Table 3

Themes from semistructured interviews of physicians

ThemesRepresentative quotations
Recognising choice architecture
 Choice architecture’s relevance in the healthcare setting“I think it applies a huge amount. I mean, every day…when we interact with patients, you have to give them their choices and their options.”
 Drawing on clinical experience to rationalise survey answers“We do scopes through the nose. Sometimes we’ll numb the nose and sometimes we won’t. The last thing I say is ‘we’re not going to numb your nose, but it’s fine. Everyone puts up with it.’ [The patients] are like ‘oh, okay’ and they kind of go with it. So I think I do it almost on a daily basis.”
 The effects of some heuristics feel intuitive, while others are surprising“I think multiple alternate bias sounds, is familiar to me. The other [choice architecture principles] are just more intuitive, like I mean social norms is very intuitive.”
“Well, since I answered the other way, I think it’s not related or…that it shouldn’t influence. Maybe it’s my way of thinking about it, but it is very interesting, that concept of anchoring, in which people can make a decision based on a priming or a number given before.”
Training in choice architecture
 Learning through the apprenticeship model“I would say that most of [what I’ve learned] has been, the vast majority – 95% plus has been observing just the random current position you happen to be dealing with, how they happen to do it, seeing a bunch of people present options and trying to decide on your own what makes sense for you.”
 Learning on the fly“We don’t talk about these things usually. People just figure, at least in anesthesia, we just figure out how we present the options to patients. You may have watched someone else do it who’s more senior to you, and then kind of picked up pieces from that like now I know how not to do it, or how to do it.”
 Training in choice architecture outside of medicine“So, I was a software engineer prior to this. So, a lot of our programming classes talked about decision making and where patients click and why they click. So, we definitely talked about [choice architecture] there.”
Ethics in using choice architecture
 Upholding patient autonomy“I think that [the use of choice architecture] can lead us to a slippery slope and I think that if you’re doing it simply to manipulate the patient into choosing what you feel might be the best option, it might be a little nefarious because ultimately autonomy is one of the pillars of the patient physician relationship and you must maintain that.”
 Acceptability of nudging in the patient’s best interest“…[choice architecture] is probably an unethical thing if you’re doing it to deceive a patient or to force them to choose something. However, if they’re making a bad decision for some other reason in your perception and you were trying to get them to do what’s right for them or what may be in their best interest then it mitigates that or may make it the right thing to do.”
 Clear, honest communication regarding options as key to ethical discussions“…as long as you don’t have a conflict of interest, which I think is really important to set up in the beginning, then I do think that [nudging] is slightly ok. However, I think our role as physicians is not to ultimately make decisions for everyone, but to provide them with the information to make an informed decision themselves.”
 Importance of training in ethical considerations“I mean, I think the only way to avoid [the unethical use of choice presentations] is to know about these biases, and to present to your patient as neutral and vanilla as a way you can….”