New approaches to teaching basic interview skills to medical students.
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Education, Medical↗
Biomedical subjects
A S Elstein
Publications and source records attributed to A S Elstein.
Assumed similarity in staff perception of psychiatric patients.
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Attitude of Health Personnel↗
Structure of staff perceptions of psychiatric patients.
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Adolescent↗
Dimensions in the perception of psychiatric patients by hospital staff.
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Adolescent↗
Decision analysis in surgical education.
Surgical education can no longer be considered adequate if limited to description of surgical diseases and methods of management. Due to the growth in numbers of surgical diagnostic and therapeutic procedures, the surgeon of the future will find it increasingly necessary to understand the principles by which algorithms are constructed and by which individualized decisions should be made. Several systematic approaches for assisting clinical decision makers have been developed. Decision analysis is particularly appealing because it is flexible and readily adapted to a wide range of clinical situations. It explicitly guides the decision maker in determining the crucial variables in a clinical decision, and permits both objective data and personal preferences to play a part in decision making. Because it provides for personal estimates and preferences, decision analysis is not dehumanizing, even though it is quantitative, explicit, and mathematically rigorous. Topics for a series of seminars or case conferences are suggested. Decision analysis should be part of the intellectual preparation of every clinician.
Decision Support Techniques↗
Women's and physicians' utilities for health outcomes in estrogen replacement therapy.
Estrogen replacement therapy (ERT) prevents fractures and relieves vasomotor symptoms, but it increases the risk of endometrial cancer. Previous studies and national prescribing patterns show that physicians are conservative in their approach to this therapy. The authors interviewed physicians and perimenopausal women to assess their utilities for the various health outcomes of estrogen replacement therapy. On all outcomes, physicians rated illness episodes followed by recovery as being closer to perfect health than did perimenopausal women. Physicians, in judging which outcomes were most important to women, estimated relief of symptoms above fracture prevention, whereas women rated fracture prevention above symptom relief. These results emphasize the need to assess patients' utilities directly, particularly when utilities for the outcome of a particular therapy may influence the choice of a therapeutic regimen.
Adult↗
Effects of a decision support system on the diagnostic accuracy of users: a preliminary report.
OBJECTIVES: To assess the effects of incomplete data upon the output of a computerized diagnostic decision support system (DSS), to assess the effects of using the system upon the diagnostic opinions of users, and to explore if these effects vary as a function of clinical experience. DESIGN: Experimental pilot study. Four clusters of nine cases each were constructed and equated for case difficulty. Definitive findings were omitted from the case abstracts. Subjects were randomly assigned to one of four clusters and were trained on the DSS prior to use. SUBJECTS: The study involved 16 physicians at three levels of clinical experience (six general internists, four residents in internal medicine, and six fourth-year medical students), from three academic medical centers. PROCEDURE: Each subject worked up nine cases, first without and then with ILIAD consultation. They were asked to offer up to six potential diagnoses and to list up to three steps that should be the next items in the diagnostic workup. Effects of DSS consultation were measured by changes in the position of the correct diagnosis in the lists of differential diagnoses, pre- and post-consultation. RESULTS: The DSS lists of diagnostic possibilities contained the correct diagnosis in 38% of cases, about midway between the levels of accuracy of residents and attending general internists. In over 70% of cases, the DSS output had no effect on the position of the correct diagnosis in the subjects' lists. The system's diagnostic accuracy was unaffected by the clinical experience of the users.
Decision Making↗
Laboratory use: attitudes implicit in a national examination.
The quantitative principles of test selection and interpretation have been reluctantly integrated into clinical practice. This reluctance may reflect an underlying faculty attitude towards the laboratory. To evaluate this attitude, the scoring standards used for 23 patient management problems (PMPs) in the 1980 and 1983 Medical Knowledge Self-Assessment Programs were reviewed. All diagnostic options were categorized by dollar cost, risk, and a determination of "routineness." Attitudes were probed by reviewing the scores obtained by indiscriminate selection of all items in a category. Our analysis indicated that the examiners valued routine, little-ticket, little-risk items. Such selection would be rewarded 85% of the time and in 95%, no penalty would be received. Further, indifference was more frequent for little-ticket items and accounted for 11.7% of acceptable diagnostic expense. An examinee analyzing these scoring keys could reasonably conclude that routine, little-ticket items should be ordered whenever offered. Hence, at a national level, there is an attitude that implicitly encourages the use of these items in clinical practice.
Attitude of Health Personnel↗
On the clinical significance of hindsight bias.
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Decision Making↗
Hormonal replacement therapy: analysis of clinical strategies used by residents.
The authors investigated strategies employed by resident physicians to decide whether to prescribe hormonal replacement therapy (HRT) for menopausal women, a matter of continuing clinical controversy. Verbal protocols were obtained from 21 residents in three specialties as they responded to 12 brief case descriptions. The cases incorporated three levels of cancer risk and two levels of osteoporosis risk in a 3 x 2 factorial design with two replications in each cell. Substantial variation in willingness to prescribe HRT was observed. By clustering subjects with relatively similar approaches to the problem, three treatment strategies were formulated that accounted for the decisions of 20 subjects. Each strategy is a simplified representation of the conflicting considerations in this clinical dilemma that facilitates rapid decision making. The differences between these representations and formal decision-analytic models help to explain why observed clinical decisions were inconsistent with expected utility maximization.
