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Errors and biases in
decision making process
Implications for public health
Aymery Constant
Maître de Conférences
Psychologie de la santé
Comparison of Risk in Health Care
With Other Industries
MODERATE
RISK
MINIMAL
RISK
(<1/100,000)
HEALTH
CARE
Bungee
jumping
Driving
Chemical
Manufacturing
Commercial
Aviation
Nuclear Power
HIGH RISK
(>1/1000)
Number of Encounters
LivesLost/Year
Modified from R. Amalberti and L. Leape
Medical decision
• Diagnoses
• Choosing a treatment?
• Initiate a new treatment? Keep the status quo?
• Death or disability?
• What’s the priority?
• Life? Well be? Freedom? Duty? Compassion?
Decision making
1) Logical and rational process
2) theAccumulation of knowledge improves the decision
3) Past experience improve judgment
4) collective decisions are more reliable
= MYTHS
Bounded Rationality
Case study
Ms. M., 62, visits her GP because she feels tired all the time and is
struggling to manage her daily activities.
Her GP ordered blood tests, that showed elevated levels of
transaminases (liver enymes)
He declared that she drinks too much alcohol and recommended
total abstinence. He talked about possible treatments, an hospitalization to
perform complementary medical exams (endoscopy, examination of the liver...),
and the possibility to join self-help groups.
Case study
= > Hepatitis C, she was infected during a sclerosis surgery ten years ago
HCV testing has been practiced several weeks after the initial
diagnosis, because Ms. M. finally convinced her GP to review his
diagnosis. Because she drinks very moderately
She was addressed to the Department of hepatology of the
University Hospital to start an antiviral treatment
No consequences (except the stress of being labeled as
alcoholic)
Where does the error comes from?
Lack of knowledge? Skills?
= > It is a graduated GP
Medical misinformation?
= > All medical data were valid
Lack of experience?
= > He works as a GP for decades
Lack of knowledge about the patient?
= > He was his family doctor for years
Hypotheses
High transaminase = alcohol abuse is the most readily
available diagnosis in memory?
May be that a large number of patients has a drinking
problem? And he made the connection with Ms. M.
Maybe he thought that the problem originated from
internal cause? Possible external causes were dismissed
He did not comprehensively seek all the relevant
information such as an invasive medical intervention 10 years
ago
He focused his attention on information confirming his
initial belief (alcoholism), ignoring those that refute it (no
clinical signs) or those who were in favor of others
hypotheses (chronic fatigue)?
Heuristic
Simplified cognitive strategy,used to save time,
allowing decision-maker to make acceptable
deductions
Evidenced byTversky & Kahneman, in the 70s
Tversky, A. & Kahneman, D. (1974). Science, 185, 1124–1130.
Kahneman, D (1972). Judgment under uncertainty: Heuristics and biases.
Cambridge: Cambridge University Press.
Three of these heuristics are particularly influential:
-Availability
- Representativeness
- Anchoring
Availability
= > Estimating the likelihood of an event according to
its availability in memory.
The first impression or the most present explanation in mind is
used in priority to explain an event or estimate a probability..
According to a survey, 50% of Americans were affraid
of dying in a terrorist attack in 2006 (Gallup poll).The
probability of such an event was estimated at one
chance over 20 million (calculated on the basis of the
available figures)
Tversky, A; Kahneman (1973). "Availability: A heuristic for judging frequency and probability". Cognitive Psychology 5
(1): 207–233
A group of 100 persons, including 30 lawyers
and 70 engineers were interviewed.These
interviews have led to the drafting of brief
fact sheets on each of these people.
One of these cards was randomly chosen:
"John is 39 year-old.He is married and has two kids.He is involved in
local politics.His favorite hobby is the collection of rare books.He loves
competition,discussion and is an articulate speaker.
Representativeness
What is the probability that John is a lawyer?
Representativeness
Good answer: 30% (30 lawyers out of 100 persons)
But participants overestimated this proportion
because we tend to:
- Neglect probability and estimates. Individual or
descriptive information is preferred, in opposition to
mathematical logic.
- Focus on the supposed similarities between the
information (speaks well...) and our initial belief (he’s a
lawyer)
Anchoring
Participants were asked to estimate the percentage ofAfrican
countries members of the United Nations
Participants’ answer : 25% on average
Participants’ answer : 45% on average
• In the other group: "Is this more or less than 65%?"
• In a group: "Is this more or less than 10%?"
Anchoring
All the reasoning process is influenced by a
single initial data, which is difficult to ignore
afterwards
Explains the influence of first impressions, or those
of early learnings on decision making or situational
analysis
Cognitive Bias
Tendency to acquire and process information by filtering it
through one's own likes, dislikes, and experiences.
