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Guest commentary: Examining cognitive bias in disease management conversations
In this guest commentary, Cedric Rutland, MD, pulmonologist at the Pacific Pulmonary Medical Group, discusses how awareness of the potential impact of cognitive bias in conversations between pulmonologists and patients may lead to better decision-making.
Not long ago, a patient with a rare, terminal lung disease called idiopathic pulmonary fibrosis (IPF) asked me why he was taking a medication that didn’t make him feel better.
The medicine delays progression of the disease, so my goal in prescribing it was to prevent his lung function from worsening and to keep him out of the hospital, not to make him “feel better.” I now realize that his question was the result of a miscommunication, or disconnect, between us.
In fact, research suggests that this type of miscommunication between patients with chronic lung disease and their doctors happens more often than we realize.
In 2017, a study about IPF identified a notable gap in the information that IPF patients wanted upon diagnosis and what they actually received from their physicians. According to the study, 44% of people with IPF said they wanted more information at the time of diagnosis, and 58% reported that they did not hear about approved treatments at the time of their diagnosis.
These disconnects can be found across the entire health care system. In fact, in 2016, The Joint Commission reported, “cognitive biases were increasingly recognized as contributors to patient safety events.” In this case, the diagnostic errors, which were primarily identified among health care providers, contributed to 6% to 17% of adverse events in hospitals, and 28% of diagnostic errors have been attributed to cognitive error.
So, what are cognitive biases? Simply put, they are unconscious mental shortcuts that our minds use to help us survive by making quick “fight-or-flight” decisions in life-threatening situations. In the everyday stresses of modern life, they can affect how we make choices; we tend to rely on them when we feel tired, stressed, overwhelmed or frightened. Decisions influenced by cognitive bias can be irrational — and, in the case of patients and physicians, they may lead to choices that might not be in the best interest of the patient’s health.
It is important to acknowledge that cognitive biases are inherent in all of us and inevitably play a part in our discussions with our patients. The pressures and demands of the modern-day health care environment, including tightly packed schedules and patient satisfaction surveys, may further influence cognitive biases and quick decision-making in our day-to-day work.
For example, in the case of my patient with IPF, I could have done more to clarify my goal in prescribing the medication, which was to prevent his condition from worsening. Though he did not vocalize it in our treatment discussion, he expected to feel better. Clearly, we were not communicating effectively, and it turns out this dialogue was a good example of the influence of the “framing of outcomes” bias.
Perhaps this realization contributed to my interest in the results of two recent nationwide surveys conducted by Genentech that explored the potential role of cognitive biases in disease management and treatment conversations between physicians and patients with chronic lung disease. One survey involved 400 pulmonologists, while the other involved 740 people aged 55 and older who reported having one or more chronic lung diseases, including IPF.
The surveys presented hypothetical situations for physicians and patients dealing with chronic lung diseases designed to identify particular cognitive biases that might come into play during their discussions. The results demonstrated that several types of cognitive biases may influence our actions on both sides, possibly affecting disease management decisions.
We have already seen an example of the “framing of outcomes” cognitive bias. Here are some interesting insights from the survey about other cognitive biases:
- Loss aversion is a cognitive bias that reflects how our fear of losing something is stronger than our desire to gain it. A medical decision can be influenced by whether the choice is framed as a loss or a gain. The survey showed that pulmonologists were more likely to prescribe treatment for patients who were worried about losing the ability to take part in a beloved activity, like singing in the church choir for example, than for patients who didn’t share such concerns. Understanding the patient’s desired outcome, even if it’s as simple as maintaining the health they have now for as long as possible, is relevant to how physicians present treatment options and discuss disease management.
- Affect heuristic reflects the influence of the emotional state of the decision-maker; for example, research shows that people in a negative emotional state are more likely to view the risks of an activity as being higher than the potential benefits when compared to people in a positive emotional state. So, in the context of IPF, a patient — who may be in a negative emotional state following diagnosis — may be afraid of pursuing treatment due to concerns about the potential side effects. If physicians could better anticipate this barrier and plan ahead to develop strategies to help patients manage these strong negative emotions, they might be more successful in encouraging their patients to adopt treatments that support long-term health earlier in the course of the disease.
- Outcome bias is the tendency to judge a decision’s quality based on the outcome. As physicians, we place the utmost importance on how our patients respond to a disease management plan; as a result, we may be disproportionately influenced by the outcomes of our own patients — in spite of what the science tells us. In the survey, physicians were asked to rate the quality of their choice to encourage a resistant patient to begin a new treatment. Physicians who were told the patient felt better in their follow-up visit gave their decision a higher rating than those who were told the patient felt no difference, or if they were told nothing about the outcome.
With these findings in mind, here are some ways we can reduce the influence of cognitive bias in patient care:
- Being aware of cognitive biases may help minimize their influence in conversations with patients.
- Having open, honest conversations about what is most important to patients will help you understand what drives their decision-making and help you develop concrete goals for their disease management.
- Asking questions to understand how a patient feels about their diagnosis and its impact on their hobbies or activities may improve disease management decisions.
- Understanding patient goals may help you and the patient develop a practical approach that eases their fears and encourages them to stick with their disease management plan.
So, how would these tips have helped me better handle my patient with IPF who wondered why he was taking the medicine I prescribed him?
Certainly, it was fortunate that the patient asked me why he was on the medication rather than him just deciding to stop taking it. It is all too common for patients to discontinue taking a prescribed medication without talking first to the physician who prescribed it.
I could have done a better job of helping him understand that the medicine he was on was not expected to make him feel better — it was intended to slow the progression of his disease, keep him out of the hospital, and — ultimately — keep him alive longer.
In fact, when the patient asked me why he was taking the medicine, I asked him in turn: “The first time you came to see me, you just got out of the hospital. That was 9 months ago. When was the last time you were in the hospital?”
The patient replied, “that was the last time.”
“That is the reason you are on treatment. I don’t want you in hospital, and I know you don’t want to be there.”
That’s when it clicked — he understood why he was taking the medication. And my guess is, he probably felt better about taking it, too.
Now, when discussing treatment plans with my patients, I make sure to take the time to better understand their needs and goals before explaining treatment options to them. That way I can frame their choices so we have a productive conversation focused on hopefully doing what’s best for their long-term health.
For more information about the surveys conducted by Genentech, visit gene.com/ cognitivebias.
References:
Maher TM, et al. Am J Respir Crit Care Med. 2017;doi:10.1164/ajrccm-conference.2017.195.1.
Joint Commission. Cognitive biases in health care. Issue 28, October 2016.
Linsky A, et al. Patient Educ Couns. 2015;doi:10.1016/j.pec.2014.11.010.
Disclosure: Rutland reports receiving financial compensation from Genentech for helping support IPF awareness activities.