Healthy Influence Blog

Rudy is out.

I was wrong. I predicted about a year ago that Mr. Giuliani and Mrs. Clinton would earn the nominations of their respective parties and that Mrs. Clinton would then win the general election. I based this prediction solely upon my intpretation of all the candidates persuasion skill as evidenced by their participation in prior elections. My claim is that the more elections you are involved with and the more often you’re on the winning team, then the better your persuasion skill.

As I analyzed the election experience of the candidates it seemed obvious to me that Mrs. Clinton is head and shoulders above the Democratic field even if a lot of her experience was merely being inside Bill Clinton’s campaigns. No one comes close to her campaigning background. On the Republican side, I dismissed John McCain’s considerable experience in campaigns because he had already lost the big one once before and that is a reliable kiss of death . . . except in the case of Mr. Ronald Reagan and I thought that Mr. McCain was no Ron Reagan. That left Mr. Giuliani as the Republican with the most campaign experience.

I think in retrospect that I broke my own rule of looking at the sheer amount of campaigns as a proxy for persuasion skill. Mr. McCain clearly has more of it than any other Republican candidate and always has. That primary loss to Mr. George W. Bush in 2000 made Mr. McCain a dead man walking in my estimation and that was incorrect.

In March of 2007 when I first thought about this rule of thumb for predicting election winners through persuasion skill, if I had stuck to a bare-faced application of the rule, I would have predicted Clinton and McCain. And, I’d be writing a different post today.

I’m not nearly as smart as I think I am, am I? I can’t even follow my own rules.

In my neverending quest to improve the persuasion IQ of the world, I scour the Internet looking for examples of accurate and inaccurate presentations of theory and research. Today my search turned up an inaccurate example concerning New Year’s Eve Resolutions.

The BBC ran this story about using self persuasion to help their readers with those perennial plans to lose 10 pounds, exercise more, stop lingering by adult book stores and so on . . . (that was a joke). What’s nice about the story is that they actually mention an outstanding example of persuasion theory and research, the work of Robert Cialdini and the six cues of influence.

As the story states,

Scientists have been studying the influence process for over half a century and have found six principles that not only help organisations to get us to say “yes” to their requests, but could also help us to achieve the goals we set ourselves.

So far, so good. Except for one thing. There is no way that these persuasion and influence cues would produce significant, lasting behavior change. As Cialdini and other persuasion researchers have noted, these kind of persuasion tactics are aimed at people who are “low WATT” thinkers, with limited Willingness and Ability To Think (Cialdini calls this “click,whir” in his great book, “Influence.”) Cues are useful to such people precisely because they require limited cognitive processing. Thus, we typically find that likable people are more persuasive when receivers really aren’t thinking closely about the topic or issue. When the persuasive situation is really important to us and we are giving it our full attention, sure, it’s nice that the source is friendly or attractive, but, to quote an old Wendy’s commercial, “Where’s the beef?”

Applying persuasion cues as they are properly described in the BBC report would be highly ineffective self persuasion tactics regarding New Year’s Eve Resolutions precisely because those Resolution typically involve significant, serious, and negative behaviors. With these “high WATT” processors, the last thing you want to do is hit them with a cue, but rather with strong arguments, compelling information about the central merits of the behavior in question. A very different animal.

Quick summary. Kudos, to the Beeb for getting the theory right. Raspberries, for getting the application wrong.

Okay, kids, today you can take a Persuasion Quiz!

Yay!

I hope you did better than I. 0 for 5 for me. Imagine that. Here I am a self styled Internet expert on all things Persuasion and Influence. And I scored 0 for 5. Hey, for those of you with a probability background you know that guessing on 5 multiple choice items each with 5 options should produce 1 correct guess. Do you know how hard it is to deliberately pick 5 consecutive incorrect answers?

That’s not a rhetorical question. What is the a priori probability of 0 for 5? I can’t immediately recall the formula.

I just took the quiz again and got 2 of 5. And again to get 3 of 5. And, now, finally after 4 attempts, I get 5 for 5. Oddly enough, the start up of the quiz advises that you can take it as many times as you’d like, but the questions will change. For my several attempts, each quiz was the same (how do you think I got better?).

I also disagree with some of the “correct” answers.

Juries rate as more believable expert witnesses who speak in incomprehensible language compared to experts who use easy to comprehend language or who appear honest? I need to see the research on that.

People are more likely to support you on some issue if you give: 1, 3, 5 or as many reasons as you can think of. The correct response is: give 1 reason. What? Argument quantity can function as an argument or a cue (or a moderator, but that’s something else), but regardless the research tends to show that more arguments produce more change. Not just one.

