Perspective
Persuasion in Radiology1 Richard B. Gunderman, Gentry C. Dodd How quick come the reasons for approving what we like! —Jane Austen (1)
Persuasion is a subject with which every radiologist, and especially every radiology leader, needs to be familiar. For radiology to thrive in the future, imaging expertise is not sufficient. In today’s complex and rapidly changing health care environment, we must excel not only in terms of clinical expertise, but also as advocates—advocates for our patients, our institutions, and our profession. Examples of such advocacy abound: we advocate for patients when we press insurers to cover beneficial imaging procedures; we advocate for our institutions when we negotiate more favorable purchasing and employment contracts; and we advocate for our profession when we educate the public about the value radiology adds to health care. In each case, there are more and less effective ways to persuade people, and we need to know the difference. If radiologists are going to represent the best interests of our organizations and the patients and communities we serve, it is vital that we thoroughly understand the art of persuasion. Persuasion works in at least two ways: attempting to persuade others and finding ourselves the objects of others’ attempts at persuasion. Both may occur around topics as diverse as clinical practice, scientific findings, compensation, promotion, equipment and facilities contracts, and organizational structure and performance. The better we understand the various approaches available to advocates, the better we can formulate our own arguments and soberly appraise those of others. This is especially important when we encounter the darker side of influence, in-
cluding attempts to coerce, deceive, or manipulate. If we do not recognize and respond effectively to such tactics, we place ourselves, our colleagues, and our organizations at substantial risk. Conversely, if we possess a strong command of the art of persuasion, we realize an important advantage. Consider the following three scenarios. ●
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From the Department of Radiology, Indiana University School of Medicine, 702 Barnhill Drive, Room 1053, Indianapolis, IN 46202-5200 (R.B.G., G.C.D.). Received October 3, 2006; accepted October 24, 2006. Address correspondence to: R.B.G. e-mail:
[email protected]
© AUR, 2007 doi:10.1016/j.acra.2006.10.011
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The chair of radiology at a university hospital determines that the medical students enrolled in a radiology course are not receiving sufficient attention from radiology department faculty members. Because the department needs to attract high-quality applicants to its residency program, and to increase the field’s standing in the minds of its future referral base, the chair believes that faculty members should devote more time to student education. However, simply issuing a mandate is not likely to succeed. Instead, the chair would like to present a persuasive case for more faculty involvement. What principles of persuasion should the chair use to build the strongest case? A radiologist is visited by a sales representative of an imaging equipment vendor, who strongly urges the department to purchase one of its new imaging devices. During the conversation, the sales representative appeals to their long professional relationship, asks if the department wishes to remain on the cutting edge of imaging technology, and states that other prestigious departments throughout the country have already placed their orders for the new product. After evaluating the advantages and disadvantages, the radiologist concludes that such a purchase would be ill-advised, yet feels pressured to say yes. What principles of persuasion does the radiologist need to understand to respond effectively to the sales pitch? Two radiologists are giving a presentation to a group of non-radiologist physicians concerning a new imaging technique. The radiologists strongly believe that the new technique represents an important advance in diagnostic imaging and wish to persuade their audience that
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they should adopt it. The radiologists are highly respected in the field, but are also by nature humble and do not wish to boast about past accomplishments. Yet it is clear that the professional esteem in which the radiologists are held by audience members will powerfully influence their decision. Should the radiologists promote their credentials, or remain silent to avoid the embarrassment of boasting? Fortunately, scholars have been studying the subject of persuasion for thousands of years, dating at least as far back as Aristotle’s Rhetoric, perhaps the greatest work ever written on the subject (2). Aristotle famously divided rhetoric into three modes of persuasion: the kind that depends on the personal character of the speaker (which he called ethos), the kind that depends on putting the audience in a certain frame of mind (pathos), and the kind that depends on the proof provided by the words of the speech itself (logos). Aristotle essentially invented the art of rhetoric, but his words were not the last to be written on the subject. Recent empirical research has shed considerable additional light on persuasion. One of the most respected contemporary scholars in this field is Robert Cialdini, a psychologist at Arizona State University (3). In an effort to better understand how salespeople understand and use influence, Cialdini began answering employment ads attempting to recruit people to work in the sales industry. These included ads for door-to-door salespeople, in-store sales staff, and telemarketers. He then attended their training programs to see how they prepared their new employees to sell more successfully.
