Omission bias and decision making in pulmonary and critical care medicine

Background: Pulmonary and critical care physicians routinely make complex decisions, but little is known about cognitive aspects of this process. Omission bias and status quo bias are well-descibed cognitive biases that can cause lay decision makers to prefer inaction that preserves the status quo even when changing the status quo through action is more likely to lead to the best outcomes. It is unknown if these biases influence trained decision makers such as pulmonologists. Study objectives: To determine whether omission bias and status quo bias influence the medical decisions of pulmonologists. Design and interventions: The study was a randomized controlled trial conducted within a cross-sectional survey of pulmonologists' opinions about the relevance of various factors in pulmonary and critical care decision making. We designed case vignettes that presented patient information with an associated patient management choice. The status quo state and the action/omission distinction were varied in two forms of otherwise identical vignettes. One form of each case vignette pair (A and B) was administered randomly to each prospective respondent during the first mailing of the opinion survey. Participants: Five hundred pulmonologists selected randomly from the membership of the American College of Chest Physicians. Measurements and results: There were 125 respondents, including 59 for form A and 66 form B (enrollment rate, 25%). In vignettes involving evaluation of pulmonary embolism and treatment of septic shock, respondents were more likely to choose a suboptimal management strategy when an omission option was present that allowed preservation of the status quo (71% vs 53%, p = 0.048; 50% vs 29%, p = 0.016, respectively). In a vignette involving a hypothetical clinical trial and the decision to prescribe tube feeding, the omission option was not significantly associated with the decision to prescribe tube feeding (54% vs 50%, p = 0.67). Conclusion: Pulmonary and critical care decisions are susceptible to the influence of omission and status quo bias. Because of the great number of decisions that are made each day involving choices between maintaining or changing the status quo, this finding could have far-reaching implications for patient outcomes, cost-effectiveness, resource utilization, clinical practice variability, and medical errors.