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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?
  5. The Cognitive Processes Underlying Doctors’ Decision Making
  6. What Can Go Wrong?
  7. The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions
  8. Fear of Regret and Reluctance in Treating
  9. Is There a Way to Avoid the Twin Trap?
  10. Contributors
  11. Acknowledgements
  12. Funding
  13. Conflicts of interest
  14. Ethical approval
  15. References

Context

The modern version of the Hippocratic Oath requires doctors to swear that they will apply, for the benefit of the sick, all measures that are required, avoiding the twin traps of overtreatment and therapeutic nihilism. This paper explores the magnitude of the problem of overtreatment and undertreatment and the potential sources of these treatment errors.

Methods

We undertook a narrative review of the literature on errors in treatment associated with flaws in doctors’ judgements and present evidence from research into clinical reasoning and from psychological research into decision making. Based on evidence from these two research fields, we explored the possible reasons why doctors erroneously withhold or unnecessarily administer treatments.

Results

Variation in treatment has been documented, even with similar clinical presentations under a variety of conditions, suggesting that overtreatment and undertreatment actually occur, with adverse effects for patients. Both types of error have been demonstrated, even when the doctor arrived at the correct diagnosis. They may be associated with the influence exerted on doctors’ treatment judgements by factors that are unrelated to the specific problem, such as patients’ socio-demographic characteristics and the doctor's practice culture. Doctors are also subject to commission bias and to omission bias, which have been demonstrated to occur in several domains. Such biases lead doctors to administer unnecessary treatments or to withhold required treatments due to anticipated regret. Little is known about cognitive processes underlying doctors’ treatment decisions, but mental representations of diseases that provide the basis for diagnostic reasoning are also probably used for treatment judgements.

Conclusions

Doctors are at risk of falling into the twin traps of overtreatment and therapeutic nihilism. Further research should explore how to avoid these traps, but it may require deliberate reflection on problems to be solved to counteract the influence of factors that are beyond the patient's problem.

Editor's note: This article has been written in response to the following line from the Modern Hippocratic Oath [1]

‘I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism’

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?
  5. The Cognitive Processes Underlying Doctors’ Decision Making
  6. What Can Go Wrong?
  7. The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions
  8. Fear of Regret and Reluctance in Treating
  9. Is There a Way to Avoid the Twin Trap?
  10. Contributors
  11. Acknowledgements
  12. Funding
  13. Conflicts of interest
  14. Ethical approval
  15. References

Many medical schools no longer require students to swear allegiance to a single oath at the end of their training, yet one basic element of a patient's trust in their doctor is the expectation that they practice according to behavioural norms laid out in the Hippocratic Oath. Throughout the centuries, the exact wording of the Hippocratic Oath has been modified and adapted, but many of the norms provided to guide those entering the medical profession in ancient Greece are part of the professional codes of conduct to modern medical practice.[2, 3] That doctors should act in the best interests of their patients and should respect their privacy, for example, continue to be core values of medical practice, and the well-known dictum ‘first do no harm’ is a basic rule to guide doctors’ decisions on how to manage a patient's problem. In the modern version of the Hippocratic Oath, the norm referring to therapy takes a slightly different form. The present article is concerned with ‘those twin traps of overtreatment and therapeutic nihilism’.[1] We will address the magnitude of the problem in clinical practice, explore possible reasons why doctors fall into these traps, making their patients victims of either overtreatment or undertreatment, and discuss ways to avoid stepping into the traps. In line with the spirit of the Hippocratic Oath, which expects doctors to hold on to this norm to the best of their ability and judgement, we will restrict our discussion to the causes of overtreatment or undertreatment that emerge from doctors’ judgements. That means, factors related to faults in the health care system, such as mistakes in medication administration, are not the focus of this article.

Rather than a systematic review of the literature, we conducted a narrative review guided by our own experience with research into clinical reasoning and diagnostic errors. We aimed at integrating a variety of literatures to shed some light on the twin traps of undertreatment and overtreatment and to highlight what remains to be known. We first addressed the question of whether doctors in fact fall victim of the twin traps by reviewing the literature on treatment errors that can be associated with flaws in individual doctors’ reasoning. As we will show, studies on treatment errors in general have been conducted for a variety of clinical conditions, and we synthesised information available from these studies about the occurrence of overtreatment and undertreatment errors specifically. These studies mostly focused on the identification of errors and did not investigate whether and how they are associated with doctors’ thinking processes. We will report evidence from research into clinical reasoning and integrate this evidence with findings from studies on variations in treatment associated with patients’ characteristics to explore potential underlying mechanisms of the two types of treatment error. As a second line of discussion about potential sources of the twin traps, we will report evidence from psychological research into cognitive biases that affect problem-solving decisions. We will do this to look into the role of commission and omission biases in treatment decision making. Finally, we will discuss how the twin traps can be avoided by exploring whether strategies that have proved effective to improve diagnostic performance can also play a role in ameliorating treatment decisions.

Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?

  1. Top of page
  2. Abstract
  3. Introduction
  4. Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?
  5. The Cognitive Processes Underlying Doctors’ Decision Making
  6. What Can Go Wrong?
  7. The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions
  8. Fear of Regret and Reluctance in Treating
  9. Is There a Way to Avoid the Twin Trap?
  10. Contributors
  11. Acknowledgements
  12. Funding
  13. Conflicts of interest
  14. Ethical approval
  15. References

As a starting point, we ask how frequently over- and undertreatment actually occur. Treatment errors have been recognised as an important threat to patient safety and a source of much waste in health care.[4, 5] The well-known Institute of Medicine report To Err is Human[4] estimated that more than 1 million preventable adverse effects occur each year in the USA, of which 44 000–98 000 are fatal. Adverse effects have been defined as injuries related to medical management (by contrast with complications of disease), and they are considered preventable when they result from errors or equipment failure.[4, 6] Failure in completing a planned action as intended may lead to an ‘error of execution’, as it happens, for example, when appropriately prescribed medication is dispensed incorrectly. However, an error can also take place because a wrong plan is used to manage a clinical problem, for example, when a doctor makes a wrong therapeutic choice for the patient, such as prescribing unnecessary antibiotics that lead to side-effects. Both types of error can cause mistakes in treatment, but it is the latter type, the so-called ‘error of planning’, that is probably related to doctors’ reasoning and its eventual flaws.

Neither the magnitude nor the sources of errors of planning in treatment are entirely clear. As the IOM report acknowledges,[4] studies on other treatment errors besides those related to medication mistakes in hospitalised patients are scarce. The persistent variation that has been documented in clinical management practices across a large range of clinical conditions suggests that inappropriate therapeutic decisions do occur frequently.[7-9] This is because discrepancies in treatment choices have been encountered even when a physiological basis that could justify them is, to say the least, questionable.[7, 8, 10] Treatment decisions are influenced by the provider's and the clinical setting's characteristics, such as doctor gender and practice culture.[7, 10] Patient characteristics, such as race, gender and socio-economic status, even when they are beyond the specific clinical problem, affect medical decisions, such as the primary care doctor's referral to another doctor,[8, 9] and treatment choices for a variety of conditions.[6, 7, 10, 12] Black patients, for example, are reported to be less likely to undergo coronary revascularisation after acute myocardial infarction than White patients and to have higher 1 year mortality, even after adjustment for socio-demographics, co-morbidity and illness severity.[12] These differences in treatment occur although studies have shown that the benefits of coronary revascularisation after acute myocardial infarction are similar for non-White and White patients.[12]

These discrepancies in therapeutic decisions may eventually cause patients to receive unnecessary treatment or to fail to receive the treatment that would be appropriate for their condition. Both over- and undertreatment were found, for example, in a 2 year cohort study in an emergency department in Australia that evaluated treatment of 12 807 young children presenting with febrile illness, but suspected of having serious bacterial infection.[13] Even when the doctors had reported relevant findings and relevant reference tests had been performed, i.e. the correct diagnosis had been made, antibiotics were not prescribed to around 30% of the children with urinary tract infection or pneumonia who should have received it. The finding that most of these children were subsequently treated with antibiotics suggested that undertreatment in fact occurred. On the other hand, overtreatment was also demonstrated, with antibiotics having been prescribed for 20% of the children without any identified bacterial infection. That a wrong treatment choice is made relatively frequently even when the doctor arrives at the correct diagnosis seems to be a persistent finding. Large-scale studies on errors contributing to in-patient trauma death have shown that around 50% of the errors occur because an incorrect decision on what to do is taken, despite the doctor correctly interpreting the patient data.[14, 15] If a correct diagnosis is certainly a requirement for choosing an appropriate treatment, it does not seem to be a sufficient condition. What could explain that a doctor, after having correctly diagnosed a patient problem, decides to withhold an appropriate treatment or to administer an unnecessary treatment?

