and on the faculty of the Department of Brain and Cognitive Sciences at MIT. She's a Wellcome Trust Senior Research Fellow and has held fellowships from the British Academy and the Forum of European Philosophy. She's the deputy editor for Science Advances, as well as on the board of several other academic journals. Dr. Sherratt's research integrates neuroscience, behavioral economics, and psychology to study how emotion and motivation influences people's beliefs, decisions, and social interactions. Please join me in welcoming Dr. Tali Sherratt as she discusses the science of behavioral change. ♪♪ Thank you, Dr. Wang, and good to be with all of you here. So, as mentioned, I'm a cognitive neuroscientist, which is a mix of brain science, psychology, and I mix in behavioral economics as well. I bring people into my lab, and I try to understand the brain mechanisms that give rise to how people act every day, how they interact, how they make decisions. So, a major goal of health practitioners is to help patients change their behavior in positive ways. So, today I'm going to share with you what we've learned about the type of approaches that are effective in changing behavior and why common strategies often fail. So, if you think about it, when you're trying to change people's behavior, what you're really trying to do is you're trying to change their future, right? You say, eat well today, and you'll be healthy tomorrow. Work hard today, and you'll get a promotion perhaps next year. Don't smoke, or else you will die young. But does warning people of these negative events in the future, does that actually change people's behavior? And what about highlighting how the future can be brighter? Which approach works better? Why and when? So, to answer these questions, I'm going to start by telling you about this really fascinating study that was conducted in a hospital in New York State, and it has to do with handwashing. So, we all know that handwashing is the number one way to spread the disease, and that's especially important in hospitals and in restaurants. So, in a hospital in New York State, a camera was installed to see how often medical staff washed their hands before and after entering a patient's room. Now, the medical staff knew that the camera was introduced. It wasn't a nanny camera situation. And yet, only one in ten medical staff washed their hands before and after entering the patient's room. This was before the pandemic. But then an intervention was introduced, an electronic board that told the medical staff in real time how well they were doing. So, every time they sanitized their hands, the numbers went up, showing them the current shift rate and the weekly rate, and they got a little positive message saying, good shift, well done. And what happened? Compliance raised to almost 90% and stayed there. So, this is such a huge effect that the medical staff wanted to make sure that it was real. So, they replicated it in another division in the hospital. Here, the medical staff started at 30%, so about one free medical staff washed their hands before and after entering the patient's room. And then the intervention was introduced, and again, it went up to 90% and stayed there. So, why does this intervention work so well? And this goes beyond handwashing in hospitals. It's much more general than that. It works well because instead of using the normal approach, what would be the normal approach? To warn the medical staff about the bad things that can happen in the future, the illness, the disease. Instead of doing that, they focus them on progress, on the numbers going up. And they also gave them a positive message saying, well done, good shift. What we have found, and I'll show you the study in a second, is that the brain does a much better job at encoding information that suggests how the future can be brighter relative to information that focuses on the potential decline. And so, what this means is that when we want to frame our message, we need to reframe it in order to highlight the opportunity for progress rather than the decline. So, for example, instead of telling someone, if you don't go to the gym, you will become weaker, which is highlighting the decline, you might say, if you go to the gym, you will then become stronger. You'll get over this injury faster. So, we have shown that people are much more likely to encode these kind of positive messages about the future than negative messages. So, in one study, we brought people into our lab and we asked them to estimate the likelihood that they will encounter all sorts of negative events, different illnesses, accidents. For example, we asked, what is the likelihood that you will suffer from cancer? And 80 different negative events like that. So, people put in their information, their estimates, and then we gave them information about the average likelihood for someone like them to experience this event, in this case, cancer. So, cancer in the population is about 30%, and we changed the number according to people's gender and age and where they're from. And then we asked them again, okay, so after you saw the information, what do you think? What is the likelihood that you will suffer from cancer? And 80 different other events. What we wanted to know is whether people will take the information that we gave them to change their beliefs. And indeed, they did, but mostly when the information was better than what they expected. So, for example, if someone said, I think my likelihood of experiencing cancer is about 