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  • 1.  Heuristics in health care

    Posted 10-18-2021 18:58

    A fascinating study in this week's "Science" magazine was able to demonstrate how heuristics (in this case the 'win/stay vs lose/switch' heuristic) contributed to adverse outcomes in delivering babies. (See Singh article, attached). 

     

    The editorial that accompanied this by Li and Colby makes the more general point that we can do better ....:  "It is time to acknowledge the prevalence of heuristics and decision biases in clinical practice and to view these patterns as predictably human instead of blaming individual doctors. Only then can we start helping doctors improve clinical decisions and, as a result, the health of the public"

     

      Mark

     

    Mark L Graber, MD FACP

    Founder and President Emeritus, SIDM

    Professor Emeritus, Stony Brook University, NY

    Cell      919 667-8585

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  • 2.  RE: Heuristics in health care

    Posted 10-19-2021 16:33
      |   view attached
    Agreed. A great paper. Makes you wonder how many covert heuristics are in operation out there (Cousens had an interesting one too on the representative heuristic which was similarly revealed through an analysis of big data - attached). The editorial made some helpful points too on how we should respond.
    Pat



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    Paper - Coussens Behaving discretly 2018.pdf   1.96 MB 1 version
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  • 3.  RE: Heuristics in health care

    Posted 10-19-2021 16:43
    Thought provoking and humbling articles.  What becomes clear is how very much we have to learn and how cautious we need to be in ascribing blame.  I appreciate the quote: "It is time to acknowledge the prevalence of heuristics and decision biases in clinical practice and to view these patterns as predictably human instead of blaming individual doctors. Only then can we start helping doctors improve clinical decisions and, as a result, the health of the public"  but it takes me back to the  nagging question: HOW do we help busy, dedicated doctors working in poorly designed systems  improve clinical decisions?   

     



    ------------------------------
    Christine Goeschel ScD RN
    MedStar Institute for Quality & Safety (MIQS)
    Professor of Medicine,Georgetown University
    chris.a.goeschel@medstar.net
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    Original Message


  • 4.  RE: Heuristics in health care

    Posted 10-19-2021 23:48

    I am sorry Mark but as a senior obstetrician and maternal fetal medicine (high risk pregnancy) specialist (and one of the few american Obstetricians who regularly support and participate in SIDM), I cant let this article slide by in the SIDM listserve without a wry chuckle and a shake of my head as to the methodology and conclusions...

    Mark Twain famously said "there are three types of lies.... lies, damn lies and statistics"

    this article once again elegantly shows that an excel spread sheet and fancy software does not make you " smarter than a fifth grader" to quote the TV show

    I wont go into detail about how much this article pained me to read except to say that people outside of one discipline should not, as a general rule, try to figure out why people in a different discipline "do what they do" as they can never fully understand all the nuanced decision-making within that second discipline

    Although there is an element of truth to what the authors claim, it strains credulity to seriously buy into their overly simplistic hypothesis and highly convoluted math (large sample sizes and mathematical gymnastics can unfortunately at times lead us astray...)

    I could easily rattle off a dozen or more confounding variables that their model did not adequately account for (definitional, attributional, documentation, temporal, causational, intent, etc etc etc) but I didn't write this response as part of a journal club, I am simply dismayed that this was published in the journal "science" and that honest and well-intentioned policy analysts and leaders such as yourself were attracted to it

    perhaps I will muster the strength to write an appropriate "letter to the authors" to critique their article in the appropriate forum....

    there is no doubt in any of our minds that allllllll clinicians need to improve their critical decision making processes and improve their clinical reasoning skills; however, this paper does little to support that effort

    we need better research and science than this to help move the SIDM initiatives forward !!!

    just saying.....

    respectfully,

    Tom

    Thomas Westover
    Assoc Professor OBGYN and MFM Cooper Medical School
    Chief MFM Capital Health
    Chair New Jersey section American College of Obgyn




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  • 5.  RE: Heuristics in health care

    Posted 10-21-2021 03:29
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    https://doramasmp4.me/



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    Ajmal Ali
    Apk
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  • 6.  RE: Heuristics in health care

    Posted 10-25-2021 12:37

    While I'm no obstetrician, I share some of Dr. Westover's concerns. Additionally, I think the following are not addressed by the author and query why this was published in Health Economics rather than in an obstetrical journal, quality and safety journal, etc (most likely because her U Mass web page indicates she's a professor of economics with no visible health care decision-making experience).

     

    1. Overpowered leading to Type 1 Error. With so many cases there may be a trend that is statistically significant but clinically irrelevant.
    2. Underlying likelihood of delivery mode: Fig 1 shows an increase in likelihood of vaginal delivery after complications of caesarean in prior patient but, unless I missed it, author does not account for underlying likelihood of vaginal delivery in next patient that would be expected as vaginal deliveries are generally more common than c-sections.
      1. If there's a statistician that cares to respond, there would be fewer patients with more and more complications so wouldn't that falsely elevate the likelihood of a subsequent vaginal delivery?
    3. I find the general premise that the choice to proceed to c-section in one patient based on complications of no c-section in a prior patient a little tough to swallow from a cognitive psychology perspective.  I concede it is likely that we calibrate our practice, for better or worse, based on the outcomes of care provided to previous patients. However, the win-stay/lose-shift heuristic as a driver of the choice of delivery mode is an overly simplistic explanation of how a recent case influences our choices with such major decisions
      1. Love to hear from the cognitive psychologists about their thoughts on this premise of the attached paper.

