Elena Viboch Introduction

Medical Decision Making

Good medical decision making is something that we expect from our doctors and hope to achieve ourselves. We hope for doctors who will take every measure to ensure the best possible outcome and who will guide us towards optimal medical decision making. When a doctor presents us with the relevant evidence and a choice, when he says “You have all of the information, now it’s up to you to choose the treatment, if any, that you prefer,” we hope that we will be able to make the best possible decision. Decision making theory can provide a normative framework for evaluating medical decision making and can identify cognitive biases than can affect medical decision making. What Doctors Don’t Know (Almost Everything),” by Kevin Patterson, discusses the use of evidence-based medicine; “The Perils of Prevention,” by Shannon Brownlee, addresses a bias toward preventative treatment. Confirmation bias, incorrect probabilistic reasoning, more specifically failure to rely on Bayesian updating, and omission bias appear in the problems the authors discuss and limit the efficaciousness of some of the solutions they suggest. Before addressing the decision making theory that relates to the types of medical decision making Patterson and Brownlee discuss, it is important to outline the arguments that the authors present. The analysis will discuss cognitive biases and failures to conform to the normative model of decision making and will explicate where these authors’ accounts are consistent with decision making theory and where they deviate from the normative understanding of decision making. Articles Patterson argues against a medicinal hierarchy. Doctors hold a position of authority from which they pass down prescriptions, diagnoses and advice; patients are not empowered with decision making or input of their opinions and preferences. Patterson predicts that “evidence-based medicine,” the practice of basing medical decision making on evidence from controlled clinical studies, will

revolutionize medicine by empowering patients to make their own medical decisions. In his model of optimal medical practice, the patient is autonomous and the doctor becomes a conduit for the information rather than the decision-making authority. Although Patterson identifies the normative value of evidence-based medicine, he overestimates the ability of patients to assess empirical evidence and make optimal medical decisions. Brownlee uses empirical evidence to analyze flaws in doctors’ and patients’ medical decision making and their tendency to view early detection and prevention as the ideal course of action. She contends that the common bias towards screening and preventative action results in frequent use of costly and sometimes risky procedures in cases where they are not necessarily helpful. The treatments were intended for the full blown disease and approved based on their efficacy in such cases. Now, tests that were intended to serve as diagnostics for patients with symptoms are given routinely to screen for disease. Even if patients do not have any apparent symptoms, doctors will aggressively treat them when screening identifies indications of disease. Doctors and patients view this as “erring on the side of caution.” Brownlee highlights that monetary considerations aside, aggressive early interventions often do not have benefits that outweigh their costs; the aggregate benefits to the few who would have gone on to develop the disease are outweighed by the overall costs in terms of the health risks of treating numerous patients who on average would have been very unlikely to develop the disease even without treatment. This method of decision making is inconsistent with normative theory because the overall costs of preventative treatment outweigh the benefits. Confirmation Bias Patterson uses the weakness of doctor’s clinical judgments as evidence in favor of giving patients empirical evidence and the responsibility to make their own decisions. Patterson recognizes that “people, doctors included, have a tendency to see what they expect to see,” which is an informal

way of describing a bias in cognition called confirmation bias. This bias is also active in producing the flaws in medical decision that Brownlee identifies. To borrow Brownlee’s title, the “perils of prevention” may be difficult for doctors to recognize if they believe that aggressive preventative treatment is effective because their confirmation bias may reinforce their belief. They may even be subject to attitude polarization, believing more strongly in their original hypothesis because their clinical observations consist of ambiguous or mixed evidence. Confirmation bias is the tendency to search for, interpret, or recall observations that confirm your hypothesis and to neglect to seek falsifying evidence or to discount evidence that does not conform to the hypothesis. Lord, Ross and Lepper found that people presented with equal amounts of evidence supporting two side of a question will accept confirming evidence and critically evaluate disconfirming evidence, an example of confirmation bias. Their subjects demonstrated attitude polarization, shifting more strongly toward their original points of view after examining mixed or ambiguous empirical findings. Confirmation bias, which is a product of the availability heuristic, is an automatic, intuitive, System I process that is not available to conscious thought. In other words, people are generally not aware that they are influenced by confirmation bias. Doctors do not choose to remember cases that confirmed their hypothesis; but rather, those cases that confirm their hypothesis are more salient and, thus, more available to memory later. The availability heuristic, which is also a System I process, causes people to judge probability by thinking of examples. They substitute the question “how frequently can I remember event A occurring?” for “how frequently does event A occur?” The availability heuristic leads people to judge an event’s frequency by the ease with which it comes to mind. The availability heuristic is operative in confirmation bias, leading doctors to believe that their more salient clinical observations that conform to their hypotheses are more frequent and, thus, confirm their hypothesis.

