Does judgment for nurse require judgment for hospital? Case in point: Eversole v. Oklahoma Hosp. Founders (818 P. 2d. 456--OK (1991)).
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Accidental Falls↗
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[Practicable judgments on characteristics of public health on a population level. 2. Diagnosis as a judgment on health].
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Diagnosis↗
Consistency of physicians' legal standard and personal judgments of competency in patients with Alzheimer's disease.
OBJECTIVES: To investigate the consistency of physician judgments of treatment consent capacity (competency) for patients with Alzheimer's disease (AD) when specific legal standards (LS) for competency are used, and to identify the LS most clinically relevant to experienced physicians. DESIGN: Control and AD patient participants were videotaped being administered a measure of capacity to consent to medical treatment. Study physicians viewed videotapes of these assessments individually and made competency judgments for each participant under different LS followed by their own personal judgment of competency. SETTING: A university medical center. PARTICIPANTS: Participants were 10 older controls and 21 patients with AD (10 with mild and 11 with moderate AD). Five physicians with experience assessing the competency of AD patients were recruited from the geriatric psychiatry, geriatric medicine, and neurology services of a university medical center. MEASUREMENTS: The 31 participants were videotaped performing on a measure of treatment consent capacity (Capacity to Consent to Treatment Instrument) (CCTI). The CCTI consists of two clinical vignettes (A-neoplasm and B-cardiac) that test competency under five LS. Vignette A and B assessments were videotaped separately for each participant (total videotapes for sample = 62). Each study physician viewed each videotaped vignette individually, made judgments under each of the LS (competent or incompetent), and then made his/her own personal competency judgment. Physicians were blinded to participant diagnosis. Within participant group, consistency of physician judgments was evaluated across LS and personal judgments using percentage agreement and kappa. Agreement between personal and LS judgments for the AD group was evaluated for each physician using logistic regression. RESULTS: As expected, physicians as a group generally demonstrated very high percentage agreement in their LS and personal competency judgments for the control group. For the AD group, mean percentage judgment agreement among physicians ranged from a high of 84% (LS1) (evidencing a treatment choice) to a low of 67% (LS3) (appreciating consequences of treatment choice). Mean percentage agreement for personal competency judgments was 76%. For the AD sample, kappa analyses for physicians as a group demonstrated significant agreement not attributable to chance for LS5 (understanding treatment situation/choices) (k = 0.57, P = .001), LS4 (providing rational reasons for treatment choice) (k = 0.39, P = .04), and also for personal judgments (k = 0.48, P = .009). Analysis of LS judgment agreement within physician indicated that physicians applied the LS as discrete standards. Within-physician and for the AD sample, personal competency judgments were associated significantly with judgments on LS5 (P = .001), LS4 (P = .004), and LS3 (P < .04). CONCLUSIONS: Experienced physicians demonstrated significant agreement assessing competency in AD patients when judgments were based upon specific legal standards. Personal competency judgments of physicians showed a substantially higher level of agreement than found in a previous study, where specific LS were not used. These results suggest that consistency of physician competency judgments can be enhanced if they are guided by knowledge of specific LS. Physicians' personal competency judgments were most closely associated with comprehension and reasoning LS, the most conservative and clinically appropriate standards for deciding competency.
Alzheimer Disease↗
Cognitive models of physicians' legal standard and personal judgments of competency in patients with Alzheimer's disease.
