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Medical Decision Making (medical + decision_making)
Selected AbstractsAltruism and Self Interest in Medical Decision MakingTHE JOURNAL OF LAW, MEDICINE & ETHICS, Issue 3 2009Paul H. Rubin We seem to prefer that medicine and medical care be provided through altruistic motives. Even the pharmaceutical industry justifies its behavior in terms of altruistic purposes. But economists have known since Adam Smith that self-interested behavior can create large and growing social benefits. This is true for medical care as well as for other goods. First, I consider specifically the case of pharmaceutical promotion, both to physicians and to consumers. I argue that such promotion is highly beneficial to patients and leads to health improvements. I consider some criticisms of promotion, and show that they are misguided. I then provide some evolutionary explanations for our erroneous beliefs about medical care. [source] Medical decision making: a selective review for child psychiatrists and psychologistsTHE JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY AND ALLIED DISCIPLINES, Issue 7 2005Cathryn A. Galanter Physicians, including child and adolescent psychiatrists, show variability and inaccuracies in diagnosis and treatment of their patients and do not routinely implement evidenced-based medical and psychiatric treatments in the community. We believe that it is necessary to characterize the decision-making processes of child and adolescent psychiatrists using theories and methods from cognitive and social sciences in order to design effective interventions to improve practice and education. This paper selectively reviews the decision-making literature, including recent studies on naturalistic decision making, novice,expert differences, and the role of technology on decision making and cognition. We also provide examples from other areas of medicine and discuss their implications for child psychiatry. [source] Cutting through the statistical fog: understanding and evaluating non-inferiority trialsINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 10 2010W. S. Weintraub Summary Every year, results from many important randomised, controlled trials are published. Knowing the elements of trial design and having the skills to critically read and incorporate results are important to medical practitioners. The goal of this article is to help physicians determine the validity of trial conclusions to improve patient care through more informed medical decision making. This article includes a review of 162 randomised, controlled non-inferiority (n = 116) and equivalence (n = 46) hypothesis studies as well as the larger Stroke Prevention using Oral Thrombin Inhibitor in atrial Fibrillation V study and the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial. Evaluation of data from small and large trials uncovers significant flaws in design and models employed and uncertainty about calculations of statistical measures. As one example of questionable study design, discussion includes a large (n = 3922), double-blind, randomised, multicentre trial comparing the efficacy of ximelagatran with warfarin for prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and additional stroke risk factors. Investigators concluded that ximelagatran was effective compared with well-controlled warfarin for prevention of thromboembolism. However, deficiencies in design, as well as concerns about liver toxicity, resulted in the rejection of the drug by the US Food and Drug Administration. Many trials fail to follow good design principles, resulting in conclusions of questionable validity. Well-designed non-inferiority trials can provide valuable data and demonstrate efficacy for beneficial new therapies. Objectives and primary end-points must be clearly stated and rigorous standards met for sample size, establishing the margin, patient characteristics and adherence to protocol. [source] Mixed venous oxygen saturation is a prognostic marker after surgery for aortic stenosisACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 5 2010J. HOLM Background: Adequate monitoring of the hemodynamic state is essential after cardiac surgery and is vital for medical decision making, particularly concerning hemodynamic management. Unfortunately, commonly used methods to assess the hemodynamic state are not well documented with regard to outcome. Mixed venous oxygen saturation (SvO2) was therefore investigated after cardiac surgery. Methods: Detailed data regarding mortality were available on all patients undergoing aortic valve replacement for isolated aortic stenosis during a 5-year period in the southeast region of Sweden (n=396). SvO2 was routinely measured on admission to the intensive care unit (ICU) and registered in a database. A receiver operating characteristics (ROC) analysis of SvO2 in relation to post-operative mortality related to cardiac failure and all-cause mortality within 30 days was performed. Results: The area under the curve (AUC) was 0.97 (95% CI 0.96,1.00) for mortality related to cardiac failure (P=0.001) and 0.76 (95% CI 0.53,0.99) for all-cause mortality (P=0.011). The best cutoff for mortality related to cardiac failure was SvO2 53.7%, with a sensitivity of 1.00 and a specificity of 0.94. The negative