February 22, 2018
N Engl J Med 2018; 378:689-691
Here is an excerpt:
The key problem is medicine’s ongoing assumption that clinicians and patients are, in general, rational decision makers. In reality, we are all influenced by seemingly irrational preferences in making choices about reward, risk, time, and trade-offs that are quite different from what would be predicted by bloodless, if precise, quantitative calculations. Although we physicians sometimes resist the syllogism, if all humans are prone to irrational decision making, and all clinicians are human, then these insights must have important implications for patient care and health policy. There have been some isolated innovative applications of that understanding in medicine, but despite a growing number of publications about the psychology of decision making, most medical care — at the bedside and the systems level — is still based on a “rational actor” understanding of how we make decisions.
The choices we make about prescription drugs provide one example of how much further medicine could go in taking advantage of a more nuanced understanding of decision making under conditions of uncertainty — a description that could define the profession itself. We persist in assuming that clinicians can obtain comprehensive information about the comparative worth (clinical as well as economic) of alternative drug choices for a given condition, assimilate and evaluate all the findings, and synthesize them to make the best drug choices for our patients. Leaving aside the access problem — the necessary comparative effectiveness research often doesn’t exist — actual drug-utilization data make it clear that real-world prescribing choices are in fact based heavily on various “irrational” biases, many of which have been described by behavioral economists and other decision theorists.
The article is here.