Micro-Effects of Language on Risk Perception in Drug Prescribing Behavior
Harold J. Bursztajn, MD; Benzion Chanowitz, PhD; Thomas G. Gutheil,
MD; and Robert M. Hamm, PhD
Drs. Bursztajn and Gutheil are affiliated with the Program in
Psychiatry and the Law, Massachusetts Mental Health Center, 74 Fenwood
Road, Boston, MA 02115. Dr. Chanowitz is affiliated with the Department
of Psychology and the Graduate Center, Brooklyn College, C.U.N.Y., New
York, NY. Dr. Hamm is affiliated with the Center for Research on Judgment
and Policy, University of Colorado, Boulder, CO. The authors wish to
thank Prof. Miriam Schustack of the Department of Psychology and Social
Relations, Harvard University, for helpful suggestions in the design
of this study. This paper was presented at Society for Medical Decision
Making meetings, November 1983, Toronto. Abstract published in: Medical
Decision Making Vol. 3, p. 539, 1983.
The decision to prescribe neuroleptics
for the treatment of psychosis involves a potentially tragic choice between,
on the one hand, a probability of psychosis and a probability of side
effects, such as tardive dyskinesia, on the other. In an experimental
paradigm, we examined this decision process. We hypothesized that linguistic
factors considered irrelevant under classical formulations of individual
choice behavior would have a significant effect on this decision. All
subjects were presented with a case vignette involving a potentially
psychotic patient Subjects were then asked what probability of tardive
dyskinesia they would either "accept" or "risk" in
order to prevent psychotic decompensation. In addition this factor was
crossed with a contextual factor that varied the patient's age. The effect
of "risk" versus "accept" language was evident in
significantly different patterns of decision making across age groups.
The data have important implications for clinical decision making, the
elicitation of informed consent, and the directions that the courts have
taken in malpractice and patient's rights cases.
The decision whether or not to prescribe a neuroleptic drug for a psychotic
patient represents an increasingly common source of anxiety for the
psychiatrist in light of emerging case law. [1-3]
These drugs effectively inhibit psychosis, but their use may induce
tardive dyskinesia. How does one weigh these risks and benefits in
order to determine what is good medical practice and what is medical
malpractice? It was in the context of this problem that the legal
foundations were first established for psychiatric patients' rights
to refuse treatment. [4-6] In another well-publicized
case, Clites v.State of Iowa, [7,8]
a mentally retarded patient was awarded nearly $800,000 in damages
for neuroleptic-induced tardive dyskinesia. The physician's actions
in this case were judged to be negligent in part because treatment
with neuroleptics was not considered to be adequate care for the
patient in question. However, when weighing the risks and benefits
of neuroleptic treatment, it is unclear what would constitute a good
clinical judgment strategy. Without such guidance psychiatrists may
be forced to practice "defensive medicine" in order to
avoid accusations of malpractice.
The process of prescribing drugs and the clinical judgment strategies
that underlie this prescribing behavior have become the focus of
increasing research interest. [9,10]
Much of this research is directed toward determining whether there
is consistency in prescribing behavior and, if so, the factors that
govern the documented consistency. A number of patient characteristics
(e.g., age, sex, symptom profiles) and physician characteristics
(e.g., age, training, practice size) have been found to affect prescribing
behavior. [11,12] However, such
research has only demonstrated regularities in prescribing behavior
given certain physician or patient characteristics that remain stable
over time. Less attention has been paid to how prescribing behavior
might be systematically influenced by the manipulation of situational
variables.
This pilot study examines the effect that one such variable may have
on drug-prescribing decisions. The language in which a hypothetical
drug-prescribing decision was presented was varied in a way that
should be irrelevant by traditional standards of clinical practice
and contemporary decision theory. It was hypothesized that two distinct
clinical judgment strategies are available for difficult medical
decisions. The micro-language manipulation was designed to elicit
these two strategies.
