“You should have surgery. It’s the best treatment for you.”

Although radiation therapy was a viable alternative to surgery,

these two sentences were enough to convince my father some years ago to elect to have surgery to treat his intermediate-risk prostate cancer. He summarily declined the urologist’s offer to facilitate a radiation oncology consultation. My father expressed confidence in his surgeon and chances for cure.

I have since seen that this experience is far more common than what I first would have thought. I regularly hear patients voice similar conclusory statements about treatment plans, and even if initially presented with an inferior or equivalent option, many strongly resist consideration of a different course when presented with supporting data.

Doctors are taught to think through medical decisions by listing a series of options, weighing the risks and benefits of each, and ultimately concluding on the superior option. This comparative maximization approach is drilled into us as medical students and residents. Many doctors, likewise, seem to present data to patients with the implicit assumption that patients will make decisions only after hearing and equally weighing all relevant data.

But for patients, medical decision making often significantly departs from this ordered framework and perhaps may be better understood as a negotiation where the patient is seeking to determine the “best deal” in response to challenging circumstances. Information often is presented to patients in a piecemeal fashion, not comprehensively. The first “offer” typically is made by one type of physician, with the patient then left to determine whether to pursue other options or move forward with the initial proposal.

Such circumstances may give rise to two decision-making biases that are well known in negotiations literature: the anchoring bias and the status quo bias.

Researchers at the Harvard Negotiation Project at Harvard Law School describe anchoring as a cognitive bias “that describes the common human tendency to rely too heavily on the first piece of information offered (the ‘anchor’) when making decisions. During decision making, anchoring occurs when individuals use an initial piece of information to make subsequent judgments. Once an anchor is set, other judgments are made by adjusting away from that anchor, and there is a bias toward interpreting other information around the anchor.”

Applying anchoring to the medical context, it may be that patients are more inclined to pursue the opinion of the doctor they heard first, simply because it was the opinion they heard first. Most physicians have anecdotal experiences with trying to reframe patient thinking after another physician recommended an alternate treatment plan. Patients in such situations often frame their questions as to how the “new” recommendation could be “better” than one they already have in hand. The source of the initial recommendation also is an important consideration—the opinion voiced by a trusted physician or family friend can be especially difficult for a newly met doctor to overcome, even when presenting with data on better outcomes.

A second bias seen in negotiations that may affect patient thinking is placing an overly high value on the status quo. When describing effects of this bias in negotiations, Deepak Malhotra, PhD, a Professor in the Negotiations, Organizations and Markets Unit and Max H. Bazerman, PhD, the Jesse Isidor Straus Professor of Business Administration, both from the Harvard Business School, recently noted that “people are more likely to be concerned about the risk of change than about the risk of failing to change and will be motivated to preserve current systems and beliefs. The status quo bias is a general source of opposition to change even when people regard the consequences of the change to be a net improvement.”

In the medical context, the status quo bias may offer an additional reason for why patients who already have scheduled a treatment plan may be especially resistant to subsequent proposals. A new cancer diagnosis is an emotionally challenging and intellectually confusing experience for any patient. Many patients obtain a great deal of comfort simply from having a “plan” of care established. To then propose a change, even if small, can be unsettling and thrusts patients into feeling out of control over their circumstances.

Studies looking at the relationship between prostate cancer patients’ ultimate treatment selection and specialty of their initial consulting physician are consistent with these anecdotal observations.

from a recent report shows treatment selected (prostatectomy versus radiation) was significantly correlated with whether the patient had seen only a urologist before setting an initial treatment plan or had seen both a urologist and radiation oncologist before making a plan.

 A recent SEER analysis likewise found that patients with low-risk prostate cancer were more likely to receive treatment if seen first by a urologist, especially if that urologist billed for the treatment received or graduated from training in earlier decades.

 Other reports have noted that when patients are seen in multidisciplinary clinics— consulting multiple specialists at once&mdash;they are more likely to pursue active surveillance, even when controlling for the number and specialty of physicians met in consultation.

 These data align with the notion that timing and source of medical information can cause patients’ treatment decisions to vary.

Such variations may have significant, negative consequences for individual patient results and the health care system more broadly. A wide body of research establishes that generally accepted treatment options can generate different costs and side effects, even when outcomes may be comparable. For example, a recent analysis of different treatments for low-risk prostate cancer found substantial variability in cost with only modest differences in quality-adjusted life-years (QALYs): Treatment costs ranged from $19,901 with robotic-assisted radical prostatectomy to $40,588 with combined external beam radiation and brachytherapy treatment, while QALYs only ranged from 10.3 to 11.8 among the different radiation and surgical treatments.

