Pitfalls from Psychology Science that Worsen with Practice
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and Lee D. Ross, PhD5
1
Department of Medicine, University of Toronto, Toronto, Canada; 2Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre , Sunnybrook Research Institute, Toronto, Ontario, Canada; 3Institute for Clinical Evaluative Sciences in Ontario, Toronto, Canada; 4Centre for Leading Injury Prevention Practice Education & Research, Toronto, Canada; 5Department of Psychology, Stanford University, Stanford, CA, USA.
J Gen Intern Med DOI: 10.1007/s11606-020-05864-5 © Society of General Internal Medicine 2020
INTRODUCTION
Advances in science have made medical treatment increasingly successful. For example, the development of monoclonal antibody medications against Ebola infections is a meaningful advance for treating patients with a fatal disease.1 The literature is also littered with reversals characterized by early successes leading to hype and followed later by disappointment; for example, carotene for protecting against cancer, tight blood sugar control for preventing postoperative infections, and coronary stents for treating stable angina.2–4 In contrast to dynamic science literature, clinical practice changes slowly because early success is hypnotic and clinicians do not automatically absorb the potential gains in wisdom that years of experience can offer. Cognitive psychology is the science that explores how people reason, formulate judgments, and make decisions (also related skills such as memory and language). The core theory is that errors can be systematic and do not necessarily disappear with experience.5, 6 Indeed, learning from experience can be difficult and susceptible to many pitfalls.7 Insights and awareness from cognitive psychology, therefore, may make people less susceptible to pitfalls in reasoning and also help in drawing correct interferences from a range of outcomes observed by experience.8–10 Because changes in a patient’s condition can result from factors other than the treatment provided, however, clinicians face a particularly difficult inferential task in learning from medical experience.11 A comprehensive review of the errors and biases relevant to medical judgment could include sources of overconfidence, wishful thinking, reliance on heuristics, loss aversion, motivational biases, and other failures beyond the scope of this article.12–14 Here, we limit the discussion to three specific pitfalls rooted in mistaken causal inferences that inhibit rather than promote learning from accumulating years of experience treating patients (Table 1). Each pitfall has counterintuitive features, is relevant to healthcare, reflects rigorous research, Received October 24, 2019 Accepted April 16, 2020
and is rarely discussed in standard medical training. The pitfalls are particularly germane in patient follow-up and address cases where the initial clinical outcome seems positive, negative, or ambiguous.
Post Hoc Fallacy A core strength of medical practice is the trial-and-error strategy of initiating a treatment and assessing a patient’s response. However, this strategy is subjec
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