Practical Implications of Behavioral Economics for Dermatology Practice
Wednesday, July 10, 2013
Patient behavior is a critical issue that affects whether
patients develop skin disease (for example, the ultraviolet [UV]
exposure behavior that causes skin cancer) and whether patients
with skin disease improve or recover with treatment (as their
adherence to treatment determines their outcomes). Addressing the
behavioral choices that patients make is an important component of
dermatologic practice. The evolving area of behavioral economics
that involves the psychology of the choices that patients make, and
which was the basis for recent Nobel Prizes in
Economics,1 has important practical implications for
Standard, traditional economic thinking modeled humans as
completely rational utility maximizers. Experimental behavioral
psychologists who have examined the choices that real people make
have found that people's behavior diverges from this model in a
long list of critically important ways (Table 1).2
Understanding these 'predictably irrational' characteristics of
human thinking has implications for nearly all aspects of
Table 1. Common Cognitive Biases That Lead People to
Behave Differently from a Rational Utility-maximizing
People place a far greater value on a loss than they do on a
The extent to which an item stands out from other items
The tendency to base decisions on a previously considered
'anchor'; even a random anchor can have a significant effect on
people's decisions and behaviors
The context in which an event is observed affects the subjective
perception of the event
'Not invented here'
People have a strong tendency to defend and act on what they
perceive to be their own ideas
Meaning makes a strong contribution to people's perceptions of
Consider the issue of loss aversion. People are
bothered much more by losses than they value equivalent gains.
Presenting information as a loss has the potential to be more
meaningful than presenting the same information as a gain. Patients
would probably be much less excited about a drug that would help
them live a year longer than one that would prevent them from dying
a year earlier. So, rather than explaining to patients that using
sunscreen has a benefit in enabling them to look better for longer,
we might choose to frame the use of sunscreen as helping to prevent
the loss of their healthful, youthful-looking complexion.
Salience, the quality of standing out relative
to other items, also has a major impact on people's thinking.
People have a far greater fear of a terrorist attack on an airplane
than they do of dying in a car accident, even though the latter is
a far more common form of death. The terrorist attack stands out
much more in the mind; the more graphic the image is, the greater
the impact. We can put this to use in encouraging better sun
protection by changing how we discuss skin cancer. Telling patients
that sunscreen can prevent skin cancer does not have the same
salience as telling patients that "sunscreen can help prevent you
from developing a golf-ball-sized, ulcerating, odious skin cancer
of your nose that requires removal of your nose, leaving a gaping
hole in the center of your face, but don't worry, you would be able
to wear a nice latex nasal prosthesis to cover the hole". The
description of the specific possibility of a golf-ball-sized nasal
tumor can have greater impact than the description of skin cancer
in general, even though skin cancer in general is far more likely
and includes the special case of the golf-ball-sized tumor.
Anchoring refers to the tendency to 'anchor' on
a reference, even a random one, when making decisions. When people
were asked to first think about the last two digits of their social
security number and then state what they thought the value of an
item was - people with higher numbers in the social security number
stated higher values for the item.4 This can be used to
affect the level of risk that patients perceive a risk to be. For
example, telling patients that "the risk of this medicine is
greater than the risk of a lightning strike", will appear much
safer to patients than telling them that "the risk of this
medication is less than a coin flip". Marketers use this same bias
in getting people to purchase products, marking the price up high
initially, then giving the consumer a lower price on discount. The
initial high price provides an anchor that makes the discounted
item appear to be of great value. Pricing cosmetic dermatology
services could benefit from similar strategies.
Context has a huge effect on people's thinking.
The frame of mind that people are in changes the way in which they
view things and their resulting behaviors. Putting people in a
religious frame of mind - even if they aren't religious - affects
their likelihood of cheating. A study examined this phenomenon by
administering a test to people on which they had the ability to
cheat. The investigators found that by asking people to try to name
some of the Ten Commandments before taking the test, cheating was
nearly completely eliminated.5 This phenomenon might be
useful for determining whether patients are taking their medication
regularly; by discussing with them their religious affiliation
before asking them about medication use, more accurate information
on medication use can be anticipated.
People have a profound tendency to prefer and defend the ideas
that they make themselves, along with a tendency to resist
the ideas of others, particularly when those ideas are
externally imposed. When we give medications to patients, there is
a considerable likelihood that patients will be poorly adherent to
the treatment regimen. It could be helpful to give strategies to
patients that they can use to remind them to use the treatment, but
if those strategies are pushed onto people, adherence may be
paradoxically reduced.6 To the extent that we can, it
may be helpful to elicit ideas on how patients will remember to use
the treatment. If it is their idea (even if we help them come up
with it), it is potentially going to be more effective.
Although standard economic theory focuses heavily on
quantitative measures of value, real people are affected by the
meaning of what they do. This was studied by
paying research subjects to put together Lego
models.7 The authors proposed that a sense of
meaning was a hidden motivational driver of productivity in the
labor-producing workforce. To study this, they recruited college
students who were asked to perform the simple repetitive task of
building pre-defined Lego models according to a per-unit wage
schedule that declined on each successive model completion. Under
one condition, the 'Meaningful' condition, subjects made multiple
copies of the same model and placed each one on a desk such that
the subject could observe steady accumulation of Lego models,
whereas under the 'Sisyphus' condition, once subjects completed the
model, the pieces were taken apart and given to them to make again.
The total lack of meaning in the second condition led the students
to put fewer models together and to require higher payment for the
ones that they did put together. Fortunately for dermatologists,
the feedback we get from patients for making their lives better
gives our work tremendous meaning. And we don't just do
dermatology; we are dermatologists. It is important that we share
meaning with all our office staff; knowing that they, too, are
contributing to making patients' lives better, which will build
their morale and encourage them in their work efforts.
- Kahneman D. Thinking, Fast & Slow. Farrar, Straus and
Giroux; New York, New York, 2011.
- List of cognitive biases. http://en.wikipedia.org/wiki/List_of_cognitive_biases.
Accessed May 11, 2013.
- Ariely D. Predictably Irrational: The Hidden Forces That Shape
Our Decisions. Harper Collins; New York, New York, 2008.
- Ariely D, Loewenstein G, Prelec D. Coherent arbitrariness:
Stable demand curves without stable preferences.Q J Econ
- Ariely D. Cheating. http://danariely.com/tag/cheating/.
Accessed May 11, 2013.
- Yentzer BA, Gosnell AL, Clark AR, et al. A randomized
controlled pilot study of strategies to increase adherence in
teenagers with acne vulgaris. J Am Acad Dermatol
- Ariely D, Kamenica E, Prelec D. Man's search for meaning: The
case of Legos. J Econ Behav Organ 2008;67:671-677
(also available at http://people.duke.edu/~dandan/Papers/Upside/meaning.pdf).
Other Recommended Readings
Ariely D. The (Honest) Truth About Dishonesty. Harper Collins;
New York, New York, 2012.