Breast Neoplasms↗
Diagnostic reasoning of high- and low-domain-knowledge clinicians: a reanalysis.
Thinking-aloud protocols provided by Joseph and Patel were reanalyzed to determine the extent to which their conclusions could be replicated by independently developed coding schemes. The data set consisted of protocols from four cardiologists (low domain knowledge = LDK) and four endocrinologists (high domain knowledge = HDK), individually working on a diagnostic problem in endocrinology. The two analyses agree that the HDK physicians related data to potential diagnoses more than did the LDK group and were more focused on the correct diagnostic components. However, the reanalysis found no meaningful difference between the groups in diagnostic accuracy, speed of diagnosis, or the breadth of the search space used to seek a solution. In the reanalysis, the HDK physicians employed more single-cue inference and less multiple-cue inference. The generalizability of results of protocol-analysis studies can be assessed by using several complementary coding schemes.
Aged↗
Effects of patient education on decisions about breast cancer treatments: a preliminary report.
The authors examined the effects of materials for educating patients about treatment options for breast cancer on knowledge about the disease, preferences for alternative treatments, and how changes in knowledge and preferences were related. Eighty-two undergraduate students acted as advisors to a hypothetical patient. They completed a knowledge test and rated their preferences for three options--breast-sparing surgery with radiation, mastectomy followed by reconstructive surgery, and mastectomy followed by use of a breast prosthesis--before and after viewing a videotape or a booklet version of the educational materials. Both formats increased knowledge scores. Treatment preferences were not affected by reading the booklet, but viewing the videotape resulted in a preference shift toward breast-sparing surgery. This media difference may be due to features of the video that were not reproduced in the booklet, such as interviews with other patients. Knowledge gains were uncorrelated with preference changes.
Adolescent↗
Valuing the future: temporal discounting of health and money.
Normative discounted utility theory specifies that the values of all future outcomes (for example, those related to health and money) should be discounted at a constant rate. Two experiments demonstrated that, contrary to this prescription, decision makers use different discount rates for health-related decisions and money-related decisions. Temporal discountings for health and money were similar in that both demonstrated two biases previously found in monetary decisions: discount rates were inversely related to magnitude of outcome and length of delay. The relatively large discount rates used by the subjects suggest why it is often difficult to implement preventive health measures that improve future health.
Decision Making↗
MDM policy regarding financial support of authors.
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Authorship↗
Prostate cancer patients' utilities for health states: how it looks depends on where you stand.
Two versions of the time-tradeoff (TTO) method were compared. In the personal TTO version, 31 prostate cancer patients decided whether they personally would give up some longevity to have perfect health rather than a longer life in a state of poor health associated with prostate cancer. In the impersonal version, 28 patients compared two hypothetical friends, one of whom has perfect health but will live less time than the other who is in poor health, and decided which person they would rather be. All patients evaluated three hypothetical health states. The two TTO methods were assessed by examining 1) how well they distinguished three health states of varying degrees of dysfunction and 2) patients' willingness to trade time for quality of life. Patients using the impersonal TTO version were more likely than those using the personal version to order the three health states appropriately (68% vs 16%, p < 0.0001) and were more willing to trade off length of life for quality of life (p < 0.05).
Activities of Daily Living↗
Framing effects in choices between multioutcome life-expectancy lotteries.
AIM: To explore framing or editing effects and a method to debias framing in a clinical context. METHOD: Clinical scenarios using multioutcome life-expectancy lotteries of equal value required choices between two supplementary drugs that either prolonged or shortened life from the 20-year beneficial effect of a baseline drug. The effects of these supplementary drugs were presented in two conditions, using a between-subjects design. In segregated editing (n = 116) the effects were presented separately from the effects of the baseline drug. In integrated editing (n = 100), effects of supplementary and baseline drugs were combined in the lottery presentation. Each subject responded to 30 problems. To explore one method of debiasing, another 100 subjects made choices after viewing both segregated and integrated editings of 20 problems (dual framing). RESULTS: Statistically significant preference reversals between segregated and integrated editing of pure lotteries occurred only when one framing placed outcomes in the gain domain, and the other framing placed them in the loss domain. When both editings resulted in gain-domain outcomes only, there was no framing effect. There was a related relationship of framing-effect shifts from losses to gains in mixed-lottery-choice problems. Responses to the dual framing condition did not consistently coincide with responses to either single framing. In some situations, dual framing eliminated or lessened framing effects. CONCLUSION: The results support two components of prospect theory, coding outcomes as gains or losses from a reference point, and an s-shaped utility function (concave in gain, convex in loss domains). Presenting both alternative editings of a complex situation prior to choice more fully informs the decision maker and may help to reduce framing effects. Given the extent to which preferences shift in response to alternative presentations, it is unclear which choice represents the subject's "true preferences."
Adolescent↗