Fear-based Medicine: Using Scare Tactics in the Clinical Encounter

flying cadeuciiHow often do doctors say something like this to patients?  “It’s really important for you to do this; if you don’t you might … have a stroke, go blind, lose a leg, die or (insert a scary outcome here).”  There are no solid data to answer this question, though patients report that conversations containing such direct threats are common in clinical encounters. The more important question is, do scare tactics work?

Fear-based messages in clinical encounters

Health communication experts call these types of messages fear-based appeals. Fear appeals create an emotional reaction to some “threat” of disease, disability or death, which in turn, is thought to motivate behavior change. Doctors may use fear-based messages when counseling patients about chronic disease self-management or prevention, especially when faced with a patient we believe to be unmotivated or non-adherent.  In such situations, using fear as a tool is appealing because it is easy, doesn’t take much time and we know intuitively that fear can be a powerful motivator.   Yet despite decades of research on the subject, there is no consensus on whether or how fear can be used effectively to motivate long-term behavior change.

Research supporting the effectiveness of fear appeals is generally from public health campaigns, where frightening facts or images can quickly capture the audience’s attention.  This makes sense when a message sender is competing for audience attention among many billboards, advertisements and other messages. But it rarely makes sense when a doctor is alone in an exam room with a patient. For many patients, the 15 minutes they have with their doctor will be the 15 most important minutes of their day.

More important, research suggests that appeals to fear can cause harm.  For example, in a study of patients with type 2 diabetes, patients recognized when their doctors were using scare tactics to motivate compliance, but many said such threats resulted in increased feelings of anxiety, incompetence and negativity towards their physician.

Why threatening patients rarely works

The reason threatening patients with bad outcomes often fails to persuade patients to change behavior lies in the powerful 2-way interdependency of fear and self-efficacy in prompting action. A recent meta-analysis of studies on fear-based messaging found that threatening information only sparks behavior change when self-efficacy is high, and self-efficacy is only correlated with behavior change when the individual perceives himself to be susceptible to a threat.  Moreover, in the absence of strong levels of self-efficacy, raising fear levels can lead to maladaptive responses such as shutting down, feeling overwhelmed or denial.  For clinicians this means that although fear-based messages can quickly increase a patient’s sense of being threatened, which may be a necessary predicate for behavior change, this fear must be matched with success in raising the patient’s sense of self-efficacy or it could backfire.  The problem is that increasing self-efficacy is a laborious process.

Several communication methods work to increase patient self-efficacy, but none are quick or easy to implement.  For instance,randomized controlled trials of motivational interviewing (MI) in primary care suggest that MI can increase self-efficacy and help patients achieve goals related to weight loss, blood pressure and outcomes related to substance use; but effective MI requires multiple counseling sessions and multidisciplinary teamwork.

There is also a robust evidence base behind self-determination theory (SDT), which leverages 3 psychological mechanisms related to self-efficacy to help individuals achieve long-term behavior change: autonomy (feeling internally motivated and not coerced into the recommended action), competence (feeling competent to act and to problem-solve), and relatedness (feeling connected to others). Studies of SDT-based interventions have shown positive effects on various health behaviors, such as smoking cessation, weight loss maintenance and physical activity.  But the effective clinical use of SDT, like using MI, requires both time and teamwork and is challenging to implement in the real world of health care practice.

Can fear-based messages be used effectively?

Knowing this, is there ever an appropriate approach to the use of fear appeals during the clinic encounter?  Consider, as an example, patients at high risk of developing diabetes. Will telling patients they have prediabetes and using the threat of developing diabetes and its potential consequences (i.e. kidney failure, losing a limb) stoke unproductive fear? Or could it be beneficial because the fear of developing diabetes motivates patients to change their lifestyles?

