Is Prescribing Behavior Rational or Emotional?

For you and your sales force, the past six months have been an absolute whirlwind. The company has been developing a longer-acting and safer alternative to a widely prescribed medication. On the heels of a highly successful clinical trial, a notice of compliance is just around the corner.

Needless to say, your sales force is fired up. Appealing to the evidence-based practitioner should be a breeze, given that the team is armed with a wealth of promising facts and figures from the recent clinical trial. Many on the force feel that the benefits of this medication are so self-evident that it will practically sell itself. The marketing team has also been firing on all cylinders and the result is a carefully crafted brand position and highly evocative messaging. Based on the marketing team’s thoughtful insights, this campaign is poised to resonate with a large majority of physicians. However, as the first wave of sales representatives report back from the field, you’re hearing an all too familiar story:

“Physicians understand that our drug is measurably superior. They also recognize that they have patients for whom it could be an exceptional fit. However, the sales numbers show that, despite their interest, they just aren’t prescribing it!”

Your efforts to propel what could otherwise be a highly beneficial medication into the mainstream are falling flat. What is going wrong? To understand this issue, we need to carefully re-examine the factors that influence physicians’ prescribing behavior.

Rational vs Emotional Pathways to Impacting Behavior

Conventional wisdom tells us that there are two primary pathways to impacting prescribing behavior: (1) the rational path and (2) the emotional path. The rational path involves using facts and figures to appeal to a physician’s logic and their drive to maximize treatment efficacy and safety.  The emotional path means building a positive and well-differentiated brand that enables physicians to connect with the product on a personal level.

New learnings from the field of behavioral science, however, have shown us that the rational vs. emotional model represents a false dichotomy. Emotional and rational influences are not mutually exclusive but rather they interact in predictable ways. More importantly, there are fundamental barriers to changing prescribing behavior that must be addressed before any combination of rational or emotional appeals will have an impact. These fundamental barriers are rooted in the need for cognitive ease. For many physicians, it’s not a matter of which treatment is measurably superior. Instead, it often comes down to which treatment requires the least amount of cognitive resources to implement. With that said, the question becomes why would any self-respecting physician prioritize cognitive ease over quality of care?

The simple answer is that they’re human. No matter how brilliant physicians are, they have a limited pool of cognitive resources at their disposal and, unfortunately, this pool is already stretched impossibly thin. Primary care physicians are increasingly expected to maintain a working knowledge of a broad range of therapeutic fields. They also contend with exceptionally high patient caseloads. It is well established that when our mental resources are depleted, we tend to rely on mental shortcuts to make the load more manageable.

When cognitive resources have been depleted and we are forced to make important decisions, we tend to do one of the following in order to ease the burden of choice:

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We rely on existing habits

We do what others are doing

We avoid doing anything at all

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Taking what we know about human decision-making, consider a physician treating an ailment where there are multiple classes of drugs to consider, each with distinct mechanisms of action. Within each class there may also be tens of specific medications whose composition and functions differ in such small increments that they are difficult to differentiate. To avoid being paralyzed by the sheer volume of available treatment options, physicians must use the mental shortcuts outlined above.

Recent research on prescribing behavior has shown that to work around their dearth of cognitive resources, physicians often rely on ready-to-wear treatments (Frank & Zeckhauser, 2007). This means that rather than carefully considering each treatment option for each unique patient, physicians will prescribe treatment X which, through a combination of established best-practices and their own experience as practitioners, they have learned is good enough for the vast majority of patients who fall into the same broad class of therapeutic needs. While it is clear that ready-to-wear treatments stand to reduce the cognitive resources, physicians need to expend on a daily basis, it may nevertheless seem alarming! Yet from a behavioral science perspective, this practice is highly adaptive as it enables physicians to overcome indecision and to improve efficiency. As discussed, depleted cognitive resources can lead the decision-maker to avoid doing anything at all. In that vein, previous research has shown that when physicians are forced to compare too many similar treatment alternatives in an experimental setting, the cognitive difficulty associated with making an informed choice can lead them to advise against any medication at all, despite the potential benefits (Redelmeier & Shafir, 1995).

While the ready-to-wear treatment strategy may carry benefits for both physicians and patients, unfortunately, the need for cognitive ease spells bad news for your new medication. While your product, treatment Y, may be optimized to a particular subset of patients, it may ultimately be the 7th product in the 5th class of drugs. Moreover, from a functional standpoint, it may only offer marginal benefits over the established alternatives.  To better differentiate treatment Y, you may feel compelled to lean in with supporting facts and figures. We understand why this compulsion is so strong. Clinical trials are very expensive and they are the culmination of years of research. Nevertheless, this is a perfect example of the sunken-cost fallacy. We often pursue fruitless endeavors simply because of the time and money we’ve already invested. The reality is that, for most physicians, facts and figures are not persuasive because the cost in terms of the cognitive resources necessary to consider both treatments X and Y will outweigh the potential benefits.

The good news is that behavioral science has given us the tools to understand and to thereby penetrate the day-to-day constraints that drive physicians’ decision-making. By shifting from old models of decision-making (rational vs. emotional) to a new model that encompasses the cognitive and behavioral barriers to prescribing behavior, it is possible to cultivate highly impactful sales tactics. Here are three key steps that you can take to greatly enhance the effectiveness of your sales tactics through the application of behavioral science:

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