Before addressing this question, a remark is necessary. One should be cautious accepting post hoc evaluations that a treatment prescribed by a doctor was, for example, unnecessary. Whether the doctor made the correct diagnosis is relatively easy to determine. The most appropriate course of action for a particular patient, however, tends to be subject to differences in interpretation to a larger extent. The ways in which diseases present themselves in real life vary widely, as do the contextual factors potentially affecting clinical decisions. Real patients rarely match the typical presentations of diseases that are encountered in textbooks. Some studies have suggested that part of the documented variability in treatment could be intentional, reflecting variations in the clinical presentations of patients.[16] Apart from differences in patients’ clinical presentations, which could lead to different treatment options, doctors may consider factors that eventually affect the appropriateness of alternative treatment options, such as contextual factors influencing compliance and patient preferences. To decide whether antibiotics should be prescribed for a child who presents with high fever, appears to be very ill but has no abnormalities in relevant tests, a doctor will also probably take into consideration the feasibility of watchful waiting. Unless we judge treatment decisions based on their outcomes – and not on whether they were as wise as the foreseeable circumstances permitted – a distinction between right and wrong may not be so clear-cut, at least not in the complexity of real clinical practice. As Hippocrates said, ‘Life is short, the art long, opportunity fleeting, experience perilous, and the crisis difficult’. However, even a cautious analysis of the studies into treatment decisions suggests that doctors indeed make wrong treatment choices leading to over- or undertreatment, despite having arrived at a correct diagnosis. To explore what may induce doctors to make these errors, we first need to understand how doctors reason through a problem to make clinical decisions.

The Cognitive Processes Underlying Doctors’ Decision Making

  1. Top of page
  2. Abstract
  3. Introduction
  4. Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?
  5. The Cognitive Processes Underlying Doctors’ Decision Making
  6. What Can Go Wrong?
  7. The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions
  8. Fear of Regret and Reluctance in Treating
  9. Is There a Way to Avoid the Twin Trap?
  10. Contributors
  11. Acknowledgements
  12. Funding
  13. Conflicts of interest
  14. Ethical approval
  15. References

Imagine that an adult patient enters a doctor's out-patient office complaining of 1-week duration productive cough, high fever and right chest pain. From these few symptoms, a diagnostic hypothesis of community-acquired pneumonia probably pops into the doctor's mind. This fast reasoning is possible thanks to ‘pattern recognition’: in a holistic, largely unconscious, process, the doctor matches the findings of the patient at hand to scripts of diseases (i.e. ‘illness scripts’) that he or she has stored in mind.[17, 18] Illness scripts are mental representations of diseases consisting of scenarios of patients with a particular disease, embodying the relationships between its signs and symptoms, its causal mechanisms and the conditions under which the disease will probably occur (so-called ‘enabling conditions’).[17-19] Experienced doctors have in memory a rich collection of illness scripts, possibly in the form of general representations of diseases, possibly as memories of actual patients they have previously encountered, or both. Illness scripts play a key role in clinical reasoning. Early in a clinical encounter, cues in the patient history, or even in patient appearance, leads to activation of one or more scripts that contain those signs and symptoms, generating one or a few diagnostic hypotheses. The activated scripts then guide the subsequent search for additional information either to confirm or refute these initial hypotheses by verifying the extent to which patient findings are consistent with the elements of the scripts.[17, 19] In the aforementioned example of the patient with cough and fever, the doctor might perform a physical examination of the lungs, searching for signs that would be expected if a patient in fact has pneumonia. As experienced doctors have seen many patients, not only do they have in memory scripts of a large number of diseases, but their scripts also tend to be rich, containing variations of typical presentations of the diseases, which helps in verifying initial diagnoses.

The role of illness scripts in clinical reasoning has been studied mostly within the context of diagnostic decision making. However, it has been proposed that illness scripts contain not only knowledge about findings to be expected in patients with a particular disease, its causal mechanisms and enabling conditions, but also knowledge about the management of that disease.[19, 20] This seems a reasonable assumption, because illness scripts derive from experience with patient problems and, therefore, that knowledge on the treatment for these problems is also probably stored in memory. The notion that illness scripts also contain treatment knowledge is also consistent with the nature of scripts as a variant of schemas, goal-directed knowledge structures that emerge from real-life events to help us perform tasks efficiently. Research on the role of scripts in treatment judgements is close to non-existent, but studies have suggested that components of the illness scripts influence management decisions[8] and that scripts indeed contain treatment knowledge.[21, 22] Apparently doctors activate diagnostic as well as treatment knowledge simultaneously when faced with a patient problem. How knowledge on treatment is organised within mental representations of diseases and used while reasoning about treatment choices is to be further investigated. Nevertheless, deciding on treatment choices might well involve verifying the extent to which initial options considered for managing a patient problem, contained in the treatment elements of the activated scripts, match the patient's particular clinical presentation, in a process perhaps similar to diagnosis verification.

