Introduction: Cognitive errors are commonly made by patients during medical visits, traditionally thought to be due to gaps in communication and a complicated subject matter; use of diagrams and post-visit summaries has had a modest effect in improving in patient understanding and recall. We hypothesize that those cognitive errors can also be understood by using the behavioral economics framework of “System 1” mindset, in which patients are reliant on intuition and vulnerable to heuristics, as opposed to “System 2” mindset, which is reflective, slow and detailed-oriented, and that patient-reported outcome measures (PROMs) can shift patients to a “System 2” mindset.
Methods: In this pilot, patients from a tertiary center adult congenital heart disease clinic were given Frederick’s Cognitive Reflection Test (CRT; score of 0 to 3, with low scores associated with System 1 mindset) prior to a routine clinical visit. They were randomly assigned to complete the PROMIS and Kansas City Cardiomyopathy Questionnaire either before or after the CRT. The primary endpoint was the mean CRT score in all patients; the secondary endpoint was a comparison of the effect of PROMs. Kruskal-Wallis test was used to compare ordinal variables.
Results: Patients (N=47) had a mean age of 48, 93% were native English speakers and all had completed high school (93% at least started college). The median CRT score was 0 (IQR 0-1; 74% had a score of 0), and the mean score was 0.45 (SD 0.85), which is lower than any previously published results in control populations (mean scores 0.57 to 2.18 in 35 studies with 3428 respondents). CRT scores were numerically but not statistically higher in the group who completed the PROMs first (32% vs 20% had a score >0, mean 0.5 vs. 0.4, p=0.46). Patients randomized to PROMs first reported more often that they remembered to ask the physician the questions they had (94.7% vs. 86.7%) and were less nervous during the visit (15.8% vs. 46.7%).
Conclusions: The finding that patients are in an intuitive state of mind prior to routine clinic visits, reliant on heuristics and vulnerable to biases, offers an important new framework in which to devise interventions to improve patient participation in their medical visits, recall of information, and decision-making. PROM are a promising candidate for intervention that will be further studied.