Human Development and Family Studies Human Development and Family Studies Publications

4-2008 Framing effect debiasing in medical decision making Sammy Almashat West Virginia University

Brian Ayotte Veterans Affairs

Barry Edelstein West Virginia University

Jennifer Margrett Iowa State University, [email protected]

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Abstract

Objective Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts. The present study investigated the effects of a debiasing procedure designed to prevent the framing effect for young adults who made decisions based on hypothetical medical decision-making vignettes.

Methods The debiasing technique involved participants listing advantages and disadvantages of each treatment prior to making a choice. One hundred and two undergraduate students read a set of three medical treatment vignettes that presented information in terms of different outcome probabilities under either debiasing or control conditions.

Results The framing effect was demonstrated by the control group in two of the three vignettes. The debiasing group successfully avoided the framing effect for both of these vignettes.

Conclusion These results further support previous findings of the framing effect as well as an effective debiasing technique. This study improved upon previous framing debiasing studies by including a control group and personal medical scenarios, as well as demonstrating debiasing in a framing condition in which the framing effect was demonstrated without a debiasing procedure.

Practice implications The findings suggest a relatively simple manipulation may circumvent the use of decision-making heuristics in patients.

Keywords Framing effect, Decision bias, Debiasing intervention, Medical decision making, Treatment choice

Disciplines Gerontology

Comments This article is published as Almashat, Sammy, Brian Ayotte, Barry Edelstein, and Jennifer Margrett. "Framing effect debiasing in medical decision making." Patient education and counseling 71, no. 1 (2008): 102-107. doi: 10.1016/j.pec.2007.11.004. Posted with permission.

This article is available at Iowa State University Digital Repository: http://lib.dr.iastate.edu/hdfs_pubs/64 Rights Works produced by employees of the U.S. Government as part of their official duties are not copyrighted within the U.S. The onc tent of this document is not copyrighted.

This article is available at Iowa State University Digital Repository: http://lib.dr.iastate.edu/hdfs_pubs/64 Patient Education and Counseling 71 (2008) 102–107 www.elsevier.com/locate/pateducou

Framing effect debiasing in medical decision making Sammy Almashat a,*, Brian Ayotte b, Barry Edelstein c, Jennifer Margrett d a West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, P.O. Box 9100, Morgantown, WV 26506-9100, United States b Center for Health Services Research in Primary Care, Durham, VAMC, United States c West Virginia University Department of Psychology, United States d Iowa State University Department of Human Development and Family Studies, United States Received 10 June 2007; received in revised form 31 October 2007; accepted 5 November 2007

Abstract Objective: Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts. The present study investigated the effects of a debiasing procedure designed to prevent the framing effect for young adults who made decisions based on hypothetical medical decision-making vignettes. Methods: The debiasing technique involved participants listing advantages and disadvantages of each treatment prior to making a choice. One hundred and two undergraduate students read a set of three medical treatment vignettes that presented information in terms of different outcome probabilities under either debiasing or control conditions. Results: The framing effect was demonstrated by the control group in two of the three vignettes. The debiasing group successfully avoided the framing effect for both of these vignettes. Conclusion: These results further support previous findings of the framing effect as well as an effective debiasing technique. This study improved upon previous framing debiasing studies by including a control group and personal medical scenarios, as well as demonstrating debiasing in a framing condition in which the framing effect was demonstrated without a debiasing procedure. Practice implications: The findings suggest a relatively simple manipulation may circumvent the use of decision-making heuristics in patients. # 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Framing effect; Decision bias; Debiasing intervention; Medical decision making; Treatment choice

