0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters | Less Is More

Investigation Momentum: The Relentless Pursuit to Resolve Uncertainty FREE

Sunita Sah, MD, MBA, PhD; Pierre Elias, BA; Dan Ariely, PhD
[+] Author Affiliations

Author Affiliations: McDonough School of Business, Georgetown University, Washington, DC (Dr Sah); Ethics Center, Harvard University, Cambridge, Massachusetts (Dr Sah); and Fuqua School of Business, Duke University, Durham, North Carolina (Dr Ariely). Mr Elias is a medical student at Duke University School of Medicine, Durham.


JAMA Intern Med. 2013;173(10):932-933. doi:10.1001/jamainternmed.2013.401.
Text Size: A A A
Published online

Debate regarding the prostate-specific antigen (PSA) screening test centers around test reliability and whether screening reduces mortality.13 We consider yet another potential downside to the widespread use of unreliable screening tests: the downstream effect of receiving inconclusive or ambiguous results. When receiving information from screening tests, we usually want to know whether the result is a “yes” or a “no.” Receiving an inconclusive result amounts to a “don't know”; this situation should have a level of uncertainty regarding the diagnosis similar to that of not conducting the test at all. Yet, we propose that the psychological uncertainty experienced after an inconclusive test result can lead to investigation momentum: additional, and potentially excessive, diagnostic testing. In contrast, not conducting the unreliable test would result in no further action. To investigate this, we evaluated whether receiving an inconclusive result from an unreliable test (the PSA screening), compared with undergoing no test, motivated more individuals to undertake an additional, more invasive and costly, test (a prostate biopsy).

We recruited 727 men aged between 40 and 75 years to an online survey through e-mail solicitation (data were subsequently collected and analyzed anonymously). Participants received information regarding prostate cancer and answered some background questions (see Table). They were randomized to 1 of 4 conditions. In the first condition, “no PSA,” participants were given information about the risks and benefits of prostate biopsies and asked whether they would have a biopsy (yes or no) and their certainty, ranging from −100 (most certain they would not undergo biopsy) to +100 (most certain they would). In the other 3 conditions, participants were given information about PSA tests, as well as prostate biopsies, and were then presented with a scenario that asked them to imagine that they had just received their PSA test result at 1 of 3 PSA levels: normal, elevated, or inconclusive—the latter result stated “this result provides no information about whether or not you have cancer.” After getting the information about the PSA test and a particular outcome, participants were asked to indicate whether, under these conditions, they would undergo a biopsy and their level of certainty in that decision.

Table Graphic Jump LocationTable. Characteristics of Survey Respondents by Assigned Prostate-Specific Antigen (PSA) Test Result Group

We conducted 2-sided χ2 tests and analyses of variance with planned contrasts to examine differences between the 4 conditions. P < .05 was considered statistically significant.

There were no significant differences among the 4 conditions in participant age, believed likelihood of developing prostate cancer, previous screening examinations, race, and family history of prostate or breast cancer (Table). As hypothesized, significantly more men indicated that they would undergo a prostate biopsy if they received an inconclusive PSA test result (40%) than if they had no PSA test (25%; χ2 = 8.80; P = .003). Men in the elevated and normal PSA level conditions also responded significantly differently: Those assigned an elevated PSA test result were more likely to state that they would undergo a biopsy (62%) compared with those who had no PSA test (χ2 = 47.76; P < .001) and compared with those assigned an inconclusive PSA test result (χ2 = 17.89; P < .001) (although 38% of men with an elevated PSA test result still would not opt for a biopsy). Those assigned a normal PSA test result were less likely to state that they would undergo a biopsy (13%) compared with those who had no PSA test (χ2 = 8.47; P = .004) (demonstrating some, but not total, reassurance from receiving a normal PSA test result)4 and compared with those assigned an inconclusive PSA test result (χ2 = 35.85; P < .001) and those assigned an elevated PSA test result (χ2 = 97.80; P < .001). Similar results, and significance, were obtained with participants' certainty ratings (Table).

