How feedback biases give ineffective medical treatments a good reputation

The Cultural Evolution of Medical Technologies : A Model of Sequential Treatments in the Medical Setting

When people get ill, they naturally want to restore health through medical interventions. Here I model a situation in which individuals can psychologically entertain multiple potential treatments at once: when illness occurs, individuals would attempt one treatment first, and if it fails to produce an observable effect within a particular time period, a second treatment is attempted, and the eventual recovery is attributed to the treatment that is temporally closer. This creates population dynamics wherein the therapeutic power of the superior/effective medical treatments is misattributed to inferior/ineffective treatments. Through both analytic formulation and agent-based simulation, I show that the equilibrium frequencies of different treatment variants depend on their natural variability in the effect timing, the level of individual patience, and the number of cultural models sampled by the naive individual. Both ineffective and effective medical treatments may stably coexist in the population under a range of parameter settings.

Ghosts, Divination, and Magic among the Nuosu: An Ethnographic Examination from Cognitive and Cultural Evolutionary Perspectives

I present a detailed ethnographic study of magic and divination of the Nuosu people in southwest China and offer a cognitive account of the surprising prevalence of these objectively ineffective practices in a society that has ample access to modern technology and mainstream Han culture. I argue that in the belief system of the Nuosu, ghosts, divination, and magical healing rituals form a closely interconnected web that gives sense and meaning to otherwise puzzling practices, and such a belief system is importantly supported and reinforced by individual's everyday experiences. Contemporary Nuosu people overwhelmingly treat these practices as instruments for achieving specific ends and often entertain considerable uncertainty regarding their efficacy, which may be overestimated for a number of reasons, including the following: (1) the intuitive plausibility of divination for ghost identification and exorcist rituals is enhanced by the belief in the existence of ghosts as a result of abductive reasoning, (2) negative instances (divinatory or healing ritual failures) are underreported, and (3) people's misperception of the probability of uncertain events' occurrence often prevents them from realizing that the efficacies of magical/divinatory practices do not outperform chance. I conclude with some comments on the generalizability of the psychological and social mechanisms discussed.

A Volunteer-Run, Face-to-Face, Early Intervention Service for Reducing Suicidality

Background: Befriending is one of many strategies with the potential to reduce suicidal ideation and decrease the risk of suicide. Aims: To measure change in suicidal ideation and behavior among visitors (service users) supported at The Listening Place (TLP), a charity which offers volunteer-run, face-to-face befriending to people who are suicidal. Method: This study was peer reviewed and preregistered on the Open Science Framework prior to data extraction. Anonymized data were extracted for visitors at the point of referral and after 3 months of receiving support. Paired-sample tests were used to test whether self-reported suicidal ideation and behaviors changed after 3 months of support from TLP. Multivariable regressions were used to test whether change in suicidal feelings was associated with demographic characteristics or baseline self-reported suicidality. Results: TLP received 13,938 referrals from July 2016 to February 2022. Self-reported suicidal ideation, suicidal behavior, and feelings of distress decreased after 3 months, while feelings of support increased. Only self-reported suicidal behavior prior to referral was associated with a lesser reduction in self-reported suicidality after 3 months. Limitations: In the absence of a control group, it cannot be concluded that TLP causes the reduction in self-reported suicidality. Conclusions: An empathetic, nonjudgmental, listening service for people who are feeling suicidal was well received by users, who experienced a reduction in suicidality.

Broad Medical Uncertainty and the ethical obligation for openness

This paper argues that there exists a collective epistemic state of 'Broad Medical Uncertainty' (BMU) regarding the effectiveness of many medical interventions. We outline the features of BMU, and describe some of the main contributing factors. These include flaws in medical research methodologies, bias in publication practices, financial and other conflicts of interest, and features of how evidence is translated into practice. These result in a significant degree of uncertainty regarding the effectiveness of many medical treatments and unduly optimistic beliefs about the benefit/harm profiles of such treatments. We argue for an ethical presumption in favour of openness regarding BMU as part of a 'Corrective Response'. We then consider some objections to this position (the 'Anti-Corrective Response'), including concerns that public honesty about flaws in medical research could undermine trust in healthcare institutions. We suggest that, as it stands, the Anti-Corrective Response is unconvincing.

Comparing the Impact of Online Ratings and Report Cards on Patient Choice of Cardiac Surgeon: Large Observational Study

Background

Patients may use two information sources about a health care provider’s quality: online physician reviews, which are written by patients to reflect their subjective experience, and report cards, which are based on objective health outcomes.

