Cognitive and Motivational Biases in Decision and Risk Analysis

Behavioral decision research has demonstrated that judgments and decisions of ordinary people and experts are subject to numerous biases. Decision and risk analysis were designed to improve judgments and decisions and to overcome many of these biases. However, when eliciting model components and parameters from decisionmakers or experts, analysts often face the very biases they are trying to help overcome. When these inputs are biased they can seriously reduce the quality of the model and resulting analysis. Some of these biases are due to faulty cognitive processes; some are due to motivations for preferred analysis outcomes. This article identifies the cognitive and motivational biases that are relevant for decision and risk analysis because they can distort analysis inputs and are difficult to correct. We also review and provide guidance about the existing debiasing techniques to overcome these biases. In addition, we describe some biases that are less relevant because they can be corrected by using logic or decomposing the elicitation task. We conclude the article with an agenda for future research.     

Fuzzy-Trace Theory, Risk Communication, and Product Labeling in Sexually Transmitted Diseases

Health care professionals are a major source of risk communications, but their estimation of risks may be compromised by systematic biases. We examined fuzzy-trace theory's predictions of professionals' biases in risk estimation for sexually transmitted infections (STIs) linked to: knowledge deficits (producing underestimation of STI risk, re-infection, and gender differences), gist-based mental representation of risk categories (producing overestimation of condom effectiveness for psychologically atypical but prevalent infections), retrieval failure for risk knowledge (producing greater risk underestimation when STIs are not specified), and processing interference involving combining risk estimates (producing biases in post-test estimation of infection, regardless of knowledge). One-hundred-seventy-four subjects (experts attending a national workshop, physicians, other health care professionals, and students) estimated the risk of teenagers contracting STIs, re-infection rates for males and females, and condom effectiveness in reducing infection risk. Retrieval was manipulated by asking estimation questions in two formats, a specific format that "unpacked" the STI category (infection types) and a global format that did not provide specific cues. Requesting estimates of infection risk after relevant knowledge was directly provided, isolating processing effects, assessed processing biases. As predicted, all groups of professionals underestimated the risk of STI transmission, re-infection, and gender differences, and overestimated the effectiveness of condoms, relative to published estimates. However, when questions provided better retrieval supports (specified format), estimation bias decreased. All groups of professionals also suffered from predicted processing biases. Although knowledge deficits contribute to estimation biases, the research showed that biases are also linked to fuzzy representations, retrieval failures, and processing errors Hence, interventions that are designed to improve risk perception among professionals must incorporate more than knowledge dissemination. They should also provide support for information representation, effective retrieval, and accurate processing.     

Models for medical practice integration

Decreased physician income, increased administrative burdens, and interference with the compassionate delivery of high-quality medical care are threatening the independent practice of medicine in solo and small group practices. Many established physicians, and the hospitals with which they relate, are searching for organizational models that, by integrating some or all aspects of their practices, will preserve incomes and reduce regulatory and administrative burdens. This article will describe several "practice integration models," pointing out advantages and disadvantages to physicians in established practices. (Many of the same arguments could be made for physicians new to practice, with different emphasis). The continuum of integration models is shown in figure 1, page 19. The group practice without walls and its two submodels, the independent group practice without walls (IGWW) and the affiliated medical practice corporation (AMPC) are more recent and more effective models and will be covered in depth in the article.     

Underestimating our influence over others at work

Employees at all organizational levels have influence over their subordinates, their colleagues, and even their bosses. But are they aware of this influence? We present evidence suggesting that employees are constrained by cognitive biases that lead them to underestimate their influence over others in the workplace. As a result of this underestimation of influence, employees may be reluctant to spearhead organizational change, discount their own role in subordinates’ performance failures, and fail to speak up in the face of wrongdoing. In addition to reviewing evidence for this bias, we propose five moderators that, when present, may reverse or attenuate the underestimation effect (namely, comparative judgments, the objectification or dehumanization of an influence target, the actual degree of influence any one influencer has, the means of influence, and culture). Finally, we offer some practical solutions to help employees more fully recognize their influence over other members of the organization.     

The limits of medical quality assurance systems

Quality Assurance (QA) via the process of review systems is a retrospective look at what was. It is a picture of the past. Any such system is bound to have limitations, because the past cannot be changed. In QA, the ultimate aim should be to educate physicians as to where they made mistakes so that they can learn how to prevent them in the future. The distribution of what mistakes can be avoided, so that all physicians can learn from others' mistakes, takes the whole team closer to the aim of real QA--preventing mistakes. The first part of this article looks at QA in general terms; the second part looks at inherent biases that should be removed so that the team reaches the goal of bona fide quality.     

