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Healthcare Provider Behavior: Key to sustainable health systems during crisis


The 21st century’s first pandemic has exposed gaps in the entire healthcare system, be it the upstream functions surrounding stocks and supplies or the downstream service delivery. Every stakeholder within the healthcare system is grappling to respond as fast and as best as they can. Healthcare service providers which include physicians, community workers, clinics, and hospitals have formed the frontline fighting the battle. But over years, be it Ebola, MDR-TB, Zika, though there have been much understanding and research on end-user or healthcare-seeking behavior, the realm of provider behavior has been kept away from the spotlight. But more grounding of provider behaviors now seems to be critical in building resilient long-term sustainable solutions in dealing with pandemics.



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For healthcare providers, a pandemic generates a landscape that is continuously changing. Some of the key factors that contribute to this dynamism are:

1. High Volume Rapid Decision Making

In high-risk areas, healthcare providers are barraged with patients with the COVID19 in addition to other medical conditions. Multiple decisions like optimizing critical medical infrastructure, diagnosis, administering patient-specific treatments, etc. need to be taken under extreme time pressures.

2. Dealing with complex interdependencies

Health providers work within a complicated ecosystem just like any other industry having both upstream and downstream functions. But the decisions made within this system impacts human lives. Pandemic crisis creates complicated functional interdependencies between service delivery, supply chain and human resource, balancing hospital policy with government directives, and catering to political, public health, and business objectives.

3. Negative feedback for positive action

Health providers find it difficult to appraise their actions since at an aggregate level there is an increasing trend in casualties, hospitalizations and infections despite their interventions and effort

4. Risk of association stigma

There is an increased perception that since health providers cater to infected patients they are more susceptible to infection themselves. Such negative perceptions can increase the risk of anticipated social isolation among physicians, community workers, and public health officials.

5. Fatigue

Increase in workload and hectic work hours, together with additional worries surrounding family well-being and risk of transmitting infection within the household leads to a debilitating fatigue

6. Uncertain probabilities

The work plans are being carried under uncertain therapeutic regimens for a novel infection, and a continuously changing treatment protocol


7. Trauma and Anxiety

Frontline workers are experiencing workload and deaths beyond the threshold levels they have been trained for. Together with this, the frontline workers may be susceptible to anxiety since there is currently no "perfect" solution available, leading to trauma and anxiety.


What Might be Happening


Like any other sector, the health sector shares the vulnerabilities within human decision making and risk that arise from them.


1. Loss Frame

Loss is more significant and salient than an equivalent gain. Healthcare providers can react differently working under conditions where decisions are framed as a probability of loss of life than the probability to save a life.

2. Information preferences under ambiguity

Ambiguity around policy, scientific evidence, and medical regimen is one that is unpleasant one where the expected utility is low. In a situation marked with risk under ambiguity, there will be bias towards information sources that reduce the unpleasantness.

3. Affect Heuristic

Individuals can be affected by the emotional state while making decisions. Negative environmental conditions surrounding can create a negative emotional premise that elicits low benefits and high-risk perception. Such differential estimation of reality can impact health-providers who become risk-averse and might require longer time frames for the response.

4. Decoy Effect

The presence of a large set of asymmetrical information can alter existing preferences because the regular infusion of new information and data which changes the lens through which the preferences are seen.

5. Ignoring Negative Evidence

Physicians and clinical care staff may find it difficult to use “negative evidence” for treatments and can be susceptible to using a treatment that has a lesser probability of success but aligned to the objective of minimizing COVID19 causalities even though there is evidence of harmful side-effects.

6. Actuarial vs Qualitative Data

Physicians place a high value on their clinical judgments. Hence in a situation where there is high involvement of data modeling to assess risk, classification, categorization, and diagnosis they might still get anchored to qualitative and categorical observables that have worked for them.

7. Frugal and Fast Decisions

In this type of decision analysis health providers search, stop, and decide with each stage having defined rules. But in pandemics where the priors of the disease are not certain or established, adopting rule-based assessment can increase risk and delay in delivery because of the absence of any robust rules.

8. Homeostasis or Risk Compensation

Since providers follow strict protocols for safety within the treatment or ward premises, there might be a tendency to lower their guard outside like the canteen and be susceptible to taking risky behavior such as not adhering to social distancing.


What is likely to work


Increasing Emotional Well-Being


1. Psychological Buffers

  • Providing buffers like social support/counseling or family time can help create the necessary shock absorbers for health providers.

2. Increase resiliency

  • Programs or activities that can facilitate adequate recovery for healthcare workers can support better sustenance during the crisis.

3. Distress Outlet

  • Giving a platform for healthcare workers to voice their feelings, and share experiences can reduce the feeling of isolation and increase the "we are in this together" feeling.


Facilitating Decision- Making


1. Information Decoding

  • Making sure the information is decoded and presented to assist in decision making. This can be in the form of a Yes-No decision tree, or Equivalence frames where the logically equivalent but easy to understand phrases are laid out, or emphasis frames that assist in less cognitive efforts.

2. Creating Fraternity Reference Points

  • Using key influencers or social norms while delivering the information can help provide the necessary credibility and assist in faster decision-making

3. Minimize cognitive effort

  • Decrease physical effort in adhering to safety protocols like setting sanitizer stations at eye level, making disposal of PPEs convenient, or reducing cognitive efforts using pre-selected defaults

4. Change Consequences

  • Ensuring a range of micro-incentives for decisions and efforts to overcome the constant loss frame within which the health providers work during a pandemic, like a daily participation reward


Managing and Coping with Risk


1. Reducing perceived risk around consequences

  • Creating coping mechanisms for providers to reduce the perceived risk can help in demolishing high-risk averseness, and lack of control. Regular positive feedbacks can reduce the perceived "constant loss" feeling

2. Facilitate Commitment

  • Bridge the intention-action gap by providing reminders and calling out incidences revolving around self-control problems, inattention, and optimism bias. For instance, projecting daily images of violations of social distancing and other safety protocols.

3. Coping with deaths

  • Rotating health care workers from high-stress to low-stress functions that helps minimize continued exposure to the deceased, can help reduce the constant unpleasantness.


What is being done


1. Providing platforms that aim to generate social support for frontline workers, by involving the neighborhoods they live in and who provide 24*7 support to HCWs and their families.


2. Community-led appreciation campaign where neighborhoods applaud healthcare providers for their efforts.


3. Exclusive mental support helplines which provide live online support to manage the mental health of the health professionals as well as provide a virtual platform for the professionals to seek immediate support.


4. Reducing anticipated loss by issuing exclusive insurance covers for doctors/frontline workers and their families.


5. Conducting "compassion fatigue" training, wellness seminars and activities to help frontline healthcare workers manage stress



References


https://sbccimplementationkits.org/provider-behavior-change/learn-about-provider-behavior-change-communication/types-of-providers/


https://www.nber.org/papers/w10881.pdf


https://www.sciencedirect.com/science/article/pii/S1201971212011794


Elstein, A. (1976). Clinical judgment: psychological research and medical practice. Science, 194(4266), 696–700. 


Blumenthal-Barby, J. S., & Krieger, H. (2014). Cognitive Biases and Heuristics in Medical Decision Making. Medical Decision Making, 35(4), 539–557.  


Dawson, N. V., & Arkes, H. R. (1987). Systematic errors in medical decision making: Journal of General Internal Medicine, 2(3), 183–187. 


https://www.uchicagomedicine.org/forefront/coronavirus-disease-covid-19/uchicago-medicine-resiliency-program-helps-the-helpers-during-covid-pandemic


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