Oh no! I totally do this! I didn’t even realize I was doing it because I thought I was being totally neutral and unbiased. Well, guess what? I’m not! I teach my patients about X, and I give them a clear definition and explain how it applies to them. Then, I present the pros and cons (because I want to be fair in my presentation). But here’s the thing, it’s mostly my nonverbal cues that show which side I’m on. Now, after reading this article, I realize that when I talk to my patients, my voice goes up and I get louder, when I [pitch] <- pun, the side I favor.
So, now that I’ve been made aware of this, I’m going to be extra careful when talking to my patients. I don’t want to be that pitcher who always finds the tippy corner of the reference box, or the catcher who moves my glove into the strike zone from a nano-cm outside the box.
Thanks for sharing this article! I really enjoyed it, and I found the baseball analogy very interesting.
Thank you! Don’t be too hard on yourself—it’s impossible to be completely unbiased. It sounds like you’re already very thoughtful about your conversations, and your patients are only going to benefit more from your wisdom going forward!
Taken in toto, I think if we said that most of what we do in medicine will provide no benefit to you individually unless you have a shard of metal sticking out of your neck and we’re repairing the artery, it would demoralize the public, even though it would be true.
Great article and I love the sports metaphor! I agree that framing is important for conveying the effects of medications and I think both positive and negative framing helps people understand the potential benefits and harms of treatments. I like NNT and NNH but I find the application to a particular patient is nontrivial as their baseline event risk/rate and duration of treatment is often different than the clinical trial from which the NNT/NNH was derived.
Thanks! I think that is a great perspective regarding NNT/NNH. Just like in baseball, recognition of the limitations of a statistic is necessary for proper application.
To say that someone is wasting their time is not the only interpretation. Given what’s at stake, gambling that you might be the one could be a totally rational decision.
It’s also important to note that NNT requires some sort of target outcome, and that just because you didn’t achieve the target outcome doesn’t mean that you couldn’t possibly have gotten some benefit.
Very well said. The more valuable the outcome, the more it makes sense to gamble on it. That’s why shared decision-making is needed, because the patient should be allowed to decide whether to play.
A helpful thought experiment to illustrate: At what price would you be willing to buy a ticket that had a 1/1000 chance to win a $200M lottery?
It’s a bet you’re very unlikely to win, but the expected value is exceedingly high.
The mirror image argument is also rather unconvincing. “I probably won’t get cancer, so I might as well smoke”. Nominally true, but not a great argument.
Regarding the concluding sentence about "robo-docs," no need to worry about them. Since AI is trained on human decision-making patterns, the training will capture the same framing biases. The only thing that will change is that the same mistakes will be made, except only faster, more efficiently, and with greater confidence!
I loved the article and the baseball metaphor. Framing is something we all do in order to present ourselves and our ideas in the best possible light. In medical practice I usually found myself framing things negatively for patients in order to counterbalance a lot of the pseudoscience and fraud that people get from the media and well-meaning friends and associates.
And we think our caregivers have it easy! Never did I ever think about framing in the baseball nerd sense. Working with addiction was tough to frame sometimes, too, as we are trying to convince those whose brains got hijacked that there’s a better way to live (sober). What a great article, Dr Scott!
The catcher is making relatively small efforts that will combine with the totality of his teammate's actions to the main purpose of winning the game. I think the way to put this scenario in context is that the physician is treating his patient rather than doing a pharmaceutical evaluation.
1. Semaglutide has many other benefits than reduction in CV risk.
2. In the totality of care for CV disease semaglutide is one factor that changes physiologic parameters in a beneficial direction.
