“You should have surgery. It’s the best treatment for you.”
Ravi A. Chandra, MD, PhD
Although radiation therapy was a viable alternative to surgery,1,2
these two sentences were enough to convince my father some years ago to elect to have surgery to treat his intermediate-risk prostate cancer. He summarily declined the urologist’s offer to facilitate a radiation oncology consultation. My father expressed confidence in his surgeon and chances for cure.
I have since seen that this experience is far more common than what I first would have thought. I regularly hear patients voice similar conclusory statements about treatment plans, and even if initially presented with an inferior or equivalent option, many strongly resist consideration of a different course when presented with supporting data.
Doctors are taught to think through medical decisions by listing a series of options, weighing the risks and benefits of each, and ultimately concluding on the superior option. This comparative maximization approach is drilled into us as medical students and residents. Many doctors, likewise, seem to present data to patients with the implicit assumption that patients will make decisions only after hearing and equally weighing all relevant data.
But for patients, medical decision making often significantly departs from this ordered framework and perhaps may be better understood as a negotiation where the patient is seeking to determine the “best deal” in response to challenging circumstances. Information often is presented to patients in a piecemeal fashion, not comprehensively. The first “offer” typically is made by one type of physician, with the patient then left to determine whether to pursue other options or move forward with the initial proposal.
Such circumstances may give rise to two decision-making biases that are well known in negotiations literature: the anchoring bias and the status quo bias.
Researchers at the Harvard Negotiation Project at Harvard Law School describe anchoring as a cognitive bias “that describes the common human tendency to rely too heavily on the first piece of information offered (the ‘anchor’) when making decisions. During decision making, anchoring occurs when individuals use an initial piece of information to make subsequent judgments. Once an anchor is set, other judgments are made by adjusting away from that anchor, and there is a bias toward interpreting other information around the anchor.”3
Applying anchoring to the medical context, it may be that patients are more inclined to pursue the opinion of the doctor they heard first, simply because it was the opinion they heard first. Most physicians have anecdotal experiences with trying to reframe patient thinking after another physician recommended an alternate treatment plan. Patients in such situations often frame their questions as to how the “new” recommendation could be “better” than one they already have in hand. The source of the initial recommendation also is an important consideration—the opinion voiced by a trusted physician or family friend can be especially difficult for a newly met doctor to overcome, even when presenting with data on better outcomes.
A second bias seen in negotiations that may affect patient thinking is placing an overly high value on the status quo. When describing effects of this bias in negotiations, Deepak Malhotra, PhD, a Professor in the Negotiations, Organizations and Markets Unit and Max H. Bazerman, PhD, the Jesse Isidor Straus Professor of Business Administration, both from the Harvard Business School, recently noted that “people are more likely to be concerned about the risk of change than about the risk of failing to change and will be motivated to preserve current systems and beliefs. The status quo bias is a general source of opposition to change even when people regard the consequences of the change to be a net improvement.”4
In the medical context, the status quo bias may offer an additional reason for why patients who already have scheduled a treatment plan may be especially resistant to subsequent proposals. A new cancer diagnosis is an emotionally challenging and intellectually confusing experience for any patient. Many patients obtain a great deal of comfort simply from having a “plan” of care established. To then propose a change, even if small, can be unsettling and thrusts patients into feeling out of control over their circumstances.
Studies looking at the relationship between prostate cancer patients’ ultimate treatment selection and specialty of their initial consulting physician are consistent with these anecdotal observations.