Physician judgment in clinical settings: methodological influences and cognitive performance

Understanding the quality of physicians' intuitive judgments is essential in determining the appropriate use of their judgments in medical decision-making (vis-a-vis analytical or actuarial approaches). As part of this process, the quality of physicians' predictions must be assessed because prediction is fundamental to common clinical tasks: determining diagnosis, prognosis, and therapy; establishing monitoring intervals; performing screening and preventive maneuvers. Critical evaluation of predictive capabilities requires an assessment of the components of the prediction process: the data available for prediction, the method used for prediction, and the accuracy of prediction. Although variation in and uncertainty about the underlying data elements are often acknowledged as a source of inaccurate predictions, prediction also can be confounded by both methodological and cognitive limitations. During the past two decades, numerous factors have been recognized that may bias test characteristics (sensitivity and specificity). These same factors may also produce bias in intuitive judgments. The use of cognitive processes to simplify judgment tasks (e.g., the availability and representativeness heuristics) and the presence of certain biases in the judgment process (e.g., ego, regret) may present obstacles to accurate estimation of probabilities by physicians. Limitations on the intuitive use of information (cognitive biases) have been demonstrated in both medical and nonmedical decision-making settings. Recent studies have led to a deepening understanding of the advantages and disadvantages of intuitive and analytical approaches to decision making. Here, many aspects of the basis for this understanding are reviewed.