Relevant
Informations
Relevant
responses
Non relevant
informations
Non relevant
responses
Selection
bias
Reasoning
bias
Heuristics
33 biases and heuristics reportedly active in medical practice
Information-gathering problems
 Unpacking – failure to elicit all relevant information
 Availability – recent exposure influences diagnosis
 Anchoring – holding onto a diagnosis after receiving
contradictory information
 Premature closure – accepting a diagnosis before it is
fully verified
Systems contributions
 Diagnosis momentum – early diagnosis by
another provider is accepted as definite
 Feedback sanction – final diagnosis does not
return to initial decision-maker
 Triage cueing – location cues management (seen
through the lens of the first provider)
Probability Pitfalls
 Aggregate bias – aggregate data do not apply to my
patients
 Base-rate neglect – ignoring the true prevalence
 Gender bias – gender inappropriately colors probability
 Gambler’s fallacy – sequence of same diagnoses will not
continue
 Posterior probability – sequence of same diagnoses will
continue
Hypotheses
High transaminase = alcohol abuse: most readily available
diagnosis in memory? Availability
May be that a large number of patients has a drinking problem?
And he makes the connection with Ms. M. Posterior Probability
Maybe he think it the problem originate from internal cause? And
not external? Attribution error
May he did not seek comprehensively all the relevant information
(invasive medical intervention it 10 years ago) Anchoring
=>Unpacking
Maybe he focused his attention on information confirming his initial
belief (alcoholism), ignoring those that refute it (no clinical signs) or
who were in favour of an others hypothesis (chronic fatigue)?
Interpretative bias
Emotions can jeopardize the rationality of
any decision maker
three types of affects:
- transitional: surrounding factors, fatigue...
- Due to personality: trait anxiety, emotional
adaptation
- Related to clinical situations: children
involved…
Affective bias
The best scientific evidence can be overlooked because of
affects, emotions….
“Our affective reactions to patients are often
our very first reactions, occurring automatically
and subsequently guiding information
processing, judgment, and decision making…”
Zajonc, American Psychologist, 1980
Two competing reasoning modes:
The first is fast, intuitive, automatic (or even
unconscious) often involves an affective or emotional
component, and requires few resources
=> satisfying responses
The second is analytic, slow, deliberate, affect-free
and costly in resources
=> Optimal responses
Most vulnerable
to biases
Bounded rationality:
Implications for public health
Some scientific information benefit from a large
consensus in the scientific community, the public
option, the media and health professionals
Strong Epidemiological evidence
high acceptance by the public and the media
health professionals practices
Public Health
Tobacco, alcohol abuse; unhealthy diet; drink
driving ….
Making relevant decisions regarding the health of
people suppose to be able to collect relevant
information
In ambiguous, new, changing unknowns, or
emotionally situations, the collection and
interpretation of the information will be influenced
by:
Information seeking
1) The way the information is presented
2) decison-makers’ initial beliefs
You are a top decision maker at WHO and you want take
preventive actions to reduce the number of deaths and
injuries from animal bites. On which animal will you
focus your intervention?
In Australia?
A) Dogs, B) Sharks, ou C) Crocodiles
In Romania?
A) Dogs, B) Sharks, ou C) Crocodiles
Public health
In South Africa?
A) Dogs, B) Sharks, ou C) Crocodiles
Framing
The entire reasoning process is governed by the
way the information is presented
Chosen by 72% of participants
Chosen by 28% of participants
We expect that an epidemic will kill 600 people.
Participants are asked to choose between two
possible actions
Option A: can save the lives of 200 people
Option B: 33% chance of saving 600 people
Framing
Same scenario, different layout
Option A: 400 people will die
Option B: 33% chance that there is no death
Chosen by 22% of participants
Chosen by 78% of participants
The expected value is the same in both cases, but the statements
mentioning death are rejected, while those mentioning saved lives are
preferred
Framing
Tendency to Loss aversion: the negative value of a loss is
considered to be superior to an equivalent gain (capacity, life,
death…)
Outcome feeling
Gain of X Positive (+)
Loss of X
Extremely negative
(---)
Framing
The framing allows to influence decision using
our tendency to loss aversion
If you are favorable to the LAMBDA treatment, you
will say to the patient:
"with the LAMBDA treatment,you have 90% chance of
survival.
If you prefer an alternative solution, you will say:
"with the LAMBDA treatment,you have 10% chance of
death”
Confirmation bias
Is organic food healthier?
Can video games make kids violent?
IsWI - FI carcinogenic?
=> Might cast a doubt, even in the absence of
scientific evidence
When faced with a closed (yes/no) question, we
naturally tend to seek confirming information to
answer “yes”
and then, ignore the alternative hypothesis
Confirmation bias
Exemple:Does Behaviour change during the full moon?
We will immediately remember some cases when we
were stressed, anxious, insomniacs or so…during full
moon nights…
….and forget the hundreds of full moon nights when
we slept normally
EHESP35
Change the question
Open-ended Question : what are the risk factors
for cancer?
- Tabacco
- Alcohol
- Unhealthy diet (sugar, fat…)
- Sedentary behavior
- Diesel
- Sun exposure
- ….
Changing mind?
