Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor
Dept. of Podiatric Medicine
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences
St. Pomona, CA

Patient Views on Obamacare and the Power of Psychology: Part 2

Last week I introduced a couple of patient examples regarding reactions to Obamacare. These patients, despite the chance that they may improve their personal medical care/insurance situations, rigidly determined they would rather stay in dire straits than consider the Affordable Care Act and Covered California. At the end of last week's editorial, I posted the general question: "If we were able to understand this aspect of human nature, would we as providers be more effective at changing our patients' behaviors?" Of course, it was a loaded question, because as many of us already know the field of social psychology has made significant insights into the understanding of human behavior. In today's issue, let's discuss a couple of pertinent concepts to help us treat our patients more successfully by convincing them to listen to us.

obamacare To start, the problem I had with my two example patients was their rigidly sticking to a personal view or philosophy without considering the possibility that they could be mistaken. I see this same rigidity in many of my diabetic patients who won't change their poor habits, despite various complications, and the devastating effect the complications have on their lives. How many of us have heard of the patient with a tracheostomy after throat cancer that continues to smoke? How many female patients continue to wear high heels despite forefoot pain? There are so many more examples each of us could list.

What I have been describing thus far is termed confirmation bias. In this form of bias, people tend to explain uncomfortable information in ways that are more consistent with their current belief systems.¹ Essentially, people tend to favor information that confirms their own opinions.

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As it turns out, confirmation bias is a factor that plays into a larger psychological model called self-affirmation theory, in which we are motivated to maintain our self-integrity.² In short, we are motivated to think we are good people. Confirmation bias is one of the ways in which we protect ourselves from "threatening" information.

In my patients' cases, introducing them to the possibility that Obamacare could be beneficial to them conflicted with their current views, which may have subconsciously threatened their positive view of themselves. So they turned away from that uncomfortable information, and I failed to convince them to follow my recommendations.

You might imagine my explanation is highly simplistic, and there is much more to the story than this convenient model. However, since I'm not a social psychologist, let's keep it at this basic level. This theory beautifully explains why we so often have a difficult time convincing our patients to stop wearing high heels. This type of shoe, in our society, supposedly enhances female beauty. As such, why would a woman who desires to look desirable break with her confirmation bias and wear shoes she feels would make her less desirable, which would decrease her own sense of value? When she weighs the conflicting values of improving her self-image with fancy shoes, versus improving her health and reducing pain by choosing healthy shoes – those two competing values caused a threat, and the normal response to that threat is to withdraw, and not reconcile the conflict. The humorous image of the ostrich sticking his head in the ground comes to mind. (Do they really do that?)

The next question then, is how could I have communicated with my patients in a way that would have supported their self-image, resolved the conflict, and convinced them to listen to me?

One method, according to psychologists, is to allow the person a chance at self-affirmation prior to introducing the "threatening" aspect.³ This translates in the clinical situation to the caregiver making some statement that reaffirms the patient's value. For example, when dealing with the smoking patient, verbally establishing their importance prior to telling them to stop may decrease their resistance to the cessation message.⁴ A study in 2000 looked at acceptance of risk behavior in AIDS education.⁵ Researchers found that those who received self-affirmation prior to viewing an advertisement about the risk of AIDS contracture were more likely to accept behavior as risky and were more likely to use protective behaviors.

This is potentially profound information when it comes to educating our patients about disease risk and convincing them to listen to our admonitions. Think about all those hours you spend educating your diabetic patients about the risk of their disease, only to have them return with complications after failing to heed your warnings. We expend all that effort, fighting against powerful, ingrained psychology. No wonder we're not successful. No wonder I failed to convince my patients to look into national healthcare. Perhaps if we providers spent more time with our social psychology colleagues, we'd better understand what drives our patients and would be more effective educators.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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References:

Darley, J. Gross, P. A Hypothesis-Confirming Bias in Labelling Effects, in Stangor, Charles, Stereotypes and Prejudice: Essential Readings, Psychology Press, 2000. 212.
Correll, J., et al. An affirmed self and an open mind: Self-affirmation and sensitivity to argument strength. Journal of Experimental Social Psychology, 2004; 40: 350-356.
Jaremka, L, Reducing defensive distancing: Self-affirmation and risk regulation in response to relationship threats. Journal of Experimental Social Psychology. 2011;47:264-268.
Harris, P, et al. 2007. Self-affirmation reduces smokers' defensiveness to graphic on-pack cigarette warning labels. Health Psychology. 26(4): 437-446.
Sherman, D, et al. 2000. Do messages about health risks threaten the self? Increasing the acceptance of threatening health messages via self- affirmation. Personality and Social Psychology Bulletin. 26:1046-1058.