Framing: What You Emphasize is What They Hear

 

Framing is the phenomenon where our perception of a choice changes depending on how the information is presented, even when the underlying facts are the same.

Imagine a new drug for hypertension. In clinical trials, it lowered blood pressure to a healthy level in 90% of patients. We could say: "This drug is 90% effective!" and it would be seen as a triumph. But we could just as accurately say: "It fails to work in 1 out of every 10 patients." Suddenly, that same drug seems a little less impressive. Nothing about the data changed—only the story around it.

This effect extends well beyond numbers. Take side effects: we could frame them as "most people experience none," or as "a significant minority do." Both are technically true. But the emotional and clinical weight those statements carry is very different.

Framing becomes even more powerful, and potentially misleading, when only one side of a therapy is presented. Whether it’s hyping the benefits or downplaying the risks, a partial truth can still be a distortion.

In healthcare, framing is everywhere. A new therapy can be made to sound miraculous by emphasizing benefits, or catastrophic by highlighting rare but serious harms. Both versions may be "true," but the framing dramatically influences how patients (and clinicians) interpret their options.

In my last article I discussed common heuristics we frequently fall victim to in assessing problems and making decisions. This was originally discussed by Daniel Kahneman in his book Thinking Fast and Slow, a recent favorite of mine which I now wish to apply to how we practice and think of common occurrences in the pharmacy / patient care.

In this article, I want to explore framing, biases that are highly relevant to how information is presented, how we communicate with patients, and how we make decisions as clinicians.

A Brief History of One-Sided Framing of Drugs

Barbiturates (early 1900s) Framing at the time: Miraculous sleep aids and tranquilizers, a chemical solution for a restless mind. Seen as a civilized alternative to alcohol and morphine. Reality: Highly addictive, easy to overdose, used in suicides. Withdrawal can be fatal.

Amphetamines (1930s onward) Framing at the time: Touted as a cure-all for depression, obesity, narcolepsy, even nasal congestion. Marketed to housewives and soldiers alike as a pep pill. Reality: Highly addictive, causes psychosis, aggression, heart problems. Massive abuse in the 1960s.

Miltown (1950s–60s) Framing at the time: “The first blockbuster psychotropic.” A tranquilizer for the modern anxieties of postwar life. Miltown was framed as the lifestyle drug for the average American. Reality: Physical dependence, withdrawal symptoms, sedative effects, questionable long-term efficacy.

Benzodiazepines (1960s onward) Framing at the time: Marketed as safer, non-addictive alternatives to barbiturates. “Mother’s little helper.” Promised serenity with none of the mess. Reality: Dependence, tolerance, addiction, withdrawal syndromes, long-term cognitive impairment.

Opioids (1990s to early 2000s) Framing at the time: New formulations like OxyContin were sold as non-addictive when used for pain, based on cherry-picked studies and aggressive marketing. Reality check: Catastrophic addiction epidemic, overdose deaths, fentanyl crisis.

The Present Echoes the Past

Drugs have undeniably become safer and more effective over time, thanks to ongoing innovation and stricter regulatory standards. Still, my hope is that we don’t repeat the same mistakes we’ve made in the past, or at least not on the same scale.

There’s a familiar pattern emerging with many newer psychotropic medications. It’s becoming increasingly easy to access these drugs, sometimes after simply telling a provider that "times have been tough." And while that experience is absolutely valid, suffering deserves recognition and treatment, it's important to be cautious.

Medications like Prozac, Paxil, Lexapro, Zoloft, and Seroquel have changed lives, no question. But for many people, they may also have been prescribed with little to no discussion of the very real, very common side effects patients are likely to experience. That omission does a disservice to informed consent.

When someone is facing severe illness, the risk of side effects can be more than justified. But when the condition is mild or moderate, the reality changes, and so should our framing of these drugs. We owe it to patients to be honest, not only about what these medications can do, but also about what they can cost.

Patients often come with their own frames, too. Some are skeptical of medications. They’ve been told drugs don’t “treat the root cause,” that they’re unnatural, or even inherently harmful. This is a limited frame that does not do justice to the role and benefit pharmacotherapy may have. At the same time that skepticism isn’t always wrong, history is filled with examples of drugs being given out like candy, widely prescribed, and only later discovered to carry serious risks (though sometimes this is known beforehand in a truly slimy scheme).

But there’s an equally dangerous counter-framing: the overconfident prescriber who presents a drug as purely beneficial, glossing over adverse effects or long-term consequences. When those realities show up later, often unannounced, patients are left feeling blindsided. That erodes trust not just in a single provider, but in the healthcare system at large.

Honest Framing

Though I may sound contrarian, I want to be fully transparent in my acknowledgement that modern drug development is one of modern medicine’s greatest achievements. Modern pharmacotherapy (including vaccination) is absolutely phenomenal and we reap the benefits everyday in a largely silent victory.

At the same time if we only tell part of the story, if we frame medications as magic bullets we’re doing a disservice to patients, and repeating mistakes we’ve made before. On the opposite side of this perspective are individuals who frame medicines as only evil and they too are falling into a false frame that neglects the whole truth.

The truth doesn’t lie neatly in the middle. It lives in the full picture: the good, the bad, and the clinically inconvenient. We should be grateful for the power of pharmacotherapy, but we also need to remain humble about its limits, risks, and the seductive power of a well-framed narrative.

Let us aim to present treatments not in their most flattering or damning light, but in their true light, one that reflects known benefits, known risks, and the realistic trajectory of care.