A fascinating short piece was recently published in the New England Journal of Medicine entitled “Beyond Belief—How People Feel about Taking Medications for Heart Disease.”1 It’s a more-creative-than-usual inclusion in the journal that highlights a physician’s interviews with 20 patients after a heart attack, supplemented by offhand but perfectly relevant opinions by two of the physician’s hairdressers! Clearly worth a read.
I’ll skip ahead to the author’s conclusion: “I want to believe that if patients knew what I know, they would take their medicine. What I’ve learned is that if I felt what they feel, I’d understand why they don’t.”
That’s powerful. It’s an admission that knowledge—about a drug, about a disease—is clearly not enough for many people. The motivation required to fill, take and persist with therapy requires an emotional buy-in as well, rational or not.
Dealing With Negative Emotions About Drugs
How can we deal with gut reactions such as (from this piece) “I’m old-fashioned—I don’t take medicine for nothing,” or “I’ve never been a pill person,” or “I don’t like taking them, period”? Interventions such as patient education, all forms of reminders and cost reductions—even free medication—are unlikely to move the adherence needle far enough for patients with such strong beliefs or emotion.
As a practicing physician, I often encountered a patient’s concern that medication wasn’t “natural,” despite the fact that all medications are ultimately derived from natural substances. It was difficult to address that emotional reaction effectively. My rational medical self always wondered, somewhat annoyed, “Why does ‘natural’ have to be the gold standard at all times?” After all, cancer is—unfortunately—natural, as are hypertension, diabetes and other chronic illnesses. (On a related note, consider hurricanes and earthquakes.)
Richard Dawkins famously said: “Nature is not cruel, only pitilessly indifferent.” That is certainly the case with the natural illnesses that plague us. I would add the obvious corollaries that “natural does not always mean good,” and “sometimes the ‘unnatural’ is actually best.”
But again, strong beliefs and emotion are often ineffectively addressed by such rational explanations. Plain language and education need to be augmented by emotion-based strategies.
To that end, for patients who have already bought-in, both rationally and emotionally, to the need to take a medication, simple reminders and cost reductions can probably work nicely to facilitate adherence. For patients on the fence emotionally, or resolutely against taking medication at all, more creative strategies will be required to encourage adherence and to drive better clinical outcomes.
Emotion-based Adherence Strategies
To start, we at least need to discover why individual patients shun medication. Simple questions can help: “What do you fear most?” “How do you feel about this medication, or medication in general?” “What concerns you more: The disease or the medication?”
If a patient harbors clear misperceptions, such as greatly overestimating the likelihood of a side effect, education makes sense as at least a first step. At the same time, conveying sensitivity towards that fear and emotion—rather than curtly dismissing the fear as irrational—should help deliver the message more effectively.
But I believe that we’ll need to go beyond education and compassion. It’s hard to know exactly what the creative emotion-based strategies of the future will look like, but I believe they will likely be more social and story-based.2 Just as television leverages rich personal stories to capture a viewer’s attention and emotion, the presentation of personal patient stories—perhaps even delivered in a cinematic format—are likely a more compelling educational medium than the dry pamphlets traditionally handed out at a physician’s office.
If a patient with a new diagnosis—skeptical or wary of treatment—can tap into another patient’s success story, or even connect with patients of similar backgrounds online, the emotional connection may do more to drive understanding and to spark action than would logic or lecture. Behavior change is difficult, but can only be accomplished by modifying the beliefs that drive emotion. That’s where it gets personal.
1. Rosenbaum L. “Beyond Belief — How People Feel about Taking Medications for Heart Disease.” N Engl J Med 2015; 372:183-187.
2. Houston TK, Allison JJ, Sussman M, et al. “Culturally appropriate storytelling to improve blood pressure: a randomized trial.” Ann Intern Med 2011; 154(2):77-84.