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July 7, 1993, Vol 270, No. 1 >
ARTICLE | July 7, 1993

Understanding Patients' Decisions: Title and subTitle BreakCognitive and Emotional Perspectives FREE

Donald A. Redelmeier, MD; Paul Rozin, PhD; Daniel Kahneman, PhD
[+] Author Affiliations

Reprint requests to Wellesley Hospital Research Institute, Jones Bldg, Room 123,160 Wellesley St E, Toronto, Ontario, Canada M4Y 1J3 (Dr Redelmeier).


JAMA. 1993;270(1):72-76. doi:10.1001/jama.1993.03510010078034
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Article
References

Objective.  —To describe ways in which intuitive thought processes and feelings may lead patients to make suboptimal medical decisions.

Design.  —Review of past studies from the psychology literature.

Results.  —Intuitive decision making is often appropriate and results in reasonable choices; in some situations, however, intuitions lead patients to make choices that are not in their best interests. People sometimes treat safety and danger categorically, undervalue the importance of a partial risk reduction, are influenced by the way in which a problem is framed, and inappropriately evaluate an action by its subsequent outcome. These strategies help explain examples where risk perceptions conflict with standard scientific analyses. In the domain of emotions, people tend to consider losses as more significant than the corresponding gains, are imperfect at predicting future preferences, distort their memories of past personal experiences, have difficulty resolving inconsistencies between emotions and rationality, and worry with an intensity disproportionate to the actual danger. In general, such intangible aspects of clinical care have received little attention in the medical literature.

Conclusion.  —We suggest that an awareness of how people reason is an important clinical skill that can be promoted by knowledge of selected past studies in psychology.(JAMA. 1993;270:72-76)

