Chest
Clinical InvestigationsOmission Bias and Decision Making in Pulmonary and Critical Care Medicine
Section snippets
Study Population
The case vignettes were included as part of a larger cross-sectional survey of 500 practicing US pulmonary specialists who were selected randomly from the membership of the American College of Chest Physicians. The main survey asked respondents for their opinions regarding psychosocial influences on medical decision making. Each prospective respondent was also randomized to receive one of two forms of the case vignette portion of the survey, which varied according to the independent variable in
Case Vignettes
The case vignettes were designed to portray common pulmonary/critical care patient scenarios and a clinical management dilemma. Content was derived from clinical practice guidelines, relevant research, and witnessed variations in clinical decision making.11, 12, 13 The specific clinical scenarios that we chose allowed us to vary the status quo in each vignette without making clinically relevant changes in the clinical information contained in the vignette. The vignettes were written in board
The Text of Case 1, Form A (Text in Brackets Was Not Present on the Questionnaire, but Was Added Here for Clarity)
A 45-year-old man with no medical history presents to the emergency department with 3 days of pleuritic chest pain and mild vague dyspnea. He has no other symptoms. His temperature is 100.2°F, heart rate is 97 beats/min, BP is 135/89 mm Hg, respiratory rate is 21 breaths/min, and oxygen saturation is 95% while breathing room air. The findings of the physical examination are normal. He is given ketorolac (Toradol; Roche Pharmaceuticals; Nutley, NJ) and is started on therapy with IV heparin. The
Statistical Analysis
We analyzed the results based on differences in decisional outcomes between forms of each vignette due to experimental manipulation of the status quo state and the action/omission distinction as the independent variable. A fractional factorial design to separate status quo and omission effects was not employed. χ2 tests were used for all comparisons of proportions and a p value of < 0.05 was considered to be significant. A statistical software package (Stata, version 8.0; Stata Corp; College
Respondents
There were 125 respondents to the first survey mailing, including 59 for form A and 66 for form B, with data missing for two respondents. The mean (± SD) age of respondents was 47.8 ± 10 years. Most of the respondents were men (86.3%) and white (82.8%). A total of 67.2% of respondents listed “private practice” as their primary practice setting, and the remainder list “academic.” Most patients (78.2%) were born in the United States. There were no differences in any demographic variables between
Discussion
We found evidence of omission bias and status quo bias in pulmonologists’ decisions relating to commonly occurring clinical dilemmas such as the evaluation of pleuritic chest pain, and the decision to place a central venous catheter for the treatment of septic shock requiring vasopressor support. Pulmonologists are outcome-oriented, expert decision makers, but our results suggest that they are not immune to cognitive biases that may contribute to suboptimal decisions. To our knowledge, this is
Conclusions
Pulmonologists are expert decision makers but, nonetheless, may be susceptible to cognitive biases such as omission and status quo bias, which can lead to suboptimal decisions. Because of the great number of decisions that are made each day involving choices between maintaining or changing the status quo, this finding could have far-reaching implications for patient outcomes, cost-effectiveness, clinical practice variability, and medical errors.
Instructions
Relatively little is known about how physicians use information during medical decision making, especially in cases involving a high degree of uncertainty. Please answer the questions pertaining to each case vignette below based on what you would do if you were in a similar situation. If a hypothetical drug, study, or test described in a vignette bears resemblance to a drug, study, or test in current use, this resemblance is unintentional, and no inferences based on this resemblance should be
Acknowledgement
We thank Jonathan Baron, PhD, Henry E. Fessler, MD, and Christian A. Merlo, MD, MPH for review and thoughtful suggestions, as well as the respondents to our questionnaire.
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