Many patients with prediabetes have described feeling fear, anxiety and uncertainty when first diagnosed. Fear and anxiety are also heightened when patients have witnessed a family member suffer the downstream consequences of diabetes, and these feelings are further intensified by the fact that few patients are confident they can make healthy lifestyle changes to reduce the threat of diabetes and its consequences.  So, being diagnosed with prediabetes dramatically increases the perceived threat of diabetes, indeed some patients perceive it as inevitable, but self-efficacy is also generally low.

What should the physician do?  A statement like, “You have prediabetes; if you don’t lose weight, you are going to develop diabetes which could lead to other more serious problems, like heart attacks or kidney failure” is likely to grab the patient’s attention but fail to motivate weight loss – it might even backfire, leading to resignation, denial or hopelessness. Evidence-based diabetes preventionprograms that help patients increase self-efficacy and chances of weight loss exist, using techniques derived from MI and SDT; but these programs takes months to complete and are typically offered outside the doctor’s office, in community-based organizations such as the YMCA. A more effective approach might be to say, “Having prediabetes means you are at high risk for developing diabetes, but there are thing you can do to avoid or prevent it –like losing weight, eating healthier and being more physically active. If you are interested, I’m going to give you a referral to a program that can help you prevent diabetes.”  Then provide the patient with a direct referral to a diabetes prevention program or other evidence-based lifestyle program.

Perhaps in an ideal world, the physician would deliver a comprehensive MI and SDT-based intervention herself – usually many weeks of intensive work with modest reimbursement at best–but for most of us this is not realistic. Still, physicians play critical roles by helping patients understand their risk, supporting the patient’s autonomy, and by staying connected to and supportive of the patient through the behavior change process.

In sum, evidence suggests that fear appeals have limited utility in the clinical encounter, and that any appeal to fear must be coupled with communication strategies that increase motivation, autonomy and competence in patients.  Using fear as part of an effective motivation strategy for patient behavior change requires a long-term, team-based approach, often extending beyond the doctor’s office.

Namratha Kandula, MD, MPH and Matthew Wynia, MD, MPH are the Directors for Patient and Physician Engagement in the American Medical Association’s Improving Health Outcomes Initiative.

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16 replies »

  1. Years ago I got a call from a nurse telling me on on the weekend to immediately see a doctor because my vitamin D level is down. I said what is the fuss I started taking vitamin D3 and will be fine. She said no it’s a serious issue. I said NO , I am not going to make any appointments I will see my PCP in 6 months. When I go there after 6 months it was normal. And another case my PCP told me my cholesterol is high so he prescribed me medication without my authorization. I said I won’t take it. I changed my diet and exercise at least 5 days a week and my total cholesterol was 185. Meaning back to normal. They just use scare tactics to put you on medication. I HATE THAT. When doctors tell me any issues I will consult my brother who is a physician before taking any steps. I wonder Americans are losing billions of dollars every year out of fear by greedy physicians.

  2. Several of my doctors use scare tactics. They are very disconcerted when I tell them that I am not concerned with how long I will live). So then they change the fear tactics to then you will be severely debilitated and live a terrible life. Of course, without medical professionals propping up very ill people to live very limited lives even that would not be an issue. Very seldom have I encountered doctors, even specialists, who talk about working cooperatively to maintain or improve the quality of life. Many people with diabetes are treated like children, as in, good boy, bad girl and if you are bad the boogeyman will get you. Very much about numbers. Also, diabetics are often faced with being blamed for clinical failures while successes are credited to medicines and their prescribers. The same applies to Blood Pressure. It is very easy to just stop going to doctors as the visits turn into shame and blame sessions. I understand that modern medicine is basically just about maintaining a degrading asset. The medical community has never designed, redesigned, built, upgraded, or overhauled a human body. There is no effort to improve on the human form. They target maintenance with concession to aging and injury and congratulate themselves when bodies last longer. It is a regressive science hoping for nothing more than to keep bodies near their natural peak. So it is to be expected that professionals in such a field would consider fear of bad outcomes since they cannot offer improvements or upgrades. It is disappointing though that intelligent adults are treated like children with fear tactics.

