The folly of optimism bias

What cripples Americans’ health as much as anything is a misguided tendency known as optimism bias. People tend to believe they are invincible. They expect misfortune to befall others rather than themselves. It is a judgment error, not to be mistaken for an optimistic outlook on life.

Rutgers psychology professor Neil Weinstein stumbled across this when he discovered that his students had unrealistic expectations about their performance on tests. He studied the bias extensively and found it exists in many facets of life, but especially in health.

Most people believe their skills are “above average,” a statistical impossibility like Garrison Keillor’s assertion about the children in mythical Lake Wobegon. They overestimate how swiftly they will accomplish tasks and usually reach optimistic conclusions based on little or no evidence.

A good example of optimism bias was found in a survey of about 1 million high school seniors in the 1970s. About 70 percent believed they had above-average leadership skills, compared with 2 percent who said they were below average. About 60 percent rated themselves in the top 10 percent in ability to get along with others, and 25 percent said they were in the top 1 percent.

Health research is full of optimism bias. Patients guide themselves with half-baked medical theories and misinformation, often with dire consequences for their health and longevity. People tend to predict the future based on experience: If there were no consequences to behavior before, there will be none in the future. They consider themselves somehow exempt from risk.

This self-confidence can be fatal. People with heart-attack symptoms delay seeking medical attention because the signals do not match their notions of what they think a heart attack should feel like. Likewise, a majority of patients with high blood pressure believe they can tell whether it is elevated,   according to one study – even though the condition has no symptoms. People in the blood-pressure “symptom” group acknowledged that most people cannot detect when their blood pressure rises  – but said they themselves could. (This actually made them more compliant patients. This false notion led them to follow doctors’ orders to take medication, watch their diet and exercise to control the mythical symptoms.)

Weinstein surveyed adults with risky lifestyles to see how they rate their chances of acquiring health conditions such as cancer or alcoholism, or encountering other negative events such as auto accidents or getting divorced. The response: Somewhere between average and lower than average. The bias occurred regardless of age, gender, income or education level.

People take this notion of self-control even farther by overrating the effectiveness of their actions. That inflates the self-delusion even more. On the other hand, people are reluctant to take responsibility for poor performance. They tend to blame factors outside their control, such as the difficulty of the task.

Optimism bias is fairly immune to intervention. It is difficult for those who have it to believe otherwise. They rarely alter their behavior even after being shown that their chances of early death and disease are no better than average. The reason: They still believe their own risk is relatively low.

In international studies, Americans show a stronger association of optimism bias and personal control than non-Americans. The sense of control over events and the concept of personal responsibility are deeply embedded in capitalist nations such as the United States. Such notions tend to result in faulty risk estimations, leading to a disconnect between misinformed judgment and reality.

However, optimism bias is not without its merits. The outlook reflects a high level of self-esteem, which itself is beneficial to good health. An attitude of invincibility has a way of reducing anxiety. People who are optimistic about their futures place a higher value on their health because they expect good things ahead. They are better at building social networks, which help protect health, and probably are less likely to have had their health compromised by life’s tragedies.

In personal health, fear is good but pessimism is not

Caution about health hazards leads to doing the right things. A wealth of research shows that the degree to which people feel vulnerable to health problems predicts how likely they are to engage in healthy behavior. Optimism bias leads to ignoring information about what promotes health, and a tendency toward riskier behavior. In short, there is not enough fear.

However, unrealistic pessimism can be as bad as optimism bias. People with fatalistic beliefs, consumed by hopelessness, think nothing they do will alter their destiny.

The onslaught of everything-causes-cancer news contributes to this. Indeed, a national survey of more than 6,000 U.S. adults found that about half agreed with the statement: “It seems like almost everything causes cancer.” Three-fourths agreed that “there are so many recommendations about preventing cancer that it’s hard to know which ones to follow.”

Remarkably, about 1 out of 4 agreed with this: “There’s not much people can do to lower their chances of getting cancer.” Those with the strongest fatalistic beliefs were less likely to eat fruits and vegetables and more likely to continue to smoke.

Transition to where?

People with chronic disease bear the full brunt of the medical system’s fragmented care. This balkanization is encouraged by the way health-care providers are paid. Usually, no one is paid to manage a patient’s overall condition. Providers are paid for procedures, visits and dispensing prescriptions. There is no direct relationship between how much physicians earn and whether the patient improves. Chronic-disease patients see health-care providers in a number of unrelated venues, many of which do not communicate with each other.

Transitional care, which patients receive after discharge from a hospital or other health-care facility, occurs during an especially vulnerable period. Patients often do not understand the purpose of their medications or receive a detailed care plan. These oversights are especially critical in chronic-disease care because the conditions are managed largely by patients and their caregivers. As a result, nearly 1 in 6 is readmitted to the hospital within 30 days of having left a health-care facility. Hospitals are paid when again the patient is readmitted.

About 1 in 7 does not make a follow-up doctor appointment within four weeks of discharge. Patients’ physicians often are not informed about the details of the care provided in the hospital. About 1 in 5 chronic-disease patients say their physicians did not do a good job of communicating about their care.

Nearly 1 out of 4 was a victim of a medical error, and nearly two-thirds of those errors created a major problem.

Cheri Lattimer, executive director of the Case Management Society of America, does not like the term “discharge,” referring to when a patient leaves the hospital.

Hospitals should call their discharge paperwork a “transitions summary,” implying that it is a proactive care plan for the patient and provider.

“That summary must be sent to the next level,” Lattimer said. “The Joint Commission says 39 percent of documentation does not get sent to the next level. Transitions of care are not just from hospitals. It is an ongoing process. They say health care is a team sport, but we don’t know who’s on the team or who to throw the ball to.”