“Choice is how we go from who we are today to who we want to be tomorrow.”
Most people likely do not know Sheena Iyengar. However it is likely that you know about her famed “jam study.” In this study she had a tasting table at a grocery store with either 24 varieties of jam, 6 varieties, or only gourmet jam. Although the larger display was able to attract more customers, the customers from the smaller selection were 10 times more likely to purchase jam. This study stood in contrast to the assumption of retailers that more choice is better.
This counterintuitive finding is at the center of her inquiry into our assumptions about choice, what we know about choice, and how can we make better choices. Professor Iyengar draws from her academic work, and also disparate fields including business, economics, biology, philosophy, cultural studies, public policy, and medicine. The book is not only an overview of the scientific study of choice, but an invitation for the reader to examine and question their own concepts of choice.
The book starts with Professor Iyengar’s personal story raised in the dual culture of a Sikh household within the United States. One culture has choices determined by either God or parents, the other culture abounds with the freedom of choices. From this she analyzes 3 assumptions often made regarding choice:
- If there is a choice to make that affects you, you should make it
- The more options there are, the more likely you are to make the right choice.
- We should never say no to the option of making a choice.
“Ask yourself: When making a choice, do you first and foremost consider what you want and what will make you happy, or do you consider what is best for you and the people around you? This seemingly simple question lies at the heart of major differences between cultures and individuals, both within and between nations” p. 30
She then compares the individualist US society with the culture found in Japan. Within the U.S., Iyengar purports that the concept of the individual is deeply shaped by the words found in the declaration of independence and constitution which emphasize the individual, their rights separate from the government, and the freedom from oppression. To provide contrast she points to Japan. She conducted experiments in which she found the Japanese preferred others to make decisions for them and felt more productive when their decisions were made by their managers. Over multiple studies, the Japanese subjects consistently saw themselves and the choices that they made within the context of the greater community. This is in stark contrast the Americans who saw choice as an opportunity to express their individuality and demonstrate their personal freedom.
Professor Iyengar moves from discussing the culturally bound nature of our concepts of choice to the role of outside influences and raises the question of free will. She goes through a series of vignettes where she shows the influence of both our desire to be unique and to eliminate cognitive dissonance as hidden forces in our decisions. She further discusses our blind spot for seeing the influence of marketing and its influences of our choices. By discussing the role of outside influences and our own unconscious biases she raises the question of the free will of our decisions. She undergoes this discussion not to describe us as robots in a Skinner box, but to raise the veil of decision making as the first step to making better decisions.
The final theme of the book is, not only are our choices fallible, they are quickly becoming overwhelming. With the increase in choice we are faced with the greater expectation from those choices.
“When the options are few we can be happy with what we choose since we are confident that it is the best possible choice for us. When the options are practically infinite, though, we believe that perfect choice for us must be out there somewhere and that it’s our responsibility to find it” p. 204
She describes a study that looked at the characteristics of 401k enrollment compared to the number of mutual funds offered. She found that as the number of mutual funds offered increased there was a drop off in enrollment. She continues to give multiple examples of people making counterproductive decisions when faced with “choice overload.”
Iyengar offers strategies to mitigate “choice overload.” The main tool is to develop expertise in choice elimination. Like the chess master who does not consider all potential moves but focuses only on those with most potential benefit, an expert in any field can benefit from abundance of choice while a novice would be overwhelmed. She elaborates by suggesting that categorizing options can make them more manageable. Finally she recommends drawing on the expertise of crowds and experts by seeking recommendations such as Zagat or Yelp when faced with overwhelming numbers of choices. Through these methods, we can narrow our search and help temper the stress of “choice overload.”
Appropriately or ironically for us, the culmination of the book is the discussion about medical decision-making. This discussion gives a great deal of perspective for the decisions that our patients and families are making at the end of their life. She points out that, although the paternalistic days of leaving patients in the dark may be over, there may be a role in easing their suffering by not putting the entirety of the decision onto the patient or family. This could be as simple as a physician providing an opinion on what should be done.
Iyengar has not only written a book challenging us to examine something that seems so fundamental, she has also given us a new perspective. All of this is softened with the tools and road map to reconciling our new views with our present selves.
Relevance to Emergency Medicine
DIFFICULT PATIENT CONVERSATIONS
Perhaps the most difficult aspect of our job is informing families that a loved one has died or suffered from a critical, disabling disease. Like the studies and cases described in the book, we are often leading discussions with patients and family about making clinical choices that will ultimately decide the fate of a loved one’s life. When a patient lacks clinical acumen, how can we expect them to fully understand the weight of their discussions/choices?
