Having established my diagnosis of conversion disorder (and no, conversion disorder is NOT a “diagnosis of exclusion” as we are commonly taught, any more than any other diagnosis is also a diagnosis of exclusion), there was no need for the MRI. But did I tell the ER to cancel the MRI? I did not. I WANTED to. I really wanted to. I agonized over the decision. Honestly. But because the MRI was already ordered, I could not bring myself to cancel this unnecessary test. What IF? At the time, I literally thought to myself “cognitive bias! cognitive bias!”, but did not cancel the test. Later, the patient was examined by ophthalmology, who came to the same diagnosis of conversion disorder. But still, none of us suggested cancelling the test, which I had initially ordered in case this was a case of optic neuritis, which it was clearly not. But, what if…? Of course, the MRI was normal and she was sent home after a lengthy discussion about her diagnosis. But in the mean time I had taken up valuable time in the MRI which could have been used by other patients, I had subjected the patient to a contrast injection she might have been allergic to or could have damaged her kidneys, and I had subjected the patient and/or her insurance company to $2000-plus of unnecessary costs. I honestly believe that had I not initially ordered the MRI, I would not have ordered one after seeing the patient. So why did she get the MRI? Read on.
This is clear example of the Power of the Default Option, officially known by the term “status quo” bias. Status quo bias is the observation that it is harder for us to make a change to a default pathway, the status quo, than it is to make the same decision without that default option already in place. Put another way, we have a “tendency to do nothing”. And this inertia is more powerful than we think. There are hundreds of examples of this, and perhaps the most commonly known example relates to organ donation rates. If one has to check a box to become an organ donor, one is much less likely to do so than if one has to check a box to NOT be an organ donor. It’s a classic opt-in or opt-out example. Apparently it is a lot of work to check a box!
There is another well known study demonstrating cognitive bias in decision making. In this study, physicians were given a patient vignette describing a woman with hip pain who had been referred to an orthopedic surgeon for a possible hip replacement. One group of MDs were told the patient had not yet tried ibuprofen for her hip pain. They were asked to decide between referral to orthopedics together with starting ibuprofen, or referral to orthopedics with no trial of medication. However, another group of MDs were given a slightly different scenario. In this case, they were told the woman had not tried ibuprofen nor another similar anti-inflammatory medication, piroxicam. This group was to choose between referral only, referral and ibuprofen, or referral and piroxicam.
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