predictive value was 100%. The best cutoff for all-cause mortality was SvO2 58.1%, with a sensitivity of 0.75 and a specificity of 0.84. The negative predictive value was 99.4%. Post-operative morbidity was also markedly increased in patients with a low SvO2. Conclusion: SvO2, on admission to the ICU after surgery for aortic stenosis, demonstrated excellent sensitivity and specificity for post-operative mortality related to cardiac failure and a fairly good AUC for all-cause mortality, with an excellent negative predictive value. [source] At what degree of belief in a research hypothesis is a trial in humans justified?JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 2 2002Benjamin Djulbegovic MD Abstract Rationale, aims and objectives,Randomized controlled trials (RCTs) have emerged as the most reliable method of assessing the effects of health care interventions in clinical medicine. However, RCTs should be undertaken only if there is substantial uncertainty about which of the trial treatments would benefit a patient most. The purpose of this study is to determine the degree of uncertainty in a research hypothesis before it can empirically be tested in an RCT. Methods,We integrated arguments from three independent lines of research , on ethics, principles of the design and conduct of clinical trials, and medical decision making , to develop a decision model to help solve the dilemma of under which circumstances innovative treatments should be tested in an RCT. Results,We showed that RCTs are the preferable option to resolve uncertainties about competing treatment alternatives whenever we desire reliable, undisputed, high-quality evidence with a low likelihood of false-positive or false-negative results. Conclusions When the expected benefit : risk ratio of a new treatment is small, an RCT is justified to resolve uncertainties over a wide range of prior belief (e.g. 10,90%) in the accuracy of the research hypothesis. Randomized controlled trials represent the best means for resolving uncertainties about health care interventions. [source] Rationality in medical decision making: a review of the literature on doctors' decision-making biasesJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 2 2001Brian H. Bornstein Abstract The objectives of this study were to describe ways in which doctors make suboptimal diagnostic and treatment decisions, and to discuss possible means of alleviating those biases, using a review of past studies from the psychological and medical decision-making literatures. A number of biases can affect the ways in which doctors gather and use evidence in making diagnoses. Biases also exist in how doctors make treatment decisions once a definitive diagnosis has been made. These biases are not peculiar to the medical domain but, rather, are manifestations of suboptimal reasoning to which people are susceptible in general. None the less, they can have potentially grave consequences in medical settings, such as erroneous diagnosis or patient mismanagement. No surefire methods exist for eliminating biases in medical decision making, but there is some evidence that the adoption of an evidence-based medicine approach or the incorporation of formal decision analytic tools can improve the quality of doctors' reasoning. Doctors' reasoning is vulnerable to a number of biases that can lead to errors in diagnosis and treatment, but there are positive signs that means for alleviating some of these biases are available. [source] Training the clinical eye and mind: using the arts to develop medical students' observational and pattern recognition skillsMEDICAL EDUCATION, Issue 3 2006Johanna Shapiro Introduction, Observation, including identification of key pieces of data, pattern recognition, and interpretation of significance and meaning, is a key element in medical decision making. Clinical observation is taught primarily through preceptor modelling during the all-important clinical years. No single method exists for communicating these skills, and medical educators have periodically experimented with using arts-based training to hone observational acuity. The purpose of this qualitative study was to better understand the similarities and differences between arts-based and clinical teaching approaches to convey observation and pattern recognition skills. Method, A total of 38 Year 3 students participated in either small group training with clinical photographs and paper cases (group 1), or small group training using art plus dance (group 2), both consisting of 3 2-hour sessions over a 6-month period. Findings, Students in both conditions found value in the training they received and, by both self- and instructor-report, appeared to hone observation skills and improve pattern recognition. The clinically based condition appeared to have been particularly successful in conveying pattern recognition concepts to students, probably because patterns presented in this condition had specific correspondence with actual clinical situations, whereas patterns in art could not be generalised so easily to patients. In the arts-based conditions, students also developed skills in emotional recognition, cultivation of empathy, identification of story and narrative, and awareness of multiple perspectives. Conclusion, The interventions studied were