Do We Really Understand How Physicians and Patients Make Decisions?

How do human beings make decisions and how do those decisions lead to actions?

Whether you are launching a new treatment for a condition, or have new data that changes how an existing treatment should be used, you will need to engender changes to existing human behavior. There is a lot of research on behavior change but do we apply it? Are we willing to recognize that physicians are humans first and doctors second?

Brand is ultimately about behavior, a person makes a decision based on their belief about a brand and that leads to a behavior.  So, underpinning every behavior is a decision and the decision has to come before the behavior or the behavior would not happen. The decision could be completely subconscious (and most likely is) and the individual may not even be aware they have made a decision.  Think about driving your normal route to work each day. You are constantly deciding when to accelerate, brake, change gear, check your mirrors. How many of those decisions are conscious rather than subconscious?

According to academic research, every day we make somewhere between 23,000-35,000 decisions that allow us to function effectively. The vast majority of these decisions are made subconsciously; in fact a study from Columbia University in 2012 estimated we only make around 70 conscious decisions each day.

System 1 and System 2 thinking

There has been a lot of research into decision making and some of the most influential work is by Daniel Kahneman who won a Nobel Prize in 2002 for his work.  He, along with his colleague Amos Tvesky, developed the concept of System 1 and System 2 thinking. System 1 thinking is fast and intuitive, it is the subconscious decision making, while system 2 thinking is slow and deliberate, the conscious decision making.  There is a constant interplay between System 1 and System 2 thinking and the brain is frugal with its cognitive capacity; wherever possible it will hand over decision making to System 1.

Understanding how people make decisions is a critical step in defining how to support people in making new decisions that lead to changes in behavior.  A common perception of medical professionals is that they make rational decisions.

Society holds healthcare professionals to very high standards but they, like the rest of us, are human and make decisions using the same processes as all other humans.  This explains why in lots of critical situations within healthcare there are set procedures and standard approaches to minimize the vagaries of human decision making.  

Think about a physician or other healthcare professional who, in order to see all the patients in their clinic, meets a different patient every 10 or 20 minutes.  They must use System 1 thinking because System 2 thinking is just too slow and laborious.  At this stage it is important to remember that the physician has accumulated years of hard earned System 2 thinking which, through continued education and development, has trained their System 1 thinking to be effective in this setting.

Even in situations like multi-disciplinary meetings, what you find is a group of professionals all applying their own System 1 thinking. Only at the stage where they do not agree will they move to System 2 thinking to resolve the difference of opinion.

The context of the decision

System 1 thinking, as we mentioned, is fast and subconscious and it is also influenced by the context of the individual.  So, we ought to not only understand how they describe the patient they made that decision for, we also ought to understand what time of day it was, what the circumstances were, i.e. was it a clinic, was it a ward round, were they alone or with others, who was the patient they had seen previously, were they on time or running late, etc?  This is the context of the decision.

On showing an anonymized product profile of brand x to physicians, their reaction was hugely positive.  They described it as ‘best in class’ and pronounced high levels of potential prescribing should the brand be available to them. However, in reality the product was already on the market with a market share of around 10%.

If subconscious decision making is a practice exhibited consistently, without conscious evaluation, then it is even more important to understand how and why that decision process has been so ingrained into an individual’s System 1 way of thinking.  This context helps you to understand the heuristic (the mental shorthand) that they use to make System 1 decisions. It allows you to take into consideration factors like decision fatigue and cognitive dissonance.

We have many examples that demonstrate ingrained System 1 thinking in practice. We recently worked with a client team whose brand (brand x) was competing against a well-established class of drugs with a number of brand choices available. On showing an anonymized product profile of brand x to physicians, their reaction was hugely positive.  They described it as ‘best in class’ and pronounced high levels of potential prescribing should the brand be available to them. However, in reality the product was already on the market with a market share of around 10%. How did this happen? The physicians’ decision making was so ingrained in System 1 thinking, that they did not disengage from this automated route to consciously re-look at the data (and engage System 2) which might lead them to make a different treatment choice.

What does it mean for market research?

The above indicates why most market research falls short. Market research approaches are developed by people thinking rationally to create a research guide. Those people also think the physician is making rational decisions. The discussion guide then goes through an approval process where it has to conform to a set of rational rules. In the case of most new therapies the physician is then confronted with a TPP crammed full of rational information that bears no relationship to how they will eventually experience the product, never mind the brand. At the end of this there is little surprise that what the research uncovers is post-rationalized System 2 thinking.

Insight is the fuel of every great brand and insight must uncover System 1 thinking and not just System 2 post-rationalization.  So how can you start to get closer to uncovering System 1 thinking and finding the core insight that will fuel your brand?

1. Start with a rigorous foundation.  Have a clear understanding of the historical market information and thinking that has shaped the decision-making process of the customer and the wider community. Remember all that hard won System 2 thinking from training and education?  It is this background that has shaped System 1 thinking.  Don’t waste research time on things you can find out through reading and investigation elsewhere.

2. Be clear on what you really need to know. Be ruthless about what you must know, versus what is nice to know, because getting a deep understanding takes time and a focus in on the key areas will uncover real insight. A mile wide and an inch deep will not build a strong brand.

3. Understand deeply the context in which the decision is made. It isn’t enough to have someone tell you about the last example of the decision that they made. You need to know when the decision happened, what had preceded it, what else were they thinking about, what day of the week it was, etc. This allows the person to put him or herself back in the situation and to give you a more realistic rather than post-rationalized account.

4. Always be aware of cognitive biases and the role they play in research both for the interviewee and those conducting and viewing the research.  For example, confirmation bias, which creates a greater awareness and recognition of information that supports the beliefs we already hold. Recall bias, where we give more importance to information that is easily recalled.

If you make these imperative to your market research approach, it will help uncover the conscious and subconscious decision making you need to understand, to affect the behavior change you are seeking.  It provides a robust foundation – real insight - on which to build a successful brand strategy.  It a philosophy and approach we believe brings huge value to our work and we welcome your thoughts, comments or examples to share from your own experience. 

David Coleiro and Michael White are Directors at Strategic North. Both have around 20 years of global experience within pharma insight, brand and commercial roles.

In their ‘Building Purposeful Brands’column, they share their unique insights on the world of healthcare and healthcare brands. Strategic North is a healthcare marketing agency that works with clients in the pharmaceutical industry around the globe to build the successful brands of today and tomorrow, grounded in human insight and scientific understanding. David, Michael and their colleagues tweet @StrategicNorth and blog at

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