Commitment Pledges Gone Wrong

June 18th, 2017

Obligatory disclaimer: All views are mine and do not necessarily represent the views of my current or former employers.


A commitment pledge is a behavior change device in which an individual makes a positive affirmation to adopt a set of behaviors or beliefs.


Pledges work in theory because people generally dislike holding inconsistent views (i.e., dissonance). High-salience pledges (e.g., a signed pledge hanging on a wall) should present more opportunities for dissonance and therefore be more effective. In addition, committing to public pledges might be even more effective because of the added effects of social pressure.


As a result of these behavioral dynamics, commitment pledges can play a valuable role in behavior change. Over the past few years, pledges have become increasingly common in primary care. Many organizations now ask primary care providers to sign commitments to avoid unnecessary antibiotics, prescribe opioids responsibly, and to deliver an excellent service experience.


Pledges garner a lot of attention sometimes yield positive results. However, I think pledges distract from much bigger opportunities to empower PCPs to deliver better care.


The problem with pledges is that they amp up motivation without increasing ability. To reduce unnecessary antibiotic prescribing, we should use a pledge if we think that PCPs are skilled at convincing patients with colds that antibiotics are not helpful, but simply don’t care enough about antimicrobial resistance to have those conversations.


This strikes me as odd. When I talk to outlier clinicians, I almost always find that they care deeply about delivering the highest quality care; they just don’t know how to confidently and persuasively talk a demanding patient out of a z-pak. Asking these clinicians to take a pledge will likely lead to blunt interactions that turn trust-building and educational opportunities into a relationship-harming events. On the other hand, the PCPs who have better antibiotic prescribing rates and better patient satisfaction scores have often cultivated an interpersonal style that instills trust and makes patients feel heard. Subtle differences in language, tone, and physical presence separate the PCP you trust from the one you second-guess.


Instead of creating pledges, we should extract tacit knowledge from high performing clinicians and teach these skills as best practices. Empowering PCPs to deliver relationship-based care will be far more effective than leveraging flashy tactics from behavioral science.