Subjects were asked either what probability of tardive dyskinesia (TD)
they would risk or what probability of TD they would accept in prescribing
a neuroleptic drug. It was hypothesized that the word "risk" would
make the dangers of the situation salient, and that subjects in the "risk" condition
would be made to feel solely and completely responsible for whatever
outcome might follow from their decision. With the word "accept," on
the other hand, the dangers of the situation would remain salient,
but in conjunction with other, equally relevant factors. It was hypothesized
that subjects in the "accept" condition would act on the
assumption that risks exist no matter what course of action is taken.
These subjects, therefore, would be better able to acknowledge and
assess rationally the risks in the hypothetical situation presented
to them.
To demonstrate these patterns we exploited a relatively well-documented
finding regarding the relationship between TD and neuroleptic drugs.
Recent research [13,14] indicates
that advancing age is associated with increasing prevalence of TD
for patients receiving neuroleptic drugs. Hence, varying the age
of the patient should produce concurrent variation in drug prescribing
decisions. Subgroups within each of the two experimental groups (i.e., "risk" versus "accept")
received information that the patient was either young, middle-aged,
or old in an otherwise identical case vignette. We expected different
patterns of drug-prescribing behavior across patient age groups as
a function of the language employed in eliciting drug-prescribing
decision. Specifically, we hypothesized that subjects would either
repress or act out (in the "risk" case) or consider (in
the "accept" case) the anxieties that emerge in prescribing
neuroleptic drugs to elderly patients. The emergence of two distinct
patterns across age would confirm that two distinct judgment strategies
do exist and can be preferentially induced.
Method
Subjects were a group of 60 persons attending a Conference on Psychiatry
and the Law: Strategies of Malpractice Prevention. They included
physicians (N = 20), attorneys (N = 15), and other (e.g., registered
nurses, social workers; N = 25). The current study population was
predisposed toward a homogeneity of disciplinary responses by virtue
of being post-tested immediately following presentation on risk management
by two of the co-authors (H.B. and T.G.). We have addressed the issue
of disciplinary role influences on risk perception elsewhere. [15]
Subjects were presented with a brief case vignette of a psychotic
patient that described costs and benefits of prescribing a neuroleptic
drug. The clinical part of the vignette read as follows:
A [70-year-old] patient of yours becomes violently psychotic
when taking any less than a neuroleptic equivalent of 400 mg of Thorazine.
As you know, Thorazine is effective in reducing psychotic behavior, but
its continuing use is associated with tardive dyskinesia (involuntary
muscle spasm).
On different forms of the vignette, the age of the patient was varied
as 20 years old, 40 years old, or 70 years old. Subjects were then
asked to answer two questions with reference to this case. The first
question was designed to elicit how they were subjectively disposed
to act in this case in prescribing a neuroleptics drug that might
induce TD. The second question was designed to elicit their objective
assessment of the probability that this patient would develop TD
if the neuroleptic drug was prescribed.
The first question was worded in one of two ways. In one form, the question
was worded as follows:
What probability of tardive dyskinesia would you [risk] to prevent
recurrence of psychosis in this [70-year-old] patient? Circle one of
the numbers below.
In the other form, the question was worded, with one word changed, as
follows:
What probability of tardive dyskinesia would you [accept] to
prevent recurrence of psychosis in this [70-year-old] patient? Circle
one of the numbers below.
In answering one of the above questions, subjects were required to circle
the probability level of TD that they would be willing to risk/accept
in prescribing neuroleptic drugs. The presented levels ranged from
0% to 100% by intervals of 10% (see Appendix).