What is so surprising to me about this quiz is that it is written by people with serious academic backgrounds, most particularly Robert Cialdini. His great book, “Influence,” would directly refute the quiz.

The quiz is an excellent teaching tool and marketing device and I don’t have any problem with it as a tactic here. I just strongly question the content of this quiz. What else scares me is that I could be reading the same research literature and can’t pass a quiz written by other folks reading the same stuff.

Gotta love social science.

What? What?

Ripped from the headlines of the New England Journal of Medicine:

“Results. In 5,063,622 person-years of follow-up, 10,235 men and 4318 women for whom childhood BMI data were available received a diagnosis of CHD or died of CHD as adults. The risk of any CHD event, a nonfatal event, and a fatal event among adults was positively associated with BMI at 7 to 13 years of age for boys and 10 to 13 years of age for girls. The associations were linear for each age, and the risk increased across the entire BMI distribution. Furthermore, the risk increased as the age of the child increased. Adjustment for birth weight strengthened the results.

Conclusions. Higher BMI during childhood is associated with an increased risk of CHD in adulthood. The associations are stronger in boys than in girls and increase with the age of the child in both sexes. Our findings suggest that as children are becoming heavier worldwide, greater numbers of them are at risk of having CHD in adulthood.”

This is from an article entitled, “Childhood Body-Mass Index and the Risk of Coronary Heart Disease in Adulthood,” authored by Jennifer Baker and colleagues. (You can read the entire article here.)

First, let me congratulate Dr. Baker who is listed as a post doc researcher at the Institute for Preventative Health in Copenhagen. She must be bouncing off the walls right now because a NEJM vita hit as a post doc is a major accomplishment. Lots of joy and happiness with the Baker people and her colleagues.

Second, let me sharply disagree with just about everyone connected to this research. The abstract notably omits any quantitative values in the Results portion which is fishy given that this is an epidemological study which means it’s only about numbers. Instead we get the rhetorical weasel word, “significant,” as the standard by which we understand the outcomes. See, kids who are heavy have “significantly” more heart disease as adults compared to kids who are lighter.

Sounds signficant, doesn’t it? Certainly the reviewers and editors at the New England Journal of Medicine thought it must be . . . significant. So what are the numbers? I mean, we’re all adults here, the children are in bed, so we can speak frankly.

The relative risk for heavy kids is 1.10.

That means, for example, if light kids have a rate of 10 per 100,000 for heart disease, then heavy kids will have a rate of 11 per 100,000. I’d give you the actual numbers from the study, except that the researchers did not provide the absolute rates or if they did they described them so poorly that I cannot tell for sure what’s going on. They do provide a lot of Tables with various relative risk ratios none of which exceed 1.10.

This is an absurb study and it is absurd that the NEJM published it and it is absurd how it is presented.

More bad news for Pharmas from the Wall Street Journal (you’ll still need a subscription to read this article, but that might change soon).

“We see puffing, advertising based on untrue facts or facts that can’t be substantiated, medically, ethically or legally,” says Michigan Democratic Rep. Bart Stupak, chairman of the Energy and Commerce investigations subcommittee.

The efforts are fueled by a growing genre of investigative research by physicians focused on industry influence and the reliability of medical literature. Catherine DeAngelis, editor in chief of JAMA, the Journal of the American Medical Association, says she has more articles on the drug industry’s role in research coming soon. “I want to show how they manipulate the data and why we have to be so cynical about them,” she says.

In the case of the recent antidepressant analysis, the New England Journal said in a statement that “it is critically important that physicians have all the available data,” and patients who participated in unpublished studies “should not be left on the cutting room floor to make a drug look better than it really is.”

You don’t need to read the entire article to see that some big players have Big Pharma in the crosshairs and are upset at the advertising claims. Let me highlight a couple of key quotes in this tangle. Rep. Bart Stupak sees “untrue facts.” The JAMA editor wants to “to show how they manipulate the data.” And the New England Journal wants physicians to “have all available data.”

Okay. Now, let’s add this story from the WSJ (again, you need a subscription).

Health plans are drawing scrutiny for offering financial incentives to entice doctors to prescribe cheaper generic medicines, including paying doctors $100 each time they switch a patient from a brand-name drug.

Pharmaceutical companies have long gone to great lengths to try to get doctors to prescribe their brand-name pills. They spend billions of dollars, plying physicians with samples, educational lunches and speaker fees. But as the patents for a growing number of blockbuster medicines expire, some health insurers are trying to trump those perks with bonuses or higher reimbursements for writing more generic prescriptions.