I recently wrote my honors these on this topic and one of the interesting things about this from a biomedical ethics standpoint is that these framing biases bring informed consent into question. Since a patient’s consent can be solely dependent upon how the procedure or medication is described, the patient is not actually consenting to the intervention but to the way in which it is described. Hypothetically speaking, there is someone who consented under the survival rate description that would have dissented if given the mortality rate description. Therefore, if consent is dependent on the way in which the procedure is described and not the procedure itself, the patient’s consent might actually be invalid (if we are taking the common view of consent here). Also to note: I am not commenting with any medical expertise so I don’t have much boots on the ground experience here, just some philosophical research. Anyway, I found this article to be very interesting and enjoyed it!
If that doesn’t work you can search it by the title “The Conservative Approach to Informed Consent: The Evidentiary Model and an Antidote to the Problem of Framing Effects in Medical Decision-Making ”
Two issues from the patient perspective: doctor's prefer to do something over nothing (commission bias). They prefer compliant patients (compliance bias - I just invented that term no idea if it is an actual concept in the medical research literature). This creates additional pressures on the patient that the doctor is unaware of, since everyone thinks that only other people have biases.
I can see why Adam decided to share Dr. Scott’s great article before finishing it. Framing is particularly powerful in pregnancy care, especially surrounding birth. Things are moving fast and many mothers can be easily talked into a physician’s (or labor nurse’s) preferred obstetrical intervention. As a maternal-fetal medicine physician I advocate for OB care that is not “too much, too soon nor too little, too late”. In the U.S. we are too often guilty of the former.
Framing is yet another example of why it is important to have a consistent source of primary care. My patients, through years of talking with me, have noticed how I frame things and the manner in which I tend to evaluate and present evidence. If it is not congenial to the manner in which they think, they drift into other doctor's schedules and if it is congenial, they say things like, "I didn't want to do what my specialist said until I talked with you."
The manner of framing is one of the many things that get folded into what a patient means by "I trust my doc."
Great content Dr. Scott. As a provider in neurology I feel this should be taught to everyone, particularly when discussing thrombotic risk/ benefit.
Oh no! I totally do this! I didn’t even realize I was doing it because I thought I was being totally neutral and unbiased. Well, guess what? I’m not! I teach my patients about X, and I give them a clear definition and explain how it applies to them. Then, I present the pros and cons (because I want to be fair in my presentation). But here’s the thing, it’s mostly my nonverbal cues that show which side I’m on. Now, after reading this article, I realize that when I talk to my patients, my voice goes up and I get louder, when I [pitch] <- pun, the side I favor.
So, now that I’ve been made aware of this, I’m going to be extra careful when talking to my patients. I don’t want to be that pitcher who always finds the tippy corner of the reference box, or the catcher who moves my glove into the strike zone from a nano-cm outside the box.
Thanks for sharing this article! I really enjoyed it, and I found the baseball analogy very interesting.
Thank you! Don’t be too hard on yourself—it’s impossible to be completely unbiased. It sounds like you’re already very thoughtful about your conversations, and your patients are only going to benefit more from your wisdom going forward!
Taken in toto, I think if we said that most of what we do in medicine will provide no benefit to you individually unless you have a shard of metal sticking out of your neck and we’re repairing the artery, it would demoralize the public, even though it would be true.
Great article and I love the sports metaphor! I agree that framing is important for conveying the effects of medications and I think both positive and negative framing helps people understand the potential benefits and harms of treatments. I like NNT and NNH but I find the application to a particular patient is nontrivial as their baseline event risk/rate and duration of treatment is often different than the clinical trial from which the NNT/NNH was derived.
Thanks! I think that is a great perspective regarding NNT/NNH. Just like in baseball, recognition of the limitations of a statistic is necessary for proper application.
Great read.
It’s always bugged me that a fantastic treatment with an NNT of 10 still means 9 people are wasting their time, (and $, and side effects, and effort).
To say that someone is wasting their time is not the only interpretation. Given what’s at stake, gambling that you might be the one could be a totally rational decision.
It’s also important to note that NNT requires some sort of target outcome, and that just because you didn’t achieve the target outcome doesn’t mean that you couldn’t possibly have gotten some benefit.
