Cognitive Bias in Postoperative Opioid Prescribing Practice: A Novel Effect

Bradley M. Brooks DO1, Chia-Ding Shih DPM, MPH, MA2, Reed W.R. Bratches MPH, MALS3, Allison S. Arp MS3, Gerard J. Coughlin BA2, Kristina B. Wolff PhD, MS, MPA, MPH3, and Brandon M. Brooks DPM, MPH3,4
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  • 1 University of South Alabama Health, Mobile, AL.
  • | 2 California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA.
  • | 3 The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH.
  • | 4 Wm. Jennings Bryan Dorn VA Medical Center, Columbia, SC.


Background: Given that excess opioid prescriptions contribute to the United States opioid epidemic and there are few national opioid prescribing guidelines for the management of acute pain, it is pertinent to determine if prescribers can sufficiently assess their own prescribing practice. The purpose of this study was to investigate podiatric surgeons’ ability to evaluate if their own opioid prescribing practice is less than, near, or above that of an “average” prescriber.

Methods: We administered a scenario-based, voluntary, anonymous, online questionnaire via Qualtrics which consisted of five surgery-based scenarios commonly performed by podiatric surgeons. Respondents were asked the quantity of opioids they would prescribe at the time of surgery. Respondents were also asked to rate their prescribing practice compared to the average (median) podiatric surgeons. We compared self-reported behavior to self-reported perception (“I prescribe less than average,” “I prescribed about average,” and “I prescribe more than average”). ANOVA was used for univariate analysis between the three groups. We used linear regression to adjust for confounders. Data restriction was used to account for restrictive state laws.

Results: One hundred fifteen podiatric surgeons completed the survey from in April 2020. Less than half of the time, respondents accurately identified their own category. Consequently, there were no statistically significant differences between podiatric surgeons who reported that they “prescribe less,” “prescribe about average,” and “prescribe more.” Paradoxically, there was a flip in scenario #5, whereas respondents who reported they “prescribe more” actually prescribed the least and respondents who believed that they “prescribe less” actually prescribed the most.

Conclusions: Cognitive bias, in the form of a novel effect, occurs in postoperative opioid prescribing practice; in the absence of procedure-specific guidelines or an objective standard, podiatric surgeons, more often than not, were unaware of how their own opioid prescribing practice measured up to other podiatric surgeons.

Corresponding author: Brandon M. Brooks, DPM, MPH, FACPM, FASPS, Wm. Jennings Bryan Dorn VA Medical Center, 6439 Garners Ferry Rd, Columbia, SC 29209 (E-mail: