Framing effect debiasing in medical decision making

Debiasing Judgements Using a Distributed Cognition Approach: A Scoping Review of Technological Strategies

ObjectiveTo review and synthesise research on technological debiasing strategies across domains, present a novel distributed cognition-based classification system, and discuss theoretical implications for the field.BackgroundDistributed cognition theory is valuable for understanding and mitigating cognitive biases in high-stakes settings where sensemaking and problem-solving are contingent upon information representations and flows in the decision environment. Shifting the focus of debiasing from individuals to systems, technological debiasing strategies involve designing system components to minimise the negative impacts of cognitive bias on performance. To integrate these strategies into real-world practices effectively, it is imperative to clarify the current state of evidence and types of strategies utilised.MethodsWe conducted systematic searches across six databases. Following screening and data charting, identified strategies were classified into (i) group composition and structure, (ii) information design and (iii) procedural debiasing, based on distributed cognition principles, and cognitive biases, classified into eight categories.ResultsEighty articles met the inclusion criteria, addressing 100 debiasing investigations and 91 cognitive biases. A majority (80%) of the identified debiasing strategies were reportedly effective, whereas fourteen were ineffective and six were partially effective. Information design strategies were studied most, followed by procedural debiasing, and group structure and composition. Gaps and directions for future work are discussed.ConclusionThrough the lens of distributed cognition theory, technological debiasing represents a reconceptualisation of cognitive bias mitigation, showing promise for real-world application.ApplicationThe study results and debiasing classification presented can inform the design of high-stakes work systems to support cognition and minimise judgement errors.

Commentary: Tolvaptan for Autosomal Dominant Polycystic Kidney Disease (ADPKD) - an update

Autosomal Dominant Polycystic Kidney Disease (ADPKD) affects up to 70 000 people in the UK and the most common inherited cause of end-stage kidney disease (ESKD). It is generally a late-onset multisystem disorder characterised by bilateral kidney cysts, liver cysts and an increased risk of intracranial aneurysms. Approximately 50% of people with ADPKD reach ESKD by age 60. Disease-associated pain, discomfort, fatigue, emotional distress and, impaired mobility can impact health-related quality of life. The approval of tolvaptan, a vasopressin V2 receptor antagonist, has greatly advanced the care for people with ADPKD, shifting the focus from general chronic kidney disease management to targeted therapeutic approaches. While guidance from NICE and SMC provides a foundational framework, this is not clear or comprehensive enough to offer practical guidance for healthcare professionals in real-world settings. This commentary expands on the previous United Kingdom Kidney Association (UKKA) commentary in 2016 with an updated evidence base, the incorporation of real-world data and expert opinion to provide practical guidance to healthcare professionals. Through co-development with people affected by ADPKD, it now incorporates valuable patient perspectives and offers practical recommendations for the UK kidney community seeking to harmonise the quality of care of all people with ADPKD.

How to activate intuitive and reflective thinking in behavior research? A comprehensive examination of experimental techniques

Experiments comparing intuitive and reflective decisions provide insights into the cognitive foundations of human behavior. However, the relative strengths and weaknesses of the frequently used experimental techniques for activating intuition and reflection remain unknown. In a large-scale preregistered online experiment (N = 3667), we compared the effects of eight reflection, six intuition, and two within-subjects manipulations on actual and self-reported measures of cognitive performance. Compared to the overall control, the long debiasing training was the most effective technique for increasing actual reflection scores, and the emotion induction was the most effective technique for increasing actual intuition scores. In contrast, the reason and the intuition recall, the reason induction, and the brief time delay conditions failed to achieve the intended effects. We recommend using the debiasing training, the decision justification, or the monetary incentives technique to activate reflection, and the emotion induction, the cognitive load, or the time pressure technique to activate intuition.

Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations

Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.

A systematic review of the effects of positive versus negative framing on cancer treatment decision making

OBJECTIVE

Presenting treatment outcomes positively or negatively may differently influence treatment preferences and lead to sub-optimal decision in a medical context. This review systematically organised how positive versus negative framing of treatment outcomes influenced cancer treatment decisions of cancer patients and individuals without a cancer diagnosis.

DESIGN

Three databases (PubMed, PsycInfo and Scopus) were searched for studies reporting the effects of positive versus negative framing on cancer treatment decision-making from 1981 to December 2020.

MAIN OUTCOME MEASURE

The effects of positive versus negative framing on cancer treatment preferences and the elimination of framing effect were evaluated.

RESULTS

A total of 12 studies that met inclusion criteria were reviewed. Framing effect was consistently observed in individuals without a cancer diagnosis. There was not enough evidence to suggest a robust framing effect in cancer patients. Surgery was preferred in positive framing, whereas adjuvant therapy was preferred in negative framing. Justification intervention significantly eliminated framing effect. Mixed framing failed to eliminate framing effect.

CONCLUSION

Current recommendations for presenting treatment options are based on research in cancer-screening decision-making. Knowledge of how positive versus negative framing affect cancer patients' treatment decisions is still limited. Our review highlighted the need for continued research in this area.

Individual differences moderate effects in an Unusual Disease paradigm: A psychophysical data collection lab approach and an online experiment

We report two studies investigating individual intuitive-deliberative cognitive-styles and risk-styles as moderators of the framing effect in Tversky and Kahneman's famous Unusual Disease problem setting. We examined framing effects in two ways: counting the number of frame-inconsistent choices and comparing the proportions of risky choices depending on gain-loss framing. Moreover, in addition to gain-loss frames, we systematically varied the number of affected people, probabilities of surviving/dying, type of disease, and response deadlines. Study 1 used a psychophysical data collection approach and a sample of 43 undergraduate students, each performing 480 trials. Study 2 was an online study incorporating psychophysical elements in a social science approach using a larger and more heterogeneous sample, i.e., 262 participants performed 80 trials each. In both studies, the effect of framing on risky choice proportions was moderated by risk-styles. Cognitive-styles measured on different scales moderated the framing effect only in study 2. The effects of disease type, probability of surviving/dying, and number of affected people on risky choice frequencies were also affected by cognitive-styles and risk-styles but different for both studies and to different extents. We found no relationship between the number of frame-inconsistent choices and cognitive-styles or risk-styles, respectively.