SIX PRINCIPLES OF PERSUASION From years of such training, Cialdini defined six basic principles of influence: affinity, reciprocity, social proof, consistency, authority, and scarcity. These principles are outlined in depth in his book, Influence: Science and Practice (4), and nicely summarized in a Harvard Business Review article (5). The purpose of this article is to outline and illustrate these principles. Before proceeding, it is important to note that Cialdini’s six principles could be regarded in one of two ways: as weapons or as tools. If they are being used by someone attempting to influence us to do something we should not do, then they are weapons against which we need to protect ourselves. On the other hand, if they are being
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used to help us clarify our true priorities and work more effectively to achieve them, then they are tools that increase our effectiveness. Affinity Cialdini calls his first principle “liking,” although a better term might be affinity. Affinity refers to the general tendency for each of us to be more influenced by people when we feel close to them. When someone we like a lot makes a recommendation, we are more likely to follow it than if the recommendation comes from someone we barely know or even dislike. Although affinity is the product of a number of factors, Cialdini singles out two in particular: similarity and praise. In general, we tend to feel most comfortable with people like us. You can tell a lot about someone’s selfimage by seeing who they approach at a cocktail party or which group they choose to sit with in a cafeteria. Radiology leaders can put similarity to work by trying to get to know people in their organizations, and seeking out and accentuating commonalities such as educational background, family circumstances, and hobbies. We also tend to like and be impressed by people who praise us, and the more we praise people, the more they will tend to like us. This principle often holds even if the praise is unfounded. We like to be liked, and people who seem to like us enjoy an advantage when it comes to influencing us. Such praise can not only build new relationships, but also repair damaged ones. All radiologists would be wise to become more cognizant of the uses and abuses of praise in daily life. Reciprocity The second principle is reciprocity. Cialdini cites the example of the Hare Krishnas, whose members were once regular fixtures in some airports. The Krishnas realized that merely asking travelers for donations tended not to be very successful. Yet when they handed people a gift such as a flower or a copy of the Bhagavad Gita, the rate of donations increased dramatically. Interestingly, the value of the gift itself turned out not to be so important. The Krishnas were able to go around the airport recovering and recycling flowers and books that donors had placed in trash receptacles. What matters a great deal is getting the prospective buyer to accept the gift. Once that happens, most of us tend to feel obligated to reciprocate in some way. One of the most effective ways to guarantee receiving holiday greeting cards or birthday gifts is to send greeting cards
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or give gifts to others. Underlying this principle of reciprocity is a psychologic corollary to the Golden Rule, which says that we should treat others as we would like to be treated. This corollary states that we should treat others as they treat us. Based on this principle, we tend to treat best those who treat us well. A growing appreciation of this psychologic tendency underlies the American Medical Association’s recent tightening of guidelines regulating the acceptance of gifts by physicians (6). Despite protests to the contrary, there is evidence that physician prescribing and purchasing behavior is influenced by the gifts we receive from pharmaceutical companies and equipment vendors (7). If we are to respond appropriately to such conflicts of interest, we must first recognize them, and one of the keys to doing so is to understand how subtly the principle of reciprocity can influence our decision making. Imitation Cialdini calls his third principle “social proof,” though a better term might be imitation. If we want to persuade a hospital administrator to purchase a particular piece of imaging equipment but are unable to bestow any kind of gift, what could we do? One approach would be to provide the administrator a list of highly esteemed peer institutions that have already purchased that same piece of equipment. Although we like to think that our decision making is purely rational and evidence based, most of us lack the time and dedication to ferret out all the evidence. In many cases, sufficient evidence is simply not available. In such circumstances, we tend to be swayed by the behavior of others, particularly those whose judgment or reputation we esteem highly. Sometimes referred to as “peer pressure,” the principle of imitation highlights the fact that testimonials from satisfied customers can be extremely effective. Radiology leaders trying to promote a new initiative might put this principle to work by identifying individuals who are regarded as thought or opinion leaders and focusing initial persuasive efforts on them. If a few people who are highly regarded can be persuaded to support the initiative, particularly if they are willing to speak or write enthusiastically on its behalf, then others are likely to be much more readily brought on board. On the other hand, it can be downright counterproductive to enlist unpopular or poorly trusted people as advocates.
