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Summary 

-For healthcare providers,  “persuasion”  through advertising is often thought to be a dirty word. However, there is no doubt it promotes patient engagement and health literacy.

-The message of health is not very..compelling. Walk more it’s good for you. Advertisers tend to pull on different levers to get the hope for behavior. For example, a a patient, you don’t want to get a knee replacement, but you do want to play with your grandkids.

-Hospital marketing, the generic “We care for you,” may not be a message that resonates. Target, personalized messages are required to connect with patients, whether from a personal or population level.

-Where’s our “Got Milk” campaign for healthcare. Healthcare gets in their own way. Clearer, better language is often disallowed by heavy regulations. We needs to learn from other industries to succeed.

Alan Pitt: Good morning. This is Alan Pitt and I’m here with Dr. Michael Mackert from the Dell Medical School. He’s an expert in medical communication. He’s with the Center for Health Communication, and is a Professor in the Department of Population Health. As some of you know, I’ve become very interested in what I call “Why don’t you eat your vegetables?”—that is, Behavioral Economics and Communication Issues in Healthcare. I was really pleased that Mike was willing to join me today to talk about some of his work and, hopefully, to see what we can learn from that. Michael, thank you very much.

Michael Mackert: I’m happy to talk to you today.

AP: Can you tell me a little bit about your role at Dell Medical School?

MM: Sure. My life involves a lot of running around campus. I’m the Director of the Center for Health Communication, as you mentioned. What that actually means is that I’m a faculty member both in Population Health at the medical school, but also in the Stan Richards School of Advertising and Public Relations in the Moody College of Communication. Our center is part of both the College of Communication and Dell Medical School. A lot of our work—and my work, particularly, leading the center—is intended to make more and more connections among faculty, staff, and students in the communication and medical schools to the rest of campus, to improve the way we think about health communication in research, training, and practice.

AP: I see. That sounds awesome. I saw you speak, and I was very interested in some of the topics. One of the things you mentioned is that drug companies advertise directly now to consumers. Certainly, when I was a medical student resident, that really wasn’t done, and that seems to be a relatively new phenomenon. Can you talk about why that happened, the impact of that type of advertising on the doctor–patient relationship, any of those kinds of things?

MM: Sure. I never really thought about prescription direct-to-consumer drug advertising until I got to Austin and landed in the School of Advertising. I never really thought about it a whole lot. It’s a very unusual system we have here in the U.S.; only the United States and New Zealand have the kind of drug advertising that people are used to seeing on their TVs and in magazines and so on. I’m not a legal policy person, but I think a lot of it goes to free speech issues, and it would be really hard to stop doing it, basically. But you ask the question about what it would do for the provider–patient relationship. I teach a web-based health communication class a lot of summers. The class is usually half nursing graduate students and half communication students. I make them debate prescription drug ads. The very first time, I expected that the ad students and the communication students would be pro-advertising, and that the nursing students would be like, “These things are the worst!” But it actually split kind of 50/50 within the majors.

MM: So, you have some nursing students who would say that they don’t like the fact that patients come in demanding a particular drug, and that’s how it can feel sometimes. But other nurses had the approach that these people were more engaged health consumers. They’re people who come in having done some research or having thought about their health in an active manner, and that can lead to a better conversation. And so, when people listen to the pros and the cons of drug advertising, the idea of what is the ideal provider–patient relationship feels like a little bit of a mixed bag?” I’m not really for or against drug advertising. I think there’s a way of doing it that would make it better for both providers and for patients. The current system isn’t the one I would design if I had my way. So that’s the way I think: You could do it better within the constraints of what you can do legally.

AP: I think it does change the relationship a little bit when a patient does come in and frankly, as a provider, it almost is disruptive, because people come in, and it can be a little adversarial at times. But it’s certainly part of our culture now. Do you think it has driven up the sales of these drugs? It must have, because they wouldn’t keep advertising, I guess, if it didn’t.

MM: Yeah, you would think. No, I don’t know. There is a little saying in advertising—”I know half of how advertising works, but I don’t know which half.” You know the other thing that I often will talk about when I’m leading that debate with the students, you mentioned the fact that a drug ad can create an adversarial relationship which is, for sure, the case. And what I’ll often do to poke and prod at the students a little bit is ask, “Well, what about a patient comes in with an article they read in The New York Times. They read The New York Times article, and are adamant that Drug X or Treatment Y is the right thing for them. Do you feel the same way about that as you do about a drug ad?” Because I think, there’s clearly a profit motive to drug advertising that is pretty unique to drug advertising, but some of the behaviors that people will have concerns about, in terms of provider–patient, it’s not entirely about drug ads. It’s sort of people’s ability on the public side to receive health information, in general, think about what it means for them, and then make use of that information. That’s got my interest in health literacy. There’s a profit motive there that no one can deny, but there are a lot of people who might see the same drug ad and do better things with it, other than create that kind of adversarial relationship.

