Supporting effective shared decision-making in surgical context: Why framing of choices matters for high-risk patients and clinicians.

AIM: In the context of high-risk surgery, shared decision-making (SDM) is important. However, the effectiveness of SDM can be hindered by misalignment between patients and clinicians in their expectations of postoperative outcomes. This study investigated the extent and the effects of this misalignment, as well as its amenability to interventions that encourage perspective-taking. METHOD: Lay participants with a Charlson Comorbidity Index of ≥4 (representing patients) and surgeons and anaesthetists (representing doctors) were recruited. During an online experiment, subjects in both groups forecast their expectations regarding short-term (0, 1 and 3 months after treatment) and long-term (6, 9 and 12 months after treatment) outcomes of different treatment options for one of three hypothetical clinical scenarios - ischaemic heart disease, colorectal cancer or osteoarthritis of the hip - and then chose between surgical or non-surgical treatment. Subjects in both groups were asked to consider the scenarios from their own perspective (Estimation task), and then to adopt the perspective of subjects in the other study group (Perspective task). The decisions of all participants (surgery vs. non-surgical alternative) were analysed using binomial generalized linear mixed models. RESULTS: In total, 55 lay participants and 54 doctors completed the online experiment. Systematic misalignment in expectations between high-risk patients and doctors was observed, with patients expecting better surgical outcomes than clinicians. Patients forecast a significantly higher likelihood of engaging in normal activities in the long term (ß = -1.09, standard error [SE] = 0.20, t = -5.38, p < 0.001), a lower likelihood of experiencing complications in the long term (ß = 0.92, SE = 0.21, t = 4.45, p < 0.001) and a lower likelihood of experiencing depression in both the short term and the long term (ß = 1.01, SE = 0.19, t = 5.38, p < 0.001), than did doctors. Compared with doctors, patients forecast higher estimates of experiencing complications in the short term when a non-surgical alternative was selected (ß = -0.91, SE = 0.26, t = -3.50, p = 0.003). Despite this misalignment, in both groups surgical treatment was strongly preferred (estimation task: 88.7% of doctors and 80% of patients; perspective task: 82.2% of doctors and 90.1% of patients). CONCLUSION: When high-risk surgery is discussed, a non-surgical option may be viewed as 'doing nothing', hence reducing the sense of agency and control. This biases the decision-making process, regardless of the expectations that doctors and patients might have about the outcomes of surgery. Therefore, to improve SDM and to increase the agency and control of patients regarding decisions about their care, we advocate framing the non-surgical treatment options in a way that emphasizes action, agency and change.

Actions Do Not Always Speak Louder Than Words.

Financial (dis)incentives (e.g., bonuses, taxes) and social incentives (e.g., public praise) have typically been proposed as methods to encourage greater cooperation for the benefit of all. However, when cooperation requires exertion of effort, such interventions might not always be effective. While incentives tend to be highly motivating when choosing to exert effort, evidence suggests that they have less of an effect on behavior during effort execution. The aim of this exploratory study was to incorporate these insights into empirical investigation of the effects of social incentives on cooperative effort. To this end, we modified a public goods game task to require effort contributions to a common good. Crucial manipulation involved incorporating social incentives into this task and linking them to (a) choices that people made or (b) effortful actions they exerted. Our findings suggest, in line with recent effort-based decision-making models, that social incentives have a stronger effect on cooperative effort when they are linked to choices that people make, rather than the actual effort they exert. This study demonstrates potential benefits of eliciting a priori declarations of cooperative effort tied to social incentives to encourage greater effort for the benefit of all.

Redefining the relationship between effort and reward: Choice-execution model of effort-based decisions.

Neuroscientific studies reliably demonstrate that rewards play a crucial role in guiding our choices when confronted with different effortful actions we could make. At the same time, psychological and economic research shows that effort we exert is not reliably predicted by the rewards we end up receiving. Why the mismatch between the two lines of evidence? Inspired by neuroscientific literature, we argue that value-based models of decision-making expose the complexity of the relationship between effort and reward, which changes between two crucial stages of the effort-based decision making process: Choice (i.e. action selection) and Execution (i.e. action execution involving actual effort exertion). To test this assumption, in the present study we set up two experiments (E1: N = 72, E2: N = 87), using a typical neuroscientific effort-based decision-making task. The findings of these experiments reveal that when making prospective choices, rewards do guide the level of effort people are prepared to exert, consistent with typical findings from Neuroscience. At a later stage, during execution of effortful actions, performance is determined by the actual amount of effort that needs to be exerted, consistent with psychological and behavioral economic research. We use the model we tested and the findings we generated to highlight critical new insights into effort-reward relationship, bringing different literatures together in the context of questions regarding what effort its, and the role that values play.