OBJECTIVES: To investigate measures of patient cognitive abilities as predictors of physician judgments of medical treatment consent capacity (competency) in patients with Alzheimer's disease (AD). DESIGN: Predictor models of legal standards (LS) and personal competency judgments were developed for each study physician using independent neuropsychological test measures and logistic regression analyses. SETTING: A university medical center. PARTICIPANTS: Five physicians with experience assessing the competency of AD patients were recruited to make competency judgments of videotaped vignettes from 10 older controls and 21 patients with AD (10 with mild and 11 with moderate dementia). MEASUREMENTS: The 31 patient and control videotapes of performance on a measure of treatment consent capacity (Capacity to Consent to Treatment Instrument) (CCTI) were rated by the five physicians. The CCTI consists of two clinical vignettes (A-neoplasm and B-cardiac) that test competency under five LS. Each study physician viewed each vignette videotape individually, made judgments of competent or incompetent under each of the LS, and then made his/her own personal competency judgment. Physicians were blinded to participant diagnosis and neuropsychological test performance. Stepwise logistic regression was conducted to identify cognitive predictors of each physician's LS and personal competency judgments for Vignette A using the full sample (n = 31). Classification logistic regression analysis was used to determine how well these cognitive predictor models classified each physician's competency judgments for Vignette A. These classification models were then cross-validated using physician's Vignette B judgments. RESULTS: Cognitive predictor models for Vignette A competency judgments differed across individual physicians, and were related to difficulty of LS and to incompetency outcome rates across LS for AD patients. Measures of semantic knowledge and receptive language predicted judgments under less difficult LS of evidencing a treatment choice (LS1) and making the reasonable treatment choice (LS2). Measures of semantic knowledge, short-term verbal recall, and simple reasoning ability predicted judgments under more difficult and clinically relevant LS of appreciating consequences of a treatment choice (LS3), providing rational reasons for a treatment choice (LS4), and understanding the treatment situation and choices (LSS). Cognitive models for physicians' personal competency judgments were virtually identical to their respective models for LS5 judgments. For AD patients, shortterm memory predictors were associated with high incompetency outcome rates (over 70%), a simple reasoning measure was associated with moderately high incompetency outcome rates (60-70%), and a semantic knowledge measure was associated with lower incompetency outcome rates (30-60%). Overall, single predictor models were relatively robust, correctly classifying an average of 83% of physician judgments for Vignette A and 80% of judgments for Vignette B. CONCLUSIONS: Multiple cognitive functions predicted physicians' LS and personal competency judgments. Declines in semantic knowledge, short-term verbal recall, and simple reasoning ability predicted physicians' judgments on the three most difficult and clinically most relevant LS (LS3-LS5), as well as their personal competency judgments. Our findings suggest that clinical assessment of competency should include evaluation of semantic knowledge, verbal recall, and simple reasoning abilities.
Alzheimer Disease↗
Functional neuroanatomy of different olfactory judgments.
Humans routinely make judgments about olfactory stimuli. However, few studies have examined the functional neuroanatomy underlying the cognitive operations involved in such judgments. In order to delineate this functional anatomy, we asked 12 normal subjects to perform different judgments about olfactory stimuli while regional cerebral blood flow (rCBF) was measured with PET. In separate conditions, subjects made judgments about the presence (odor detection), intensity, hedonicity, familiarity, or edibility of different odorants. An auditory task served as a control condition. All five olfactory tasks induced rCBF increases in the right orbitofrontal cortex (OFC), but right OFC activity was highest during familiarity judgments and lowest during the detection task. Left OFC activity increased significantly during hedonic and familiarity judgments, but not during other odor judgments. Left OFC activity was significantly higher during hedonicity judgments than during familiarity or other olfactory judgments. These data demonstrate that aspects of odor processing in the OFC are lateralized depending on the type of olfactory task. They support a model of parallel processing in the left and right OFC in which the relative level of activation depends on whether the judgment involves odor recognition or emotion. Primary visual areas also demonstrated a differential involvement in olfactory processing depending on the type of olfactory task: significant rCBF increases were observed in hedonic and edibility judgments, whereas no significant rCBF increases were found in the other three judgments. These data indicate that judgments of hedonicity and edibility engage circuits involved in visual processing, but detection, intensity, and familiarity judgments do not.
Adult↗
Duration, distance, and speed judgments of two moving objects by 4- to 11-year olds.
Four- to 11-year-old children (N = 133) made duration, distance, and speed judgments on a Piagetian task where two cars ran on two parallel tracks. Special effort was made to make duration judgment tasks and distance judgment tasks comparable. Among younger children, difficulties of duration judgments and distance judgments were approximately the same. Additionally, temporal attributes had nearly the same effects on duration judgments as spatial attributes had on distance judgments, and spatial attributes had nearly the same effects on duration judgments as temporal attributes had on distance judgments. Among older children, distance judgments were easier than duration judgments, and the above-mentioned symmetry in effects of temporal and spatial attributes decreased somewhat. Temporal and spatial attributes affected speed judgments equally, across age groups.
Acceleration↗
Cognitive models that predict physician judgments of capacity to consent in mild Alzheimer's disease.
