Choice Architecture in Physician–patient Communication: A Mixed-methods Assessment of Physicians' Competency

Background: Clinicians’ use of choice architecture, or how they present options, systematically influences the choices made by patients and their surrogate decision makers. However, clinicians may incompletely understand this influence.
Objective: To assess physicians’ abilities to predict how common choice frames influence people’s choices.
Methods: We conducted a prospective mixed-methods study using a scenario-based competency questionnaire and semistructured interviews. Participants were senior resident physicians from a large health system. Of 160 eligible participants, 93 (58.1%) completed the scenario-based questionnaire and 15 completed the semistructured interview. The primary outcome was choice architecture competency, defined as the number of correct answers on the eight-item scenario-based choice architecture competency questionnaire. We generated the scenarios based on existing decision science literature and validated them using an online sample of lay participants. We then assessed senior resident physicians’ choice architecture competency using the questionnaire. We interviewed a subset of participating physicians to explore how they approached the scenario-based questions and their views on choice architecture in clinical medicine and medical education.
Results: Physicians’ mean correct score was 4.85 (95% CI 4.59 to 5.11) out of 8 scenario-based questions. Regression models identified no associations between choice architecture competency and measured physician characteristics. Physicians found choice architecture highly relevant to clinical practice. They viewed the intentional use of choice architecture as acceptable and ethical, but felt they lacked sufficient training in the principles to do so.
Conclusion: Clinicians assume the role of choice architect whether they realise it or not. Our results suggest that the majority of physicians have inadequate choice architecture competency. The uninformed use of choice architecture by clinicians may influence patients and family members in ways clinicians may not anticipate nor intend.