The idea, health plans say, is to save everyone — patients, employers and insurers — money. And many doctors argue that it’s only right to reimburse them for spending time evaluating whether a cheaper generic alternative is better or as good for a patient.

What’s going on here? You’ve got Congressional Members, journal editors, and health researchers closing in on the Evil Pharma guys, yet everyone seems to think that physicians need to get extra pay for prescribing drugs. Isn’t that a fundamental part of the job description already? Haven’t they been trained and hired to do this? And the idea that even if they need to do extra work, why should they earn extra money every time their prescribe a new pill? Why not just one lump payment for the “extra” learning?

For me, the persuasion lesson here comes from attribution theory. When money is flowing to physicians, journal editors, and researchers, it is “good” money. When money is flowing to Evil Pharmas, it is “bad” money. “Good” money buys expert service and life-saving pills, while “bad” money lines the pockets of greedhead businessmen (while also, it must be admitted, providing that life-saving pill).

In the last quoted WSJ story, there is also a graphic that details potential savings if physicians prescribed generic drugs rather than branded drugs. In the category of chloesterol lowering drugs, the WSJ claims that currently only 7% of physician prescriptions are for generics. Only 7%! If instead, 70% of the prescriptons were for generics, it would save over $7 billion annually. For the majority of cases, generic drugs for lowering chloesterol as just as effective as branded drugs. How much training and financial incentive does any physician need to know this?

I simply cannot fathom the mindset of the health and safety community in this fight with the Pharmas. From a persuasion perspective they are exposing themselves to incredibly dangerous lines of attack with their own biased attacks on Evil Pharmas. Please realize here that as I’ve explained in prior posts, my own past here is on all sides of every fence in this exchange. I’ve worked “for” virtually all of the players here (except for insurance companies, I think). I’m trying to focus on the persuasion elements of this case while also trying to see my own blinders (always a difficult task).

Consider the editor of JAMA and her advance statement of wanting to expose the bias. She’s making it sound like she’s on a hunting expedition while she’s supposed to be an unbiased arbiter of science. Please scan JAMA for the studies that show how her readership, physicians, clearly avoid prescribing generic drugs because they receive incentives from Pharmas for using branded drugs. That research you won’t find very often especially compared to the mob science she’s proposed to wield against the Evil Pharmas. Her position lacks proportionality. If people are biased by profit, then there should be research addressing all of those people, not just the one’s outside of your circulation base. Yet, because of attributional biases, the health and safety community cannot see the risks they run with their laserlike focus against for profit operations.

We are headed for a bad train wreck in our society with the collision of science, profit, government, and pride.

As I’ve noted much earlier, based on my forceful, relentless, and unique method of analysis, I’m predicting that Hillary Clinton and Rudy Giuliani will win the nominations of their respective parties and that Senator Clinton will win the general election. Until everyone in the race wakes up to this unavoidable persuasion truth, we continue the charade that these primaries actually matter. Sigh. Onward.

Currently, Clinton hammers away at her nearest competition, Barack Obama, and based on results in Nevada and New Hampshire, the attacks are working. The interesting persuasion question here is: What is Senator Obama’s method of defense? Here’s a quote from the New York Times that seems to be (from my general reading of many sources) the basic tactic.

Mr. Obama, asked in a brief interview whether his rivals had distracted him from making a positive case to voters, snapped: “Why would that rattle me? My suspicion is the other side must be rattled if they’re continually saying false things about us.”

The key phrase here is “saying false things.” Obama seems to think that when the Other Side makes arguments against you, the best persuasion response is to relabel those arguments as “false.” This has been a consistent line with Mr. Obama since Mrs. Clinton began to argumentatively dispute Obama’s issues and positions. When the Other Side makes a negative claim about me, respond by saying the negative claim is false.

As a persuasion expert extraordinaire, I must admit to being perplexed at this tactic. I’ve noted in the past with great embarassment, I did not attend Harvard or Law School, and maybe in my 30 year career as a persuasion maven, I missed the line of research that supports the “it’s false” line of defense against attacks. Nothing in my vast, deep, and complex reservoir of persuasion wisdom suggests, nay, whispers that when the Other Side is raising negative arguments about you that the best persuasion tactic is to, in essence, throw a yellow flag, and call the play, “false.” My sports metaphor is most apt in this instance as Mr. Obama seems to think that in politics there is an official referee and that he can play that role, too. Hey, that claim is out of bounds, 15 yard personal foul, play on.