50%, and we said, hey, good news. It's only about 30% for someone like you. The next time around, they said, okay, well, maybe it's about 35% or so. But if someone started off saying, I think my likelihood is closer to 10%, and we said, hey, bad news. The average likelihood is closer to 30% for someone like you. The next time around, they said, I still think it's about 11% for me. So, it's not that they didn't update at all, but they update their beliefs much less when the information was worse than what they expected than when the information was better than what they expected. So, we wanted to know what goes on inside the human brain that causes people to relatively discount unexpected negative information. So, we conducted our study again, and this time we recorded people's brain activity using a brain imaging scanner. So, our participants come in. They lie down like that. There's a head coil. On the head coil, there's a little mirror. And on the mirror, they can see everything that we project on a screen behind them. So, we can put in the questions, and they can answer using the button boxes in both hands. And so, what we found is when people got unexpected positive information, quite a few brain regions encoded this information, including this region here called the left inferior frontal gyrus. On the other side of the brain, the right inferior frontal gyrus was encoding unexpected negative information in this task. And it wasn't doing as good a job. And the more optimistic someone was, according to trait questionnaire, the less likely they were to encode this unexpected negative information. So, we were wondering, can we change this? Can we change the way that the brain encodes information by changing activity in the brain directly? And so, there's a way for us to do this. This is my collaborator. And what he's doing is he's passing a small magnetic pulse through the scalp of this participant, and he can direct that to a specific brain region. And by doing that, he's interfering with the activity of that brain region for about half an hour or so. And after that, everything goes back to normal, or so we hope. But doing that half an hour, we gave our participants our task, and let me show you what happened. So, first of all, if I was to test all of you here, this is the average amount that you would learn from unexpected positive and negative information. Then, we interfered with a part of the brain that normally in this task was encoding unexpected negative information, and so the bias became even larger. And when we interfered with the part of the brain that usually in this task encodes positive information, we interfered with it, the bias was eliminated altogether. So, we were quite amazed by this because we're able to eliminate a deep-rooted bias in humans. But of course, we're not going to go around zapping people's brains, and so what this means is that on average, when people see warning signs such as this, they say, yes, smoking kills, but mostly it kills the other guy. But when they see that the housing market is going up, they say, well, my house will definitely rise in price. And so because we tend to take in the unexpected positive information a little bit better than the negative information, then that results in unrealistic expectations of future events. Let's take marriage as an example. So, in the Western world, divorce rates are about 40%, so that means that out of every five couples walking down the aisle, two will end up splitting their assets. But when you ask newlyweds about their own likelihood of divorce, they estimate it at around 0%. And even divorce lawyers, who should really know better, hugely underestimate their own likelihood of divorce. Well, it turns out these optimists are not less likely to divorce, but they are more likely to remarry. In the words of Samuel Johnson, remarriage is a trime of hope over experience. Now, if you're married, statistically speaking, you're more likely to have children, and we all think that our kids will be especially talented. Out of every four people, three said that they were quite optimistic about their future of the family, so that's 75%. But only 30% said that they think that the next generation will be doing better than the present one. And that's a really important point, because people tend to have these optimistic expectations about their own future, the future of their families, but not necessarily about global issues. We are not necessarily optimistic about the ability of our leaders, or where our country is going. We call that private optimism, but public despair. And one reason for this is a sense of control. We have a sense that we are in control over our own future, so we can steer the wheel in the right direction. But we're not necessarily, we don't feel that we're in control over global issues, or even national issues, so we're not as optimistic about those. Let me give you an example. A few weeks after the pandemic started, we asked people what they thought about the virus, and people thought it was quite dangerous. But they also believed that they themselves are much less likely to get the virus than other people from the same age and gender. So these are examples of what we call the optimism bias, which is our tendency to overestimate our likelihood of experiencing positive events, such as professional success, or having talented children, and underestimate the likelihood of negative events, such as accidents and illnesses. And the question is, and we see this in 80% of the