HealthOctober 20, 2017

So a neuroscientist, a computer hacker and a rabbi walk into a patient engagement technology company…

OK, there was no Rabbi, but I have your attention now, right? Was the title engaging? Did it pique your interest or even annoy you? What engages the brain? Helps it pay attention to information and helps it hold on to and retain it? Humor? Fear? Other emotions? Personal relevance?

An Interview with Moran Cerf and Chris Rose

For the past year, we’ve had the extraordinary opportunity to partner on research with neuroscientist Moran Cerf and his student Chris Rose. I asked them to tell us more about their work and approach and how neuroscience can inform the multimedia programs we create to continue to build our understanding of what creates engaging, memorable experiences in healthcare.

As neuroscientists studying brain engagement, how do you typically define engagement?

In a seminal ruling on pornography by the Supreme Court Justice Potter Steward said “I cannot define, but I know it when I see it.” For the first time in history, science can now rigorously investigate many key concepts that are hard to define: consciousness, free will, life, and engagement. As Francis Crick, who defined ‘life’ put it, I don’t care how people define “life”. I’ll study it and let the results define it. Such is my view of engagement.

Despite multiple interpretations of it and many ways to define it - our approach is to measure it using a metric that disregards its definition. Our metric: how content affects multiple brains. The idea is that engaging content is not only powerful in taking over our brain faculties and making our journey through the content immersive and fully governed by the content author, but it also does this in similar way across individuals - no matter who you are.

Great content, be it a movie, a soundtrack, a political speech, or a conversation, take over our brains in a fashion that is so powerful, it leaves little room for idiosyncrasies. If a piece of content makes all brains look alike, it is engaging. When we watch a marvelous speech by a great professor, our brains are fully recruited by the experience, leaving little room for us to mind-wander in different directions. We are all one with the content. When the content is boring - to each his own. One person may think of their grocery shopping, whereas another may think of a fun date he plans. No matter what - people’s brains will look very different.

We use this functional definition to assert that some content is engaging. If a piece of content makes all brains look alike — it is engaging. The less similar we are - the less engaging the content. A Mozart symphony makes nearly all listeners collapse into a single unique brain behavior. In many ways, one may say the genius of Pablo Picasso is that he from the brink of his atelier in France, he was able to tap into the brains of multiple individuals, across geographies (spatially) and across decades (temporally) and still find a commonality within us all that would make people experience some awe in a similar fashion when exposed to his work. That is engagement.

Broadly, one could say engagement is the intensity with which groups of individuals interact with the various stimuli in their environment. As such it is connected with many other psychological constructs such as memory, arousal, attention, or emotion. Our work with group engagement leverages this continuous interweaving of engagement with everything going on in the brain by comparing the aggregate activity of multiple systems as a means to assess how engaged groups are.

One point that often gets overlooked when people consider engagement is that it is assumed to exist only in positive contexts. However, we’re often engaged in things we do not feel positively about. For instance, the recent political climate has shown how people do not just get caught up in the things they support, but also when they actively oppose elements of our world; one of our studies found that voters viewing presidential debates were more engaged when viewing their least favorite candidate than any of the candidates they felt favorably about.

When working with video formats like movies and ads, how do you know if viewers are engaged?

The clearest way to verify our metrics are to compare them with behavioral data generated by participants (i.e., either their self-report on engagement, or the independent reports of other viewers of the same content), as well as the world at large (i.e. outcomes).

While these types of metrics, like self-report of interest, are often faulty in their own ways (and thus drive us to look deeper into the brain) they are, at times, a good proxy for one’s engagement. Some of our initial tests generated particularly engaging and un-engaging content and looked at the brains of viewers to confirm that engaging content indeed generates high similarity in brain activity across individuals.

Our later works used prediction of such neural similarity to suggest that content that we deemed more engaging will indeed perform better in future metrics - namely, sales. For example, we recently looked at movie trailers and identified ones that we thought would be more engaging based on the neural activity. We then waited a few months to see the sales outcomes of the movies that the trailers try to persuade you to watch; we could easily see that the engaging trailers had a lot more success in the box office and were remembered more. This indicates that engagement is key for future behavior, but also that our measure can capture it.

Using neuroscience to capture engagement is particularly important in video formats, and similar real-time moving and continuous formats (like conversations, speeches or concerts) since any other method (say, stopping the movie to ask you questions about it, or waiting for the movie to end and then asking you about it) will actually corrupt your ability to be engaged. If I stop the movie to ask you about the engagement in the movie, I most likely, just ruined the engagement by halting it mid-experience. If I waited to the end of the movie and then asked you about it I will probably be biased by the ending of the movie (if it were bad you might color the entire movie as ‘unengaging’ even though this wasn’t the case in your brain).

So only an independent tool that can read your momentary experience without affecting it can give us an accurate measure that doesn’t biasing the experience itself. Here, neuroscience is the perfect answer.

How are you using EEG technology to look at how people engage with multimedia patient education and engagement programs, like Emmi programs?

To give a simple explanation, we compare their brains using a method called Cross-Brain correlation. We collect neural data using a device called EEG that reads the electrical residues of brain cells inside your head from the surface of your scalp. Having multiple people watch the same content, such as a presentation on treating low back pain, we look at how similar the activity of their brains is. We then estimate how engaged they were based on the level of similarity in each moment.

