We all make thousands of choices each day—from what we’ll eat for breakfast to when we’ll go to bed at night. But conscious choices are an energy-intensive undertaking for the human brain. To conserve the body’s resources, our brains are structured to automate decision-making with mental shortcuts, in some instances based on our background, cultural environment and personal experiences. These mental shortcuts are known as cognitive biases.

In theory, humans developed cognitive biases as an evolutionary advantage to help us make quick decisions in survival situations—think “fight-or-flight.” While cognitive biases are part of our thinking at all times, in the modern world, we tend to rely on them when we feel tired, stressed, overwhelmed or frightened, which can lead to irrational decision-making.¹

In 2017, a study about a rare, terminal lung disease called idiopathic pulmonary fibrosis (IPF) identified a notable gap in the information that IPF patients wanted upon diagnosis and what they actually received from their physicians. We were intrigued by this disconnect and wondered if cognitive biases might be at play in the communication breakdown – and in healthcare decision-making.¹

Cognitive Biases In Physician-Patient Dialogues

To test our hypothesis, we conducted two nationwide surveys to examine how certain cognitive biases may affect conversations between people with chronic lung diseases and their doctors. Our hope was that we’d learn something valuable to help the 32 million Americans living with chronic lung diseases—such as IPF and chronic obstructive pulmonary disease (COPD)—have more productive conversations with their doctors (you can jump to the action plan here).² The first survey included 740 people age 55 and older who reported having one or more chronic lung diseases, and the second surveyed 400 pulmonologists.

When we analyzed the results, we saw that both patients and physicians are affected by cognitive biases when discussing disease management. Among those living with chronic respiratory diseases, survey responses suggested that fear and anxiety play a key role in provoking cognitive bias, which is understandable in the face of a terminal diagnosis like IPF, for example. Below are five particular biases we identified in people with chronic respiratory disease.³

• Loss aversion: This bias provides insight into how people's comfort with risk is influenced by whether the choice is framed as a loss or as a gain. On average, patients with chronic respiratory diseases gravitated toward a treatment 59 percent more often when the benefits of the treatment were emphasized versus the downsides.
• Licensing effect: Licensing effect leads people to forgo virtuous behaviors if they have recently engaged in an activity that’s good for them. For example, they don’t feel as bad ordering dessert if they just ate a salad. IPF patients were, on average, 17 percent more likely to indulge in a “bad” behavior (in the case of our survey, not beginning treatment) when they had previously engaged in a “good” behavior, such as improving their diet.

• Construal level theory: Construal level theory observes that people tend to think in abstract terms about actions in the future, whereas they think in concrete terms about activities that will happen in the near term. The survey found that people with chronic respiratory disease thought a person would seek treatment more immediately if they were asked about the details of how they were going to begin treatment (concrete), rather than the more abstract concept of why they should start treatment (abstract).

• Affect heuristic: The affect heuristic posits that negative emotions often color a person’s decisions. Among people with IPF, 63 percent reported feeling fear at diagnosis and 50 percent reported feeling fear when beginning treatment, which could delay decisions about how they will manage their disease.
• Illusion of transparency: People tend to assume that others understand what they are feeling and thinking. IPF patients were confident that their doctor could tell how they were feeling about treatment recommendations, while the doctors were, on average, 11 percent less confident that they could tell how their IPF patients were feeling about treatment recommendations during their conversations.

Among the pulmonologists we surveyed, we observed that cognitive biases tend to arise from not considering the full context of a patient’s situation. This too is understandable given the time constraints and workloads that doctors face on a daily basis. Below are the three most prominent biases among the pulmonologist population: ³

• Loss aversion: The results indicated that pulmonologists were, on average, 18 percent more likely to prescribe treatment when confronted with something the patient might lose.
• Framing of outcomes: People’s decisions depend on the context. IPF doctors were, on average, 12 percent more satisfied with existing treatment options if they were reminded how it compared to those available in the past.
• Outcome bias: This bias observes that people often judge the quality of a course of action based on their own or observed experience with a small number of cases, rather than the statistically expected outcome. Doctors were more likely to rate their treatment choice higher if they were told the patient was feeling better as a result than if they were told the patient was feeling the same or they did not have any information about the patient.

Improving The Dialogue

While cognitive biases are unavoidable, the results of our surveys indicate that there are three simple actions people with chronic respiratory diseases can take to support more effective communication with their doctors. View the action plan here.

Through an awareness of cognitive biases, both doctors and patients may be able to better evaluate why they are making certain important healthcare decisions, and ultimately overcome the hidden barriers we all face in communicating about our health.

More resources for IPF and PF can be found at pulmonaryfibrosis.org.

^{References
1 The Joint Commission, Cognitive biases in health care. October 2016. https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_28_Oct_2016.pdf   
2 American Lung Association. (2017, July 27). Mission Impact & History. Retrieved July 13, 2018, from http://www.lung.org/about-us/mission-impact-and-history/our-impact.html  
3 Genentech data on file. Accessed December 2018.}