Confirmation bias is active in maintaining doctors’ belief in preventative action. Brownlee discusses the increase in treatment for prostate cancer resulting from widespread screening as an example of doctors and patients favoring too much preventative treatment. PSA screening results prompt doctors to aggressively treat prostate cancer, often by removal of the prostate. Many doctors treat low risk, asymptomatic patients. The prevalence of preventative treatment presumably reflects widespread belief in the hypothesis that the benefits of treatment outweigh the costs for these patients. Doctors’ convictions may be reinforced by confirmation bias when they attempt to assess their hypotheses by reflecting on their clinical experiences. Among cases in which patients did not have their prostates removed, patients who subsequently developed prostate cancer are more salient than those who did not develop prostate cancer in their lifetimes. A doctor evaluating whether the treatment is beneficial will try to recall the outcomes of his patients’ cases. Available cases will more readily come to mind. The doctor will be convinced by his biased assimilation of observations that his clinical experience supports PSA screening and an increase in preventative treatment. Empirical evaluation of aggressive prevention might reach a different conclusion about treatment efficacy than that of doctors’ assessing their clinical observations. Patterson’s prescription of evidence-based medicine may alleviate some of the problems which Brownlee identifies in preventative treatment. Numerous studies have observed that actuarial judgments, which prescribe a course of action according to a consistent decision rule derived from empirical evidence, perform as well as, or better than, the best doctors’ clinical assessments and subsequent choices of action. Similarly, as Patterson argues, turning to empirical studies to guide evidence-based medicine will improve treatment by eliminating clinical practices that are not efficacious but are maintained by confirmation bias. Patterson correctly identifies that doctors’ conclusions are often biased and that evidence-based medicine provides more accurate judgments. However, he assumes that the logical

consequence of shifting from relying on clinical judgment to empirical evidence of treatment efficacy is for doctors to present evidence to patients and allow them to make their own medical decisions. Research in decision making and probabilistic reasoning provides evidence that giving the weight of decision-making to patients is not the best way to improve medical decision making and outcomes. Bayesian Analysis Assigning the burden of difficult probability judgments to patients who are under emotional stress and most likely have no background in probabilistic reasoning is a very poor idea. Patterson’s prescription fails to take into account patients’ limited probabilistic reasoning, a critical tool in evaluating empirical data to make a decision. Bayesian updating is the normative method of revising the probability that a hypothesis is true based on evidence that it is true.i If patients cannot perform Bayesian analysis, then they will make medical decisions on the basis of incorrect assessments and are unlikely to choose the option that best achieves their goals. Brownlee discusses patients’ and doctors’ decisions regarding preventative action, which often does not result in the optimal outcome. Due to flaws in their probabilistic reasoning, patients and doctors interpret evidence from screening incorrectly which biases their decisions to favor preventative treatments that have suboptimal results. Empirical evidence indicates that most people perform poorly at revising probability judgments. Research has shown that even doctors make incorrect probability judgments from screening and diagnostic results, failing to perform Bayesian updating. Evidence from testing should enable doctors to revise their judgments of the probability that the patient has a disease from the estimated prior probability of disease. The relevant data for revising probability estimates are the true positive rate, in which the test correctly identifies the disease, and the false positive rate, in which the test indicates the disease when the patient does not have the disease. This data is

combined via Bayes’s theorem with the patient’s prior probability of disease and prior probability of not having the disease to determine the updated probability that a patient has the disease given that she tested positive. The updated probability estimate can guide subsequent decision making. Patterson claims that doctors are often unreliable, which is plausible in light of confirmation bias and doctors’ poor probability judgments. Patterson suggests the responsibility for medical decision making should be given to patients. He does not consider that, lacking the experience and greater mean mathematical educations of doctors, patients are less likely to reach use Bayesian updating to make probability judgments. Patients would base their decisions on their incorrect probability judgments, resulting in suboptimal outcomes. Doctors’ difficulty with Bayesian updating could be ameliorated by greater emphasis on probabilistic reasoning in medical school and continued education, but it is not feasible to educate an entire population in Bayesian updating. Unlike Patterson, Brownlee recognizes patients and doctors demonstrate poor probability assessment; in particular, she focuses on their preference for prevention in cases where the test results do not result in a normatively revised probability estimate that necessitates treatment. Elective angioplasty has proliferated in response to excess angiogram screening. Evidence of narrowing is incorrectly used to revise the probability judgment of an imminent heart attack; the resulting overestimated prompts preventative treatment, angioplasty. Increased screening provokes a rise in treatment that is often not correlated with a corresponding decrease in mortality from a given disease because the screening, via incorrect probability judgments, causes treatment of patients who would have been unlikely to develop the disease if they had not been treated. Brownlee’s example supports an implication of Bayesian updating, that screening is unnecessary in cases in which, given either a positive or negative result, normatively revised probability estimates do not necessitate preventative treatment. Doctors and patients choose screening when the evidence cannot change the normative optimal medical decision, often believing that any information that can be collect