An approach to the impaired physician

The 1988 California Administrative Code requiring all acute care medical staffs to provide assistance to impaired physicians has not resulted in an increase in the annual census in the Medical Board of California Diversion Program. In part, this lack of an increase is due to the failure of some hospitals to form physician aid committees and to the poor functioning of such committees in other hospitals. The common reasons for these deficiencies are that the medical staff leadership does not think there are any impaired physicians on staff and that they don't know what the committee would do if it were formed. This attitude demonstrates a lack of appreciation for the prevalence of impaired physicians and the tremendous amount of work required (establishing policies and procedures) to identify and help them. This article discusses the prevalence of the impaired physician, the types of impaired physicians, a "cookbook" approach to managing these physicians, and the success of intervention.     

Physician resiliency?

The profound changes in the health care industry have led to the anger, frustration, and unhappiness that physicians are feeling. It is important to examine physicians' responses to the threats to their professional autonomy, image, lifestyles, and relationships with their patients. The "learned helplessness" behavior exhibited by physicians is astounding, considering the education, status, and reputation of physicians as healers for those in need. This article explores the concept of resiliency among physicians and describes why physicians as a group may be less resilient than other individuals. In fact, the structure and training of the medical profession stacks the deck against those who want to change or to be resilient in the face of the changing environment.     

The value circle. A profile of J. Richard Gaintner, MD.

This article describes how the arrival of CEO J. Richard Gaintner, MD, at Shands HealthCare signaled a time for refocusing the organization's direction and helping physicians to cope with the changes buffeting the industry. He saw angst and disenfranchisement, sentiments that characterized not only Shands and the University of Florida Health Science Center, but also the entire establishment of American scientific medicine. Gaintner believes--and continually preaches--that practicing medicine in a cost-effective manner will improve, not harm, the quality of care. His willingness to face reality objectively is perhaps his greatest asset in helping physicians deal with managed care. He conveys heartfelt empathy with the day-to-day conflicts they face. But he does not allow himself the temporary luxury of cynicism, and he refuses to accept negativity and pessimism in others. Rather, he asks that physicians and managers understand the system and develop the capacity to work within it and take responsibility for improving it. Beyond exhorting physicians to be accountable for the success of the enterprise, Gaintner creates mechanisms for meaningful physician participation in enterprise management.     

Physician-centered management guidelines.

The "Fortune 500 Most Admired" companies fully understand the irreverent premise "the customer comes second" and that there is a direct correlation between a satisfied work force and productivity, service quality, and, ultimately, organizational success. If health care organizations hope to recruit and retain the quality workforce upon which their core competency depends, they must develop a vision strategic plan, organizational structure, and managerial style that acknowledges the vital and central role of physicians in the delivery of care. This article outlines a conceptual framework for effective physician management, a "critical pathway," that will enable health care organizations to add their name to the list of "most admired." The nine principles described in this article are based on a more respectful and solicitous treatment of physicians and their more central directing role in organizational change. They would permit the transformation of health care into a system that both preserves the virtues of the physician-patient relationship and meets the demand for quality and cost-effectiveness.     

Is there a physician union in your future?

Physician unions are in the news. Patient management and patient care decisions are increasingly being taken out of the hands of physicians and put into the hands of "The Suits." To take their case for a return to physician-driven patient care to the people, some physicians are joining unions. Some are even collectively bargaining for salary and other issues that are historically more closely associated with unions. The simple fact is that physician unions exist and the number of physicians joining them is expected to increase. What are the pros and cons of unionization? What motivates physicians to join unions, and what potential negative and positive factors are associated with physician unionization? This article reviews the pros and cons and the issues related to physician unions, for physicians attempting to answer the question, "Is there a union in my future?"     

Changes in the practice of medicine

In constructing this report, the author interviewed physicians to ask them how the practice of medicine has changed and what changes bother them most. She also talked to physician executives to find out how they were managing an increasingly disgruntled group of doctors. Four changes in the professional environment that physicians face dominated these conversations--lowered income, loss of control, the threat of litigation, and greatly increased paperwork. This article is a summary of comments in these four areas.     

Dual agency and fiduciary responsibilities in modern medicine

In today's complex medical world, physicians often face difficult decisions about whom they serve first--patients, corporations, insurance companies, the government, etc.     

Physician glut. Physicians--the next victims of "downsizing?"

Should physicians really be polishing up their CVs or preparing to enter another line of work? In a word: No. What a recent survey makes clear is that, while managed care is driving physicians from some markets, jobs are still available in other markets traditionally underserved by physicians. This is not to suggest that the physician employment market has gone unchanged. Many physicians, particularly specialists, have taken income hits, and some specialists truly are in need of work. Primary care physicians, however, have seen their stars rise and are now in a position to work wherever they want. Physicians may no longer be able to practice within 50 miles of where they were raised or where they were trained, as has been their wont. Instead, they will have to do what other professionals have long done--go where job opportunities take them. In short, they will have to add a career strategy to their scientific mindset, and that means an aggressive job search, coupled with a strong consumer orientation.     

Getting a firm grip on the realities for physician executives

Today, physician executives can be found in every health care setting-group practices, hospitals and academic medical centers, insurance companies, drug companies, airlines, the government, and more. But before physicians land these positions, they must negotiate the often difficult passage from clinician to manager to executive to business-minded leader. To manage this transition successfully, physicians must be aware of and understand some basic realities of management positions. The nature of these realities and how physicians interested in management can deal with them are the subject of this article.     

