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How Decision Science Can Make You Floss

Created 07.13.09 by Laura Turner
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Talya Miron-Shatz, PhD, is a decision scientist, studying the way people interpret medical information. She teaches consumer behavior at Wharton and is a keen public speaker, advocating the importance of understanding the psychological aspects of medical decision making.

She recently sat down to speak with SDN about how consumers and health care providers make medical decisions.

What is decision science, and how does it apply to health care decisions that consumers make?

Imagine you are designing a sticker promoting flossing. Should you say, “Flossing helps you prevent gum disease,” or should you emphasize the loss of protection that results from neglecting to floss? It turns out that people are more motivated to act when something they have is about to be taken away from them. So, when you’re in the bathroom at night, being aware of the potential risks to your gums might prompt you to dedicate a few extra minutes to the fine art of flossing. This, in a nutshell, is what decision science is about.

Decision scientists make sense of people’s judgment and decisions, even when these seem random, erroneous or irrational. Decision science was developed by Amos Tversky and Daniel Kahneman, Nobel Laureate of Economics, 2002, with whom I had the honor of working closely at Princeton University. This science draws on psychology and, rather than concluding that people are unpredictable, or just plain dumb, helps explain their behavior.

A really cool thing that decision science does is that it incorporates emotions into the equations. After all, the facts don’t change in the flossing example – what matters is how the information is presented. We show that the way alternatives are presented often dictates, or at least influences, how people feel and the choices they make.

Does this apply to every medical setting?

I always tell my students that there is no such thing as a neutral way of presenting information. The beauty of decision science is that the principles apply across the board, even where you least suspect it.

Consider an expectant mother who arrives at a prenatal clinic. The genetic counselor presents her with a list of the available screening tests for the fetus. Some tests are standard at the clinic, while others need to be specifically opted into. This varies across clinics. When a woman receives a list of, say, seven standard tests and five optional ones, adding the optional tests seems unnecessary, perhaps even overly anxious.

Now consider an expectant mother who arrives at a clinic where all 12 tests are standard, and the counselor tells her she can opt out of five of them. Opting out feels different from opting in. The woman may feel that by neglecting to take some of the tests, she is jeopardizing her unborn child. Thus, she will keep all 12 tests.

Most people tend to stick with the standard option or the default, which means that medical students need to be mindful of what they set as the standard.

What trends do you see in health care decisions by consumers that will impact current health professional students?

The emerging trend is patient autonomy – delegation of choice and decision to patients.  The premise is that, given sufficient information, patients will make the health choices that are best for them. This shift poses a huge challenge to doctors, who are trained to treat patients but not to explain treatment options in a way that patients will easily comprehend. Medical students and residents seldom receive training on these types of communication skills.

Nowadays patients have access to online medical information. Does this make a provider’s work any easier?

You would think that greater availability of information should relieve some of the burden off of doctors’ shoulders, but such is not always the case. Medical information is often presented in a way that is confusing and hard to grasp. Probabilities, which are key in risk evaluation, are a particularly tricky concept.

I showed people text from reputable websites that supposedly cater to a wide audience. It is distressing that fifty percent of the participants misinterpreted what lifetime risk probability means – and this concept is broadly applied.

I also inquired about a test for the BRCA 1 or BRCA 2 gene mutations, associated with increased risk of breast cancer. Half the participants knew that the test could not tell them with certainty whether they will develop breast cancer. Yet about a third of the participants expected this kind of certainty from the test. Just imagine how misguided they were.

Doctors cannot assume that their patients are in the know just because there’s more information out there.

Don’t issues of misunderstanding apply only to certain patients?

People with low numeric skills and low health literacy are more prone to misunderstandings. However, doctors are not so good at detecting patients with low health literacy. Moreover, patients are good at hiding their bafflement, because it is embarrassing to tell your doctor you do not know what he or she is talking about.

Recently I heard about a man who had a prostatectomy. Before the surgery the doctor said, “You are going to be impotent,” to which the man replied, “It’s ok. I already have children.” The doctor had assumed that “impotent” is a common term.

The same thing happens when a doctor explains how to titrate medication. The patient nods, then returns weeks later having never increased the dosage.

Are doctors and medical students themselves immune to miscomprehensions and judgment biases?

Not quite.  In one of the most inventive studies, conducted by Gerd Gigerenzer and his colleagues, a healthy heterosexual white male went to a few dozen doctors’ appointments with a positive HIV test result. Almost all of the doctors told him he had HIV. Only a minority remembered that the test is not 100% diagnostic, that there is a 1:10,000 chance of a false positive result. Various ways of presenting probabilities and risk information help medical students and doctors understand those concepts.

