Physician and Nonphysician Estimates of Positive Predictive Value in Diagnostic v. Mass Screening Mammography: An Examination of Bayesian Reasoning

Med Decis Making. 2019 Feb;39(2):108-118. doi: 10.1177/0272989X18823757. Epub 2019 Jan 24.


Background: The same test with the same result has different positive predictive values (PPVs) for people with different pretest probability of disease. Representative thinking theory suggests people are unlikely to realize this because they ignore or underweight prior beliefs when given new information (e.g., test results) or due to confusing test sensitivity (probability of positive test given disease) with PPV (probability of disease given positive test). This research examines whether physicians and MBAs intuitively know that PPV following positive mammography for an asymptomatic woman is less than PPV for a symptomatic woman and, if so, whether they correctly perceive the difference.

Design: Sixty general practitioners (GPs) and 84 MBA students were given 2 vignettes of women with abnormal (positive) mammography tests: 1 with prior symptoms (diagnostic test), the other an asymptomatic woman participating in mass screening (screening test). Respondents estimated pretest and posttest probabilities. Sensitivity and specificity were neither provided nor elicited.

Results: Eighty-eight percent of GPs and 46% of MBAs considered base rates and estimated PPV in diagnosis greater than PPV in screening. On average, GPs estimated a 27-point difference and MBAs an 18-point difference, compared to actual of 55 or more points. Ten percent of GPs and 46% of MBAs ignored base rates, incorrectly assessing the 2 PPVs as equal.

Conclusions: Physicians and patients are better at intuitive Bayesian reasoning than is suggested by studies that make test accuracy values readily available to be confused with PPV. However, MBAs and physicians interpret a positive in screening as more similar to a positive in diagnosis than it is, with nearly half of MBAs and some physicians wrongly equating the two. This has implications for overdiagnosis and overtreatment.

Keywords: Bayesian reasoning; base rate neglect; diagnosis; positive predictive value; screening.

MeSH terms

  • Adult
  • Bayes Theorem
  • Breast Neoplasms / diagnosis*
  • Clinical Competence
  • Diagnostic Tests, Routine
  • Early Detection of Cancer*
  • Female
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Intuition
  • Male
  • Mammography*
  • Mass Screening*
  • Medical Overuse
  • Physicians* / psychology
  • Predictive Value of Tests
  • Probability
  • Sensitivity and Specificity
  • Thinking*