1. Introduction regarding life-threatening diseases can be influenced by the way in which the medical information is framed [11].Thatis, There is considerable evidence that we often make irrational different medical decisions are made on the basis of the same or biased decisions [1,2] and that several factors can contribute medical information. Several studies have examined the to such decisions. One of these factors is the way in which the framing effect in the context of medical decision making decision options are framed [3]. There is a significant body of [10,12–18]. The results of these studies suggest that the framing research demonstrating that people often make decisions based effect can be reliably produced in the context of medical on how the expected outcome is framed [4]. This phenomenon, decision making, although the conditions under which this termed the framing effect, was first characterized in the effect has been demonstrated varies from study to study. The prospect theory [5]. The framing effect has been the object of failure to use the same scenarios and outcome probability numerous studies conducted in a variety of contexts [6,7], formats across studies tends to preclude conclusions regarding including, for example, financial decisions [8], taxes [9], and the maximal conditions for the demonstration of framing. medical decisions [10]. Demonstrations of the framing effect with medical decisions The framing effect in medical decision making is cast doubt on whether patients are making rational or optimal particularly troubling, as it often reveals that decisions decisions. The fact that individuals make different decisions based on varied presentation of the same information (e.g., outcome probabilities, survival versus mortality) suggests at least biased, if not non-optimal, decision making [10]. If we are * Corresponding author at: 1340 Riddle Avenue, Morgantown, WV 26505, United States. Tel.: +1 304 433 2226; fax: +1 304 599 9012. to encourage unbiased optimal decision making, we must find E-mail address: [email protected] (S. Almashat). methods for reducing decisional biases such as the framing

