By Mariya Rozenblit, MD
Peer Reviewed
On my first day of internship I was faced with the seemingly simple task of consenting a patient for a blood transfusion. I went over the informed consent form with the patient, explaining the benefits and possible risks, and asked the patient if he had any questions. He did not and happily signed the form. However, I was left wondering if he truly comprehended the information. How much did he know about hepatitis C and HIV and how these diseases are transmitted? To someone with a limited knowledge of statistics, what does it truly mean to hear that the risk of hepatitis B is 1:220,000, hepatitis C is 1:1,800,000 and HIV is 1:2,300,000? In addition, I had mentioned possible allergic reactions, but not their probabilities. The risk of febrile reactions is 4:100, delayed hemolytic reactions 1:1000, TRALI 1:5000, acute hemolytic reaction 1:12,000, fatal hemolytic 1:100,000 and anaphylactic 1:150,000. How much information is enough information and how much information is too much information?
I had always been taught to err on the side of more information. Knowledge is power and I want to educate my patients as much as possible so that they can make informed decisions. However, recent studies suggest that too much information can be confusing and frustrating. In a recent cross sectional survey, patients were asked to rate their experience with cancer-related information that they received from their health care provider and that they found on the internet. Thirty nine percent of survey respondents stated that they felt frustrated with the information that they received from their healthcare provider, 43% stated that the information was too difficult to understand, and 54% didn’t trust the quality of the information. The experience with the internet search was similar, with 41% expressing frustration, 32% stating information was too difficult to understand and 58% not trusting the quality of the information. It’s disheartening to note that the information from the healthcare provider was just as confusing as random information found on the internet. In addition, the study found that lower education level and lack of health insurance was associated with a more frustrating experience (p<0.001). At the conclusion of their search, more than half of the survey respondents came to erroneous conclusions. Fifty one percent stated that everything causes cancer and 75% stated there were too many cancer prevention recommendations and that they were too difficult to follow [2]. This study shows that not only can too much information lead to confusion, frustration, and erroneous conclusions, but also that individuals from low socioeconomic backgrounds are the most vulnerable to experiencing the negative consequences of information overload.
In addition to confusion and frustration, information overload can also negatively impact decision-making. Some studies suggest that presenting patients with too much information can actually lead to worse decisions. For example, when patients were presented with hypothetical information about the cost and quality of different hospitals, they were able to accurately choose the cheaper and better quality option when they were presented with fewer facts. Individuals were randomized to three groups. Group one was presented with 9 facts about two hospitals; out of pocket costs, number of beds, quality of hospital food, % of heart attack guidelines followed, % pneumonia guidelines followed, number of visiting hours, number of nurses per patient, availability of patient references, and whether the hospital has a computer system. Group two was presented with the same information, but with the quality indicators at the top and highlighted. Group three was presented only with the cost and quality indicators (number of nurses, presence of computer system, % heart attack guidelines followed, % pneumonia guidelines followed). The survey respondents were then asked to pick the cheapest highest quality hospital and were asked questions regarding their comprehension of the facts that they were presented with. Comprehension was highest in group 3, they answered the most questions correctly and 62% chose the highest quality hospital vs. 40% in group 1, vs. 48% in group 2 (p<0.01) [3]. Although grouping and ordering the information slightly helped, presenting only the relevant information and reducing the amount of the overall information presented, increased comprehension and increased the probability of choosing the correct choice. In healthcare decision making, there is often no right or wrong answer, but it is important to consider what information is truly relevant so that the patient can be presented with less but higher quality information.
One of the dangers of being presented with too much information is the cognitive shortcuts that patients may utilize to handle the overload. Studies that have analyzed how individuals cope with too much information, have found that they tend to consider only part of the information. In one scenario, study participants were asked to choose a hospital for a knee arthroscopy using online information regarding three hospitals, and scales were used to assess their confusion and whether they hastily narrowed down information. The study found that individuals reported more confusion when presented with a lot of information, and especially when the information was ambiguous or contradictory. Individuals who reported higher levels of confusion, narrowed down their choices more quickly (p<0.01) [4]. When individuals hastily narrow the information that they are considering, this is usually using associative, automatic reasoning, which is faster, but relies on intuitive heuristics and associations rather than facts. This usually involves scanning the information, looking for information that confirms what they already have in mind based on their previous knowledge or experience [5]. Unfortunately, if their preconceived notions are inaccurate, they will disregard information that contradicts their viewpoint, and will miss a lot of information without realizing its importance.
