The Simple and Non-Obvious Reason that Making Change is Hard—It's Time.

Why do people do what they do? Why do they make the choices that they make? And why are so many of their choices, as manifest in their behaviors, so consistently harmful to their own long term wellbeing? These questions are near and dear to my professional experience. I’m not a therapist or counselor, nor do I professionally study human behavior. I do however, see the consequences of behavior every day. In particular I see the damage that certain choices lead to. Choices made consistently and repeatedly over years and decades. Most curiously, all of these choices are known by everyone, most pointedly by the person making them, to be harmful. In some cases they amount to slow-motion suicide. So, why do they do it? Why do so many insist on making choices that, over time, lead inexorably to the Emergency Department? Which is where they meet me.

You see, I’m an Emergency Physician. I’ve been practicing in a mid-sized hospital on the rural/suburban cusp in the midwest since completing my residency at an urban Level 1 Trauma Center. It’s been over ten years now and every single shift the overwhelming majority of my patients are people who are the principle cause and architect of whatever issue (from mild to life threatening) is troubling them.

For most of that decade on the front lines of illness and injury, I was content to shrug my shoulders and dive into diagnosing and treating whatever vexed my patients. In the Emergency Department (it’s way more than just a room) we deal primarily with the ‘what next’ rather than the ‘why’. Of course thoughts of the ‘why’ always cross my mind. But they rarely cross my lips. At least not beyond a snide comment to a coworker or something muttered under my breath as I enter orders into the computer. You see, it’s rarely productive to discuss the ‘why’ with patients. They know. My saying something about their smoking, obesity, medication non-compliance, alcohol overindulgence, drug abuse, lack of exercise, reckless ladder use, careless discharge of firearms, etc. does nothing to help their situation. It only serves to undermine their belief that I want to help them. Judgement, while perhaps a natural human response, is from a practical point of view not useful.

Modern medicine is pretty amazing. It’s also amazingly limited. I can nudge things in a favorable direction. Nebulizers and steroids for COPD, maybe call respiratory therapy to put them on BIPAP. Heparin and aspirin for a myocardial infarct plus/minus a beta-blocker depending on when they’re scheduled for the cath lab. These interventions help. But by the time I administer those treatments the damage is largely done. It’s not quite just rearranging the deck chairs on a sinking ship, medical interventions do help. But mostly, the ship is going down. It’s just a matter of when. If I meet someone new (outside of work), and I’m feeling cynical, I answer the inevitable, “What do you do?” with, “I delay the inevitable” or, “I deal with bad decisions and their consequences.”

People find those responses either baffling or unprofessionally nihilistic. But they are honest and true. The inevitable outcome of everyone’s choices will come, because all decisions have consequences. Which brings us back to the ‘why’. Why do people insist on making decisions that inevitably shorten their lives and degrade the quality of the life they have?

Recently this question, which had been smoldering in the back of my mind, moved to the front of my brain. During a rare slow night shift, for some reason I can’t recall, I decided to look into some of the literature around procrastination (no I wasn’t ignoring a looming deadline). What I found was fascinating. One of the main themes is that we differentially value rewards based on how close we are to those rewards in time. That is to say, a reward in the short term is prioritized more strongly than a long term reward. This is true even when the reward with the longer time horizon is bigger and more valuable, and when the more immediate indulgence undermines the longer term benefit. There is an obvious evolutionary argument for this tendency—we evolved in a world of scarcity, rather than the current overabundance of the developed world. Seeking immediate rewards was more likely to contribute to our ancestors’ survival than pursuing longer term benefits that would never be realized if they failed to live through the day.

This time biased tendency to prefer the immediate over the long term noted in procrastination (in the case of a student for example: enjoying video games now vs a good grade on a thoroughly prepared term-paper due at the end of the semester) applies to other poor behavioral decisions (enjoying a cigarette now vs the benefits of better health that come with quitting). It turns out that our relationship with time is one of the main determinants of how we make decisions that impact us across time.

While there is obviously a huge interest in human behavior amongst the public, particularly in how to control it—evidenced by the enormous size of the self-help industry and the flurry of books and articles about how to change behaviors and habits—I’ve found little attention to the connection between time and behavior in the lay press. I’m starting this newsletter as on outlet for my own curiosity and in the hope that others find this avenue of inquiry interesting. Even better if they benefit from what I learn.

I’ll be exploring the scientific and lay literature around behavior and habit with a particular focus on how they are impacted by our experience of time. Sometimes this will take the form of my take on a scientific paper or a book in the popular press. In other posts I may synthesize some of what I have learned. I might even include some wild-eyed speculation about what it all means.

I hope others find this interesting. My impression is that this niche of behavioral research is underexposed and has the potential to illuminate a great deal about what we do and why we do it. Perhaps it can even offer strategies for changing our behaviors that are not part of the standard playbook. I suspect there’s a lot that can be useful to people just hiding in plain sight. This area of knowledge is new to me, so we’ll be learning and exploring it together. I don’t claim any authority or special knowledge and I’m going to approach it with humility, respect for the people who did the actual work, and above all else—curiosity.

Changing direction isn’t easy. Making different choices and forming new habits is hard. I find framing these difficulties as a consequence of how we’re impacted by time to be clarifying. Because cultivating the life you want is really a matter of learning to navigate your future.

-TheTimeDoc

PS- Of course it goes without saying that none of what you read here constitutes medical advice. These posts represent an exploration of research and ideas I find interesting, but which falls outside my area of professional expertise or training. I am a doctor, but I don’t play one on the internet.