population, so in the Western world, in the non-Western world, in females and males in different ages. And the question is, well, is this a good thing, or is this a bad thing? And the answer is yes. So on the positive side, if we have these expectations of a bright future, well, that motivates us, right? If I think I'm going to get that promotion that I put in the effort, if I think I'm going to heal, I'm going to get better, then I put in the effort. If I think, well, this is never going to happen, I'm not going to get the promotion, I'm not going to find love, I'm not going to be able to heal, then I don't do anything. And it becomes a self-fulfilling prophecy, right? My expectations change my actions, and my actions change the outcomes. and also if I have these positive expectations that is very good for my mental health it reduces stress which is also good for my physical health on the negative side if I underestimate my risk I might not take precautionary action so I might not wear a helmet when I bike not put a belt on when I ride I might not go to medical screenings I might not wash my hands in a medical settings so how do we protect optimism in order to enhance motivation and well-being but at the same time ensure that people do not hurt themselves when they underestimate the risk so we saw that one thing in the experiment with a hand-washing was to show people progress right to highlight how they can get to the goal and that was more effective in them encoding the information but there's another reason that that intervention works so well and it is because they gave the medical staff immediate rewards so every time they wash their hands immediately they got a positive message saying well done good shift so we have reason to believe that rewards are more likely to change action than the threat of a punishment and this is because of something known as the approach avoidance principle let me tell you what that is so in order to get the good stuff in life whether it's a chocolate cake or promotion or love we often need to do something we need to act so if I'm thirsty I need to move my hand and drink and so our brain has evolved in this kind of environment where the expectation of reward is associated with action and so when we anticipate something good a ghost signal is activated deep in our brain in our midbrain and it goes all the way to our frontal cortex and it makes action more likely on the other hand to avoid the bad stuff in life whether it's poison or deep waters or untrustworthy people often what we need to do is just not do anything right not always but often that's the best approach and so our brain has evolved in this kind of environment where the expectation of punishment is related to inaction and so when we anticipate something bad and no ghost signal is activated deep in our brain goes all the way to our frontal cortex and inhibits action now of course we're sophisticated creatures we can overcome this but our immediate reaction is to freeze and so you can see why warning the medical staff of the punishment of the bad things that can happen in the future was not as effective at getting them to act to wash their hands as was a very simple reward in the form of positive feedback now there's many studies showing that small material rewards are also very effective at changing people's behavior they're studying showing that giving people just a dollar or a few dollars every time they go to the gym enhances the likelihood they will do so paying them to stop smoking also helps paying them to eat well also helps but also these social positive rewards are very effective as well I mean people go out of their way to just get those little likes on Facebook right they're very very powerful and that really relates to our third principle we're social creatures we want to know what other people are doing we want to do the same we want to do it better in the hospital experiment the medical staff could see how other people were doing they could see the current shift rate and the weekly rate people are more likely to change the behavior when they see the positive action of the majority when they listen about to the opinions of the majority and these other people do not even have to be real people it turns out that even fictional characters have a huge impact on people's actions take for example the movie sideways so sideways is a movie about a wine connoisseur by the name of miles who goes on a trip of Southern California wineries and miles really likes Pinot and he doesn't like Merlot and in some point in the movie he says if anyone orders Merlot I'm leaving I'm not drinking any F Merlot and after the movie came out the sales of Pinot went up by 16 percent and the sales of Merlot went down by 2 percent of Southern California Merlot and this effect continued for about a decade so even fictional characters can change our actions what we have seen is that when people learn about the actions of the majority a part of the brain called the amygdala which is important for emotional arousal is activated and the more it's activated when people learn about the behavior of the majority the more likely they are to subsequently conform to this behavior the British government is using this principle to get people to pay taxes on time so normally when they don't pay taxes on time they get a letter and the letter says how important it is to pay their taxes but that seems not to work very well so then the British government added one sentence and that sentence said nine out of ten