The Psychology of Clinical Decision Making: Implications for Medication Use

From the New England Journal of Medicine

By Jerry Avorn, MD

SUMMARY: In this NEJM Perspective written shortly after Richard Thaler won the Nobel Prize in Economics for behavioral economics, Dr. Avorn applies behavioral decision-making insights to clinical practice — particularly to prescribing decisions. Avorn argues that the simplified rational-actor model of physician decision-making fails to account for the psychological biases, heuristics, and cognitive shortcuts that shape how clinicians actually choose medications. The piece draws on Thaler's work and related behavioral economics research to illuminate why physicians may choose suboptimal drugs not from ignorance or corruption, but from predictable human cognitive tendencies such as availability bias, anchoring, and status quo preference. Understanding these mechanisms, Avorn suggests, should inform both medical education and the design of interventions — like academic detailing — that aim to improve prescribing.

BACKGROUND: Richard Thaler's Nobel Prize-winning work in behavioral economics demonstrated that human decision-making diverges systematically from the rational-actor model. Clinical practice involves constant decision-making, including choices about which medications to prescribe.

KEY FINDINGS: Behavioral economics insights — including cognitive biases, heuristics, and predictable departures from rationality — have profound implications for how physicians make prescribing decisions, independent of knowledge or intent.

IMPLICATIONS: Medical education and prescribing-improvement interventions should be informed by behavioral economics, designing choice environments and communication strategies that account for how clinicians actually make decisions rather than how they ideally should.