Behavioural Science is a rapidly expanding field and everyday new research is being developed in academia, tested and implemented by practitioners in financial organisations, development agencies, government ‘nudge’ units and more. This interview is part of a series interviewing prominent people in the field. And in today's interview the answers are provided by Angie Fagerlin.
Angie is currently Chair of the Department of Population Health Sciences at University of Utah School of Medicine and Research Scientist, Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS). She studied psychology and literature at Hope College and received her PhD in experimental (cognitive) psychology at Kent State University. Her primary research focus is testing methods for communicating the risks and benefits of treatment to patients (e.g., in decision aids) and testing the use of decision aids in clinical practice. Her current research is testing how decision aids affect patient-physician communication. Her outside interests include exploring the national parks in Utah, skiing with her kids, and traveling with her husband and three sons.
Who or what got you into behavioural science? Everyone always said, “oh, you should become a psychologist!” But when they said that they were thinking of a clinician (clinical psychologist). My course progressed and in my second semester of my freshman year, I took a class called Research Methods in Psychology. I was sneaky – it was one of those classes you're not actually supposed to take until your sophomore year. So somehow I got in - I got special permission to join it. And that was the first time in my life I felt I learned something that I never even knew existed. I mean, how often do you learn about randomized controlled trials or observational study? I thought it was so cool. So I asked Margaret Kamas if I could support their research – but I wasn’t a sophomore yet. I talked my way into it though and got to work with her! And then in my junior year of college Dr. Lorna Hernandez Jarvis came and she taught cognitive psychology. And the class was amazing, but even better, Lorna actually got me a mentor, who worked on advanced directives and end of life decision making. And I really liked – and still like - the idea of taking psychological principles and applying it to a very applied contexts. So that's how I got into that topic. It really shows the role that mentors have in your life; people who are encouraging you to take classes and then to work in their labs even when you're just 19 years old.
So I knew I wanted to do applied psychology. I wanted to take these principles to have an impact on day-to-day life. I knew I wanted to be an academic and I wanted to be a professor, but focusing on applied work. So when I was looking for my real job, my first job out of school, I had some connections to leverage, but I also went through journals to find out who's doing really cool work. And that’s how I got connected to Peter Yuval, who is now at Duke University. Him and George Loewenstein, who was at Carnegie Mellon, were doing all these really cool combinations of economics and health work. And I first talked to George and he told me he wasn’t taking students at the time, but he directed me to Peter. Issue was, I'd never heard of this guy. And he was a physician, not a psychologist. But when I met with him and just started working together - we just started developing all these studies on risk communication; how do you communicate really complex information, especially to patients, especially to people with low literacy and low numeracy skills? Just imagine: you get this new really kind of dramatic diagnosis - you get a breast cancer diagnosis or a prostate cancer diagnosis - and you have a week usually to make this like really huge decision (how to treat it). Especially if you have more advanced cancers. And we know that when people go talk to the doctor they remember very little accurately about what happens in those conversations as it can be traumatizing. We wanted to figure out how do you supplement that one-to-one visit with your physician, so that people can make these decisions right outside the context and remind themselves of the pros and cons and take it to talk to their loved ones. Because the decisions we really focused on don’t have one right decision. For example, with breast cancer you can have a lumpectomy or you can have a mastectomy. It's gonna keep you along alive about the same amount of time, but there's different side effects, different concerns, different things you have to worry about, different recovery periods as well. What is most important to you and what is the best treatment is, is based on kind of those values rather than medical evidence, as they're gonna keep you alive the same amount of time. There’s also no difference in survival between the two. But how do you help people make those decisions and how do you present them so that people will look at it and read it and then remember it and be able to use it in their decision making? That's what I've been doing ever since for about 20 years.
What are you proudest of in terms of achievement and what is it that you would still like to achieve? I had a really proud moment when one of my colleagues kind of slipped a little information into me that one of my letter writers wrote. They had written that my research and the work that I've done with obviously my collaborators, because everything I do is team science and team effort, has fundamentally changed the way people have developed decision making. So I've had an impact. That I really did have an impact on how people think about developing decision aids and how to communicate information better. And that made me really happy.
And what I still want to accomplish? Although I’m really happy to have made an impact already, especially through designing decisions aids and tools, I’d want to know more about how we make these tools actually effective when we get outside of the clinical or the research context. So if I'm paying a brilliant research assistant to stand outside doors to hand the decision aid, I'm gonna hand out a hundred percent of the decisions because my staff is amazing. But you can't pay somebody 50, $60,000 a year to stand outside a door. That's a terrible economy of scale. So how do you get these tools into patient's hands in an easy and cost effective way so that they can use it?
And so the other thing I really want to try to figure out is, how can I develop a strategy to help people who don't have a lot of education, who don't feel like they have a lot of power, who are intimidated by physicians to be able to get the treatment that they want, and not necessarily the treatment the physician thinks is right?
