Surveillance in Barrett's Esophagus: Lessons from Behavioral Economics

Abstract

Several observations in clinical practice including that of digestive diseases appear to be difficult to explain on a rational basis. These include doing “too much” such as repeated testing, parallel testing, expensive and extensive testing for unlikely rare disorders, as well as doing “too little” such as screening for common cancer, vaccination, or counseling. Some of the practices seem baffling at first glance especially given the presence of decision analysis models, cost effectiveness models, and occasionally evidence-based published guidelines that delineate rational medical decision making. Conventional economics (i.e., rational utility theory) assumes that decisions are arrived at through a “rational” process of weighing benefits against costs for the goal of maximizing one’s utility. Medical decision making is modeled by similar assumptions; namely, physicians (and patients) should make utility maximizing (i.e., rational economic) decisions about each patient who presents to them considering all the available data and balancing benefits/harms against costs. However, there has been a growing interest in behavioral economics, which concerns itself with describing how decisions are actually made. Behavioral economics assumes that we (people) are “predictably irrational”(1) in the way we make decisions on several things including those decisions pertaining to health, and that understanding the basis for this irrationality might be used to make us “do the right thing” despite ourselves. Daniel Kahneman was awarded the Nobel prize in Economics in 2002 for his and Amos Tversky’s empiric work describing how individuals do not make decisions based on a rational, utility maximizing process. Kahneman and Tversky (1973) demonstrated that individuals use mental short-cuts (heuristics) to efficiently and reliably make decisions that are often in contrary to models that determine preferences based on weighing benefits against costs. Furthermore, using the term “prospect” to refer to a set of outcomes with a probability distribution, they state that where winning is possible but not probable, i.e. when probabilities are low, most people choose the prospect that offers the larger gain. Conversely, with the same quantitative probability for a loss, most people choose the prospect that offers the smallest loss. Their Prospect theory (1979) illustrated how individuals predictably overweigh losses and underweigh gains. We will illustrate these concepts with an example of seemingly non-rational behavior in GI practice, highlight the relevant explanations from behavioral economics, and conclude with proposed ways to intervene based on these theories.