Steven R. Feldman, M.D., Ph.D., describes several tactics based on concepts from behavioral economics that can be implemented in counseling conversations with patients.
Applying principles from the field of behavioral economics and establishing patient accountability are useful strategies for getting patients to accept new treatments and use them as directed, according to Steven R. Feldman, M.D., Ph.D.
“Our goal in caring for patients is to get them well, and to do that physicians have to make the right diagnosis and prescribe the right treatment. But those two things are not enough because adherence to treatment is still a limiting factor in treatment success,” says Dr. Feldman, professor of dermatology, pathology, and social sciences & health policy at the Wake Forest School of Medicine, in Winston-Salem, North Carolina.
“Through understanding of behavioral economics and use of accountability we can improve on our ability to make sure medications are used well.”
Behavioral economics is a field that combines elements of psychology and economics to gain insight into human decision-making. It is utilized by marketing professionals to influence consumer purchasing and can be used by physicians to get patients to stick with treatment recommendations.
“Humans are not computers, and we behave in ways that have been called ‘predictably irrational’. Physicians can use knowledge of human behavior tendencies for our patients’ benefit,” Dr. Feldman says.
Anchoring is one behavioral economics concept that can be adapted by dermatologists. This technique primes the mind on a reference point that creates a more favorable perception of a subsequently introduced idea.
Dr. Feldman illustrated how anchoring can be used to influence patient acceptance of starting treatment with a subcutaneously administered biologic agent. He explained that some patients may be afraid or reluctant to use an injectable treatment, and so he puts it into a context that is more familiar and more burdensome.
“I tell these patients that I have something to offer for treatment that I think will be very effective and that it involves an injection under the skin, like insulin. I tell them, “You are familiar with insulin, right? It is injected typically twice a day. The medication I am recommending is not exactly like insulin though. You’ll only need to take it once a month.” If I don’t mention the insulin, patients may be comparing taking a shot once a month to not taking a shot at all. By anchoring them on the twice-a-day dosing of insulin, the monthly biologic regimen seems entirely appealing,” he says.
Further support for the utility of this approach comes from a survey Dr. Feldman conducted that QUICK asked patients to rate their willingness to be treated with a medication that required a monthly injection. The average rating was a two on a scale of 0 (not willing) to 10 (very willing). However, when the patients were first asked to rate their willingness to be treated with a medication requiring an injection once daily, the average rating for willingness to use a monthly injection rose to seven.
Another behavioral economics tactic that transfers to dermatology takes advantage of the fact that the mind is engaged better by a human story about a product than to facts about the product itself and particularly when the story parallels the individual’s situation. Investigating how that concept plays out in patient decision-making, Dr. Feldman asked one group of patients to rate how comfortable they would be to start a drug if their doctor provided data on its efficacy and safety and a second group about their comfort starting a drug if they were told about a patient whose condition was similar to their own and who did well on the medication. The second group was more comfortable than the first and did not gain greater comfort if they were also given data about the drug.
Therefore, to help convince patients about the potential benefit of starting a biologic agent, Dr. Feldman starts by saying he used the medication in another individual who had very similar disease features. He explains by adding that the individual was actually sitting in the same room in the same chair and then adds that the patient did very well.
Further highlighting the effectiveness of this approach, Dr. Feldman reveals how it affected his decision for treating his own painful sciatica. Having conducted a thorough review of published studies, Dr. Feldman had decided on physical therapy because the literature indicated there was no difference in long-term outcomes achieved with physical therapy, steroids or surgery.
“As a data-driven person, I was resigned to choosing physical therapy. After hearing from my practice partner that his slipped disk responded well to prednisone, however, I immediately called my gerontologist and demanded a course of prednisone,” Dr. Feldman says.
As supported by the findings of another study, customization is another effective strategy for influencing patients’ perceptions of treatment. In this investigation, patients with atopic dermatitis were given an instruction sheet for their treatment plan that consisted of three components – bleach baths, a topical steroid, and a moisturizer. A second group was given a sheet listing several additional treatment options, but the information for bleach baths, the topical steroid and a moisturizer were circled.
When the groups were asked about their comfort and confidence using the recommended plan, the latter patients scored higher.
“Even though the plans were identical, it seemed the second group considered their plan more ideal because it appeared to be tailored to their specific needs,” Dr. Feldman says.
Once a patient agrees to use a treatment, compliance can still be a barrier to success. Although there is abundant research focusing on understanding reasons that underlie poor treatment compliance, Dr. Feldman believes that the studies generally overlook the number one issue, and that is failure to establish patient accountability.
The key here is that people are much more likely to do what they are supposed to if they know they are being monitored. Therefore, Dr. Feldman likes to have some kind of contact with patients after about a week of starting a new treatment – it can be an early follow-up visit, a phone call, or a text message.
“The effect of this contact is analogous to the power a piano lesson has on getting people to practice and to how a visit to the dentist makes people floss,” he says.
Dr. Feldman notes that many of the behavioral economic approaches he has tested work on getting patients to accept and start on treatment. The big problem, however, is that dermatologic diseases are chronic, and over time, adherence to topical treatment becomes abysmal.“Tachyphylaxis, I believe, occurs when patients stop using the medicine. Hopefully we can come up with some behavioral economic solutions that can help in the long run,” he says.