Generally speaking the evidence strongly indicates that politics is like a knife fight - you know you are going to get cut, so just expect it and deal with it. The most common response is, therefore, cut back in response. (The theatrical sigh of unsophisticated observors about “going negative” is the mark of someone who’s never been in knife fight.)

The newest tactic is inoculation and you can read all about it. Basically, you use inoculation in advance of the knife fight and the anticipated cuts you’re going to receive. The tactic aims at reducing the damage or deflecting the attack. Perhaps the greatest example of inoculation comes from none other than former President Bill Clinton in 1992 and his infamous “woman problem,” then with Gennifer Flowers (how about that for a flashback?). Ms. Flowers let it be known privately that she was about to go public with allegations of an adulterous relationship with Candidate Bill Clinton early in the 1992 primaries. The Clinton campaign used this private knowledge to make a hasty appearance on the TV show, “60 Minutes,” literally the night before Ms. Flowers called her press conference. We know how it all worked out. Inoculation works.

Yet, Senator Obama appears to have superior persuasion knowledge and the “it’s false” defense. I wonder if he picked it up while watching “Cops” on TV. Doesn’t it seem that most of the suspects try to use the “it’s false” defense?

Past the bad kidding here, this looks like the response of an unexperienced, untrained, and unschooled persuader. Mr. Obama has been noted as a compelling speaker, but he clearly lacks basic persuasion skill. He orates effectively, but he can’t take a punch very well. Stated another, old fashioned way (with a tip of the hat to Aristotle) Senator Obama is good at ceremonial speaking, but not at political speaking.

I’m probably more than a little biased here because of my predictions, so take this with a grain of salt and a little patience.  If Mr. Obama doesn’t come up with some besides “Hillary is lying about me and so is her husband” then he should be giving a speech something like Fred Thompson did today.  And if Obama defies persuasion gravity (and my expert prognostication) and wins, well then, maybe I’m applying to Harvard.  Go Crimson!  Rah! Rah! Rah!

The most recent issue of the Journal of the American Medical Association reports a study that is shocking and I’ll bet you dollars to donuts that it won’t get much attention. Just read the abstract:

Persistence of Contradicted Claims in the Literature

Athina Tatsioni, MD; Nikolaos G. Bonitsis, MD; John P. A. Ioannidis, MD
JAMA. 2007;298(21):2517-2526.

Context Some research findings based on observational epidemiology are contradicted by randomized trials, but may nevertheless still be supported in some scientific circles.

Objectives To evaluate the change over time in the content of citations for 2 highly cited epidemiological studies that proposed major cardiovascular benefits associated with vitamin E in 1993; and to understand how these benefits continued being defended in the literature, despite strong contradicting evidence from large randomized clinical trials (RCTs). To examine the generalizability of these findings, we also examined the extent of persistence of supporting citations for the highly cited and contradicted protective effects of beta-carotene on cancer and of estrogen on Alzheimer disease.

Data Sources For vitamin E, we sampled articles published in 1997, 2001, and 2005 (before, early, and late after publication of refuting evidence) that referenced the highly cited epidemiological studies and separately sampled articles published in 2005 and referencing the major contradicting RCT (HOPE trial). We also sampled articles published in 2006 that referenced highly cited articles proposing benefits associated with beta-carotene for cancer (published in 1981 and contradicted long ago by RCTs in 1994-1996) and estrogen for Alzheimer disease (published in 1996 and contradicted recently by RCTs in 2004).

Data Extraction The stance of the citing articles was rated as favorable, equivocal, and unfavorable to the intervention. We also recorded the range of counterarguments raised to defend effectiveness against contradicting evidence.

Results For the 2 vitamin E epidemiological studies, even in 2005, 50% of citing articles remained favorable. A favorable stance was independently less likely in more recent articles, specifically in articles that also cited the HOPE trial (odds ratio for 2001, 0.05 [95% confidence interval, 0.01-0.19; P < .001] and the odds ratio for 2005, 0.06 [95% confidence interval, 0.02-0.24; P < .001], as compared with 1997), and in general/internal medicine vs specialty journals. Among articles citing the HOPE trial in 2005, 41.4% were unfavorable. In 2006, 62.5% of articles referencing the highly cited article that had proposed beta-carotene and 61.7% of those referencing the highly cited article on estrogen effectiveness were still favorable; 100% and 96%, respectively, of the citations appeared in specialty journals; and citations were significantly less favorable (P = .001 and P = .009, respectively) when the major contradicting trials were also mentioned. Counterarguments defending vitamin E or estrogen included diverse selection and information biases and genuine differences across studies in participants, interventions, cointerventions, and outcomes. Favorable citations to beta-carotene, long after evidence contradicted its effectiveness, did not consider the contradicting evidence.

