It is four o’clock in the morning and you are peacefully sleeping in your new high-rise apartment when suddenly an alarm starts blaring. You wake up, startled by the alarm, and then hear an automated voice giving instructions over the speaker system: “Attention! Attention! Attention! An emergency has been reported in the building. Please exit using the stairwell. Do not use the elevator.” Still slightly befuddled from sleep, you dart into action getting dressed and grabbing just the essentials as you quickly evacuate down the stairwell. You meet up with other residents along the way as you hurry to descend 22 stories of seemingly endless stairs. Finally, you reach the bottom and exit into the lobby only to hear the speakers announce: “We have investigated the alarm. It is now safe to resume normal activity.” Confused by what had happened, you overhear one of the residents saying that someone had accidentally set off the smoke alarm again.
A few weeks later, you are woken up in the middle of the night by the same alarm: “Attention! Attention! Attention! An emergency has been reported in the building. Please exit using the stairwell. Do not use the elevator.” You groan in frustration and stare at the ceiling while the announcement repeats, hoping that the source of the alarm will be investigated and that they will cancel the alert quickly. After the third time the announcement repeats, you get up and walk over to the window wondering if you will see any firetrucks or emergency lights to cue you in if this is serious or not. The announcement repeats itself again, so you grudgingly get dressed and grab your essentials for the trek down 22 flights of stairs. You are nearing the third floor and have almost made it to the bottom when you hear a change in the announcement: “We have investigated the alarm. It is now safe to resume normal activity.” Even before the message ends you meet residents heading back up the stairs complaining that someone just set off the smoke alarm. Again.
The next time you are awakened by the alarm — “Attention! Attention! Attention! An emergency has been reported in the building. Please exit using the stairwell. Do not use the elevator.” — you roll over and go back to sleep without another thought to the consequences … You have just experienced habituation.
Habituation in Healthcare
The previous story provides an illustration of habituation, one of the oldest and simplest forms of nonassociative learning. Habituation is defined as “a behavioral response decrement that results from repeated stimulation and that does not involve sensory adaptation/sensory fatigue or motor fatigue”(1) In other words, habituation is a diminishing physiological or emotional response to a frequently repeated stimulus or after prolonged exposure to a given stimulus. Habituation is a process that occurs over time and often is considered a prerequisite to other forms of learning, because it allows individuals to filter out largely irrelevant stimuli and instead focus selectively on only the most important stimuli.(2) Essentially, habituation affects an individual’s tolerance to a given stimulus (i.e., “the intensity of disturbance that an individual tolerates without responding in a defined way”).(3)For instance, those who live in large and heavily populated urban environments may habituate to repeated sudden loud noises (e.g., car backfires, sirens, yelling) when they become used to thinking that these are likely of no immediate consequence to their personal safety.
Under this conceptualization, we are conditioned to ignore a given stimulus when we perceive that there are no resulting consequences. However, what if the consequence is not absent but, instead, only occurs infrequently (e.g., assuming a fire alarm is just a drill or malfunction when there is really a fire)? Alternatively, what if the consequence is cumulative in nature or delayed to the point that we fail to connect it to the stimulus in the moment and do not react until it’s too late (e.g., assuming that the check engine light being on is not serious and then months later the engine blows)? Whereas habituation in most of our everyday lives is normal and can lead to more efficient cognitive processing, we argue that habituation in healthcare can be particularly dangerous if we become too relaxed about being complacent.
The potential consequences of habituation in healthcare are profound for patients, physicians, and the practice. We see the issues discussed in the following sections as quintessential examples of how habituation could be hazardous in healthcare.
Patient Habituation
Patient habituation may be seen in any of the following circumstances:
Habituating to subtly progressive symptoms without perceiving that they could develop into serious medical conditions or life-threatening illnesses (e.g., stomach pain and ulcers, change in a mole and skin cancer).
Diminishing responses to warnings about high-risk behaviors because the potential consequences seem distant or uncertain (e.g., smoking and lung cancer, excessive alcohol use and liver disease, unhealthy diet and heart disease).
Decreased response to long-term prescription use and adaptation to increasingly stronger dosages, despite the potential of leading to addiction or drug abuse.
Disregarding notifications and alerts related to health updates and screenings because of the high volume and distribution through multiple communication channels (e.g., email, text, phone, postal mail), which could hinder preventative care and delay disease detection.
Frequently arriving late to scheduled appointment times because of the expectation that they will be seen and treated regardless of their arrival time.
Physician Habituation
Physicians may exhibit habituation in any of the following ways:
Diminishing responses to sleep deprivation and signs of stress (e.g., fatigue, headaches, blurred eyesight), which could lead to poor job performance (e.g., erroneous or inferior diagnoses) and personal mental health concerns (e.g., anxiety, depression, burnout).
Ignoring double-booking of appointments, despite concerns related to potential fluctuations in the time and complexity involved with each encounter.
Delaying the completion of clinical documentation because of persistent overscheduling and disregarding the potential negative downstream impacts (e.g., coding/Health Information Management, billing, follow-up scheduling).
Practice Habituation
Negative effects of habituation in the running of the practice may include the following:
Habituating to poor workplace conditions (e.g., offensive smells in the office/clinic, endlessly ringing phones, stressful environment), faulty equipment (e.g., antiquated or malfunctioning computers and tech systems), or ineffective administrative processes (e.g., inefficient work protocols and tasks) that could adversely impact the care and treatment of both patients and staff.
Diminishing responses to and acceptance of employees arriving late for work despite the potential to create unnecessary delays or bottlenecks in workflow and patient care.
