New study identifies a "sweet spot" in clinical decision-making

Having more options is always better - until it's not. 

Doctors face this paradox daily when choosing treatment plans for patients, especially under the pressure of packed clinical schedules. Too few choices can limit care, but too many can lead to decision fatigue. 

In a new study involving 402 U.S.-based primary care physicians, researchers from Northwestern University and the University of Sydney identified a "sweet spot" in clinical decision-making. By presenting just the right number of treatment alternatives in the electronic health record (EHR) system, physicians were more likely to choose a high-quality alternative rather than defaulting to the status quo.

The study will be published Nov. 13 in JAMA Network Open. 

The new trial found that offering two or more appropriate treatment options significantly increased the odds of physicians selecting an alternative (62%) compared to those offered only one (44%). Adding more than two options didn't further improve decision-making, which suggests more isn't always better.

"We have this unrealistic notion that doctors are rational all the time about the decisions we're making for our patients, but we're human, too," said study author Dr. Jeffrey Linder, chief of general internal medicine at Northwestern University Feinberg School of Medicine and a Northwestern Medicine physician who played a key role in designing the study. "We're trying to make it easier for physicians to do the right thing."

To support better care, health systems should design EHRs with thoughtfully curated prompts that nudge physicians toward evidence-based alternatives, whether that's ordering a test, prescribing a drug or considering a less-invasive treatment, Linder said.

Doctors are getting more and more alerts during patient consultations, but if they are based on outdated evidence, the systems designed to improve care could end up doing more harm than good. These very simple changes could support better care on a massive scale."

Gemma Altinger, lead author, applied behavioral economist and Ph.D. candidate, Faculty of Medicine and Health, University of Sydney, Australia

How the study worked

Physicians were presented with two scenarios: one involving surgery referral for hip osteoarthritis, the other opioid prescribing for back pain. They were asked whether to stick with the current management plan or choose an alternative. Control physicians saw one appropriate alternative in the EHR while intervention physicians saw two, three or four.

The findings challenge a widely cited 1995 study that suggested more physician choice may lead to "status-quo bias" and worse decisions because the doctors are overloaded by too many choices. This new trial found that doctors made better care decisions when given more options and found no evidence of status-quo bias.