naturally complementary and, taken together, can bring greater texture to the process of teaching clinical medicine by helping us see a more complete ,picture' of the patient. [source] Stability of decisional role preference over the course of cancer therapyPSYCHO-ONCOLOGY, Issue 4 2006Julie B. Mallinger Abstract Cancer patients vary in their preferred level of involvement in medical decision making, and responding to patients' desired level of involvement is a key element of good medical care. While the literature has clearly demonstrated heterogeneity among cancer patients' preferences, less is known about how the preferences of any given patient may change over time. This longitudinal study compared cancer patients' preferences for involvement in medical decision making from the time of diagnosis to the time of completion of therapy. Data from 729 cancer patients with mixed diagnoses were analyzed. Most patients reported a change in preferred level of involvement over time, and multivariate analysis demonstrated that patients tend to prefer a decreasing level of involvement over time (p<0.0001). Stability of patients' preferences was also associated with type of cancer, but not with other sociodemographic characteristics. The results from this study highlight the importance of reevaluating patients' preferences for involvement in medical decision making throughout the course of cancer therapy, as such preferences are likely to change. Copyright © 2005 John Wiley & Sons, Ltd. [source] Do patients benefit from participating in medical decision making?PSYCHO-ONCOLOGY, Issue 1 2006Longitudinal follow-up of women with breast cancer Abstract This study sought to examine the relationships between decisional role (preferred and assumed) at time of surgical treatment (baseline), congruence between assumed role at baseline and preferred role 3 years later (follow-up), and quality of life at follow-up. Two hundred and five women diagnosed with breast cancer completed the decisional role preference scale at baseline and follow-up, and the EORTC QLQ-C30 at follow-up. A statistically significant number of women had decisional role regret, with most of these women preferring greater involvement in treatment planning than was afforded them. Women who indicated at baseline that they were actively involved in choosing their surgical treatment had significantly higher overall quality of life at follow-up than women who indicated passive involvement. These actively involved women had significantly higher physical and social functioning and significantly less fatigue than women who assumed a passive role. Quality of life was significantly related to reports of experienced involvement in treatment decision making, but not to reports of preferred involvement, or congruence between preferred and experienced involvement. Copyright © 2005 John Wiley & Sons, Ltd. [source] Faculty training in evidence-based medicine: Improving evidence acquisition and critical appraisalTHE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, Issue 1 2007Laura J. Nicholson MD Abstract Introduction: Evidence-based medicine (EBM) integrates published clinical evidence with patient values and clinical expertise, the output of which is informed medical decision making. Key skills for evidence-based practice include acquisition and appraisal of clinical information. Faculty clinicians often lack expertise in these skills and are therefore unable to demonstrate this process for students and residents. Methods: We conducted a yearlong case-based EBM workshop for 28 clinician educators, with precourse and postcourse evaluations of EBM resource use and literature appraisal skills. Results: Of the original 28 participants, 26 completed the course. Self-assessed EBM resource use improved significantly. Self-reported EBM knowledge correlated with measured skill (r = 0.45), and both improved with the intervention (both p < .001). Higher EBM skills scores correlated with time logged on the course's EBM Web sites (r = 0.56; p < .05), workshop attendance rates (r = 0.55; p = .003), and fewer years since medical school graduation (r = ,0.56; p < .005). Discussion: An interactive, longitudinal, EBM course derived from a needs assessment can improve 2 skills important for evidence-based practice: online literature retrieval and critical appraisal skills. [source] The Performance of Risk Prediction ModelsBIOMETRICAL JOURNAL, Issue 4 2008Thomas A. Gerds Abstract For medical decision making and patient information, predictions of future status variables play an important role. Risk prediction models can be derived with many different statistical approaches. To compare them, measures of predictive performance are derived from ROC methodology and from probability forecasting theory. These tools can be applied to assess single markers, multivariable regression models and complex model selection algorithms. This article provides a systematic review of the modern way of assessing risk prediction models. Particular attention is put on proper benchmarks and resampling techniques that are important for the interpretation of measured performance. All methods are illustrated with data from a clinical study in head and neck cancer patients. (© 2008 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim) [source] |