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What affects the doctor' prescription?

The world of commercial medicine is fascinating, in that it is really simple and complicated at the same time. I'll write a little more about this in the future, but for now, let's take a look at this example.

For many common ailments, generic (i.e. no brand medications) are no different from branded medication. Think about a normal and a branded T-shirt - in most cases really not much difference besides the brand. Doctors, of course, are aware of this. 

However, researchers at the Perelman School of Medicine at the University of Pennsylvania noticed that the doctors at the UPenn health system tend to prescribe branded drugs instead of generic drugs (to be clear, there is no financial incentive for them to peddle more expensive drugs - these doctors do not get a cut from sales). This meant greater costs for both patient and the health care system, and studies actually show that branded drugs have a lower rate of adherence (it's expensive, so people tend to default).


In other words, there is no benefit for branded drugs to be prescribed when generic drugs were just as good and cheaper*. The researchers wanted to change such behaviour, and so they thought about the default system that was so useful in changing behaviour for organ donation.  

Organ donation rates upon death for many countries was barely in double-digits when the default was not to donate (i.e. you had to specifically indicate that you wanted to opt-in to donate your organs). When the default was changed to donate (i.e. your organs will be donated upon death unless you specifically indicated you wanted to opt-out), the donation rates were in the high 90%.

One argument against this though (terribly bad one but the world is full of bad arguments) is that people aren't experts on organ donation. They don't know if they should donate their organs upon death or not, because it's not a question people think about. So they simply follow the default option.

But will the default option be as effective for experts - the doctors? What do you think? if we try out the effectiveness of the default option on experts?

*(In a blog post, I supported the theory that just branding and making the same medication more expensive leads to a placebo effect where people actually felt it was more effective. In this case, there is no placebo effect because patients have nothing to compare to - they don't know the prices of drugs other than what they were prescribed)


Image Credit: David Asch, "Why it's so hard to make healthy decisions", TedMED 2018

The default option was introduced in mid-November, where doctors defaulted all prescriptions to an equivalent generic, if available. If they wanted to prescribe a brand name, physicians had to opt-out by checking a box labelled "dispense as written."


And was it effective? Look at the graph above (click to magnify). Every line on the graph represents a type of drug choice. Before the default, the generic drug was chosen between 20% to 100% of the time, an average of about 75%. With a simple change to the default option being the prescription of generic drugs - the rate rose to 98% across all drugs.


This study, like many others shared on this page, affirms how our decisions can be changed even though the decision factors remain exactly the same, merely with simple modifications to how the options are presented. This happens without us really realising it. For example, even though the doctors were now prescribing almost exclusively generic drugs, they would formulate a logical reason to explain their decision, perhaps that generic drugs were just as good. But we know for a fact that this explanation is falsely manufactured - if they truly believed as such, why did they do so only after we changed the way choice was presented using the default option?


As humans, we are not rational, we have innate inclinations and biases which most of the time we are not even aware of. This is not news. We all know this. But because we are irrational in predictable ways, we can leverage on our biases to instead guide ourselves to making better decisions. 

Read the full paper here.

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