Ilona Fridman

Appropriate Use of Psychology in Patient-Physician Communication: Influencing Wisely.

Contemporary clinical decision making involves a 5-step process: asking clinical questions, finding the evidence, appraising the evidence, making a decision, and evaluating performance.1 Yet in transitioning from the evidence to the decision that performs best, there is a crucial intermediate step that is often overlooked, namely, optimal framing of the physician’s recommendations to the patient. Principles of social psychology could shed light on how to lead conversations with patients, which may help to ensure they make decisions that best meet their true long-term goals. This is especially important in serious illnesses like advanced cancer, when erroneous decisions have the potential to have an adverse impact on the quality of care at the end of life. When discussing late-line chemotherapy in debilitated patients, planning end-of-life care, establishing advance directives, and transitioning to hospice, physicians frequently face a challenge: how to advocate for an option that represents the patient’s least preferable choice but that best meets their long-term goals. Patients’ preferences are influenced by multiple factors that may make their choices deviate from evidence-based recommendations and statistical likelihood. Therefore, it is vital for physicians to have a deeper understanding of the psychological forces that influence patients’ decisions—the quality of patient-physician communication and the ultimate care delivered are at stake. Herein, we outline 3 principles of behavioral psychology that provide insight into how patients’ preferences are influenced. Understanding these principles is important, particularly when eliciting which treatments patients would be willing to tolerate when their diseases critically advance. They are framing effect, availability bias, and affective risk perception (Table). These cognitive missteps can influence patients’ preferences together or separately and can make patients’ judgments biased in either direction, both in favor or against aggressive interventions, when the evidence would suggest doing otherwise, as the following 3 scenarios show.

Adaptive Appraisals of Anxiety Moderate the Association between Cortisol Reactivity and Performance in Salary Negotiations

Prior research suggests that stress can be harmful in high-stakes contexts such as negotiations. However, few studies actually measure stress physiologically during negotiations, nor do studies offer interventions to combat the potential negative effects of heightened physiological responses in negotiation contexts. In the current research, we offer evidence that the negative effects of cortisol increases on negotiation performance can be reduced through a reappraisal of anxiety manipulation. We experimentally induced adaptive appraisals by randomly assigning 97 male and female participants to receive either instructions to appraise their anxiety as beneficial to the negotiation or no specific instructions on how to appraise the situation. We also measured participants’ cortisol responses prior to and following the negotiation. Results revealed that cortisol increases were positively related to negotiation performance for participants who were told to view anxiety as beneficial, and not detrimental, for negotiation performance (appraisal condition). In contrast, cortisol increases were negatively related to negotiation performance for participants given no instructions on appraising their anxiety (control condition). These findings offer a means through which to combat the potentially deleterious effects of heightened cortisol reactivity on negotiation outcomes.

The Physician Recommendation Coding System (PhyReCS): A Reliable and Valid Method to Quantify the Strength of Physician Recommendations During Clinical Encounters.

Background. Physicians’ recommendations affect patients’ treatment choices. However, most research relies on physicians’ or patients’ retrospective reports of recommendations, which offer a limited perspective and have limitations such as recall bias. Objective. To develop a reliable and valid method to measure the strength of physician recommendations using direct observation of clinical encounters. Methods. Clinical encounters (n = 257) were recorded as part of a larger study of prostate cancer decision making. We used an iterative process to create the 5-point Physician Recommendation Coding System (PhyReCS). To determine reliability, research assistants double-coded 50 transcripts. To establish content validity, we used 1-way analyses of variance to determine whether relative treatment recommendation scores differed as a function of which treatment patients received. To establish concurrent validity, we examined whether patients’ perceived treatment recommendations matched our coded recommendations. Results. The PhyReCS was highly reliable (Krippendorf’s alpha = 0.89, 95% CI [0.86, 0.91]). The average relative treatment recommendation score for each treatment was higher for individuals who received that particular treatment. For example, the average relative surgery recommendation score was higher for individuals who received surgery versus radiation (mean difference = 0.98, SE = 0.18, P < 0.001) or active surveillance (mean difference = 1.10, SE = 0.14, P < 0.001). Patients’ perceived recommendations matched coded recommendations 81% of the time. Conclusion. The PhyReCS is a reliable and valid way to capture the strength of physician recommendations. We believe that the PhyReCS would be helpful for other researchers who wish to study physician recommendations, an important part of patient decision making.

Eye-tracking evidence shows that non-fit messaging impacts attention, attitudes and choice

When patients have strong initial attitudes about a medical intervention, they might not be open to learning new information when choosing whether or not to receive the intervention. We aim to show that non-fit messaging (messages framed in a manner that is incongruent with recipients’ motivational orientation) can increase attention to the message content, thereby de-intensifying an initial attitude bias and reducing the influence of this bias on choice. In this study, 196 students received information about the pros and cons of a vaccine, framed in either a fit or non-fit manner with their motivational orientation. The results show that when information was presented in a non-fit (vs. fit) manner, the strength of participants’ initial attitude was reduced. An eye-tracking procedure indicated that participants read information more thoroughly (measured by the average length of fixation time while reading) in the non-fit condition versus fit condition. This average time of fixation mediated the effect of message framing on the strength of people’s attitudes. A reduction in attitude was associated with participants’ ability to recall the given information correctly and make a choice consistent with the provided information. Non-fit messaging increases individuals’ willingness to process information when individuals’ pre-existing attitude biases might otherwise cause them to make uninformed decisions.

Perspectives on using decision-making nudges in physician-patient communications

Patients engaging in shared decision making must weigh the likelihood of positive and negative outcomes and deal with uncertainty and negative emotions in the situations where desirable options might not be available. The use of “nudges,” or communication techniques that influence patients’ choices in a predictable direction, may assist patients in making complex decisions. However, nudging patients may be perceived as inappropriate influence on patients’ choices. We sought to determine whether key stakeholders, physicians, and laypersons without clinical training consider the use of nudges to be ethical and appropriate in medical decision making. Eighty-nine resident-physicians and 336 Mechanical-Turk workers (i.e., non-clinicians) evaluated two hypothetical preference-sensitive situations, in which a patient with advanced cancer chooses between chemotherapy and hospice care. We varied the following: (1) whether or not the patient’s decision was influenced by a mistaken judgment (i.e., decision-making bias) and (2) whether or not the physician used a nudge. Each participant reported the extent to which the communication was ethical, appropriate, and desirable. Both physicians and non-clinicians considered using nudges more positively than not using them, regardless of an initial decision-making bias in patients’ considerations. Decomposing this effect, we found that physicians viewed the nudge that endorsed hospice care more favorably than the nudge that endorsed chemotherapy, while non-clinicians viewed the nudge that endorsed chemotherapy more favorably than the nudge that endorsed hospice care. We discuss implications and propose exploring further physicians’ and patients’ differences in the perception of nudges; the differences may suggest limitations for using nudges in medical decisions.