Tuesday, 4 March 2014

Why I keep on getting parking tickets and you can’t seem to take your drugs


Arriving home the other day I noticed that on the table, together with the other letters, was an open envelope containing a penalty charge notice….

“What is this?” I asked, shocked.

My husband looked at me and said “You got another fine for entering and stopping on a box junction, will you ever learn not to do it?”

The truth is that we are all able to understand the implications of our behaviour. We know that certain acts will have certain consequences. And we have this in the back of our minds.

Yet why do we keep on making the same mistakes? Why is it that we ignore the warning signal? Or in other words; why does our brain fail to learn from previous experience without allowing this cause-effect chain to positively guide our behaviour, for better outcomes?

I think these questions are very much related to what happens when patients fail to comply with their treatment regimes.

We are extremely capable of assessing immediate threats. It’s something we are hardwired to do. But our brain, to a certain extent, is less skilled at assessing more long term risks. When we assess long term possibilities we get clumsy. We somehow dismiss the possibility of not getting over our sickness or injury and often overestimate our capacity to overcome symptoms even with irregular compliance to treatments.

It seems so straight forward that if you are sick, the only way to get better is by following the treatment that the doctor has suggested. And yet there are many articles, papers and research examining why patients struggle to comply with their medication regimes.

So why doesn’t the patient comply?

There are many theories to explain this. For example, some patients have illnesses where symptoms do not get in the way of everyday life, so it is easy to ignore the illness and hence the treatment. This is the Denial theory.

The cost of the treatment could also somehow explain why the patient does not comply, specifically in cases where the treatment is very expensive for the patient and no insurance company willing to cover that cost. For me, this reason only explains why the patient does not buy the treatment rather than why he refuses to follow it.

In certain cases, complex treatment regimens are a critical reason for noncompliance. They might be too difficult for a patient to follow, especially if we take into account the age and also if the patient have multiple conditions at once. I would justify that this is a reason for overdose or wrong compliance. This could be fatal, so establishing clear instruction is a must for the doctor. However, nowadays this can be overcome and treatments simplified for the patient making them easier to follow.

Others reasons might be related to the side-effect profile of the treatment; the flavour of the medicine; or even the lack of trust in the drugs. In the short term, this can explain why some people push back the time of taking their medicine or find a quick way out to avoid taking it completely.

I have observed this often with my children. If they do not “like” the flavour of a certain drug, they will try to negotiate the amount they ingest or attempt to avoid it all together. In turn this increases the likelihood that I will give up as soon as I see there is a certain improvement in their symptoms.

Don’t get me wrong, I am sure that some cases of non-compliance have a simple explanation. And we should always identify individual differences. However, I am going one step beyond these traditional theories to discuss non-compliance in terms of the subliminal human mind.

I’ve already mentioned that we do not evaluate risk in the short term the same way we evaluate risks in the long term. To put this into context, we are often more aware of the weather issues that can ruin our flight arrangements when we go on holiday than the need to recycle more to reduce the long term impact of climate change.

Early approaches in Psychology assumed that individuals behave in a rational manner, weighing information before making a decision. So, the more information you have the more likely you will accurately assess risk and hence the higher the probability you will act accordingly. In our case, the more you know about your drug and illness the more you will comply with your treatment. However, this approach is not the entire story. Evidence has shown that the possession of additional information alone, won’t shift perceptions. So, we need to understand what factors influence how individuals assess the information they are presented with - not an easy task!

And I have not yet talked about something that is becoming increasingly important in the field of behavioural economics; our emotions. Specifically, what feelings are associated with an individual’s experiences and how do these feelings guide their behaviour?

Emotions can be positive or negative, so if we associate a negative emotion with a consequence we may avoid that outcome by not pursuing it. So, a positive feeling about something will increment the probability that we repeat an action.  However, even this theory has proven to be missing pieces of the puzzle.

Research has shown that risk perception is highly dependent on intuition and experimental thinking as well as emotions.  In summary, it seems that we evaluate our environment in a rather non-rational way.

So going back to my initial questions; why I do keep collecting parking tickets, why does a patient not comply with his medication, and why we do we not do anything to avoid the dangers of climate change?

I think we assess the future in a rather blurred way and only act in the immediate present. This is a basic survival instinct, and as a result we fail to link our actions today with a potential negative outcome of tomorrow and understanding how maladaptive our behaviour can be.

What does this mean? Well, we like to take our chances, or at least I do!

This article was written by Ana Puglisi in our UK office.

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