REFERENCES

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Wagener JJ, Taylor SE.  What else could I have done? patients' responses to failed treatment decisions. Health Psychol . 1986;;5:481-496.
2 +
Merz JF, Fischhoff B.  Informed consent does not mean rational consent: cognitive limitations on decision-making. J Leg Med . 1990;;11:321-350.
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Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making . Woburn, Mass: Butterworths; 1988;.
4 +
Simon H. Models of Man: Social and Rational . New York, NY: John Wiley & Sons Inc; 1959;.
5 +
Bell DE, Raiffa H, Tversky A, eds. Decision Making . New York, NY: Cambridge University Press; 1988;.
6 +
Sleet DA.  Motor vehicle trauma and safety belt use in the context of public health priorities. J Trauma . 1987;;27:695-702.
7 +
Viscusi WK, Magat WA, Huber J.  An investigation of the rationality of consumer valuations of multiple health risks. RAND J Economics . 1987;; 18:465-479.
8 +
Cates W, Hinman AR.  AIDS and absolutism: the demand for perfection in prevention. N Engl J Med . 1992;;327:492-494.
9 +
McGervey JD. Probabilities in Everyday Life . Chicago, Ill: Nelson-Hall Publishers; 1986;.
10 +
Olshansky SJ, Carnes BA, Cassel C.  In search of Methuselah: estimating the upper limits to human longevity. Science . 1990;;250:634-640.
11 +
North American Symptomatic Carotid Endarterectomy Trial Collaborators.  Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med . 1991;;325: 445-453.
12 +
Tversky A, Kahneman D.  The framing of decisions and the psychology of choice. Science . 1981;; 211:453-458.
13 +
McNeil BJ, Pauker SG, Sox HC, Tversky A.  On the elicitation of preferences for alternative therapies. N Engl J Med . 1982;;306:1259-1269.
14 +
Naylor CD, Chen E, Strauss B.  Measured enthusiasm: does the method of reporting trial results alter perceptions of therapeutic effectiveness? Ann Intern Med . 1992;;117:916-921.
15 +
Redelmeier DA, Tversky A.  On the framing of multiple prospects. Psychol Sci . 1992;;3:191-193.
16 +
Christensen C, Heckerling PS, Mackesky ME, Bernstein LM, Elstein AS.  Framing bias among expert and novice physicians. Acad Med . 1991;;9: S76-S78.
17 +
Meyerowitz BE, Chaiken S.  The effect of message framing on breast self-examination: attitudes, intentions, and behavior. J Pers Soc Psychol . 1987;; 52:500-510.
18 +
Wilson DK, Wallston KA, King JE.  Effects of contract framing, motivation to quit, and self-efficacy on smoking reduction. J Appl Soc Psychol . 1990;;20:531-547.
19 +
Fischhoff B.  Hindsight does not equal foresight: the effect of outcome knowledge on judgment under uncertainty. J Exp Psychol Hum Percept . 1975;; 41:288-299.
20 +
Caplan RA, Posner KL, Cheney FW.  Effect of outcome on physician judgments of appropriateness of care. JAMA . 1991;;265:1957-1960.
21 +
Wu AW, Folkman S, McPhee SJ, Lo B.  Do house officers learn from their mistakes? JAMA . 1991;;265:2089-2094.
22 +
Kassirer JP, Kopelman RI.  A fatal flaw in Sutton's law.  In: Kassirer JP, Kopelman RI. Learning Clinical Reasoning . Baltimore, Md: Williams & Wilkins; 1991;.
23 +
Dawson NV, Arkes HR, Siciliano C, Blinkhorn R, Lakshmanan M, Petrelli M.  Hindsight bias: an impediment to accurate probability estimation in clinicopathological conferences. Med Decis Making . 1988;;8:259-264.
24 +
Kessler DA.  The basis for the FDA's decision on breast implants. N Engl J Med . 1992;;326:1713-1715.
25 +
Angell M.  Breast implants: protection or paternalism? N Engl J Med . 1992;;326:1695-1696.
26 +
Llewellyn-Thomas HA, Naylor CD, Cohen MM, Basinski AS, Ferris LE, Williams JE.  Studying patients' preferences in health care decision making. Can Med Assoc J . 1992;;147:859-864.
27 +
Kahneman D, Knetsch JL, Thaler RH.  The endowment effect, loss aversion, and status quo bias. J Econ Perspect . 1991;;5:193-206.
28 +
Polak BCP, Wessling H, Shut D, et al.  Blood dyscrasias attributed to chloramphenicol: a review of 576 published and unpublished cases. Acta Med Scand . 1972;;192:409-414.
29 +
Owens DK, Nease RF.  Occupational exposure to human immunodeficiency virus and hepatitis B virus: a comparative analysis of risk. Am J Med . 1992;;92:503-512.
30 +
Harker LA, Bernstein EF, Dilley RB, et al.  Failure of aspirin plus dipyridamole to prevent restenosis after carotid endarterectomy. Ann Intern Med . 1992;;116:731-736.
31 +
Boyd NF, Sutherland HJ, Heasman KZ, Tritchler DL, Cummings BJ.  Whose utilities for decision analysis? Med Decis Making . 1990;;1:58-67.
32 +
Kahneman D, Snell J.  Predicting utility.  In: Hogarth RAM, ed. Insights in Decision Making . Chicago, Ill: University of Chicago Press; 1990;.
33 +
Brickman P, Coates D.  Lottery winners and accident victims: is happiness relative? J Pers Soc Psychol . 1978;;36:917-927.
34 +
Christensen-Szalanski JJ.  Discount functions and the measurement of patients' values: women's decisions during childbirth. Med Decis Making . 1984;; 4:47-58.
35 +
Frederickson BL, Kahneman D.  Duration neglect in retrospective evaluations of affective episodes. J Pers Soc Psychol . In press.
36 +
Redelmeier DA, Kahneman D.  The pain of invasive procedures: an evaluation of patients' experiences and memories of colonoscopy. Med Decis Making . 1992;;12:338.
37 +
Rozin P, Fallon AE.  A perspective on disgust. Psychol Rev . 1987;;94:23-41.
38 +
Rozin P, Millman L, Nemeroff C.  Operation of the laws of sympathetic magic in disgust and other domains. J Pers Soc Psychol . 1986;;50:703-712.
39 +
Rozin P, Nemeroff C.  The laws of sympathetic magic: a psychological analysis of similarity and contagion.  In: Stigler J, Herdt G, Shweder RA, eds. Cultural Psychology: Essays on Comparative Human Development . New York, NY: Cambridge University Press; 1990;.
40 +
Jauchem JR.  Epidemiologic studies of electric and magnetic fields and cancer: a case study of distortions by the media. J Clin Epidemiol . 1992;; 45:1137-1142.
41 +
Linville PW, Fischer GW.  Preferences for separating and combining events. J Pers Soc Psychol . 1991;;60:5-23.
42 +
Tversky A, Shafir E.  Choice under conflict: the dynamics of deferred decision. Psychol Sci . 1992;; 3:358-361.