How did you become involved in medical decision making?

I was a grad student in psychology, studying decision science, when the mission of making medical information comprehensible snuck up on me.  One of my professors asked if I might be interested in teaching a decision making course to Masters’ students of genetic counseling. I accepted, then realized I had no idea what knowledge would most benefit my future students.  So I sat in on genetic consultations.

I will never forget the first couple I encountered. The father was albino, and both parents were hearing impaired, so they were accompanied by an interpreter. They also brought their two year old, for want of a babysitter. The wife was pregnant, and the couple wanted to know what to expect from the newborn – what were the chances that he or she would also lack pigmentation and/or be deaf. They just wanted to know. They were also curious as to whose “fault” the baby’s condition would be, mom or dad. It mattered to the mother-in-law, who constantly blamed the husband for the first child’s lack of hearing.

The genetic counselor was just the kind of health expert you would want to meet – highly professional, well-prepared, and very caring. She spread out the charts of paternal and maternal heritage, then methodically explained how genetics worked, starting with chromosomes and genes.

None of this was redundant for me despite my education. I did not major in science and had not taken a biology class since, I believe, the 9th or 10th grade – it had been quite a while. Remembering which was the bigger unit, chromosome or gene, was not easy. I had to dig in my memory to figure out that there were 23 pairs of chromosomes and, well, lots of genes.

Meanwhile, the counselor was explaining this to the translator, who would explain it all to the couple. The interpreter seemed no less bewildered than I was. Information just kept coming in, which had to be conveyed to the couple through sign language. I could not help but wonder what they would say if we asked them to translate back what they’ve just been told.

The couple was physically there, but they were not really listening, and it wasn’t because they required hearing aids. They had gotten lost fairly early. You could see it in their faces. Chromosomes, genes, dominant, recessive – lots of terms, but not a lot of meaning.

Of course, the confusion had nothing to do with being hearing-impaired or albino. It had everything to do with being a patient. For all my fancy graduate training, I don’t think I would have fared any better than they did. The added layer of concern for the baby certainly did not make things easier.

Knowledge doesn’t just pour out of the medical system and into the patients’ minds, I realized. It has to be understood, processed, and dealt with emotionally. It was the counselor’s job to explain and the patient’s job to get it. Leaving the medical center that day, I still thought I was just going to teach decision making to genetic counselors. I did not realize that making medical information comprehensible was going to take over my interests to become my vocation. I did not realize it just then, but that was when my mission began.

For more information on medical decision making, please visit “Baffled by Numbers”, Dr. Miron-Shatz’s blog published on the Psychology Today website:

http://www.psychologytoday.com/blog/baffled-numbers

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Comments

  1. a_c says:

    Wait, isn’t “That’s OK, I already have children” a perfectly reasonable response to “You’ll be impotent”?

    1. W.Stern says:

      No, I don’t believe it is. It suggests that he interprets “impotent” as fertile.

  2. noqu says:

    pretty interesting concept. sounds like a lot of the ideas that are integrated into motivational interviewing…

    @a_c: not exactly. being impotent can mean infertile and/or unable to achieve an erection. the term “impotent” itself is problematic for this reason, since it doesn’t have a specific meaning (as well as it has certain negative connotations that can be avoided by using different terms such as erectile dysfunction and/or infertility, but that’s sort of besides the point). the patient might not be concerned about having future children, but he might very much be concerned about not being able to have penetrative sex.

  3. ekramvahsedi86 says:

    What this article fails to mention is that consumers evolve. Look up something called the “thrift phenomenon” and it explains it well. Rational consumers always lead the pack; and, 10 years after DIS (Decision Information Science) comes up with a way into trick consumers into doing stuff that is beneficial for them, they will find away to thwart our benevolent intentions.

    It’s about how to influence people; and, I would have loved to written a corollary on the ethical implications of what this author is discussing. Decision information science is a way to “optimize humanity” through scientific principles; and, it subtlely takes away the freedoms of people who are less thrift than the people who are presenting the information to them.

    What if a Bank manager studies D.I.S. and ordinary people who come into get a loan. There are some banks out there that solely exist to make a profit; and, you can’t sequester D.I.S. from leaking out of the health care industry or some other noble profession and into the professions where businesses and agencies will gain a scientific advantage over their customers.

