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Tuesday Apr 17, 2018

Two Approaches to Making Your Point With Patients

Pursuing a master's degree in public health during my first year as an attending is difficult, but oh so educational. I think family doctors are the physicians best suited to enacting public health changes in our communities, so I have decided to distill my MPH classes into digestible, useful-to-the-family-doc bits in this blog.

[turning dial - low, medium, high, impact]

Today, I bring you Part II, in which we talk about persuasion and marketing.

My class is called Intro to Persuasive Communication. The basic premise is that science, when presented in tables and glossy journals in 10-point type, is not nearly as persuasive to the public as we think it is. For decades, we have believed that the "data will speak for itself." As it turns out, for the average consumer, using market research and a basic understanding of human psychology will make that data heaps more influential than quoting p-values and confidence intervals.

For this summary, I will cover the basics of how we make decisions and then detail a few of the most common heuristics (a.k.a. mental shortcuts) marketers use to bend us to their wills.

Significant credit goes to the excellent book Thinking, Fast and Slow by Nobel laureate Daniel Kahneman, Ph.D., whose summary informed much of my class. Basically, Kahneman wrote that humans make decisions using one of two systems. System 1, or peripheral processing, relies on heuristics, quick judgements and gestalt. It is constantly operating, nearly automatic, uses little effort and results in default behaviors. It is helpful to us because it allows us to do easy, rote tasks constantly, immediately and without expending energy. Think about things like 2 + 2, or jumping back when you think you see a snake. You do these things without really thinking about them, and they can be helpful. Sometimes you are embarrassed because it was just a stick, but your subconscious mind would rather be safe than sorry.

System 2, or central processing, is effortful. It requires focus and time and consideration. You cannot multitask when trying to use System 2, but it allows you to make measured, thoughtful decisions. Think about things like 374 x 845, learning from someone using a PowerPoint, or reading and comparing nutrition labels. You can do them, but it will take some effort.

When someone is using System 1 to make a decision, certain techniques are more powerful than others, and vice-versa when they are using System 2. Further, you can structure your outreach or interaction to force the audience into System 1 or System 2 processing by managing the context and situation. I am going to show you how to do both.

People tend to use System 1 processing when they

  • do not have a lot of time;
  • are not knowledgeable in the subject material;
  • do not care much about the topic, that is, they have a low understanding or need for cognition;
  • are distracted, say by loud noises or bright lights (or mascots);
  • have no responsibility for the outcome; or
  • are in a low-consequence situation.

Conversely, people tend to use System 2 processing when they

  • are invested in the topic;
  • are knowledgeable, think they are knowledgeable, or curious about the topic;
  • are responsible for the outcome;
  • have abundant time;
  • will be affected by the outcome directly in a way they care about; or
  • are in is a high-consequence situation.

Thus, if you want someone to process via System 1 thinking, you rush them, make everything flashy and loud, and then diminish the perceived importance, responsibility and consequences of the decision. For example, if you want college students to use System 1 thinking while discussing a proposed change to graduation requirements, make it come into effect 10 years after they graduate. If you want them to process via System 2 thinking, make it come into effect before they graduate. Think about toy commercials -- flashy, loud, full of jump cuts and other people having the fun that you want to have. They are trying to force you into System 1 thinking to sell you something you don't need.

So what kinds of arguments hit hardest in each of these systems?

If dealing with System 2, make sure you are a credible source, then lay out thoughtful, understandable, actionable arguments. Use facts, be relevant, anticipate concerns or questions. It's straightforward and obvious, but it works. If it is important to someone, they will try to make a measured, considerate decision. Feel free to use the following heuristics to bolster your credibility or appeal, but for System 2 thinkers, you must have a strong, reasonable base.

If dealing with System 1, we rely exclusively on heuristics. These are good to know because you, dear reader, inevitably use them as well, and it is revealing to learn how you make unconscious decisions. We will go through the eight most common heuristics, with examples.

  • Affect/liking: If we generally like the person giving the argument, we are more likely to agree with what they say. So be likable. When it comes to liking something or someone, you often cannot explain why, cannot change your mind, and your conclusions rapidly dissociate from facts and reason. Thus, if they are not going to pay attention to the quality of your arguments, make sure your presenter is likable. In short, if we want to be like them, we want to like the things they like.
  • Anchoring and adjustment: Get the audience to set an anchor, something to which their product or argument is to be compared, like an "original price" on a sale item or a statement that "Some people might tell you that this cannot be done, but ..." When compared to the anchor, your arguments feel powerful and motivating.
  • Representativeness: If it looks like a thing, it must be like that thing. People ranked two different soda cans on "lemon flavor." One can was green. The other was green and yellow. They responded that the drink in the green and yellow can had significantly stronger lemon flavor even though it was the same soda in both types of cans. It seems crazy, but data support it. People think pasta sauces with more green on the labels are healthier than others, and anything that says "natural" must be better for you.
  • Availability: We rely more heavily on data that come quickly to mind. People tend to remember recent information better, making opinions biased toward the latest or most frequent news. Secondly, people tend to remember simple stories and anecdotes better than numbers and figures, meaning that they will be more impactful simply because people remember them easier.
  • Price/quality: We use price as a proxy for quality. My favorite example is a 2015 study(n.neurology.org) in which two Parkinson's medications were pitted against each other in a double-blind crossover. The twist? Both drugs were placebos. One was more expensive than the other. Want to guess which one was said to work best?
  • Scarcity: If there is only one left, or it's a limited-time offer, we are more likely to spring for it. You will see this time and time again in retail environments. Either the sale is ending, or there is a limited supply, or maybe the sky is falling, but marketers definitely try to impart urgency and scarcity. What can we say, we fear missing out. FOMO is real.
  • Consensus: If everyone in our reference group (the people we want to be like and be liked by) is doing something or believing something, we probably ought to, as well.
  • Credibility: Also called argument from authority, it means we give more weight to points made by people who seem credible. You can augment credibility with appearance, degrees or maybe even by disagreeing with what you "should" be thinking, thus identifying yourself as a truth teller and nonconformist.

How does this apply to patients, you ask? Well, you can usually tell when someone is interested in a topic or not. If they are interested, use strong arguments, make connections and reason with them. If they are not interested, you might expend some time getting them interested by making the topic highly personal, germane to their interests and desires, and give them the time to think. If not, rely on your System 1 heuristics: quote experts, use anecdotes rather than numbers, highlight costs and savings, detail how if they don't protect their heath it is indeed a "limited-time offer," and make sure that you are likable, even when saying things they don't want to hear.

For extra fun, pay attention to how you shop next time you are at the grocery store. Are you convinced to buy something you normally wouldn't because it is such a "good deal," or "used to be so expensive." Have your heard yourself thinking, "It's such a good deal, I can't afford not to buy it!?" Are you drawn to one brand of salsa instead of the other because it uses what looks like recycled materials for the label? Are you convinced to enter a store by signs that say "Sale! Today only!"

If so, you are not alone. And definitely not in the wrong. We all use heuristics, and we all use System 1 processing. It would, quite literally, be crazy not to. I find that once you have names for the two systems, you can sometimes catch yourselves using System 1 when you shouldn't. Then you can decide which system you want to use, and thereby resist getting tricked into buying yet another Ninja Turtles toy, regardless of how many actions, colors and sounds it may boast.

Stewart Decker, M.D., is a family physician practicing in southern Oregon. He focuses on the intersection of public health and primary care. You can follow him on Twitter at @drstewartdecker.(twitter.com)

Posted at 10:03AM Apr 17, 2018 by Stewart Decker, M.D.

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