Where do you see the field go in about that amount of time? Are there any like particular developments that you see coming through?
My whole world is in the context of physician and patient decision making. So I've been really trying to think about how to help people make these specific decisions. And one of the things and I don't want to get political, I'm too tired for it, is misinformation. And the lack of trust that we have in science.
I think Covid was really devastating for a lot of aspects of science. We had this huge grant to study how to communicate about pandemics, which ended in 2016 so I was able to take some of those insights and try to translate it into Covid practices, helping people make decisions about Covid behaviours, whether it was masking or hand washing, or ultimately vaccinations. We studied it, ran interventions and nothing helped. We could not move people because it was so based on their beliefs. If you didn't want vaccines, we couldn't change your mind about it.
At first I was really frustrated. Why won't they just listen to the science? Why won't they listen to our CDC? What is going on? But then you saw six months later that the CDC came out and said, “okay, you don't have to mask”, and then the masses were like, “oh, the CDC information is terrible. They're dumb”.
So how do we combat this? One of my mentees did a study recently that showed the most shared articles in medical science were those that were false – because they’re interesting! It has shock value. So what are we gonna do to combat this misinformation?
Is that a frustration of yours or do you have, if you look at the, the field as a whole, your, your frustrations lie somewhere else? I think people are doing great work, but it's kind of like David and Goliath. And we are David. We have our cute little methods and our studies and stuff like that and we're competing with YouTube, Insta, Elon Musk and Twitter and that kind of (mis)information and, and we're, you know, in culture and those are things are really difficult. But in general I’m impressed with the field. I do think we have challenges about reproducibility and making sure we use the utmost rigor. But I think the people who are in the field, at least the ones, again, I'm mostly in a medical school my whole career, but the work I'm reading is done by people who really want to use the best methods to try to solve these problems. It's just really hard to change people in this environment, and that's frustrating. And it's also terrifying. Because it has real impact. We just published a couple studies looking at how much people lied about their Covid behaviours, and a huge amount had lied, for example but having Covid. But they didn't tell someone and then went to hang out with people anyway. Or that they were pretending they were doing all these really good behaviours to keep people safe, but they weren't. And this can kill people.
What kind of advice would you give to someone who's looking to get into the field of behavioural science?
To really do the science properly you need to be a team scientist. So you can't just hang out with, if you're a psychologist, other psychologists. If you have three or four people with different skills and different methodological approaches, I think you can solve the problem better than if you're in your office by yourself trying to figure it out. Really making sure it's not just people who look like you or think like you is a must. The other piece of advice, and this goes for any kind of science, is that you’re going to face a lot of rejection. Your paper's gonna be get rejected, a grant's gonna be rejected. A hypothesis that you spent a year developing a study for is gonna turn out to have a null effect. You’re just gonna get beat up. And I think especially early on, you have more failures than successes. So you have to make sure that you are doing this for a reason. Not just because it looked cool you wanted to be a professor etc. You have to find a reason that explains why your work is important: because I'm gonna change the world in this way, or this is my mission to really understand this so that this can happen. It is important and I'm gonna keep at it because I know I'm going to have an impact.
Do you think there is a specific skill set set that makes for a really good behavioural scientist? I think having an open mind. And second, to make sure you're really rigorous. To be really thoughtful about what your biases are in trying to make sure that they're not creeping into your study design.
The other kind of skill set is team science. Being able to look at things from multiple perspectives, get those people in, and then create a coherent study and a coherent narrative, even if you're taking into all these different perspectives to be able to learn from people with very different perspectives.
If you hadn't found this field and wouldn’t be a behavioural scientist now, what do you think you would have become?
One of the things I wanted to do is write for Sports Illustrated, which back then was a really prestigious sports magazine. I love sports. So that would've been cool. Second, and this is crazy in this day and age, but I would really like to be involved in the government. Be a senator maybe. I want to be able to make impact and if it’s done well, politics can make a huge impact. So yes, I love politics. I love reading about politics. I love thinking about politics.
Do you apply any behavioral sciences to yourself, to your own life?
There was a really kind of a book in the Behavioral Sciences about how to raise your kids. And I've used like knowing some of the heuristics and the biases of trying to play with my kids. Convince them to do things that I want, I mean, to raise them. So I've used it a little bit, probably not as much as I should to be honest. But it also definitely helped me in terms of my own family. When people have medical conditions, I can help get them resources and I can help them think through the process. And unfortunately with aging parents and aging siblings, I've been using that more than I would like to more recently.
Who would you recommend me to interview? Rapid round for really interesting people: Ellen Peters. Noel Brewer. Valerie Reyna. You already interviewed Gerd. And last, Dan Daniel Goldstein. How about that?
Thank you so much for taking the time to answer my questions Angie!
As I said before, this interview is part of a larger series which can also be found here on the blog. Make sure you don't miss any of those, nor any of the upcoming interviews!