Article examines why delivery complications can influence physician decision-making for the next patient

In a new commentary article published in Science, Meng Li, associate professor and director of undergraduate studies in the Department of Health and Behavioral Sciences at the University of Colorado Denver, attempts to explain why physicians commit a damaging error in the delivery room, and offer insight on how to deal with it.

Li’s article, co-authored with Helen Colby, PhD, at Indiana University, comments on a research article appearing in the same issue of Science by Manasvini Singh, health economist at the University of Massachusetts Amherst.  Analyzing more than 86,000 patient medical records, Singh’s research shows that if a physician delivers a baby through a vaginal or Cesarean birth (C-section) and the delivery has complications, the physician is more likely to switch to the opposite delivery method for the next patient’s birth. This pattern comes with significant consequences including an increased probability of death for the mother and/or baby (by about 0.11%), a decreased probability of the patient being discharged home (by about 0.11%), and an increased number of outpatient visits (by 0.03 visits within one-month post-delivery). This strategy, often referred to as “win-stay/lose-shift” is a common learning strategy in other areas of life, but why does it cause such negative consequences in the delivery room, and what can be done?

Li and Colby’s commentary points out that humans oftentimes use heuristics, or mental shortcuts, to make fast decisions in complex situations, which is usually an effective strategy, but occasionally can lead to errors in decision-making, and in this case, in the delivery room.

“This type of decision-making in deliveries would make sense if the specifics of the previous patient matched the specifics of the current patient and was thus a ‘learning experience,’” said Li. “However, two patients who happen to have consecutive deliveries are not typically highly familiar, meaning this switching behavior is being inappropriately applied, thus leading to potentially dangerous outcomes.”

The reason behind such a phenomena, Li and Colby note, is due to recency, affect heuristic, or confirmation bias:

• In the case of recency, psychology tells us that the most recent events are the most prominent in our memory. Because of this, a complicated birth may exert an over-pronounced influence on a physician’s choice with the next patient.
• Affect heuristic is the “mental shortcut” where individuals tend to perceive how big a risk is depending on how strong their emotions are about the risk. Because unsuccessful deliveries are highly emotional, a physician’s estimate of risk can be distorted, prompting them to switch to a different delivery mode to avoid the increased perceived risk.
• Confirmation bias is the tendency to seek out information that provides support for one’s initial opinion. Physicians who are uncomfortable with a delivery mode due to a recent negative experience already have an initial inclination toward a different delivery mode, and they may inadvertently seek out signs that would support this initial tendency. In other words, doctors may notice more reasons to switch the mode of delivery to help them feel more comfortable and confident that modality switching is appropriate for the current patient.

“My article isn’t meant to put blame on doctors,” said Li. “Instead, it shows that physicians, just like the rest of us, are human and we know that humans are not perfect or always rational.”

Li notes that people frequently rely on heuristics, or decision rules, to make decisions and the doctors’ misapplication of the otherwise useful decision rule can only be addressed if medicine starts to embrace an important concept—human irrationality.

“Only then can medicine be open to studying and implementing decision aids that can help doctors make better decisions in high-pressure, complex situations such as the delivery room,” said Li.