Difference between representativeness heuristics and stereotyping in adherence-psychology

• Heuristics are the mental shortcuts that enable fast and optimal decision-making to conserve cognitive power. However, they are error-prone and can result in biased decisions^{1, 7}.
• Representativeness heuristics, a sub-type of heuristics, compares and categorizes the given scenario with existing prototypes to arrive at quick decisions. These prototypes are based on our past experiences and are constantly updated with new probabilities to enhance their predictability and reduce judgment bias^{2, 8}.
• On the other hand, stereotypes are generalized, rigid, and oversimplified views emanating from cultural influences. They completely disregard the new experience and the associated probabilities are not updated resulting in mostly biased judgments⁸. 

Heuristics are commonly known as “mental shortcuts” or “rules of thumb” that simplify our decision-making process. First formulated in the 1970s by Tversky & Kahneman¹, it helps us to make choices in unfamiliar and ambiguous circumstances within a short time with minimal cognitive involvement. It is a way of predicting the plausibility of an event and guides our decisions with a limited set of information. Although a very efficient approach for quick decision-making, it is mired with associated biases and judgment errors^1,2.

Heuristics help formulate judgment by focusing on the most important aspects of the problem to arrive at the most plausible solution⁴. This subjective assessment while analyzing complex situations frequently results in incorrect and irrational responses. For example, when posed with a hypothetical medical situation requiring surgery, most people chose the procedure that had a success rate of 80% and ignored the other where the failure rate was 20%, even though a rational analysis would reveal both options to be equally effective or risky ⁴. Importantly, heuristics-based decision-making is not accounted for by social cognitive theories (SCTs) that address rational decision-making. (For more on SCTs, please read – Methods of behaviour change).

In our previous article, Two systems of thought: Why “rational” people make “irrational” choices, we discussed how two systems of thinking are employed while making any decision – system 1 (spontaneous and intuitive) and system 2 (reflective and rational). Heuristics is drawn-on to make rapid decisions under system 1 requiring less cognitive thinking and is used for the majority (95%) of the decision-making processes. Ironically, these decisions are based upon incomplete information (either unavailable or ignored) that sometimes can result in ill-informed judgments.

What are decision heuristics and associated biases in healthcare decision-making?

Slips during clinical decision-making like misdiagnosis or errors in the emergency room have long been documented and there is an immense focus to eliminate/reduce them. Therefore, it is useful to understand the psychological processes that are behind these cognitive errors. The limitations of cognitive capacity while processing information to arrive at decisions result in reliance on heuristics³.

As described above heuristics is an intuitive way of decision-making to arrive at solutions that may not necessarily be perfect, but serves the purpose. Nevertheless, heuristic-aided decisions are error-prone and at times irrational³. It saves a lot of cognitive effort in analyzing and finding the perfect solution that may not even be necessary or possible to discern. Heuristics plays a pivotal role in most of our day-to-day activity including medication adherence behavior. For more on this, please read our article on heuristics, decision-making, and medication adherence behavior.

• Heuristics in clinical diagnosis: Using heuristics produces fast and efficient, but a mixed bag of decisions that are sometimes correct and other times erroneous. For example, a patient presenting with hematuria and possible exposure to benzidine as an occupational hazard of working at oil rigs could be quickly diagnosed as suffering from bladder cancer and not prostate cancer that presents similar symptoms and is more common due to heuristic guided prompt association with the carcinogen exposure³.
• Heuristics in adherence psychology: Heuristics is an important driver in the decision-making process and medication non-adherence is a behavioral issue. The assumption by various SCTs is that medication adherence is rational behavior. Ironically, these theories do not account for unconscious biases and irrational choices while predicting behavior⁵. One of the principle assertions of SCTs is that behavior change depends upon risk-benefit analysis resulting in a rational decision-making process. However, irrational choices can be made by underestimating the risks and overvaluing the benefits using heuristics⁵. While therapy initiation is done after cost-benefit analysis (System 2), the persistence or adherence to therapy is prone to engaging heuristics (System 1). Various situational factors like the cost of the drug can activate associations leading to non-adherence while other factors like treating the disease can be ignored especially if it is symptom-less⁶.

