Making Sense of Medical Decision Making

Making medical decisions is not as easy as following the evidence. When dealing with people, there are a number of anomalies that influence the decisions someone might make, explained Douglas E. Hough, PhD, from Johns Hopkins University, during a plenary session at ISPOR’s annual meeting.

Hough outlined the thought processes that impact someone’s decisions or behaviors and the implications behavioral economics could have in healthcare. He provided 5 examples of anomalies that influence behavior:

1. Loss aversion: not only do people like to win, but they really hate to lose. Hough explained that people hate to lose about twice as much as they like to win.
2. Endowment effect: people don’t take probabilities as probabilities, instead they will overweight a small probability and underweight a large one.
3. Framing: the same statement framed in 2 different ways can get different reactions because people will latch onto a different part of a statement depending on how it is framed.
4. Power of the default: this is the opt-in vs opt-out situation. Hough gave the example of organ donation in Europe. Although the Netherlands and Belgium share a border, the former has a much lower donation rate because it follows the opt-in format. “Defaults have significant power and we need to deal with that,” he said.
5. Hyperbolic discounting: people really, really prefer the present over the future, so they will make decisions that benefit them more in the now. “Once you get to the future, you regret the decision you made in the past.”

These all influence things in healthcare, such as how we fight obesity, how adherent we are to medication, physician engagement and hand offs in the emergency room, and more, Hough concluded.

Kevin Volpp, MD, PhD, of the University of Pennsylvania, discussed the 5000-hour problem, whereby even for patients with a chronic illness who see their doctor multiple times a year, there are 5000-plus hours where these patients are largely on their own. Technology is creating an enormous opportunity for population health, but it cannot work on its own.

“While the technology creates enormous new opportunities in this space, just giving people these devices by themselves is unlikely to change their behavior,” he said. “People who buy these [devices] are typically those who are already motivated and thinking about their health.”

The devices need to be part of a larger ecosystem where patients have a device that uploads information to a health system’s services and either the patient or a social supporter and the provider gets feedback and the information goes into the electronic medical record.

What will ultimately drive change, though? The relationship, said David Meltzer, MD, PhD, of University of Chicago. The literature on patient-doctor relationships has shown the importance of trust, interpersonal relationships, communication, and knowledge of the patient in the form of lower costs and better outcomes.