Very well said. The more valuable the outcome, the more it makes sense to gamble on it. That’s why shared decision-making is needed, because the patient should be allowed to decide whether to play.
A helpful thought experiment to illustrate: At what price would you be willing to buy a ticket that had a 1/1000 chance to win a $200M lottery?
It’s a bet you’re very unlikely to win, but the expected value is exceedingly high.
The mirror image argument is also rather unconvincing. “I probably won’t get cancer, so I might as well smoke”. Nominally true, but not a great argument.
YES!
Regarding the concluding sentence about "robo-docs," no need to worry about them. Since AI is trained on human decision-making patterns, the training will capture the same framing biases. The only thing that will change is that the same mistakes will be made, except only faster, more efficiently, and with greater confidence!
Touché! Great point 😆
I loved the article and the baseball metaphor. Framing is something we all do in order to present ourselves and our ideas in the best possible light. In medical practice I usually found myself framing things negatively for patients in order to counterbalance a lot of the pseudoscience and fraud that people get from the media and well-meaning friends and associates.
Thank you!
And we think our caregivers have it easy! Never did I ever think about framing in the baseball nerd sense. Working with addiction was tough to frame sometimes, too, as we are trying to convince those whose brains got hijacked that there’s a better way to live (sober). What a great article, Dr Scott!
Thank you for the kind words, and for the meaningful work you are doing for those suffering from substance use disorders
The catcher is making relatively small efforts that will combine with the totality of his teammate's actions to the main purpose of winning the game. I think the way to put this scenario in context is that the physician is treating his patient rather than doing a pharmaceutical evaluation.
1. Semaglutide has many other benefits than reduction in CV risk.
2. In the totality of care for CV disease semaglutide is one factor that changes physiologic parameters in a beneficial direction.
I recently wrote my honors these on this topic and one of the interesting things about this from a biomedical ethics standpoint is that these framing biases bring informed consent into question. Since a patient’s consent can be solely dependent upon how the procedure or medication is described, the patient is not actually consenting to the intervention but to the way in which it is described. Hypothetically speaking, there is someone who consented under the survival rate description that would have dissented if given the mortality rate description. Therefore, if consent is dependent on the way in which the procedure is described and not the procedure itself, the patient’s consent might actually be invalid (if we are taking the common view of consent here). Also to note: I am not commenting with any medical expertise so I don’t have much boots on the ground experience here, just some philosophical research. Anyway, I found this article to be very interesting and enjoyed it!
I would like to read your thesis if it is online somewhere.
Sure thing! Here is the link:
https://egrove.olemiss.edu/cgi/viewcontent.cgi?article=4398&context=hon_thesis
If that doesn’t work you can search it by the title “The Conservative Approach to Informed Consent: The Evidentiary Model and an Antidote to the Problem of Framing Effects in Medical Decision-Making ”
Thank you for sharing that!
Two issues from the patient perspective: doctor's prefer to do something over nothing (commission bias). They prefer compliant patients (compliance bias - I just invented that term no idea if it is an actual concept in the medical research literature). This creates additional pressures on the patient that the doctor is unaware of, since everyone thinks that only other people have biases.
I can see why Adam decided to share Dr. Scott’s great article before finishing it. Framing is particularly powerful in pregnancy care, especially surrounding birth. Things are moving fast and many mothers can be easily talked into a physician’s (or labor nurse’s) preferred obstetrical intervention. As a maternal-fetal medicine physician I advocate for OB care that is not “too much, too soon nor too little, too late”. In the U.S. we are too often guilty of the former.
Thank you for the kind words and for the work you do
Framing is yet another example of why it is important to have a consistent source of primary care. My patients, through years of talking with me, have noticed how I frame things and the manner in which I tend to evaluate and present evidence. If it is not congenial to the manner in which they think, they drift into other doctor's schedules and if it is congenial, they say things like, "I didn't want to do what my specialist said until I talked with you."
The manner of framing is one of the many things that get folded into what a patient means by "I trust my doc."