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1 +
Wagener JJ, Taylor SE.  What else could I have done? patients' responses to failed treatment decisions. Health Psychol . 1986;;5:481-496.
2 +
Merz JF, Fischhoff B.  Informed consent does not mean rational consent: cognitive limitations on decision-making. J Leg Med . 1990;;11:321-350.
3 +
Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making . Woburn, Mass: Butterworths; 1988;.
4 +
Simon H. Models of Man: Social and Rational . New York, NY: John Wiley & Sons Inc; 1959;.
5 +
Bell DE, Raiffa H, Tversky A, eds. Decision Making . New York, NY: Cambridge University Press; 1988;.
6 +
Sleet DA.  Motor vehicle trauma and safety belt use in the context of public health priorities. J Trauma . 1987;;27:695-702.
7 +
Viscusi WK, Magat WA, Huber J.  An investigation of the rationality of consumer valuations of multiple health risks. RAND J Economics . 1987;; 18:465-479.
8 +
Cates W, Hinman AR.  AIDS and absolutism: the demand for perfection in prevention. N Engl J Med . 1992;;327:492-494.
9 +
McGervey JD. Probabilities in Everyday Life . Chicago, Ill: Nelson-Hall Publishers; 1986;.
10 +
Olshansky SJ, Carnes BA, Cassel C.  In search of Methuselah: estimating the upper limits to human longevity. Science . 1990;;250:634-640.
11 +
North American Symptomatic Carotid Endarterectomy Trial Collaborators.  Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med . 1991;;325: 445-453.
12 +
Tversky A, Kahneman D.  The framing of decisions and the psychology of choice. Science . 1981;; 211:453-458.
13 +
McNeil BJ, Pauker SG, Sox HC, Tversky A.  On the elicitation of preferences for alternative therapies. N Engl J Med . 1982;;306:1259-1269.
14 +
Naylor CD, Chen E, Strauss B.  Measured enthusiasm: does the method of reporting trial results alter perceptions of therapeutic effectiveness? Ann Intern Med . 1992;;117:916-921.
15 +
Redelmeier DA, Tversky A.  On the framing of multiple prospects. Psychol Sci . 1992;;3:191-193.
16 +
Christensen C, Heckerling PS, Mackesky ME, Bernstein LM, Elstein AS.  Framing bias among expert and novice physicians. Acad Med . 1991;;9: S76-S78.
17 +
Meyerowitz BE, Chaiken S.  The effect of message framing on breast self-examination: attitudes, intentions, and behavior. J Pers Soc Psychol . 1987;; 52:500-510.
18 +
Wilson DK, Wallston KA, King JE.  Effects of contract framing, motivation to quit, and self-efficacy on smoking reduction. J Appl Soc Psychol . 1990;;20:531-547.
19 +
Fischhoff B.  Hindsight does not equal foresight: the effect of outcome knowledge on judgment under uncertainty. J Exp Psychol Hum Percept . 1975;; 41:288-299.
20 +
Caplan RA, Posner KL, Cheney FW.  Effect of outcome on physician judgments of appropriateness of care. JAMA . 1991;;265:1957-1960.
21 +
Wu AW, Folkman S, McPhee SJ, Lo B.  Do house officers learn from their mistakes? JAMA . 1991;;265:2089-2094.
22 +
Kassirer JP, Kopelman RI.  A fatal flaw in Sutton's law.  In: Kassirer JP, Kopelman RI. Learning Clinical Reasoning . Baltimore, Md: Williams & Wilkins; 1991;.
23 +
