title: Pitfalls of counterfactual thinking in medical practice: preventing errors by using more functional reference points.
abstract: BACKGROUND
  Counterfactual thinking involves mentally simulating alternatives to reality. The current article reviews literature pertaining to the relevance counterfactual thinking has for the quality of medical decision making. Although earlier counterfactual thought research concluded that counterfactuals have important benefits for the individual, there are reasons to believe that counterfactual thinking is also associated with dysfunctional consequences. Of particular focus is whether or not medical experience, and its influence on counterfactual thinking, actually informs or improves medical practice. It is hypothesized that relatively more probable decision alternatives, followed by undesirable outcomes and counterfactual thought responses, can be abandoned for relatively less probable decision alternatives.
  
  
  METHODS
  Building on earlier research demonstrating that counterfactual thinking can impede memory and learning in a decision paradigm with undergraduate students, the current study examines the extent to which earlier findings can be generalized to practicing physicians (N=10). Participants were asked to complete 60 trials of a computerized Monty Hall Problem simulation. Learning by experience was operationalized as the frequency of switch-decisions.
  
  
  RESULTS
  Although some learning was evidenced by a general increase in switch-decision frequency across block trials, the extent of learning demonstrated was not ideal, nor practical.
  
  
  CONCLUSIONS
  A simple, multiple-trial, decision paradigm demonstrated that doctors fail to learn basic decision-outcome associations through experience. An agenda for future research, which tests the functionality of reference points (other than counterfactual alternatives) for the purposes of medical decision making, is proposed. Significance for public healthThe quality of healthcare depends heavily on the judgments and decisions made by doctors and other medical professionals. Findings from this research indicate that doctors fail to learn basic decision-outcome associations through experience, as evidenced by the sample's tendency to select the optimal decision strategy in only 50% of 60 trials (each of which was followed by veridical feedback). These findings suggest that professional experience is unlikely to enhance the quality of medical decision making. Thus, this research has implications for understanding how doctors' reactions to medical outcomes shape their judgments and affect the degree to which their future treatment intentions are consistent with clinical practice guidelines. The current research is integrated with earlier research on counter-factual thinking, which appears to be a primary element inhibiting the learning of decision-outcome associations. An agenda for future research is proposed.
authors.affiliation: Department of Psychology, Wake Forest University , Winston-Salem, NC, USA.
authors.forename: John V
authors.initials: JV
authors.lastname: Petrocelli
keywords: counterfactual thinking; medical errors; medical reasoning