Failure to pay attention to obtain prior authorization approval before scheduling procedures without perceiving that this could delay or prevent the payer from reimbursing the practice for services rendered.
Becoming complacent with inconsistent policies and enforcement of point-of-service copay collection despite downstream consequences such as delays to self-pay cash collection and expenditures for sending statements and deploying additional customer service resources.
Sensitization as a Solution
Fortunately, seminal work at the intersection of neurobiology and psychology may provide an answer to the problem of habituation. According to dual-process theory, “two hypothetical processes, one decremental (habituation) and one incremental (sensitization), are assumed to develop independently in the central nervous system and interact to yield the final behavioral outcome.”(4) Response sensitization is the theoretical antithesis of habituation, whereby a repeated stimulus often generates increased (as opposed to decreased) responsiveness. Sensitization, or increased responsiveness, is likely to occur when a stimulus produces particularly strong and salient reinforcement value, either positive or negative. This means that although habituation is more likely to happen in the absence of an observed consequence, sensitization should result when there is a new, significant, or obvious reinforcement.
Thus, response sensitization could be used to combat habituation in healthcare by drawing attention to, and increasing the salience of, potential reinforcements. Marketing communications techniques could be used to shine a light on consequences that might otherwise go unnoticed. We recommend some sensitization approaches to help mitigate these effects by proposing potentially salient reinforcements (both positive and negative) to combat the hazards of habituation in healthcare.
Patient Sensitization
Approaches that may help minimize patient habituation include the following:
Charge higher premiums or deductibles for patients with high-risk behaviors (e.g., smoking) and those who do not complete required preventative screenings (e.g., annual physicals and wellness check-ups).
Provide reduced premiums or deductibles for patients with healthy lifestyle behaviors (e.g., nutritional planning and tracking, gym memberships, logging physical activity) and those who complete required preventative screenings (e.g., annual physicals and wellness check-ups).
Improve both provider and patient education about alternative treatments and diversion methods for pain management, such as multifaceted treatment approaches rather than prescription-only methods (e.g., combinations of physical therapy, psychotherapy, and non-addictive prescription treatments).
Consider eliminating or significantly reducing the number of notifications and alerts sent to patients and sending only those of the highest importance.
Use promotional campaigns as incentives for more patients to enroll in a patient portal (e.g., MyChart) to serve as a central repository for all their important medical and billing information, reducing the need for multiple communication channels (e.g., email, text, phone, postal mail) that can confuse or overwhelm patients with duplicate information.
Reward patients (e.g., monthly raffle entry, new patient gift/branded merchandise, priority scheduling privileges) who complete their patient questionnaires, demographics, and insurance information online before coming to the office for their appointments.
Implement a policy requiring the mandatory rescheduling of all patients arriving late for their appointments, or charge patients a fee for late and missed appointments with dismissal from the clinic after exceeding a certain number of violations.
Physician Sensitization
Strategies to overcome physician habituation might include the following:
Create policies and procedures that normalize mental wellness programs for physicians and allow for more breaks or time off without the pressure of potential repercussions.
Set fixed rules for maximum appointment scheduling and build mandatory office hours into daily schedules to enable physicians to take breaks from seeing patients and be provided with additional time to complete clinical documentation.
Establish enforcement penalties (e.g., probationary periods, corrective action, charges for delayed closures to patient medical records and submitting codes for visits and procedures performed) to prompt timely encounter closure.
Provide incentives (e.g., increased compensation) for physicians who meet and maintain 100% closed encounter rates within 24 hours of the time of service.
Practice Sensitization
Members of the practice can help overcome habituation in the following ways:
Collect survey data from both patients and staff regarding the clinic environment and their personal experiences, and reward practices that receive high scores (e.g., increased compensation, catered lunches, celebratory parties).
Design a formal rewards program (e.g., drawings for prizes, gift certificates, additional PTO) for staff members who share their ideas about how to improve work processes or patient experiences and recognize those whose ideas lead to marked improvements.
Develop a more expedited prior authorization request process (e.g., real-time authorizations via electronic applications instead of paper requests) and establish set protocols requiring the rescheduling of appointments if authorization is still pending or is declined within 24 hours before the date of service.
Reward staff for implementing a recall list for patients requiring follow-up appointments, and for using the patient waiting list to fill cancelled or no-show appointments.
Create standard scripting for copay collection, generate self-pay estimates, and require payment at the point-of-service for the patient to be seen.
Bottom line: With a greater understanding of habituation, healthcare providers can refine their approaches to patient care, improve workflow, enhance patient satisfaction, and, ultimately, improve clinical outcomes. We have explained the phenomenon of habituation in healthcare, provided some helpful guidance for mitigating these consequences through response sensitization, and shown that further research investigating habituation in medical practices will ultimately advance the quality and efficiency of healthcare delivery.
References
Rankin CH, Abrams T, Barry RJ, et al. Habituation revisited: An updated and revised description of the behavioral characteristics of habituation. Neurobiology of Learning and Memory. 2009;92(2):135-138. https://doi.org/10.1016/j.nlm.2008.09.012
Thompson RF, Spencer WA. Habituation: a model phenomenon for the study of neuronal substrates of behavior. Psychological Review. 1966;73(1):16. https://doi.org/10.1037/h0022681
Blumstein DT. Habituation and sensitization: new thoughts about old ideas. Animal Behaviour. 2016;120:255-262. https://doi.org/10.1016/j.anbehav.2016.05.012
Groves PM, Thompson RF. Habituation: a dual-process theory. Psychological Review. 1970;77(5):419. https://doi.org/10.1037/h0029810