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Biomedical subjects

J J Christensen-Szalanski

Publications and source records attributed to J J Christensen-Szalanski.

11 recordsLinked to original sources
PubMed1987

Circumcision and informed consent. Is more information always better?

This study observes that physicians routinely inform parents about a small minority of the medical complications and risks associated with elective circumcisions. When selecting which medical complications to mention to parents, physicians appeared to use a policy based on their subjective assessment of the frequency and seriousness of the complications' occurrence. Subsequent analyses revealed that the physicians' probability estimates were biased and their seriousness assessments were consistently less than those expressed by mothers of newborn sons. Replacing the physicians' policy of partial disclosure with a comprehensive disclosure of "unbiased" information of possible risks and complications had no effect on the mothers' decisions to have their sons circumcised but did generate numerous influences on the mothers' attitudes. Among the effects observed in mothers were a reduction in their confidence in the appropriateness of their decision and a dissatisfaction with their physician's behavior. The implications of these findings to informed consent are discussed, and a greater flexibility in providing informed consent is advocated.

Adult↗
PubMed1985

Patient compliance behavior: the effects of time on patients' values of treatment regimens.

Present medical models of treatment compliance have not addressed the role that time plays in the perception of a treatment regimen's costs and benefits. This paper re-evaluates the role of time in understanding compliance behavior. Models from the economic and psychological literature are used to demonstrate that the 'discounting effect' associated with future events, and the 'sunk cost effect' associated with past events may have a direct and predictable impact on the patient's values in health care choices. This article suggests that when the effects of time are incorporated into expectancy models of compliance behavior (such as the Health Belief Model) the resulting predictions are supported by numerous findings in the compliance literature, many of which were previously unaccountable by these expectancy models. From this finding an explanation is derived for the variable results of educational and attitudinal change programs upon compliance behavior, the success of patient contracts, the sudden occurrence of preference reversals in health care choices, and the 'confusing' effect of treatment cost on treatment adherence. This paper also introduces to the compliance literature the concept of a treatment's 'time adjusted rate of return', and speculates upon how this concept may be used to understand the relationship between a treatment's 'desirability' or its ability to motivate a person to start the treatment, and its 'resistance' or its capacity to help a person to finish the treatment once it has begun. It proposes that changes in the temporal distribution of a treatment's benefits and costs can improve the treatment's desirability and resistance, and that a treatment's time adjusted rate of return can be used to allocate more efficiently the effort that providers spend monitoring patient compliance.

Attitude to Health↗
PubMed1984

Discount functions and the measurement of patients' values. Women's decisions during childbirth.

This paper discusses the measurement of patients' values for future outcomes and examines some problems clinicians confront when making management decisions that attempt to comply with those values. It presents a model that implies that a patient's preference varies with the passage of time, and that during certain periods of time a patient's values may not be representative of his or her long-term preference. An examination of the attitudes of 18 pregnant women toward avoiding pain and avoiding anesthesia bore out the predictions of this model. The women preferred to avoid using anesthesia during childbirth when asked one month before labor and during early labor; however, during active labor their preferences suddenly shifted toward avoiding pain (p less than 0.05). Their preference shifted again toward avoiding the use of anesthesia (p less than 0.05) when evaluated at one month postpartum. The women's preferences one month before labor were the best predictors of their postpartum preferences. The women's preferences during active labor and transition phase of labor were unrelated to their postpartum preferences. These results suggest that, depending upon when a patient's values are measured, (1) they may not be representative of his or her long-term preference, and (2) their use in decision analyses may not maximize the patient's long-term satisfaction so much as they maximize the probability that the decision will be based on the patient's impulsive response. These results also imply that (3) patients may make inherently less reliable value assessments of abstract outcomes they have never experienced, and (4) the distinction between current and long-term values can create a problem when determining whether people behave rationally.

Anesthesia↗
PubMed1983

Physicians' misunderstanding of normal findings.

