Critical Care Physicians' Perspectives on Nudging in Communication.

Importance: Research in behavioral economics has demonstrated that people have irrational biases, which make them susceptible to decisional shortcuts, or heuristics. The extent to which physicians consciously might use nudges to exploit these heuristics and thereby influence their patients' decision-making is unclear. In addition, ethical questions about the conscious use of nudges in medicine persist, yet little is known about how physicians experience and perceive their use. Objective: To explore critical care physicians' perspectives on nudging to guide patients in clinical decision-making. Design, Setting, and Participants: This qualitative study involved semistructured interviews of critical care physicians at 3 tertiary care hospitals in Boston conducted between June and September 2024. Adult, pediatric, and neonatal critical care attending physicians were randomly selected to participate in the study. Transcripts were analyzed using qualitative thematic analysis from October 2024 to February 2025. Main Outcomes and Measures: Themes and subthemes that reflected physicians' experiences and views. Results: A total of 100 physicians were invited, and 54 physicians (29 [53.7%] male) were interviewed; 35 (64.8%) were adult intensivists, 13 (24.1%) were pediatric intensivists, and 6 (11.1%) were neonatal intensivists. Four main themes were identified: (1) nudging was generally seen as a positive and necessary part of medical communication; (2) physicians had ethical concerns about nudges, especially relating to autonomy; (3) nudging may be more effective and appropriate in certain situations but counter-productive in others; and (4) physicians' experiences and perspectives varied by practice setting, sex, and experience. Adult intensivists engaged in more direct recommendations and transparent nudges, while pediatric and neonatal intensivists supported more subtle nudging to foster shared decision-making. Female physicians tended to use nudges to emphasize patient and family emotional well-being, while male physicians tended to highlighted efficiency and outcomes as the primary reasons to nudge; junior physicians were more hesitant to use nudges compared with their more senior counterparts. Conclusions and Relevance: In this qualitative study, physicians acknowledged that it was important to use nudges when communicating with patients, while noting ethical uncertainty. These findings have implications for how nudging may be used as an effective and appropriate communication technique depending on context.