As a physician, I received extensive  training in all medically relevant areas of basic science, including extensive study of pharmacology and grounding in medical statistics. I know how to interpret statistical significance, relative risk and absolute benefit. I understand effect size and sample size.

As new drugs are developed, my background enables me to evaluate the strengths and weaknesses of the clinical trials that led to approval, to understand the risks and benefits of the medication, and to objectively weigh those risks and benefits in planning an optimal treatment for each of my patients.

You can imagine then how frustrating it can be for the physician advising the patient on the next step of treatment only to hear him or her say, “No, I don’t want that. I know someone who got X from taking that medication.” And X usually refers to some rare horrible outcome, perhaps cancer or, God forbid, anal leakage.

The human mind was not designed for evaluating objective data. Marketing professionals and physicians may not realize how hard it is for patients to objectively evaluate data on medications. In our roles in marketing and in medicine (not to mention in our schooling) we’ve had extensive training in learning how to think in terms of data. We have tons of experience with numerators and denominators and we can rationally weigh risks and benefits appropriately. But if a patient’s distant cousin, Mildred, or someone he met at a party experienced some terrible adverse effect of a medication, that patient—who could very well need the same treatment—may be heavily swayed to avoid the drug.

On top of that, explaining the statistics of adverse effects to the patient is likely to be time consuming, frustrating, quixotic and fruitless in regard to changing the patient’s mind. That single emotionally charged adverse anecdote stands out in the patient’s mind and is not easily overcome by reason.

We are largely emotional—not rational—beings, as is evidenced every day. The horrible news of a beheading certainly affects our perceptions so, so much more than tens of thousands of lives lost from auto accidents or heart disease. A patient’s tendency to turn down treatment is, at times, a terrible shame because many of our new medications are life saving and life changing. In spite of these benefits, a black box warning of possible rare side effects truly terrifies patients. It might actually be better to have black box warnings against a lack of treatment, against letting patients continue to suffer with their diseases.

As, physicians, how can we overcome this? I fight fire with fire. Instead of inundating a skeptical patient with data, I respond with an anecdote or two. I might point out a celebrity who is doing well on the medication or present the patient with the good experiences some of my other patients have had with drug. Salience is powerful—and it can work for us or against us.

  • Steven Feldman, M.D.

    Dr. Steven Feldman is Professor of Dermatology and Public Health Sciences at Wake Forest Baptist Medical Center. Steve studies patient adherence at North Carolina’s Wake Forest Baptist Medical Center. He is also Chief Science Officer of Causa Reseach, an adherence solutions company (www.causaresearch.com), founder of www.DrScore.com, and author of “Compartments” and “An Illustrated Dictionary of Behavioral Economics for Healthcare Professionals.”

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