In this interview Dan Ariely and Ada Lê talk about the biggest psychological barriers in today’s healthcare system.

Learn about new treatment adoption, improving patient-physician trust, and medication compliance.

Dan Ariely is a Professor of Behavioral Economics at Duke University and co-founder of BEworks.

Ada Lê is the Vice President, Strategy at BEworks. As an experience practitioner she applies behavioral science to complex challenges in healthcare.

Listen to the interview here

Key Highlights from the conversation

Medication compliance: memory and emotional barriers

Ada: There are people who work in the healthcare field that believe that habit or routine plays an important role in medication compliance. From your perspective, is that necessarily the biggest barrier to medication compliance?

Dan: I don’t know what the biggest barrier is, and I think it varies by medication.

If you think about the psychological causes. One of them is memory. People just don't remember. And there's lots of things we can do for memory, including where we place things, reminders, and so on. And habits are good for that too.

We need to think about medications that have negative side effects very differently. It’s not about memory, “Oh, if I only remembered, I would have taken it”, it's something that people actually decided not to take because it's not the right short-term cost-benefit analysis for them.

Then there's another category, which are not the ones that have negative side effects, but are the ones that make people feel they are unhealthy. For example, in diabetes, physicians often tell the patients that unless they take their medication regularly, they will be forced to take mealtime insulin. Then when they get to mealtime this has the implication that they failed in some way.

“I wouldn't have gotten here if I only did things well.”

There are all kinds of medications that create a negative self-image.

So if you asked me how big pure memory is compared to the other ones, I don't think it's very big. I think it's important, but I think you could have the perfect reminder and there would still be lack of medication adherence.

Patient barriers of adoption: emotions of shame and failure

Ada: How can we help patients overcome the barriers of emotion, the feelings of shame and failure?

Dan: The way we inform people about their illness is very depressing. As we age, most things are going to get worse. There are very few things [in our health], that are going to get better with age.

The most you can do is slow down your deterioration. But the way we report on these things is depressing, because we show the number, not the improvement.

Imagine that you're a diabetic patient and you're A1C has deteriorated. But as your physician, I’m really happy because your deterioration has been slower than average, much lower than average, yet still, you deteriorated.

Are you going to be happy with those numbers? No, you want to see improvement. Staying the same as last year doesn't give people the satisfaction of improvement. I think what we need to do is to change the numbers. I think what we need to report to people is how their A1C has deteriorated compared to the expectation of deterioration. If someone deteriorated less than expected they should feel successful.

What I learned from SHAPA is that we have three goals: accuracy, motivation, and the relation between cause and effect. If you want to change behavior, you might first want to instill motivation, then you want them to understand the relationship between cause and effect, and finally, you want accuracy.

Actually, if accuracy is counterproductive, you might not want to show it at all. Do I really want to show people their A1C? No, I want to give them the kind of score that would motivate people who are taking the right steps, to take more of these steps. We need to understand that, in most cases [in healthcare], the data is anti-motivating.

As we age, our health inevitably deteriorates. How do we motivate the patient to continue treatment? 

Ada: One of the things you always talk about, is making the invisible, visible. Late last year, C2 organised a bio summit with Novartis focused on cardiovascular disease (CVD) on how to get people to pay more attention to CVD and engage in more preventative behaviors.

One thing we talked about was cause and effect. If you do everything right, the optimal outcome is that nothing bad actually happens to you — not very motivating. But if you do certain things and you fail at others, then you will get feedback. And that's the only feedback that you get.

Dan: And even if you do the right things, you might still get negative feedback. You still get older.

Here's another thing. Take a C student, somebody who is destined to get between 70 and 80. How motivating would it be it for that person to get an A? You would think that they’d be very happy to get an A, but it’s not so, because an A doesn't represent success to them. A test score of a 100 still represents a long way from success. You can think in this same way with someone who is born with bad genes or who has a history of illness. They are a C student and could never be an A student. No matter what they do, the best thing they could get is an 80. How exciting is that?

“Would you join a marathon if you knew that you were likely not going to finish? No”

So what we need to do, to continue with our classroom example, is give people different scores. The guy who is a C student and got an 80, needs to feel the same way as the guy who got a 100.

Integration and resilience in treating co-morbidities, a study on breaking points in diabetic patients.

Ada: Let’s talk about multiple comorbidities. When you work in a certain disease state, say dermatology, and you're assigned to work on a particular drug or treatment, it’s like you are wearing blinders. The problem is that many conditions tend to happen at the same time.

What are some of the ways we can think more holistically about a health condition, especially when these conditions are dealt with by multiple providers?

Dan:  There are lots of things to say here. The first thing we need to do is appreciate the complexity of the patient managing multiple diseases, especially, when coming from different providers, because they have to do the integration. And if you think about the stress of managing the disease, its extra tough.

If you asked me to draw it, all physicians would give the information to one physician and then that physician creates the demand for the patient.

If you're if you're diabetic and you have psoriasis, how exactly do you manage it? I think we need to pay much more attention to treatment plan, so that people have a chance to integrate everything. We need to understand that this will be taking a bigger chunk of people's day in terms of time, attention, and commitment, so it becomes important to provide them with a feeling of success.

Now, here's something I haven't thought about in this context. I think COVID has taught us how important resilience is. Resilience has a lot of different definitions, but I think about it as an insurance policy. Basically, the knowledge that if something goes bad, somebody will be there to catch me. Like secure attachment in childhood development, the feeling that the world is on your side.

And I think that with multiple illnesses, there's a good chance that people feel that their body's betraying them, so we need to think about what their source of resilience is.

We did research on breakpoints [with Centene Center for Health Transformation] whereby we tried to see the difference between the people who manage their A1C and the people who don't manage their A1C. Some people are better, some people are worse. We found was that none of the regular candidates were misunderstanding the illness or their side effects. Their motivation was all about how many times a week they reported having a break point, in which you basically get to the evening and say, excuse the language, “fuck it, I don't care” and eat something bad, right?

We all live complex lives, things accumulate throughout the day. And at some point, we can lean into something bad. If you manage multiple diseases, that just more of that. I think what we need to recognize it again, is this kind of you, you just have no energy to deal to deal with anymore. So the feeling of success, the feeling of support, all of those are so much more important.

Listen to the audio above to hear the whole discussion.

Reference Links

https://www.centenecenter.wustl.edu/behavioral-factors-impacting-diabetes/

https://www.c2international.com/work/biome/

If you want to learn more about how we can use behavioral science to change the way we think about healthcare and begin to shift toward person-centered care on a global scale, watch our webinar recording ‘Code blue! Can behavioral science resuscitate our failing healthcare system?’