These results are likely not confined to the PSA test and provide evidence that an inconclusive test result sparks investigation momentum. When tests give no diagnostic information, rationally, from an information perspective, it should be equivalent to never having had the test for the purpose of future decision making. Yet, we find that more men would opt to undergo the more invasive biopsy after receiving a meaningless test result than when they have no result at all. This has financial and clinical implications owing to the cost and invasive nature of further investigations. Furthermore, such a tendency is likely to have an impact not only on those physicians who incorporate patients' preferences into medical decision making5 but on all physicians, because they are vulnerable to the same psychological processes that encourage patients to resolve ambiguity.6 These results suggest that the ubiquitous use of simple but unreliable screening tests may lead to consequences beyond the initial cost and patient anxiety of inconclusive results; they could also lead to investigation momentum. Furthermore, it is possible that just ordering a test may lead to a commitment to pursue and find abnormalities.7 As we have also seen previously, sometimes “less is more” when it comes to health care procedures with incremental benefit but definite risks such as imaging for low back pain (a symptom likely to generate investigation momentum).8 These findings need to be replicated in broader populations and clinical settings to allow us to better understand how ambiguous information affects medical decision making.

Correspondence: Dr Sah, Georgetown University, McDonough School of Business, 37th and O Street, Rafik B. Hariri Bldg, Washington, DC 20057 (ss3250@georgetown.edu).

Published Online: April 15, 2013. doi:10.1001/jamainternmed.2013.401

Author Contributions: Dr Sah had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition of data: Elias. Analysis and interpretation of data: Sah and Elias. Drafting of the manuscript: Sah. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Sah and Elias. Obtained funding: Ariely. Study supervision: Sah and Ariely.

Conflict of Interest Disclosures: None reported.

Moyer VA.US Preventive Services Task Force.  Screening for prostate cancer: US Preventive Services Task Force recommendation statement.  Ann Intern Med. 2012;157(2):120-134
PubMed   |  Link to Article
Welch HG, Black WC. Overdiagnosis in cancer.  J Natl Cancer Inst. 2010;102(9):605-613
PubMed   |  Link to Article
Chou R, LeFevre ML. Prostate cancer screening—the evidence, the recommendations, and the clinical implications.  JAMA. 2011;306(24):2721-2722
PubMed   |  Link to Article
Detsky AS. A piece of my mind: underestimating the value of reassurance.  JAMA. 2012;307(10):1035-1036
PubMed   |  Link to Article
McNaughton-Collins MF, Barry MJ. One man at a time—resolving the PSA controversy.  N Engl J Med. 2011;365(21):1951-1953
PubMed   |  Link to Article
Ellsberg D. Risk, ambiguity, and the savage axioms.  Q J Econ. 1961;75(4):643-669
Link to Article
Staw BM. The escalation of commitment to a course of action.  Acad Manage Rev. 1981;6(4):577-587
Srinivas SV, Deyo RA, Berger ZD. Application of “less is more” to low back pain.  Arch Intern Med. 2012;172(13):1016-1020
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable. Characteristics of Survey Respondents by Assigned Prostate-Specific Antigen (PSA) Test Result Group

References

Moyer VA.US Preventive Services Task Force.  Screening for prostate cancer: US Preventive Services Task Force recommendation statement.  Ann Intern Med. 2012;157(2):120-134
PubMed   |  Link to Article
Welch HG, Black WC. Overdiagnosis in cancer.  J Natl Cancer Inst. 2010;102(9):605-613
PubMed   |  Link to Article
Chou R, LeFevre ML. Prostate cancer screening—the evidence, the recommendations, and the clinical implications.  JAMA. 2011;306(24):2721-2722
PubMed   |  Link to Article
Detsky AS. A piece of my mind: underestimating the value of reassurance.  JAMA. 2012;307(10):1035-1036
PubMed   |  Link to Article
McNaughton-Collins MF, Barry MJ. One man at a time—resolving the PSA controversy.  N Engl J Med. 2011;365(21):1951-1953
PubMed   |  Link to Article
Ellsberg D. Risk, ambiguity, and the savage axioms.  Q J Econ. 1961;75(4):643-669
Link to Article
Staw BM. The escalation of commitment to a course of action.  Acad Manage Rev. 1981;6(4):577-587
Srinivas SV, Deyo RA, Berger ZD. Application of “less is more” to low back pain.  Arch Intern Med. 2012;172(13):1016-1020
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Kinetic theory molecular dynamics and hot dense matter: Theoretical foundations. Phys Rev E Stat Nonlin Soft Matter Phys 2014;90(3-1):033104.