0738-3991/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2007.11.004 S. Almashat et al. / Patient Education and Counseling 71 (2008) 102–107 103 effect. Unfortunately, the simple technique of informing people personal medical problem, making the decision much less of a particular bias (e.g., framing effect) and then imploring personally relevant. them not to be influenced by the bias has proven ‘‘absolutely Though the debiasing studies described above were worthless’’ ([19], p. 326). effective in demonstrating the effects of a debiasing Some researchers [12,20–22] have utilized other methods procedure, all of them employed the Asian disease problem. for circumventing the framing effect, including having The use of this classic problem is commendable, as it permits individuals provide rationales for their decisions. This approach one to compare results across studies. However, this problem hypothetically forces individuals to consider carefully all the scenario is considerably less relevant for the investigation of alternatives and reduces the likelihood of the use of heuristics how people make personal decisions, such as choosing (i.e., learned cognitive ‘‘shortcuts’’) in the decision-making medical treatments. In fact, findings using the Asian disease process. In other words, providing a rationale for decisions problem are often contrary to findings related to medical should, theoretically, result in participants making their scenarios (i.e., participants viewing the Asian disease problem decisions on the basis of the concrete aspects of decision tend to be more risky in negatively framed problems, whereas situations as presented rather than relying on prior experience participants viewing medical scenarios tend to be more risky or heuristics [23]. in positively framed problems). Kim et al. [12] addressed this The effect of requesting that participants provide a rationale void in the literature in part by studying debiasing using two after making a decision has been examined previously in the scenarios, a ‘‘fatal disease’’ scenario [24] and a cancer context of seven decision problems, including the original scenario [10], with younger and older adults. The findings Asian disease problem and six similar problems [20]. Using a indicated that the framing effect was demonstrated in the older within-subjects design, this research varied the degree of the adult population, but not with younger adults. The framing risk and whether a decision rationale was requested. Both effect was avoided for both scenarios requesting that factors influenced the size of the framing effect. The framing participants provide rationales for their decisions. As with effect was found only when a rationale was not requested. the previously described studies [20,21], Kim and colleagues Unfortunately, the absence of a control condition with employed no suitable control for the cognitive activities or the comparable activities and cognitive demands, along with the passageoftimethatwereassociated with the debiasing confounds associated with each participant experiencing all of procedures. In addition, no framing effect was demonstrated the conditions, precludes definitive conclusions regarding the within the group without the debiasing procedure, thus making effects of the independent variables. the argument that the debiasing procedure was successful, Siek and Yates [21], in a partial replication of the above difficult to support. Overall, the initial absence of the framing study [20], utilized a between-subjects design with the classic effect and the absence of a control group preclude firm Asian disease problem to avoid possible confounds associated conclusions regarding the efficacy of their debiasing with a within-subjects design. The results of this partial procedure. replication were consistent with those of the previous study. In summary, previous studies of framing using medical Participants exposed to a survival frame (i.e., the likelihood of scenarios have consistently demonstrated the strength of the surviving a certain procedure) chose the less risky option more framing effect; however, the framing format with which the often than those exposed to a mortality frame (i.e., the effect has been demonstrated has varied across studies. likelihood of dying from the same procedure). This study also Attempts to avoid the framing effect have been effective, but demonstrated the effectiveness of a debiasing effect in which virtually all of these studies have used scenarios that did not participants provided rationales for their decisions following involve personal medical decisions. In the case that personal their choices. It is noteworthy that there was no alternative task medical decision scenarios were used [12], methodological for the control participants in this study, raising the question of shortcomings precluded firm conclusions. In addition, many whether it was the consideration of alternatives that resulted in studies have used repeated-measures designs, which may not be the debiasing or the extra time the participants took in making a relevant in ‘‘real-world’’ medical decision making (i.e., patients decision. are likely presented with information in one format, not Takemura [22] obtained a similar debiasing effect of the multiple formats). Finally, many of the studies have not decision justification requirement with college students using a employed a control group, thus making the interpretation of the between-groups design and the classic Asian disease problem. efficacy of the debiasing technique difficult. The current study The participants received a low or high elaboration (i.e., degree was designed to address these potential methodological of required decision justification) instruction. Participants in shortcomings in debiasing research by: (a) employing a control the low elaboration condition demonstrated the framing effect, group that engaged in a cognitive task that lasted approximately whereas those in the high elaboration condition did not. the same amount of time as the debiasing procedure, (b) using a Although this study utilized a control group, the low- between-subjects design, and (c) using a personal medical elaboration group was instructed only to choose an option decision scenario. without completing an alternative task, which again leaves The present study examined the effects of a debiasing open the possibility that the extra time that the high- procedure on three different medical decisions involving cancer elaboration group had in making a decision resulted in a treatments. Participants in the control and experimental decreased framing effect. In addition, this study did not use a conditions were presented with three medical decision-making 104 S. Almashat et al. / Patient Education and Counseling 71 (2008) 102–107 vignettes that varied with regard to the statement of potential ’’of 100 patients having surgery, 90 patients live until the end outcome probabilities that were manipulated to achieve a of treatment, 78 patients live through treatment but less than 1 framing effect. The experimental group received questions that year, 44 patients live for 1–5 years, and 10 patients live required them to list the advantages and disadvantages of each longer than 5 years.’’ Finally, for the life expectancy format, option as well as their rationale for making a decision, which participants were told the long-term survival rate of patients. was intended to preclude the framing effect. The control For example, participants were told that, ‘‘of 100 patients group did not receive the debiasing questions and was asked to having surgery, 90% of the patients live through treatment. answer unrelated questions. It was hypothesized that: (a) the The patients who survive surgery have an average life framing effect would be present in at least one of the decision expectancy of 6.8 years’’ (see Appendix A for vignette vignettes in the control group and (b) the participants receiving introduction and example mortality frames for each treatment the debiasing questions would not display a framing effect outcome format). in those vignettes in which the control group had displayed the effect. 2.2.3. Decision-making questionnaires In addition to the vignettes, the experimental group was 2. Methods given a debiasing questionnaire containing five questions. The five questions were identical for each vignette, thus each 2.1. Participants participant received 15 questions (5 questions  3 vignettes). The questions required the participant to list the advantages and A sample of 107 undergraduate students was recruited disadvantages of each treatment, and the information that was from psychology courses and offered extra course credit for most relevant in making his or her treatment choice. The participation. Two selection criteria were employed: (a) purpose of this questionnaire was similar to that used in participants could not have personal experience with making previous research [20], in which a rationale was requested to cancer-related treatment decisions and (b) participants were avoid the framing effect. To control for testing duration and between the ages of 18 and 25. Of the sample, eighty (74%) of cognitive effort, the control group received a questionnaire the participants were women, and eighty-nine (83%) were containing information related to stress, dental hygiene, and White. Participants were randomly assigned to the control physical fitness. More specifically, the questions addressed the group or the experimental group. Five participants’ data participant’s status with regard to each topic and his or her were eliminated due to incomplete responses (n =3) or willingness to make changes to improve in these areas. The falling outside of the eligible age range (n = 2) resulting in a questionnaire contained no information related to any of the final sample size of 102 participants (M = 19.77 years, vignettes that could have potentially affected the control S.D. = 1.46). group’s treatment choice. Questionnaires were completed between the presentation of the vignettes and elicitation of 2.2. Materials treatment choices. There was no appreciable difference between the control group and experimental group in the 2.2.1. Demographic questionnaire amount of time spent on the questionnaires. A demographic questionnaire elicited information, includ- ing age, sex, and whether the participant had ever known 2.3. Procedure someone close who had had cancer. Participants were randomly assigned to the control group 2.2.2. Vignettes (n = 54) or the experimental group (n = 48). Next, participants The bases for decisions included a set of three vignettes were presented with the written consent form, three vignettes containing information about treatments for lung cancer (along with the debiasing questionnaire for the experimental [16,18]. Each vignette consisted of an imaginary scenario group and a control questionnaire for the control group), and the depicting a diagnosis of cancer followed by two treatment demographic questionnaire. The materials were presented to options, surgery or radiation. The outcomes of each treatment participants in a university classroom in groups of 5–10. option were framed as either the probability of surviving Written instructions were included with each packet of (survival frame) or the probability of dying (mortality frame) materials. following each treatment. Treatment outcomes were pre- Participants were instructed to: (a) read the background sented in three different ways. In the cumulative probability information on the first page; (b) read the first vignette, with format, the cumulative number of people who have died/ outcome information stated in terms of cumulative probability survived up to a certain time period was noted. For example, (CP), interval probability (IP), or life expectancy (LE); (c) participants were told that, ’’of 100 patients having radiation answer the questions (control or debiasing); and (d) choose a therapy, all patients live through the treatment, 77 patients treatment. They were instructed to repeat this same procedure liveformorethan1year,and22patientsliveformorethan5 with the second and third vignettes. The presentation order for years.‘‘ In the interval probability format, the number of the three vignettes was counterbalanced, with the six orders people who are said to die/survive during each specified time matched with participants on a random basis, with between 12 period was noted. For example, participants were told that, and 20 participants receiving each presentation order. Analyses S. Almashat et al. / Patient Education and Counseling 71 (2008) 102–107 105

