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Choice architecture in physician–patient communication: a mixed-methods assessments of physicians’ competency
  1. Joanna Hart1,2,3,4,
  2. Kuldeep Yadav1,
  3. Stephanie Szymanski1,
  4. Amy Summer1,
  5. Aaron Tannenbaum1,2,
  6. Julian Zlatev5,
  7. David Daniels6,
  8. Scott D Halpern1,2,3,4
  1. 1Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  4. 4Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  5. 5Negotiation, Organizations & Markets Unit, Harvard Business School, Boston, Massachusetts, USA
  6. 6NUS Business School, National University of Singapore, Singapore
  1. Correspondence to Dr Joanna Hart, Palliative and Advanced Illness Research Center, Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA 19104, USA; joanna.hart{at}


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.

  • cognitive biases
  • communication
  • decision making
  • graduate medical education
  • human factors

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  • Twitter @JHartMD, @KuldeepNYadav

  • Correction notice The article has been corrected since it was published online first. The affiliation of the co-author David Daniels has been updated to NUS Business School, National University of Singapore, Singapore.

  • Contributors All authors made substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data. All authors were involved in drafting the work or revising and reviewing it critically for important intellectual content. All authors gave final approval of the version published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This study was funded by the National Heart, Lung, and Blood Institute (K23HL132065) and Leonard Davis Institute - Center for Health Incentives and Behavioral Economics Penn Roybal Center, National Institute on Aging (P30AG034546).

  • Disclaimer The funding sources played no role in designing the study, interpreting the data, or writing and publishing the manuscript.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The Institutional Review Board of the University of Pennsylvania approved this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Protocols and analytic plans are available upon request. The full instruments were included in the supplemental materials. Data may be shared upon reasonable request in alignment with institutional policies.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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