During training, I got a few pieces of advice that I still remember.
One was: When you get to the code, check your pulse first.
Another was: Don’t just do something, stand there.
The second one is what I want to focus on today. It is called “Action Bias.” A famous example of this is in soccer penalty kicks. Statistics suggest that approximately 1/3 of shots are aimed at the left, right, and middle. That would mean that if the goalie does not dive to either side, there is a 1/3 chance of saving a score. By diving to the left or right, they statistically would be wrong 2/3 of the time. Yet, goalies either dive to the right or left more than 90% of the time. Psychologists have named this “action bias,” as doing something seems better than “not doing something.”
The same phenomenon can be highlighted in medicine. As a doctor, when you are asked a question (or you think you are asked a question), your first instinct is to answer that, or answer what you think was asked. A specific example in oncology is a what is thought to be a “prognostic question.” It is a learned behavior because, most of the time, that is expected. A patient, a family member, a nurse, or a team member is looking for advice and guidance from you, and answering that seems completely natural, and more often than not, it will be a satisfactory response.
But just like the goalie, the physician has to decide - should I presume the question I think I am being asked, or should I clarify the question?
This goes back to Daniel Kahneman’s system 1 and system 2 thinking. As discussed earlier, System 1 is reflexive - it is fast, automatic, intuitive, and operates with little or no effort (thus reflexive). System 2, on the other hand, is slow, deliberate, and conscious, requiring reflection.
So, why is it important to activate system 2 thinking? We discussed this in the “Discussing Prognosis” post without leveraging systems thinking. When is it important to activate it when dealing with action bias? Here are some examples:
You are a fellow, called for a new consult for “lung cancer” - you have an algorithm about how to approach each new diagnosis -
The systems 1 thinking would be to follow the Oncology 101
The systems 2 thinking would be to review all of the history with patient, family, and records to obtain the primary data (pathology, imaging).
The systems 2 thinking would also allow you to ask patients what their questions are, to listen to their concerns BEFORE answring them.
You are called for a consult in the ICU for a patient in declining health. In oncology, poor performance status implies poor outcome and further systemic therapies would not be advised.
That is the System 1 thought process
The System 2 thought process would involve the same as above
understand the patient's situation
understand the patient and family perspective
allowing this understanding may facilitate more “patient-centered” discussions
As an oncologist, this bias is active more often than not. When there is a decision to make about what to do next, how we present the choices may impact what patients and families choose. If we frame it as either we can “do X” or “do nothing,” the patient may interpret it as “we can address the cancer” or “we can not address the cancer,” and the choices may seem false to the listener. Action bias may dictate that doing something is better than not doing something.
The same can be offered slightly differently: we can “choose X” or “choose Y,” where Y focuses only on symptoms.
Framing for or against Action bias is not just about patients; it is also about us, physicians. It goes back to our worldview, what do we see ourselves as? Are we technicians who “fix things that are broken” by taking action, or are we more reflective people whose goal is to help patients on their journey, where the destination is always known?
This last point is probably the most important point in medicine: who are you and what is your goal? There is no right or wrong answer, but it is entirely possible that many of us have not reflected adequately on this meta-cognitive point about our goals and our roles, which help define our worldview.