Tiny Nudges

A few years ago, out of the blue, I received two written complaints about my practice. Generally, I have a complaint rate of about one in every four thousand consultations. It doesn’t seem like a large amount, and what’s important is that neither of these complaints were about misdiagnosis, medical error, or clinical mistakes.

The most common reason people complain at all is that there’s either a breakdown of communication, they don’t get what they want, or as in the case of these two complaints, I was guilty of pushing a person too far.

There’s an old analogy. You can help people by pointing them in the right direction. You can push them in the right direction. Or you can help people get back up after they’ve fallen down. In medicine, we do all three. We help people. We give direction and advice. For some, we pick them back up and get them back on their feet after illness.

The question I often ask myself is this: how hard do you push a person?

When does a gentle nudge go too far? My problem is that I can gauge wrong. I nudge at the wrong time, or I nudge too hard. My only defence is that I want to help people. It’s why I do what I do. It’s my job. It’s what I’m passionate about. But I’m only human, and sometimes I make mistakes. I’m also guilty of taking people at their word and still believing them when they say they want help, which is, after all, why most people come to the doctor’s in the first place.

The Push Too Far

I’m one hundred percent guilty of pushing some people a bit too far. I bring up the elephant in the room. I help people take their heads out of the sand. I nudge people out of their comfort zone, and I believe that if I didn’t do this, I wouldn’t be doing my job properly. In fact, I may be guilty of collusion if I didn’t do this.

A good proportion of the written complaints I’ve had over the last ten years are from people who’ve pushed back. Pushed back against me. Pushed themselves back into their problem state. Some people are prepared to do anything to get their problem back, because often it’s easier to have a problem than put in the effort to get rid of it.

Let me explain what I mean by this.

The Threshold

I believe that for some people to change, they first need to decide within themselves that they need to change. To do this, they need to cross what some therapists call a threshold.

This threshold refers to the line that needs to be crossed mentally for change to take place. In coaching terms, if a client hasn’t reached or won’t commit to breaching their threshold, they won’t follow through. They won’t take the action they need to make.

A threshold can be crossed by taking the first step. A small next step. A real-life practical step like agreeing to surgery, taking a medication, attending an AA meeting, or even just making an internal mental decision to let go of something and move on.

It’s that moment when you stop thinking about change and start doing change. When you stop planning and start acting. When you stop talking and start walking.

Why Push At All?

You might be saying, “Why push? Isn’t it down to the autonomy of the individual to make their own decisions?” Well, yes, it is. But in the real world, waiting for someone to decide to stop smoking after they’re on long-term oxygen, or after their diagnosis of lung cancer, is almost always too late. Because in medicine, sometimes people don’t get up after a fall.

That’s why I push, even knowing that for some it’s too hard, or too soon, and that a share of the complaints I’ve had over the years are a direct result of it. But I push anyway, because not pushing means watching people slowly destroy themselves while assuring me they’re going to change, just not yet, not today, maybe next week, maybe next month, maybe never.

Some people have conditions that modern medicine can easily fix if they’re willing to take the treatment. Sometimes the fix isn’t easy. Not everything can be fixed with tablets. Sometimes a patient can only be helped as much as they want to help themselves. The solution, the fix, the treatment is in their hands.

The right mindset. The right habits. The right attitude. A better lifestyle. A better diet. Better decisions. These things can prevent a high proportion of society’s ills. A person has the potential to make a real change in their life. My work is about how people can reach their potential and also how they get stuck in their problem state.

The Easy Route

I know colleagues who throw medicines at patients just to get them out of the room. Who rotate a patient through half a dozen antidepressants when the real answer is to stay on the one they’re on, start engaging in life again, and do something practical about the situation they’re in.

Some people push back because life outside of their problem is more difficult. Their comfort zone is to stay inside their problem state. The empathy. The primary gain (the direct benefit of having the problem). The secondary gain (what they get from others because of it). Their identity. Their income. Their relationships with others. All built on one thing: their problem.

I ask myself, do I take the easy route travelled by some of my colleagues? Because there’s a time when being too empathic, overmedicating, over testing, and needlessly referring patients is not going to get you anywhere except into a dysfunctional doctor-patient relationship and a waiting room stretched thin, with less time and effort left over for the patients who really need my help.