     

     

    Joe Grubenhoff, MD, MSCS (he/him/his) | Associate Professor of Pediatrics 

    Section of Emergency Medicine | University of Colorado

    Medical Director – Diagnostic Safety Program

    Children's Hospital Colorado

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  • 7.  RE: Heuristics in health care

    Posted 11-04-2021 10:55
     I have looked at the Supplementary Materials in the Singh paper on heuristics in the delivery room and learn from Table S3 that 18626 current patients were seen following Cesarean mode complications in prior patients and 45297 current patients were seen following vaginal mode complications in prior patients. As the probability of making a switch in the former set of patients is 3.4 percent and it is 3.6 percent in the latter set, the total number of current patients in whom a switch is likely to occur following delivery complications in prior patients is (3.4 percent of 18626) + (3.6 percent of 45297) or 2164. The switches  in these 2164 patients are made by 231 physicians in 21 years, so that one physician will, on average, make a switch in one patient only every 28 months! This extremely low frequency of switching in patients far apart in time by a physician in practice is not likely, in my view, for the heuristic of win-stay/lose-shift to play a significant role in obstetric care of these patients.
    Bimal
    Salem Hospital/Mass General Brigham
    Salem, MA 01970
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  • 8.  RE: Heuristics in health care

    Posted 10-21-2021 11:07
    I have looked carefully at the attached Singh article and the editorial. Here are my comments on them.
    1.The author as well as the two editorial commentators are healthcare economists affiliated with business schools. They have no experience in practice of medicine or in practice of ob-gyn.
    2.  The statement made by the author, "Lack of high quality evidence to guide the central physician decision (i.e. when to perform a Caesarean or a vaginal delivery)" does not have any reference. This statement is incorrect as information about indications for C-section are easily available in any ob-gyn textbook or on Uptodate.
    3. The total number of deliveries out of 86,000 deliveries in which a switch was made (from vaginal to C-section or vice versa) is not mentioned in the article. This number is 3066 as I learn from an interview in the online magazine, (The Conversation) given by the author recently. This means each of the 231 physicians makes about 13 switches in 21 years on average (obtained by dividing 3066 by 231).
    4. This means each physician makes a switch on average every 18 to 19 months (obtained by dividing 21 years by 13). The elapsed time between the prior patient with complications and the current patient in whom the switch is made is not given in the article. Is it one day, one week, one month, one year or more? I suspect this elapsed time is probably long as only one switch is being made every 18 to 19 months.
    5.I need to know more clinical information about patients in whom the switch was made. I suspect the switch was made because it was required due to a patient's clinical status. For example, if the prior patient had a complication during vaginal delivery, it is possible the subsequent patient had a complication during vaginal delivery as well such as fetal distress which required a C-section. So this switch would be entirely appropriate. I do not find the explanation given by the author in ruling out patient factors being responsible for the switch to be satisfactory.
    6. In my view, what would be a good way to study the influence of heuristics would be to study the medical records of say about 25 patients who had a delivery complication and the records of 25 subsequent patients taken care of by the same physician and note if the physician  made a switch and document the reason for the switch in each patient.
    7. In the outcomes, it is not clear what the maternal/neonatal mortality is due to the switch. I should be very low, I believe, but in the Conversation interview, the author says the switch can cause death!
    8.I wonder if this paper was reviewed by a subject matter reviewer, that is, by an ob-gyn specialist, before it was accepted By Science. I am frankly surprised this paper was accepted by Science, which is one of the two leading general science journals in the world (the other being Nature).
    9.Due to the eminence of Science, this article is bound to be picked up by the media and all sorts of erroneous news circulated about risk of delivery due to heuristics.
    10.I wish, the American Ob-Gyn Society sends a strong rebuttal to this article to Science.

    Bimal

    Bimal Jain MD
    Mass General Brigham/Salem Hospital
    Salem MA 01970.




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  • 9.  RE: Heuristics in health care

    Posted 10-24-2021 12:16
    I have looked at the Singh paper on heuristics again and made some calculations and reached certain conclusions as follow:
    1.This study is conducted in 86,345 deliveries over 21 years by 231 physicians in 2 hospitals.
    2  I find from Table S3 in Supplementary Materials that complications occurred in 63,923 of these deliveries with a complication rate of 74 percent. This rate seems to be high as I find the complication rate to be 8 percent from an online search.
    3. Therefore switch in delivery mode in a patient following a complication in a prior patient was studied in 86,345 - 63,923, that is in 22,422 deliveries.
     4. As the switch rate is 3.5 percent, this switch is likely to occur in 3.5 percent of 22,422 patients or in 785 patients.
      5. Thus each of the 231 physicians makes 3.4 switches (785 divided by 231) in 21 years.
      6.  Thus each physician makes one switch every 6 years (21 divided by 3.4).
       7. This very, very low switch rate is obviously insignificant clinically and does not support the presence of a win-loss heuristic. We can reach the same conclusion more directly by noting that the switch does not occur in 96.5 percent deliveries following delivery complications in prior patients. That is to say no switch is made in overwhelming majority of patients.
        8. This very low switch rate of 3.5 percent achieves statistical significance with a p value less than 0.05 due to the very large data set of 22,242 deliveries in which it was calculated. That a trivial small change may lead to statistical significance if the sample size is large is well known.
         9. To me, this paper is an example of data dredging or p hacking in which large data sets are examined and trivial small changes identified which are statistically significant but have no clinical importance. Data dredging has been beautifully discussed by Deborah Mayo in her marvelous book Statistical Inference as Severe Testing.
         10. It would be great if Ob Gyn members of SIDM comment on this paper.


    Bimal
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