Are Patients Harmed When Doctors Explain Things too Simply?
The benefits of cognitive disfluency
Posted March 17, 2015
A quick quiz before we start today’s lesson.
What do we call a tree that grows from acorns?
What do we call a funny story?
What sound does a frog make?
What is another word for a cape?
What do we call the white part of an egg?
On that last question, were you tempted to answer “yolk?” If so, you are in good company, because most people give that answer even though the correct answer is “albumen.” People answer yolk—after oak, joke, croak, and cloak—because that’s the fast choice. Primed by rhymes, people provide the wrong answer.
Sometimes fast-thinking is not so good. Which raises an interesting question for physicians trying to help patients navigate important medical decisions: Will they harm patients by explaining things so simply that patients make fast, erroneous choices?
To answer this question, it helps to understand: (1) when and why fast thinking leads to bad decisions, (2) how behavioral scientists have slowed down thinking to improve people’s decisions and (3) what any of this has to do with medical decision-making.
1. When fast is wrong:
In his best-selling book Thinking, Fast and Slow Daniel Kahneman explains that people’s judgments and decisions can be arrived at quickly—through intuitive, low effort, even non-verbal reasoning—or more slowly—through conscious, deliberate, even rule-based reasoning. Ask people to multiply 36 by 17 and the vast majority will resort to (in my case, at least) very slow thinking (“7 times 6 equals 2 carry the 4…”). Ask somebody how many animals of each kind Moses took aboard the ark, however, and most people will quickly and effortlessly say 2, even though the answer is 0. It was Noah, after all, who took animals aboard the ark, not Moses.
Kahneman, a psychologist whose work inspired the field of behavioral economics, made his early reputation documenting a wide array of colorful examples of fast thinking leading people astray. In one study, he and Amos Tversky described a fictional graduate student named Tom W. to people. Tom was really smart but not creative, had a high need for order and clarity, and his writing was dull and mechanical, occasionally enlivened by corny puns and flashes of imagination of the sci-fi type. Stereotypical computer nerd, in other words. Kahneman and Tversky asked people to guess Tom’s field of study. Encouraged by the power of stereotype, people quickly assumed Tom was an engineer or computer programmer. The study took place in the seventies however, when such majors were uncommon fields of study. Slower thinking would have taken account of the far larger percent of students pursuing degrees in the humanities or social sciences, and adjusted their guesses accordingly.
Fast thinking leads people astray when proper judgments and decisions diverge from intuition. When I walk through a doorway, my fast thinking usually works stupendously well. With almost no effort, I turn left or right, and pass through with little risk to life or limb. When I’ve had too much to drink, on the other hand, or when I’m struck by a bout of vertigo, my fast thinking processes are not up to the task and I’d better slow down, unless I want to become overly familiar with the feel of my body smashing into the frame.
2. How slow thinking works:
A series of clever studies have shown that simple techniques to slow down people’s thought processes can prevent intuition from leading them astray. Consider Moses and the ark. Almost 90% of people mistakenly indicate that Moses brought two of each animal on the ark. That error drops down to almost 50%, however, simply by changing the questionnaire, from a simple, clean font to a gray “brushed script” font, a change that makes the sentence slightly harder to read and therefore slows people down.
Or consider Tom W., that prototypical computer nerd who is probably studying the social sciences. When people are asked to furrow their brows while guessing Tom’s major, they are significantly less influenced by fast, stereotypical reasoning. The brow-furrowing exercise simulates mental difficulty, signaling people to exert more mental effort. (For a great review of this disfluency literature, read here.)
3. The right speed for medical decisions:
When it comes to important medical decisions, it would seem that slower is usually better . A woman deciding between mastectomy versus lumpectomy plus radiation—she won’t want to rush into that choice. A man deciding whether to treat his early Multiple Sclerosis with expensive and potentially toxic new drugs versus less expensive but potentially less effective ones—he should take the time to sort things out. A rush to judgment in these circumstances could have a large impact on people’s lives.
If fast thinking is hazardous in these situations, does that mean physicians should intentionally make the choice difficult in order to slow patients down? Does it mean that patient educational materials should be printed in disfluent fonts? My short answer to these questions is: Physicians need to help patients make decisions at the right speed, while simultaneously making it simple and fast for them to understand the information relevant to their choices.
In my research on medical decision making, I have learned that physicians often have a hard time simplifying information for patients in ways that properly engage them in their treatment choices. They use inscrutable medical jargon, even though simpler words would be easy for them to understand. This use of jargon may even be unconsciously encouraged by patients, who rate physicians as more knowledgeable when they use lots of jargon.
By making it hard for patients to understand their choices, physicians are not usually improving medical decisions. For starters, these choices are often hard to make even when they are explained simply and clearly. The errors people make racing through psychological studies (Moses…ark…how tricky…) don’t easily map on to the challenges they face making important medical decisions. In addition, when people are overwhelmed by the complexity of medical choices, they don’t necessarily slow down and rely on systematic, rule-based reasoning. Instead, they opt out of the choice by asking their doctor: “What do you think I should do?”
Good medical communication requires giving patients healthcare information in comprehensible form, while giving them the time to process this information. Clinicians should make the information as simple for patients as possible, without leaving out critical facts. And they should help patients avoid the hazards of fast thinking when possible by delaying decisions so patients have time to absorb decision-relevant information.
Simple but not too simple. Comprehensible, but not so straight forward it prompts fast thinking. This is a daunting communication goal. For physicians to master this task, they not only need to recognize the art of medicine, but also need to embrace the relevance of social science in pointing the way towards better medical practice.
***Previously Published in Forbes***