Appendix
| A [40-year-old] patient of yours becomes violently
psychotic when taking any less than a neuroleptics equivalent
of 400 mg of Thorazine. As you know, Thorazine is effective in
reducing psychotic behavior, but its continuing use is associated
with tardive dyskinesia (involuntary muscle spasm). What probability
of tardive dyskinesia would you [risk] to prevent recurrence
of psychosis in this [40 year-old] patient? Circle one of the
numbers below: |
| |
| low probability |
high probability |
| |
| 0% |
10% |
20% |
30% |
40% |
50% |
60% |
70% |
80% |
90% |
100% |
| |
|
| Profession: _________________________ |
Years in profession: _________ |
| Age: __________ |
Sex: _________ |
All subjects then received the same second question, which read as follows:
What is the likelihood that this patient will get tardive dyskinesia?
Subjects again were required to express their assessments of probability
in percentile form. By subtracting each subject's answer to the second
question from their answer to the first, the responses were adjusted
to represent whether (+) or not (-) the subjects would prescribe
in this situation. Subjects' responses to the second question were
an expression of their baseline assessments of the probability of
inducing TD if the patient received Thorazine. In subtracting this
figure from the response to the first question (that assessed the
willingness to act in prescribing the drug), we assessed the willingness
of subjects to prescribe and thereby take risks that either undershot
or overshot the baseline probability of inducing TD. This adjusted
risk figure was used to compare the drug prescribing behaviors of
different subjects with different assessments of the baseline probability
of inducing TD.
These adjusted responses of the subjects were embedded in a 3 (age: 20,
40, or 70 years old) by 2 (language: risk or accept) between-subjects
design. An analysis of variance [16] was performed
to examine the pattern of subjects' responses. It was hypothesized
that "risk" subjects would be motivated to reduce uncertainty
and anxiety; they would take steadily decreasing risks with the increasing
age of patient, in response to the anxieties that attend the treatment
of elderly patients. This effect was hypothesized not to occur among "accept" subjects,
who would be induced to act under a "cooler" judgment strategy.
[17] Under the latter conditions, subjects might
concede that uncertainty exists regardless of which alternative is
chosen. As such, they would be willing to cope with rather than yield
to the anxieties that accompany the treatment of elderly patients.
Results
The primary dependent measure was the adjusted figure (i.e., each subjects'
response to question 1 minus the response to question 2) that represents
the probability of TD that each subject was willing to risk/accept
in prescribing a neuroleptic. A distinctive pattern of variation
in this measure emerges when subjects' responses across age groups
are compared. Table 1 presents these data. As can be seen, "risk" subjects
radically decrease the risks that they are willing to take with the
increasing age of patient, while "accept" subjects are
willing to take increasing chances. These data were subjected to
a two-way analysis of variance and yielded the predicted interaction
effect, F(2,52) = 4.59, p < .015. There were no main effects. That
is, neither language nor age of patient perse was responsible for
variations in subjects' responses, Rather, differences in micro-language
induced different levels of willingness to take chances as a function
of the varying age of patient. The data indicate that all subjects
were aware that the probabilities for TD change as a function of
changing age, but that "risk" and "accept" subjects
used this perception differentially as a basis for action. Under "risk" versus "accept" conditions,
subjects employed different judgment strategies in order to arrive
at a drug-prescribing decision in a situation that becomes increasingly
exacerbated with the increasing age of the patient.
Table 1
| Responses Across Age Groups |
| |
20 yr old |
40 yr old |
70 yr old |
Subjective assess-
ment/action
question |
Accept
(x̄ = 42.67) |
33.33% |
41.82% |
52% |
Risk
(x̄ = 45.81) |
47.27% |
49.00% |
41% |
Objective Assess-
ment question |
Accept
(x̄ = 41.88) |
47.45% |
36.55% |
41.25% |
Risk
(x̄ = 39.98) |
24.50% |
35.92% |
59.10% |
Adjusted willing-
ness to take
chance of tar-
dive dyskinesis |
| Accept |
-13.71% |
+5.27% |
+10.75% |
| Risk |
+26.50% |
+10.74% |
-18.10% |
Discussion
The data in our pilot study indicate that prescribing behavior is affected
by the way in which risks are perceived and that the orientation
toward risks can be significantly affected by micro-language differences
in the presentation of the situation. Distinctive orientations foster
different patterns of response to the uncertainties and anxieties
that are presented in the situation, and language can be effective
in producing one attitude or the other. The inconsistent patterns
of decision produced by the use of "risk" versus "accept" cannot
be accounted for by the decision models of classical utility theory
or its modem descendants. [18,19]
These models rely on context-independent factors that do not distinguish
between the "risk" and "accept" manipulations
that produced different patterns of decision across age.
