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Theory—understanding mental processes that drive decisions—is important to help patients and providers make decisions that reflect medical advances and personal values. Building on a 2008 review, we summarize current tenets of fuzzy-trace theory (FTT) in light of new evidence that provides insight regarding mental representations of options and how such representations connect to values and evoke emotions. We discuss implications for communicating risks, preventing risky behaviors, discouraging misinformation, and choosing appropriate treatments. Findings suggest that simple, fuzzy but meaningful gist representations of information often determine decisions. Within minutes of conversing with their doctor, reading a health-related web post, or processing other health information, patients rely on gist memories of that information rather than verbatim details. This fuzzy-processing preference explains puzzles and paradoxes in how patients (and sometimes providers) think about probabilities (e.g., "50-50" chance), outcomes of treatment (e.g., with antibiotics), experiences of pain, end-of-life decisions, memories for medication instructions, symptoms of concussion, and transmission of viruses (e.g., in AIDS and COVID-19). As examples, participation in clinical trials or seeking treatments with low probabilities of success (e.g., with antibiotics or at the end of life) may indicate a defensibly different categorical gist perspective on risk as opposed to simply misunderstanding probabilities or failing to make prescribed tradeoffs. Thus, FTT explains why people avoid precise tradeoffs despite computing them. Facilitating gist representations of information offers an alternative approach that goes beyond providing uninterpreted "neutral" facts versus persuading or shifting the balance between fast versus slow thinking (or emotion vs. cognition). In contrast to either taking mental shortcuts or deliberating about details, gist processing facilitates application of advanced knowledge and deeply held values to choices. Highlights: Fuzzy-trace theory (FTT) supports practical approaches to improving health and medicine. FTT differs in important respects from other theories of decision making, which has implications for how to help patients, providers, and health communicators. Gist mental representations emphasize categorical distinctions, reflect understanding in context, and help cue values relevant to health and patient care. Understanding the science behind theory is crucial for evidence-based medicine. [ABSTRACT FROM AUTHOR]

Background. It is difficult to write about cancer for laypeople such that everyone understands. One common approach to readability is the Flesch-Kincaid Grade Level (FKGL). However, FKGL has been shown to be less effective than emerging discourse technologies in predicting readability. Objective. Guided by fuzzy-trace theory, we used the discourse technology Coh-Metrix to create a Gist Inference Score (GIS) and applied it to texts from the National Cancer Institute website written for patients and health care providers. We tested the prediction that patient cancer texts with higher GIS scores are likely to be better understood than others. Design. In study 1, all 244 cancer texts were systematically subjected to an automated Coh-Metrix analysis. In study 2, 9 of those patient texts (3 each at high, medium, and low GIS) were systematically converted to fill-the-blanks (Cloze) tests in which readers had to supply the missing words. Participants (162) received 3 texts, 1 at each GIS level. Measures. GIS was measured as the mean of 7 Coh-Metrix variables, and comprehension was measured through a Cloze procedure. Results. Although texts for patients scored lower on FKGL than those for providers, they also scored lower on GIS, suggesting difficulties for readers. In study 2, participants scored higher on the Cloze task for high GIS texts than for low- or medium-GIS texts. High-GIS texts seemed to better lend themselves to correct responses using different words. Limitations. GIS is limited to text and cannot assess inferences made from images. The systematic Cloze procedure worked well in aggregate but does not make fine-grained distinctions. Conclusions. GIS appears to be a useful, theoretically motivated supplement to FKGL for use in research and clinical practice. [ABSTRACT FROM AUTHOR]

The bureaucratization of psychological science exacts intellectual costs that go beyond the sheer amount of time that is drained away from creative scientific activity. Additional administrative hurdles are now being generated in an attempt to ensure the replicability of psychological effects. A cognitive analysis of those hurdles shows that impairment of scientific creativity is a foreseeable consequence, owing to their frequent verbatim-processing focus and the negative emotional context in which they are embedded. We consider whether it is possible to enhance replicability without increasing bureaucratic obstacles and to enhance scientific creativity in the presence of such obstacles. [ABSTRACT FROM AUTHOR]

Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians’ prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians’ specialized training, the categorical gists driving clinicians’ and patients’ decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was “why not take a risk,” which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that “germs are germs” conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the “why not take a risk” representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians’ and patients’ expectations, suggesting opportunities to reduce overprescribing. [ABSTRACT FROM AUTHOR]

Risky decision making, especially in adolescence, is a major public health problem. However, fuzzy-trace theory suggests that bad outcomes are preventable by changing thinking and, therefore, feelings about risks. The theory aligns with new findings and has been shown to be effective in experiments on decreasing sexual risk taking, increasing medication adherence, and tailoring genetic testing. Despite the vulnerabilities of the adolescent brain, decision processes can be modified by applying evidence-based theory. [ABSTRACT FROM AUTHOR]