What Can Go Wrong?

  1. Top of page
  2. Abstract
  3. Introduction
  4. Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?
  5. The Cognitive Processes Underlying Doctors’ Decision Making
  6. What Can Go Wrong?
  7. The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions
  8. Fear of Regret and Reluctance in Treating
  9. Is There a Way to Avoid the Twin Trap?
  10. Contributors
  11. Acknowledgements
  12. Funding
  13. Conflicts of interest
  14. Ethical approval
  15. References

From the previous section, it seems clear that the primary requirement for doctors to make appropriate clinical decisions is to possess a large and well-organised knowledge base. The crucial role of knowledge in clinical diagnosis has been widely demonstrated,[23, 24] and there is no reason why it should be different when treatment decisions are concerned. However, research has shown that diagnostic errors are mostly caused by flaws in doctors’ reasoning rather than by gaps of knowledge.[25, 26] Possessing the knowledge that would allow them to diagnose the problem correctly does not prevent the doctor falling victim to faulty reasoning and making diagnostic mistakes. As this article is concerned primarily with treatment errors that are made in spite of having arrived at a correct diagnosis, we will not elaborate on the sources of cognitive diagnostic mistakes. What matters here is that failure in appropriately verifying initial diagnoses has come out as the main cause of diagnostic errors.[25, 26] Research has suggested that successful diagnostic reasoning relies on integrating non-analytical reasoning based on pattern recognition with reflective reasoning.[23, 27, 28] Whereas initial diagnostic hypotheses are usually generated through pattern recognition, reflection upon to-be-diagnosed problems has been shown to help in diagnosis verification, even repairing wrong initial hypotheses in such cases.[23, 27-29]

Deliberate reflection plays a role in clinical diagnosis, especially because the doctors’ first impressions of a problem are influenced by a variety of contextual factors that may distort reasoning. Patients expect doctors (and doctors expect themselves) to be unaffected by factors other than the patient clinical presentation, which they should analyse objectively, using information obtained through history taking, physical examination and laboratory tests to develop an effective treatment plan. These expectations are obviously unrealistic. Doctors’ diagnostic judgements of a particular problem have been shown to be affected by the suggestion of a diagnosis,[30, 31] by having seen a similar patient before,[29] or even by exposure to media information about a similar disease several hours before they encounter the to-be-diagnosed case (H.G. Schmidt, S. Mamede, K. van den Berge, T. van Gog, J.L.C.M. van Saase, R.M.J.P. Rikers; unpublished data). For example, doctors misdiagnosed a case of aortic dissection as acute myocardial infarction more often when they had evaluated a case of myocardial infarction in a prior task than when they had not.[29] As stated above, there is scarce experimental evidence of factors that influence doctors’ treatment judgements, but at least two sources of potential distortion in reasoning emerge from empirical studies and are worth exploring below.

The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?
  5. The Cognitive Processes Underlying Doctors’ Decision Making
  6. What Can Go Wrong?
  7. The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions
  8. Fear of Regret and Reluctance in Treating
  9. Is There a Way to Avoid the Twin Trap?
  10. Contributors
  11. Acknowledgements
  12. Funding
  13. Conflicts of interest
  14. Ethical approval
  15. References