people in Britain paid their taxes on time and that one sentence enhanced compliance by 15 percent and is thought to bring to the government 5.6 billion pounds so highlighting the positive actions of others is a cost-effective and easy way to change behavior so before I tell you about the next principle I want to share this anecdote with you so one day I got home and I saw this bill on our fridge and I was wondering why my husband put this bill on our fridge we don't usually do that so looking at the bill what I could see that what the bill was doing was it was trying to get me to be more efficient with my electricity use and how was he doing it social incentives rewards and progress highlighting progress let's look at each one of those we'll start with social incentives so in gray is my use of electricity sorry in blue is my use of electricity in gray is a use of the average neighbor and in green is a use of the most efficient neighbor and what this does it makes me want to get closer to that green guy and here's my reward it's a smiley face and it says good and it makes me want to put this bill of my fridge however I can see it's very small you might not be able to see but above it there's an opportunity to get to smiley faces and to get to great and finally here's my progress over the year and the other thing that the bill did it gave me a sense of control it gave me a sense that I'm in control over my electricity use no one is threatening me no one is telling me what to do it's up to me to become better and that's the next principle that is important in behavioral change which is agency the number one thing that the brain is trying to do at all times it's trying to control its environment in order to gain reward and avoid harm and every time that we feel that we're in control that we have agency that enhances our well-being when we feel that our agency has been taken away from us that causes us anxiety this is one reason that people are quite anxious on planes it's not necessarily that they only fear the worst but also because we have no control on a plane when are we gonna get there what are we gonna eat and that causes people anxiety in that same survey that I told you about that happened just after the pandemic we wanted to see what are the most important factors that maintain people's well-being during the pandemic what was related to their happiness during the pandemic and we found that the number one factor was a sense of control so people who still felt that they had control even in this situation where we were told to stay at home they were the happiness the happiest now other things matter like income but you can see that income only had about half the effect than a sense of control age mattered we're going to talk about age in a second whether we had insurance and how much risk we thought we had but a sense of control was a number one reason one number one factor to keep a sense of well-being so how do we enhance people's agency well one simple way is to give them a choice what we and many other people have found is when people make a choice themselves they become more committed to the routes they selected relative to if someone else gave them that same exact option told them what to do let me give you an example to make it clear so imagine that you have two projects that you can work on one will take you to London and the other one will take you to New York and they're both great and you don't know what to do but you have to choose one and so you say okay fine I'm gonna take New York what we find is that seconds after people make a choice they rationalize their choice and they say it's a good thing that I took New York I mean London is rain rainy and you know New York it's a better project I'm gonna learn more so now they value what they selected more than just a few seconds ago and more than if someone else made the choice for them and when we look at people's brains we see that the part of the brain that is called the reward center in the brain the nucleus accumbens is more activated when people consider the option after they selected it versus a few seconds before they selected it so you want to give people a choice now you don't want to give them too many options you may have heard about the famous jam experiment where people were given an option to choose between 60 different jams some people were so overwhelmed they just left the store empty-handed but two or three option is the optimal number now sometimes patients want you to make a choice for them but the best approach is to say would you like to make the choice or should I make a choice for you right and then they still feel that they have a sense of agency and also it's fine to direct people towards the option that you think best but if they have a sense of agency that gives them a sense of well-being okay so everything that I told you about so far the fact that we're more likely to learn from unexpected positive and negative information that making a choice causes us to reevaluate the options all of these things are true for most individuals in most cases but the rules of the mind are not like the rules of physics we don't have something like gravity that is true in every single situation right it does matter who's a person in front of us what the context is and especially what is their mental state and one thing that matters a lot is how much stress they're under because stress really changes the way that our brain works and it changes the way that we take in information it makes us focus