Table 1 Logistic regression analyses examining debiasing intervention in CP and IP vignettes Variable Cumulative probability vignette Interval probability vignette B S.E. OR 95% CI B S.E. OR 95% CI Step 1 Gender À0.55 0.55 0.58 0.20–1.69 À1.11* 0.55 0.33 0.11–0.96 Age 0.25 0.18 1.28 0.91–1.80 0.28 0.17 1.32 0.95–1.84 Step 2 Frame 0.99 0.61 2.68 0.81–8.89 0.67 0.61 1.93 0.58–6.40 Condition À1.98* 0.88 0.14 0.03–0.78 À1.44* 0.73 0.24 0.06–0.99 Step 3 Frame  Condition 2.51* 10.80 12.29 1.49–101.12 1.98* 0.96 7.27 1.11–47.51 Note: A significant Frame  Condition interaction indicates successful debiasing of the framing effect. * p < .05. revealed no order effects so this variable was not included in Frame  Condition interaction would indicate a successful any further analyses. debiasing intervention. Overall, the results indicated that the debiasing intervention 3. Results was successful. For the CP vignette, the odds ratio for selecting surgery (risky choice) in the control group was 0.30 (95% CI, A series of chi-square analyses were performed to determine 0.17–0.54) for the mortality frame, and 7.64 (95% CI, 2.01– if a framing effect was present. It should be noted that debiasing 29.01) for the survival frame. In other words, control could only be tested when the control group displayed a participants were more likely to select the risky choice in significant framing effect. A nonsignificant difference between the survival frame and less likely to select the risky choice in the the control and experimental group would indicate that a mortality frame. In the experimental group, the odds ratio for debiasing technique was not needed. If the framing effect was selecting surgery (risky choice) in the control group was 0.60 present (i.e., there was a significant Frame  Condition chi- (95% CI, 0.34–1.08) for the mortality frame, and 1.69 (95% CI, square value), a follow-up logistic regression was performed to 0.90–3.18) for the survival frame. The 95% confidence intervals determine if the intervention had the desired effect. included 1.0 in the experimental group, indicating successful The first hypothesis was that in the control condition, the debiasing. proportion of participants in the survival wording condition Similar results were found for the IP vignette. The odds ratio who selected surgery would differ from the proportion of for selecting surgery (risky choice) in the control group was participants in the mortality wording condition who selected 0.38 (95% CI, 0.22–0.66) for the mortality frame, and 3.78 surgery in at least one vignette. That is, participants who were (95% CI, 1.51–9.46) for the survival frame. Here again, control given the same outcome information, but framed differently, participants were more likely to select the risky choice in the would make different decisions. To assess the effect of frame on survival frame and less likely to select the risky choice in the treatment choice for the control group, three chi-square mortality frame. In the experimental group, the odds ratio for analyses were run for the three vignettes in the control selecting surgery (risky choice) in the control group was 0.72 condition. Significant chi-square values indicate the presence of (95% CI, 0.41–1.26) for the mortality frame, and 1.41 (95% CI, a framing effect. A significant framing effect was obtained for 0.77–2.57) for the survival frame. Again, in the experimental treatment choice with the CP vignette, x2 (1, n = 54) = 20.53, group, the 95% confidence intervals included 1.0, indicating p < .01, as well as the IP vignette, x2 (1, n = 54) = 13.35, successful debiasing. p < .01. In contrast, no significant effect was obtained for the LE vignette, x2 (1, n = 54) = 0.43, p > .05. Thus, the efficacy of 4. Discussion and conclusion the debiasing technique could only be tested in the CP and IP vignette. 4.1. Discussion The second hypothesis was that in the experimental group, the framing of the information (survival or mortality) would not The overall goal of this study was to investigate whether be significantly related to the likelihood of selecting surgery or the use of a debiasing strategy would prevent a framing effect radiation in the vignettes (i.e., the framing effect would not be in a hypothetical medical treatment situation. This required present). To assess the effects of the intervention, two logistic two steps: (a) the demonstration of a framing effect and (b) regressions were performed (see Table 1). The first step in the the avoidance of this effect following a debiasing interven- regression included age and gender as control variables, the tion. second step entered frame (mortality versus survival) and The finding of a framing effect for the medical scenario condition (control versus experimental), and the third step stated in CP and IP formats in the control group is consistent included the Frame  Condition interaction. A significant with previous research [16,18,20]. The reliable presence of a 106 S. Almashat et al. / Patient Education and Counseling 71 (2008) 102–107 framing effect with CP and IP formats may be due to the analyses and pilot research it is unlikely that the order of relatively higher amount of cognitive processing that is needed presentation had any significant influence on decision out- to comprehend information presented in terms of probabilities comes. [25]. In other words, the information in the cumulative Finally, the decisions that were made by the participants probability vignette, and perhaps the IP vignette, may be less were hypothetical and thus had no ‘‘real’’ consequences. straightforward compared to the life-expectancy information. Evaluating the efficacy of the debiasing technique in applied However, additional research examining the actual decision- settings would provide additional evidence that forced making process when participants are provided with different elaboration helps people avoid the framing effect in actual outcome probabilities is needed. For example, a ‘‘think out medical decisions. loud’’ study could investigate what information is most salient and useful to participants during the decision-making. 