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Cover Focus | Sept/Oct '19

Learning From a Box of Chocolates

Is having more options better or worse for patients?

Cataract surgery is not what it used to be. The procedure has evolved dramatically, and surgeons have access to more tools and technologies than ever before. As a result, our patients now have more choices to make regarding their treatment. And these choices are important—they could have ramifications for patients’ vision and quality of life, and they carry financial implications. As their educators and the experts in their care, it is important that surgeons understand how patients make decisions and how to help them process the choices before them.


In a well-known study from the psychology literature, researchers at Columbia University and Stanford University set up an end-cap display in a grocery store.1 On Sundays, they displayed 24 varieties of Wilkin & Sons fine jams; on the other days of the week, they featured only six varieties. The researchers then tracked the number of purchases made on the days when the different quantities were displayed. They found that the smaller offering resulted in 900% more purchases than the larger offering. Individuals with fewer offerings had a ten times higher rate of making a purchase.

This study confirms that, with more options, people make fewer decisions. Currently, cataract surgeons have access to about 10 types of IOLs. Based on the variations among these options, there are about 170 different IOL plans that we could present to our patients. Sure, no one actually presents 170 options, and the vast majority of our patients proceed to scheduling surgery. But this raises the question: Could we simplify our offerings for the benefit of our patients?


For the sake of this article, let’s say the choice is affirmatively made—the patient confirms his or her scheduled surgery, you give your counselors a high-five, and you say, “We have a high closure rate for scheduling. Our patients do not disappear after their cataract evaluations, so we’re fine.” Well, it turns out that the psychological ramifications go beyond the decision time.

In another study, the same researchers had some chocolates available for sampling. People were randomly assigned to select from either a small box or a large box of chocolates. They were simply told to choose one chocolate, eat it, and tell the investigators what they thought. The researchers found that the group who chose from the large assortment felt that choosing the chocolate was more enjoyable than those who selected from the small assortment. Paradoxically, they also felt more difficulty and more frustration with their choice. And this is chocolate—you can’t really make that wrong of a decision. We can imagine how much more difficult and frustrating making a decision about an expensive and emotional purchase, such as cataract surgery, could be.

But the experiment did not end there. The investigators told the participants, “Thank you for participating. Please go speak with our manager, who is going to compensate you for your participation.” Here, the manager said, “Your option for compensation is $5 or a $5 box of chocolate.” The people who had chosen from the small assortment opted for the chocolate 48% of the time, whereas those who had chosen from the large assortment opted for the chocolate 12% of the time. The simple act of having chosen from a larger assortment made them financially devalue the product.

This experiment has been replicated with many different offerings—pens, coffee, gift boxes, and even retirement plans.2 They all point to the same conclusion: that people strongly value potential missed opportunities. In my practice, we perform LASIK, PRK, and SMILE. Even though the cost to us differs for each procedure, we charge the same for all three. We do this because we do not want patients to think for a second that we are up-selling them when, in reality, our goal is to give them the best, most personalized recommendation. Spaces such as MIGS and dry eye disease are also exploding with treatment options. In all of these scenarios, rather than presenting patients with every option available, I would recommend showing them what you consider to be the best option and keeping it simple from there.


With more options, fewer choices are made, and the chosen option is ultimately devalued. Even if a consumer makes a “right” decision, he or she may not feel satisfied with it. Understanding how our patients make decisions most effectively and adapting our practices to match these behaviors is key, especially when it comes to an offering as important as vision correction. Patients deserve to know their options, and a thoughtfully prepared response is important, rather than a laundry list that creates frustration or regret.

1. Iyengar SS, Lepper MR. When Choice Is Demotivating: Can One Desire Too Much of a Good Thing? J Personality Social Psychology. 2000;79(6):995-1006.

2. Scheibehenne B, Greifeneder R, Todd PM. Can There Ever Be Too Many Options? A Meta-Analytic Review of Choice Overload. J Consumer Res. 2010;37(3):409-425.

Bennett Walton, MD, MBA
  • Ophthalmologist, Slade & Baker Vision, Houston, Texas
  • drwalton@visiontexas.com
  • Member, MillennialEYE Editorial Advisory Board
  • Financial disclosure: None