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Psychology of Patient Sections
Author Bio
Introduction
Omission Bias
Discount Rates
Currently selected section: Framing
Assessing Probabilities
Predicting Utility
Sequences
Role-based decisions
Role of Emotions
Visceral Influences
Conclusion
Chapter 4: The Psychology of Patient Decision Making: Framing
         

“Framing” refers to several related phenomena ( Levin, Schneider and Gaeth, 1998).  For the purposes of this chapter, I will simply define it as the influence of the format or wording of a question on its answer.  The classic framing study by McNeil, Pauker, Sox, and Tversky (1982) provides a good example. Physicians, students, and patients with chronic diseases other than lung cancer were asked to consider two possible treatments for lung cancer: surgery or radiation.  Approximately half of the participants examined the survival probabilities for the two types of treatment.  The other half of the participants examined mortality data.  Of course, survival data is the converse of mortality data, so the information provided to each group was essentially identical.  Nevertheless the persons who received survival data chose radiation therapy less frequently than did subjects who received mortality data.  Because the information shown to each group should have had no influence on which type of therapy is favored, this result calls into question exactly what status the patient’s expressed preference should have.  Again, the assumption has generally been that patients should be given the opportunity to express what they feel is in their own best interest.  If it is known that seemingly trivial factors can influence what a patient thinks is in his or her own best interest, then how can a physician be sure that such interests are truly being heeded?

Some recent research has suggested that in important medical decisions in which there is high patient involvement, the framing of a question may have less influence than in the McNeil et al., (1982) study, which used persons who did not have the disease described in the questionnaire.  For example, Donovan and Jalleh (2000) found that when confronted with an infant immunization scenario, mothers of infants, pregnant women, and women who intended to get pregnant in the next 12 months were not influenced by a framing manipulation.  However the framing of the scenario did influence women who were not in any of these three categories.   Similarly, Christensen et al., (1995) found that framing had only limited impact in a large number of medical scenarios.  (See also Llewellyn-Thomas, McGreal, and Thiel, 1995.)

The frames used by McNeil et al., (1982), Donovan and Jalleh (2000), and Christensen et al., (1995) were all gain/loss manipulations.  In general, participants are more risk-averse when responding to scenarios framed in terms of gains or survival; participants are more risk-seeking when responding to scenarios framed in terms of loss or mortality.  To understand this asymmetry it is necessary to present some key aspects of prospect theory (Kahneman and Tversky, 1979).


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