...not an easy task
Interpretation bias
University of Santford (USA):
Two groups of students are formed according to their
opinions on death penalty:A group in favor of death
penalty, and a group against the death penalty
Then two studies were presented: one demonstrating
the usefulness of death penalty, and one showing DP is
counter-productive
…And they are asked to assess the
methodological quality of these two studies
“Biased assimilation and attitude polarization: The
effects of prior theories on subsequently considered
evidence”
Conclusions regarding death penaly
« efficient » « counter-productive »
In favor of death
penalty
Quality ++ Quality --
Conclusions regarding death penaly
« efficient » « counter-productive »
In favor of death
penalty
Quality ++ Quality --
Against death
penalty
Quality ++ Quality --
The studies are considered valid if they are in
line with personal opinions, and discredited
otherwise
“Biased assimilation and attitude polarization: The
effects of prior theories on subsequently considered
evidence”
Other effects
Media covering a political campaign will be considered
hostile by both sides
Lobbies will select studies which suit their own
interest (bicycle helmet; adverse effect of a food or a
drug benefit...) and ignore others studies
Scientific work will be judged from political or
ideological perspectives, regardless of actual
scientific value (especially in social sciences…)
Case study from France
Rapport INSERM 2005
INSERM is the French institute for Health and
Medecine
Relying upon data from over a thousand international
scientific studies, INSERM experts advocate in a 364-pages
document (available online) to best inform parents and
educators on conduct disorders in children and to detect it as
soon as possible (3 years old), to ensure the prevention.
Conduct disorders (esp ADHD) are a major
cause of unintentional injuries in children
http://www.ipubli.inserm.fr/bitstream/handle/10608/142/expcol_2005_trouble_synthese_eng.p
df?sequence=1
Recommandations from the report
Improving information on conduct disorder in France,
through epidemiological studies among children and
adolescents in the general population, as well as in high risk
populations
• Identify risk: family factors, pre - and perinatal, genetic.
• Develop specific prevention programs, train teachers and
educators, intervene with families at risk, track as soon as
possible warning signs, i.e. at the age of 3, and record
. Perform regular, accurate and multidisciplinary assessments
for subjects with symptoms.
Assess the effects of various psychotherapies. Further
pharmacological research.
Lobbying from French physicians
The very next day, the national Union of physicians of
maternal and child welfare (SNMPMI), protested.
Its leaders created a petition (available online) signed
by nearly 200 000Web users, along dozens of
associations , psychologists, doctors, educators….
The first signatories include child psychiatrists, clinical
psychologists, doctors, lecturers, childhood professionals,......
Many belonging to a lobby which pushed health minister to
censor a report from INSERM in 2004 (namely
psychoanalysts…)
Online Petition
• "detected children would be subjected to a battery of tests
developed on the basis of the theories of behavioral
Neuropsychology" “According to the criteria of the Anglo-
Saxon studies"
• Nurseries and schools transformed into“hunting places',
• The potential offender ,too small to defend himself,will
be transformed into a junkie
• "the slightest gesture,the first child nonsense may be
interpreted as the expression of a pathological personality
at the mercy of a "robotic health care thinking.
“http://www.pasde0deconduite.org/appel/
Framing: changing terms
Terms used in the
Report
Terms used in the online
petition
International studies « Anglo-saxons » studies
screening Hunting down
Identify risk factors and
prevent disorders
Relentless linearity principle
and deterministic approach
Early prevention Early hunt
Pharmacology as a second
line
Drug use
Psychotherapeutic support Behavioral conditioning
Interventions towards
families at risk
stigmatization
Children: high emotional bias
political context , cultural lobbies and ideological opinions
beliefs concerning the "Anglo-Saxon" (behaviorists)
use of international recommendations to change local
practices (esp those deriving from psycho-analysis)
Pétition: framing and loss
aversion
Discredit :
INSERM
"Anglos-Saxon"
Renowned experts
international studies
scientific recommendations
Achieved Result: statut quo
context
Change in practices
=
Fascism
Early screening and detection is
advocated for aged people
Past experience improve decison-making ?
Not sure….
Question # 1: "describe the exact content of the midday
meal you took 15 days ago.
Memory bias
Question # 2: "describe the situation in which you were
when you heard about the 9/11 attacks “
Recall is facilitated by emotions related to the
event: their presence (yes/no); their intensity
(high/low) and their nature (positive/negative)
“Dissociation of recall and fragment completion”
Journal of Abnormal Psychology, 101, 575–580
Memory bias
In the absence of mental health disorder, recalling
pleasant memories is easier than recalling unpleasant
ones
increased availability producing a memory
bias
Our past experiences seem to be much more
positive than they actually were
Memory bias
Aims:
- mechanism of protection against depressed mood
("positive illusions"),
- justify aftermath decisions made during lifetime
("choice-supportive bias")
But: Any subjective reference to a past situation may
not be relevant to assess a present or predict a future
situation
And:Tend to reinforce resistance to change, anchoring
bias, perseverance of false beliefs, interpretation bias…
Is it possible to question ourselves ?
Fundamental attribution
error
Highlighted by Jones and Harris (1967)
Participants were asked to judge essays written by
students and defending ideological positions imposed
by the teacher.
