Written by Sarah Smith | Daniel Sterzi | Regina Gowindah
The role of emotion in research.
“The best and most beautiful things in the world cannot be seen or even touched. They must be felt with the heart”- Helen Keller - author
As humans, we like to think that we are rational, that we make logical decisions. We particularly like to think that those responsible for our health, healthcare professionals, are rational and that they will make the best possible decisions on our behalf.
And in part this is true. Clinical and scientific data supporting the use of recently approved treatments, for example, is indispensable but there are many layers to decision-making and many factors that come into play which should not be disregarded.
As humans we are fallible, illogical and often messy in the way we make decisions. We are often not aware of what influences our decisions, including contextual influences and emotional reactions. Despite the focus on evidence-based medicine, despite a culture of objectivity and despite training to that effect, healthcare professionals are human too. They are not rational decision-making machines any more than you or I are1 2– and if we want to truly understand what drives their choices and behaviors, we need to stop treating them as such.
Research confirms that emotion is a powerful driver of decision-making
Neurological studies involving patients unable to process emotional information suggest that people make decisions not only by rationally evaluating likely consequences and their probability of occurring, but also (and sometimes primarily) at an emotional level. 3,4
Emotions affect attention, learning and memory. Emotions may precede thoughts and associated cues are automatic in nature and influence behavior. For any action we take, the positive or negative consequences we experience as a result create an automatic emotional response which influences our behavior the next time we encounter a similar scenario.5 Our anticipation of the likely reward or regret we will experience, and our expectations of how this will make us feel, has an influence on the choices we make next time around.
Moreover, emotion doesn’t just influence our own behavior but also that of others, for example, facial expressions communicate to others the value of a stimuli they haven’t yet experienced.
However, far from being a hindrance, in certain circumstances, emotion can actually improve the effectiveness of our decisions.
Emotions can override rational responses6 which can sometimes improve the effectiveness of decisions7,8,9
The influence of emotion on decision-making has advantages in terms of:
- Enhancing attention10
- Influencing how we perceive and react to risk11
- Facilitating learning and problem solving12
- Promoting flexibility – an important aspect of creative thinking13
Emotion affects the utilization and efficiency of cognitive processes, influencing what is stored in memory, allowing us to hone in and focus attention on the most relevant information for further storage, so that only these items are remembered14.
Going with what ‘feels right’ can help us simplify highly complex decisions and is particularly useful when fast decisions are needed15.
Healthcare professionals are no exception to this
Clinicians’ experienced emotions can and do affect clinical decision-making, although acknowledgement of this is far from universal.16
We can see this reflected in physicians’ use of language. A qualitative study by Cerner Enviza found that oncologists used more emotive descriptions such as “glorious”, “lucky”, “hopeful” and “upbeat” to describe an advanced cancer presenting an actionable genomic alteration compared to the description of the same cancer without the genomic alteration.17
In fact, medicine is one of the most emotional settings for decision-making18 being characterized by life-or-death decisions, accompanied by long working hours19 and requiring time-pressured judgements.20
Even experienced, highly trained physicians harbor strong emotional reactions that may affect their physician-patient interactions.21 For example, studies have shown that:
- Experiencing a negative, potentially anxiety-provoking event can influence decision-making to prioritize the avoidance of risk, even among experienced vascular surgeons who have ready access to statistical risk information.22
- Amongst anesthetists, a positive emotional state has been shown to improve cognitive fixation23. Cognitive fixation is a well-recognized influence on mortality and morbidity which can be informally described as difficulty thinking ‘outside of the box’, such as tending to stick with the same plan even when the circumstances change, and/or finding it difficult to come up with creative new solutions.
- Nurses demonstrating more emotional arousal perform better on decision tasks in simulated medical emergency scenarios.24
Seduction beats persuasion: Emotional advertising is an important driver of brand choice
When looking at communication intended to drive purchase or use of a product, brand or service, data shows that emotional advertising campaigns are often more profitable and correspond more strongly with performance than rational campaigns, offering ‘moving power’ rather than ‘stopping power’.
The IPA (Institute of Practitioners in Advertising)25 databank contains 1,400 case studies of successful advertising campaigns submitted for the IPA Effectiveness Award competition over the last 30 years. Analysis by Binet and Field26 compared the profitability of campaigns which relied primarily on emotional appeal vs. those which used rational persuasion and information.
The analysis showed that:
- Campaigns with purely emotional content performed about twice as well (31% vs. 16%) compared to those with only rational content.
- And purely emotional campaigns also did a little better (31% vs 26%) than those that mixed emotional and rational content, implying that the addition of a rational message actually weakened the impact.
The Binet and Field analysis found that emotional campaigns build brands more strongly regardless of the measure: awareness, commitment, trust, differentiation, fame or image.
Emotional campaigns are far more powerful at building brands. They create emotional bonds and associations which outlast memories of facts and figures about the brand.27
Binet and Field also found that emotional-based advertising generates far stronger business results. Whilst rational campaigns lead to greater short- term sales uplift, over time, emotional campaigns drive higher long-term sales, share, pricing power and loyalty.
