Nine cognitive biases behind low-value care

What are the most-common cognitive biases that influence clinical decision-making?

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The Choosing Wisely campaign will not achieve its full potential if doctors and researchers don’t understand the cognitive biases that nudge clinicians towards low-value care, according to the authors of an MJA narrative review.

Because day-to-day clinical decision-making was largely intuitive, relying on heuristics and internalised tacit guidelines, those decisions were vulnerable to common errors, 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.

Associate Professor Ian Scott, director of the department of Internal Medicine and Clinical Epidemiology at Princess Alexandra Hospital, and colleagues searched through 25 years of research on the effect of these biases on clinical decision-making to identify the most common ones. These were:

–          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. There is an under-appreciation of placebo effects and regression to the mean;

–          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 invested in it already;

–          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.

MJA 2017; online 8 May