Earlier work [20,21] has described
two paradigms for both medical practice and decision behavior. Under
the mechanistic paradigm, medicine is practiced with the assumption that
there are sharply defined causes responsible for observed pathologies
and that these pathologies can be unerringly treated by eliminating those
causes. Complete certainty is within reach through the strict use of
the classically defined experimental method. The practitioner continues
to search for "the cause" and "the proper treatment" until
certainty is achieved. Under the probabilistic paradigm, knowledge is
gathered about a range of factors that are probabilistically associated
with a given pathology. Complete certainty about either "the cause" or "the
proper treatment" is conceded to be an unrealistic goal from the
outset. Instead, one seeks relevant information while recognizing that
there is no completely satisfying solution to the problem of how to treat.
The search, then, is not driven by the attempt to achieve complete certainty.
We believe that these paradigmatic distinctions are at the root of the
inconsistent patterns of choice behavior among the "risk" and "accept" subjects.
Each word elicits a distinctive orientation to the dangers of a potentially
tragic situation. Under the "risk" condition, where complete
certainty is presumed to be an achievable goal, subjects act out
the anxieties that emerge when treating elderly persons. The practice
of "defensive medicine" thrives under such circumstances.
For the prescriber, an already dangerous situation involving psychotic
patients and neuroleptic drugs becomes all the more threatening,
by the context-specific variation of age, as the age of the hypothetical
patient increases. Subjects are less willing to intervene actively
and therefore take fewer active risks (i.e., they are willing to "risk" only
a low probability of TD).
Under the "accept" condition, the probabilistic orientation
is implicitly instituted and complete certainty is recognized as an unachievable
goal. From the outset, uncertainty is an ineliminable aspect of treatment.
The micro-language of "accept" seems to be effective in helping
subjects realize and consciously cope with the added uncertainties that
are introduced when treating an elderly patient, and to be able to balance
the benefit of psychosis control with the potential tragic outcome in
a younger person of being disfigured for life by tardive dyskinesia.
In weighing the merits of the two orientations, it is arguable that the
probabilistic paradigm elicited by the word "accept" is
the more productive framework, and that the pattern of drug prescribing
displayed by subjects in the "accept" condition constitutes
better medical practice. Despite the fact that the probability of
inducing TD increases with the age of the patient, it would appear
to be an overriding consideration that fewer chances should be taken
with younger patients who have longer lives ahead of them.
In summary, if micro-language differences are effective in altering risk
perception in risky situations, then in principle we have a tool
in hand for adjusting the amount of risk that persons are willing
to assume in such situations. Risks are psychologically more acceptable
once it is made clear, by the language that is used, that any chosen
course of action entails the acceptance of uncertainty. Under such
conditions, the task becomes one of minimizing the risks rather than
avoiding them. If, however, the language that is used implies that
risks can in principle be completely eliminated, then either people
will engage in a futile search for a risk-free course of action,
or the risks will be denied, repressed, or acted out as in the form
of defensive medicine.
In suggesting that the manner in which the clinician frames the question
of costs and benefits of treatment and side effects will significantly
influence the decision strategy, one implication is that, when facing
decisions involving tragic choices, clinicians should ask themselves
the questions of treatment choice in both "risk" and "accept" terms.
This may be a useful corrective to the overemphasis on control and
clinician omnipotence when framing the question solely in anxiety-provoking
"risk" terms. By keeping in mind that in science some degree
of uncertainty must be accepted, the clinician can take a cooler look
at the relative merits of the available treatment options.