Ethics of the algorithmic prediction of goal of care preferences: from theory to practice

Artificial intelligence (AI) systems are quickly gaining ground in healthcare and clinical decision-making. However, it is still unclear in what way AI can or should support decision-making that is based on incapacitated patients' values and goals of care, which often requires input from clinicians and loved ones. Although the use of algorithms to predict patients' most likely preferred treatment has been discussed in the medical ethics literature, no example has been realised in clinical practice. This is due, arguably, to the lack of a structured approach to the epistemological, ethical and pragmatic challenges arising from the design and use of such algorithms. The present paper offers a new perspective on the problem by suggesting that preference predicting AIs be viewed as sociotechnical systems with distinctive life-cycles. We explore how both known and novel challenges map onto the different stages of development, highlighting interdisciplinary strategies for their resolution.

Nudging attitudes toward IT innovations by information provision that serves as a reminder of familial support

There is concern among the general public that information technology (IT) innovations may make existing jobs redundant. This may be perceived to pose a greater problem to future generations because new technologies, not limited to IT innovations, will be sophisticated in the future. Our previous work revealed that messages reminding people of familial support as a nudge can moderate risk-averse attitudes toward risks that are perceived to threaten future generations, which could be effective for other kinds of risks. Therefore, we conducted a randomized controlled trial to examine the message effects for information provision on IT innovations. The study was conducted via an online questionnaire survey in January 2020, before the COVID-19 pandemic, and more than 3,200 samples were collected from respondents aged 20 years or older living in Japan. The treatment groups received basic information supplemented with additional text or additional text and an illustration that highlighted IT innovations as support from previous generations. The control group received only the basic textual information. The effects of the intervention were evaluated by comparing changes in average subjective assessment of IT in the treatment groups with those in the control group. The intervention effect was statistically significant, and the sense of familial support after receiving the intervention messages was significantly increased in the treatment group that viewed the illustration compared with the control group. Additionally, we discuss how each component of the HEXACO personality traits influences responses to the intervention messages. Through a series of surveys, we demonstrated the potential of our framework for a wide variety of applications involving information provision perceived to involve future generations.

Analysis of types of and language used in online information available to patients with periodontitis

Introduction This research investigates framing in online patient information for those newly diagnosed with periodontitis.Methods This study is a cross-sectional analysis of websites using corpus linguistic techniques. A Google search was conducted with the term 'gum disease.' Ten pages of search results were reviewed and information available was separated into types of resource: retail, healthcare, and dental practice websites. The dataset was analysed in terms of word frequency, collocation and keyness as compared to the British National Corpus Written Sampler. Differences between sources were assessed.Results Across combined data sources, there was a tendency for the most advanced symptoms of periodontitis to be given prominence. There was also a negative skew towards avoidance of negative outcomes of treatment rather than achieving positive ones. When comparing types of resource, retail websites tended to be more positive, with a focus on improving 'milder' stages of disease.Conclusions Negative framing could potentially induce engagement with treatment and self-care by the process of 'fear-appeal'; however, there is a risk that negativity demotivates an already anxious patient. Further research is required to evaluate patient perceptions of the information and to investigate effects this could have on behaviour change.

Health Literacy and eHealth: Challenges and Strategies

Given the impact of health literacy (HL) on patients' outcomes, limited health literacy is a major barrier to improve cancer care globally. HL refers to the degree in which an individual is able to acquire, process, and comprehend information in a way to be actively involved in their health decisions. Previous research found that almost half of the population in developed countries have difficulties in understanding health-related information. With the gradual shift toward the shared decision making process and digital transformation in oncology, the need for addressing low HL issues is crucial. Decision making in oncology is often accompanied by considerable consequences on patients' lives, which requires patients to understand complex information and be able to compare treatment methods by considering their own values. How health information is perceived by patients is influenced by various factors including patients' characteristics and the way information is presented to patients. Currently, identifying patients with low HL and simple data visualizations are the best practice to help patients and clinicians in dealing with limited health literacy. Furthermore, using eHealth, as well as involving HL mediators, supports patients to make sense of complex information.

Ethics and the 2018 Practice Guideline on Disorders of Consciousness: A Framework for Responsible Implementation

The 2018 practice guideline on disorders of consciousness marks an important turning point in the care of patients with severe brain injury. As clinicians and health systems implement the guideline in practice, several ethical challenges will arise in assessing the benefits, harms, feasibility, and cost of recommended interventions. We provide guidance for clinicians when interpreting these recommendations and call on professional societies to develop an ethical framework to complement the guideline as it is implemented in clinical practice.

Decontextualisation for framing effect reduction

BACKGROUND

The aim of this study is to demonstrate the presence of a framing effect that influences residents' decision-making and to assess decontextualisation as an intervention strategy to reduce the influence of framing on their decision.

METHODS

This is a randomised controlled trial in which researchers sent an evaluation questionnaire to all residents of … University including clinical vignettes, with questions formulated in two different ways on the same subject and a decontextualisation test involving logical reasoning problems. The researchers then sent to all participants different clinical vignettes evaluating the same dimensions as those addressed in the previous part.

RESULTS

The response rate was 86 (28.2%), of which they included 52 (60.4%) in the analysis. The framing effect was present in 37 (71.1%) of responses and then decreased to 35 (67.3%) after the decontextualisation test, especially at the level of the type of framing involving risky decision-making (p = 0.03).

DISCUSSION

Decontextualisation is an effective strategy for reducing bias related to the framing effect among residents, particularly the type of framing involving risky decision-making. In medical teaching, decontextualisation exercises may help improve critical thinking and reduce the framing effect.

Lay, professional, and artificial intelligence perspectives on risky medical decisions and COVID-19: How does the number of lives matter in clinical trials framed as gains versus losses?