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Consistency The fourth principle is consistency. Most of us want to be consistent in our thoughts and behavior. We do not like to feel that we have changed our mind, or worse, betrayed a principle or position that we advocated. Most of us would be deeply stung if someone demonstrated that we were acting hypocritically. On the other hand, if a leader can show us that a proposed course of action flows naturally from positions we have taken in the past, then we are much more like to support it. Suppose the research and education fund of a national radiology organization wants to increase its membership’s rate of participation in an annual fundraising campaign. Instead of simply asking members for contributions, it might first ask them which research and education activities they believe should be the highest priority. When a radiologist highlights a particular initiative, such as research or education in cardiac imaging, then the organization can increase its rate of success by focusing solicitations around such a program. There is also evidence that expressed opinions—those either spoken in public or written down— exert much greater influence that those left unexpressed; therefore, it is important both to get us to recognize what we care about and get us to say so. Expressing our allegiance increases our level of clarity and commitment. This is one of the impetuses behind mission statements, which represent public and widely disseminated statements of an organization’s purposes. When everyone in the organization can explain the mission, the organization’s prospects for success are enhanced. Authority The fifth principle is authority. This relates to the principle of imitation, but highlights that all of us tend to be influenced by the degree of authority behind a recommendation. For example, most of us are unlikely to be heavily swayed by the health care recommendations of a supermarket tabloid. But if the same recommendations are made by a panel of acknowledged experts, and if those recommendations are published in a prestigious medical journal, then we are much more likely to follow them. One implication is that radiology leaders should not take for granted the level of authority they enjoy. Without boasting, it is important to make sure that those we hope to persuade appreciate our level of understanding of the problem at hand. This can mean sharing our educational and professional credentials, the length of time and nature of our responsibilities in the area, and any publications or
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offices and awards we have received. Viewed in the appropriate light, what might first seem boasting turns out to be a necessary form of education. Often the key piece of evidence that establishes a person’s authority is anecdotal, such as a story about a past problem or opportunity and how the individual successfully responded to it. Those who are able to establish their expertise early in the course of a negotiation or planning process usually enjoy substantially more influence over the course of the discussions. Conversely, someone whose formal or informal credentials turn out to have been misrepresented will suffer a serious loss of authority. Scarcity The sixth and final principle is scarcity. This refers to the general human tendency to value more highly things we think are more difficult to obtain. This is why advertisers so often describe their offers as limited time, limited supply, or one of a kind. Salespeople may try to exploit this principle by telling us that they are willing to bend the rules by reducing the price even further or by adding extra features, services, or warranties. Such “exceptional” offers may be believable when they come from a close friend or long-time associate, but suspicion is warranted when dealing with strangers. In medicine, as in the stock market, secret or closely guarded information also tends to be more persuasive than facts that are widely known. Radiology leaders can put this principle to work by sharing information in ways that build trust and loyalty. For example, when something important happens in a radiology department, news might be shared first in person with vice chairs and section chiefs before being sent out to the whole department in a broadcast e-mail. Again, it is important to note the potentially disastrous consequences of deception. When we find that a supposedly exclusive or once-in-a-lifetime offer was disingenuous, we are likely to treat future offers from that source much more skeptically.
CONCLUSION With these principles of persuasion in hand, let us return to the three scenarios at the beginning of this article. The chair seeking to persuade faculty members to devote more effort to medical student education first needs to base that appeal on good preexisting relationships with the faculty, the principle of affinity. If they dislike or dis-
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trust the chair, then such initiatives will be undermined from the start. The chair might also apply the principle of consistency, by asking faculty members to discuss different roles they think medical student education should play in the department’s future, and outline the pros and cons associated with each alternative. Along these same lines, the chair might invoke faculty members’ sense of professional identity, the reasons they entered academic medicine in the first place, and appeal to their desire to live up to that mission. The radiologist who wants to resist an equipment vendor’s sales pitch might first consider the principle of reciprocity. Would the representative be making the visit if a sale were not on the line? In addition, the radiologist might attempt to explain to the representative the pros and cons from the department’s point of view of making the purchase, thereby helping the salesperson understand the factors that enter into purchasing decisions. When good salespeople understand a client’s priorities, they can do an even better job of partnering for mutual success. If the representative cannot or will not understand the department’s current situation and simply keeps pressing the same offer, then the radiologist can more readily appreciate that a fundamental misalignment of understandings and incentives underlies the relationship. In the case of the radiologists attempting to persuade physicians to incorporate a new imaging technique in the care of their patients, it is important for the radiologists to attend to the principle of authority by clearly understanding their audience and making that understanding evident in their presentation. There is nothing boastful about citing one’s own credentials and experience, so long as it represents a good faith effort to educate others about the authority behind the recommendation. Each of the radiologists could arrange for the other to provide such background information during an introduction. In this way, the audience is adequately informed of the presenters’ credentials, but neither presenter feels awkward about doing it. To keep the audience in the dark about such expertise is not only rhetorically self-defeating but even ethically dubious, if it undermines their ability to make a fully informed judgment. In decades past, the persuasive power of leaders was often conceptualized in terms of mere influence. Leaders were thought to be defined by their capacity to influence others, to get us to do things we otherwise would not choose to do. The more effective the leader, it was supposed, the greater the change in behavior they could produce. We now recognize that this model of leadership is
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fundamentally flawed. True leadership in every field, including radiology, has less to do with influencing people than with helping us to discover what is truly most important and working together with us to achieve it. Great leaders do not bend us to their will. Instead they use their persuasive abilities to bring out the best in us. REFERENCES 1. Austen J. Persuasion. Available online at: http://books.mirror.org/austen/ persuasn. Accessed June 22, 2006.
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2. Aristotle. Rhetoric. Available online at: http://classics.mit.edu/Aristotle/ rhetoric.html. Accessed June 22, 2006. 3. Cialdini RB. The science of persuasion. Scient Am 2001;February: 76 – 81. 4. Cialdini RB. Influence: science and practice. 4th ed. Boston: Allyn and Bacon; 2001. 5. Cialdini RB. Harnessing the science of persuasion. Harv Bus Rev 2001; 2003:72–79. 6. American Medical Association. Gifts, ethics, and professionalism. Available online at: http://www.ama-assn.org/ama/noindex/category/ 9986.html. Last accessed June 22, 2006. 7. Stelfox HT, Chua G, O’Rourke K, et al. Conflict of interest in the debate over calcium channel antagonists. New Engl J Med 1998; 338: 101–106.