A clinician in this frame of mind can also use the informed consent process
as an opportunity for building a therapeutic alliance. [22]
Attention must be paid to the language of informed consent forms
in which patients are asked to risk side effects from a recommended
course of treatment. Too often these forms leave the impression that
risk can be avoided by abstaining from the treatment. An informed
consent dialogue that clarifies the need to accept the costs of any
course of action (including inaction) will allow for wiser consideration
of treatment choices—by both physician and patient. By fostering
sound clinical decisions, increased patient participation in decision
making, and greater trust between patient and physician, such a process
stands to reduce both the fear and the actuality of malpractice liability.
References
-
Davis JM, Schyve PM, Parkovic I: Clinical
and legal issues in neuroleptic use. Clin Neuropharmacol 6:117-28,
1983
-
Wettstein RM: Tardive dyskinesia and malpractice.
Behav Sci Law 1:85-107, 1983
-
Gelenberg AJ: $375,000 for tardive dyskinesia.
Biol Therapies Psychiatry 3:41-2, 1982
-
Rogers v. Okin, 634 F.2d 650 (1st Cir. 1980)
-
Rogers v. Okin, 478 F. Supp. 1342 (D. Mass.
1979)
-
Mills V. Rogers, 457 U.S. 291, 102 Sp. Ct.
2442 (1982)
-
Clites v. State of Iowa, no. 46274 (August
7, 1980, 4th District)
-
Clites v. State, 322 N.W. 2d 917 (Iowa Ct.
App. 1982)
-
Fisch H-U, Hammond KR, Joyce CRB, O'Reilly
M: An experimental study of the clinical judgment of general physicians
in evaluating and prescribing for depression. Br J Psychiatry 138:100-9,
1981
-
Rudestam KE, Tarbell SB: The clinical judgment
process in the prescribing of psycho- tropic drugs. Int J Addictions
16:1049-70, 1981
-
Yamamoto J, Coin MK: Social class factors
relevant for psychiatric treatment. J Nerv Ment Dis 142:332-9, 1966
-
Shader RI, Binstock WA, Scott D: Psychiatrists'
biases: who gets drugs? Soc Sci Med 2:213-6, 1968
-
Mwkheyee S, Rosen AM, Cardenas C, Varia
V, Olarte S: Tardive dyskinesia in psychiatric outpatients: a study
of prevalence and association with demographic, clinical and drug
history variables. Arch Gen Psychiatry 39:466-9, 1982
-
Kane JM, Smith JM: Tardive dyskinesia: prevalence
and risk factors, 1959 to 1979. Arch Gen Psychiatry 39:473-81, 1982
-
Bursztajn H, Chanowitz B, Kaplan E, Gutheil
TG, Hamm RM, Alexander V: Medical
and judicial perceptions of the risks associated with use of antipsychotic
medication. Bull Am Acad Psychiatry Law 19:271-5, 1991
-
Keppel G: Design and Analysis: A Researcher's
Handbook. Englewood Cliffs, NJ, Prentice-Hall, 1973, pp. 187-223
-
Janis IL, Mann L: Decision Making. New York,
Free Press, 1977
-
Kahneman D, Tversky A: Prospect theory.
Econometrica 47:263-92, 1979
-
Tversky A, Kahneman D: The framing of decisions
and the psychology of choice. Science 211:453-8, 1981
-
Bursztajn H, Feinbloom RI, Hamm RM, Brodsky
A: Medical Choices, Medical Chances: How
Patients, Families, and Physicians Can Cope with Uncertainty. New
York, Routledge, 1990
-
Bursztajn H, Hamm RM: Medical
maxims: two views of science. Yale J Biol Med 52:483-6, 1979
-
Gutheil TG, Bursztajn H, Brodsky A: Malpractice
prevention through the sharing of uncertainty: informed consent and
the therapeutic alliance. N Engl J Med 311:49-51, 1984