AP: Now, that actually gets to the major thrust of what you presented, which is that you’re kind of a glass half-full guy. And you said, “Look, if we look at what these drug companies are doing, it’s an idea of how do I get you to change behavior through advertising in a positive way? How do I get you to do better health behaviors?” Can you talk about how you extracted out some of those themes for better health, better wellness from advertising generally?

MM: Sure. A lot of my life, that’s really what I’m doing now, is I teach advertising courses, and so I have students who are doing work with commercial advertisers on big national brands that you’ve certainly heard of before. And a lot of our work as a center is built around a lot of those same principles that advertisers follow, and that there’s just ways of solving problems in advertising that I don’t think people who come up from more of a public health or medicine framework are as likely to take advantage of. Just as an example, I gave my advertising students a challenge at one point to get people out of the elevators and into the stairways in one of the buildings on campus. If I give that to a group of public health folks, they tend to focus a lot on getting people walking up the stairs, and it’s for your health, and all the things that you would want to say.

MM: You give it to a bunch of advertising students, and they will think about all the other reasons you might not like an elevator, like: “It’s Texas—It’s sort of hot and sticky in the elevator, and people are talking on their cell phones, and it’s faster to take the stairs.” Well, actually, I didn’t say, “Get people to walk up the stairs,” I said get them out of the elevators. Maybe we should request them to go down the stairs! How you frame the problem and how communication can help solve it, it’s just that advertisers think about that a bit differently, and it can open more options for messages that aren’t just sort of the standard, “Take the stairs; you can burn three calories walking up 10 flights of stairs.” And it’s not a super-compelling message in a lot of ways. If people really acted on that—I think everyone knows it’s the healthier thing to do, but people generally still don’t do it. So what are other levers you can pull to help get them to change their behavior?

AP: Now, that really raises an interesting question for me, because I think we all do see problems from where we’re from, right? So healthcare providers tend to see it in calories. How many calories can you burn? It’s almost a physiologic response as opposed to an emotional response. Do you think there are any lessons that we can learn at the bedside when we’re talking to patients? We’re not advertisers as providers. Are there any ways that we can present options to patients that are different than we traditionally do, based on your experiences as an advertiser?

MM: Yeah, it’s funny. So for the final assignment in that class I teach, I ask: “What did you get out of this semester? And what does it mean for you and your career going forward?” And all the communications students, for years now, have independently written a very similar paper, and it’s always some version of, “I never really thought about the fact that I could sell health and promote health with the advertising tools I’ve been taught.” It just opens career doors they wouldn’t have thought about opening before. And the nursing students, the more health and clinical-oriented folks I have, almost to a person write something like, “I always thought persuasion was a dirty word, and I have been trained and generally think about it as like, ‘I’m going to educate you into submission. I’m going to keep telling you what to do and why you should do it, and then sooner or later, you’re going to manage your diabetes better, or you’re going to… ‘” Whatever the case may be—for example like they’re going to educate a patient into losing 10 pounds so that patient can get a knee replacement.

MM: If you frame that as, “Well, what are the things that you want to do once your knee is better?” And the patient responds, “Oh, I want to go play with my grandkids.” Okay, well let’s use that as motivation to get you to lose the 10 pounds so you can have your knee replaced. That might be the more emotional, persuasive lever that you can use to help people get to where you want them to get, and where they want to get themselves.

AP: Now, you must spend a lot of time personalizing this messaging around age, sex, and race. How do you look at those levers that we might be able to extract out as providers, in terms of conversation?

MM: That’s a really good question. And so one of the things that my ad students always kind of worry about and think about a lot is How do you target based on demographics without stereotyping? That’s a really hard line to walk. Which is one of the reasons that I teach them that when you’re building a communication campaign like an ad campaign, I actually really encourage them to build a persona of the person they’re trying to reach. I teach advertising students to build campaigns based more on an interpersonal conversation they want to have with a customer, and then scale it up. And so, in some ways, I think the way healthcare providers might be trained to deal with the patient one-on-one is an easier starting point for thinking about, “What matters to this person in front of me that isn’t about their age, their gender, their race, ethnicity?” What matters to the person? And then you work from that, and so it’s in some ways, I think providers kind of approach it from the easier, better angle rather than generalizing patients, thinking “Okay, 18-to-22-year-olds tend to… ” That’s just a hard way to think about building effective messages.

AP: You know, the reverse of that is interesting. You had mentioned in your talk that generic messaging, and any time that I can sub out one group for another and the message would not have to change—that’s bad messaging. A lot of healthcare advertising I see is hospital systems competing with other hospital systems with very generic messages about, “We care about you, we want to take care of you.” Do you have any comments around hospital messaging? How would you best spend advertising dollars as a hospital system to make a difference for the populations you’re responsible for?

MM: Yeah, it’s really hard. I think you can’t go through a big city and see a couple of different competing hospital systems, and they all have similar messages; something like: “But WE’RE the ones who care about you as a person!” Okay, great. You’re all the same.