more on the negative information we've seen this in one experiment where we brought people into the lab and we wanted to stress them out these were undergrads and so we told them that they're gonna have to give a surprise talk in front of everyone else we're gonna rate them we're gonna judge them we're gonna videotape them we're gonna put it on YouTube and so our students got quite stressed they told us that they were stressed but we also measured the cortisol and their saliva we measured their skin conductance and all this indicators suggest that yes they were stressed and then we gave them the task that I told you about at the very beginning where they had to estimate their likelihood of experiencing all sorts of negative events accidents illnesses and so on what we found that when they were under stress immediately they started focusing on the negative information and they learned from it perfectly well much better than people did when they were calm and so you can see how this relates to stressful public events such as a market collapse or a terrorist attack or a pandemic under those situations people are quite stressed then they start focusing on negative information from which there is a lot of at the time that can actually cause them to be overly pessimistic and take suboptimal decisions so for example after a market collapse people tend to sell stocks where really what they should be doing is holding on after a terrorist attack people cancel their flights and get in a car where driving is more dangerous than flying and turns out how stress you are relates quite closely to how old you are so on average stress starts quite low and kids and teenagers and it goes up up up up up reaches peak in your midlife and then starts going down again and happiness goes the other way so happiness on average tends to be higher in kids and teenagers and then it goes down down down down down down reaches rock bottom in your midlife but we can all relate but the good news is the good news is that it starts going up again and in fact it stays up until the couple last years of life on average so what happens if you're dealing with someone like this and what you're trying to do is reduce stress enhance well-being enhance optimism well it turns out that one thing that really matters for our happiness is not necessarily what we're doing at the moment but what we believe will be doing later on in a week in a month maybe even next year let me show you a couple of experiments that show this and then say how can we use this right in our interactions in our daily life so this is a really fun experiment that was conducted at Harvard where people who were about to go on vacation were asked every day for a week before vacation how happy they were every day for the week of vacation how happy they were and then every day for the week after vacation how happy they were do you want to guess what the happiest day was it was a day before a vacation right the day before vacation they were still in the office working on the computers but in their mind they were already on vacation and in their mind it was quite wonderful when they went on vacation it was quite good but it wasn't as good as it was in their mind the day before so the anticipation and the imagination of what was to come next made the people the most happy and it turns out that individuals are even willing to pay for such anticipation so this was shown by a study by behavioral economist George Loewenstein who asked people in his University to pick a celebrity so everyone now pick a celebrity and then he said imagine getting a kiss from the celebrity so I hope you chose a good one and then he said how much are you willing to pay if the kiss was to be delivered immediately celebrity will come in and give you a kiss how much are you willing to pay if the kiss was delivered in three hours one day three days one year ten years and what he found was that people were willing to pay the most to get the kiss in three days in other words they were willing to pay in order to wait now no one wanted to wait ten years no one wanted an elderly celebrity but three days was the optimal amount why is that well if you get the kiss now it's over and done with but if you get the kiss in three days that's three days of pure anticipation imagining how is it gonna happen where is it gonna happen and the students wanted that time then he asked him another question he said imagine that you're gonna get a really strong shock electric shock it's gonna be very very very painful but it's not gonna kill you how much would you be willing to pay to avoid the shock if the shock was to delivered immediately in three hours one day three days one year in ten years and what he found was that people were willing to pay the most to avoid a shock that was to be delivered in ten years right why is that well if the shock is delivered now it's over and done with but if the shock is delivered sometime in the future ten years not only do you get the shock but you get ten years of anxiety right and people were willing to pay to avoid that waiting time so now if we take these two things together anticipation of the good stuff makes us happy thinking about the bad stuff causes us anxiety that leads to another really fun finding which is people's favorite day of the week so think about your favorite day of the week whose favorite day of the week is Monday one person okay oh two two people Tuesday anyone for Tuesday can't see anyone Wednesday one for Tuesday Wednesday one for Wednesday