“Buy on apples, sell on cheese” is an old proverb among wine merchants. Taking a bite of an apple before tasting wine makes it easier to detect flaws in the wine, and the buyer who does so will not as easily make the mistake of paying more than the wine is worth. Cheese, on the other hand, pairs well with wine and enhances its flavor, so a seller who offers cheese may command a higher price for the wine (and may even deserve it, if the wine is intended to be drunk with cheese).

The proverb captures important psychological nuances of choice. The same product – a bottle of wine or a risky medical procedure – may be perceived differently depending on its context, and it is often possible to arrange the context to influence a choice while still maintaining the decision maker’s autonomy.

The practice of structuring choices is called “choice architecture” in a brilliant and important new book, Nudge: Improving Decisions About Health, Wealth, and Happiness, by University of Chicago Distinguished Professors Richard Thaler (Business) and Cass Sunstein (Law). Nudge lays out the groundwork for the science of choice architecture in investing, insurance, health care delivery, and other areas, and argues for a “libertarian paternalism” in which choices are structured to make it more likely that a decision maker will select what is considered the most beneficial option, without impairing the ability to decision makers to select other options. For example, making enrollment in 401(k) plans automatic for new employees, with a form for opting out, is likely to result in greater retirement savings than an opt-in system, without limiting anyone’s freedom to choose.

Thaler and Sunstein apply the principles of choice architecture to a few problems in health care (How could Medicare part D be improved? How can organ donation rates be increased? Why shouldn’t patients be allowed to waive their right to sue for medical negligence in return for cheaper health care?) But the concepts in the book go beyond their specific examples and could prove very useful to practicing clinicians, who, they note, are often in the position of being choice architects for their patients.

Their principles of choice architecture (paraphrased by me and focused on physicians helping patients make decisions) are:

• Make sure incentives are aligned with desired outcomes
• Help patients map outcomes of different alternatives into formats they can understand (a major focus of Medical Decision Making as well)
• Arrange default options to favor better health. Pediatricians have done a good job of making vaccination a default option.
• Provide timely and relevant feedback about choices and outcomes. A patient seeking to lose weight needs to experience feedback in the form of measurable progress soon enough that they are not discouraged.
• Expect error and develop systems to prevent, detect, and minimize it. For example, pill cases and inhalers with dosage counters are simple and valuable ways to reduce the frequent errors people make in remembering medication. Psychological research provides direction as to what kinds of errors are to be expected when people are making decisions.
• Structure complex choices to reduce the difficulty of making good decisions. In many ways, that’s what medical decision making — and Medical Decision Making — is about.

I highly recommend Nudge. It’s a great read, and has the potential to change the way you think about clinical practice. Here’s a link to the Nudge web site and blog for more information.