Outcomes of clinical trials need to be communicated effectively to make decisions that save lives. We investigated whether framing can bias these decisions and if risk preferences shift depending on the number of patients. Hypothetical information about two medicines used in clinical trials having a sure or a risky outcome was presented in either a gain frame (people would be saved) or a loss frame (people would die). The number of patients who signed up for the clinical trials was manipulated in both frames in all the experiments. Using an unnamed disease, lay participants (experiment 1) and would-be medical professionals (experiment 2) were asked to choose which medicine they would have administered. For COVID-19, lay participants were asked which medicine should medical professionals (experiment 3), artificially intelligent software (experiment 4), and they themselves (experiment 5) favour to be administered. Broadly consistent with prospect theory, people were more risk-seeking in the loss frames than the gain frames. However, risk-aversion in gain frames was sensitive to the number of lives with risk-neutrality at low magnitudes and risk-aversion at high magnitudes. In the loss frame, participants were mostly risk-seeking. This pattern was consistent across laypersons and medical professionals, further extended to preferences for choices that medical professionals and artificial intelligence programmes should make in the context of COVID-19. These results underscore how medical decisions can be impacted by the number of lives at stake while revealing inconsistent risk preferences for clinical trials during a real pandemic.

Don't Throw Your Heart Away: Increased Transparency of Donor Utilization Practices in Transplant Center Report Cards Alters How Center Performance Is Evaluated

BACKGROUND

Publicly available report cards for transplant centers emphasize posttransplant survival and obscure the fact that some centers reject many of the donor organs they are offered (reflecting a conservative donor acceptance strategy), while others accept a broader range of donor offers (reflecting an open donor acceptance strategy).

OBJECTIVE

We assessed how the provision of salient information about donor acceptance practices and waitlist survival rates affected evaluation judgments of hospital report cards given by laypeople and medical trainees.

METHODS

We tested 5 different report card formats across 4 online randomized experiments (n1 = 1,003, n2 = 105, n3 = 123, n4 = 807) in the same hypothetical decision. The primary outcome variable was a binary choice between transplant hospitals (one with an open donor acceptance strategy and the other with a conservative donor acceptance strategy).

RESULTS

Report cards featuring salient information about donor organ utilization rates (transplant outcomes categorized by quality of donor offers accepted) or overall survival rates (outcomes from both waitlist and transplanted patients) led lay participants (studies 1, 3, and 4) and medical trainees (study 2) to evaluate transplant centers with open donor acceptance strategies more favorably than centers with conservative strategies.

LIMITATIONS

Due to the nature of the decision, a hypothetical scenario was necessary for both ethical and practical reasons. Results may not generalize to transplant clinicians or patients faced with the decision of where to join the transplant waitlist.

CONCLUSIONS

These findings suggest that performance evaluations for transplant centers may vary significantly based not only on what outcome information is presented in report cards but also how the information is displayed.

Framing of and Attention to COVID-19 on Twitter: Thematic Analysis of Hashtags

Background

Although past research has focused on COVID-19–related frames in the news media, such research may not accurately capture and represent the perspectives of people from diverse backgrounds. Additionally, research on the public attention to COVID-19 as reflected through frames on social media is scarce.

Objective

This study identified the frames about the COVID-19 pandemic in the public discourse on Twitter, which voices diverse opinions. This study also investigated the amount of public attention to those frames on Twitter.

Methods

We collected 22 trending hashtags related to COVID-19 in the United States and 694,582 tweets written in English containing these hashtags in March 2020 and analyzed them via thematic analysis. Public attention to these frames was measured by evaluating the amount of public engagement with frames and public adoption of those frames.

Results

We identified 9 frames including “public health guidelines,” “quarantine life,” “solidarity,” “evidence and facts,” “call for action,” “politics,” “post-pandemic life,” “shortage panic,” and “conflict.” Results showed that some frames such as “call for action” are more appealing than others during a global pandemic, receiving greater public adoption and engagement. The “call for action” frame had the highest engagement score, followed by “conflict” and “evidence and facts.” Additionally, “post-pandemic life” had the highest adoption score, followed by “call for action” and “shortage panic.” The findings indicated that the frequency of a frame on social media does not necessarily mean greater public adoption of or engagement with the frame.

Conclusions

This study contributes to framing theory and research by demonstrating how trending hashtags can be used as new user-generated data to identify frames on social media. This study concludes that the identified frames such as “quarantine life” and “conflict” and themes such as “isolation” and “toilet paper panic” represent the consequences of the COVID-19 pandemic. The consequences could be (1) exclusively related to COVID-19, such as hand hygiene or isolation; (2) related to any health crisis such as social support of vulnerable groups; and (3) generic that are irrespective of COVID-19, such as homeschooling or remote working.

Decision-making following identification of an infant's unilateral hearing loss: Parent and professional perspectives

BACKGROUND

Parents of infants identified with unilateral hearing loss (UHL) make decisions about managing their infant's hearing loss based on limited evidence and before knowing whether their infant will require additional support.

OBJECTIVES

The decision-making processes of parents and clinicians regarding the management of UHL following newborn hearing screening were examined.

PROCEDURE

Two convenience samples were recruited: 15 parents of children with permanent UHL aged under 4 years, and 14 clinicians. Applied thematic analysis of the semi-structured interviews elicited insight into the complexities surrounding decision-making from a parent and clinician perspective.

RESULTS

Three main themes captured the decision-making process: motivation for decision-making, limited evidence creates uncertainty, and available evidence builds certainty. The diverse experiences and opinions of parents and clinicians highlight the complexity of decision-making when there are contested opinions and no clear best management option.

CONCLUSIONS

The choices parents make about the management of their child's UHL can have lifelong implications for their child. Many questions need answering before parents can effectively evaluate the short- and long-term consequences of their options and whether the advantages outweigh the disadvantages in the long-term. This uncertainty is challenging for professionals and parents and risks cognitive biases influencing clinical and parental decision-making.

Systematic review of clinician-directed nudges in healthcare contexts

OBJECTIVE

Nudges are interventions that alter the way options are presented, enabling individuals to more easily select the best option. Health systems and researchers have tested nudges to shape clinician decision-making with the aim of improving healthcare service delivery. We aimed to systematically study the use and effectiveness of nudges designed to improve clinicians' decisions in healthcare settings.