    –제제 Kelly

  4. Emily says:

    Ekra,
    Applying concepts of psychology to advertisement is nothing new, nor is taking those techniques and applying them to public health campaigns. In the age of information, most people still aren’t going to research things for themselves and come to rational decisions. Thinking for yourself takes too much time and effort. They are going to buy into whatever is fed to them. You are right that a con man can take advantage of this fact as much as somebody with good intentions who is promoting public health. But con men and benevolent big brother have been around for a long, long time, and I don’t think decision science is going to increase their power. The only thing that can do that is the willingness of the people to be told what to think. For better or worse.

  5. ekramvahsedi86 says:

    @emily

    Psychology and advertising have been around a long time; however, D.I.S. is actually new. For example, I have two toddler-age girls that I’m not happy about D.I.S. being applied to dating & seduction tips and techniques when they enter high school and all the guys have read those books and have a scientific advantage.

    Scientific principles are very powerful, and I think it is like opening Pandora’s box to allow the analytical study of human behavior and figure out how to influence other people through scientific findings.

    I’m a very ethical person, and I wish science would not study how humans think and publish tips of how to influence people. I wish psychology forever remains a “soft science” but with D.I.S., there’s potential that the ability to influence other people will be studied by top minds.

    I have seen the DIS literature, and it is like a “hard science” and makes psychology and social sciences seem like a joke science. I did my undergrad in business and it worries me to no end, that DIS seeks to use science to manipulate other people.

    Emily, have you read snakes in suits? DIS is like opening the floodgates to allow thrifty humans to take advantage of less thrifty humans. You are right–Thinking for yourself takes too much time and effort. I just HATE the fact that DIS will allow unethical business practices to be financially favored.

    Ethical firms and agencies will be less profitable in the long run, and this worries me. D.I.S. applies to every facet of life, including friends and familial relationships.

    Sorry I am not way off topic from the article; but, I just see D.I.S. being completely at odds with ethics. I agree with your comment, I’m just so upset with an article that isn’t neutral and doesn’t discuss ANY ethical implications.

    ekram,

  6. These are some interesting topics to read about; I studied psychology for undergrad, and these topics were only briefly covered in a social psychology course.

    I agree with Emily. Salespersons, “pick-up artists”, advertisers, etc. have been taking advantage since the beginning of time.

  7. ekramvahsedi86 says:

    @Pharm, in my last paragraph, I too admitted that I agree with her comment. I am overreacting. I just completed an 80 hour project on the philosophy of science and how technological innovation ignores the ethical implications every single time, and never even mentions negative outcomes during the development phase, like we are in now for DIS.

    internet ==> (most ethical implications)
    combustion ==> global warming
    Free trade ==> Trade Deficit
    D.I.S. ==> ?
    health innovations ==> global overpopulation

    I guess the only comment I wish to be remembered with is that I genuinely worry about “hard science” scientific research being done on humans to analyze how they make decisions, and how you can present the information in a biased or “loaded” way; and, in effect, you change the probability distribution of their expected decision, which leaves the consumer only having the remnant illusion of any freedom.

    I’m very shameful that I’m trying to hijack this comments section. I wish I could delete my earlier posts; but, I can’t.

    Sorry all, I just never felt so emotional about the SDN weekly article. It’s just that I spent an equal amount of work as the author of this article did; and, I came to a different conclusion. The comments section is not the place to hawk a differing viewpoint–it’s just for comments about the article.

    I’ll leave now before I get an invitation to argue with somebody, or get real upset by a future troll. I agree with Emily and Pharm; however, I just advise skepticism about the ethical implications of what DIS on humans can lead to. D.I.S. is VERY IMPRESSIVE and VERY SCIENTIFIC and makes social sciences such as psychology, and sociology, look like “joke sciences”. DIS makes use of statistics more than psychology, and use of inferential reasoning more than subjective reasoning.

    Examples:

    McDonald’s value meals show the price of med fry and med drink. When you order, they ask “do you want large or super size” and that takes advantage of consumers who don’t want to put in as much effort as necessary to give themselves the same level of scientific advantage over a fast food firm, as the fast food firm has over them.

