AlignMap

Alternative Perspectives On Patient Compliance

We Interrupt This Rant, …
As ongoing readers know, recent AlignMap posts have been a series of jeremiads lamenting both (1) the repetitive nature of patient compliance research, programs, and theoretical thinking and the resultant paucity of advances in the field and (2) the questionable value of  recurrent skirmishes over details such as the most appropriate appellation du jour for the system currently known as patient compliance, a battle which strikes me as the equivalent of a bidding war for naming rights to the Titanic breaking out just after the collision with the iceberg.

Well, to invoke the astoundingly convenient Monty Python pseudo-segue, now for something completely different, i.e., an atypically positive post suggesting a pragmatic means of expanding the conventional knowledge base of patient compliance. While that appropriately modest goal falls short of a universal panacea for treatment failure, the redemption of men’s souls, or the establishment of cosmic justice, it’s not a bad way to start the week.¹

Patient Compliance Information Source Alternatives:
We Are Not Alone

The key to unlocking a wealth of information and thoughtful research with direct and inferential links to treatment adherence is the willingness to consider the possibility that the two-part iconoclastic hypothesis presented a few lines below may, however incredible  it may seem, be valid.

Before revealing this fundamental reshaping of the intellectual firmament, authorial responsibility  dictates that I issue certain caveats. Those easily shocked, those with sensitive temperaments, and those diagnosed with high anxiety, severe cardiac conditions, or other disorders known to be  exacerbated by strong  emotional or intellectual challenges may wish to confer with their personal physicians before continuing. Medications, if appropriate to the situation, should be at hand. Ladies and older gentlemen, even those in superb health, should be seated or recumbent upon reading the remainder of this post. Those who feel they cannot tolerate further chaos in their lives at this point should cease reading no later than the end of this paragraph.  Knowing ones own limitations is a strength, not a weakness. The  official AlignMap Blog position holds that  there is no shame in dropping out now rather than risk ones wellbeing.

Those intrepid souls determined to pursue this idea should now prepare themselves.

Precursor Principles For Expanding The Patient Compliance Model

Principle 1. Patients are not exclusively patients. Reliable evidence has begun to accumulate, for example, that some individuals, despite meeting rigid criteria identifying them as “patient,”  also hold  jobs, sometimes devoting 40 hours or more a week to their occupational roles. Others are now known to operate as parents, grandparents, brothers, sisters, friends, partners, and a myriad of other roles. Rumors have even arisen that many patients have strong positive and negative feelings toward others that seem to have nothing to do with health or healthcare. There have been confirmed sightings of patients functioning simultaneously in several social, cultural, and spiritual spheres independent of their medical treatment status. Further, many patient brazenly and casually admit to these non-clinical identities and invest considerable psychological resources in them. At a minimum, these observations cast doubt on prevailing Patient Theory which holds that patients, when not in the presence of a clinician or in the act of executing a prescribed treatment, are maintained in a state of suspended animation until awakened for their next clinic appointment or medication dose.

Principle 2. The processes that culminate in Patient Compliance or Noncompliance do not operate exclusively in matters of health and healthcare. In fact, the manner in which a patient responds to treatment recommendations from a clinician and the extent to which that patient follows those treatment recommendations may be similar to the manner in which that person responds to and follows recommendations from a lawyer, a broker, a business consultant,  a teacher, a military superior, a friend, a mechanically derived algorithm, …  – even if those  recommendations have no direct implications for healthcare.

Heady stuff, eh?

It’s a lot to digest, but there is a payoff. Because of the extensive data, research, and literature available about how people respond to and follow those non-healthcare recommendations (often called “advice” in the non-medical world), these metaphysical musings transform into something real – and something immediately useful. In the fields of psychology (in this case, that portion of psychology not directly linked to medicine), sociology, economics, political science, education, business, and market research, among others, a plethora of data, interpretations, studies, and reports exist under topical headings such as decision-making, the spread of ideas, purchase resistance, learning processes, behavioral influences, … .

And, even better, most of that material is not a rehashing of the medical literature on patient compliance, but, in fact, may offer  perspectives that are unique from yet could be applicable to clinical adherence.

Serendipitously, an example is at hand.

The Impact Of Emotion On Patient Compliance

Source: Feeling the Love (or Anger): How Emotions Can Distort the Way We Respond to Advice Knowledge@Wharton, October 1, 2008

Knowledge@Wharton is the online newsletter of the Wharton School of the University of Pennsylvania. Wharton is, of course, an eminent business school and the newsletter is congruently oriented.

