Applied Behavior Science for Health and Happiness
The Law of Unintended Consequences
The Law of Unintended Consequences

The Law of Unintended Consequences

The Law of Unintended ConsequencesUnintended consequences are sometimes happy surprises, sometimes sad disappointments, and sometimes just totally weird. I’m interested in unintended consequences in terms of thinking of organizational systems. Often, unintended consequences pop up when someone focuses only on one aspect of a larger system when making changes. They reveal dynamics that might otherwise be hard to see or understand.

Here are a couple of interesting unintended consequences:

Unintended consequences on the gridiron

Fantasy football must have seemed like a golden opportunity to the NFL when it first became a big thing. Although fantasy football–where you create a personal roster of players across all teams and accrue points based on their individual performance–has been around since the 1960s, it was being able to run leagues through Internet software in the late 1990s that brought it to the mainstream.

From the NFL perspective, fantasy football seemed like something worth encouraging. People would now watch more games than just their favorite teams’, and would be more interested in other related media properties to educate themselves about players and strategies. As recently as 2011, some research has suggested that people who play fantasy football do attend more live games and watch more televised games than people who don’t.

However, NFL game attendance has been in decline since 2007, and some parties blame fantasy football. Serious fantasy football players may prefer to watch games at home or in a bar, where they can receive updates on multiple games and players at once rather than focusing on just two teams (a fact acknowledged by the NFL and DirecTV with their fantasy-specific shows) . Stadiums may need to adjust how they use multimedia in order to attract fantasy players to live games rather than televised alternatives.

Additionally, if you have ever watched football with a dedicated fantasy football player, you know how fantasy has changed the fan experience. Rather than rooting unequivocally for a certain team, now fans attend to individual players’ performances. The excitement of a touchdown for your team may be tempered by disappointment that the person catching it isn’t on your fantasy roster (or, worse, that he is and you have him benched this week).

Fantasy football was intended to enhance the fan experience of watching professional football, and it undoubtedly has. But as technology has evolved to make real-time updates on games around the country available, fantasy has also changed the way people consume game media and how they respond emotionally to the events on the field. The former change has implications for NFL stadium revenue, and was surely not intended by the League’s attempts to promote fantasy play.

Unintended consequences: Rush hour edition

Large cities with too much auto congestion would love a way to reduce the number of cars entering their streets each day. Shanghai requires drivers to have an expensive and limited-in-number license plate to drive within the city, which has resulted in auctions for the plates and establishment of city driving as a class difference. San Francisco increased tolls during peak traffic hours on the Bay Bridge coming into the city–and saw traffic increases anyway.

Another unintended consequence occurs with congestion-based pricing such as the scheme implemented at the Bay Bridge. Drivers wishing to avoid higher costs may work to pass through the tolls as close as possible to the time the lower rate goes into effect. This means you see drivers moving well below the speed limit or idling on the side of a speedway not intended to accommodate vehicles in the shoulders. This behavior creates a new source of congestion as well as raises the risk of accidents. Unintended consequences!

Traffic management seems to be an area rife with unintended consequences. Another interesting one? Widening roads to accommodate more cars encourages more people to drive, negating any extra roadway space earned.

Unintended consequences in the hospital

As part of health care reform, hospitals are required to measure their efficacy using a patient survey called HCAHPS. Hospitals’ and doctors’ scores on this survey have implications for how they are reimbursed by health plans, so getting a high score is important.

Pain management is one of the areas assessed by the HCAHPS survey, and as such, has become a priority for providers and hospitals who are now judged on their ability to help patients control pain. Here is an actual question from the HCAHPS survey, given to patients when they leave the hospital:

During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

Imagine you are a doctor with a hospitalized patient struggling with post-operative pain. How do you decide to treat him, knowing he will be answering this question when he leaves and his responses may impact your job?

Dr. James Merlino notes, a focus on earning positive scores from patients on questions like this one have led to a heavier reliance on medication as opposed to non-prescription pain management solutions. Merlino says 74% of Ohio physicians agree that doctors now over-prescribe pain medications specifically from a focus on getting a good score on this and similar HCAHPs questions. Something tells me that’s not what the Centers for Medicaid and Medicare had in mind when they began their quest to have standard measurements of hospital performance. In the long term, it’s often more effective to treat pain using not just medication but also mental coping techniques, but those don’t help with the short term HCAHPS measurement. Doctors are caught between practicing the best medicine and earning top patient satisfaction scores.

Systems-Based Thinking

Unintended consequences will probably always happen (and as I mentioned, sometimes they’re good; Post-Its were an accidental invention!). That said, a systems-based approach, where you consider not just the immediate impact of a change you’re thinking of making but also the ripples it might have in the broader system, can help minimize them. This is also why it’s good to collaborate with cross-functional teams. A technologist, a psychologist, and a physician (respectively) would have predicted some of the unintended consequences in the three examples I’ve given here (I’m actually biased to think a psychologist could have helped in all three cases). It means more planning, but a systems-based approach hopefully also means less adjustment to unintended consequences.

What are some unintended consequences you’ve seen? What caused them?