Prospect Theory In Patient Empowerment for Medical Decision Making

Is that a decision tree an Iva stick figure?

Iva Pairabigglutees was just informed she has diabetes and needs to start taking medicines.  Since she is leery about taking pills, she quietly wonders why she can't cure herself with a diet. Little does her doc know that she doesn't intend to follow her medication instructions. She also doesn't know that Iva's poor diabetes control is destined to undermine the clinic's pay-for-performance bonus payment.

What went wrong?

The answer, according to this JAMA article, is that the doctor didn't deploy a behavioral economics framework to support Iva's decision-making.  One such framework is the "prospect theory" model that boils patient decision-making into a "three step heuristic."
 
As the DMCB understands it, prospect theory makes the unspoken biases that we all have more explicit.  By identifying all the background assumptions and preferences that patients bring to the physician's office, decision-making can be crafted so that everyone (family, doc and patient) is on the same page.

Briefly, the three steps are:

1. Simplify choices by focusing on the key differences between the treatment options, such as survival rates, quality of life, costs or side effects.

Iva wants to lose weight, while the doctor wants the measure of blood sugar control, the A1c, to be below a target.  What Iva didn't know is that she might live longer (survival) to see her grandchildren (quality of life) by taking a once-a-day generic (cost) with minimal side effects. What the doc doesn't know is that Iva could care less about P4P.

2. Understanding that patients prefer greater certainty when it comes pursuing gains and are willing to accept uncertainty when trying to avoid a loss.

In contrast to a patient battling cancer with a "nothing to lose" attitude about the option of toxic chemotherapy, Iva isn't about to "lose" anything: she otherwise feels well.  No wonder why some, including the Disease Management Care Blog, thinks pay-for-performance should be extended to patients (dubbed "P4P4P").  Iva is far more likely to respond to the certainty of, say, a discount on her next purchase at Whole Foods.

3. Cognitive processes lead people to overestimate the value of their choices thanks to survivor bias, cognitive dissonance, appeals to authority and hindsight biases.

Iva's favorite TV show is The Biggest Loser, but what she doesn't know is that for every successful dieter there are dozens that never make it.

Naturally, the DMCB is taking a very complicated topic in a densely written article and simplifying things, but it hopes the point is made.

CODA: the current blunt-force approach to the measurement of health care quality falls fall short of recognizing the sophisticated approaches like prospect theory and assisted patient decision-making.  After Iva has had a chance to review the pros and cons of the various options for diabetes control, she still may choose to try a diet.  We should be measuring how often patients are given a choice about their A1c, not how many achieved A1c target levels.

Image from Wikipedia

What the White House's Diffidence Over Syria Teaches Us About Complex Medical Decision Making

Talk about a no win situation.  After seeing his "red line" go rudely unheeded, the President is facing the prospect of appearing weak if he does nothing or warmongering if he launches an attack.

Medical decision scientists ask: how did it come to this?

Mr. Obama is correctly admired for his "no-drama' informed style of decision-making.  And good physicians, says medical science, should operate the same way.  According to this recent New England Journal article, consciously deliberative and logical approaches to diagnosis and treatment selection are far more reliable than the intuitive shoot-from-the-hip pattern recognition that used to rule the bedside.

Psychologists describe the latter as "Type 1" processing while the former is "Type 2."   Think George W. Bush's gut instincts over Iraq's weapons of mass destruction versus Barack Obama's disciplined rationality when he decided to attack the Bin Laden compound. He undoubtedly used the same methodology when he was pondering Syria.

But, thinks the Disease Management Care Blog, there are limits to brainy decision-making when the choices are overwhelmingly numerous.  In this retail business-oriented TEDTalk, Sheena Iyengar points out that dozens of options lead to procrastination followed by bad choices followed by low satisfaction. 

It can also apply to foreign policy. Given the vast array of pieces and potential moves on the Middle East chess board, little wonder that Mr. Obama would procrastinate for days saying he has "not made a decision," then apparently select an attack option disdained by even the New York Times and then engender even more second guessing by the very Congress that the President has repeatedly criticized as unreliable.

Ditto health care.  The downside to shared decision making is that an overwhelming number of testing and treatment options can lead befuddled patients to a "you decide, doc" mentality that leads the physician to regress to "Type 1" decision-making.

The DMCB isn't too sure how TEDTalk's Dr. Iyengar's suggested solutions can help the folks in the White House Situation Room, but the DMCB wonders if the national security staff shouldn't have done a better job of presenting the Commander in Chief with 1) a limited number of choices that were 2) more "concrete," as well as 3) arranged into categories with the 4) low complexity options offered first. 

That 4-fold approach could help docs and patients too.  The DMCB looks forward to additional research in the area.

In the meantime, there is one additional medical rule that has withstood the test of time that may also be useful in dealing with Syria. The DMCB offers it up to business and politicians alike: primum non nocere.