Framing effect debiasing in medical decision making

Diagnostic Reasoning and Decision Making in the Context of Health Information Technology

Diagnostic reasoning and medical decision making have been focal areas of research in the fields of medical education, cognition, and artificial intelligence in medicine. Drawing on several decades worth of research, we propose an integrated summary of prior research on diagnostic reasoning and decision making—in terms of both historical development and theoretical shifts. We also characterize the changes in research and theory resulting from the incorporation and adoption of health information technology in the clinical work place. In this paper, we differentiate between the various forms of diagnostic reasoning and trace the evolution of the various models of reasoning, including knowledge-based, exemplar-based, and visual strategies. We also discuss the effect of clinical expertise on reasoning processes. Within the medical decision-making research, we delineate the various approaches highlighting decision-making errors that arise due to the nature of heuristics and biases and other factors. Although there has been significant progress in our understanding, there is still a need for greater theoretical integration of disparate empirical phenomena. Specifically, there is a need to reconcile the various characterizations of reasoning and to evaluate the similarity and differences in the context of current health care practice. Finally, we discuss the role of human factors research in the study of clinical environments and also in relation to devising approaches and methodologies for understanding, evaluating, and supporting the diagnostic reasoning and decision processes.

Simple but powerful health messages for increasing condom use in young adults

In a large longitudinal study involving young adults, we conducted an eight-hour STD educational intervention and examined the impact of the intervention on the efficacy of a message for promoting condom use. The message was framed in positive or negative terms and was presented visually or in numbers (percentages or frequencies). Results indicated that the numerical positive-framed message increased condom use among young adults who did not receive the intervention, whereas the numerical negative-framed message did not. Attitudes toward condom use along with changes in intentions to use condoms mediated this framing effect. In contrast, the positive-framed and negative-framed messages were equally and highly effective for promoting condom use when the messages were presented visually or when young adults received the STD educational intervention before reading the message, suggesting that the simple brochures featuring visual aids were as effective in changing attitudes and behavioral intentions as the extensive intervention. These findings add to a growing body of evidence detailing the mechanisms that allow well-constructed visual aids to be among the most effective, transparent, memorable, and ethically desirable means of risk communication. Clinical and public health implications are discussed.

Framing effects in medical situations: distinctions of attribute, goal and risky choice frames

OBJECTIVE

To verify whether three different framing effects (risky choice, attribute and goal) exist in simulated medical situations and to analyse any differences.

METHODS

Medical decision-making problems were established, relating to medical skill evaluation, patient compliance and a selection of treatment options. All problems were described in positive and negative frame conditions.

RESULTS

Significantly more positive evaluations were made if the doctor's medical records were described as 'of 100 patients, 70 patients became better' compared with those described as 'of 100 patients, 30 patients didn't become better'. Doctor's advice described in a negative frame resulted in significantly more decisions to comply, compared with advice described in a positive frame. Treatment options described in terms of survival rates resulted in significantly more adventurous choices compared with options described in terms of mortality rates. Decision-making reversal appeared in the risky choice and attribute frames, but not the goal frame.

CONCLUSIONS

Framing effects were shown to exist in simulated medical situations, but there were significant differences among the three kinds of such effects.

On avoiding framing effects in experienced decision makers

The present study aimed to (a) demonstrate the effect of positive–negative framing on experienced criminal justice decision makers, (b) examine the debiasing effect of visually structured risk messages, and (c) investigate whether risk perceptions mediate the debiasing effect of visual aids on decision making. In two phases, 60 senior police officers estimated the accuracy of a counterterrorism technique in identifying whether a known terror suspect poses an imminent danger and decided whether they would recommend the technique to policy makers. Officers also rated their confidence in this recommendation. When information about the effectiveness of the counterterrorism technique was presented in a numerical format, officers' perceptions of accuracy and recommendation decisions were susceptible to the framing effect: The technique was perceived to be more accurate and was more likely to be recommended when its effectiveness was presented in a positive than in a negative frame. However, when the information was represented visually using icon arrays, there were no such framing effects. Finally, perceptions of accuracy mediated the debiasing effect of visual aids on recommendation decisions. We offer potential explanations for the debiasing effect of visual aids and implications for communicating risk to experienced, professional decision makers.

Altered risk-aversion and risk-taking behaviour in patients with Alzheimer's disease

AIM

Normal individuals are risk averse for decisions framed as gains but risk taking for decisions framed as losses. This framing effect is supposed to be attenuated in Alzheimer's disease (AD) patients. We investigated the effects of highlighting rewards versus highlighting punishments on the risky decision-making of AD patients.

METHOD

Fourteen mild to moderate AD patients (Mini-Mental Status Examination score, 11-23; Clinical Dementia Rating, 1-2) and 16 healthy volunteers were recruited for the study. Subjects completed a computerized task on risky decision-making in which mathematically equivalent dilemmas were presented in terms of opportunities to gain monetary rewards ('positive frame') or avoid suffering losses ('negative frame').

RESULTS

As expected, AD patients chose more risky options under the positive frame than the negative frame, contrary to the control group (Z =-2.671, P= 0.007). The normal difference in the distribution of risky choices between positively and negatively framed dilemmas was significantly reduced in the AD group after we adjusted for years of education, mean age and depression (F= 5.321, P= 0.030). Deliberation time did not differ significantly between the two groups.

CONCLUSION

These results suggest that AD patients making high-risk choices is associated with attenuated sensitivity to the emotional frames that highlight rewards or punishments, possibly reflecting altered evaluations of prospective gains and losses.