Half of the participants knew that the
ideological position was imposed, the other
half thinking that students expressed their
opinions
« The attribution of attitudes », 1967
Even participants who knew that the position
was imposed considered that it reflected the
true opinion of the writer
Writers’ attitudes were estimated in line with the
position they were forced to defend
Overestimation of internal characteristics at
the expense of possible external causes
Fundamental attribution error
Self serving bias
Following a misdiagnosed cancer in 1980, Mr. Paul
Mongerson decided to create a company
programming diagnosis software to help physicians
In 2006, he asked his GP on the reasons why he did not use
diagnosis software .
- "it takes time and I do less than 1% error“
- “the literature shows that the error rate is 5-10%"
- "it is because of others physicians.“
The American Journal of Medicine (2008) Vol 121 (5A), fvii
Self serving bias
Gosling (1992) asked teachers on the cause of their
students’ success and failure
The results showed that:
- when students succeed, teachers thought it
was due to the quality of their teaching
- when students fail, they thought it was
related to external causes (family context)
Qui est responsable de l’échec scolaire ? (1992 ) PUF, Paris
Reinforcing false beliefs:
Self fulfilling prophecies
September June
IQ test IQ test
Normal children intellectual bloomers
“Teacher Expectation for the
Disadvantaged”
Changes
Changes over a school year
All pupils labelled as “intellectual bloomers”
improved their results significantly
Better relationships were observed between these
students and teachers
Most important roles were attributed to spurters
(keep the class, manage activities, etc.)
Errors committed were minimized by teachers
Rosenthal effect
Children were labeled as “intellectual bloomers"or
"normal" randomly
Rosenthal and Jacobson induced, for each child, either
a “positive expectation” or “no expectation” among
teachers
These expectations influnced teachers’ behaviors
towards each child, and academic outcomes….
…and confirmed the (falsified) IQ test !
A student was asked to call someone on the
phone for some reason.A picture of the
interlocutor was shown to him/her
Normal shape Overweight
(obese)
Sterotype : « obese persons are bad-tempered »
“Why does behavioral confirmation occur? A
functional perspective on the role of the perceiver”
Self-fulfilling prophecies
Those who called someone they believed to be
overweight behaved in a most unpleasant way that
those who called a person they believed to have a
normal shape
in return the person on the phone was also unpleasant with the
caller
=> confirming the initial belief (again)
Snyder M, Haugen JA. 1994. Why does behavioral confirmation occur? A functional perspective on the role of the
perceiver. J. Exp. Soc. Psychol. 30:218–46
Prospective study on adolescent alcohol use
“Self-Fulfilling Prophecies : The Synergistic
Accumulative Effect of Parents' Beliefs on Children's
Drinking Behavior”
Adolescent alcohol use
Estimation by parents
Time 2
Adolescent alcohol use
12 months
Time 1
• Parents’ estimates similar to actual alcohol use
• overestimation
• underestimation
Higher alcohol
use
A study conducted in Britain, showed that the number of
emergency visits following a road accident was 52% higher on
Friday 13 as compared to Friday 6th, even though there were
fewer road traffic.The authors recommend to stay at home that
day
Scanlon, Luben, Scanlon, & Singleton, 1993
Is Friday the 13th bad for your health?
This student is an“intellectual bloomer”
obese persons are bad-tempered
my child drink a lot of alcohol
Friday the 13th is an unlucky day
Decisions, behaviors
expectations
Beliefs, sterotypes
Reactions and
consequences in line
with the expectations
Confirming
initial beliefs
« Placebo effect»
Persistence of obsolete
practices and false beliefs
Collective decision?
Beware! : Conformism
The ASCH Effect
A group of students is asked to perform a simple vision test:
which line among the comparison line is like the standard one?
The ASCH effect
The group is composed of "accomplices", except one
student, who is the real subject of the experience
When accomplices unanimously support a wrong
answer, 37% of the subjects prefer to comply with
this false response rather than opposing the group
when the social pressure disappears, the correct response
rate reach 100 %
=>Normative social influence
=> Conformism
The ASCH effect
Fear to look ridiculous or silly, to be rejected (fear of
social disapproval)
= > Normative influence (conformism)
Not sure of its own response, lack of self confidence.
= > Informational influence
Informational influence is particularly important when someone
is faced with a task he does not control.
Normative influence is important when belonging to the group
is important
Obedience to authority figures
people obey orders from authority
figures: doctors, experts, scholar, intellectual,
etc. without asking neither the origin nor the
relevance of their statements
Bounded rationality
Why all these biases exist in the first place?
Because they give satisfactory results in familiars,
commons, routine situations and require few effort
=> adapted to the every day life situations
BUT: Adverse consequences for public health in
ambiguous situations: the discrediting of valid
knowledge, the persistence of false beliefs and obsolete
practices, status quo maintenance (resistance to change)
Counter measures:
From Bounded rationality to
critical rationalism
- Raise awareness of cognitive biases by information and
education, using concrete examples and detailed
descriptions of their potential effects
- Consider alternative hypothesis in any question.
- Take the step back from the immediate problem and
analyze it.
- Do not rely (too much) on memory
- - develop decision algorithms adapted to new situations
Critical rationalism
- Focus on information from several independent sources
using rigorous and transparent methods to collect and
analysis data (review of literature;)
- Make distinction between knowledge from science and
knowledge from ideology, politics, religion (not
evidence based)..
