Good Patients, Bad Patients, Economic Man, & Other Nonexistent Species

1. Compliance models & programs beg the question of how real patients in real clinical situations decide to follow – or not follow – a specific treatment

2. Compliance models & programs assume a rational patient, which is no more realistic than the rational man assumption of discounted economic theories

3. The implicit requirement that patients behave rationally leads to the clinically & ethically flawed classification of patients, vis-à-vis compliance, as “Good Patients” “Bad Patients” and “Pitiful Patients”

The Myth Of The Rational Patient

The consensus view gleaned from research and clinical experience toward these theories and programs can be summarized in a Lincolnesque aphorism:

And, as it turns it, none work with most of the patients most of the time. It is especially discouraging that, even when potentially helpful methodologies are available, we are unable to predict which patients will respond to which methods.

The problem with the hypothetical models of compliance and compliance programs is that they beg the question of how real patients in real clinical situations decide to follow – or not follow – a specific treatment. The orthodox medical perspective that patients first make a careful analysis of the benefits and risks of each course of action and then choose the alternative with the best ratios of pros (anticipated health benefits) to cons (fiscal and non-fiscal costs associated with compliance, including side-effects, discomfort from feelings re use of medication, reluctance to accept the sick role, … ).

This kind of assumption leads to researchers developing mathematical representations of the patient’s decision-making process; for example, one paper conveniently condenses the “probability of noncompliance” to

and the patient’s calculation of the pros and cons of compliance to

That such formulas appear to be gibberish to those of us who struggled with pre-med calculus does not, of course, necessarily rule out their capacity to generate insight into medical compliance. On the other hand, the idea that such mathematical equation directly reflects an individual’s decision-making triggers, at least in me, a severe case of cognitive dissonance.

A consideration of an analogous situation is helpful. The rational patient who populates theoretic models of compliance is closely related to the “economic man” who once inhabited economic theory, behaving exclusively on the basis of perfect understanding of perfect data used in a perfectly logical and reasonable manner to optimally satisfy his self-interest.

In fact, if a purebred economic man ever existed, it was in a land far away and a time long ago. At best, the economic man is an oversimplified ideal, useful in generating theory but inadequate to account for real life behavior. Instead, most economists, all stock brokers, used car dealers, eBay merchants, and anyone making a living in retailing, advertising, or marketing have long recognized that emotions, cultural beliefs, self-concept, altruism, personality factors, social mores, and other forces, albeit often disguised as rational determinations, are significant influences when an individual selects a brand of cereal or chooses a spouse or adheres to a doctor’s recommendations.

While few economists would intentionally base their recommendations and predictions on the concept of the economic man, most clinicians and researchers, however, still seem to subscribe to the notion of a universe of healthcare populated by logical patients, who, even in the midst of the incapacity and distress caused by their disorder, operate exclusively on the basis of intellectual and rational processes to choose and execute their treatments.

Two indictments of the “economic man” model statements by economists are equally applicable to healthcare:

Ernest Partridge:
Clearly, “economic man” and “the perfect market” are severely truncated accounts of human nature and society, and thus very poor foundations for public policy-making, for practical politics, and for just provision for future generations. … And intelligent men and women will wonder how it was possible that anyone could ever have believed such nonsense.

Colin Camerer and George Loewenstein:
The Platonic metaphor of the mind as a charioteer driving twin horses of reason and emotion is on the right track—except that cognition is a smart pony, and emotion a big elephant.

A particularly malignant outcome of the rational patient model is the casual but all too real grouping of patients into Good Patients (i.e., those who follow their prescribed course of treatment and get better), Bad Patients (i.e., those who do not follow their prescribed course of treatment although they are capable of understanding the doctor’s advice, apparently because they are spitefully oppositional), and Pitiful Patients (i.e., those not bright enough to understand the wisdom of the treatment plan or not functional enough to execute that plan).

This de facto classification can cause clinically and ethically flawed practices. For example, the fear that nonadherence to the anti-HIV medication cocktails causing the development of treatment-resistant HIV strains combined with the notion of bad or pitiful patients (who are noncompliant in either case) has sometimes led to recommendations that these drugs be withheld in certain cases, usually designated by the presence of race, ethnicity, socio-economic class, or history of substance abuse, factors believed – inaccurately – to be predictive of poor compliance.

Replacing the idea of a patient who is perfectly rational with a more realistic hypothesis that accounts for other, non-intellectual influences is an essential step toward understanding compliance management.

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The State Of The Art Section, which includes The Verdict, Current Models, Current Programs, and Patient Behavior subsections and all citations is available in PDF format for download at ~State Of The Art~


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