As all human beings, doctors make use of adaptive strategies that allow them to manage the huge amount of information with which they have to deal. An example of these strategies is to make judgements about groups of people and generalise these judgements to individuals who are mentally assigned to that group. If a doctor sees a patient as a member of a particular group, the characteristics assigned to that group tend to be automatically and unconsciously assigned to the patient.[10] This process, which influences the impressions that the doctor forms of the patient, seems to underlie much of the variation documented in treatment provided for patients presenting with similar symptoms but of different race, gender or socio-economic status.[7, 10, 12] It should be realised that such an attribution process does not necessarily mean unfairly stereotyping patients, but may rather mean that epidemiological knowledge is incorporated in doctors’ mental representations of disease and unconsciously applied to individuals.[10] Expert doctors tend to rely heavily on patients’ background information to make diagnostic decisions, which suggests they have in memory illness scripts that are rich in epidemiological knowledge.[18] For instance, when a previously healthy patient complains about a headache, fever and muscular pain in arms and legs, in the midst of an influenza epidemic, his doctor would tend to send him home with the advice to stay in bed for a few days, to drink plenty of fluid and take acetaminophen or aspirin if necessary. However, when this patient later in the encounter confides that he has been in Africa recently, the doctor will probably request a complete blood count, a routine chemistry panel and malaria-specific diagnostic tests. Such treatment knowledge, as part of the appropriate script, will tend to be consistent with the epidemiological information, and so will be the treatment choices guided by these scripts when activated in the clinical encounters. What helps to do the right thing can, however, also be the source of wrong management decisions. Because women have lower prevalence of coronary heart disease in epidemiological base rates, for example, they tend to be treated less aggressively than men in risk assessments and treatment for coronary disease.[7, 10] However, studies showing poorer outcomes of care after myocardial infarction among women suggest that doctors may actually fail to correctly consider this kind of knowledge as the source for their decisions, eventually withholding the most appropriate treatment.[7, 10]

Patients’ socio-demographic characteristics have been extensively studied as a source of treatment variation, but other, less obvious, characteristics of patients may also influence a doctor's reasoning. Although limited, research has demonstrated that doctors may experience, sometimes unconsciously, emotional reactions and negative attitudes towards ‘difficult patients’.[32, 33] The term ‘difficult patients’ has been used to describe the subjective experience of doctors who care for patients with behaviours that make the doctor–patient interaction particularly distressful and challenging.[34] Negative emotional reactions are apparently elicited by patients that challenge a doctor's integrity and self-esteem or threaten a doctor's autonomy,[32, 33] repeatedly request unnecessary laboratory tests or medications,[6] continuously interrupt the consultation or return repeatedly for care.[32, 34] It has been suggested that doctors’ emotional reactions to those patients may have an adverse influence on diagnostic accuracy and treatment decisions.[32, 35] To our knowledge, empirical evidence that this happens is lacking. However, emotional involvement in decision making has long been demonstrated in social psychology research.[36, 37] Apparently, evaluations about a stimulus, e.g. a particular object, that people have stored in memory are automatically activated by the mere presence of the object, unconsciously leading to avoidance or approach tendencies. Emotional involvement in decision making has recently gained additional support from Functional magnetic resonance imaging (fMRI) studies.[38, 39] The findings support a model that has been advocated by dual-process researchers: when people are faced with decisions, choices are usually dominated by an initial emotional evaluation; overriding this initial reaction requires the intervention of analytical processes either to inhibit the intuitive response or to integrate the emotional reactions with other information.[38, 40] How far this applies to the interaction between doctors and difficult patients remains to be determined. Research is sorely needed, but, needless to say, to say, many doctors have already seen their interest turned into irritation by repeated requests for referral and know the feeling raised by the nurse's announcement that the patient came again with the same complaints he has every week.

Fear of Regret and Reluctance in Treating

  1. Top of page
  2. Abstract
  3. Introduction
  4. Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?
  5. The Cognitive Processes Underlying Doctors’ Decision Making
  6. What Can Go Wrong?
  7. The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions
  8. Fear of Regret and Reluctance in Treating
  9. Is There a Way to Avoid the Twin Trap?
  10. Contributors
  11. Acknowledgements
  12. Funding
  13. Conflicts of interest
  14. Ethical approval
  15. References