- The level of evidence contradicting an hypothesis must
be at least equal to those confirming it, in order to cast
a legitimate doubt
- As a decision maker, emotion is not your friend
EHESP81
Nullius in Verba
« words are nothing »
Motto of the Royal Society (London)

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Errors and biases in medical decision making

  • 1. Errors and biases in decision making process Implications for public health Aymery Constant Maître de Conférences Psychologie de la santé
  • 2. Comparison of Risk in Health Care With Other Industries MODERATE RISK MINIMAL RISK (<1/100,000) HEALTH CARE Bungee jumping Driving Chemical Manufacturing Commercial Aviation Nuclear Power HIGH RISK (>1/1000) Number of Encounters LivesLost/Year Modified from R. Amalberti and L. Leape
  • 3. Medical decision • Diagnoses • Choosing a treatment? • Initiate a new treatment? Keep the status quo? • Death or disability? • What’s the priority? • Life? Well be? Freedom? Duty? Compassion?
  • 4. Decision making 1) Logical and rational process 2) theAccumulation of knowledge improves the decision 3) Past experience improve judgment 4) collective decisions are more reliable = MYTHS
  • 6. Case study Ms. M., 62, visits her GP because she feels tired all the time and is struggling to manage her daily activities. Her GP ordered blood tests, that showed elevated levels of transaminases (liver enymes) He declared that she drinks too much alcohol and recommended total abstinence. He talked about possible treatments, an hospitalization to perform complementary medical exams (endoscopy, examination of the liver...), and the possibility to join self-help groups.
  • 7. Case study = > Hepatitis C, she was infected during a sclerosis surgery ten years ago HCV testing has been practiced several weeks after the initial diagnosis, because Ms. M. finally convinced her GP to review his diagnosis. Because she drinks very moderately She was addressed to the Department of hepatology of the University Hospital to start an antiviral treatment No consequences (except the stress of being labeled as alcoholic)
  • 8. Where does the error comes from? Lack of knowledge? Skills? = > It is a graduated GP Medical misinformation? = > All medical data were valid Lack of experience? = > He works as a GP for decades Lack of knowledge about the patient? = > He was his family doctor for years
  • 9. Hypotheses High transaminase = alcohol abuse is the most readily available diagnosis in memory? May be that a large number of patients has a drinking problem? And he made the connection with Ms. M. Maybe he thought that the problem originated from internal cause? Possible external causes were dismissed He did not comprehensively seek all the relevant information such as an invasive medical intervention 10 years ago He focused his attention on information confirming his initial belief (alcoholism), ignoring those that refute it (no clinical signs) or those who were in favor of others hypotheses (chronic fatigue)?
  • 10. Heuristic Simplified cognitive strategy,used to save time, allowing decision-maker to make acceptable deductions Evidenced byTversky & Kahneman, in the 70s Tversky, A. & Kahneman, D. (1974). Science, 185, 1124–1130. Kahneman, D (1972). Judgment under uncertainty: Heuristics and biases. Cambridge: Cambridge University Press. Three of these heuristics are particularly influential: -Availability - Representativeness - Anchoring
  • 11. Availability = > Estimating the likelihood of an event according to its availability in memory. The first impression or the most present explanation in mind is used in priority to explain an event or estimate a probability.. According to a survey, 50% of Americans were affraid of dying in a terrorist attack in 2006 (Gallup poll).The probability of such an event was estimated at one chance over 20 million (calculated on the basis of the available figures) Tversky, A; Kahneman (1973). "Availability: A heuristic for judging frequency and probability". Cognitive Psychology 5 (1): 207–233
  • 12. A group of 100 persons, including 30 lawyers and 70 engineers were interviewed.These interviews have led to the drafting of brief fact sheets on each of these people. One of these cards was randomly chosen: "John is 39 year-old.He is married and has two kids.He is involved in local politics.His favorite hobby is the collection of rare books.He loves competition,discussion and is an articulate speaker. Representativeness What is the probability that John is a lawyer?
  • 13. Representativeness Good answer: 30% (30 lawyers out of 100 persons) But participants overestimated this proportion because we tend to: - Neglect probability and estimates. Individual or descriptive information is preferred, in opposition to mathematical logic. - Focus on the supposed similarities between the information (speaks well...) and our initial belief (he’s a lawyer)
  • 14. Anchoring Participants were asked to estimate the percentage ofAfrican countries members of the United Nations Participants’ answer : 25% on average Participants’ answer : 45% on average • In the other group: "Is this more or less than 65%?" • In a group: "Is this more or less than 10%?"
