Cedric Rutland, a pulmonologist at Pacific Pulmonary Medical Group has shared his experience, research, and thoughts on cognitive bias in an effort to spread awareness for the issue, and hopefully, foster change.
Doctor Rutland’s interest in cognitive bias began after a miscommunication he had with one of his own Idiopathic Pulmonary Fibrosis (IPF) patients. This individual asked him why he wasn’t feeling better after taking his prescribed medication. Actually, the medication wasn’t supposed to make him feel better. It’s purpose was to slow the progression of his disease. Rutland quickly realized that he hadn’t told this to the patient when he’d first prescribed the medication.
To explain, Rutland asked the patient when he had last been admitted to the hospital. The patient replied that he had not been admitted since right before he started seeing Dr. Rutland 9 months ago. Rutland explained that the medication he had been prescribed was the reason why. It had prevented his lung function from getting worse and kept him out of the hospital.
Thankfully, this patient didn’t just stop taking the medication thinking it wasn’t producing results, and instead asked his doctor. Too often, the opposite occurs.
However, a simple discussion could have eliminated this problem all together. It truly comes down to effective communication between patient and doctor which, according to recent surveys, may be worse than we think.
Understanding Cognitive Bias
Cognitive bias is an inherent trait that every single person has. It’s an unconscious decision-making system that we utilize when our body is in “fight-or-flight” mode. Considering the fact that the healthcare system can be full of stress, pressure, tight schedules, and high demands, cognitive bias and the quick decisions that result from it can be amplified in this field. Unfortunately, we rely on cognitive bias in these moments when we are stressed, tired, scared, or overwhelmed. Ultimately, this can lead to irrational decisions which aren’t actually in our patients best interest.
A study conducted in 2017 showed that 44% of IPF patients wanted more information than they were provided at the time they were diagnosed. 58% of the patients in the study also were not told about any approved treatments at the time of diagnosis. There is clearly a gap in the information out there, and the information patients receive. We need to work to close this gap.
Additionally, a study conducted in 2016 showed that 6-17% of AEs in hospitals were due to diagnostic errors. 28% of these diagnostic errors were caused by cognitive errors, which could have been avoided if it were not for cognitive bias.
Forms of Bias
Genentech recently conducted two nationwide surveys in an effort to understand the effects of cognitive bias and how they can influence disease management decisions. Specifically these surveys examine the role of cognitive biases in chronic lung disease management. The first survey included 400 pulmonologists. The second included 740 patients with IPF or another chronic lung disease who were at least 55 years of age. The surveys utilized hypothetical scenarios to assess different forms of cognitive bias that may be present in patient/physician discussions.
- Framing of Outcomes: expected outcomes must be explained to the patient clearly (as explained in Dr. Rutland’s example).
- Loss Aversion: Physicians may be more likely to prescribe a therapy to a patient if they have physically expressed their fear of losing their ability to participate in an activity they love. For those who have not explicitly expressed this, even though they may feel the exact same way, physicians are less likely to prescribe a therapy.
- Affect Heuristic: People in a positive emotional state will view potential benefits of a therapy whereas people in a negative state (such as those who have just received their diagnosis) will view potential risks.
- Outcome Bias: Physicians may be biased by the outcomes they have viewed in their own practice versus the outcomes that science tells them exist.
What Can be Done to Fix it
So what can we do about cognitive bias? Rutland outlines a few simple steps we can take to ultimately, improve patient care.
- Be aware of the fact that we all have cognitive bias. This in and of itself should help minimize the influence of bias within discussions with patients.
- Encourage your patients to be open and honest about what is most important to them in their disease management. This should help improve the decision-making process and the goals you set together for their care.
- Ask your patient questions about how they are feeling in regards to their diagnosis and how it may potentially impact the activities they love.
- Make sure you understand the goals of your patients. This will help ensure that not only is the right care plan created for them, but that they will be more likely to stick to this plan.
These simple changes will help ensure that every conversation with your patient is open, productive, and positive. Ultimately, it will help make sure that the right choices are being made for the individual patient and their long-term health.
You can read more about cognitive bias and steps that can be taken to minimize it here.