Physicians are also impacted by emotional advertising
The IPA analysis conducted by Binet and Field looks at advertising across
a wider variety of industries. What about healthcare? Are physicians more rational? The short answer is no: physicians are people too and as such they are subject to exactly the same emotional influences.
To demonstrate this, a recent study28 tested creative concepts with n=500 primary care physicians whose patients are vulnerable to osteoporosis. The aim of the materials was to increase bone density screenings. Concepts were divided along four dimensions: rational vs. emotional and personal vs. impersonal.
As the chart below shows, for rational, impersonal concepts, 56% of physicians stated that they would order bone density screening tests. This is little improvement on other industry data which suggests that only about half of all doctors follow guidelines for ordering bone density screening tests. When an emotional element is added however, the number of physicians stating that they would order a test rises to 69% - an uplift of 23%. The effect is even stronger (75%) when the emotional appeal is personalized to the physician’s own motivations.
At a brand level, physicians can be emotional about therapeutic classes as a group
Analysis using Cerner Enviza’s proprietary behavioral science-based STAR (Sense-Think-ACT-Relate) assessment tool in chronic lymphocytic leukaemia (CLL)30 shows emotional associations to be the strongest driver of treatment choice, more so than rational, social or environmental influences, with the strongest individual driver being ‘a treatment that I love.’ Although slightly stronger for the market leader, ‘I love’ is also strongly associated with key novel systemic therapies making it a category-level driver for this class of treatment.
Physicians can also associate emotions with specific brands
An anecdotal example of this can be seen in neurologists citing stories of the launch of Biogen’s Tecfidera in Multiple Sclerosis (MS).
The Tecfidera success story in numbers:
- After one week, Tecfidera reached sales it took Gilenya about three months to hit
- In three months, it outperformed all other MS drugs
- In six months, it captured newer ‘scripts than Gilenya and Aubagio combined, and was prescribed by 5,000 physicians
- In the first year, it made $300 million in US sales
In a market which had been notoriously cautious since having its ‘fingers burned’ by Tysabri, anecdotes were starting to emerge from neurologists who claimed to be consciously holding back from switching patients to an in-market treatment in anticipation of Tecfidera’s launch.
In fact, Biogen noted that roughly $82 million sales in the first year came from pre- ordered inventory
“Sometimes physicians may be hesitant to prescribe a drug that just launched, but the broad number of physicians writing prescriptions and putting newly diagnosed patients on Tecfidera are positive indicators about the broad acceptance of the product in the market, and that people think it has a very good profile.“
- Tony Kingsley – Biogen’s executive vice president of global commercial operations
At the time these stories were emerging, most neurologists had seen relatively little published data on the product. Clinical evidence was clearly not the only thing driving their high expectations. The most striking thing about this was the strongly emotive language used by neurologists. A tangible level of excitement and enthusiasm was apparent, with some neurologists describing Tecfidera as a potential ‘chimera – like a dream come true’.
Helped by a strong commercial share of voice from Biogen (who also market the widely-used Avonex and Tysabri in multiple sclerosis), and supported by persuasive peer-level momentum (‘everyone is talking about it’), this suggests that an emotional brand relationship was starting to build well before all of the rational evidence was in place.
The influence of emotion is reflected in behavior
An example of the influence of emotion on prescribing can be seen in the case of Keytruda (pembrolizumab). Despite clinical trial failures, pembrolizumab enjoyed sustained use in second-line, PD-L1 positive metastatic gastric cancer patients in the US.
Initially, pembrolizumab gained accelerated approval in a mixed second/third-line setting based on Phase 2 clinical data, but later more robust pivotal clinical trials resulted in failures in both second- and first-line settings.
Nonetheless, respondents to Cerner Enviza’s Treatment Architecture survey shortly after the trial failures reported using pembrolizumab in ~45% of second-line, PD-L1 positive patients. 31
Such high usage in an indication where pembrolizumab lost an approval suggests physicians are thinking beyond clinical data.
Qualitative research conducted by Cerner Enviza in UK, US and Singapore32 shows oncologists exhibiting strong emotional associations with pembrolizumab which reflect perceptions of:
- Quality
- “High end colors like silver and gold, maybe purple, because purple is a royal color”
- Emotional closeness
- “I would be excited to see Keytruda and I would say good to see you, you’re back here again, nice to see a familiar face”
- It’s more enthusiasm when I’m talking about Keytruda for my patients”
- And the ongoing emotional rewards associated with successful treatment
- “I had a patient with lung cancer who was very, very young, he was 40+ years old, and he had disease in the brain but with Pembrolizumab he had a complete response so I still remember him coming to my office [...] it was truly one of the highlights in my career”
- Confidence in treatment
- “It’s big and it’s confident. It’s Freddie Mercury out there, strutting his stuff”
Emotion can help distinguish brands in a crowded market
In research conducted by Cerner Enviza we have often found that emotion can help articulate brand perceptions that may otherwise be difficult to pin down. In one particular example33, qualitative research was conducted to explore the factors differentiating two oncology products in the same treatment class. At first sight, these two products appeared relatively similar. Indeed, over a quarter of the oncologists sampled could find no rational differentiators at all and although most were users of both products, many were unable to explain when or why they used one product over another.