DESIGN

A systematic review was conducted to collect and consolidate results from studies testing nudges and to determine whether nudges directed at improving clinical decisions in healthcare settings across clinician types were effective. We systematically searched seven databases (EBSCO MegaFILE, EconLit, Embase, PsycINFO, PubMed, Scopus and Web of Science) and used a snowball sampling technique to identify peer-reviewed published studies available between 1 January 1984 and 22 April 2020. Eligible studies were critically appraised and narratively synthesised. We categorised nudges according to a taxonomy derived from the Nuffield Council on Bioethics. Included studies were appraised using the Cochrane Risk of Bias Assessment Tool.

RESULTS

We screened 3608 studies and 39 studies met our criteria. The majority of the studies (90%) were conducted in the USA and 36% were randomised controlled trials. The most commonly studied nudge intervention (46%) framed information for clinicians, often through peer comparison feedback. Nudges that guided clinical decisions through default options or by enabling choice were also frequently studied (31%). Information framing, default and enabling choice nudges showed promise, whereas the effectiveness of other nudge types was mixed. Given the inclusion of non-experimental designs, only a small portion of studies were at minimal risk of bias (33%) across all Cochrane criteria.

CONCLUSIONS

Nudges that frame information, change default options or enable choice are frequently studied and show promise in improving clinical decision-making. Future work should examine how nudges compare to non-nudge interventions (eg, policy interventions) in improving healthcare.

Accuracy incentives and framing effects to minimize the influence of cognitive bias among advanced cancer patients

Many patients with advanced illness have unrealistic survival expectations, largely due to cognitive biases. Studies suggests that when people are motivated to be accurate, they are less prone to succumb to these biases. Using a randomized survey design, we test whether offering advanced cancer patients (n = 200) incentives to estimate their prognosis improves accuracy. We also test whether presenting treatment benefits in terms of a loss (mortality) rather than a gain (survival) reduces willingness to take up a hypothetical treatment. Results are not consistent with the proposed hypotheses for either accuracy incentives or framing effects.

Judgment and decision-making in clinical dentistry

The development of clinical judgment and decision-making skills is complex, requiring clinicians—whether students, novices, or experienced practitioners—to correlate information from their own experience; from discussions with colleagues; from attending professional meetings, conferences and congresses; and from studying the current literature. Feedback from treated cases will consolidate retention in memory of the complexities and management of past cases, and the conversion of this knowledge base into daily clinical practice. The purpose of this narrative review is to discuss factors related to clinical judgment and decision-making in clinical dentistry and how both narrative, intuitive, evidence-based data-driven information and statistical approaches contribute to the global process of gaining clinical expertise.

Numbers do not add up! The pragmatic approach to the framing of medical treatments

The risky choice framing effect disclosed that presenting data in a loss scenario lead decision-makers towards risky choices. Conversely, a gain scenario prevents them from taking a risk. Framing effect robustness has been widely confirmed by psychological literature. However, the framing of medical treatments, based on McNeil et al. (1982) paradigm, raised both methodological doubts and contrasting evidence. Our research aimed to investigate the presence and the nature of the framing effect in the McNeil et al. (1982) paradigm. In particular, we thought that the obtained switch of preferences across frames was due to a misleading formulation of the data given in a negative cumulative frequency format. We conducted three studies: (1) we replicated McNeil et al.’s (1982) original study (N=150) with medicine (n=50), statistics (n=50) and lay (n=50) students; (2) we tested (N=180) our hypothesis by comparing a cumulative frequency format with an alternative version, namely a linear progression one; (3) we compared (N=430) the effect of different formats (cumulative frequency, linear progression and interval frequency) on choices. Our results showed that, while the framing effect is present when employing a cumulative frequency format, it disappears when using a linear progression one. Moreover, our results show that decision-makers better understand information when given in a linear progression and an interval frequency format. In the current paper, we argue that the way in which a problem is formulated plays a relevant role in the representation of the decisional task and the decision-making.

How to Influence the Results of MCDM?—Evidence of the Impact of Cognitive Biases

Multi-criteria decision-making (MCDM) methods aim at dealing with certain limitations of human information processing. However, cognitive biases, which are discrepancies of human behavior from the behavior of perfectly rational agents, might persist even when MCDM methods are used. In this article, we focus on two among the most common biases—framing and loss aversion. We test whether these cognitive biases can influence in a predictable way both the criteria weights elicited using the Analytic Hierarchy Process (AHP) and the final ranking of alternatives obtained with the Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS). In a controlled experiment we presented two groups of participants with a multi-criteria problem and found that people make different decisions when presented with different but objectively equivalent descriptions (i.e., frames) of the same criteria. Specifically, the results show that framing and loss aversion influenced the responses of decision makers during pairwise comparisons, which in turn caused the rank reversal of criteria weights across groups and resulted in the choice of a different best alternative. We discuss our findings in light of Prospect Theory and show that the particular framing of criteria can influence the outcomes of MCDM in a predictable way. We outline implications for MCDM methodology and highlight possible debiasing techniques.

Teaching the use of framing and decontextualization to address context-based bias in psychiatry

The framing effect in medical decision making is a type of cognitive bias that can lead a medical trainee at undergraduate and graduate level to reach a diagnosis or take action based on emotional states induced by the frame in which the information has been approached. This literature review on the framing effect in medical decision making will be done in the context of a case presentation in which the framing of scientific information may lead to conflicting decisions in psychiatry. As a matter of fact, debiasing techniques which help medical students/residents become aware of the fact that they might be easily influenced by the frame used in scientific data, have started to be implemented in medical teaching programs. It is important to incorporate exercises that improve debiasing skills in the curriculum at all levels of medical education. An example of such exercises is decontextualization which consists of improving problem-solving in a non-medical context in order to consolidate the use of the same schema of critical thinking in a medical context afterwards.

