Decisions, decisions, …

How do physicians make them? To what extent are they prone to the same cognitive biases and errors that plague the rest of us? Here’s some literature on these questions.

Medical Decision Making in Situations That Offer Multiple Alternatives,” by Donald Redelmeier and Eldar Shafir (JAMA, 1995):

In one scenario involving a patient with osteoarthritis, family physicians were less likely to prescribe a medication when deciding between two medications than when deciding about only one medication (53% vs 72%; P<.005). Apparently, the difficulty in deciding between the two medications led some physicians to recommend not starting either. Similar discrepancies were found in decisions made by neurologists and neurosurgeons concerning carotid artery surgery and by legislators concerning hospital closures.

Rationality in Medical Decision Making: A Review of the Literature on Doctors’ Decision-Making Biases,” by Brian Bornstein, A Christine Emler (Journal of Evaluation in Clinical Practice, 2001):

The objectives of this study were to describe ways in which doctors make suboptimal diagnostic and treatment decisions, and to discuss possible means of alleviating those biases, using a review of past studies from the psychological and medical decision-making literatures.

The Psychology of Medical Decision Making,” by Gretchen Chapman (Blackwell Handbook of Judgment and Decision Making, 2004):

The current chapter reviews six intersections between the psychology of decision making and medicine.

A Universal Model of Diagnostic Reasoning,” by Pat Croskerry (Academic Medicine, 2009):

In more than four decades of research, a variety of approaches have been taken, but a consensus approach toward diagnostic decision making has not emerged. […] Dual-process theory has emerged as the predominant approach, positing two systems of decision making, System 1 (heuristic, intuitive) and System 2 (systematic, analytical). The author proposes a schematic model that uses the theory to develop a universal approach toward clinical decision making.

Emerging Paradigms of Cognition in Medical Decision-Making,” by Vimla Patel, David R Kaufman, Jose Arocha (Journal of Biomedical Informatics, 2002):

This paper critically reviews both traditional and recent approaches to medical decision making, considering the integration of problem-solving and decision-making research paradigms, the role of conceptual knowledge in decision-making, and the emerging paradigm of naturalistic decision-making. We also provide an examination of technology-mediated decision-making.

Five Pitfalls in Decisions About Diagnosis and Prescribing,” Jill Klein (BMJ, 2005):

I present five examples of cognitive biases that can affect medical decision making and offer suggestions for avoiding them.

Overconfidence as a Cause of Diagnostic Error in Medicine,” by Eta Berner, Mark Graber (American Journal of Medicine, 2008):

We argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence is related to both intrinsic and systemically reinforced factors. We present a comprehensive review of the available literature and current thinking related to these issues.

A Theory of Medical Decision Making and Health: Fuzzy Trace Theory,” by Valerie Reyna (Medical Decision Making, 2008):

A core idea of fuzzy trace theory is that people rely on the gist of information, its bottom-line meaning, as opposed to verbatim details in judgment and decision making. […] People can get the facts right, and still not derive the proper meaning, which is key to informed decision making. Getting the gist is not sufficient, however. […] Theory-based interventions that work (and why they work) are presented, ranging from specific techniques aimed at enhancing representation, retrieval, and processing to a comprehensive intervention that integrates these components.

The Cognitive Psychology of Missed Diagnoses,” by Donald Redelmeier (Annals of Internal Medicine, 2005):

A 65-year-old man who was followed in a dermatology clinic for moderately severe lichen planus was called back to the emergency department after blood cultures grew Staphylococcus aureus. The patient’s ultimate diagnosis was initially missed through a series of errors in diagnostic reasoning.

Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias,” by P Croskerry (Academic Emergency Medicine, 2002):

It is important that emergency physicians be aware of the nature and extent of these heuristics and biases, or cognitive dispositions to respond (CDRs). Thirty are catalogued in this article, together with descriptions of their properties as well as the impact they have on clinical decision making in the ED. Strategies are delineated in each case, to minimize their occurrence.

(Somewhat related: a study showed that surgeons perform just as well even when they get less sleep.)


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