Types of heuristics: Representativeness heuristic vs availability heuristic

Multiple types of heuristics aid our decision-making process like anchoring heuristics, emotional heuristics, affect heuristics, base-rate heuristics, and simulation heuristics. The two major heuristics are discussed below:

• Availability heuristic: The decision-making is guided by the readily available memory of the relevant real instances experienced by the person. However, the process is biased towards the events that exist more frequently in our memory and perceives them to be more common as compared to less frequent events. For example deaths due to airplane crashes vs car crashes. Since deaths due to airplane crashes are more publicized and sensationalized, we tend to capture each of the crashes in our memories more often and perceive air travel to be more unsafe as compared to traveling in a car. While the odds of death due to a car crash are higher as compared to a plane crash^2,7. This heuristic often misleads diagnosis by quickly assigning the presented symptoms with a similar recently encountered disease without factoring in the probable frequency of the event^3,11.
• Representativeness heuristic: It is used to make decisions based on representative experiences by taking into account the similarity of the current event with an older similar event or a standard process. Our brain tends to match and categorize the input data with similar or representative mental models called prototypes (formed by our past experiences) without analyzing all the different aspects of the input. The Representativeness heuristic is used in the face of uncertainty to give satisfactory solutions quickly by analyzing minimal information. However, this becomes a major drawback since other details of the problem are not analyzed and neither associated statistics nor rationally is considered, which sometimes can result in stereotyping and biases. For example, a shy, introverted, orderly, detail-oriented, self-absorbed, but invariably helpful person is often categorized as most likely to be a librarian rather than a farmer, physician, salesman, or pilot without factoring in the relevant statistics². Similarly, an elderly patient with joint pain and a positive RF factor can be misdiagnosed as Rheumatoid arthritis (based on the prototype) rather than accounting for the age or the fact that RF is positive in a subset of individuals with no disease and therefore actually the patient is suffering from osteoarthritis³.

What are stereotypes?

A stereotype is an oversimplified, exaggerated, and generalized belief about objects or people. It is a widely held view in a given community/culture and is rather fixed or rigid – not amenable to change. It often comes from social and cultural experiences firmly entrenched in our memory and is based on attributes that may not necessarily be true⁸.

Stereotypes are based on two concepts – associative memory and automatic activation. As semantic memory is stored in an associated network, activating one concept automatically and unconsciously activates the related concepts through system 2 of thinking. For example, the word hospital is associated with doctors, nurses, medicines, etc. Such associations once formed are very difficult to unlearn or undo. Although overt or explicit stereotypes are less prevalent (present in less than 10% of the population), implicit stereotypes (cognitive bias) are present in everyone⁸.

Representativeness heuristics vs. stereotyping – similar yet different?

Our brain is considered a “predictive machine” and has evolved to make implicit associations for fast decision-making using heuristics through factors such as recognition or familiarity. Quick decisions are made based on predictions that in turn are dependent on probabilities experienced in the past. For instance, recognizing a familiar person in a crowd judging from their gait or clothes requires predictions based on earlier experiences or simply put cognitive biases. However, such biases are amenable to change or upgradation. Each time we commit a mistake in recognizing our friend, our friend’s representative image is updated such that we are less likely to make that mistake in the future⁸. On the other hand, stereotypes are more generalized and exaggerated predictions about a particular group/object based on rigid and culturally influenced views that are attributed to “all” the members of a particular group. For example, stereotyping “all lawyers are crooked” is a generalization of the attribute “crooked” to all members of the group, which is not supported by the probability in the real world. Even after encountering an honest lawyer, the stereotype doesn’t change. However, the representativeness heuristic would update the attribute accordingly such that the next lawyer encountered is less likely to be predicted as crooked resulting in less biased decision-making⁸. For instance, stereotypes in healthcare results in poor disease outcomes in women and minorities.

