Understanding clinical and non-clinical decisions under uncertainty: a scenario-based survey

Background: Prospect theory suggests that when faced with an uncertain outcome, people display loss aversion by preferring to risk a greater loss rather than incurring certain, lesser cost. Providing probability information improves decision making towards the economically optimal choice in these situations. Clinicians frequently make decisions when the outcome is uncertain, and loss aversion may influence choices. This study explores the extent to which prospect theory, loss aversion, and probability information in a non-clinical domain explains clinical decision making under uncertainty. Methods: Four hundred sixty two participants (n=117 non-medical undergraduates, n=113 medical students, n=117 resident trainees, and n=115 medical/surgical faculty) completed a three-part online task. First, participants completed an iced-road salting task using temperature forecasts with or without explicit probability information. Second, participants chose between less or more risk-averse (defensive medicine) decisions in standardized scenarios. Last, participants chose between recommending therapy with certain outcomes or risking additional years gained or lost. Results: In the road salting task, the mean expected value for decisions made by clinicians was better than for nonclinicians(-$1,022 vs -$1,061; <0.001). Probability information improved decision making for all participants, but nonclinicians improved more (mean improvement of $64 versus $33; p=0.027). Mean defensive decisions decreased across training level (medical students 2.1 +/- 0.9, residents 1.6 +/- 0.8, faculty1.6 +/- 1.1; p-trend <0.001) and prospect-theoryconcordant decisions increased (25.4%, 33.9%, and 40.7%; p-trend =0.016). There was no relationship identified between road salting choices with defensive medicine and prospect-theory-concordant decisions. Conclusions: All participants made more economically-rational decisions when provided explicit probability information in a non-clinical domain. However, choices in the non-clinical domain were not related to prospect-theory concordant decision making and risk aversion tendencies in the clinical domain. Recognizing this discordance may be important when applying prospect theory to interventions aimed at improving clinical care.