    In Ron Legrand’s real estate course, you are told that once you and a homeseller agree on the price, start adding personal property into the pre-agreed price, i.e. the lawn-mower, all power tools in garage, etc… He says on his tapes, that if they don’t accept being bilked out of $3,000 of personal property, then just act mad and threaten to sue them for breach of contract (hiring a lawyer costs them $5,000, and you only want $3000, you’re doing the seller a favor by giving them the cheaper option), and then they will glad to renegotiate the price of the home $1500 cheaper than what has already been signed in a legal contract. He says, “Just don’t laugh after you made the easiest $1500 of your life”

    Ramada Plaza Resorts–google this one. They are the HUGEST practitioners of DIS. I am a very manipulative person, and they out-manipulated even me! I got all my money back through the FTC; but, I have lost all trust in the travel industry after learning their unethical practices, which made extensive use of DIS.

    National Youth Leadership Forum–This current “reputable” company sends false deadlines and other, unethical DIS tactics aimed at luring one high school student per school to spend $2k on trips to D.C., Boston, LA, etc… (http://en.wikipedia.org/wiki/National_Youth_Leadership_Forum)

    I have 7 more examples. I don’t want to imagine a world in which consumers (including children, college students, and senior citizens) have to self-educate and learn a sufficient level of DIS just to not let the current scientific advantage that businesses have over consumers augment any further.

    And who’s going to provide the education resources? The same people that do DIS research for industry? All I’m saying is that hard science should not be used to study humans, ever. Let psychology and soft sciences and subjective reasoning explore why people make decisions. Psychology is still the major of choice for “undecided”‘s. Don’t let hard science study humans and ignore the ethical implications. Read “Snakes in Suits” and DIS will make serpents of all businessmen. Consumers will not trust businesses. Consumers will evolve and pass ridiculous pro-consumer legislation. DIS will evolve, consumers will re-evolve, etc…

    Sorry for my timing. It seems the author and I were in sync and spent a ton of time doing research on the same thing. DIS might have good intentions, but all it will really accomplish in the long-term is to just keep driving an augmenting wedge of distrust and resentment between firms and customers; akin, to what malpractice lawyers (even just the fear, uncertainty, and doubt of lawsuits worry us good doctors…) do to the doctor-patient relationship.

    Ethical business practices are what aligns the best interests of the customer with the best interest of the business. This has worked very well for a long time. I do not want to see those firms squeezed out by firms who use DIS business practices, for although the intentions are initially good, DIS does not have the customer’s best intentions at heart if there isn’t ethical oversight.

    Ethics>Science and I apologize in advance for anyone who thought my three comments took away value from the article. The article is well written; but, I strongly disagree with the non neutrality in which I may have rudely opined, which may or may not have been warranted.

    –제제 Kelly

    ps I vow no further comments; and, if someone types my name into the Name_field, it’s not really me.

  8. Ali says:

    @noku Yes, but in the context of the situation, the doctor was referring to infertility and not erectile dysfunction. So the patient’s response did make sense and didn’t in any way show he was ignorant of what impotence meant.

  9. Paul says:

    I dont think there is anything wrong with not telling people there is a 1 in 10,000 chance that their positive HIV test could me wrong, in 9,999 out of 10,000 cases you’ll have just given them false hope, and in that 1/10,000 you’ll catch the error by the diagnostic western blot test and that person will be so happy they dont have HIV they dont care about the mistake

  10. Milton Dentist says:

    This decision science is very cool. That’s why it’s important that parents educate their children from an very early age. I truly believe that incentives can work to motivate a child to floss more often, for example.

  11. Amy says:

    Very interesting subject, even if it is just a form of social engineering which we can see EVERYWHERE in our society, like the advertising, etc. mentioned above. It all equals manipulation, but it isn’t always nefarious in its intent. And though this is not a new field of study, if we aren’t constantly talking about it, then it might as well be.

    And really good article, except for the fact the author harped on how the albino and deaf couple, through those particular conditions, could possibly have been less likely to comprehend a difficult concept (almost like the white, heterosexual male that I would take issue with except for the fact she mentioned this as part of an actual study). The author’s character probably just got lost in the style, because I think that her pursuit really is to give credit to the patient but also teach doctors how to err on the side of caution.

    I think researchers and doctors, for that matter, sometimes assume people/patients lack intelligence. But it isn’t a doctor’s job, at least, to perform an IQ test during every session with a new patient; it is their job, however, to confirm understanding. And the word “impotence” can mean either that someone “can’t get it up” or that they are actually sterile. Another poor joe becoming anecdotal evidence of patient ineptitude.

  12. Manipulative Behavior says:

    The field of DS is always changing. Its changes are driven by the technology it uses and that it extends, and the applications that it affects.

  13. [...] scientist Talya Miron-Shatz spoke in this rather interesting article about what motivates us to make health related decisions, saying that we are more likely to act [...]

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