  3. I know this is an old article, but I like what is being said here. I am an analytical person as well as a cynic. Because of this I have very little use or respect for theatrics and drama. My BS meter is very sensitive, and when a medical professional tries these tactics on me, I typically respond to them be letting them know that I don’t appreciate it. In the end I usually end up just not going to the doctor anymore, because I don’t trust that the decisions being made are all based on fact or even in my best interest. Many doctors have an ego that makes them believe that the patient has an obligation to follow their “orders”. When in reality the patient is a paying customer who can take his business elsewhere!

  4. My Doctor knows of my depression, has no empathy of my condition or physical pain uses scare tactics on me every time we visit . If it’s not my posture , it’s smoking, or it’s my weight . Every visit it’s something different. He offers nothing to help with his complaints on me . It seems to me that he is a very unhappy individual. Degrading and condescending comments are not exactly how I would handle a patient. I’ve verbally told him about the risk of my habits , yet he talks to me as if I am 6 years old. He knows I am a retired medical professional. If I have a complaint on side effects of a medication he plays it off that it’s “ just in my head” . He offers no options of medications, that I could try that may be better . I’ve been to many physicians in my life and worked with many and I have never heard one as rude as mine ! All of his scare Tactics are things that I’m already aware of & have seen. He makes me so much more depressed because all I hear is condemnation . I’m wondering if he treats his other patients with such indignation. Is there ever a time to change physicians ? Could this be a time to change? I’ve seen him 6 times.

  5. I really like that this article even exists. Since I am a patient, I will let others see exactly how letters have affected me. I feel I am being victimized. I am a target. And money is the main reason for these letters, not their overwhelming concern for my health. I was getting routine testing done from a Gastrointerologist. All of the tests, as well as everything that was being evaluated over a period of 18 months was absolutely perfect. I could not have asked for better reports and results. And the doctor himself was pleased.
    The problem is that he just asked that I make one more appointment in 6 months to pretty much make sure everything was still ok. I did not make that appointment. And that is when the letters started. The first letter was only a reminder. As was the second. I finally called. The only thing that was going to take place was a bone density test that I already had with good results with this same doctor. Since I was taking Nexium, he wanted to see if anything changed. Well, I said to the girl on the phone that I feel fine and since I’ve been taking nexium for so long, I doubt there is anything that will change that much in such a short time.
    Soon, another letter comes. It was filled with reasons I must come in for an appointment. Scare tactics that seemed as if they were designed to scare me to make an appointment immediately. The most dominant threat was that not coming in would prevent further evaluation which could result in undiagnosed problems that may even have cancer. Really? If after all those excellent results from the tests I had, and not going for that 2nd bone density test suddenly means I might have cancer, then I am the president of the United States. All because I missed a followup? If they did not see that cancer was something I was prone to within the first 18 months after doing upper endoscopy, colonoscopy & while in there, a routine biopsy, which was not done because he found any reasons to worry. he said just because. If there was any concern for cancer, thet shoulld have told me by now. I have not had any symptoms or problems and my original reason for even going to this doctor was only a temporary case of constipation caused by a medication I was taking.
    Well, since the threatening letter of possible cancer, I’ve gotten another. This letter is unbelievable. I almost want to go get a lawyer because I know this is not about their overwhelming concern for my health. It is about the fact that my health insurance is able to cover alot of these expensive procedures and visits to specialists, making me a target. They want money and if they think letters that hold my emotional response captive are going to seduce me into rushing to come in for an appointment, they are sadly mistaken. I would go to a different doctor after this. But let me quote the exact words of the letter:

    It has come to our attention that you either did not complete a test or keep a scheduled appointment, despite being reminded several times.This letter is being sent because your medical problems warrant further evaluation. Failure to complete diagnostic tests can leave you with undiagnosed diseases to life threatening illness or even death.

