19 May 2017

PLAN to tackle cognitive biases


A professional reflection process is crucial if clinicians want to overcome the common cognitive biases that drive the provision of low value care, the RACGP president says.

The president was commenting on a review published in the MJA, in which Australian researchers found doctors were often advocating treatments, investigations or interventions that had little or no evidence of benefit, but they believed were worthwhile based on their own biases.

Without recognising and addressing these biases, campaigns such as Choosing Wisely will not achieve their potential, the review authors said.

The researchers including lead author Associate Professor Ian Scott, director of the department of Internal Medicine and Clinical Epidemiology at Princess Alexandra Hospital, analysed the effect of bias on clinical decision-making in over 25 years of research.

The most common biases held by doctors were found to be:

– Commission bias, where clinicians have a strong desire to avoid experiencing a sense of regret at not administering an intervention that could have benefited at least a few recipients;

– Attribution bias, when the perceived beneficial effects of treatment are based on anecdotal and selective situations;

– Impact bias, where clinicians overestimate the benefits and underestimate the harms of interventions;

– Availability bias, when previous vivid and emotionally charged cases lead clinicians to overinflate the likelihood of that scenario being repeated;

– Ambiguity bias, where the lack of certainty around the disease or outcomes drives clinicians to over-investigate;

– Extrapolation bias, where benefit in a small group of patients is generalised to a broader set of patients, often seen in off-label prescribing;

– Status-quo bias, the reluctance to stop interventions, sometimes because the discussion around the pros and cons of discontinuing medication can be confronting;

– Sunken-cost bias, when clinicians continue with potentially inappropriate care due to the amount of time, effort and resources already invested in it;

– Groupthink bias, where the human impulse to be like, and belong to, a group may quell dissenting opinions about the value of care, or override policy mandates.

Because day-to-day clinical decision-making was largely intuitive, relying on mental short-cuts and internalised tacit guidelines, decision-making was vulnerable to common errors, the authors of the review said.

“While accurate and efficient for many decisions, this intuitive decision-making is vulnerable to various cognitive biases … which can distort both probability estimation and information synthesis, and steer clinicians towards continuing to believe in, and deliver, care that robust evidence has shown to be of low value,” the authors said.

RACGP president Dr Bastian Seidel said that the review authors’ recommendation to introduce strategies such as ‘reflective practice’ vindicated the college’s much-maligned introduction of PLAN.

“We know that reflective learning is the most evidence-based way of improving us as professionals and improving outcomes for our patients,” Dr Seidel said. “That’s based on what international evidence suggests.”

Dr Seidel pointed out that the authors of the study were primarily physicians and researchers, and said that GPs working in more of a “real-life” environment were likely to be a bit more pragmatic.

“But I might be slightly biased there.”

MJA 2017; online 8 May

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1 year 4 days ago

It sounds good, and reflection could be useful. However for me the reflection required for the PLAN did not relate to the biases that lead to ineffective treatment. The PLAN seemed very general, while the examples of practice that is not based on evidence are very specific.

To improve the evidence base of patient care, we would need to reflect on specific management options for specific patients, rather than general learning objectives.