Activating reflective thinking with decision justification and debiasing training

Manipulations for activating reflective thinking, although regularly used in the literature, have not previously been systematically compared. There are growing concerns about the effectiveness of these methods as well as increasing demand for them. Here, we study five promising reflection manipulations using an objective performance measure — the Cognitive Reflection Test 2 (CRT-2). In our large-scale preregistered online experiment (N = 1,748), we compared a passive and an active control condition with time delay, memory recall, decision justification, debiasing training, and combination of debiasing training and decision justification. We found no evidence that online versions of the two regularly used reflection conditions — time delay and memory recall — improve cognitive performance. Instead, our study isolated two less familiar methods that can effectively and rapidly activate reflective thinking: (1) a brief debiasing training, designed to avoid common cognitive biases and increase reflection, and (2) simply asking participants to justify their decisions.

Cognitive biases in MCDM methods: an embedded filter proposal through sustainable supplier selection problem

Purpose

Expert evaluation is the backbone of the multi-criteria decision-making (MCDM) techniques. The experts make pairwise comparisons between criteria or alternatives in this evaluation. The mainstream research focus on the ambiguity in this process and use fuzzy logic. On the other hand, cognitive biases are the other but scarcely studied challenges to make accurate decisions. The purpose of this paper is to propose pilot filters – as a debiasing strategy – embedded in the MCDM techniques to reduce the effects of framing effect, loss aversion and status quo-type cognitive biases. The applicability of the proposed methodology is shown with analytic hierarchy process-based Technique for Order-Preference by Similarity to Ideal Solution method through a sustainable supplier selection problem.

Design/methodology/approach

The first filter's aim is to reduce framing bias with restructuring the questions. To manipulate the weights of criteria according to the degree of expected status quo and loss aversion biases is the second filter's aim. The second filter is implemented to a sustainable supplier selection problem.

Findings

The comparison of the results of biased and debiased ranking indicates that the best and worst suppliers did not change, but the ranking of suppliers changed. As a result, it is shown that, to obtain more accurate results, employing debiasing strategies is beneficial.

Originality/value

To the best of the author's knowledge, this approach is a novel way to cope with the cognitive biases. Applying this methodology easily to other MCDM techniques will help the decision makers to take more accurate decisions.

Senior nurses' perceptions of junior nurses' incident reporting: A qualitative study

AIM

To develop an understanding of senior nurses' ranking and perceptions of incident reporting by junior nurses.

BACKGROUND

Nurses must be encouraged to report incidents to nursing management. It is important to ascertain how senior nurses perceive their concerns, as it is crucial to ensuring that patient safety is managed.

METHOD

Qualitative study. Four focus groups explored senior nurses' perceptions of risks identified by nurses from a live incident reporting database. Data were analysed using framework analysis.

RESULTS

Five themes emerged demonstrating the differences in opinions in relation to the classification of events by senior and non-senior nurses. Senior nurses held the view that some junior nurses use incident reporting to 'vent frustration.'

CONCLUSION

There is a mismatch between senior nurses' and junior nurses' perceptions of safety incidents. Nurses need to develop the writing style and use language that red flags incidents when reporting incidents. Senior nurses need to create a positive culture where risk from incident reporting is used to improve patient safety and subsequently a positive work environment. Implications for Nursing Management Our research identified the need for joint training to promote a shared understanding among nurses as to how incident report should be completed to promote patient safety.

Interventions to Mitigate Cognitive Biases in the Decision Making of Eye Care Professionals: A Systematic Review

SIGNIFICANCE

Cognitive biases, systematic errors in thinking that impact a person's choices and judgments, can influence decision making at various points during patient care provision. These biases can potentially result in misdiagnoses, delayed clinical care, and/or patient mismanagement. A range of interventions exists to mitigate cognitive biases. There is a need to understand the relative efficacy of these interventions within the context of eye care practice.

PURPOSE

The aim of this systematic review was to synthesize the evidence relating to interventions for mitigating cognitive biases associated with clinical decision making by eye care professionals.

DATA SOURCES

Electronic databases (including Ovid MEDLINE, Embase, Scopus, PsycINFO) were searched from inception to October 2017 for studies investigating interventions intended to mitigate cognitive biases in the clinical decision making of eye care professionals. This review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines.

STUDY ELIGIBILITY CRITERIA

To ensure inclusion of all relevant literature, a wide range of study designs was eligible for inclusion, such as randomized controlled trials, nonrandomized trials, interrupted time series and repeated measures, controlled before-after studies, and qualitative studies that were a component of any of these quantitative study designs.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two review authors independently screened titles, abstracts, and full-text articles in duplicate, applying a priori eligibility criteria.

RESULTS

After screening 2759 nonduplicate records, including full-text screening of 201 articles, no relevant studies were identified.

CONCLUSIONS AND IMPLICATIONS OF FINDINGS

Given that cognitive biases can significantly impact the accuracy of clinical decision making and thus can have major effects on clinical care and patient health outcomes, the lack of studies identified in this systematic review indicates a critical need for research within the area of cognitive bias mitigation for decision making within eye care practice.

Individual and contextual influences on framing effect: Evidence from the Middle East

Framing effect occurs when decision makers choose inconsistent solutions for identical problems based on the way the problems are presented to them. Despite considerable scholarly investigations in this area, the majority of existing work tends to be western-centric and systematically overlooks the characteristics of decision makers and context. Using a sample of Iranian health-care providers, this article addresses these challenges in investigation of framing effect. The results based on responses of 62 decision makers to multiple decision scenarios indicate that framing has a very strong influence on Iranian experts’ choices. Additionally, the findings show that framing interacts with decision makers’ general risk-taking propensity and domain-specific expertise to shape choice. Theoretical and practical implications are discussed.