    I find letters like this to be a very unfair way of preying on the emotional weakness of others. It has caused a great attitude change in me. I am angered, outraged and almost I want to take my angusih and stress out on them and tell them how they have upset my family as well. I am sick of the way people use leverage for the sake of money and mask it as an overwhelmiong concern for someone’s health. If anyone can actually say they do not think money is one of the reason’s this is taking place, then you are not very bright. I am not even someone with any diagnosed health condition that would require me to go to any appointments for treatment. I am being targeted because I am a man with good health insurance and the protocols in place for the course of treatment sometimes are so long nd drawn out and it’s not because of this great ambition to be thorough. That is only part of it. Money is the other part. But we have to draw the line somewhere and I believe this line has been crossed. If I had a diagnosed health condition and the doctor is trying to cause me to react with letters like this, I still believe going from the threat of cancer and then death are strategic, but way too harsh a terminology for any patient. Writing letters like this is an example of the worst behavior I’ve ever witnessed from a professional.

  6. What is your view on the Procheska model of stages of change?


    Rick Lippin

  7. I think there are a couple of variables when we think about having these kinds of interactions with our patients:
    1. What is your relationship with the patient (Do you have a relationship of trust? How well do you know the patient? Have you and your patient been able to work together on hard things prior?);
    2. Where is the patient at today (Is this a patient who usually likes lots of information or are they easily overwhelmed? Has this patient been able to navigate changes and challenges in their life in the past? What is going on in your patient’s life today and how are they coping with it? – sometimes, timing and coping skills on a given day really are everything);
    3. Where are you today (How are your coping and communication skills today? Are you feeling frustrated or rushed? What is the origin of your desire to present information to this patient this way today?)

    All this to say – I think it is not as easy as “fear appeals” are always wrong/right or effective/ineffective. I believe the preexisting patient-clinician relationship matters a great deal, as does the spirit in which the information is offered (“I need you to know that these are the risks…” or “I am concerned about…”).

  8. Sarah, it is true that sometimes, some individual will respond well to scare tactics in the short term. Unfortunately, this tactic relies on paternalism and the old-school power differential for effectiveness. I believe most patients are looking for a different relationship with their provider- a relationship of mutual goal-setting, working in a partnership, and finding intrinsic motivation for change. Short-term scare tactic may drive initial change, but there is no evidence that it will sustain meaningful health improvement over time.

  9. If you have the patient trusting you, you can get to the honesty level, as Allan says very aptly. One thing for sure: If you use fear too much the patient will not come back. So this tactic is auto-correcting.

  10. I appreciate everything the author has to say, but there is more. Physicians have to earn the trust of patients. Honesty is one way. Communication is another, but unless the patient trusts the physician the physician will not be able to communicate with the patient.

    All that being said honesty alone, without attempting to scare the patient, forces the physician to tell the patient what might happen under the circumstances. There is no honest way to avoid disclosure of a lot of bad things that can happen.

  11. With all due respect, the patient communication “challenge” isn’t so much one of how to “frame” one’s message so much as the larger issue of whether you are employing a patient-centered vs. a traditional physician-directed (aka paternalistic) style when talking with patients.

    All the fear appeals in the world will not move a patient to change their behavior if they
    don’t believe or agree with the physician’s diagnosis, don’t think the treatment will work or feel that the “cons” of doing what the doctor recommends outweigh what the patient sees as the “pros.” Patient-centered physicians will strive to understand the patients’ health beliefs about their condition…and strive to arrive at a consensus or shared mind with the patient. A physician-directed clinician will just tell the patient the pros and cons and assume that engaged and enlightened individuals will make the right decision. If they are nonadherent it is the patient’s fault. After all the doctor told them what to do (can you say beneficent paternalism). Two different philosophies, with two views of the patient and their role in health care.

    The evidence on the subject is crystal clean … patients of patient-centered physicians have higher levels of trust in their doctor, are more adherent and make fewer requests for unnecessary services than do patients of physician-directed doctors. It gets back to the basics – trust and patient-centered communications.

