An overview on cognitive aspects implicated in medical decisions

doi:10.1016/j.ejim.2011.06.008

European Journal of Internal Medicine

Volume 22, Issue 6, December 2011, Pages 547-553

https://doi.org/10.1016/j.ejim.2011.06.008 Get rights and content

Abstract

Cognitive theories on decision making show that individuals often do not decide in a full and rationale way, but instead use cognitive strategies that allow them to overcome the limitations imposed by their limited rationality and the difficulties derived from uncertainty. The first part of the paper will discuss the role of heuristics and biases in medical decision making. This is an interesting field of research since medical decisions must be fast and are often complicated by rapid changes in the patient's clinical condition, uncertain prognosis and unexpected or uncontrollable treatment effects. In such contexts individuals are forced to rely on heuristics to assist them in taking decisions which can sometimes produce cognitive biases.

The second part of the paper will be dedicated to discussing ways in which the patients' decisions can be improved. The role of the shared decision making approach will be discussed as well as the role of decision aids. Based on personal information coming from the physical and psychological characteristics and needs of the patient, decision aids give information about specific options and outcomes related to the patient's disease. Provided with a set of well-defined alternatives, patients are assisted in taking their preferred decisions, especially when there is more than one medically reasonable opinion available. Moreover, decision aids facilitate and support the shared decision-making, a process by which patients and physicians discuss and evaluate the alternatives for a particular medical decision together.

Section snippets

Theoretical framework

Patients' health and quality of life depend on two main factors: decisions made by physicians and patient's compliance. Decisions concerning a diagnosis or treatment, especially in the case of serious diseases, can often make a difference between life and death, while patient's compliance is fundamental to the effective delivery of health care. Therefore, it is very important for physicians to make the best possible decisions and for patients to understand their clinical situation and to follow

Normative versus descriptive theories of decision making

Traditional decision making models can be divided into two different approaches, the normative and the descriptive approach. Normative approach models describe how people should make decisions, whereas descriptive approach models describe how people actually make decisions.

The ‘Expected Utility Theory’ developed by von Neuman and Morgenstern [5] is one of the most well-known normative decision making models. It assumes people to be fully rational decision makers and it is based on the idea that

Heuristics and biases in medical decisions

Despite cognitive limitations and uncertainty individuals must continuously take decisions. To do it they are forced to rely on simplifying cognitive short-cutting strategies, called heuristics, which assist them in taking decisions especially when only incomplete or poor information is available [8]. The advantage of relying on heuristics is that they reduce time and effort that would have otherwise been required in order to make reasonably good judgments and decisions. However, there is also

The role of patients in health care: the shared decision making approach

Until recently, medicine was dominated by the paternalistic approach. In this approach the physician is parental, but also dominant and autonomous, recommending what he/she feels is best for the patient. The patient can either follow the recommendations or not. The paternalistic approach causes a power imbalance between health professionals and patients, especially when the patient's condition makes him/her vulnerable. From an ethical point of view, the paternalistic model is often expressed in

Decision support interventions

Decision support interventions (also called decision aids, system or technologies, or interactive health communications systems) are tools that facilitate and support the shared decision-making process [38], [39], [40] reducing the possible biases occurring when decisions are taken without considering all the necessary (or correct) information (as it usually happens in human decisions). They provide information about specific options and outcomes related to a certain disease supporting patients

Conclusions

The present paper offers a general overview on the main issues related to the decision making process in medicine. Starting from the consideration that, due to the bounded rationality and uncertainty that characterize every day choices, humans do not decide according to the normative theories, we have discussed the role of heuristics and biases in medicine and their importance in promoting a shared decision making approach between patients and physicians. Through sharing decisions, patients

Learning points

•
Traditional decision making models can be divided into two different approaches: the normative and the descriptive approach. Normative models describe how people should make decisions, whereas descriptive ones describe how people actually make decisions, taking into account the limitations imposed by the human cognitive system and the uncertainty characterizing every real life decision context.
•
In many situations, the decision maker acts in dynamic and nontransparent conditions characterized by

Competing interests

The authors declare that they have no competing interests.

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Review articleAn overview on cognitive aspects implicated in medical decisions

Abstract

Section snippets

Theoretical framework

Normative versus descriptive theories of decision making

Heuristics and biases in medical decisions

The role of patients in health care: the shared decision making approach

Decision support interventions

Conclusions

Learning points

Competing interests

Clin Chim Acta

Am J Prev

Soc Sci Med

Soc Sci Med

Patient Educ Couns

Patient Educ Couns

The effects of message framing on breast self-examination attitudes, intentions, and behavior

J Pers Soc Psychol

Investing in deliberation: a definition and classification of decision support interventions for people facing difficult health decisions

Med Decis Making

Emerging paradigms of cognition in medical decision-making

J Biomed Inform

Theory of games and economic behaviour

A behavioral model of rational choice

Q J Econ

Prospect theory: an analysis of decision under risk

Econometrica

Clinical judgment: psychological research and medical practice

Science

Judgment under uncertainty: heuristics and biases

Science

Systematic errors in medical decision making: judgment limitations

J Gen Intern Med

Achieving quality in clinical decision making: cognitive strategies and detection of bias

Acad Acad Emerg Med

Thinking and deciding

Diagnostic failure: a cognitive and affective approach. Advances in patient safety: from research to implementation

Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study 1

N Engl J Med

The quality in Australian Health Care Study

Med J Aust

Incidence and types of adverse events and negligent care in Utah and Colorado

Med Care

Naturalistic decision making

Hum Factors

On the psychology of prediction

Psychol Rev

The importance of cognitive errors in diagnosis and strategies to minimize them

Acad Med

Achieving quality in clinical decision making: cognitive strategies and detection of bias

Acad Emerg Med

The psychology of judgment and decision making

J Mark

Review article
An overview on cognitive aspects implicated in medical decisions