Dawson NV, Arkes HR, Siciliano C, Blinkhorn R, Lakshmanan M, Petrelli M.  Hindsight bias: an impediment to accurate probability estimation in clinicopathological conferences. Med Decis Making . 1988;;8:259-264.
24 +
Kessler DA.  The basis for the FDA's decision on breast implants. N Engl J Med . 1992;;326:1713-1715.
25 +
Angell M.  Breast implants: protection or paternalism? N Engl J Med . 1992;;326:1695-1696.
26 +
Llewellyn-Thomas HA, Naylor CD, Cohen MM, Basinski AS, Ferris LE, Williams JE.  Studying patients' preferences in health care decision making. Can Med Assoc J . 1992;;147:859-864.
27 +
Kahneman D, Knetsch JL, Thaler RH.  The endowment effect, loss aversion, and status quo bias. J Econ Perspect . 1991;;5:193-206.
28 +
Polak BCP, Wessling H, Shut D, et al.  Blood dyscrasias attributed to chloramphenicol: a review of 576 published and unpublished cases. Acta Med Scand . 1972;;192:409-414.
29 +
Owens DK, Nease RF.  Occupational exposure to human immunodeficiency virus and hepatitis B virus: a comparative analysis of risk. Am J Med . 1992;;92:503-512.
30 +
Harker LA, Bernstein EF, Dilley RB, et al.  Failure of aspirin plus dipyridamole to prevent restenosis after carotid endarterectomy. Ann Intern Med . 1992;;116:731-736.
31 +
Boyd NF, Sutherland HJ, Heasman KZ, Tritchler DL, Cummings BJ.  Whose utilities for decision analysis? Med Decis Making . 1990;;1:58-67.
32 +
Kahneman D, Snell J.  Predicting utility.  In: Hogarth RAM, ed. Insights in Decision Making . Chicago, Ill: University of Chicago Press; 1990;.
33 +
Brickman P, Coates D.  Lottery winners and accident victims: is happiness relative? J Pers Soc Psychol . 1978;;36:917-927.
34 +
Christensen-Szalanski JJ.  Discount functions and the measurement of patients' values: women's decisions during childbirth. Med Decis Making . 1984;; 4:47-58.
35 +
Frederickson BL, Kahneman D.  Duration neglect in retrospective evaluations of affective episodes. J Pers Soc Psychol . In press.
36 +
Redelmeier DA, Kahneman D.  The pain of invasive procedures: an evaluation of patients' experiences and memories of colonoscopy. Med Decis Making . 1992;;12:338.
37 +
Rozin P, Fallon AE.  A perspective on disgust. Psychol Rev . 1987;;94:23-41.
38 +
Rozin P, Millman L, Nemeroff C.  Operation of the laws of sympathetic magic in disgust and other domains. J Pers Soc Psychol . 1986;;50:703-712.
39 +
Rozin P, Nemeroff C.  The laws of sympathetic magic: a psychological analysis of similarity and contagion.  In: Stigler J, Herdt G, Shweder RA, eds. Cultural Psychology: Essays on Comparative Human Development . New York, NY: Cambridge University Press; 1990;.
40 +
Jauchem JR.  Epidemiologic studies of electric and magnetic fields and cancer: a case study of distortions by the media. J Clin Epidemiol . 1992;; 45:1137-1142.
41 +
Linville PW, Fischer GW.  Preferences for separating and combining events. J Pers Soc Psychol . 1991;;60:5-23.
42 +
Tversky A, Shafir E.  Choice under conflict: the dynamics of deferred decision. Psychol Sci . 1992;; 3:358-361.

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