MM: Years ago, we had ad students working on a project with a specialty clinic practice here in Austin, and the students spent a lot of time digging into the clinic and finding out how the people there worked and how the patients felt about it. One key thing they put their finger on, more from the patient perspective, was that this was a clinic where the specialists actually communicated effectively—so patients were not seeing three doctors in one month, with each physician in turn asking, “So, have you seen anyone lately?” They were clearly very good on their coordination behind the scenes, in a way that a lot of other specialists—in the patients’ experience—had never acted. So that became kind of a point of competitive advantage. Not financially, maybe, but certainly from the patient perspective. That became a thing that they could build an effective campaign around, because people’s experiences are generally so terrible with clinicians coordinating behind the scenes. As a patient, it’s annoying to say, “I went and saw a different doctor yesterday. Why do you guys not know? This is in my chart?” So that was a thing these students could talk about and then deliver on in an ad campaign.

AP: Interesting.

MM: The generic messaging, “We care for you” is just that—generic. How do you do that? Is your hospital really that different from the one down the street in terms of how patients are going to feel if they’re being cared for? And if not, it’s probably not a thing you can build a great campaign around. One of the Dell Medicine doctors I know said that he had seen marketing material for a hospital that showed that their rate for some kind of infection that mattered to him as a surgeon, was above average. The clinic was marketing the fact that they were less effective than their peers on a particular metric. And he said, “I went there, because they were willing to communicate to me that they knew the thing they weren’t not good at, and indicated that they were going to work on it.”

MM: If that’s the kind of thing that you’re aware of, to this physician, that helped him decide “That’s the kind of place I want to go, because that’s the way I practice medicine as a doctor here.” It made him like them more, and that is a really different way of thinking about communication and advertising that isn’t just the standard, “We care for you the best, and here are three metrics we’re awesome at.”

AP: So, I guess thematically what I’m hearing from you is that things really have to be targeted, personalized, rather than generic, if you’re going to hope to have any real impact on changing behaviors. Both to some degree from a patient perspective, but also from provider perspective, in terms of how they view their system.

MM: For sure. I always tell my ad students, “If you’re aiming for everybody, you’re not gonna hit anybody.”

[laughter]

AP: That’s a pretty good quote actually, that’s a pretty good quote…

MM: Even campaigns like the original “Got Milk?” campaign way back in the day. Lots of people drink milk, but the way that campaign was really built, was basically around people who already drank milk, and the message of the campaign was not, “Drink more milk because it’s healthy for you,” because that’s what they’ve been saying for years, and milk sales have been going down. The original “Got Milk?” campaign was actually “Don’t run out of milk.” Being out of milk means, you don’t get cookies. Peanut butter and jelly sandwiches aren’t as good, all the things that are not as good if you’re out of milk. And so, it wasn’t really targeting everyone, it was really aimed at current milk consumers and encouraging them to not run out of milk. And milk sales went up in California when the campaign ran only in California, and they rolled it out nationally.

AP: Yeah. I’m a big believer that healthcare needs to start looking at other industries for lessons learned, if we want to do a better job taking care of people. How open do you think conventional advertisers in the healthcare space are open to your ideas, or are they just kind of stuck in these more generic campaigns?

MM: I think a lot of good ad people occasionally, I think, feel overly constrained working in the health space because of conservative clients, because of legal policy things that make it harder for them to do their jobs. I actually interviewed a bunch of people who designed prescription drug ads. And it was interesting because they all have been trained, and Pfizer has this really good, clear health communication program. Basically, if you touched the Pfizer brand, you have to go to a big training program. The program would do things like teach people, “Don’t say renal—say kidney.” Sure, you lose some medical precision, but many, many, many more people are going to know if their family has history or kidney problems than “renal” problems.

MM: And the way the law works and the regulations work are that you have to use a medically precise term, even if many fewer people understand it. So there are well-intentioned policies, the unintended effects of which are to make the language more complex than it needs to be. And so those people are… Well, they’re better at their jobs than they’re being allowed to be. I think that’s one of the things where the system could work better, and that would benefit both the patients and the providers—and the people designing the ads, in that case. It’s those kinds of changes that I think could help everyone win.

AP: Michael, I completely agree. It’s not what we can do, but what we’re allowed to do that will dictate our future, and in a lot of ways, we need to get out of our own way, right? I mean, HIPAA is a primary example of a well-intended law, but in a lot of ways, in terms of care, it involves very perverse outcomes.

AP: I really appreciate your time and thank you very much for your insights. If people want to reach out to you, can they email you at Dell with questions?

MM: Yes. Our Center for Health Communication Division, uthealthcomm.org—or just type UT Center for Health Communications, I’m sure it will pop up pretty easily. But I’m always happy to field questioned and emails about this. I feel very fortunate that I get to spend a lot of my life working with colleagues in communication, medicine, public health, nursing, social work, pharmacy, and other fields to do this work. I always welcome people who are interested to drop me a line.

AP: Thank you, thank you very much for your time, it’s much appreciated.