title: Omission bias and decision making in pulmonary and critical care medicine.
abstract: BACKGROUND
  Pulmonary and critical care physicians routinely make complex decisions, but little is known about cognitive aspects of this process. Omission bias and status quo bias are well-described cognitive biases that can cause lay decision makers to prefer inaction that preserves the status quo even when changing the status quo through action is more likely to lead to the best outcomes. It is unknown if these biases influence trained decision makers such as pulmonologists.
  
  
  OBJECTIVE
  To determine whether omission bias and status quo bias influence the medical decisions of pulmonologists.
  
  
  METHODS
  The study was a randomized controlled trial conducted within a cross-sectional survey of pulmonologists' opinions about the relevance of various factors in pulmonary and critical care decision making. We designed case vignettes that presented patient information with an associated patient management choice. The status quo state and the action/omission distinction were varied in two forms of otherwise identical vignettes. One form of each case vignette pair (A and B) was administered randomly to each prospective respondent during the first mailing of the opinion survey.
  
  
  METHODS
  Five hundred pulmonologists selected randomly from the membership of the American College of Chest Physicians.
  
  
  RESULTS
  There were 125 respondents, including 59 for form A and 66 form B (enrollment rate, 25%). In vignettes involving evaluation of pulmonary embolism and treatment of septic shock, respondents were more likely to choose a suboptimal management strategy when an omission option was present that allowed preservation of the status quo (71% vs 53%, p = 0.048; 50% vs 29%, p = 0.016, respectively). In a vignette involving a hypothetical clinical trial and the decision to prescribe tube feeding, the omission option was not significantly associated with the decision to prescribe tube feeding (54% vs 50%, p = 0.67).
  
  
  CONCLUSIONS
  Pulmonary and critical care decisions are susceptible to the influence of omission and status quo bias. Because of the great number of decisions that are made each day involving choices between maintaining or changing the status quo, this finding could have far-reaching implications for patient outcomes, cost-effectiveness, resource utilization, clinical practice variability, and medical errors.
authors.affiliation: Johns Hopkins Medical Institutions, Division of Pulmonary and Critical Care Medicine, 1830 Monument St, Fifth Floor, Baltimore, MD 21205, USA. scottaberegg@hotmail.com
authors.forename: Scott K
authors.initials: SK
authors.lastname: Aberegg
authors.forename: Edward F
authors.initials: EF
authors.lastname: Haponik
authors.forename: Peter B
authors.initials: PB
authors.lastname: Terry
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D015982:Bias; D002405:Catheterization, Central Venous; D002637:Chest Pain / Q000150:complications / Q000628:therapy; D003422:Critical Care; D003430:Cross-Sectional Studies; D003657:Decision Making; D004750:Enteral Nutrition; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D015272:Pulmonary Medicine; D015983:Selection Bias; D012772:Shock, Septic / Q000628:therapy