Thursday quite a few for Thursday what about Friday yeah most of us for Friday Saturday a lot for Saturday too and what about Sunday we have one maybe two okay so people obviously prefer Friday over Sunday. Now, most of us work on Friday, right? So is it that we prefer being in the office than strolling around in the park on Sunday? No, it is that Friday brings with it the anticipation of the weekend that we have, all the plans that we have, all the fun stuff. Well, Sunday brings with it the anxiety of the work week ahead. So people prefer Friday to Sunday. Okay, so given that we know that anticipation is important for how we're feeling at the moment, this means that we should create what I call anticipatory events. These are events that are gonna happen in the future, but make us happy in the present, right? Book that holiday, make those plans for the weekend, or if it's with a client, have them create these anticipatory events, right? Mark them on the calendar, and those are events that will happen in the future that will make them feel better at the moment. Or with our teams as well at work, create anticipatory events. Okay, so we're not necessarily aware of how our brain works. We're not necessarily aware that normally we learn more from the positive than the negative, but under stress, we start learning from negative information more, that anticipation makes us happy, that a choice changes the way that we perceive our options. But once we know that, that can really be helpful in changing our own behavior and the behavior of others even more so. And so the things that we've talked about is focusing on the progress, what needs to be done to get to the goal, rather than focusing on the decline, that saying, oh, if you do this, you're gonna end up here, right? Because really, what we're trying to say is we wanna end up here, and this is what we need to do. Identify rewards in order to elicit action. Those rewards can be simple, just social feedback. Highlight social incentives, what the majority are doing. Expand agency by giving people a choice. Consider mental state. If people are stressed, they are gonna focus on the negative information. And create anticipatory events to reduce that stress and enhance well-being. And so normally when people hear about all these, they say, well, now that I know about all of these tricks that our brain is playing on me, are they gonna go away, right? If I know about the optimism bias, is it gonna go away? And the answer is no. Being aware of these tricks does not mean that they're gonna go away. You're gonna start seeing them around you all the time, right, other people, optimism bias, other people change their preference after they make a choice. But knowing about these can then help us to direct people's behavior in better ways. And so to make this point, I'm gonna show you another trick that our brain plays on us. It's a visual illusion, but it's gonna make this point. So look at this image and what does it look like? Upside down photo of the singer Adele, right? Nothing unusual. Okay, let's look at this upright. So when we look at it upright, it's clear that something is wrong. But when we look at it upside down, it looks fine. Why is that? Well, our brain has evolved to perceive upright faces because we see hundreds of them, thousands of them all the time. So we're really good at perceiving upright faces, anything that's slightly off, we will detect it. But we don't normally see upside down faces, so our brain hasn't evolved to detect problems in upside down faces, right? If you wanna do this at home, by the way, you cut the eyes and the mouth, you rotate them and you paste them back. But what is the point of this? The point of this is to show you that despite the fact that I explained the illusion to you, I showed it to you, you saw it in front of your eyes and you understand why it is, it hadn't gone away, right? And the same thing is true also for those behavioral biases and cognitive biases that I told you about. Knowing about them is not gonna make them go away, but that knowledge can be used in our daily practice. Okay, so if you want to learn more about any of this, a lot of the studies and information are in this book. And I think now we're gonna have some time for questions online and in the audience. Thank you. So I think Sarah's at the back with the questions. Oh, sorry, there's one, yeah, yes, please, one, it's hard to see. Hi, thanks so much for a great talk and sort of highlighting all of those factors that go into somebody's decision making. Can you talk about the contributions to someone's behavior between those sorts of factors you were describing and then altering default choices? Yeah, okay, so the default bias is a tendency simply to go with what is the default in front of us, right? So it's true with forms, so the well-known example is that if you are, in some countries, you by default donate your organs, and so in those countries, you need to opt out. The default is opting in, but you need to opt out. So in those countries, about 98% of the people don't opt out, right, because the default is opting in. But then in another country, where the opt in is that you don't donate your organs and you actually have to tick, right, to opt in, in those countries, 98% of the people are opting out. So usually we just go ahead with the default for a few reasons, partially because it is the easiest thing to do, right, it's there, we don't need to do anything. Second of all, when something is a default, we assume