Objective

The aim of this study was to examine the impact of online ratings on patient choice of cardiac surgeon compared to that of report cards.

Methods

We obtained ratings from a leading physician review platform, Vitals; report card scores from Pennsylvania Cardiac Surgery Reports; and information about patients’ choices of surgeons from inpatient records on coronary artery bypass graft (CABG) surgeries done in Pennsylvania from 2008 to 2017. We scraped all reviews posted on Vitals for surgeons who performed CABG surgeries in Pennsylvania during our study period. We linked the average overall rating and the most recent report card score at the time of a patient’s surgery to the patient’s record based on the surgeon’s name, focusing on fee-for-service patients to avoid impacts of insurance networks on patient choices. We used random coefficient logit models with surgeon fixed effects to examine the impact of receiving a high online rating and a high report card score on patient choice of surgeon for CABG surgeries.

Results

We found that a high online rating had positive and significant effects on patient utility, with limited variation in preferences across individuals, while the impact of a high report card score on patient choice was trivial and insignificant. About 70.13% of patients considered no information on Vitals better than a low rating; the corresponding figure was 26.66% for report card scores. The findings were robust to alternative choice set definitions and were not explained by surgeon attrition, referral effect, or admission status. Our results also show that the interaction effect of rating information and a time trend was positive and significant for online ratings, but small and insignificant for report cards.

Conclusions

A patient’s choice of surgeon is affected by both types of rating information; however, over the past decade, online ratings have become more influential, while the effect of report cards has remained trivial. Our findings call for information provision strategies that incorporate the advantages of both online ratings and report cards.

The Impact of Signals Transmission on Patients' Choice through E-Consultation Websites: An Econometric Analysis of Secondary Datasets

(1) Background: The COVID-19 pandemic has dramatically and rapidly changed the overall picture of healthcare in the way how doctors care for their patients. Due to the significant strain on hospitals and medical facilities, the popularity of web-based medical consultation has drawn the focus of researchers during the deadly coronavirus disease (COVID-19) in the United States. Healthcare organizations are now reacting to COVID-19 by rapidly adopting new tools and innovations such as e-consultation platforms, which refer to the delivery of healthcare services digitally or remotely using digital technology to treat patients. However, patients' utilization of different signal transmission mechanisms to seek medical advice through e-consultation websites has not been discussed during the pandemic. This paper examines the impact of different online signals (online reputation and online effort), offline signals (offline reputation) and disease risk on patients' physician selection choice for e-consultation during the COVID-19 crisis. (2) Methods: Drawing on signaling theory, a theoretical model was developed to explore the antecedents of patients' e-consultation choice toward a specific physician. The model was tested using 3-times panel data sets, covering 4231 physicians on Healthgrades and Vitals websites during the pandemic months of January, March and May 2020. (3) Results: The findings suggested that online reputation, online effort and disease risk were positively related to patients' online physician selection. The disease risk has also affected patients' e-consultation choice. A high-risk disease positively moderates the relationship between online reputation and patients' e-consultation choice, which means market signals (online reputation) are more influential than seller signals (offline reputation and online effort). Hence, market signals strengthened the effect in the case of high-risk disease. (4) Conclusions: The findings of this study provide practical suggestions for physicians, platform developers and policymakers in online environments to improve their service quality during the crisis. This article offers a practical guide on using emerging technology to provide virtual care during the pandemic. This study also provides implications for government officials and doctors on the potentials of consolidating virtual care solutions in the near future in order to contribute to the integration of emerging technology into healthcare.

Aversive medical treatments signal a need for support: a mathematical model

Ineffective, aversive and harmful medical treatments are common cross-culturally, historically and today. Using evolutionary game theory, we develop the following model to explain their persistence. Humans are often incapacitated by illness and injury, and are unusually dependent on care from others during convalescence. However, such caregiving is vulnerable to exploitation via illness deception, whereby people feign or exaggerate illness in order to gain access to care. Our model demonstrates that aversive treatments can counter-intuitively increase the range of conditions where caregiving is evolutionarily viable, because only individuals who stand to gain substantially from care will accept the treatment. Thus, contemporary and historical "ineffective" treatments may be solutions to the problem of allocating care to people whose true need is difficult to discern.

A cross-sectional study assessing the association between online ratings and clinical quality of care measures for US hospitals: results from an observational study

Background

Little is known about the usefulness of online ratings when searching for a hospital. We therefore assess the association between quantitative and qualitative online ratings for US hospitals and clinical quality of care measures.