Table 1: Difference between representativeness heuristics and stereotyping^1,8

	Representativeness heuristics	Stereotyping
Causes Cognitive Bias	Yes	Yes
Judgment	Sometimes biased	Mostly biased
Flexibility	The views are updated and recalibrated based on recent experiences	Views are rigid and inflexible. Memory is entrenched in the brain and difficult to change
Statistical consideration	Updates statistics based on experiences to produce less biased judgment next time	Ignores statistics and thus provides biased judgments
Prototypes	Based on past experiences	Based on cultural influences
Effect on non-adherence	Yes, but can be addressed by factoring heuristics into the program-design	Yes. Although difficult to address, programs creating stereotype awareness and training conscious suppression during decision-making

Stereotyping in adherence psychology

Stereotyping and deriving clinical decisions based on common stereotypes by HCPs can affect adherence to therapy and recommendation. Established racial stereotypes can also result in stereotype threats – a perceived threat of being judged based on stereotypes – among minority patients. This could create mistrust, miscommunication, and disengagement with HCPs leading to lesser care satisfaction and finally non-adherence to therapy⁹. Providing training to enhance awareness about implicit biases can go a long way in influencing patient-provider interaction and subsequently medication adherence¹⁰

Conclusions Making HCPs aware of stereotypes and implicit bias in clinical decision-making can help them in fair and better judgment. HCPs should consider and prioritize patients’ concerns and allow their participation in decision-making to give patients enhanced control. This would lead to better care satisfaction and enhanced patient-provider trust. Enhancing probabilistic teaching – taking into account the probability of the event while predicting the solutions rather than basing it solely on associations – will help reduce biased decision-making due to heuristics. Also, incorporating heuristics-influenced biases and decision errors in behavioral interventions will be important to enhance medication adherence.

“Stereotypes lose their power when the world is found to be more complex than it suggests. When we learn that individuals do not fit the stereotype, then it begins to fall apart” – ED Koch

References

1.    Tversky A, Kahneman D. Judgment under Uncertainty: Heuristics and Biases. Science. Sep 27 1974;185(4157):1124-31. doi:10.1126/science.185.4157.1124

2.    Dale S. Heuristics and biases: The science of decision-making. Business Information Review. July 1, 2015 2015;32(2)doi:10.1177/0266382115592536

3.    Payne VL, Crowley RS. Assessing the use of cognitive heuristic representativeness in clinical reasoning. AMIA Annu Symp Proc. Nov 6 2008;2008:571-5.

4.    SMITH D. Psychologist wins Nobel Prize. Daniel Kahneman is honored for bridging economics and psychology. Americal Psychological Association. 2002;33(11)

5.    Lehane E, McCarthy G. Intentional and unintentional medication non-adherence: a comprehensive framework for clinical research and practice? A discussion paper. Int J Nurs Stud. Nov 2007;44(8):1468-77. doi:10.1016/j.ijnurstu.2006.07.010

6.    Elliott RA, Ross-Degnan D, Adams AS, Safran DG, Soumerai SB. Strategies for coping in a complex world: adherence behavior among older adults with chronic illness. J Gen Intern Med. Jun 2007;22(6):805-10. doi:10.1007/s11606-007-0193-5

7.    Heuristics. Mind Help. Accessed June 09, 2023, https://mind.help/topic/heuristics/

8.    Hinton P. Implicit stereotypes and the predictive brain: cognition and culture in “biased” person perception. Palgrave Communications 2017;3(17086 (2017))doi:doi.org/10.1057/palcomms.2017.86

9.    Burgess DJ, Warren J, Phelan S, Dovidio J, van Ryn M. Stereotype threat and health disparities: what medical educators and future physicians need to know. J Gen Intern Med. May 2010;25 Suppl 2(Suppl 2):S169-77. doi:10.1007/s11606-009-1221-4 10.       McQuaid EL, Landier W. Cultural Issues in Medication Adherence: Disparities and Directions. J Gen Intern Med. Feb 2018;33(2):200-206. doi:10.1007/s11606-017-4199-3