Interviews were exhaustive in exploring all possible rational differentiators. At every turn, oncologists responded with ‘they are the same, I use them interchangeably, there is no difference’. However, using a variety of emotion-based projective questioning techniques, we were able to find nuances which started to explain the differences in brand perceptions and use.
The closer emotional relationship with Brand B starts to provide insight into the factors driving broader use.
It’s clear that if we only measure rational drivers in our research, we miss a big part of the picture
If we want to truly understand behavior, we need to understand all of the factors that have an influence upon it. Cerner Enviza’s STAR (Sense-Think-ACT-Relate) framework is based on behavioral science principles and developed from a combination of academic theory and empirical experimentation. It provides a holistic assessment of the factors influencing prescribing, going beyond rational drivers for a more comprehensive in-depth view.
In the case study below34, Cerner Enviza’s proprietary behavioral assessment tool, based on the STAR framework, was used to explore drivers to prescribing amongst 200 physicians treating cardiovascular patients.
As the chart shows, emotion is the strongest driver of brand choice in this therapy area, with rational factors playing a comparatively small role.
In our qualitative research we use a variety of projective techniques to facilitate the expression of thoughts or ideas which may otherwise be difficult to articulate.35,36
In quantitative research, emotion is equally essential to include but is more challenging to elicit and measure.
Most traditional quantitative research approaches are inherently rational in both nature and approach. Emotions, however, are visceral, nebulous, sometimes irrational. They can be difficult to explain in a traditional written question and answer format.
We need to think differently if we are to measure and quantify emotion more effectively.
There are a variety of ways we can do this. One approach is to consider the use of neuroscience tools such as implicit association tests, facial coding, electroencephalogram (EEG) and Galvanic Skin Response (GSR) (although these are certainly not without their critics with regard to their limitations in validity, reliability and logistical application in research).
As a first step, however, there are some much simpler options to consider. The use of visual ‘drag and drop’ scales rather than text-based question; card sorts; image association and selection tasks; using facial expression photographs, pictograms or emojis (based on Eckman’s theory of six universal human emotions)37 to help articulate and categorize feelings. All of these approaches provide alternatives to a traditional, predominantly rational text-based question-and-answer approach and start to give us more flexibility in tapping into emotional responses.
In addition, as voice technology and our ability to accurately capture, transcribe and analyze natural language increases, there is further potential for respondents to articulate their emotions more freely (indeed, the AI emotion detection and recognition market is expected to grow to $39.03 billion in 202638 with several companies investing in specific AI machine learning solutions that suit the particularities of the healthcare market and its medical and scientific language.
More holistic solutions such as Cerner Enviza’s STAR behavioral assessment tool can help to quantify the levels of behavioral influences beyond rational perceptions, incorporating emotional, social and contextual factors to help us build a more comprehensive picture of behavioral drivers.
In summary: There is strong evidence for the importance of measuring emotion in our research
- Emotions are powerful drivers of decisions and emotional advertising is an important driver of brand choice – healthcare professionals are no exception
- The influence of emotion is reflected in behavior
- At a brand level, physicians can be emotional about whole categories, or associate emotions with specific brands
- Emotion can help articulate brand differences which can be difficult to explain rationally
- It’s clear that if we only measure rational drivers in our research, we miss a big part of the picture. We use a variety of techniques to elicit emotion in our qualitative work. In quantitative research, emotion is equally essential to include but is traditionally more challenging to elicit and measure
It’s time to get to the heart of the matter, to go beyond rational responses and measure the drivers of behavior more holistically in healthcare.
“The feeling is often the deeper truth, the opinion the more superficial one.”
– Augustus William Hare - writer
To find out more about Cerner Enviza’s proprietary STAR framework, how we use this to provide holistic diagnoses of behavioral influences, how we include emotion in our qualitative and quantitative research, or further information on any element of the work we do, please contact us:
Sarah Smith, Strategy Lead, Global Behaviour Science
Sarah.Smith@CernerEnviza.com
Daniel Sterzi, Associate Principal, Integrated Research
Daniel.Sterzi@CernerEnviza.com
Regina Gowindah, Business Lead, Global Behaviour Science
Regina.Gowindah@CernerEnviza.com
About Cerner Enviza SM
Cerner Enviza aims to accelerate the discovery, development, and delivery of extraordinary insights and therapies to improve everyday health for all people globally. By combining decades of innovation, life sciences knowledge and collaborative research, Cerner Enviza provides data-driven solutions and expertise that helps bring remarkable clarity to healthcare’s most important decisions. For more information on Cerner Enviza, visit www.cernerenviza.com.
For more information, please contact info@cernerenviza.com
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2871592197 Cerner Enviza white paper: Getting to the heart of the matter v1/February 2023
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