Methods

First, we collected a stratified random sample of 1000 quantitative and qualitative online ratings for hospitals from the website RateMDs. We used an integrated iterative approach to develop a categorization scheme to capture both the topics and sentiment in the narrative comments. Next, we matched the online ratings with hospital-level quality measures published by the Centers for Medicare and Medicaid Services. Regarding nominally scaled measures, we checked for differences in the distribution among the online rating categories. For metrically scaled measures, we applied the Spearman rank coefficient of correlation.

Results

Thirteen of the twenty-nine quality of care measures were significantly associated with the quantitative online ratings (Spearman p = ±0.143, p < 0.05 for all). Thereof, eight associations indicated better clinical outcomes for better online ratings. Seven of the twenty-nine clinical measures were significantly associated with the sentiment of patient narratives (p = ±0.114, p < 0.05 for all), whereof four associations indicated worse clinical outcomes in more favorable narrative comments.

Conclusions

There seems to be some association between quantitative online ratings and clinical performance measures. However, the relatively weak strength and inconsistency of the direction of the association as well as the lack of association with several other clinical measures may not enable the drawing of strong conclusions. Narrative comments also seem to have limited potential to reflect the clinical quality of care in its current form. Thus, online ratings are of limited usefulness in guiding patients towards high-performing hospitals from a clinical point of view. Nevertheless, patients might prefer different aspects of care when choosing a hospital.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2886-3) contains supplementary material, which is available to authorized users.

A Cultural Evolution Approach to Digital Media

Digital media have today an enormous diffusion, and their influence on the behavior of a vast part of the human population can hardly be underestimated. In this review I propose that cultural evolution theory, including both a sophisticated view of human behavior and a methodological attitude to modeling and quantitative analysis, provides a useful framework to study the effects and the developments of media in the digital age. I will first give a general presentation of the cultural evolution framework, and I will then introduce this more specific research program with two illustrative topics. The first topic concerns how cultural transmission biases, that is, simple heuristics such as “copy prestigious individuals” or “copy the majority,” operate in the novel context of digital media. The existence of transmission biases is generally justified with their adaptivity in small-scale societies. How do they operate in an environment where, for example, prestigious individuals possess not-relevant skills, or popularity is explicitly quantified and advertised? The second aspect relates to fidelity of cultural transmission. Digitally-mediated interactions support cheap and immediate high-fidelity transmission, in opposition, for example, to oral traditions. How does this change the content that is more likely to spread? Overall, I suggest the usefulness of a “long view” to our contemporary digital environment, contextualized in cognitive science and cultural evolution theory, and I discuss how this perspective could help us to understand what is genuinely new and what is not.

Examining the role of patients’ experiences as a resource for choice and decision-making in health care: a creative, interdisciplinary mixed-method study in digital health

Background

Traditional health information has been based on facts and figures and not on patient experience (PEx). Websites featuring people’s accounts of their experiences of health and illness are popular as a source of information, support and much else. However, there are concerns that experiential information on the internet might have adverse effects on health.

Aims

To find out whether, when and how the NHS should incorporate PEx into online health information and elucidate the mechanisms through which PEx might influence health, develop a tool to measure the effects of online PEx, explore how PEx is used, and investigate the feasibility and acceptability of a randomised controlled trial of online PEx.

Methods

Mixed methods, including a conceptual literature review, qualitative secondary data analysis, the development of a new questionnaire, online ethnography, observational and experimental studies in an internet café environment, and finally feasibility trials to compare new websites based on PEx with those based on facts and figures.

Results

The review concluded that online PEx could affect health outcomes through seven domains (information, support, affecting relationships, providing ideas on how to use health services, influencing behaviour change, learning to tell the story and visualising illness). We developed the e-Health Impact Questionnaire, which demonstrates good psychometric properties and is suitable for use across different health groups and various styles of online information. Online ethnographic studies found three types of PEx on multiple sclerosis (MS) platforms: accounts of ‘living with MS’, self-expression and creativity, and experiences of health care and treatment. Observational and laboratory-based methods included studies of how people find and use PEx to inform health choices. We developed a three-stage model (gating, the engagement loop and outcomes) which guided the development of six prototype multimedia websites featuring either experiential information (intervention) or factual information (comparator) for three exemplar health issues. We evaluated the feasibility and acceptability of a trial of the prototype PEx websites, comparing self-report and process measures with a comparator. In the three conditions we randomised 87 (smoking cessation), 148 (asthma), and 42 (caring for someone with MS) participants. At final (2-week) follow-up, retention rates were 75%, 82% and 86%, for smoking cessation, asthma and MS carers, respectively. Usage of the allocated websites was low. The median number of logins to the websites over the 2-week period was two, two and four; the median number of page views was 10, 15 and 27.5, respectively, with a median total duration on site of 9 minutes, 17 minutes and 31.5 minutes respectively. There were no reported adverse events or harms. The qualitative interviews with 30 trial participants found that the trial methods were acceptable and not burdensome and that preferences for combinations of different types of information were both idiosyncratic and dependent on timing and need.