Intelligence agents make risky decisions routinely, with serious consequences for national security. Although common sense and most theories imply that experienced intelligence professionals should be less prone to irrational inconsistencies than college students, we show the opposite. Moreover, the growth of experience-based intuition predicts this developmental reversal. We presented intelligence agents, college students, and postcollege adults with 30 risky-choice problems in gain and loss frames and then compared the three groups’ decisions. The agents not only exhibited larger framing biases than the students, but also were more confident in their decisions. The postcollege adults (who were selected to be similar to the students) occupied an interesting middle ground, being generally as biased as the students (sometimes more biased) but less biased than the agents. An experimental manipulation testing an explanation for these effects, derived from fuzzy-trace theory, made the students look as biased as the agents. These results show that, although framing biases are irrational (because equivalent outcomes are treated differently), they are the ironical output of cognitively advanced mechanisms of meaning making. [ABSTRACT FROM PUBLISHER]

This article presents a summary of major findings and rationale for each of the papers presented at the 2008 Annual Meeting of the Society for Medical Decision Making (SMDM). Several barriers have limited the widespread adoption and use for real-time decision making. A major impediment has been the lack of coherent and evidence-based predictive scientific theory.

The tenets of fuzzy trace theory are summarized with respect to their relevance to health and medical decision making. Illustrations are given for HIV prevention, cardiovascular disease, surgical risk, genetic risk, and cancer prevention and control. A core idea of fuzzy trace theory is that people rely on the gist of information, its bottom-line meaning, as opposed to verbatim details in judgment and decision making. This idea explains why precise information (e.g., about risk) is not necessarily effective in encouraging prevention behaviors or in supporting medical decision making. People can get the facts right, and still not derive the proper meaning, which is key to informed decision making. Getting the gist is not sufficient, however. Retrieval (e.g., of health-related values) and processing interference brought on by thinking about nested or overlapping classes (e.g., in ratio concepts, such as probability) are also important. Theory-based interventions that work (and why they work) are presented, ranging from specific techniques aimed at enhancing representation, retrieval, and processing to a comprehensive intervention that integrates these components. [ABSTRACT FROM AUTHOR]

Different studies have documented opposite relations between perceived risk and behavior. The present study tested a theoretical explanation that reconciles these conflicting results. Adolescents ( N= 596) completed alternative measures of risk perception that differed in cue specificity and response format. As predicted by fuzzy-trace theory, measures that emphasized verbatim retrieval and quantitative processing produced positive correlations between perceived risk and risky behavior; risk perceptions reflected the extent to which adolescents engaged in risky behavior. In contrast, measures that assessed global, gist-based judgments of risk produced negative correlations; higher risk perceptions were associated with less risk taking, a protective rather than reflective relation. Endorsement of simple values and principles provided the greatest protection against risk taking. Results support a dual-processes interpretation of the relation between risk perception and risk taking according to which observed relations depend on whether the cues in questions trigger verbatim or gist processing. [ABSTRACT FROM AUTHOR]

