Physicians’ years of experience may not guarantee they will make the best treatment choices. According to research by a team including City of Hope’s Meghana Bhatt, Ph.D., physicians who pay attention to their failures as well as successes become more adept at selecting the correct treatment.

The research, led by Read Montague, Ph.D., director of the Human Neuroimaging Laboratory of the Virginia Tech Carilion Research Institute, was published in the Nov. 23 issue of PLoS One, the Public Library of Science open-access journal.

Meghana Bhatt (Photo by p.cunningham)

Scientists studied 35 experienced physicians within a variety of nonsurgical specialties and used functional magnetic resonance imaging to look at physicians’ brain activity as they made treatment decisions.

The doctors were instructed to select between two treatments for a series of simulated patients who had gone to the emergency room with heart attack symptoms.

First, the physicians had a chance to learn by experience which of the two medications worked better for the 64 simulated patients, based on a simplified history, said Bhatt, co-lead author on the study.

Each of the simulated patients had six factors in their medical history. But unknown to the physicians, out of the six factors, only one was actually relevant to the decision: whether the patient had diabetes. One medication had a 75 percent success rate in patients with diabetes, but only a 25 percent success rate in patients without diabetes. The other medication had the opposite profile.

The physicians had 10 seconds to select a treatment for each patient. Then they were told whether the treatment worked or failed for that patient.

After the training, the scientists tested physicians to see how often they were able to pick the best drug in a second series of 64 simulated patients.

“When we looked at their performance, the doctors separated into two distinct groups,” Bhatt said. “One group learned very effectively from experience and chose the best drug more than 75 percent of the time. The other group was terrible; they chose the best drug only at coin-flipping levels of accuracy, or half the time, and they also came up with inaccurate systems for deciding how to prescribe the medications, based on factors that actually didn’t matter at all.”

Every doctor reported including at least one of the five irrelevant factors, such as age or previous heart attack, in his or her decision process.

Brain imaging showed a clear difference in the mental processes of the two groups. “The high performers activated their frontal lobes when things didn’t go as expected and the treatments failed,” Montague said. That activation showed that the doctors learned from their failures. These physicians gradually improved their performance.

In contrast, the low performers activated their frontal lobes when their selected treatment worked for a patient, said Bhatt. “In other words, they succumbed to ‘confirmation bias,’ ignoring failures and only learning from the successful cases. Each success confirmed what the low performers falsely thought they already knew about which treatment was best.” The researchers termed this counterproductive learning pattern “success-chasing.”

Remembering successes and ignoring failures leaves physicians unable to abandon faulty ideas, according to Jonathan Downar, M.D., Ph.D., assistant professor of psychiatry at the University of Toronto and co-lead author. But the physicians probably can be trained to think more like high-performers.

Noted Montague: “These findings underscore the dangers of disregarding past failures when making high-stakes decisions.”

The National Institute on Aging and a fellowship from the Kane Foundation supported the research.