Limitations

This programme used a pragmatic, mixed-methods approach, in which we adapted some standard approaches (e.g. realist review). The conceptual review provided a framework for the whole programme but did not draw on a single overarching theoretically informed approach. Instead, we used relevant theory and methods from the work package leads, who represented a range of disciplines.

Conclusions

Online PEx is not seen as an alternative to facts, or to care from a health professional, but is used in addition to other sources of information, support and expression. This programme of work indicates how the sharing of online PEx may benefit people, and how this can be measured. A randomised controlled trial is feasible but an allocated ‘exposure’ to a ‘dose of information’ is far from from how online experiences are shared in everyday life. Future work evaluating online health interventions which incorporate personal experiences should aim to reflect ‘natural’ use of the internet and might include online ethnography and offline interviews. Studies might explore how and why people use online sources of experience-based health information, and the effects on subsequent behaviour and health and social outcomes in different conditions. Future intervention research evaluating online health interventions should examine and explain issues of engagement and use, and seek to identify how to increase engagement.

Trial registration

Current Controlled Trials ISRCTN29549695.

Funding

This project was funded by the Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 17. See the NIHR Journals Library website for further project information.

The development of online doctor reviews in China: an analysis of the largest online doctor review website in China

BACKGROUND

Since the time of Web 2.0, more and more consumers have used online doctor reviews to rate their doctors or to look for a doctor. This phenomenon has received health care researchers' attention worldwide, and many studies have been conducted on online doctor reviews in the United States and Europe. But no study has yet been done in China. Also, in China, without a mature primary care physician recommendation system, more and more Chinese consumers seek online doctor reviews to look for a good doctor for their health care concerns.

OBJECTIVE

This study sought to examine the online doctor review practice in China, including addressing the following questions: (1) How many doctors and specialty areas are available for online review? (2) How many online reviews are there on those doctors? (3) What specialty area doctors are more likely to be reviewed or receive more reviews? (4) Are those reviews positive or negative?

METHODS

This study explores an empirical dataset from Good Doctor website, haodf.com—the earliest and largest online doctor review and online health care community website in China—from 2006 to 2014, to examine the stated research questions by using descriptive statistics, binary logistic regression, and multivariate linear regression.

RESULTS

The dataset from the Good Doctor website contained 314,624 doctors across China and among them, 112,873 doctors received 731,543 quantitative reviews and 772,979 qualitative reviews as of April 11, 2014. On average, 37% of the doctors had been reviewed on the Good Doctor website. Gynecology-obstetrics-pediatrics doctors were most likely to be reviewed, with an odds ratio (OR) of 1.497 (95% CI 1.461-1.535), and internal medicine doctors were less likely to be reviewed, with an OR of 0.94 (95% CI 0.921-0.960), relative to the combined small specialty areas. Both traditional Chinese medicine doctors and surgeons were more likely to be reviewed than the combined small specialty areas, with an OR of 1.483 (95% CI 1.442-1.525) and an OR of 1.366 (95% CI 1.337-1.395), respectively. Quantitatively, traditional Chinese medicine doctors (P<.001) and gynecology-obstetrics-pediatrics doctors (P<.001) received more reviews than the combined small specialty areas. But internal medicine doctors received fewer reviews than the combined small specialty areas (P<.001). Also, the majority of quantitative reviews were positive-about 88% were positive for the doctors' treatment effect measure and 91% were positive for the bedside manner measure. This was the case for the four major specialty areas, which had the most number of doctors—internal medicine, gynecology-obstetrics-pediatrics, surgery, and traditional Chinese medicine.

CONCLUSIONS

Like consumers in the United States and Europe, Chinese consumers have started to use online doctor reviews. Similar to previous research on other countries' online doctor reviews, the online reviews in China covered almost every medical specialty, and most of the reviews were positive even though all of the reviewing procedures and the final available information were anonymous. The average number of reviews per rated doctor received in this dataset was 6, which was higher than that for doctors in the United States or Germany, probably because this dataset covered a longer time period than did the US or German dataset. But this number is still very small compared to any doctor's real patient population, and it cannot represent the reality of that population. Also, since all the data used for analysis were from one single website, the data might be biased and might not be a representative national sample of China.