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WHY do doctors persist in providing treatments that are known to be of low value? There are plenty of potential reasons: it could be because of pressure from patients, or for financial gain, or even because the clinician is just not up-to-date on the latest evidence.
But a new Narrative Review published in the MJA points to another, potentially more insidious problem: hard-to-shift cognitive biases that drive suboptimal clinical decision making.
These deeply-held biases and intuitions can predispose doctors towards a range of low value treatments, such as antibiotics for viral infections, imaging for general back pain or arthroscopy for osteoarthritis.
At the same time, cognitive bias may lessen the impact of large-scale campaigns aimed at reducing such practices, such as NPS’ Choosing Wisely or the RACP’s EVOLVE initiatives.
The Narrative Review outlines some of the most commonly encountered biases in medical practice. They include:
- commission bias, where clinicians feel driven to act to avoid experiencing regret at not having tried everything;
- attribution bias, when treatment is based on anecdotal and selective cases of favourable outcomes rather than hard evidence;
- impact bias, where doctors overestimate the benefits and underestimate the harms of an intervention;
- availability bias, where doctors base their treatment on striking or memorable cases they have dealt with in the past;
- uncertainty bias, where doctors are unsure of what to do and are therefore more likely to overinvestigate;
- extrapolation bias, where doctors think that because a treatment works in one type of patient, it will work in another;
- endowment bias, where doctors place more value than they would otherwise on a longstanding treatment that is about to be withdrawn from public subsidy;
- vested interest bias, where doctors persist with a strategy because so much time, effort and resources have already been invested in it; and
- groupthink, where doctors and their colleagues mutually reinforce their own wrongly held beliefs.
Lead author Associate Professor Ian Scott, who heads the Department of Internal Medicine and Clinical Epidemiology at Brisbane’s Princess Alexandra Hospital, said that the problem of cognitive bias cuts across all medical disciplines and concerns GPs and specialists alike.
“We all need to take time to reflect on our thinking, go back and review decisions, particularly in relation to follow-up and what has happened to the patient over time in response to our treatment decision.”
Dr Rob Hosking, a Victoria-based GP who is a member of the Choosing Wisely Advisory Group, said that even when a doctor understood that a treatment or test is of low value, it could still be extremely difficult to shake off the desire to recommend it.
“People fear missing cases, and they rationalise. Every doctor will be able to tell you of cases where they’ve not done something and it’s come back to haunt them.”
Dr Hosking said that the legal context may also promote the use of low value treatments.
“Very rarely does anyone get in trouble for treating a patient or ordering a test. But if a doctor doesn’t order a test and then something happens, they may be sued or disciplined by AHPRA, and that’s happening on a regular basis. So, it’s a very difficult area to find a balance.”
Bond University’s Professor Jenny Doust, who is a practising GP and who has also been involved with Choosing Wisely, said that cognitive bias is a particularly important concern for GPs because they work in an area where there’s more uncertainty than in the specialist setting.
“You’ve got patients whose conditions are milder, less clear, with less filtering of the information. This drives some GPs to overorder tests to try and reduce uncertainty, but then you get the flow of incidental findings and inappropriate treatments.”
She said that the issue was not simply a question of knowledge.
“If we really want to tackle low value care, we have to act on these cognitive biases. Initiatives such as Choosing Wisely are a good start, but it’s not going to be sufficient. And one of the good things in this new review is that it comes up with ideas of how we can get people moving in the right direction.”
The review outlines several potential “debiasing” strategies, including “cognitive huddles” where doctors can discuss case studies of low value care with their colleagues.
Defining acceptable levels of risk of adverse outcomes and providing statements detailing perceived benefits, harms and costs of any planned treatment are among a number of other suggestions that the authors make to mitigate cognitive bias in decision making.
Associate Professor Scott and colleagues also say that “nudge strategy” may play a part. The idea is not to explicitly tell doctors what not to do, but to gently push or nudge them away from low value care.
For example, prompting doctors to justify prescribing antibiotics in their patients’ electronic health records has been shown to reduce the inappropriate prescribing of antibiotics.
But ironically, the authors admit that there’s not yet much hard evidence that their suggested strategies will work.
“We’re starting to understand the issues, but we need much more research in identifying effective debiasing strategies,” said Associate Professor Scott.
“And we have to involve psychologists, sociologists and other experts who can assist clinicians gain a better understanding of how humans think and behave.”
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Along with the insuperable problem of fear of litigation, or even the inconvenience of getting a complaint it the patient does not get their expectation is that many of my colleagues are functionally innumerate. Yes they can add up and balance their cheque books, but when it comes to discussing effectiveness of particular treatments, for example anti-resorptive therapy for osteopororis, you can say to them “this treatment is close to useless for this patient, the NNT over 3 years to prevent a single hip fracture is around 100 and the NNH is not much higher”. “But” they reply, “it reduces the fracture risk by 30% !”. “Yes. but the NNT is still 100”. …
Perhaps the epidemiologists who look at population figures should study the cultural trends of modern society, such as the L’Oreal advertisement “because you’re worth it”, and the individual focus of court decisions like Rogers and Whitaker, that a 1 in 14,000 risk is considered material. The replacement of a paternalistic ‘doctor knows best’ mindset with a primary focus on the free choice of an informed consumer, has been a major shift in medical care.
