Pitfalls of Counterfactual Thinking in Medical Practice: Preventing Errors by using more Functional Reference Points

Abstract

BackgroundCounterfactual thinking involves mentally simulating alternatives to reality. The current article reviews literature pertaining to the relevance counterfactual thinking has for the quality of medical decision making. Although earlier counterfactual thought research concluded that counterfactuals have important benefits for the individual, there are reasons to believe that counterfactual thinking is also associated with dysfunctional consequences. Of particular focus is whether or not medical experience, and its influence on counterfactual thinking, actually informs or improves medical practice. It is hypothesized that relatively more probable decision alternatives, followed by undesirable outcomes and counterfactual thought responses, can be abandoned for relatively less probable decision alternatives.Design and MethodsBuilding on earlier research demonstrating that counterfactual thinking can impede memory and learning in a decision paradigm with undergraduate students, the current study examines the extent to which earlier findings can be generalized to practicing physicians (N=10). Participants were asked to complete 60 trials of a computerized Monty Hall Problem simulation. Learning by experience was operationalized as the frequency of switch-decisions.ResultsAlthough some learning was evidenced by a general increase in switch-decision frequency across block trials, the extent of learning demonstrated was not ideal, nor practical.ConclusionsA simple, multiple-trial, decision paradigm demonstrated that doctors fail to learn basic decision-outcome associations through experience. An agenda for future research, which tests the functionality of reference points (other than counterfactual alternatives) for the purposes of medical decision making, is proposed.Significance for public healthThe quality of healthcare depends heavily on the judgments and decisions made by doctors and other medical professionals. Findings from this research indicate that doctors fail to learn basic decision-outcome associations through experience, as evidenced by the sample’s tendency to select the optimal decision strategy in only 50% of 60 trials (each of which was followed by veridical feedback). These findings suggest that professional experience is unlikely to enhance the quality of medical decision making. Thus, this research has implications for understanding how doctors’ reactions to medical outcomes shape their judgments and affect the degree to which their future treatment intentions are consistent with clinical practice guidelines. The current research is integrated with earlier research on counter-factual thinking, which appears to be a primary element inhibiting the learning of decision-outcome associations. An agenda for future research is proposed.

Why Humans Fail in Solving the Monty Hall Dilemma: A Systematic Review

“…In addition, in the study of Herbranson and Wang (2014) and in one experimental condition (with the classical MHD) of the study of Mazur and Kalhbaugh (2012), participants showed no significant increase in switching rates over trials. These participants, however, already showed a high switching rate in the first block of trials as compared to other studies (Franco-Watkins et al, 2003; Klein et al, 2013; Petrocelli, 2013; Petrocelli & Harris, 2011; Saenen et al, 2015b; Slembeck & Tyran, 2004). An important question that arises with the evidence of increased switching behaviour across successive trials is whether participants gain understanding of the problem as well.…”

“…The results of most of these studies provide strong evidence for learning from experience: Increased switching rates over trials were observed (Franco-Watkins et al, 2003; Herbranson & Schroeder, 2010; Hirao et al, 2017, Klein et al, 2013; Mazur & Kahlbaugh, 2012; Petrocelli, 2013; Petrocelli & Harris, 2011; Saenen et al, 2015b; Slembeck & Tyran, 2004; Tubau & Alonso, 2003). However, in none of these studies the repeated experience led to participants consistently switching on all trials.…”

“…In the literature, it is argued that at this point, people may engage in counterfactual thinking (Petrocelli, 2013; Petrocelli & Harris, 2011). Counterfactual thinking is defined as thinking about an alternative decision that could have been made or thinking about different outcomes of a decision that has been made (e.g., Roese, 1997).…”

“…First, in several studies, participants were given multiple trials of the MHD which allowed the researchers to investigate whether repeated experience and feedback with the problem would improve performances (Efendic & Drace, 2015; Franco-Watkins et al, 2003; Herbranson & Schroeder, 2010; Herbranson & Wang, 2014; Hirao et al, 2016, 2017; Klein et al, 2013; Mazur & Kahlbaugh, 2012; Petrocelli, 2013; Petrocelli & Harris, 2011; Saenen et al, 2015b; Slembeck & Tyran, 2004; Tubau & Alsonso, 2003). The results of most of these studies provide strong evidence for learning from experience: Increased switching rates over trials were observed (Franco-Watkins et al, 2003; Herbranson & Schroeder, 2010; Hirao et al, 2017, Klein et al, 2013; Mazur & Kahlbaugh, 2012; Petrocelli, 2013; Petrocelli & Harris, 2011; Saenen et al, 2015b; Slembeck & Tyran, 2004; Tubau & Alonso, 2003).…”

“…Unfortunately, several articles do not report the observed switching percentages (e.g., exact switching percentages and standard errors, as well as individual switching profiles) in sufficient detail, so it is impossible to investigate whether the improvement in switching rates is merely due to a probability matching trend or not (e.g., Franco-Watkins et al, 2003; Klein et al, 2013; Petrocelli, 2013; Petrocelli & Harris, 2011). Several other articles do report results that in principle could be explained by the probability matching phenomenon (e.g., Efendic & Drace, 2015; Herbranson & Schroeder, 2010; Herbranson & Wang, 2014; Hirao et al, 2017; Mazur & Kahlbaugh, 2012).…”