Since many systems hang out under the umbrella of engagement, when people are more engaged there is a cascading effect where each of these neural sites is evoking similar activity. By comparing the overall electro-cortical output we get an idea of exactly how aligned the whole group is. This is new territory for neuroscientists. However, the chance to pioneer new directions is not one we’re going to pass up. And anything we find just adds to our understanding.

In healthcare, people often have gaps in understanding health conditions and they may have assumptions about their treatment options. For example, many people with chronic low back pain assume the pain means that something is permanently wrong with their backs and that no solution is possible. They may also be told they have herniated discs or degenerative disc disease and assume that certain behaviors of theirs are the cause, while they could be merely the natural aging of the spine. All these assumptions and feelings the patients experience might not be verbalized, but they affect their perception of the offered care and their likelihood to follow a treatment plan. Generally, the experience is often colored by a lot of unnecessary fear and confusion.

Now we can carefully identify gaps of understanding in the conversation with the doctors and blind spots in the treatment and care instructions that we can quickly remedy and fix before they are amplified.

How can technology such as multimedia programs, engage people and help address health literacy, understanding, and engage patients in their care?

Health literacy is important and doesn’t get enough attention. Clinicians often believe that what patients (and customers/voters, in business/political context) are missing is more information.

“If they only knew the facts they would surely act properly.”

Or, in the context of business: “If they only understood our products perfectly, they would surely buy it.”

Or: “If they knew what we stand for they would surely vote for us.”

This is a common misconception. Think about dieting: what information does one need if they’re interested in losing weight? Eat healthy and exercise. That’s basically it. Then how come most of us are not easily healthy and fit?

Somehow information is not enough.

It’s our ability to implement it and translate it to actions that’s challenging. This is true in healthcare as well. Patients often ‘get told’ what to do, but they still end up not adhering to the instructions. Despite their health being on the line, many people do not act in their best interest. Not taking pills they’re given, not seeing their doctors, etc.

The advantage to multimedia outreach and engaging programs like the ones we are hoping to tailor to patients is that they create a more immersive experience that is ideally targeting the needs of the individual. Instead of merely hearing or reading information about their health, patients are now seeing the treatment, feeling it, and are part of the discovery journey that ultimately leads to a better understanding of the therapy. We aim to ultimately extend it to other sensory modalities as we get a more in-depth understanding of the tools and techniques that would make content as engaging as possible.

Another upside of multimedia and sensory experiences is they’re accessible and adaptable. People can access the content from their computer or phone and the information presented can be perfectly suited to their specific condition. Furthermore, the content and the aggregated sensory experience will hopefully open people up to considering their condition more holistically. Oftentimes, we learned that an individual’s health conditions get simplified in the explanation given to them because of wrong assumptions about the patient’s interest or ability to cope with news or understand complex treatments. We feel that this is not necessary. With engaging content, even a complex and challenging topic can be made clear and specific. We, therefore, hope to help alleviate these complexities and help patient adapt their lifestyle, so that they can experience lasting benefits.

Is there anything you can say about engagement and longer-term recall of info based on previous research?

Our previous work in the business domain has shown that there is a link between engaging content and the ultimate memory of the experience. Engaging content tends to be remembered for longer and in greater detail.

This is true for both positive and negative content. That is, the events of 9/11 were traumatic for many and at the same time were engaging. Our brains were all shocked by the images and manifested the emotions and shock by coding various memories and being fully immersed with the experience. Everyone remembers where they were the moment they got the news about the planes hitting the Twin Towers. This is true for grave situations like accidents and sickness, but also for positive ones like marriage proposals or first kisses.

Given the importance and dominance of health experiences - they are no different. And we treat them this way in our studies. We try to understand the collective experience that will be shared by all patients and create content that will speak to all, while at the same time understand the potential individual differences in the experience and create options and ‘lanes of data’ that one can venture into alone if they feel their experience is unique.

For instance, when assessing something like viewers of a presentation of lower back pain there are a number of variables to consider in terms of recall. Each person is going to have their own pre-existing understanding of the content beforehand and may want to journey through the information in different pace and with different levels of details. The information is sometimes complex and subjective and we have to understand the mindset of each person as they go through their journey. While certainly a challenge, it’s one we are approaching with vigor.


Moran Cerf, PhD is a professor of neuroscience and business at the Kellogg School of Management and the neuroscience program at Northwestern, a member of the institute on complex systems, and a visiting professor at the MIT Media Lab. His research uses methods from neuroscience to understand the underlying mechanisms of our psychology, behavior changes, emotion, decision making, and dreams. His research appears in journals such as Nature and Scientific American Mind. His talks from TED, PopTech and other venues are available online. He’s also the Alfred P. Sloan professor at the American Film Institute, and consults on films and TV shows such as Bull and Limitless, Mr. Robot, and Falling Water. 

Chris Rose has been working with Professor Cerf since 2014. Initially interested in the economic implications of neuroscience, his work in the lab has steered him in the direction of more psychological work. He is currently working on a Master’s degree at NYU, and is especially interested in social and affective neuroscience as well as political psychology.


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