Crime, smoking, drug use, alcoholism, reckless driving, and many other unhealthy patterns of behavior that play out over a lifetime often debut during adolescence. Avoiding risks or buying time can set a different lifetime pattern. Changing unhealthy behaviors in adolescence would have a broad impact on society, reducing the burdens of disease, injury, human suffering, and associated economic costs. Any program designed to prevent or change such risky behaviors should be founded on a clear idea of what is normative (what behaviors, ideally, should the program foster?), descriptive (how are adolescents making decisions in the absence of the program?), and prescriptive (which practices can realistically move adolescent decisions closer to the normative ideal?). Normatively, decision processes should be evaluated for coherence (is the thinking process nonsensical, illogical, or self-contradictory?) and correspondence (are the outcomes of the decisions positive?). Behaviors that promote positive physical and mental health outcomes in modern society can be at odds with those selected for by evolution (e.g., early procreation). Healthy behaviors may also conflict with a decision maker's goals. Adolescents' goals are more likely to maximize immediate pleasure, and strict decision analysis implies that many kinds of unhealthy behavior, such as drinking and drug use, could be deemed rational. However, based on data showing developmental changes in goals, it is important for policy to promote positive long-term outcomes rather than adolescents' short-term goals. Developmental data also suggest that greater risk aversion is generally adaptive, and that decision processes that support this aversion are more advanced than those that support risk taking. A key question is whether adolescents are developmentally competent to make decisions about risks. In principle, barring temptations with high rewards and individual differences that reduce self-control (i.e., under ideal conditions), adolescents are capable of rational decision making to achieve their goals. In practice, much depends on the particular situation in which a decision is made. In the heat of passion, in the presence of peers, on the spur of the moment, in unfamiliar situations, when trading off risks and benefits favors bad long-term outcomes, and when behavioral inhibition is required for good outcomes, adolescents are likely to reason more poorly than adults do. Brain maturation in adolescence is incomplete. Impulsivity, sensation seeking, thrill seeking, depression, and other individual differences also contribute to risk taking that resists standard risk-reduction interventions, although some conditions such as depression can be effectively treated with other approaches. Major explanatory models of risky decision making can be roughly divided into (a) those, including health-belief models and the theory of planned behavior, that adhere to a “rational” behavioral decision-making framework that stresses deliberate, quantitative trading off of risks and benefits; and (b) those that emphasize nondeliberative reaction to the perceived gists or prototypes in the immediate decision environment. (A gist is a fuzzy mental representation of the general meaning of information or experience; a prototype is a mental representation of a standard or typical example of a category.) Although perceived risks and especially benefits predict behavioral intentions and risk-taking behavior, behavioral willingness is an even better predictor of susceptibility to risk taking—and has unique explanatory power—because adolescents are willing to do riskier things than they either intend or expect to do. Dual-process models, such as the prototype/willingness model and fuzzy-trace theory, identify two divergent paths to risk taking: a reasoned and a reactive route. Such models explain apparent contradictions in the literature, including different causes of risk taking for different individuals. Interventions to reduce risk taking must take into account the different causes of such behavior if they are to be effective. Longitudinal and experimental research are needed to disentangle opposing causal processes—particularly, those that produce positive versus negative relations between risk perceptions and behaviors. Counterintuitive findings that must be accommodated by any adequate theory of risk taking include the following: (a) Despite conventional wisdom, adolescents do not perceive themselves to be invulnerable, and perceived vulnerability declines with increasing age; (b) although the object of many interventions is to enhance the accuracy of risk perceptions, adolescents typically overestimate important risks, such as HIV and lung cancer; (c) despite increasing competence in reasoning, some biases in judgment and decision making grow with age, producing more “irrational” violations of coherence among adults than among adolescents and younger children. The latter occurs because of a known developmental increase in gist processing with age. One implication of these findings is that traditional interventions stressing accurate risk perceptions are apt to be ineffective or backfire because young people already feel vulnerable and overestimate their risk. In addition, research shows that experience is not a good teacher for children and younger adolescents, because they tend to learn little from negative outcomes (favoring the use of effective deterrents, such as monitoring and supervision), although learning from experience improves considerably with age. Experience in the absence of negative consequences may increase feelings of invulnerability and thus explain the decrease in risk perceptions from early to late adolescence, as exploration increases. Finally, novel interventions that discourage deliberate weighing of risks and benefits by adolescents may ultimately prove more effective and enduring. Mature adults apparently resist taking risks not out of any conscious deliberation or choice, but because they intuitively grasp the gists of risky situations, retrieve appropriate risk-avoidant values, and never proceed down the slippery slope of actually contemplating tradeoffs between risks and benefits. [ABSTRACT FROM AUTHOR]

Many health and safety problems, including war and terrorism, are by-products of how people reason about risk. I describe a new approach to reasoning about risk that implements a modern dual-process model of memory called fuzzy-trace theory. This approach posits encoding of both verbatim and gist representations, with reliance on the latter whenever possible; dependence of reasoning on retrieval cues that access stored values and principles; and vulnerability of reasoning to processing interference from overlapping classes of events, which causes denominator neglect in risk or probability judgments. These simple principles explain classic and new findings, for example, the finding that people overestimate small risks but ignore very small risks. Fuzzy-trace theory differs from other dual-process approaches to reasoning in that it places intuition at the apex of development, considering fuzzy intuitive processing more advanced than precise computational processing (e.g., trading off risks and rewards). The theory supplies a conception of rationality that distinguishes degrees of severity of errors in reasoning. It also includes a mechanism for achieving consistency in reasoning, a hallmark of rationality, by explaining how a person can treat superficially different reasoning problems in the same way if the problems share an underlying gist. [ABSTRACT FROM AUTHOR]

Background. The use of a simpler procedure for the measurement of utilities could affect primarily the variance or both the mean and the variance of measurements. In the former case, simpler methods would be useful for population studies of preferences; however, in the latter, their use for such studies might be problematic. Purpose. The purpose of this study was to compare the results of utility elicitation using single-item questions to computer elicitation using the Ping-Pong search procedure. Methods. In a convenience sample of 149 primary care patients with symptoms of depression, the authors measured and compared standard gamble (SG) utilities elicited using a single-item “open question” to SG elicitations performed using a computerized interview procedure. Elicitations were performed 1 to 2 weeks apart to minimize memory effects. Results. More than 90% of persons with utilities of 1.0 to the single-item standard gamble had utilities of less than 1.0 on the computer SG instrument. Consistent with this finding, the mean utilities were lower in computer interviews (0.80 vs. 0.90; P< 0.0001 for differences). Within subjects, utility measures had only a fair degree of correlation (r= 0.54). Conclusions. Use of single-item questions to elicit utilities resulted in less precise estimates of utilities that were upwardly biased relative to those elicited using a more complex search procedure. [ABSTRACT FROM PUBLISHER]

Examines the validity of fuzzy-trace theory predicting the cognitive development of children. Biases affecting decision quality; Focus of children on quantitative differences between outcomes; Absence of framing effects during decision making.

The article presents an obituary for French economist Maurice Allais.