  • 15. Anchoring All the reasoning process is influenced by a single initial data, which is difficult to ignore afterwards Explains the influence of first impressions, or those of early learnings on decision making or situational analysis
  • 16. Cognitive Bias Tendency to acquire and process information by filtering it through one's own likes, dislikes, and experiences. Relevant Informations Relevant responses Non relevant informations Non relevant responses Selection bias Reasoning bias Heuristics
  • 17. 33 biases and heuristics reportedly active in medical practice
  • 18. Information-gathering problems  Unpacking – failure to elicit all relevant information  Availability – recent exposure influences diagnosis  Anchoring – holding onto a diagnosis after receiving contradictory information  Premature closure – accepting a diagnosis before it is fully verified
  • 19. Systems contributions  Diagnosis momentum – early diagnosis by another provider is accepted as definite  Feedback sanction – final diagnosis does not return to initial decision-maker  Triage cueing – location cues management (seen through the lens of the first provider)
  • 20. Probability Pitfalls  Aggregate bias – aggregate data do not apply to my patients  Base-rate neglect – ignoring the true prevalence  Gender bias – gender inappropriately colors probability  Gambler’s fallacy – sequence of same diagnoses will not continue  Posterior probability – sequence of same diagnoses will continue
  • 21. Hypotheses High transaminase = alcohol abuse: most readily available diagnosis in memory? Availability May be that a large number of patients has a drinking problem? And he makes the connection with Ms. M. Posterior Probability Maybe he think it the problem originate from internal cause? And not external? Attribution error May he did not seek comprehensively all the relevant information (invasive medical intervention it 10 years ago) Anchoring =>Unpacking Maybe he focused his attention on information confirming his initial belief (alcoholism), ignoring those that refute it (no clinical signs) or who were in favour of an others hypothesis (chronic fatigue)? Interpretative bias
  • 22. Emotions can jeopardize the rationality of any decision maker three types of affects: - transitional: surrounding factors, fatigue... - Due to personality: trait anxiety, emotional adaptation - Related to clinical situations: children involved… Affective bias The best scientific evidence can be overlooked because of affects, emotions….
  • 23. “Our affective reactions to patients are often our very first reactions, occurring automatically and subsequently guiding information processing, judgment, and decision making…” Zajonc, American Psychologist, 1980
  • 24. Two competing reasoning modes: The first is fast, intuitive, automatic (or even unconscious) often involves an affective or emotional component, and requires few resources => satisfying responses The second is analytic, slow, deliberate, affect-free and costly in resources => Optimal responses Most vulnerable to biases
  • 26. Some scientific information benefit from a large consensus in the scientific community, the public option, the media and health professionals Strong Epidemiological evidence high acceptance by the public and the media health professionals practices Public Health Tobacco, alcohol abuse; unhealthy diet; drink driving ….
  • 27. Making relevant decisions regarding the health of people suppose to be able to collect relevant information In ambiguous, new, changing unknowns, or emotionally situations, the collection and interpretation of the information will be influenced by: Information seeking 1) The way the information is presented 2) decison-makers’ initial beliefs
  • 28. You are a top decision maker at WHO and you want take preventive actions to reduce the number of deaths and injuries from animal bites. On which animal will you focus your intervention? In Australia? A) Dogs, B) Sharks, ou C) Crocodiles In Romania? A) Dogs, B) Sharks, ou C) Crocodiles Public health In South Africa? A) Dogs, B) Sharks, ou C) Crocodiles
  • 29. Framing The entire reasoning process is governed by the way the information is presented Chosen by 72% of participants Chosen by 28% of participants We expect that an epidemic will kill 600 people. Participants are asked to choose between two possible actions Option A: can save the lives of 200 people Option B: 33% chance of saving 600 people
  • 30. Framing Same scenario, different layout Option A: 400 people will die Option B: 33% chance that there is no death Chosen by 22% of participants Chosen by 78% of participants The expected value is the same in both cases, but the statements mentioning death are rejected, while those mentioning saved lives are preferred
  • 31. Framing Tendency to Loss aversion: the negative value of a loss is considered to be superior to an equivalent gain (capacity, life, death…) Outcome feeling Gain of X Positive (+) Loss of X Extremely negative (---)
  • 32. Framing The framing allows to influence decision using our tendency to loss aversion If you are favorable to the LAMBDA treatment, you will say to the patient: "with the LAMBDA treatment,you have 90% chance of survival. If you prefer an alternative solution, you will say: "with the LAMBDA treatment,you have 10% chance of death”
  • 33. Confirmation bias Is organic food healthier? Can video games make kids violent? IsWI - FI carcinogenic? => Might cast a doubt, even in the absence of scientific evidence When faced with a closed (yes/no) question, we naturally tend to seek confirming information to answer “yes” and then, ignore the alternative hypothesis
  • 34. Confirmation bias Exemple:Does Behaviour change during the full moon? We will immediately remember some cases when we were stressed, anxious, insomniacs or so…during full moon nights… ….and forget the hundreds of full moon nights when we slept normally
  • 36.
  • 37. Change the question Open-ended Question : what are the risk factors for cancer? - Tabacco - Alcohol - Unhealthy diet (sugar, fat…) - Sedentary behavior - Diesel - Sun exposure - ….
  • 38.