Image Theory’s counting rule in clinical decision making: Does it describe how clinicians make patient-specific forecasts?

The field of clinical decision making is polarized by two predominate views. One holds that treatment recommendations should conform with guidelines; the other emphasizes clinical expertise in reaching case-specific judgments. Previous work developed a test for a proposed alternative, that clinical judgment should systematically incorporate both general knowledge and patient-specific information. The test was derived from image theory’s two phase-account of decision making and its “simple counting rule”, which describes how possible courses of action are pre-screened for compatibility with standards and values. The current paper applies this rule to clinical forecasting, where practitioners indicate how likely a specific patient will respond favorably to a recommended treatment. Psychiatric trainees evaluated eight case vignettes that exhibited from 0 to 3 incompatible attributes. They made two forecasts, one based on a guideline recommendation, the other based on their own alternative. Both forecasts were predicted by equally- and unequally-weighted counting rules. Unequal weighting provided a better fit and exhibited a clearer rejection threshold, or point at which forecasts are not diminished by additional incompatibilities. The hypothesis that missing information is treated as an incompatibility was not confirmed. There was evidence that the rejection threshold was influenced by clinician preference. Results suggests that guidelines may have a de-biasing influence on clinical judgment. Subject to limitations pertaining to the subject sample and population, clinical paradigm, guideline, and study procedure, the data support the use of a compatibility test to describe how clinicians make patient-specific forecasts.

Decision-making heuristics and biases across the life span

We outline a contextual and motivational model of judgment and decision-making (JDM) biases across the life span. Our model focuses on abilities and skills that correspond to deliberative, experiential, and affective decision-making processes. We review research that addresses links between JDM biases and these processes as represented by individual differences in specific abilities and skills (e.g., fluid and crystallized intelligence, executive functioning, emotion regulation, personality traits). We focus on two JDM biases-the sunk-cost fallacy (SCF) and the framing effect. We trace the developmental trajectory of each bias from preschool through middle childhood, adolescence, early adulthood, and later adulthood. We conclude that life-span developmental trajectories differ depending on the bias investigated. Existing research suggests relative stability in the framing effect across the life span and decreases in the SCF with age, including in later life. We highlight directions for future research on JDM biases across the life span, emphasizing the need for process-oriented research and research that increases our understanding of JDM biases in people's everyday lives.

How to reduce the effect of framing on messages about health

BACKGROUND

Patients must be informed about risks before any treatment can be implemented. Yet serious problems in communicating these risks occur because of framing effects.

OBJECTIVE

To investigate the effects of different information frames when communicating health risks to people with high and low numeracy and determine whether these effects can be countered or eliminated by using different types of visual displays (i.e., icon arrays, horizontal bars, vertical bars, or pies).

DESIGN

Experiment on probabilistic, nationally representative US (n = 492) and German (n = 495) samples, conducted in summer 2008.

OUTCOME MEASURES

Participants' risk perceptions of the medical risk expressed in positive (i.e., chances of surviving after surgery) and negative (i.e., chances of dying after surgery) terms.

KEY RESULTS

Although low-numeracy people are more susceptible to framing than those with high numeracy, use of visual aids is an effective method to eliminate its effects. However, not all visual aids were equally effective: pie charts and vertical and horizontal bars almost completely removed the effect of framing. Icon arrays, however, led to a smaller decrease in the framing effect.

CONCLUSIONS

Difficulties with understanding numerical information often do not reside in the mind, but in the representation of the problem.

Young adult preferences for physician decision-making style in Japan and the United States

Studies in Japan and the United States investigate preferences for patient-physician decision-making style among young adults in the context of a primary care clinic visit for an upper respiratory infection. A treatment scenario described 1 of 3 decision-making styles: a young adult and doctor using a passive (physician decides), shared (patient and physician decide together), or autonomous (patient decides from a set of medically appropriate alternatives) decision-making style. Unexpectedly, Japanese respondents evaluated the autonomous interaction most positively. US respondents evaluated the shared decision-making scenario most positively. Overall, despite large cultural differences, both country samples favored higher participation in decision making. These results suggest that passive patient approaches are falling out of favor as patient-centered care expectations diffuse globally, even in traditionally hierarchic societies with high levels of respect for authority. The implications of these findings along with managerial implications and suggestions for future research are presented.

What constitutes evidence-based patient information? Overview of discussed criteria

OBJECTIVE

To survey quality criteria for evidence-based patient information (EBPI) and to compile the evidence for the identified criteria.

METHODS

Databases PubMed, Cochrane Library, PsycINFO, PSYNDEX and Education Research Information Center (ERIC) were searched to update the pool of criteria for EBPI. A subsequent search aimed to identify evidence for each criterion. Only studies on health issues with cognitive outcome measures were included. Evidence for each criterion is presented using descriptive methods.

RESULTS

3 systematic reviews, 24 randomized-controlled studies and 1 non-systematic review were included. Presentation of numerical data, verbal presentation of risks and diagrams, graphics and charts are based on good evidence. Content of information and meta-information, loss- and gain-framing and patient-oriented outcome measures are based on ethical guidelines. There is a lack of studies on quality of evidence, pictures and drawings, patient narratives, cultural aspects, layout, language and development process.

CONCLUSION

The results of this review allow specification of EBPI and may help to advance the discourse among related disciplines. Research gaps are highlighted.

PRACTICE IMPLICATIONS

Findings outline the type and extent of content of EBPI, guide the presentation of information and describe the development process.