I’m not covering the article in depth. Instead, I will present excerpts to give a flavor of the entire piece, point out some specific elements I think are significant to those of us invested in understanding patient compliance, and, finally, invite the reader to review the original essay itself along with the relevant research on which the article is based. Both the article and the essay are available on the same Knowledge@Wharton web page.

Here’s a piece of advice: Don’t read this story if you have just had a fight with your spouse or a co-worker. You will probably ignore it, despite its grounding in solid academic research. At least that’s what Maurice Schweitzer, a Wharton professor of operations and information management, would most likely suggest. In a recent paper written with Francesca Gino of Carnegie Mellon University, he shows that emotions not only influence people’s receptiveness to advice but they do so even when the emotions have no link to the advice or the adviser.

“We focus on incidental emotions, emotions triggered by a prior experience that is irrelevant to the current situation,” the two scholars note in their paper, titled “Blinded by Anger or Feeling the Love: How Emotions Influence Advice Taking.” “We find that people who feel incidental gratitude are more trusting and more receptive to advice than are people in a neutral emotional state, and that people in a neutral state are more trusting and more receptive to advice than are people who feel incidental anger.”

… until recently, economic analysis has taken as its premise the idea that, when it comes to dollars and cents, people can wall off their emotions. “Classical economics is predicated on this rational-man idea and also on the idea that mistakes will get extinguished by the market,” Schweitzer says.

But Schweitzer and Gino’s research suggests that emotions can systematically distort people’s receptiveness to advice and thus their rationality. And if everyone errs in similar ways, that could skew the classicists’ perfect calculus. “My intuition was that we often base complicated decisions on how we feel,” Schweitzer says. “If I ask you something complicated like, ‘Should we hire this person or should we buy this house?’ you have to consider a lot of attributes and compare a lot of complex things. So we often use a simple summary statistic, which is how we feel about the job candidate or the house. When we do that, we open ourselves up to the possibility of making a mistake based on emotion.”

That makes sense, but how do you prove it? Schweitzer and Gino designed experiments in which they — as difficult as it sounds — manipulated their subjects’ emotions, gave them advice and measured the effects. In their first experiment, they recruited college students and asked them to make a judgment about something they were sure they could not know for certain. In this case, they showed each subject a photograph of another person and asked them to estimate the body weight of the person in the photo. They then induced an emotion by having each subject watch a short movie clip. Some subjects saw an anger-inducing bit from The Bodyguard in which a man gets treated unfairly. Others viewed a gratitude-inducing clip from Awakenings in which another man receives an unexpected favor from his co-workers. And the rest saw a neutral outtake from a National Geographic documentary about Australia’s Great Barrier Reef.

In a separate study, the two scholars assessed how the videos induced different emotions. Because the students had no real connection to the scenes, the researchers could classify their reactions as incidental as opposed to integral. If you watch The Sopranos and then get angry with your spouse, that’s incidental emotion. If your spouse slaps you and you get angry with your spouse, that’s integral.

After watching the clips, the students reflected in writing on what they had seen and how it had made them feel, and then had a chance to re-estimate the weights of the people in the pictures. This time, they also received estimates that the researchers told them had been done by another participant. Though the subjects didn’t know it, everyone received the same set of second estimates. These estimates — the advice — were helpful, not misleading. “The emotion manipulations significantly influenced the accuracy of participants’ final estimates,” the two scholars state.

Participants “who experienced incidental gratitude weighed advice more heavily than did participants in a neutral state,” they write. “Participants who experienced incidental anger weighed advice less heavily than did participants in a neutral state. Even though the emotions induced in this study were unrelated to the judgment task, we find that these emotions significantly changed the extent to which participants relied upon advice.”

In the real world, as opposed to a behavioral lab, these findings play out in all sorts of ways. Co-workers, for example, often annoy each other, sometimes for legitimate reasons, like missed deadlines, and sometimes for silly ones, like how stupid someone’s laugh sounds. And sometimes, a person will get ticked off and fail to heed another’s good counsel just because of a bad mood.