To help battle the negative consequences of information overload, the physician can thoughtfully limit the amount of information presented, limiting it to the most pertinent facts. Interpretive symbols added to the data that individuals were presented appeared to improve comprehension. In the study regarding choosing a low cost high quality hospital, mentioned above, for example, when dollar signs were used to represent level of cost rather than actual numbers, and when pluses were put next to high quality data such as a high nurse per patient ratio, participants scored higher in comprehension questions and 73% chose the low cost high quality hospital (p<0.01) [3]. In addition, physicians should add their own interpretation of the information presented, based on their knowledge and experience,. A patient may get overwhelmed by a lot of numbers and it is helpful to contextualize something as a low probability and interpret it as a low risk. Physicians could also clearly state their own recommendations. Studies have shown that a clear recommendation from the physician helps to alleviate patient stress. For example, when patients were presented with a video of a physician describing the risks of a new medication, they were more willing to take the medication and expressed less worry about the adverse effects when the patient instructions included a recommendation from the physician to take the medication. Including a statement that the physician recommends the medication reduced the patient’s level of worry from 6.1 to 5.5 on a scale of 0-10 (p<0.001) [6].
In a thoughtful commentary in the NEJM, Dr. Rosenbaum argues that it is the duty of the physician not just to inform but to actively participate in the decision making process. She describes her own uncertainty in whether to recommend an ICD to a patient with nonischemic cardiomyopathy. After she presents the pros and cons she feels a sense of relief when the patient says that he will think about it and make his own decision. She realizes that the relief comes from her avoiding having to make a difficult decision. By not making a direct recommendation, she left the difficult decision completely up to the patient. Therefore, although she felt that she had informed the patient, she hadn’t fulfilled her responsibility as a physician by actually assuming responsibility for his care. She mentions how her greatest admiration is for physicians who can read their patients and accurately determine how much information needs to be shared and in what manner [7].
The goal of presenting information to patients is to empower them to make their own healthcare decisions because as a medical institution we highly value patient autonomy. However, too much information can actually hinder patient autonomy by increasing confusion, frustration, and utilization of cognitive shortcuts that can all lead to misinterpretation of the information. In order to battle information overload, the physician must find a fine balance between patient autonomy and what Dr. Rosenbaum refers to as ‘paternalism preference’. A clear recommendation from the physician can help to contextualize the data and alleviate stress for the patient. As a young physician, I don’t want to be paternalistic, but at the same time, I realize that my role as a physician is more than just being a source of information. I hope that with training and years of experience I can become one of the physicians that Dr. Rosenbaum describes as having “sophisticated intuition” that allows me to determine the perfect amount of information in the best possible format needed for my patients so that together we can come to the best decision possible.
Dr. Mariya Rozenblit is an internal medicine resident at NYU Langone Medical Center
Peer reviewed by Dr. Antonella Surbone, MD, Ethics Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
References
1) Dzieczkowski J, Anderson K. Harrison’s Principles of Internal Medicine 18e: Chapter 113 Transfusion Biology and Therapy. McGraw Hill 2012 http://accessmedicine.mhmedical.com/content.aspx?bookid=331§ionid=40726852
2) Arora N, Hesse B, Rimer B, et al. Frustrated and Confused: The American Public Rates it’s Cancer-Related Information-Seeking Experiences. J Gen Intern Med 2008; 23(3):223-228. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359461/
3) Peters E, Dieckmann N, Dixon A, Hibbard JH, Mertz CK. Less is more in presenting quality information to consumers. Med Care Res Rev 2007;64:169-90 https://www.ncbi.nlm.nih.gov/pubmed/17406019
4) Gebele C, Tscheulin D, Lindenmeier J, et al. Applying the concept of consumer confusion to healthcare: Development and validation of a patient confusion model. Health Serv Manage Res. 2014;27(1-2):10-21. https://www.ncbi.nlm.nih.gov/pubmed/25595013
5) Damman OC, Hendriks M, Rademakers J, et al. How do healthcare consumers process and evaluate comparative healthcare information? BMC Public Health 2009;20:9:423 http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-423
6) ) Fraenkel L, Peters E. Patient responsibility for medical decision making and risky treatment options. Arthritis Rheum 2009;61: 1674-6. https://www.ncbi.nlm.nih.gov/pubmed/19950320
7) Rosenbaum L. The Paternalism Preference- Choosing Unshared Decision Making. N Eng J Med 2015;373(7):589-592. http://www.nejm.org/doi/full/10.1056/NEJMp1508418#t=article