Clinicians must make diagnostic treatment decisions using a large body of probabilistic information and process this information under the pressure of time and workload. The pressure of this task is thought to result in mental shortcuts, otherwise known as heuristic decision-making.
Psychologists posit that to integrate probabilistic information, the cognitive process must be optimized during the decision-making process. Heuristics are defined as simple decision-making strategies, otherwise known as rules of thumb.
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How do heuristics fit in with decision-making?
The concept of heuristics was posited by the psychologists Amos Tversky and Daniel Kahneman. Kahneman and Tversky investigated the use of heuristics and considered these mental shortcuts as largely positive as they enabled people to arrive at predominantly well-balanced decisions.
However, there is a supposition that making this in the absence of incomplete information leads to faulty decision-making. As such, heuristics has been used to blame the errors in clinical reasoning.
Increasingly, research has rectified the view of heuristics, emphasizing that expertise and good decision-making may involve the absence of some information. Recent research has been used to rectify the notion that heuristics can result in poor decisions, and in the context of healthcare, can be used to simplify complex decision-making processes.
Clinical decision-making can be considered as a process of five stages:
- the collection and analysis of relevant information
- judgment making
- decision-making
- acting on decisions
- post hoc evaluation of the outcome
The environment and context in which decisions are made play an important role in the outcome. The context factors to consider include the speed at which decisions need to be made and the weight of that outcome.
Decision-making can be either intuitive or reflective. Intuitive decision-making is fast and is influenced by personal cognitive biases that have arisen from experiences through interacting with society. Reflective decision-making is analytical, considered, and logical. Intuitive decision-making involves different areas of the brain (ventral medial prefrontal cortex) relative to reflective decision-making (the right inferior prefrontal cortex).
A framework that is used to describe the relationship between reflective and intuitive decision-making is that of a dual system. An intuitive process is rational rules are not followed when making fast decisions. Instead, personal experiences and perceptions direct the outcome of the decision-making process. These experiences on perceptions are known as cognitive biases and are responsible for creating shortcuts i.e., heuristics.
Heuristics are used optimally for tasks which or in high volume and have low impact. Heuristics reduce the burden of cognitive stress associated with analytical thinking and ensure that decisions are guided efficiently and economically.
Reflective decision-making requires an analytical thought process and is typically reserved in situations where the outcome of a decision-making process has a high impact and therefore demands evidence-based reasoning.
The prevalence of heuristics in medicine
Attempts to quantify the prevalence of heuristic use in the medical setting have reported figures ranging from 7.8 to 75.6% for availability heuristics and 5.9 to 87.8% for anchoring heuristics. Availability and anchoring heuristics are the two most comprehensively studied heuristic types.
The availability heuristic can be defined as the process of making a decision based on previous experience in a similar situation. The anchoring heuristic is defined when a certain piece of information is used as an ‘ anchor point’; the healthcare professional will anchor their diagnosis to this information without considering other presenting signs and symptoms equally.
What is the impact of heuristics in medicine and patient outcomes?
Heuristics offers the advantage of producing fast decisions. Heuristics is especially useful when decision-making is highly time-dependent i.e., in the clinical setting where timely decisions are frequent. However, overuse of heuristics can result in patient harm and error if not applied in the correct setting.
Most heuristics have been researched in the context of clinical diagnosis, with fewer studies considering the impact of heuristics on treatment or management and prognosis. It is important to note that research to evaluate the effect of heuristics in real life is limited by the methodologies employed - that is, through survey and simulation.
The positive impact of heuristics can be seen when they are used to diagnose common conditions. Heuristics are found to be particularly useful for efficient care provision. The negative impact of heuristics is less likely when employed by experienced clinicians. These practitioners are less likely to take risks and can use heuristics effectively.
An example in which heuristics is beneficial is when the clinician needs to rapidly analyze an ECG to diagnose an ST-segment elevation myocardial infarction (STEMI). In this scenario, a clinician uses a recognition heuristic to see a pattern from the patient’s history. Regardless of how experienced a practitioner is, heuristics become less effective when analytical decision-making is required.
Heuristics can be both positive and negative. When applied in the correct context, they can help clinicians simplify complex tasks and allow focus on only the most relevant information.
References
- Islam R, Weir C, Del Fiol G. (2014) Heuristics in Managing Complex Clinical Decision Tasks in Experts' Decision Making. IEEE Int Conf Healthc Inform. doi:10.1109/ICHI.2014.32.
- Wegwarth O, Gaissmaier W, Gigerenzer G. (2009) Smart strategies for doctors and doctors-in-training: heuristics in medicine. Med Educ. doi:10.1111/j.1365-2923.2009.03359.x.
- Whelehan DF, Conlon KC, Ridgway PF. (2020) Medicine and heuristics: cognitive biases and medical decision-making. Ir J Med Sci. doi:10.1007/s11845-020-02235-1
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