“If I’m angry at my wife and therefore trust you less and am less receptive to your advice, then that’s clearly irrational,” Schweitzer says. “The fact that my wife crashed my car has nothing to do with you. But maybe I’m angry because you cancelled our last meeting and now we’re interacting again. Maybe there’s some real information about your reliability in the fact that you cancelled our meeting. It takes a controlled, clean experiment to disentangle rational reasons from biased ones. What we haven’t shown [with this study] but I’m confident would work is that, if you do something that makes me angry, then I trust your advice differently.”

Schweitzer says that people with what he calls “high emotional intelligence” are probably already putting his and Gino’s insights into action without even knowing it. “Emotional intelligence is the ability to recognize emotions and understand how they operate and also the ability to manipulate or change them. If I have emotional intelligence, I know what the right time to talk to my boss is. I know that my new partners had a terrible flight and lost their luggage and aren’t going to be receptive to what I’m saying, so I shouldn’t make my pitch right now. Or I know that, if I take them to this particular restaurant or I buy tickets to this Indy car race, I can shift their emotional state to feeling more gratitude toward me and listening to me.”

Skilled negotiators tend to have high levels of this kind of aptitude, and they apply it in small, subtle ways when they are doing their work. They might, for example, apologize for a perceived wrong, even when no apology was expected or required. Or they might, during a particularly tense time, call for a break, go get a soda and also bring something back for the people on the other side of the table.

Schweitzer sees what he and Gino observed operating in all sorts of business interactions. When a sales person takes a client to a ball game, for example, he’s not just cozying up in the obvious way. He’s also creating a sense of gratitude. When a drug rep brings lunch to a doctor’s office, she’s doing the same thing. “Can this backfire?” he asks. “Yes. If it doesn’t seem genuine, people aren’t going to believe it. Suppose that I try to induce gratitude and I go over the top. That’s the sales rep who’s giving too many gifts.” Push it too far, in other words, and you could end up making someone angry.

Observations On Patient Compliance Articles Not Presented As Patient Compliance Articles

Those accustomed to reading about patient compliance in publications such as The New England Journal Of Medicine, The American Journal of Psychiatry, The American Journal of Managed Care, white papers put out by pharmaceutical manufacturers and benefits management companies, and, of course, AlignMap.com, may find my free form observations helpful in orienting themselves in this brave new world.

1. The referenced article does not mention healthcare but does list an extensive set of business scenarios in which emotional content could affect ones decisions. The application of the content to compliance seems, as I read it, strikingly apparent. This is not, in my experience, unusual. Literature with a business, sociology, or economics orientation, for example, seem less concerned about how decision-making (in this case) works in specific, well defined situations than finding general principles that are valid in many settings. When healthcare is mentioned, it is often as one of many examples.
2. The article’s primary finding, that emotions experienced by the individual affect how that person responds to advice, even if the origin of those emotions have nothing to do with the immediate decision to be made – or, to extrapolate, the patient’s disorder or the healthcare situation, has not been emphasized in the medical literature.² Although in this example the findings are only moderately different from the conclusions of analogous articles with medical orientations, other instances will demonstrate entirely different, but not necessarily contradictory, approaches.
3. The experiments designed to test the hypothesis in this article lie closer to the basic research pole of the pure science-applied science spectrum than do the typical patient compliance studies and, not incidentally, are more akin to the animal behavior labs than naturalistic clinical trials favored in healthcare journals. Experimental approaches to similar questions vary dramatically from field to field.

My contention is not that the compliance-pertinent material available from non-medical fields is of higher (or lower) quality, that its experimental style is more (or less) valid, or that its findings are more (or less) useful. My contention is that the work done in non-medical fields often asks different questions, approaches solutions differently, presents findings in different contexts, … .³

Given the lack of progress in comprehending the workings of, let alone improving, compliance after many years of effort by the mainstream healthcare fields, the exploration of the potential contributions from these legitimate, well credentialed alternatives would seem a wise investment, if not an obligation, for anyone invested in understanding the phenomenon that most of us know by its healthcare-names, patient compliance or treatment adherence.


Footnotes

1. Re the more optimistic tone of today’s post, not to worry; this blog’s normal apocalyptic programming will resume forthwith↩
2. There has been significant material published in the medical compliance literature on stress caused by the medical problem being treated, the coping styles of the patients, and co-existing psychiatric diagnoses, especially depression.↩
3. Research and theoretical work in each of these non-healthcare fields may be as restrictive and narrowly focused as that done in healthcare. I am only pointing out that these fields view and treat issues that are part and parcel of patient compliance differently than do those of us in medicine.↩