CORR Insights®: Decision-making in Orthopaedic Oncology: Does Cognitive Bias Affect a Virtual Patient's Choice Between Limb Salvage and Amputation?

Where Are We Now?

Cognitive bias, defined as a “psychological tendencies to process information in predictable patterns that result in deviations from rational decision making” [8], is well-recognized in almost all medical subspecialties [2]. But only recently have researchers examined how cognitive bias affects patient decision making [8, 10], and more specifically, how it affects the patient decision-making process in orthopaedic surgery [1, 3].

In the current study, Gurich and colleagues [3] examined the effect of physicians introducing cognitive bias into a simulated preoperative discussion with patients deciding between amputation and limb-salvage surgery for the treatment of bone sarcomas. The authors found that more people chose amputation when physicians presented the intervention as a way of avoiding loss of function compared to presenting limb salvage as a way of gaining function (framing bias). Patients exposed to affect (influence of emotional states) or bandwagon bias (influence of other individual choices) by physicians were no more likely to choose amputation compared to those who were not exposed to these biases. The authors found that older patients were more likely to choose limb salvage when they were exposed to framing bias, but a respondent who was employed in the healthcare industry was more likely to choose amputation when exposed to framing (influence of how the information is presented) and bandwagon bias [3].

Where Do We Need To Go?

Patients often come to the office after having done considerable research on their own; in light of this, orthopaedic surgeons need to be sensitive to patients’ desires for greater autonomy—or at least greater participation—in the decisions that affect their bodies. The era of the paternalistic physician is (or should be) behind us. In order to be more effective in this environment, physicians need to learn more about the kinds of cognitive biases that patients and physicians alike carry into the examination room. This is a relatively recent area of research inquiry, and major gaps in our knowledge remain.

How Do We Get There?

Researchers should perform studies with methodologies similar to the current paper to determine other biases that could influence the decision-making process for patients with orthopaedic tumors. In particular, it seems important to determine what sorts of bias are most influential in the decision-making process for patients with orthopaedic tumors, how providers might be made more aware of them, and whether recognition of these biases is sufficient to mitigate their influence.

One way to mitigate the influence of cognitive biases is through shared decision-making [5]. Numerous tools are available to help providers engage their patients in a shared decision-making model [6]. For example, the American Board of Internal Medicine developed the “Choosing Wisely” campaign to promote communication between physicians and their patients on topics ranging from treatment options to medical costs. By focusing on these important issues, patients will feel comfortable playing a key role in the shared decision-making process and can confidently “choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary” [7].

Although their perceptions of the shared decision-making process vary [9], one study found that patients from a variety of different backgrounds want to be involved in medical decisions, particularly for serious medical issues [11]. As the authors of the current study show, it is important not only to present a choice between limb salvage and amputation, but also to provide information about all reasonable limb-salvage options, their potential outcomes, as well as survivorship results for each approach according to the type of tumor being treated.

In her recent Virtue Ethics in a Value-driven World column, Casey Humbyrd MD noted that physicians must respect the autonomy of patients without conditions or judgement [4]. Although it is not easy to do, as none of us ever will be fully aware of our biases (that is the very definition of the term “unconscious” bias), I believe Dr Humbyrd’s suggestion represents an excellent aspirational standard for all of us.