should be which creates an additional opportunity for poor Bayesian updating to impact medical decision making. Omission Bias The choice of aggressive preventative treatment may not only be influenced by patients’ and doctors’ poor probabilistic reasoning, which leads them to an overestimate of disease probability, but also by a common intuition that Brownlee identifies. Most doctors and patients feel that “it is better to err on the side of doing more rather than less” or to “err on the side of caution.” Their intuitions reflect omission bias, an automatic, intuitive System I process. Omission bias leads people to judge two equally bad outcomes differently depending on whether the outcome resulted from an act of commission or omission. Actions that deviate from the status quo, commission, are more morally reprehensible than failures to act, omission, in a situation in which not acting is the norm. Patient-driven medical decisions may be more influenced by omission bias than doctorprescribed decisions. Doctors are more likely to become aware of, and compensate for, omission biases than patients. Doctors have greater exposure to actuarial methods, which accurately weigh the costs and benefits of omissions and commission, and have more experience in making medical decision than patients who are unlikely to be aware that they are influenced by omission biases. Omission biases are operative in patients’ and doctors’ choices concerning preventative treatment. Brownlee gives the example of angiograms; when doctors observe evidence of narrowing in angiogram they want to do something about it. In addition to doctors’ incorrect revision of their probability judgments, they respond to angiogram evidence that indicates an uncertain future potential for heart attacks with the intuition that they must err toward treating every narrowing as if it could potentially cause an immediate heart attack. By favoring treatment, which is the norm, they hope to prevent some of the low risk patients’ potential heart attacks. In medicine, taking action and treating indications of disease are the norm; preventative action is in effect not acting, an omission.

Choosing to not act is an act of commission because it is a deviation from the norm. Patients and doctors seek to avert the possible risk of heart attack from even the mildest cases of narrowing of the arteries without considering the costs and benefits of preventative action. Angioplasty has heath risks and monetary costs, but omission bias causes most doctors and patients to neglect the costs of omission, in this case the costs of preventative action. Conclusion Research indicates, and our discussion of confirmation bias supports, that evidence-based medicine’s empirical tests of hypotheses and actuarial prediction result in better medical outcomes than clinical judgments. Patients should not be responsible for trading off the costs and benefits of medical decisions. Actuarial assessments would be very difficult to transmit to patients due to confirmation bias, hard for them to assimilate due to probabilistic reasoning that violates the normative standard of Bayesian analysis, and difficult to get them to act on because of omission bias. Patients rely more on their intuitions than doctors and would not be able to reap the benefits of evidence-based medicine’s prescriptions because of their limitations in processing and the time costs of evaluating evidence. Doctors are also subject to confirmation bias, poor probabilistic reasoning and omission bias, but the costs to doctors of receiving training to enable accurate assimilation of evidence into probability judgments and to utilize actuarial predictions are much lower than the costs of the same training would be for patients. The training would have limited future applications for the patient, but would consider serving doctors throughout their careers. In addition, the aggregate cost of training doctors would be lower than training patients. Patients should benefit from evidence-based medicine but they should not have to navigate a complex set of data that would be very difficult for them to interpret. Ideally, doctors would engage in a variant on what Patterson calls “shared decision making.” Though patients would not be responsible for evaluating evidence, patients could collaborate with their doctors so that doctors

could guide the decision-making process according to patients’ preferences for risk, tolerance for aggressive measures and any other relevant preferences. This system would bring together doctors armed with evidence-based knowledge and training in decision making analysis and patients who are actively engage in guiding decisions according to their preferences.

i

Bayesian updating requires the use of Bayes’s theorem, given below. Bayes’s Theorem: p(H/D) = p(D/H) ∙ p(H) ---------------------------------------p(D/H) ∙ p(H) + p(D/~H) ∙ p(~H) where H represents the probability that the hypothesis is true and D represents evidence that the hypothesis is true and ~H represents the probability that the hypothesis is not true p(H/D) is the probability that the hypothesis is true contingent on evidence that the hypothesis is true p(D/H) is the probability of evidence that the hypothesis is true contingent on the hypothesis being true (hit rate, or true positive rate) p(H) is the probability that the hypothesis is true p(D/~H) ) is the probability of evidence that the hypothesis is true contingent on the hypothesis being not true (false positive rate) p(~H) is the probability that the hypothesis is not true

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