Gorry, Pauker, and Schwartz [1] demonstrated that a normal test result, when assessed quantitatively, can sometimes be extremely valuable in differential diagnosis. In the present study we extend the principle of the normal finding to include signs and symptoms. This extension proved to be clinically valuable for the present population of patients with acute cough, because the identified normal findings provided significant (p less than 0.001) information predictive of radiographic pneumonia and unrelated to that provided by the abnormal findings. This suggests that both types of findings should be used to diagnose pneumonia efficiently. Another result of the extension of this principle to signs and symptoms was the identification of the clinicians' use (p less than 0.001) of abnormal findings but not (p greater than 0.75) normal findings when managing patients with acute cough. Several possible causes for this misuse of normal findings are discussed, including limitations in the clinicians' cognitive processing of "absent problems," emphasis on abnormal findings by patients, and confusing epidemiological terminology that discourages the recognition of pertinent normal findings.

Cough↗
PubMed1982

Two studies of good clinical judgment.

There is a continuing controversy about the quality of unaided clinical judgment. This paper reports two studies that show that experienced medical providers made accurate probability assessments and applied those assessments to patient care in a manner consistent with principles of optimal decision making. In the first study, experienced clinicians and physician assistants accurately judged the relative frequency of three cough-related diagnoses in an outpatient population, suggesting that their encounter with several "unrelated" diagnostic problems does not interfere with their ability to judge accurately the frequency of any single diagnostic problem. In the second study, a group of clinicians assessed the probability that each patient seen in an outpatient clinic had pneumonia. Physicians were more likely to assign a pneumonia diagnosis and to order a radiograph for patients with a greater assessed probability of pneumonia (p less than 0.05). Most of the physicians appeared to use cutoff probabilities or "thresholds" above which they acted as though the patient had the disease and below which they acted as though the patient did not have the disease, consistent with rational decision-making principles. However, the threshold probabilities being used were quite different from physician to physician, implying that the physicians managed the patient population in a nonuniform manner. Thus it may be desirable to supplement "good" clinical judgment with decision aids to ensure standardized medical care.

Bronchitis↗
PubMed1982

Phased trial of a proven algorithm at a new primary care clinic.

A previous study showed that a clinical algorithm for respiratory illnesses, consisting of a checklist, a set of instructions (logic), and computer audit/feedback, could reduce costs significantly while maintaining a high quality of care. The results of this study show that the algorithm system, developed and validated at one primary care clinic, can be successfully imported to another primary care clinic. In the present study, the algorithm system significantly improved the completeness of the medical records, reduced the use of medical tests by 20 per cent-75 per cent, and reduced non-provider costs by 36 per cent per patient visit. This study also shows that all three components of the algorithm system appear to be necessary to achieve these improvements and maintain a high quality of medical care. These results suggest that a wider use of the algorithm system for minor acute medical problems is both feasible and useful in providing high-quality cost-effective care that is auditable.

Adult↗
PubMed1981

Physician's use of probabilistic information in a real clinical setting.

This study reports on physicians' processing of probabilistic information while they were treating possible pneumonia patients at an outpatient clinic. Physicians overestimated the patients' probability of pneumonia but were sensitive to relative differences in the predictive value of symptoms when present and absent, and appeared to use base-rate information correctly when making clinical judgments.

Diagnosis, Differential↗
PubMed1981

Feedback and the illusion of validity in a medical clinic.

This paper discusses the effect of feedback from an imperfect diagnostic test-ordering decision upon clinicians' ability to evaluate their management strategies. It presents data from a medical outpatient clinic that show that physicians rely on chest radiographs to diagnose pneumonia but fail to request them for all patients with pneumonia. The data show that physicians preferentially use clinical attributes associated with pneumonia as perceived from the feedback of this imperfect chest radiograph-ordering decision (p less than 0.001) even though the attributes do not predict pneumonia as accurately as clinical attributes associated with all pneumonia cases (p less than 0.001). It is concluded that incomplete feedback based on an imperfect chest radiograph-ordering decision may perpetuate inefficient chest radiograph ordering patterns.

Decision Making↗