Incorporating Emotions into Clinical Decision-Making Solutions

Health and emotions are inexorably connected. Anxiety, excitement, grief, confusion, and relief often mark the experiences of illness and recovery, influencing how patients and their loved ones process disease- or treatment-related information. Positive or negative emotional states are associated with a range of health behaviors and outcomes [1–7]. Public health interventions can be designed to drive health behaviors by prompting certain emotions. For instance, campaigns to discourage smoking may involve images or information that ostensibly seek to trigger fear or disgust about smoking-related consequences [8].

Yet there is still remarkably little emphasis on emotions in most clinical decision-making tools and interventions. Instead, existing solutions have tended to target cognition – how people comprehend and act on information about health and disease. For example, clinicians frequently use risk algorithms or calculators to quantify treatment risks for medications (e.g., potential side effects of blood thinners) or procedures (e.g., complications after surgery) and use that information to counsel and make decisions with patients. Decision-making interventions often target cognitive heuristics that can distort perceptions and information processing. The emphasis on cognition also extends to decision aids developed to educate patients and help them process information related to health decisions. For instance, tools that seek to help patients understand cardiovascular disease focus on sharing information from guideline recommendations and using numbers and data visualizations to quantify the risks of heart attack, stroke, or other negative outcomes [9].

Of course, there is nothing wrong with applying tools and interventions to optimize how patients and their clinicians comprehend and think about clinical choices. As physicians, we believe that clinicians and patients should accurately understand risks, benefits, and other features of each option. As behavioral scientists, we believe that cognitive biases should be identified and addressed, and information presented in a de-biased way that accounts for health numeracy, literacy, and educational level. These factors can impede informed decisions, and clear thinking contributes to better choices.

But a potential consequence of heavily targeting cognition is an under-emphasis on emotions – a tendency to work on improving how people think about health care choices without addressing how they feel about them. By systematically presenting, framing, and ensuring comprehension of probabilities and numerical values, decision-making interventions and tools often entrain clinician and patient focus on facts. In contrast, existing solutions do not use a similar approach to elicit, provide reference points, or otherwise guide or respond to patients’ emotions.

Indeed, there has traditionally been less systematic attention paid to the relationships between emotions and decisions in health domains, compared to others [10]. This asymmetry not only leaves the emotional aspects of clinical decisions unmanaged; it also creates a potentially compounding problem, since the processes of providing information via tools or influence decisions via interventions can themselves accentuate already emotionally charged situations. How can clinicians and decision scientists address these dynamics? Several solutions may help.

First, clinicians and scientists should critically evaluate current decision-making conceptual frameworks and strategies, searching for areas where emotions may play a role and where they may have been overlooked in prior work. For instance, in programs to promote physical activity as a health behavior, clinicians and behavioral scientists may adopt a framework that assumes the positive motivational benefits of providing feedback – give patients feedback about their performance (e.g., daily steps, exercise frequency) and poor performance can drive motivation to improve. However, that may be a flawed framework. In reality, patients may have emotional reactions to the feedback that then influence their motivation and behaviors. If performance feedback triggers shame or guilt, those emotions may demotivate individuals and prompt them to disengage from the intended behavior [11]. Similar dynamics could exist for decision-making tools, which could unintentionally trigger emotions that lead to suboptimal choices. The first step in addressing emotions systematically in healthcare is recognizing where and when they may play important roles in driving decisions.

Second, clinicians and scientists can work to fill any identified gaps by drawing on insights from affective science, a field that encompasses the study of emotional elicitation, experience, and emotion-driven behaviors [12]. These insights can then be used to design and test clinical decision-making interventions and tools that combine affective science principles with those from cognitive psychology, behavioral economics, and other decision sciences. One particular benefit of doing so is to generate a more holistic view of how emotions can affect clinical decisions. While negative emotions are often associated with illness, positive emotions can also play important roles in decision-making.

For instance, researchers have tested decision-making interventions that use positive affect induction strategies – including prompts to help individuals recall positive past experiences – to encourage physical activity among patients that had recently undergone cardiac procedures [13]. Such strategies could be incorporated into decision aids that patient use to make health decisions. Positive affect induction may also play a role in how clinicians approach decisions by promoting information integration and reducing bias in ways that improve clinical reasoning [14]. More broadly, affect-oriented strategies should be tested more widely across clinical scenarios and when they demonstrate benefits, incorporated into decision-making tools and interventions.

To be fair, addressing emotions alone is not a panacea. Healthcare decisions can be affected by other influences, such as financial incentives and social norms. Social determinants, access to care, and other structural factors can also affect health behaviors. Promising solutions for addressing emotions must also be incorporated into real-world policy and practice – work that will require input from health system leaders, insurers, technologists, implementation scientists, and others.

Nonetheless, emotions play an undeniable role in how patients work with clinicians to make choices, and it is time for clinical decision-making tools and interventions to more systematically address those realities. Solutions must address how individuals feel, not just how they think.