  • 40. Interpretation bias University of Santford (USA): Two groups of students are formed according to their opinions on death penalty:A group in favor of death penalty, and a group against the death penalty Then two studies were presented: one demonstrating the usefulness of death penalty, and one showing DP is counter-productive …And they are asked to assess the methodological quality of these two studies
  • 41. “Biased assimilation and attitude polarization: The effects of prior theories on subsequently considered evidence” Conclusions regarding death penaly « efficient » « counter-productive » In favor of death penalty Quality ++ Quality --
  • 42. Conclusions regarding death penaly « efficient » « counter-productive » In favor of death penalty Quality ++ Quality -- Against death penalty Quality ++ Quality -- The studies are considered valid if they are in line with personal opinions, and discredited otherwise “Biased assimilation and attitude polarization: The effects of prior theories on subsequently considered evidence”
  • 43. Other effects Media covering a political campaign will be considered hostile by both sides Lobbies will select studies which suit their own interest (bicycle helmet; adverse effect of a food or a drug benefit...) and ignore others studies Scientific work will be judged from political or ideological perspectives, regardless of actual scientific value (especially in social sciences…)
  • 44. Case study from France
  • 45. Rapport INSERM 2005 INSERM is the French institute for Health and Medecine Relying upon data from over a thousand international scientific studies, INSERM experts advocate in a 364-pages document (available online) to best inform parents and educators on conduct disorders in children and to detect it as soon as possible (3 years old), to ensure the prevention. Conduct disorders (esp ADHD) are a major cause of unintentional injuries in children http://www.ipubli.inserm.fr/bitstream/handle/10608/142/expcol_2005_trouble_synthese_eng.p df?sequence=1
  • 46. Recommandations from the report Improving information on conduct disorder in France, through epidemiological studies among children and adolescents in the general population, as well as in high risk populations • Identify risk: family factors, pre - and perinatal, genetic. • Develop specific prevention programs, train teachers and educators, intervene with families at risk, track as soon as possible warning signs, i.e. at the age of 3, and record . Perform regular, accurate and multidisciplinary assessments for subjects with symptoms. Assess the effects of various psychotherapies. Further pharmacological research.
  • 47. Lobbying from French physicians The very next day, the national Union of physicians of maternal and child welfare (SNMPMI), protested. Its leaders created a petition (available online) signed by nearly 200 000Web users, along dozens of associations , psychologists, doctors, educators…. The first signatories include child psychiatrists, clinical psychologists, doctors, lecturers, childhood professionals,...... Many belonging to a lobby which pushed health minister to censor a report from INSERM in 2004 (namely psychoanalysts…)
  • 48. Online Petition • "detected children would be subjected to a battery of tests developed on the basis of the theories of behavioral Neuropsychology" “According to the criteria of the Anglo- Saxon studies" • Nurseries and schools transformed into“hunting places', • The potential offender ,too small to defend himself,will be transformed into a junkie • "the slightest gesture,the first child nonsense may be interpreted as the expression of a pathological personality at the mercy of a "robotic health care thinking. “http://www.pasde0deconduite.org/appel/
  • 49. Framing: changing terms Terms used in the Report Terms used in the online petition International studies « Anglo-saxons » studies screening Hunting down Identify risk factors and prevent disorders Relentless linearity principle and deterministic approach Early prevention Early hunt Pharmacology as a second line Drug use Psychotherapeutic support Behavioral conditioning Interventions towards families at risk stigmatization
  • 50. Children: high emotional bias political context , cultural lobbies and ideological opinions beliefs concerning the "Anglo-Saxon" (behaviorists) use of international recommendations to change local practices (esp those deriving from psycho-analysis) Pétition: framing and loss aversion Discredit : INSERM "Anglos-Saxon" Renowned experts international studies scientific recommendations Achieved Result: statut quo context Change in practices = Fascism
  • 51. Early screening and detection is advocated for aged people
  • 52. Past experience improve decison-making ? Not sure….
  • 53. Question # 1: "describe the exact content of the midday meal you took 15 days ago. Memory bias Question # 2: "describe the situation in which you were when you heard about the 9/11 attacks “ Recall is facilitated by emotions related to the event: their presence (yes/no); their intensity (high/low) and their nature (positive/negative)
  • 54. “Dissociation of recall and fragment completion” Journal of Abnormal Psychology, 101, 575–580
  • 55. Memory bias In the absence of mental health disorder, recalling pleasant memories is easier than recalling unpleasant ones increased availability producing a memory bias Our past experiences seem to be much more positive than they actually were
  • 56. Memory bias Aims: - mechanism of protection against depressed mood ("positive illusions"), - justify aftermath decisions made during lifetime ("choice-supportive bias") But: Any subjective reference to a past situation may not be relevant to assess a present or predict a future situation And:Tend to reinforce resistance to change, anchoring bias, perseverance of false beliefs, interpretation bias…
  • 57. Is it possible to question ourselves ?
