Helping patients improve their decision-making

How a situation is framed affects the decisions that people make. For example, consider a situation where there is the opportunity to risk the loss of money so that one can gain a larger sum (much like we see in gambling). When framed as a loss, people respond more strongly to losing something than they do to a corresponding gain.

Now consider a similar situation that has health implications. A patient has to decide what treatment course to take and has been told that there is the potential for a fatal or catastrophic outcome, along with the potential benefit of that treatment. Patients often focus more strongly on the potential risk versus the potential benefit – a phenomenon known as the “loss aversion bias.”

As physicians, it is important to understand this predisposition so that you can better prepare patients for certain procedures, interventions, and health behaviors. There is actually an evolutionary basis to loss aversion bias. We are wired to avoid losses more than to seek gains because we are more likely to stay alive and reproduce if we perceive threats (losses) as more urgent than rewards. Therefore, patients will often make decisions based on the perceived negative risks or outcomes without giving sufficient weight to the potential benefits and/or risks of NOT pursuing a certain course of action.

Consider this example: A 67-year-old male has refused a colonoscopy because he read on the internet that it could cause bowel perforation. When asked why he will not have a screening colonoscopy, he states, “they tear people’s bowels open.” His bias towards loss aversion cause him to believe that the risks of the procedure far outweigh the benefits. The more someone perceives a potential loss (to life, limb, or in this case, bowel), the greater the loss aversion.

Loss aversion and the “framing effect” often work together and can get activated depending upon how information is framed. Our brains respond fairly quickly to emotion, thus, language that conveys emotion will get people’s attention. And if people hear words that have a negative connotation – “bad news,” “cancer,” “death,” “fatal,” “complications” – they pay even more attention to those words.

I am not suggesting that we avoid giving patients all the relevant information. What I am suggesting is that physicians be aware that the way in which information is presented has a strong influence on risk perception. When patients are told the potential risks and benefits of various treatment options, their ability to rationally reflect can be impacted (often unconsciously) by various factors. For example, there is the impact of associative memory – “my grandmother died during surgery.”

If you think that physicians are immune to these effects, consider this experiment done at Harvard Medical School. Subjects (all physicians) were presented with treatment outcome statistics for surgery versus radiation for lung cancer. Half of the subjects were provided with survival rate statistics of surgery (the one-month survival rate is 50 percent), while the other half received statistics on mortality rate of surgery (there is 10 percent mortality in the first month). The physicians were more likely to recommend the treatment associated with the survival rate statistics than the treatment associated with the mortality rate statistics (84 percent chose surgery while only 50 percent chose radiation). This experiment demonstrates that emotional words – “mortality” and “survival” – are enough to sway our rational decision-making.

The typical approach that physicians make when presenting treatment options is to present the risks of treatment alongside the benefits of treatment. When patients hear the potential risks of a procedure or treatment, the degree to which their aversion to risk is prominent will cause the risks to carry more weight than the benefits. This can lead to less effective treatment choices. As a physician, your awareness of this tendency can guide how you present information to patients so that they are more likely to engage their rational decision-making processes.

Here are some strategies to consider when helping patients decide upon a medical course of action.

• To minimize loss aversion, it is helpful to provide both the risks of treatment or medical procedure AND the risks of not having the treatment (a reframe of the benefits).
• Be aware that how you frame the situation will affect decision-making – avoid overuse of negative, emotionally-laden words.
• If a patient appears overly reluctant, ask them about what is fueling their hesitancy. There may be some associative effects (e.g., the person has had a negative experience or has a family member or friend who had a negative experience).
• Determine if your patient has read information from other sources (e.g. the internet) and if this might be influencing their decision.
• Stay alert for your own biases and assumptions when considering treatment options. Take the time to engage in rational analysis of the data.

Catherine Hambley, PhD, is a consulting psychologist who offers brain-based strategies to organizations, leaders, teams, and healthcare providers to improve their effectiveness and promote greater success. She can be reached at catherine.hambley@gmail.com