Doctors’ dud beliefs

Doctors’ own biases could keep them suggesting tests and treatments that aren’t worth it

The impact of campaigns to reduce low value care in medicine, such as Choosing Wisely Australia and EVOLVE, may be limited by cognitive biases that predispose doctors towards low value care unless these are also addressed, say experts writing in the Medical Journal of Australia.

Associate Professor Ian Scott, director of Internal Medicine and Clinical Epidemiology at Brisbane’s Princess Alexandra Hospital, and colleagues from the Royal Australasian College of Physicians, the Menzies Centre for Health Policy and NPS MedicineWise, have written a Narrative Review for the MJA which summarises these biases and suggests mitigating strategies.

“Low value care” is defined as “care that confers little or no benefit, may instead cause patient harm, is not aligned with patient preferences, or yields marginal benefits at a disproportionately high cost”, they write.

The authors write that “much of everyday clinical decision making is largely intuitive behaviour” derived “not only from formal education and training… but from peer opinion, personal experience, professional socialisation and societal norms”.

Cognitive biases, or systematic errors driven by psychological factors, can “steer clinicians towards continuing to believe in, and deliver, care that robust evidence has shown to be of low value”.

Such biases include:

  • Commission bias: doctors have a strong desire to avoid experiencing a sense of regret (or loss) at not administering an intervention that could have benefited at least a few recipients (omission regret). Errors of omission are a stronger driver for doctors than errors of commission;
  • Attribution bias: Anecdotal and selective observations of favourable outcomes attributed to an intervention may lead to undue confidence in its effectiveness;
  • Impact bias: Patients and clinicians tend to overestimate the benefits and underestimate the harms of interventions;
  • Availability bias: Emotionally charged and vivid case studies with either good or bad outcomes that come easily to mind (ie, are available) can unduly inflate estimates of the likelihood of the same scenario being repeated; and
  • Ambiguity bias: Even when the evidence base that defines an intervention as being of low value is well known and accepted by most clinicians, interventions are still performed simply to provide added reassurance and assuage patient or peer expectations.

A/Prof Scott and his colleagues suggested strategies to reduce cognitive biases, such as cognitive huddles and autopsies, including case studies of low value cases; narratives of patient harm from low value care; adding a value statement detailing the perceived benefits, harms and costs of what is being planned to the patient’s management plan; defining acceptable levels of risk of adverse outcomes; shared decision making, in which the patient is fully informed of alternative treatments; and reflective practice and role modelling.

“Relatively few [of these debiasing strategies] have been subject to randomised effectiveness trials. More research within the field of behavioural economics is needed to fill this evidence gap,” the authors concluded.

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