Doctor bias can lead to low-value care


By Mardi Chapman

9 May 2017

The impact of campaigns aimed at reducing low value care may be limited by the cognitive biases that influence clinical decision-making more than most doctors would like to admit, according to a review in the Medical Journal of Australia.

The review said failure by doctors to recognise the cognitive biases that can affect anyone, had the potential to result in the provision of low value care.

Co-author Associate Professor Ian Scott, director of Internal Medicine and Clinical Epidemiology at Brisbane’s Princess Alexandra Hospital, told the limbic commission bias – a desire to avoid regret for not doing an intervention – was one the most prevalent biases especially among specialty groups.

“Specialists are referred a patient, they are highly reputable and knowledgeable, and they feel the needs to do things. They certainly don’t want to feel regret if they didn’t do a test or intervention.”

He said doctors were driven to do more, regardless of potential consequences, than do less and risk missing something. In the context of screening and diagnostic tests, this could lead to a ‘treadmill of investigations’.

Associate Professor Scott said GPs and emergency physicians were more influenced by ambiguity bias when presented with undifferentiated syndromes and no clear diagnosis. The impact was typically to over-investigate for unlikely conditions.

“The most important thing doctors need is more time to reflect and think about the most appropriate form of care; to collect all the necessary information from a history, clinical exam, talking to patients and their families and other doctors.”

The review identified other biases and influences including selectively attributing favourable outcomes to an intervention, extrapolation leading to indication creep, a preference to maintain the status quo, and the impact of vested interests and groupthink.

Importantly, there were ways to mitigate the influence of cognitive biases including through initiatives such as Choosing Wisely Australia and the RACP’s EVOLVE program.

He said while data was still accumulating locally, overseas evidence suggested low value care such as unnecessary screening or investigations and inappropriate use of antibiotics could be turned around.

The review suggested group learning from case studies of low value care and patient harm, incorporating value statements into patient management plans, better definition of risks, role modelling, and ‘nudge strategies’ or default options towards high value care were also useful.

“Knowledge is not enough to get people to change their ways. It’s finding the balance between the professional desire for autonomy and a nudge towards new forms of practice.

It’s not dictating but persuading that this could be a better way to improve the benefits for patients, reduce the waste in the system and minimise the potential harms,” he said.

Associate Professor Scott said while doctors had more access than ever to the evidence base, he felt MBS reimbursements could be reconfigured to support doctors with more time for shared decision-making with their patients.

“At the end of the day, doctors, like all humans, are affected by cognitive bias. We’re all vulnerable to emotions, being harassed or pressured for time, which can affect our decision-making. For doctors though, the issue is their decisions affect other people too.”

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