4.2. Conclusion As hypothesized, the framing effect was avoided in the experimental condition in the two vignettes for which the The results of this study suggest that a relatively simple framing effect was present in the control group (i.e., the CP and manipulation can lead to the avoidance of the framing effect. IP vignettes). This finding is consistent with previous research The design of this study addressed potential weaknesses in that suggests that elaboration reduces the framing effect [22] previous research by using a between-subject design, an active and is particularly interesting given the robust framing effect control group, and a personally relevant medical decision obtained for cumulative probability outcomes in previous scenario. Taken together, these design components strengthen research [16,18,19]. According to prospect theory [5], the the conclusion that elaboration and justification can pre-empt elaboration component of the decision making process might the framing effect in a medical decision making scenario. The have changed the frame of the vignette and the overall construal results of this study could be applied to ‘‘real-life’’ medical of the problem for individuals who were ‘‘forced’’ to consider decision making by utilizing rational techniques to eliminate the information more deeply [26]. framing and other biases in medical treatment decisions. As There were several limitations of note in this study. The both physicians and patients have been shown to succumb to sample population consisted almost entirely of young, White biases when making medical decisions [27], it is important that college undergraduates who reported themselves in good new techniques be applied to current decision making (47.1%) or excellent (38.5%) health. Young adults may think procedures to ensure that rational treatment choices are made. less about serious health issues than older individuals, and so The findings of this study may be expanded upon and applied so the topic may seem distant and not likely to be a ‘‘real-life’’ that more careful thought is put into seemingly objective situation for them, and may thus be perceived as less relevant. statistics and predictions. Certain decision biases are reduced or eliminated when the problem is made to be more personally relevant [1]. Although some previous research found that there was no difference in 4.3. Practice implications framing effects on the medical scenarios between university students and older adults [16], the effect of age on debiasing of The results of this study have direct implications in health- those framing biases has not been thoroughly explored. Despite care settings. The results suggest that the relatively simple the potentially limited generalizability of this study, the manipulation may circumvent the use of heuristics that might homogeneity of this college-aged sample controlled for a ordinarily be used for making such decisions. Additionally, by number of possible confounds (e.g., health problems, cognitive leading patients to consider all of the relevant information of a ability) that might otherwise influence the presence of the problem, the patient will likely make more informed decisions. framing effect. The current results provide a foundation for By asking patients to consider the consequences of treatments future research that can determine how a relatively simple they may feel more involved in the decision-making process, manipulation might preclude the framing effect in more diverse which may lead to better outcomes, including satisfaction and samples. treatment compliance [28,29]. Finally, given that the framing In addition, only two of the three vignettes could be used to effect was not demonstrated in the life-expectancy vignette, it demonstrate the efficacy of the debiasing technique in the may be beneficial to train care providers to communicate present study because the framing effect was not obtained for outcome information in terms of life-expectancy rather than the third vignette. Thus, the efficacy of the debiasing technique cumulative or interval probabilities. remains unclear when outcomes are presented in ways other I confirm all personal identifiers have been removed or than cumulative or interval probabilities. Future research disguised so the persons described are not identifiable and should address the mechanisms and decision processes that cannot be identified through the details of the story. underlie the decisions participants make under different conditions (e.g., when information is presented in terms of Acknowledgments life expectancy). A third potential limitation was the relatively small number The first two authors contributed equally in this research and of participants in each presentation order, resulting in limited Dr. Ayotte’s efforts, particularly on the final manuscript and the power to detect an order effect. However, based on preliminary statistics, were invaluable. S. Almashat et al. / Patient Education and Counseling 71 (2008) 102–107 107

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