Clinical judgement heuristics: Methods and models

In this issue, you will find a paper by Hirsh et al. (2013), entitled ‘The influence of patient sex, race, and depression on clinician pain treatment decision’, exploring the wide diversity of clinician decisions on treatment of simulated chronic pain patients according to sex, race and depression status. In an ideal situation, treatment decisions are informed by evidence, unbiased by personal characteristics such as sex or ethnicity except where relevant difference is established, and modulated by negotiation with the individual patient. As in earlier studies by the first author (e.g., Hirsh et al., 2009; Stutts et al., 2010), group level and individual level decisions were analysed according to a lens model, widely used in judgement and decisionmaking research but largely neglected in the pain field. Systematic variation of a range of cues allows decision strategies to be studied, and weighing and integrating of factors identified. This study used computer-simulated patients, all displaying the same pain intensity in facial expression; their depression status was systematically varied in accompanying vignettes, whereas their sex and ethnicity was presented in a still image. Practising clinicians and trainees rated the likelihood for each patient of recommending opioids, antidepressants, referral to a pain clinic or referral to a mental health clinic. Some decision strategies were shared by as many as 75% of participants: recommending antidepressant medication in depressed patients, for instance. Others appeared idiosyncratic: five clinicians referred depressed patients to a pain specialist, whereas three clinicians did not. Personal beliefs appear to have informed judgements, and although we do not know the reason for differences – for instance, in the example of prescribing antidepressants for depressed patients, the clinicians who decided against it may have weighed more strongly the evidence on psychological treatment or may have been disinclined to attend to depression – the study identifies cues that may require further investigation. In contrast to the sophisticated design and analysis in terms of decision making, there were unsatisfactory aspects whose influence on results is hard to gauge. Static images are inferior to moving images (Prkachin, 2009; Foley et al., 2012), which are used elsewhere by the first author (e.g., Hirsh et al., 2009), among others. More puzzlingly, the images showed pain facial expression but not depression, when it is possible to morph the two in a still image; this may have undermined the credibility of the vignette account of depression for those who read the face more sensitively. On a more fundamental level, there is a puzzling lack of theory of depression in the context of chronic pain. The co-morbidity formulation is oversimple in the context of evidence that depression and chronic pain share substrates, from the evolutionary function of resource conservation in difficult times (Gilbert, 1992; Williams, 2002) to common neurotransmitters and brain processing (Gatchel et al., 2007; Berna et al., 2010). Perhaps this underlies the decision not to blend depression and pain in faces. The authors also neglected to specify whether the option of antidepressant prescription implied a low analgesic dose or a higher antidepressant dose (Lynch, 2001), and participants may have interpreted it either way. Despite these problems, the rigorous approach to decision making in clinicians helps to deepen our understanding of the cues individuals use in making treatment decisions. It would advance our knowledge of pain assessment and treatment to use methods from the judgement and decision-making field more frequently. We could identify the cues observers look for, how they combine the cues (e.g., in a form of simple heuristics rather than complex regression-like decision processes) and when observers stop searching because they are satisfied. These are crucial issues given the widely reported inadequacy of pain assessment and treatment in general, and in relation to biases that, wittingly or unwittingly, affect those decisions.