  • 58. Fundamental attribution error Highlighted by Jones and Harris (1967) Participants were asked to judge essays written by students and defending ideological positions imposed by the teacher. Half of the participants knew that the ideological position was imposed, the other half thinking that students expressed their opinions « The attribution of attitudes », 1967
  • 59. Even participants who knew that the position was imposed considered that it reflected the true opinion of the writer Writers’ attitudes were estimated in line with the position they were forced to defend Overestimation of internal characteristics at the expense of possible external causes Fundamental attribution error
  • 60. Self serving bias Following a misdiagnosed cancer in 1980, Mr. Paul Mongerson decided to create a company programming diagnosis software to help physicians In 2006, he asked his GP on the reasons why he did not use diagnosis software . - "it takes time and I do less than 1% error“ - “the literature shows that the error rate is 5-10%" - "it is because of others physicians.“ The American Journal of Medicine (2008) Vol 121 (5A), fvii
  • 61. Self serving bias Gosling (1992) asked teachers on the cause of their students’ success and failure The results showed that: - when students succeed, teachers thought it was due to the quality of their teaching - when students fail, they thought it was related to external causes (family context) Qui est responsable de l’échec scolaire ? (1992 ) PUF, Paris
  • 62. Reinforcing false beliefs: Self fulfilling prophecies
  • 63. September June IQ test IQ test Normal children intellectual bloomers “Teacher Expectation for the Disadvantaged” Changes
  • 64. Changes over a school year All pupils labelled as “intellectual bloomers” improved their results significantly Better relationships were observed between these students and teachers Most important roles were attributed to spurters (keep the class, manage activities, etc.) Errors committed were minimized by teachers
  • 65. Rosenthal effect Children were labeled as “intellectual bloomers"or "normal" randomly Rosenthal and Jacobson induced, for each child, either a “positive expectation” or “no expectation” among teachers These expectations influnced teachers’ behaviors towards each child, and academic outcomes…. …and confirmed the (falsified) IQ test !
  • 66. A student was asked to call someone on the phone for some reason.A picture of the interlocutor was shown to him/her Normal shape Overweight (obese) Sterotype : « obese persons are bad-tempered » “Why does behavioral confirmation occur? A functional perspective on the role of the perceiver”
  • 67. Self-fulfilling prophecies Those who called someone they believed to be overweight behaved in a most unpleasant way that those who called a person they believed to have a normal shape in return the person on the phone was also unpleasant with the caller => confirming the initial belief (again) Snyder M, Haugen JA. 1994. Why does behavioral confirmation occur? A functional perspective on the role of the perceiver. J. Exp. Soc. Psychol. 30:218–46
  • 68. Prospective study on adolescent alcohol use “Self-Fulfilling Prophecies : The Synergistic Accumulative Effect of Parents' Beliefs on Children's Drinking Behavior” Adolescent alcohol use Estimation by parents Time 2 Adolescent alcohol use 12 months Time 1 • Parents’ estimates similar to actual alcohol use • overestimation • underestimation
  • 70. A study conducted in Britain, showed that the number of emergency visits following a road accident was 52% higher on Friday 13 as compared to Friday 6th, even though there were fewer road traffic.The authors recommend to stay at home that day Scanlon, Luben, Scanlon, & Singleton, 1993 Is Friday the 13th bad for your health?
  • 71. This student is an“intellectual bloomer” obese persons are bad-tempered my child drink a lot of alcohol Friday the 13th is an unlucky day Decisions, behaviors expectations Beliefs, sterotypes Reactions and consequences in line with the expectations Confirming initial beliefs « Placebo effect» Persistence of obsolete practices and false beliefs
  • 73. The ASCH Effect A group of students is asked to perform a simple vision test: which line among the comparison line is like the standard one?
  • 74. The ASCH effect The group is composed of "accomplices", except one student, who is the real subject of the experience When accomplices unanimously support a wrong answer, 37% of the subjects prefer to comply with this false response rather than opposing the group when the social pressure disappears, the correct response rate reach 100 % =>Normative social influence => Conformism
  • 75. The ASCH effect Fear to look ridiculous or silly, to be rejected (fear of social disapproval) = > Normative influence (conformism) Not sure of its own response, lack of self confidence. = > Informational influence Informational influence is particularly important when someone is faced with a task he does not control. Normative influence is important when belonging to the group is important
  • 76. Obedience to authority figures people obey orders from authority figures: doctors, experts, scholar, intellectual, etc. without asking neither the origin nor the relevance of their statements
  • 77. Bounded rationality Why all these biases exist in the first place? Because they give satisfactory results in familiars, commons, routine situations and require few effort => adapted to the every day life situations BUT: Adverse consequences for public health in ambiguous situations: the discrediting of valid knowledge, the persistence of false beliefs and obsolete practices, status quo maintenance (resistance to change)
  • 78. Counter measures: From Bounded rationality to critical rationalism
  • 79. - Raise awareness of cognitive biases by information and education, using concrete examples and detailed descriptions of their potential effects - Consider alternative hypothesis in any question. - Take the step back from the immediate problem and analyze it. - Do not rely (too much) on memory - - develop decision algorithms adapted to new situations
  • 80. Critical rationalism - Focus on information from several independent sources using rigorous and transparent methods to collect and analysis data (review of literature;) - Make distinction between knowledge from science and knowledge from ideology, politics, religion (not evidence based).. - The level of evidence contradicting an hypothesis must be at least equal to those confirming it, in order to cast a legitimate doubt - As a decision maker, emotion is not your friend
  • 82. Nullius in Verba « words are nothing » Motto of the Royal Society (London)