The influence of emotions in treatment decisions may also lead doctors to biases derived from anticipated regret, which have been largely studied in psychology research. After having made a decision about alternative choices of action, people compare outcomes of their choice with that of the forgone choice, deriving from that comparison feelings of regret or rejoicing.[41-43] Knowledge of these feelings influences future decisions, with people trying to make decisions that would reduce the risk of regret. Moreover, people are more sensitive to regret when a bad outcome results from commission, i.e. action, than from inaction, because actions tend to be seen as more causal than inaction.[41-44] Omission bias, this preference for harm caused by omission over equal or lesser harm caused by action, has been largely studied in psychology research and demonstrated to influence decisions in several domains.[41-44] The bias also seems to be present among doctors. When asked, for example, to weigh potential adverse outcomes either from an ‘active’ or a ‘passive’ treatment, doctors evaluated harmful commissions (e.g. a prescribed treatment that led to an adverse effect) as more severe or blameworthy than otherwise equivalent omissions (e.g. an adverse effect that was consequence of the disease but was potentially preventable by a withheld treatment).[45] In clinical practice, doctors (and their patients) have to choose frequently, often in situations that involve risk and uncertainty, between ‘action’ and ‘inaction’ treatment options. These treatment options may involve decisions to admit the patient to hospital or to treat at home, to prescribe antibiotics or not, to operate or to wait. Omission bias linked to the fear of blame may compel doctors to withhold a required treatment,[46] and it has been shown to occur in experimental studies with pulmonologists who were more likely to choose a suboptimal management strategy to evaluate pulmonary embolism and treat septic shock when an omission option was present.[47] The Hippocratic ‘First, do no harm’ dictum may reinforce tendencies towards omission bias. Although watchful waiting may often be the most appropriate choice, this is not always the case, and it has been shown that omission bias has prevented patients from benefiting from appropriate treatment.

In an opposing direction, a bias towards action may eventually affect doctors’ treatment decisions as well. Judgements about the seriousness of harmful actions or omissions tend to be affected by expectations about the social roles of those who make the decisions.[48] Some professionals are distinguished more by the obligation to avoid harmful omissions than to avoid harmful actions, and adverse events that occur because these professionals opted for inaction would then tend to be judged more severely. Doctors may feel compelled towards action, because of team pressure or because their patients expect them ‘to do something’. When omission would be seen as irresponsible or unacceptable, doctors may fall for the urge to act, e.g. ordering an examination or prescribing antibiotics, even if the best choice was inaction. Commission bias has been shown to occur less frequently than omission bias in studies in other domains, and the same pattern is probably true for medical practice. Nevertheless, it may be a source of overtreatment, with negative consequences for patients.

Is There a Way to Avoid the Twin Trap?

  1. Top of page
  2. Abstract
  3. Introduction
  4. Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?
  5. The Cognitive Processes Underlying Doctors’ Decision Making
  6. What Can Go Wrong?
  7. The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions
  8. Fear of Regret and Reluctance in Treating
  9. Is There a Way to Avoid the Twin Trap?
  10. Contributors
  11. Acknowledgements
  12. Funding
  13. Conflicts of interest
  14. Ethical approval
  15. References

Much debate has taken place over the sources of flaws in clinical reasoning and how they can be minimised. It seems clear that doctors’ reasoning is influenced by a variety of factors and is subject to biases.[29, 31] The underlying mechanisms of biases are much less clear. Why doctors fall victim of biases despite having the knowledge to solve the problem is a question still under investigation. Some authors have attributed errors to non-analytical reasoning and compelled doctors to be more analytical while solving patient's problems.[49] However, other authors have argued that non-analytical reasoning is an adaptive strategy that allows doctors to make efficient decisions most of the time.[50] Deliberate reflection upon a to-be-solved problem, a strategy that the present authors have studied extensively, has been shown to improve the quality of diagnosis, at least when cases are complex, and to counteract bias.[27-29] It does not mean, however, that reflective reasoning is a better approach to solve problems than the predominantly used non-analytical, pattern recognition-based reasoning. Instead, optimal clinical reasoning seems to comprise both non-analytical and reflective reasoning in ‘doses’ that depend on the demands of the situation.[23] Whereas solving routine problems can rely largely on non-analytical reasoning, unusual, complex problems and situations in which uncertainty prevails apparently benefit from a higher dose of reflection. One might realise, however, that although these statements are supported by experimental evidence, they come largely from research on diagnostic reasoning. Experimental studies on faulty clinical reasoning have mostly investigated diagnostic decision making. If a parallel can be drawn with treatment decision making, doctors treatment decisions could benefit from verifying initial choices considered for a problem, generating alternative courses of action, searching for contradictory evidence that speaks in favour of these alternatives and weighing up the pros and cons of the different courses of action. However, this is simply a conjecture, because we know little about doctors’ cognitive processes within the context of treatment decisions. Similar words of caution are required regarding the use of different de-biasing cognitive strategies or approaches to increase doctors’ self-awareness and insights about their own reasoning processes, as their role in reducing errors in treatment decisions requires further exploration.[49, 50] Research on doctors’ treatment judgements is in its infancy and much more is needed before approaches to improve treatment decision making can be safely recommended. Future studies should aim at understanding better how knowledge about treatment is organised in memory and used to make treatment judgements and at clarifying the sources of flaws in doctors’ reasoning to open the door for the design and test of interventions to minimise them.

