Learn the Rules Before Playing the Game

Note: The author would like to thank Bruce Thomas, founder and managing director at Arcady Group, LLC, for sharing the story of the 99DOTS team and supporting the development of this article.

Think of a game you consider yourself to be good at. Any game will do – a board game, a sport, anything with a defined set of rules. When you play that game, are you actively thinking about the rules? I would posit that, in most instances, you’re not thinking about them; you just know them. My sport of choice growing up was rugby union, a shockingly complex game that has finicky rules that govern 15 players in a relentless struggle of strategy and physicality. After playing for a while, however, the rules were rarely on my mind; I turned my focus instead to execution and to understanding the opponent. Playing within the rules became a given.

Credit: Izuddin Helmi Adnan

When games look similar, people often assume that being good at one should make you good at another. For instance, people often imagine that American football players would make good rugby players and vice versa. The rationale is reasonable. Big, fast people are common in both sports, the balls and fields are similar, and the goal is the same: get the ball in the end zone or kick it between the posts to outscore the other team. When players attempt to cross over, however, they are often ineffective or, worse yet, they get injured quickly. Similarly, it’s not hard to imagine a chess grandmaster trying checkers for the first time and being felled by a decent player despite the near identical board and playing conditions. For all the similarities within each pair of games, the rules at play are different, and nothing seems intuitive. While the football player’s athleticism and the chess master’s mental prowess will surely prove valuable at some point, each player will make some potentially costly mistakes if they do not devote themselves to learning the rules.

On the other hand, imagine taking Wayne Gretzky in his prime and asking him to play three on three instead of five on five. He would still be an effective force on the rink. In fact, the three-on-three game may even be favorable for Gretzky, who always thrived in open spaces during his NHL career. The alterations in the rules, while substantial, keep the intuitive feel of the sport intact. Similarly, restricting Gretzky in some ways – such as only allowing him to shoot with his backhand – would limit him, but he would likely still be a formidable player.

Similar situations arise outside of sports on a regular basis, in business, public service, and in almost any other field you might pursue. Consider medication adherence – getting people to keep taking their medication properly – a problem that gets a lot of attention in the health world. Companies producing Western medications spend massive amounts of time thinking about how to ensure patients keep taking their pills and stay on protocols. A host of strategies, ranging from directly observing patients taking their medication to embedding sensors in pills, have been deployed. Whether the pharma company implementing these methods has motivations driven by profits or by patient outcomes, their objective is the same.

Imagine you’ve successfully developed an adherence solution for weight management. The patient population you’ve addressed is middle-aged men in North America, and the solution is a simple digital application. Based on its success, you are considered something of an expert in adherence. If I were to then task you with designing a new adherence solution for young adult men in North America, you would likely hit the ground running. While the conditions are fairly different, the principles that make the rules of the “game” are largely the same, and the task will seem intuitive. You might simply make a more sophisticated version of your last product to suit a more digitally adept population. But what about a pediatric population, or elderly people who need to gain weight instead of lose it? Do these patients have access to or the ability to use digital applications? Are their behavioral drivers the same? What if the medication was for a sexually transmitted infection? The stigmas surrounding weight problems and sexually transmitted infections are wildly different. And what if I asked you to design for a population in rural Peru? Suddenly, cultural and language barriers would come into play. Despite your experience and expertise in adherence, trying to implement your “proven solution” in these alternative scenarios would leave you with an ineffective solution. You would need to learn the new rules to play in these new scenarios.

Moving from the hypothetical to the real, with support from the Bill & Melinda Gates Foundation, the Government of India’s Revised National TB Control Program (RNTCP) recently piloted a tuberculosis medication-adherence program in India called 99DOTS. Even surface-level research would tell you that mobile phone penetration in India is fairly high, even in less affluent areas, and that frequent clinic visits lead locals to become stigmatized. Based on this, you might decide that a lightweight application that would allow patients to be monitored from a distance could be developed for monitoring and tracking. If you trusted your gut there, you would likely fail at the moment of download.

Because if you were to delve deeper, you would learn that most of the mobile phones in India are not smartphones. So, you might think, perhaps healthcare providers could call or text these patients in a systematic way to check in on them. Wrong again.

Thankfully, the team behind 99DOTS didn’t stop at surface-level research, or even one layer below. They did in-depth fieldwork and observed the technology environment, mobile phone behaviors, and patient/user cultural norms. With this deliberate act of immersion, they were able to learn the rules at play. They discovered that the high number of “spam” SMS messages limited the utility of SMS. Combined with high prices for voice calls and text messages, this high volume of spam had driven locals to develop a language of missed calls. People effectively page one another by calling and hanging up in patterns, allowing them to avoid any charges from the telecom providers.

With this key insight in hand, the 99DOTS team developed a solution. By buying a large bank of toll-free phone numbers, they could associate a unique random phone number with each pill. When the patient takes the pill from the packaging, it reveals the number. They “send a free call” to the number and hang up, creating a data trail in a computer system to indicate that they’ve taken the pill. This hybrid of high and low tech has produced stunning results at an astonishingly low cost of less than $5 per patient over 6 months.

The funny thing is that the solution works brilliantly in India and Myanmar, but if you were to deploy the same mechanism in California, it would likely fail. People would rather push a button or swallow a microchip that sends a signal to their smartphone when it touches stomach acid than place a phone call.

It’s a strange thing to consider yourself an expert in something and yet find yourself completely inept due to a shift in context. This speaks to a real business need, one that requires great humility: accepting that you might not know enough to solve a problem you’re supposed to be an expert in. With that understanding, however, you are open to learning, and one step closer to success.

But how should you go about learning? Sometimes it’s better to learn by doing, while other times it’s best to prepare extensively. In technology, where speed to market can make or break your company, it can be best to introduce a product you aren’t comfortable with, knowing full well you have the freedom to adjust it as you go. In pharmaceuticals, knowing a drug has been well received by oncologists specializing in lung cancer does not guarantee a similar reception for experts in bladder cancer, even with similar data, and new messaging must be written and evidence assembled. For surgeons, knowing how to perform a kidney transplant on a 45-year-old man is wildly different than performing the same procedure on a 6-month-old baby – and each requires years of preparation.

If you want to play a new game, you have to learn the rules through preparation or immersive iteration. Determining the best approach all comes down to a singular question: How many mistakes are you willing to make?

the author

Tom Masterson

Tom Masterson is a senior healthcare innovation strategist at Idea Couture.