Cognitive Style and Frame Susceptibility in Decision-Making

The susceptibility of decision-makers' choices to variations in option framing has been attributed to individual differences in cognitive style. According to this view, individuals who are prone to a more deliberate, or less intuitive, thinking style are less susceptible to framing manipulations. Research findings on the topic, however, have tended to yield small effects, with several studies also being limited in inferential value by methodological drawbacks. We report two experiments that examined the value of several cognitive-style variables, including measures of cognitive reflection, subjective numeracy, actively open-minded thinking, need for cognition, and hemispheric dominance, in predicting participants' frame-consistent choices. Our experiments used an isomorph of the Asian Disease Problem and we manipulated frames between participants. We controlled for participants' sex and age, and we manipulated the order in which choice options were presented to participants. In Experiment 1 (N = 190) using an undergraduate sample and in Experiment 2 (N = 316) using a sample of Amazon Mechanical Turk workers, we found no significant effect of any of the cognitive-style measures taken on predicting frame-consistent choice, regardless of whether we analyzed participants' binary choices or their choices weighted by the extent to which participants preferred their chosen option over the non-chosen option. The sole factor that significantly predicted frame-consistent choice was framing: in both experiments, participants were more likely to make frame-consistent choices when the frame was positive than when it was negative, consistent with the tendency toward risk aversion in the task. The present findings do not support the view that individual differences in people's susceptibility to framing manipulations can be substantially accounted for by individual differences in cognitive style.

Parental Decision-Making on Childhood Vaccination

A growing number of parents delay vaccinations or are deciding not to vaccinate their children altogether. This increases the risk of contracting vaccine-preventable diseases and disrupting herd immunity, and also impairs the trust in the capacities of health care systems to protect people. Vaccine hesitancy is related to a range of both psychological and demographic determinants, such as attitudes toward vaccinations, social norms, and trust in science. Our aim is to understand those determinants in parents, because they are a special group in this issue-they act as proxy decision makers for their children, who are unable to decide for themselves. The fact that deciding to vaccinate is a socially forced choice that concerns a child's health makes vaccine-related decisions highly important and involving for parents. This high involvement might lead to parents overemphasizing the potential side effects that they know to be vaccine-related, and by amplifying those, parents are more focused on the potential outcomes of vaccine-related decisions, which can yield specific pattern of the outcome bias. We propose two related studies to investigate factors which promote vaccine hesitancy, protective factors that determine parental vaccination decisions, and outcome bias in parental vaccination intentions. We will explore demographic and psychological factors, and test parental involvement related to vaccine hesitancy using an online battery in a correlation panel design study. The second study is an experimental study, in which we will investigate the moderating role of parents' high involvement in the specific domain of vaccination decision making. We expect that higher involvement among parents, compared to non-parents, will shape the pattern of the proneness to outcome bias. The studies will be conducted across eight countries in Europe and Asia (Finland, Germany, Hong Kong, the Netherlands, Serbia, Slovenia, Spain, and the United Kingdom), rendering findings that will aid with understanding the underlying mechanisms of vaccine hesitancy and paving the way for developing interventions custom-made for parents.

Alternation between different types of evidence attenuates judgments of severity

Most real-world judgments and decisions require the consideration of multiple types of evidence. For example, judging the severity of environmental damage, medical illness, or negative economic trends often involves tracking and integrating evidence from multiple sources (i.e. different natural disasters, physical symptoms, or financial indicators). We hypothesized that the requirement to track and integrate across distinct types of evidence would affect severity judgments of multifaceted problems, compared to simpler problems. To test this, we used scenarios depicting crop damage. Each scenario involved either two event types (i.e. mold damage and insect damage), or one event type. Participants judged the quality of the crop following each scenario. In Experiments 1 and 2, subjective judgments were attenuated if the scenario depicted multiple event types, relative to scenarios depicting single event types. This was evident as a shallower slope of subjective severity ratings, as a function of objectively quantifiable severity, for scenarios with multiple event types. In Experiment 3, we asked whether alternation between event types might contribute to this attenuation. Each scenario contained two event types, and the sequence of events either alternated frequently between types or was organized into two sequential groups. Subjective judgments were attenuated for scenarios with frequently alternating sequences. The results demonstrate that alternation between distinct event types attenuates subjective judgments of severity. This suggests that a requirement to integrate evidence across multiple sources places extra demands on the cognitive system, which reduces the perceived evidence strength.

Debiasing Health-Related Judgments and Decision Making: A Systematic Review

BACKGROUND

Being confronted with uncertainty in the context of health-related judgments and decision making can give rise to the occurrence of systematic biases. These biases may detrimentally affect lay persons and health experts alike. Debiasing aims at mitigating these negative effects by eliminating or reducing the biases. However, little is known about its effectiveness. This study seeks to systematically review the research on health-related debiasing to identify new opportunities and challenges for successful debiasing strategies.

METHODS

A systematic search resulted in 2748 abstracts eligible for screening. Sixty-eight articles reporting 87 relevant studies met the predefined inclusion criteria and were categorized and analyzed with regard to content and quality. All steps were undertaken independently by 2 reviewers, and inconsistencies were resolved through discussion.

RESULTS

The majority of debiasing interventions ( n = 60) was at least partially successful. Optimistic biases ( n = 25), framing effects ( n = 14), and base rate neglects ( n = 10) were the main targets of debiasing efforts. Cognitive strategies ( n = 36) such as "consider-the-opposite" and technological interventions ( n = 33) such as visual aids were mainly tested. Thirteen studies aimed at debiasing health care professionals' judgments, while 74 interventions addressed the general population. Studies' methodological quality ranged from 26.2% to 92.9%, with an average rating of 68.7%.

DISCUSSION

In the past, the usefulness of debiasing was often debated. Yet most of the interventions reviewed here are found to be effective, pointing to the utility of debiasing in the health context. In particular, technological strategies offer a novel opportunity to pursue large-scale debiasing outside the laboratory. The need to strengthen the transfer of debiasing interventions to real-life settings and a lack of conceptual rigor are identified as the main challenges requiring further research.

How best to obtain consent to thrombolysis: Individualized decision-making

OBJECTIVE

To investigate the factors that influence the preferences of patients and their proxies concerning thrombolytic therapy and to determine how best to convey information.

METHODS

A total of 613 participants were randomly assigned to a positively or negatively framed group. Each participant completed a series of surveys. We applied latent class analysis (LCA) to explore participants' patterns of choices of thrombolysis and to classify the participants into different subgroups. Then we performed regression analyses to investigate predictors of classification of the participants into each subgroup and to establish a thrombolytic decision-making model.