As a medical student in the 1970s I never saw scarlet fever or erysipelas, but on cardiac surgical rotations in the early 80s, the majority of our valve work was post rheumatic fever. We saw the renal failure sequelae of acute post streptococcal glomerulonephritis at the Children’s Hospital. Our tutors credited the widespread use of antibiotics with the decreased incidence of nasty diseases.
When the patient sits in front of you with a sore throat, what is the probability that it is viral versus bacterial? (Remember, this patient has taken time off work to see you, he thinks it’s serious enough to seek professional help, not just to suck a lozenge. The objective evidence is that Australian courts will favour his recollection of how serious he thought his infection was, over your scant contemporaneous notes of minor, probably viral, URTI.)
What is the complication risk of unnecessary antibiotic treatment versus failure to treat a bacterial infection? What is the cost of a throat swab and a repeat consultation to review and discuss the results of the swab (both the Medicare costs and the lost productivity as the patient takes more time off work), versus a prescription? How much time is spent in your informed consent process contrasting the merits of antibiotic stewardship versus the risks of quinsy or rheumatic heart disease – remembering of course that under Australian law the treating doctor is required to do this with every single patient.
Having had recurrent episodes of culture proven Strep. tonsillitis, I have no qualms about taking a course of amoxycillin on spec, given its dual potential benefit of treating the acute problem, and minimising the risk of the rare complication. I have no allergy and am unaware of any side-effect. Have I treated viral sore throats unnecessarily? – Indubitably. But for the cost/benefit/risk balancing, it’s not low value care – I think I am worth it.
An excellent article.
3 available pragmatic avenues to behaviour change:
1. Education – tragically slow due factors mentioned in this excellent article,
2. Legal repercussion – heavy handed but very effective,
3. INCENTIVISATION – difficult to alter but probably the most accessible tool if expert opinion based ‘stakeholder’ influence can be controlled.
There is however another mammoth in the room and that is how indulgent and unscientific cognitive dissonance can and does result in harms. Maintaining the current methods, eg: in pain, fuels maladaptive neurobiological processes in addition to many other factors eg: sociological ones. This is the best explanation for the paradoxical trajectory of chronic pain in recent decades which coincide with a health profession obsession with physical changes, technology leading to lucrative but highly questionably effective interventions. Understanding pain biology reveals that there is not ‘physical / psychological’ etc pain as is the common vernacular, there is only physical / psychological etc INPUT to pain. This input accompanies a serious number of other ‘sociopsychbio’ cues for the brain to process to decide if protection is required and for how long. And then the pain predictably becomes sensitised, entrenched and resistant to treatment in epidemic numbers. Therefore the context that clinicians bring to patients is a vital factor in pain and there is abundant research to support the iatrogenicity of current methods that often begin with a plethora of well-intentioned but very unhelpful comments such as “you have a disc bulge / ‘rupture’ / degeneration …”
When patients accept the risks of interventions eg: spinal fusion for back pain, they rarely actually have an understanding of their pain beyond physical damage being advised by an expert needing to be ‘fixed’ for a chance at pain relief. They rarely understand the contextual factors that influence their outcomes and how. They rarely even know that their scan discovered changes have no reliable association with pain or outcomes. First, do no harm?
Perhaps we do need to have a serious think about option 2 above.
To encourage GPs from using low value treatments and investigations, there will need to be better legal protections against them being punished (or fear being punished) for errors of omission.
The other reason for low value care choices, not mentioned in the article is non availability of high value options (as regulatory and funding systems so slow to adopt newer technologies even if proven). A good example of this is faecal calprotectin testing – it is VERY reliable at distinguishing between IBS and organic GI disease – meaning many colonoscopies could be avoided! Yet, the submission for funding faecal calprotectin testing has been before MSAC for >5 years without a decision…….
Not all the biases in the system belong to Drs…. if we can address our biases, we should also expect the regulators to be a little more efficient
As with all issues there are doctor ,patient and social reasons for offering low value interventions.
Effective change involves addressing the understanding and expectations at all three levels .
On the other hand ,medical practitioners are demonstrating enough professional maturity to address these issues.
Other low value interventions in the recent news might include neck manipulation in newborns ,routine vitamin supplementation ,and OTC low dose codeine/NSAID combinations and Rehydration Clinics for hangovers..
It is a useful contrast to observe how the purveyors of said treatments perform compared to medical practitioners when challenged.
Ivan Illich wrote extensively on “value free care” in the US system in Medical Nemesis .
Value free care is not restricted to medical practitioners.
Professional self scrutiny must not be mistaken for incompetence or portrayed a such in the media without a broader discussion.