Based on the foregoing, we propose here a research agenda and some possible directions for research in this underdeveloped domain of medical expertise research.

First, attempts should be made to test whether treatment knowledge cognitively is subject to the same expertise effects as other illness script knowledge. We know for instance that, unlike intermediate-level students, experts remember patient information in encapsulated mode.[51] Therefore, recall of treatment information given in a case should be subject to distortions similar to other elements of a case. In addition, treatment knowledge should be recognised quicker in recognition tasks and false recognition should emerge more often as a function of increasing expertise in medicine. Finally, experts should be quicker in describing the optimal treatment for a particular patient, with lesser hesitations and with less redundancy.[52] These would be indications that treatment knowledge develops in a similar way as diagnostic knowledge and that this kind of knowledge is an integral part of the illness script.

Second, an experimental approach to the effect of variations in patient characteristics on treatment decisions should be taken. Most studies observing treatment variations for patients of different race, gender, age or socio-economic status are observational in nature.[11-13] However, these characteristics are easily manipulated in an experimental context. Random groups of doctors can be presented with standard cases varying only in the characteristics of interest to see how these patient features affect their treatment decisions.

Third, how do emotions affect treatment decisions? Again an experimental approach is called for. Psychological research has shown that it is possible to induce in humans varying emotions that affect their behavior.[53, 54] We have been successful in inducing the emotion of regret in internal medicine residents and were able to demonstrate that it influences subsequent diagnostic decisions.[55] The same approach can be chosen for treatment decisions. Are there emotions that induce doctors to engage in commission bias, or, conversely, in omission bias? Can these emotions be manipulated effectively in the laboratory?

Fourth, are treatment decisions as sensitive to deliberate reflection as diagnostic decisions? As stated before, we have been able to show on several occasions that doctors could correct a wrong initial diagnosis by engaging in deliberate reflection, a systematic procedure developed in previous studies. Would this procedure help doctors to recover from a wrong initial treatment decision as well?

A final remark relevant in particular for medical educators, who should be aware of the potential influence of factors related to the culture of the clinical settings in tendencies towards omission or commission biases. Because these biases are associated with anticipated regret, it is reasonable to expect that doctors would be less prone to fall prey of these biases in environments in which shame, fear of peer disapproval or of loss of reputation are minimised.

Summing up, errors of treatment represent a substantial proportion of adverse events, with negative consequences for patient safety. Variation in treatment has been documented even in comparable clinical presentations, suggesting that over- and undertreatment actually occur. Doctors appear to fall victim of these twin traps because their decisions are influenced, usually largely unconsciously, by factors that are beyond the specific patient problem. Patients’ socio-demographic characteristics have been shown to affect treatment choices even when they are unrelated to the present problem, probably because doctors do not correctly adjust to the individual patient's findings the treatment options that are stored in the illness scripts activated while dealing with the problem. Psychology research on reasoning and decision making suggests that other, more subtle, factors related to the patient, such as patients’ behaviours, can also influence doctors’ decisions. Commission bias and, in particular, omission bias, which has been largely shown to occur in other domains, may lead doctors to administer an unnecessary treatment or to withhold a required treatment. As research on doctors’ reasoning has focused on diagnostic decisions, we know little about doctors’ cognitive processes while making treatment options. Deliberate reflection upon cases at hand has been shown to improve diagnoses, repairing mistakes made through intuitive judgements. It may be that a combined reasoning mode with non-analytical and reflective reasoning represents an optimal approach to make treatment options, similarly to what has been suggested for diagnostic decisions, but further research is required to better understand factors affecting treatment decision making before strategies to prevent errors may be safely recommended.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Do Doctors Actually Fall into the Twin Traps of Overtreatment and Therapeutic Nihilism?
  5. The Cognitive Processes Underlying Doctors’ Decision Making
  6. What Can Go Wrong?
  7. The Influence of Patients’ Characteristics on Doctors’ Treatment Decisions
  8. Fear of Regret and Reluctance in Treating
  9. Is There a Way to Avoid the Twin Trap?
  10. Contributors
  11. Acknowledgements
  12. Funding
  13. Conflicts of interest
  14. Ethical approval
  15. References