RESULTS

LCA indicated an optimal 3-subgroup model comprising intermediate, favorable to thrombolysis, and aversion to thrombolysis subgroups. Multiple regression analysis revealed that 10 factors predicted assignment to the intermediate subgroup and 4 factors predicted assignment to the aversion to thrombolysis subgroup compared with the favorable to thrombolysis subgroup. The χ(2) tests indicated that the information presentation format and the context of thrombolysis influenced participants' choices of thrombolysis and revealed a framing effect in different subgroups.

CONCLUSIONS

The preference for thrombolysis was influenced by the positive vs negative framing scenarios, the format of item presentation, the context of thrombolysis, and individual characteristics. Inconsistent results may be due to participant heterogeneity and the evaluation of limited factors in previous studies. Based on a decision model of thrombolysis, physicians should consider the effects of positive vs negative framing and should seek a neutral tone when presenting the facts, providing an important reference point for health persuasion in other clinical domains.

Framing Effects on Physicians' Judgment and Decision Making

This study aimed to assess physicians' susceptibility to framing effects in clinical judgment and decision making. A survey was administered online to 159 general internists in the United States. Participants were randomized into two groups, in which clinical scenarios varied in their framings: frequency vs percentage, with cost information vs without, female patient vs male patient, and mortality vs survival. Results showed that physicians' recommendations for patients in hypothetical scenarios were significantly different when the predicted probability of the outcomes was presented in frequency versus percentage form and when it was presented in mortality rate vs survival rate of the same magnitude. Physicians' recommendations were not different for other framing effects.

Probabilities of benefit and harms of preoperative radiotherapy for rectal cancer: What do radiation oncologists tell and what do patients understand?

OBJECTIVE

Probabilities of benefits and harms of treatment may help patients when making a treatment decision. This study aimed to examine (1) whether and how radiation oncologists convey probabilities to rectal cancer patients, and (2) patients' estimates of probabilities of major outcomes of rectal cancer treatment.

METHODS

First consultations of oncologists and patients eligible for preoperative radiotherapy (PRT) (N=90) were audio taped. Tapes were transcribed verbatim and coded to identify probabilistic information presented. Patients (N=56) filled in a post-consultation questionnaire on their estimates of probabilities.

RESULTS

Probabilities were mentioned in 99% (local recurrence), 75% (incontinence), 72% and 40% (sexual dysfunction in males and females, respectively) of cases. Most patients (89%) correctly estimated that PRT decreases the probability of local recurrence, and 10% and 38%/54% that it increases the probability of incontinence and sexual dysfunction in males/females, respectively. Patients tended to underestimate the probabilities of harms of treatment.

CONCLUSION

Our results show that oncologists almost always mention probabilities of benefit of PRT. In contrast, probabilities of harms often go unmentioned. The effect of PRT on adverse events is often underestimated.

PRACTICE IMPLICATIONS

Oncologists should stay alert to patients' possible misunderstanding of probabilistic information and should check patients' perceptions of probabilities.

Management of Crohn's disease - are guidelines transferred to clinical practice?

BACKGROUND

Management of Crohn's disease (CD) is a clinical challenge. In terms of an evidence-based approach, clinical guidelines help to deal with this challenge. However, little is known about guideline adherence concerning the management of CD in Germany.

OBJECTIVE

To survey German gastroenterologists with regards to their guideline adherence in daily clinical care.

METHOD

A web-based national survey was conducted among German gastroenterologists.

RESULTS

A total of 175 inflammatory bowel disease (IBD) practitioners responded to the survey. Overall, in the different clinical situations covered in the questionnaire guideline adherence is good. However, the 5-aminosalicylic acid (5-ASA) prescribing habits represent a striking exception. About 10-36% use 5-ASA as mono-therapy in CD, depending on the clinical scenario. Predominantly it is used in mild CD and in colonic involvement. To maintain a surgically achieved remission, therapeutic decisions broadly rely on individual approaches with azathioprine and 5-ASA being used by about 30% of the respondents. Cessation of smoking as a "therapeutic" strategy of maintenance therapy is used by only half of the surveyed physicians.

CONCLUSION

Amongst German IBD practitioners, the guideline adherence is good overall. Reflecting ongoing uncertainty about the efficacy of mesalazine, its use in Crohn's disease is still heterogeneous.

The attitude-behavior discrepancy in medical decision making

Background:

In medical practice, the dissatisfaction of patients about medical decisions made by doctors is often regarded as the fuse of doctor-patient conflict. However, a few studies have looked at why there are such dissatisfactions.

Objectives:

This experimental study aimed to explore the discrepancy between attitude and behavior within medical situations and its interaction with framing description.

Patients and Methods:

A total of 450 clinical undergraduates were randomly assigned to six groups and investigated using the classic medical decision making problem, which was described either in a positive or a negative frame (2) × decision making behavior\attitude to risky plan\attitude to conservative plan (3).

Results:

A discrepancy between attitude and behavior did exist in medical situations. Regarding medical dilemmas, if the mortality rate was described, subjects had a significant tendency to choose a conservative plan (t = 3.55, P < 0.01) yet if the survival rate was described, there was no such preference (t = -1.48, P > 0.05). However, regardless of the plan chosen by the doctor, the subjects had a significant opposing attitude (P < .05). Framing description had a significant impact on both decision making behavior and attitude (t _behavior = -3.24, P < 0.01；t _{attitude to surgery} = 4.08，P < 0.01；t _{attitude to radiation} = -2.15，P < 0.05).

Conclusions:

A discrepancy of attitude-behavior does exist in medical situations. The framing of a description has an impact on medical decision-making.

Are health nudges coercive?

Governments and policy-makers have of late displayed renewed attention to behavioural research in an attempt to achieve a range of policy goals, including health promotion. In particular, approaches which could be labelled as 'nudges' have gained traction with policy-makers. A range of objections to nudging have been raised in the literature. These include claims that nudges undermine autonomy and liberty, may lead to a decrease in responsibility in decision-making, lack transparency, involve deception, and involve manipulation, potentially occasioning coercion. In this article I focus on claims of coercion, examining nudges within two of the main approaches to coercion-the pressure approach and the more recent enforcement approach. I argue that coercion entails an element of control over the behaviour of agents which is not plausibly displayed by the kinds of serious examples of nudges posited in the literature.

Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy

BACKGROUND

The role of cognitive biases and heuristics in medical decision making is of growing interest. The purpose of this study was to determine whether studies on cognitive biases and heuristics in medical decision making are based on actual or hypothetical decisions and are conducted with populations that are representative of those who typically make the medical decision; to categorize the types of cognitive biases and heuristics found and whether they are found in patients or in medical personnel; and to critically review the studies based on standard methodological quality criteria.

METHOD

Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and the CINAHL databases published in 1980-2013. Predefined exclusion criteria were used to identify 213 studies. During data extraction, information was collected on type of bias or heuristic studied, respondent population, decision type, study type (actual or hypothetical), study method, and study conclusion.

RESULTS

Of the 213 studies analyzed, 164 (77%) were based on hypothetical vignettes, and 175 (82%) were conducted with representative populations. Nineteen types of cognitive biases and heuristics were found. Only 34% of studies (n = 73) investigated medical personnel, and 68% (n = 145) confirmed the presence of a bias or heuristic. Each methodological quality criterion was satisfied by more than 50% of the studies, except for sample size and validated instruments/questions. Limitations are that existing terms were used to inform search terms, and study inclusion criteria focused strictly on decision making.

CONCLUSIONS

Most of the studies on biases and heuristics in medical decision making are based on hypothetical vignettes, raising concerns about applicability of these findings to actual decision making. Biases and heuristics have been underinvestigated in medical personnel compared with patients.

Decision aid influences on factors associated with patient empowerment prior to cancer treatment decision making

BACKGROUND

Despite progress, models that incorporate antecedent and mediating factors associated with shared decision making (SDM)-related outcomes remain limited. An experimental study tests patient decision aid (DA) effects on a network of antecedents and mediators associated with patient empowerment prior to a medical decision-making consultation regarding cancer treatment.

METHODS

A pilot study initially evaluated measurement scales, model fit, and the overall effect of the DA experience. The pilot compared matched treatment and control group samples of US adult online panel members exposed to a vignette about meeting their dermatologist to decide on skin cancer treatment. The treatment group also experienced a skin cancer DA with treatment options and value clarification activity, while the control group did not. The main study employed a randomized experimental design to formally test hypothesized path coefficients across the groups.

RESULTS

The pilot study suggested an overall enhanced DA effect on self-empowerment. In the experimental study, the DA experience strengthened the direct path from desire for medical information to self-empowerment and the indirect path from comprehension/participation confidence to self-empowerment through cancer attitude. The DA had no strengthening effect on the direct path from life satisfaction to self-empowerment, but in the DA condition, the factor appeared to play a role by contributing to the enhanced association between confidence and cancer attitude.

CONCLUSION

Evidence from this research indicates that experiencing a DA prior to treatment decision making affects patient empowerment through a network that includes desire for information, life satisfaction, and multiple mediators. The studies also demonstrate the role that theory-based, multigroup structural equation modeling (SEM) can play in increasing understanding of DA effects. Such understanding is critical to improving SDM between patients and their physicians.

Framing Options as Choice or Opportunity

Objective. Health professionals must enable patients to make informed decisions about health care choices through unbiased presentation of all options. This study examined whether presenting the decision as “opportunity” rather than “choice” biased individuals’ preferences in the context of trial participation for cancer treatment. Methods. Self-selecting healthy women ( N = 124) were randomly assigned to the following decision frames: opportunity to take part in the trial (opt-in), opportunity to be removed from the trial (opt-out), and choice to have standard treatment or take part in the trial (choice). The computer-based task required women to make a hypothetical choice about a real-world cancer treatment trial. The software presented the framed scenario, recorded initial preference, presented comprehensive and balanced information, traced participants’ use of information during decision making, and recorded final decision. A posttask paper questionnaire assessed perceived risk, attitudes, subjective norm, perceived behavioral control, and satisfaction with decision. Results. Framing influenced women’s immediate preferences. Opportunity frames, whether opt-in or opt-out, introduced a bias as they discouraged women from choosing standard treatment. Using the choice frame avoided this bias. The opt-out opportunity frame also affected women’s perceived social norm; women felt that others endorsed the trial option. The framing bias was not present once participants had had the opportunity to view detailed information on the options within a patient decision aid format. There were no group differences in information acquisition and final decisions. Sixteen percent changed their initial preference after receiving full information. Conclusions. A “choice” frame, where all treatment options are explicit, is less likely to bias preferences. Presentation of full information in parallel, option-by-attribute format is likely to “de-bias” the decision frame. Tailoring of information to initial preferences would be ill-advised as preferences may change following detailed information.

Differences in simulated doctor and patient medical decision making: a construal level perspective

BACKGROUND

Patients are often confronted with diverse medical decisions. Often lacking relevant medical knowledge, patients fail to independently make medical decisions and instead generally rely on the advice of doctors.

OBJECTIVE

This study investigated the characteristics of and differences in doctor-patient medical decision making on the basis of construal level theory.

METHODS

A total of 420 undergraduates majoring in clinical medicine were randomly assigned to six groups. Their decisions to opt for radiotherapy and surgery were investigated, with the choices described in a positive/neutral/negative frame × decision making for self/others.

RESULTS

Compared with participants giving medical advice to patients, participants deciding for themselves were more likely to select radiotherapy (F1, 404 = 13.92, p = 011). Participants from positive or neutral frames exhibited a higher tendency to choose surgery than did those from negative frames (F2, 404 = 22.53, p<.001). The effect of framing on independent decision making was nonsignificant (F2, 404 = 1.07, p = 35); however the effect of framing on the provision of advice to patients was significant (F2, 404 = 12.95, p<.001). The effect of construal level was significant in the positive frame (F1, 404 = 8.06, p = 005) and marginally significant in the neutral frame (F2, 404 = 3.31, p = 07) but nonsignificant in the negative frame (F2, 404 = .29, p = 59).

CONCLUSION

Both social distance and framing depiction significantly affected medical decision making and exhibited a significant interaction. Differences in medical decision making between doctors and patients need further investigation.