		Figure. Physician Visits Prior to Treatment for Clinically Localized Prostate Cancer

		Specialists who were seen prior to definitive treatment for 18,201 men who had a radical prostatectomy (A) and 35,925 men who had radiation therapy (B).

With respect to treatment morbidity, a recent analysis of 1655 men from the Prostate Cancer Outcomes Study within the first five years after treatment noted increased rates of urinary incontinence and erectile dysfunction among surgery patients and increased rates of bowel urgency among radiotherapy patients.

 Patients may not appreciate these distinctions if unduly influenced by anchoring or status quo biases.

In light of these concerns, physicians can and should seek to ensure biases seen in negotiations do not impair their patients’ ability to make appropriately informed medical decisions. On an individual level, we should be mindful of the words we use, particularly in the setting of a new diagnosis, and consider how they may affect how patients perceive options and interactions they have with doctors. We need to encourage and explain the purpose of obtaining multiple opinions where possible, and when patients seem to have their mind made up quickly, we should take the time to understand why this may be the case.

But to enable more targeted improvements, the medical field needs a better understanding for how anchoring and status quo biases may impact patients’ treatment decisions, and how physicians can guard against undue influence of these biases. More research is needed on how much a subsequent opinion has the ability to change patient treatment, and under what circumstances. And when and why do patients skip second opinions in cases where multiple treatment modalities are available? To my knowledge, little or no studies meaningfully answer these questions directly. Future work—such as through patient satisfaction and questionnaire-based studies&mdash;should seek to clarify how the timing, source, and context of medical information influence how patients come to conclusions, and identify optimal strategies for avoiding undue anchoring and the status quo bias.

We ultimately may find that the best responses to any decision-making biases are more systemic in nature. As with the prostate cancer examples above, multidisciplinary teams that recommend consensus-based treatment opinions and produce balanced educational materials may offer a key solution to overcoming biases that unduly influence patient decisions. Studies should consider whether and when such approaches lead to better outcomes and efficiencies in specific disease areas. Researchers also should seek to determine whether multidisciplinary teams are able to instill more confidence in their patients who, like my father, want to feel sure that they made the best choice possible under difficult circumstances.

: Harvard University Radiation Oncology Program, Harvard Medical School, Boston, MA.

: The author has no conflicts of interest to disclose.

 Ravi A. Chandra, MD, PhD, 75 Francis St. L2, Boston, MA 02115. (617)732-6310. rachandra@partners.org.

			D’Amico AV, Whittington R, Malkowicz SB, Schultz D, Blank K, Broderick GA, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998;280(11):969-974.

			Kupelian PA, Elshaikh M, Reddy CA, Zippe C, Klein EA. Comparison of the efficacy of local therapies for localized prostate cancer in the prostate-specific antigen era: A large single-institution experience with radical prostatectomy and external-beam radiotherapy. J Clin Oncol 2002;20:3376-3385.

			Anchoring Effect (Accessed May 30, 2014, at http://www.pon.harvard .edu/tag/anchoring-effect).

			Malhotra D, Bazerman MH. Psychological influence in negotiation: an introduction long overdue. J Manag 2008;34:509-531.

			Jang TL, Bekelman JE, Liu Y, Bach PB, Basch EM, Elkin EB, et al. Physician visits prior to treatment for clinically localized prostate cancer. Arch Intern Med 2010;170:440-450.

			Hoffman KE, Niu J, Shen Y, Jiang J, Davis JW, Kim J, et al. Physician variation in management of low-risk prostate cancer. JAMA Intern Med. 2014; 174(9):1450-1459.

			Aizer AA, Paly JJ, Zietman AL, Nguyen PL, Beard CJ, Rao SK, et al. Multidisciplinary care and pursuit of active surveillance in low-risk prostate cancer. J Clin Oncol. 2012;30(25):3071-3076.

			Cooperberg MR, Ramakrishna NR, Duff SB, Hughes KE, Sadownik S, Smith JA, et al. Primary treatments for clinically localized prostate cancer: a comprehensive lifetime cost-utility analysis. BJU Int. 2013;111(3):437-450.

			Resnick MJ, Koyama T, Fan KH, Albertsen PC, Goodman M, Hamilton AS et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med. 2013;368(5):436-445.

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Doctors are taught to think through medical decisions by listing a series of options, weighing the risks and benefits of each, and ultimately concluding on the superior option. This comparative maximization approach is drilled into us as medical students and residents.

Ravi A. Chandra, MD, PhD

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