Why I Keep Pushing

My hit rate, where I’ve helped others, far exceeds my rate of complaints. The reason I keep nudging, I keep pushing people towards their threshold, towards the point where change happens, is that the difference that will make the difference for that person is taking action to help themselves.

The question for me is, do I roll over to avoid complaints and the almighty monster of the NHS complaints process? Do I smile and give the patient everything they want? Do I make my life easier as I lose heart and drift into early retirement? Or do I give the patient a gentle push in the right direction?

In 2017, Richard Thaler won the Nobel Memorial Prize in Economic Sciences for his contributions to behavioural economics, including the concept of the ‘nudge’: the idea that small prompts can lead to significant behavioural change without restricting freedom of choice. I’ll continue to nudge with my patients, and I’ll nudge you with this article too, because each of these short articles is a nudge in the right direction.

For some, it could be the nudge that nudges them towards that threshold. But be warned of the threshold. It’s a point of no return. For some, it’s where life starts again, where things start to happen. For some, it’s a push too far.

The Nudge You Need

This article is a nudge. This whole hub is a series of nudges. I’m not going to force you to change. I can’t. Nobody can. But I can point out the path. I can show you the direction. I can give you a gentle push and see if you’re ready to take that first step across the threshold.

Some of you will read this and feel annoyed. Defensive. Resistant. That’s fine. That’s your right. Push back if you want. Write me a complaint in your head. Tell yourself I don’t understand your situation, your circumstances, your unique challenges that make change impossible for you right now.

Or you could recognise that the resistance you’re feeling is exactly what I’m talking about. The discomfort of being nudged toward that threshold. The fear of crossing it. The part of you that wants to stay in the problem state because at least it’s familiar.

The Point of No Return

The threshold is a point of no return. Once you cross it, you can’t go back. Not really. You can’t unknow what you know. You can’t unsee what you’ve seen. You can’t un-feel the possibility of something different.

For some people, crossing that threshold is where life starts again. Where things start to happen. Where change becomes not just possible but inevitable. For others, it’s terrifying. It’s too much. It’s a push too far, and they’ll do anything, including sabotaging their own progress, to get back to the safe side of that line.

I’ve seen both. I’ve pushed people across that threshold and watched them transform their lives. I’ve also pushed people who weren’t ready, watched them panic, and retreat back into their problem state with even more determination to stay there.

The art is knowing which is which. When to push. When to wait. When to nudge gently. When to shove hard. I don’t always get it right. Nobody does. But I keep trying because the alternative is worse.

Your Choice

So here’s your nudge. You’re reading this because something in your life isn’t working. Something needs to change. You know it. I know it. The question is whether you’re ready to cross that threshold or whether you’re going to push back, retreat to your comfort zone, and convince yourself that change can wait.

It can’t. It really can’t. Life is happening now. Time is passing. Every day you stay on this side of the threshold is a day you’re not living the life you could be living. Every excuse you make is another brick in the wall between you and the person you’re supposed to become.

I’m giving you a nudge. A gentle push. Take it or leave it. Cross the threshold or don’t. But don’t pretend you weren’t warned. Don’t pretend you didn’t have the opportunity. Don’t look back in five years, ten years, twenty years and wonder what might have been if you’d just taken that first step when you had the chance.

The nudge is here. The threshold is in front of you. The choice is yours.

Further reading

• Thaler, R. H., & Sunstein, C. R. (2008). Nudge: Improving Decisions About Health, Wealth, and Happiness. Yale University Press.
• Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking. Journal of Consulting and Clinical Psychology, 51(3), 390-395.
• Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing (3rd ed.). Guilford Press.
• Kahneman, D. (2011). Thinking, Fast and Slow. Farrar, Straus and Giroux.
• Duhigg, C. (2012). The Power of Habit. Random House.
• Heath, C., & Heath, D. (2010). Switch: How to Change Things When Change Is Hard. Broadway Books.
• Pressfield, S. (2002). The War of Art. Black Irish Entertainment.
• Clear, J. (2018). Atomic Habits. Avery.
• Fogg, B. J. (2019). Tiny Habits. Houghton Mifflin Harcourt.
• Rogers, C. R. (1961). On Becoming a Person. Houghton Mifflin.