    And no…a patient-centered communications approach does not lead to longer visits. In my work with physician-patient communications …just the opposite can happen over time. Why? You are are training the patient how to think and communicate during the visit which means you can get more done in less time without impacting patient satisfaction.

    So if you want to persuade patients to do something … get their input … arrive at a consensus decision …and follow up in their same patient-centered line of thinking at the next visit.

    This ain’t rocket science.

    Steve Wilkins, MPH
    Mind the Gap Academy
    http://www.mindthegapacademy.com .

  12. This article caught my eye because just today a good friend of mine saw an Orthopedic Specialist today for a possible Total Knee Replacement. The specialist explicitly informed my friend that he is refusing to perform the surgery unless steps are taken to improve his health. He then continued using a fear-based approach by listing multiple consequences that would become a reality if he failed to do so. Discussing this with my friend, he stated that at first he was taken back by the boldness of the comments; however, he also stated that it was a reality check and encouraged him to change his behaviors.

    Out of curiosity, I did a quick search on recent studies regarding fear-based appeals. In the recent literature, topics range from prenatal physical activity, HIV prevention, unregulated dietary supplements in teens…etc. It seems as though there is very limited evidence, some well designed studies show some efficacy of using a fear-based approach (links to the studies are attached below).

    I agree with the comment below that simply some individuals respond differently to various tactics. I think it is vital that we address positive gains and attempt motivational interviewing before trying this tactic; however, I do not believe that we as healthcare providers should entirely avoid the approach.


  13. It is a good point that doctors have a responsibility to provide certain risks as facts. The problem is when we take the facts and start projecting into the future about the risks. i.e. “you could end up with a stroke or an amputation….., etc.” Giving a patient a diagnosis and telling them about the possible risks is not in itself a scare tactic- it is more so when the physician starts projecting into the unknown. I also think we need to focus less of the conversation on the possible “risks,” and more time on asking the patient about what would motivate them to do X, Y, and Z.

  14. I agree. And I disagree!

    The problem here is that people respond differently.

    There are people who will benefit from having the riot act read to them, there are others who will literally worry themselves sick – with terrible consequences.

    As with Rob’s post, I think there’s room for us to use our radar and try to work it out.

    But you’re right. Not enough is done work is done here. A very compelling post.

    / j

  15. I agree with the negative effects of fear-based intervention. My experience is that patients are coming to me for reassurance and solutions, not guilt and shame. Most patients know being overweight is bad, or that smoking is dangerous. I don’t need to tell them that to get them to change. On the other hand, presenting the risk as a fact and then presenting solutions to deal with that risk can really help. Acknowledging that it is hard to quit smoking or lose weight will make patients hear my solutions, as I clearly understand the situation better and am not against them. Again, I think a certain amount of transference – the depositing of our emotional luggage on the patient – is done more for the physician’s sake, not the patient. We need to be aware of those emotions and to not transfer them to the patient without a clear reason it will be helpful for the patient. Getting angry at noncompliance is a good example of this (and one which makes me very frustrated at other clinicians).

    To me, the important thing is that I address risk and find ways to reduce it. My role is not one of accuser, but of support and helper. When we forget that, we lose our most important tool to help our patients: their trust.

  16. I appreciate the authors’ loking at how fear can be used in a positive way.

    The last few articles seem to place too much pressure on physicians in how to communicate with patients on sensitive, potentially life-threatening issues. Physicians this blog refers to, are, generally, not psychiatrists.

    While communication is important, and our system needs to encourage more talking together, and less testing in lieu of conversation, the bottom line is that patients need to learn the truth. The potential facts need to be presented, for, if not, the physician would have to deal with the ultimate guilt when the illness deteriorates, and there was still time to deal with the problem.

    People are responsible for how they handle situations. Physicians are not responsible how their patients react to the facts, as the physician sees them.

    The truth will set you free, but, at first, it may make you miserable.

    Don Levit