key: cord-0777328-feqtnpff
authors: Wang, Tim T.; Wang, Steven
title: Applying behavioral economics to address COVID-19 fear among oral and maxillofacial surgery patients
date: 2020-12-24
journal: J Oral Maxillofac Surg
DOI: 10.1016/j.joms.2020.12.020
sha: e5e3687b2f83331999718ecd352aeda006c6619b
doc_id: 777328
cord_uid: feqtnpff

nan

The novel coronavirus (COVID-19) pandemic has changed the practice of oral and maxillofacial surgery over the last number of months. Elective surgeries were postponed for several months, and many emergency cases were triaged and deferred via telemedicine. As states reopened and resumed in-person procedures, surgeons have taken a plethora of safety precautions including additional personal protective equipment (e.g. N95 respirators, face shields, shoe coverings), new patient clinical flow protocols (e.g. waiting in the car and being seated immediately after checking in), and COVID-19 screening questionnaires. While these measures address patients' physical safety, there have been less discussion about the psychological wellbeing of patients. Specifically, fear of COVID-19 exposure, if not sufficiently addressed, can prevent patients from accurately weighing benefits and risks of receiving in-person oral and maxillofacial surgery care.

The Centers for Disease Control and Prevention reports that over 40% of American adults avoided medical care due to concerns about COVID-19. [1] In a presentation in late July, the American Dental Association Health Policy Institute discussed that while there have been a rebound in dental demand, polls find that one in five patients would still hesitate to get dental care. [2] This suggests that fear of the virus may affect patient decision-making and can have negative consequences on patient outcomes. As such, it is important to help patients calibrate their perceptions to accurately weigh risks and benefits of receiving or delaying oral and maxillofacial surgery services during the COVID-19 pandemic. For example, delaying surgical J o u r n a l P r e -p r o o f care for an oral cancer diagnosis can have detrimental effects on mortality and quality of life that may outweigh the risks of potential exposure to COVID-19 for some patients.

To this end, behavioral economics, which has been increasingly applied to improve health care in recent years, offers surgeons a fresh perspective to analyze patient fear of COVID-19 and in turn guide them to make an informed decision about treatment. Behavioral economics integrates economic and psychological principles to explain human decision-making, which tends to be predictably irrational because of reliance on cognitive biases and mental shortcuts when processing information. [3] Risk Evaluation during COVID-19

Behavioral economics can help surgeons elucidate how fear of COVID-19 infection can skew patients' decisions on whether or not to receive in-person oral and maxillofacial surgery care. Risk compensation bias describes the phenomenon in which individuals adjust their behavior based on perceived risk. [3] Therefore, it is important to dispel any misconceived notions about COVID-19 and oral and maxillofacial surgery care.

Some patients may over-weigh the risks of COVID-19 and under-weigh the benefits of receiving care. While the risks of the pandemic are undoubtedly serious, they may become overly heightened because of availability bias, or the tendency of humans to place greater cognitive weight on information that more readily come to mind when making a decision. [4] The extensive coverage of the pandemic in mainstream and social media likely contributes to this.

Relatedly, the framing of emotional information surrounding COVID-19 can tip the scales on how facts and probabilities are evaluated. Positive emotion framing tend to make individuals focus more on positive facts, whereas the same is true for negative framing. [3] Most news media J o u r n a l P r e -p r o o f tend to focus on the negative aspects of the pandemic (i.e. number of infections and deaths, rather than the number of recoveries), thus leading individuals to focus more on the negative information regarding the pandemic when making a decision.

On the flip side, there may be individuals who underestimate the risks of the pandemic.

Optimism bias describes a phenomenon in which individuals are overly confident that bad events are less likely to happen to them and their families than to strangers. [3] While this reduces patient fear, it is still important to inform patients to help them avoid behaviors that can endanger fellow patients as well as their providers (e.g. not wearing a mask, not observing social distancing in the waiting room).

Finally, salience bias is dichotomous and can influence decision-making in either direction. People tend to place greater weight on information that is emotionally and cognitively striking. [3, 4] For example, patients in pain from a dental abscess or facial trauma will relegate high salience to receiving oral and maxillofacial surgery care despite the pandemic, as the pain's salience surpasses that of the risks of infection. However, oral and maxillofacial surgery services for asymptomatic conditions or those perceived to be less acute, such as some biopsies and jaw surgeries, are far less salient and thus can be easily overtaken by the fear of COVID-19. A related principle, present bias, in which individuals tend to prefer immediate benefits and forgo While the magnitude of the aforementioned cognitive biases have yet to be quantitatively defined, it is nevertheless critical that oral-maxillofacial surgeons understand them when communicating with patients to help them make informed decisions about their care. With the end of the pandemic still likely many months away, providers should calibrate their consultations with patients to ensure a balance between patient safety from COVID-19 exposure and optimal clinical outcomes.

To this end, communication will be key to reduce the role of fear and elevate facts to the forefront of decision making. First, it is important for surgeons to convey all of the precautions that their institutions are taking to minimize risk of COVID-19 exposure. Also, surgeons should explain benefits and drawbacks of delaying treatment. Specifically, providers can decide whether to frame their explanation in gain frame (i.e. receiving care will bring positive consequences) or loss frame (i.e. not receiving care will bring negative consequences) depending on the situation.

Research has found that humans tend to respond more to loss frame than gain frame, though both can be effective strategies. [5] Also, it may be helpful to explain what other patients in similar circumstances are electing to do, because social comparisons have a large subconscious effect on our decision making. [5] Ultimately, surgeons should aim to remove fear from the equation and equip patients with the relevant facts to make informed and personalized decisions about their care. We hope that these insights can help surgeons better understand patients' decision-making processes and cognitive biases in order to more effectively communicate about surgical care during this pandemic and beyond.

J o u r n a l P r e -p r o o f

Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns -United States

American Dental Association Health Policy Institute (2020) How COVID-19 is Impacting Dental Practices and Patient Attitudes Toward Visiting the Dentist

Using social and behavioural science to support COVID-19 pandemic response

The Behavioral Economics of Health and Health Care

To Re-Open Health Care, Leaders Should Address Patient Fear. NEJM Catalyst Innovations in Care Delivery