37 Addressing uncertainty, fears and beliefs that drive and bolster low-value care

Background

Low-value care - care that has limited benefit for patients, possibly harms them and wastes health care resources - is increasingly recognized as a global problem that places strain on health care systems and undermines global sustainability goals. Uncertainty and cognitive biases seem to have a crucial role in driving and bolstering low-value care. Uncertainty has many sources, such as scientific, practical, and personal and result from stochastic processes, ambiguity, and complexity. Uncertainty spurs fears in health care professionals to miss a diagnosis, undertreat, or dissatisfy patients, and poor willingness of patients and the society to accept that there are always uncertainties. This comes together with beliefs that early detection is always good, that advanced diagnostics and treatment is better than simple or ordinary treatment, and that many tests are better than few. All these forms of fears and beliefs promote low-value care, and lead to more diagnostic testing and treatments than beneficial to the patient. Awareness of various types of inevitable uncertainties as well as of the fears and beliefs (cognitive and affective biases) is a crucial step to reduce low-value care, free resources for high-value care, and increase the quality of care. Accordingly, it is crucial for all stakeholders to be aware that uncertainty can never be ruled out completely, and that reliance on more diagnostic testing and treatment as a response to uncertainty is the result of using intuitive, fast, and affective/cognitive processes (System-1 thinking) in decision making under time pressure. However, until now most de-implementation initiatives that aim to tackle the globally pervasive and persistent intractable problem of low-value care use mainly strategies that are geared at our analytic slow, de-liberative, cognitive processes (System-2 reasoning). Examples of such strategies are education on harms and providing performance feedback. In these types of strategies decision making is expected to change as function of a conscious intention to change. However, this assumption ignores the dominant role of System-1 thinking in clinical decision making.

Aim seminar

To discuss how we can address uncertainty, fears and beliefs that drive an bolster low-value care in clinical practice.

Seminar content

The seminar will first provide an introduction of the uncertainties and the fears and beliefs that we apply to handle them (in term of cognitive and affective biases) and how they drive and bolster the use of low-value care. Then we propose that various non-rational ways (geared at system-1 thinking) are needed to address these uncertainties and cognitive biases in the de-implementation of low-value care. Next, we discuss with the audience in an interactive way which of the suggested solutions seems worth the effort and whether additional or other solutions may be appropriate for addressing uncertainties, fears and beliefs that drive and bolster the use of low-value care . The introduction of the discussion point will be provided by Bjørn Hofmann PhD, Professor in philosophy of medicine and medical ethics, and Leti van Bodegom-Vos – PhD, Implementation scientist.