In her book, Iyengar raises the question of paternalism in end-of-life choices. She discusses her study examining the differences between the French and American approach. In France, the decision to withdraw care is made by the doctors, while in America although we engage in shared decision-making, the ultimate decision is made by the family. When she interviewed French and American families who had a neonate die after withdrawal of care, despite the fact that they had no role in the choice, the French families coped better. They were more likely to express feelings of inevitability and had less confusion or anger. In contrast the American families had persistent guilt, doubt, and resentment as they often felt that their decision was the cause for the patient’s death even when they were certain of their decision.
Iyengar gives us a suggestion on how to navigate this dilemma. In her study on informed choice, she found that patients were more satisfied when they understood the clinical scenario even if they were not given any choice about the treatment. Further the addition of the doctor providing their opinion on the right course of action boosted the confidence that the withdrawal of care was the right course of action. Iyengar offers that this approach could relieve the family from owning the burden of their choices.
CLINICAL DECISION MAKING
Our metamorphosis from emergency medicine interns to seasoned emergency physicians is heavily dependent on our ability and duty to make choices in patient care. Interestingly, throughout this process of growth, we likely maintain the same overall bandwidth of processing data in our minds. However, our ability to compartmentalize and analyze patient’s symptoms and clinical data points changes dramatically as we learn to process this information more effectively. As interns, we have to consider multitudes of diagnoses and workups. As we progress we increase speed by reducing our cognitive load through the use of heuristics. We then gain expertise through our realization about the limitations of our heuristics and increase our awareness of cognitive biases and how to mitigate them. Ultimately, we alter our clinical approach to function efficiently by acquiring and processing only the most pertinent patient information, decreasing our overall burden of choice.
Chess players similarly recognize a variety of patterns during opening, middle and endgames. The understanding and familiarity of these patterns allows a chess master to play several boards at once while choosing the optimal moves for the given chessboard configuration. In Iyengar’s book, the chess master is able to routinely outperform the novice when natural patterns are presented on multiple chessboards. Conversely, when the chess pieces were no longer placed in a natural configuration, the chess masters were no longer able to handily defeat the novices. In this scenario, like the novices, the chess masters incurred an increased cognitive burden by having too many choices available to them, losing the benefit of compartmentalizing their choices into predictable patterns.
In the emergency department, we too are ultimately able to decrease our cognitive load by limiting the number of choices we have to make with any given clinical presentation. Just as the wise chess master can glance at a chess board and categorize his choices into groups of patterns rather than an overwhelming collection of individual choices, the emergency physician must process clinical data points into groups of symptoms consistent with a disease process. When the number of symptoms increases without any discernable disease pattern, as Iyengar alludes to throughout the book, the emergency physician can similarly be overwhelmed with the number of choices available.
Iyengar’s jam experiment highlights an important issue within medical education. The prominence of the adult learner model has coincided with a rise in the amount and variety of educational materials available. This has created an environment whereby the learner now struggles to continuously navigate a seemingly endless sea of resources to ultimately discover the “best material” for their education.
The subjective emotional response of our learners reflects the objective findings in Iyengar’s studies. This inability to process the array of study materials and subject matter raises the question about the appropriateness of wholesale adoption of an andragogical learning model for students coming out of a pedagogical system. Perhaps there is a need for a middle ground or a graduated transition from the pedagogy of medical school to the andragogy of the lifelong learning model. Perhaps as educators we should spend equal effort in curating materials as much as we do on creating materials.
We must appreciate both the positive and negative powers of choice in our lives and in our careers as emergency physicians. The freedom of choice will continue to present itself every day in and out of the emergency room. It is up to us to understand its complexity to minimize the negative effects of superfluous options, while maximizing the positive potential of our freedom to choose.
- How does our personal view of choice shape how we view and utilize mentors and how we view or use their guidance. Can our desire to make a choice hinder our ability to be a good mentee?
- How does this book influence how we might view the concepts of paternalism and shared decision making with patients and their families.
- How does this discussion of choice make you view the present discussion about Obama care and the health insurance mandate, mandatory immunization, or gun control where there is a clear public good however at the cost of the loss of choice.
You can choose a ready guide in some celestial voice
If you choose not to decide, you still have made a choice
You can choose from phantom fears and kindness that can kill
I will choose a path that’s clear
I will choose freewill
– “Rush” Freewill
- NY Times Article: Too many choices: A problem that can paralyze, 2010 [Link]
- The Paradox of Choice: Why More Is Less by Barry Schwartz
ALiEM Bookclub post edited by Dr. Nikita Joshi.