The Zen of physician initiatives

Many physicians today feel ravaged by the brutal speed with which change has been occurring. They see the beliefs and practices of a lifetime being abandoned and replaced by the flavor of the month, management du jour. But if you are willing and able to take the brave step of approaching your physicians without an agenda, meeting with them to listen to their concerns, and can also avoid hanging a lightning-rod label on every bright new idea that comes out of the sessions, you'll be on the way to effective new management. This new style is a "Zen" approach (but don't give it that label) that lets real collaboration come into the place that is supposed to be all about healing--the health care organization. From "never call it anything" to "stay with them until they get it," ideas on how to be a Zen manager are presented, with the ultimate goal of truly partnering with physicians and infusing them with a desire to move beyond the frustration and disenchantment they are feeling.     

Serf or citizen: physician status and organizational structure

For more than a decade, dynamic changes in the health care industry have created new organizations for physicians. The major change for physicians has not been the organization itself, but the principles by which it is governed. This fundamental shift is studied with its impact on physicians, by analogy, becoming more like serfs or more like citizens. A review of the general organizational direction and results of non-physician health care organizations is made followed by the statistical trends of physician groups. Historical comparisons of non-health care industries are made with current organizational choices of physicians and physician groups. Observations of physician decisions are made identifying the direction they send physician status along the continuum from serf to citizen. Physicians are unknowingly making decisions regarding the principles by which they will be governed in new organizations. The choices they are making give them less autonomy and less opportunity to make future choices. The seductive invitation to spend less time in administrative matters and more time practicing medicine is a siren's call that will diminish the status of physicians and the autonomy by which medicine is practiced.     

中国人的脸面观及其对消费者解读奢侈品广告的影响研究

本研究从心理学视角的面子定义出发,通过运用探索性因子分析、验证性因子分析开发了面子需要量表并探索了其内涵。研究发现,面子需要包涵了以道德型面子需要为主的"脸需要",以及涵盖了能力、地位和社会关系等意义更为广泛的"面需要"。在此基础上,本研究比较了在加入不同面子需要内涵之后的三种广告情境下奢侈品购买意向的差异。结果发现,在广告中加入品牌的正面道德信息,会提高消费者购买该品牌的意向。此外,本研究运用ANOVA分析发现,与"脸需要"相比,"面需要"与奢侈品购买意向的关系表现得更为复杂。在管理启示中,本研究讨论了西方国家奢侈品道德化消费趋势的出现及其对中国市场的启示。     

The managed care world order. The revolution is here

What are the belief clashes caused by the shift from a fee-for-service medical setting to a managed care environment? Right now, most physicians are enculturated in the old world order that emphasizes physician autonomy, control, security, and specialness. Physicians feel squeezed--by third-party payers wanting to be involved in the decision-making process of care delivery and by a new focus on teams versus the captain of the ship role. When traditional expectations clash with a changing reality, most people feel stressed. Physicians are no exception. If physicians have clear and realistic expectations, they can better cope with the uncertainties they face. And, the only realistic expectation in the medical profession is increasing uncertainty. Here are 10 predictions of what is happening in the health care industry--a list of the belief clashes that are so unsettling to those practicing medicine.     

Equity, equity, that's our cry. Interview by Richard L. Reece.

On February 11, 1999, Richard L. Reece, MD, interviewed J.D. Kleinke to talk about his new book entitled Bleeding Edge: The Business of Health Care in the New Century. A medical economist and author living in Denver, Kleinke advocates a true partnership between hospitals and physicians--a marriage with both parties contributing equally to the relationship. He believes that "physicians and people who are running the administrative infrastructures of hospitals and other facilities need to recognize that they are equal partners in a death struggle against the insurers for ultimate control of the premium and the consumer." Though physicians are sure to balk at the suggestion that they become "captive" to the hospital, Kleinke explains that, "captivity is a necessary condition before they can work functionally together and take on managed care and contract directly with consumers, employers, and the government." Kleinke discusses five trends that he explores in his book: risk assumption, consumerism, consolidation, integration, and industralization.     

Getting started as a physician executive

In clinical practice, technical skills often outweigh interpersonal and leadership skills as success factors--you can be a great doctor and a so-so person. But the reverse seems to be true in the physician executive role; it is precisely the intangible leadership skills that contribute to and determine potential success. And they can be tough to master, especially when you focus on them for the first time, partway through an already-successful career. Practicing leadership is like practicing medicine. It's not just a matter of learning some new things--if it were only that, physicians are known to be excellent learners. Nor is it just a matter of determination or application--this is not a battle that sweat and effort alone can win. Most physicians will want to "try on" the executive role before making strategic moves in that direction. But be clear about what you want to get out of any project or activity before you jump in. If you're seeking a management degree, the best approach is to tie together developing your technical and interpersonal skills, as well as the formal credentials.