that's probably the correct state of the world, of the status quo, and in fact, I think in many, many of these strategies that I talked about, it is changing the default, right? Our default is we sit at home and we don't go to the gym, right, we're already sitting there on the sofa, that's kind of the default, right, we need to do something, we need to change. A lot of these are about changing, so it's, we have to go against the default bias, which is why it's so difficult to do, yeah. You're free, I think, is that, yeah. Yes, hi. Hi. I haven't fully formulated my question, but, so I apologize in advance. There may be certain industries with agendas that may not be in good alignment with health promotion. How do we protect ourselves when encountering these nudging events that can be used for both positive and negative? Do you have any frameworks to protect our minds? Yeah, so if I understand your question correctly, these, this knowledge can be used in negative ways, right? It can, it could be used to make us spend money on things that we don't want to spend money. A great example is Uber is using a lot of these, a lot of this knowledge to get their drivers to drive longer and more hours. So for example, they were using like immediate rewards. So if you drive once, like at the end of the day, immediately you can go in and get your money from the regular account. So they were using a lot of these things as well, and not necessarily in a positive way because drivers were actually spending too many hours on the road. I think the only thing that I could say is awareness is helpful, right, because you might be more likely to detect these things. Like for example, when you go into a supermarket or CVS, they usually put next to the counter the things that they want you to kind of buy last minute, right? Now in some, in some supermarkets, these are the healthy things, right? They make an effort to put the healthy frames in front of you just before you pay. But in others, it might be not necessarily very healthy, high sugar, but maybe like a little bit more expensive. So I think awareness can, can be helpful. But I think in general, we always want to have the science and have the research and almost any, any research in science that we could do, people can use it in a mal way or like in a positive way. Thanks. Yes. Number one. Unless. Yeah. Oh, sorry. Yeah. Sorry. With the light, I can't release. Yes. Go ahead. Number two. Hi. Thanks for a great talk. As an undergraduate at the University of California, I did some research for Matthew Rabin on behavioral economics and anchoring biases. We found it in the research I did on a limited basis undergraduate, very difficult to unwind or to counteract this anchoring bias that sometimes presents itself when you're exposed to information in the first instance. Do you have any strategies to counteract this or, or address this kind of a problem? Yeah, so the anchoring bias can be shown in many different contexts and situations. So one famous example is you ask people to write down the last two numbers of their social security number. So let's say it's 82. And then like as if it's unrelated later on, they ask people, oh, how much would you pay for this wine? And there was a correlation where people would pay for the wine, a price that was correlated with their last two security numbers, because that was kind of like what anchored them, what was in their mind. Or for example, if you have two options and you say you really want people to buy option B, but you say option A, actually you see that in restaurants, right? There's a few different items on sale. And maybe one dish is really, really expensive, but it makes the other dish that is not as expensive seem like it's reasonable just because it's next to like this very high one. So how do you counter it? I mean, again, these, okay, one thing to say about all of these bias, they have, most of them evolved over a million and millions of years, sometimes for good reason, and we can talk about what those good reasons are. And so they're very hard to counteract, right? And I think the best thing you could do is be aware of them and think through what are possible negative consequences that can come from them, and then what policy you can put in place. Let me give you an example about a different bias, not the anchoring bias. So for example, the optimism bias. So it's not that we could make the bias go away, just like Adele's photo, right? It still looks fine when it's upside down. We can't make the bias go away because it evolved over many, many, many millions of years. But if we know it, we can think about what is, how is it affecting our life and what can we do about it? And can we put a policy in place in our company or in the government, for example? So the British government did do that. I'll explain to you what they did, because it's a really good example. So they have a book that's called the Green Book with recommendations for project appraisers. And they say there's an optimism bias that causes people to underestimate budgets and underestimate how long projects will take. And they say that these optimism bias has to be corrected in the British government projects. And they have a long PDF to explain how to do that. But the principle is very simple. They look at past similar projects. For example, for the Olympics 2012, they actually used this, where they looked at past Olympics, what the budget estimate was and how long they estimated it will take, what the actual outcome was. They