Physician decision-making: Heuristics at work

[sue_frantz]

When about to give birth, I would like my healthcare provider to make a recommendation for cesarean or vaginal delivery based on my particular set of circumstances and indicators, and mine alone. I would also like a pony. Both may be equally likely.

Using 21 years-worth of data (2000 to 2020), Manasvini Singh* reviewed reports of “86,345 deliveries by 231 physicians” that occurred at two hospitals, one urban and one suburban (Singh, 2021). She discovered that if a particular physician delivered a baby say, via cesarean at 1pm and the birth had complications, then the next delivery overseen by that physician later that day would be more likely to be vaginal. Conversely, a vaginal birth with complications was more likely to be followed by a cesarean birth. Interestingly, the more experienced the physician, the more likely the physician was to make the switch.

Similar results were found among physicians regarding colonoscopies. If a physician referred a patient for a colonoscopy, and the patient experienced serious complications, the rates of colonoscopy referrals from that physician decreased during the next quarter of the year (Keating et al., 2017). The same is true for prescribing drugs. Physicians who had a patient who had a bad reaction to a drug were less likely to prescribe that drug again (Choudhry et al., 2006).

Now, the million-dollar question: why? The data, unfortunately, are silent on the matter. One possibility identified by Singh, Keating et al., and Choudhry is the availability heuristic. When it comes to making decisions about whether to recommend a vaginal or cesarean birth, whether to recommend a colonoscopy, and whether to recommend a particular drug, the physician may mentally flip through how things have gone in the past. Events that stand out—such as events with bad outcomes—will most easily come to mind.

For the purposes of teaching Intro Psych, the availability heuristic is a perfectly fine explanation. For those who would like to split cognitive hairs, there are some other possibilities, such as the recency effect, the frequency illusion, or the affect heuristic. In my mind, those are all subtypes of the availability heuristic. I will concede that if this were my area of research, I might have a better appreciation for the nuance.

If you would like to challenge your students while introducing them to even more cognitive biases, ask students to review the biases in one section of the Cognitive Bias Codex. Are there any other biases in that section that could possibly explain the physician decision-making described above? Explain.

* Singh’s website includes this tidbit: “My secret talent: If you send me your study, I’ll summarize the results in a limerick for you.”

References

Choudhry, N. K., Anderson, G. M., Laupacis, A., Ross-Degnan, D., Normand, S. L., & Soumerai, S. B. (2006). Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis. BMJ (Clinical research ed.), 332(7534), 141–145. https://doi.org/10.1136/bmj.38698.709572.55

Keating, N. L., James O'Malley, A., Onnela, J. P., & Landon, B. E. (2017). Assessing the impact of colonoscopy complications on use of colonoscopy among primary care physicians and other connected physicians: an observational study of older Americans. BMJ open, 7(6), e014239. https://doi.org/10.1136/bmjopen-2016-014239

Singh, M. (2021). Heuristics in the delivery room. Science, 374(6565), 324–329. https://doi.org/10.1126/science.abc9818