Clinicians do not wake up in the morning thinking, "looking forward to providing crappy treatment to my patients today." We genuinely want to help pour patients and we believe the treatments we use work. Why then, is low-value care so prevalent in healthcare? There are many angles you could take to answer that question. In this post, I am going to focus on clinician decision-making.
This narrative review addresses many of the biases and cognitive fallacies that cause healthcare providers to overvalue ineffective treatments. It discusses why clinicians believe ineffective treatments are helpful and why they continue to use them.
3 common and related components causing deductive malfunction
The natural history of the disease, regression to the mean, and the placebo effect cause real signs and symptoms to improve — regardless of the type of treatment (or presence of any treatment).
Patients and clinicians often convince themselves that treatment was effective — when it was not. Often due to confirmation bias and other biases (I’ll throw in outcome bias and sunk-cost fallacy)
Personal evaluation of efficacy is quick and convincing but properly controlled, scientific determinations can be slow, complex, and costly. This is system 1 vs. system 2 thinking. The fast and frugal model can help in triage situations and initial assumptions but reflection should occur later.
The author addresses Post Hoc, Ergo Propter Hoc fallacy which is essentially the outcome bias. “After this, therefore because of this” is the fallacy of assuming a cause and effect relationship. This is why clinicians need to start with controlled trials to determine if something has an effect. From there, they use their experience and patient values to fine-tune treatment (timing, dosage, context, etc.) No matter how many times a treatment has “worked” for a clinician, without controls conclusions cannot be drawn.
Solution: Use the Evidence-Based Medicine Funnel
This is why I prefer the Evidence-Based Medicine funnel rather than the stool. Evidence-Based Medicine (EBM) is often presented as a three-legged stool — best available research, clinical expertise, patient values, and circumstances — but this analogy is faulty as it supports the notion that all three legs are equally weighed and siloed. Instead, we should use the funnel approach proposed by Erik Miera. In this EBM framework, all three aspects work together to narrow down treatment choices.
Start with the best available research then filter the treatments through clinical expertise and patient values and circumstances. This approach ensures only research-supported treatments are used and they are applied in an individualized manner.
Biases and cognitive fallacies negatively influence clinical decision making. To minimize the impact of the fallacies, healthcare providers can use decision-making frameworks, such as the Evidence-Based Funnel, to restrict treatment options to the best patient-centric approach.