calculated the optimism bias for all these past Olympics, and then they added that to correct their own budget. And so what they did well is they didn't tell people, you have to change the way you think, but rather, okay, that's the way you think, there's likely a bias there, let's counter it because otherwise we will be over budget. And we can do this in our own life. So for example, I might, I know that I'm not always, I don't always put a helmet on when I bike to work. So perhaps because I'm too optimistic. And so I say, well, anytime that I put a helmet on when I get to work, I get a little reward in the form of like a little chocolate, right? And anytime that I don't put a helmet on when I get to work, I need to put money in a charity that I'm against, right? So think about like, what, because of these biases, what, how is it affecting you in a negative way? And then what policy you can put in to counteract them. So just kind of case by case. Thanks. Yes. So you answered the question in part was how you might apply some of these individual traits and biases to organizations as a whole, because that's what we are all out here is this organization. So you did answer that question in part. I was also thinking in terms of that strategy, I don't know if you're familiar with Al Grant's psychology, think again. And the topic is if you have or come across a problem or an issue, the strategy is think twice. You know, don't go with your first instinctive reaction because that may be more susceptible to bias. Yeah. So, okay. Let's start with your first point about how, what can we do as organizations? And there's a lot that we can do with this in our organization level. I can give you two examples. One is in interfacing with clients and the other will be within the organization itself. So there's an insurance company called Vitality. And what they did, they had this system where people would get points every time that they were in the supermarket and bought like healthy food, they would get points. Every time that they went to the gym, they got points. So that's the rewards, right? And not only that, those rewards were online on a website. So if you go into your profile, you can see those scores going up all the time. So that's a progress. And you could also have connections with friends and family. So you can see their rewards versus like where you are, right? So those are the social incentives. So that's one example. And in fact, companies are using these kind of things all the time. Internally, to motivate employees, I mean, what you just did with giving people awards, that's a sort of, you know, give people rewards, you know, and they are more motivated to perform well. And so this is an award that you give after you work for years and years and years. But there are also smaller things on more of like a weekly basis, right, that can happen within an organization, whether it's, you know, a medical organization or a hospital employee of the week and so and things like that. Looking at progress, teams are really, if there's something that you're trying to change within the organization, let's say you want people to start using a new software system or something. Right? And you can have, okay, people get points for their team, not just personal points, for like the department, right? Or in our department, in our university, you get points for like doing green stuff. So our department is really into getting those green points, right, and they win an award every year. And so those kind of things, and choice, like giving employees a choice, in cases where you can work from home or not, perhaps you tell them, well, you can choose, you can have to work like three or four days, you can choose, but also you can choose which days, these are just kind of an example. So give people a sense of control. Another good example, two companies were going to merge, and it caused a lot of stress in those companies. And so what they did is they told, and this is not a solution for everything, but they told employees, come up with a name that we're going to have for this new company. So employees came up with different names, and then everyone voted, right? So that's kind of another strategy of giving people a voice. Thanks. Yes, number three. Hi, thank you so much for your time in preparing this talk. In the interest of learning more, and in the interest of reading extensively on the background of your subjects, what additional references could you provide for myself as a recent graduate of medical school, as well as anybody else in this room or on the videos who are interested in reading more about the subject, other than the green book, which is available? The green book is just, it's just very technical. I wouldn't recommend that. That's just like a technical government book. I think Thinking Fast and Slow is a really good book by Daniel Kahneman, who won the Nobel Prize. So that talks a lot about biases. What other, I mean, if you're just interested in books about the brain in general, I'm sure there's a lot of good ones. I'm not sure which one I would recommend off the top of my mind, but yeah, I think Daniel Kahneman is good. One that I really like is Daniel Gilbert's Stumbling Unhappiness. That's also fun. Yeah. Okay. I think we're out of time. Is that right? Yeah. Thank you.

behavioral change

cognitive biases

decision-making

positive information

positive expectations

framing messages

social incentives

agency

anticipating positive events

individual mental states

anchoring bias