Conclusion Claims from highly cited observational studies persist and continue to be supported in the medical literature despite strong contradictory evidence from randomized trials.

Author Affiliations: Department of Hygiene and Epidemiology, (Drs Tatsioni, Bonitsis, and Ioannidis) and the Department of Dermatology (Dr Bonitsis), University of Ioannina School of Medicine; and the Biomedical Research Institute, Foundation for Research and Technology-Hellas (Dr Ioannidis), Ioannina, Greece; Institute for Clinical Research and Health Policy Studies, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts (Drs Tatsioni and Ioannidis).

Even if you are not trained as a statistician you get the drift from the article title. Doctors persist in believing disproven claims. Let’s drill down a bit here.

The researchers in this article draw a distinction between information generated from “epidemiological” studies versus information generated from “randomized controlled trials (RCT).” These researchers put forth the claim that RCTs are the gold standard and if epi studies conflict with the experiments, science goes with the experiments. (If you want all the pain and glory of learning about these things you can start with this chapter from Steve’s Primer on research methods. You’ll like it. Really. It won’t hurt a bit.)

To demonstrate their point, the researchers use the example of Vitamin E studies. The initial findings of a positive effect for using Vitamin E came from a couple of epi studies published in the early 1990s. (I remember reading the NEJM one and using it in, of all things, a large lecture introductory media effects class - the kids were bedazzled.) An epi study is a type of survey where you ask a lot of people (millions sometimes), “Do you take Vitamin E?” and then wait 10 years and ask all the same people, “Are you still alive?” Now, of course, you ask a lot more than the Vitamin E question and you also ask for other interesting outcomes besides mortality, but you get the point.

Experimenters, by contrast, take a slightly different approach. They will get a smaller group of people (sometimes less than one hundred), give everyone a pill, but some folks are randomly assigned a real Vitamin E pill while the others get sugar pill, a placebo. The researchers then watch everyone for awhile and see if anyone dies or gets sick or files a lawsuit.

Experimenters typically mistrust epi researchers while epi researchers tend to view themselves as the true Children of Science. Let’s just say that there is a tension between the RCP folks and those epi mavens. Oddly enough, I am an experimentalist and I can also play statistics like chords on a guitar, so guess where my biases lie. Back to the opera.

We have frightening evidence that medical researchers and physicians and nurses and all those people who went to Schools of Medicine or Public Health, keep on believing things that are untrue. And not just believing, they keep on citing them, teaching them, defending them.

There is likely to be a brief debate about this article, especially from the epi community. Please make sure I’m not on the jury for this one because I’ve already tangled with the epi folks. They require budgets slightly larger than the national debt, typically find piddling effect sizes expressed in those lame 1.1 relative risk ratios, and then they think they’ve discovered blue sky, white snow, and a free lunch . . . not to be harsh or judgmental or unfair or wicked or even accurate about it.

Now, the thoughtful among you might be wondering what all of this has to do with persuasion besides Steve whaling away on some group of people you’ve never met.

Here: if scientists get it wrong and persist in getting it wrong, what explains their beliefs and behavior?

Persuasion theory and research.

Not health theory and research.

This research study demonstrates a common finding in persuasion research on biased, central route processing. Smart, thoughtful people will try to make the data fit their hypothesis even when it is apparent that the data don’t fit.

This is another way of saying that scientists and physicians and their ilk are human after all and behave according to the same rules of psychology that all us mere mortals obey. We tend to believe we are smart, consistent, and justified and we tend to make data fit our key beliefs more often than we make our beliefs fit “scientific reality.”

As I mentioned at the top of this post, it’s unlikely that this JAMA story will get much attention despite its critical importance. Here’s a quick illustration.

On the same day that JAMA published this research article, the New England Journal of Medicine published a study on childhood obesity and adult heart disease. Using the Googe news aggregator, I found that in the two days following these publications the childhood obesity study has been picked up in 350 different web sources, the majority of which are standard news sites like the New York Times or the Washington Post. By contrast, in the two days since the publication of this scientific bias study, the Google news aggregator lists fewer than a dozen sites carrying a story about it.

What’s interesting to me about this comparison is that the childhood obesity study is an epi-style method that finds about the same effect size as the Vitamin E studies. As we’ve seen with those epi studies on Vitamin E, we need to be extremely careful in accepting the conclusions until we get stronger evidence from experimental studies (RCTs).