OBJECTIVE: To identify cognitive measures that predict consent capacity of normal and demented older adults as judged by experienced physicians. This study is a companion to the physician competency judgment research reported in this issue. DESIGN: Predictor models for competency judgments of individual physicians were developed using independent patient neuropsychological test measures and discriminant function analyses (DFA). SETTING: University medical center. PARTICIPANTS: Subjects were 16 normal older controls and 29 patients with mild AD (MMSE > or = 20). Five experienced medical center physicians were recruited as competency decision-makers. MEASUREMENTS: Subjects were videotaped responding to a standardized consent capacity interview (SCCI) designed to evaluate capacity to consent to treatment. Interview subjects were also independently administered (off videotape) a battery of neuropsychological measures theoretically and empirically linked to competency function. Study physicians blinded to subject diagnosis and neuropsychological test performance individually viewed each SCCI videotape and made a judgment of competent or incompetent to consent to treatment. Stepwise DFA identified neuropsychological predictors of each physician's competency judgments for the full sample (N = 45). Classification DFAs determined how accurately these predictor models classified competency outcomes assigned by the individual physician. RESULTS: Cognitive models differed across individual physicians and were related to stringency of judgments for AD patients. Under stepwise DFA, delayed verbal recall (R2 = .57, P < .0001) predicted judgments of Physician 1 (incompetency rate of 90% for AD patients), short term verbal recall (R2 = .43, P < .0001) predicted judgments of Physician 2 (incompetency rate of 52%), phonemic word fluency (R2 = .27, P < .001) predicted judgments of Physician 3 (incompetency rate of 24%), and visuomotor tracking/sequencing (R2 = .31, P < .001) predicted judgments of Physician 4 (incompetency rate of 14%). (No predictor model was available for Physician 5 as this physician found all subjects to be competent). These single predictor solutions correctly classified 93%, 87%, 87%, and 96% of cases for Physicians 1-4, respectively. Use of two predictor solutions achieved successful classification rates between 98% and 100%. CONCLUSIONS: We identified two cognitive models of consent capacity as judged by physicians: (1) verbal recall and (2) simple executive function. The verbal recall model predicted judgments of physicians likely to find mild AD patients incompetent, whereas the executive function model predicted judgments of physicians likely to find mild AD patients competent. Assessment of verbal recall and simple executive functions may provide important information in the clinical evaluation of capacity to consent to treatment.
Aged↗
Do different metamemory judgments tap the same underlying aspects of memory?
We compared the predictions from several kinds of metamemory judgments (on the same set of items), both in terms of their predictive accuracy and in terms of the commonality of predictions. Undergraduates made judgments about the ease with which they could learn each item in a list (ease-of-learning judgments); then they learned every item, either to a minimal criterion of learning or with overlearning, and made judgments about how well they knew each item (judgments of knowing); finally, they returned 4 weeks later for a retention session and made feeling-of-knowing judgments on every time they could not recall, after which a recognition test assessed predictive accuracy. Ease-of-learning judgments had the least predictive accuracy. Surprisingly, however, the recognition of nonrecalled items was predicted equally well by judgments of knowing (made 4 weeks earlier) as by feeling-of-knowing judgments (made immediately prior to recognition). Moreover, those two kinds of judgments were only weakly correlated with each other, which implies that they do not tap memory in the same way.
Attention↗
Relative and absolute duration judgments under prospective and retrospective paradigms.
A dual-process contingency model of short duration judgment is proposed and tested. The first process, or P(t), is a timer that uses cognitive capacity to keep track of units of time. If capacity is directed toward other tasks, P(t) will record fewer units and produce lower time judgments than when capacity is not directed toward other tasks. This timing process is most likely to affect performance when people know in advance (prospective judgments) that time judgments will be required and when absolute, rather than relative, judgments are made. The second process, or P(m), which is used for retrospective and relative judgments, judges duration on the basis of the number of remembered high priority events (HPEs) occurring during the interval. When this process is used, time judgments increase with the amount of HPEs that can be retrieved at the moment of judgment. Two experiments are reported. Tactual stimuli were presented, and nontemporal information processing load (simple or complex stimuli), type of judgment (absolute or relative), and judgment paradigm (prospective or retrospective) were manipulated. The results obtained support the proposed dual-process contingency model.
Adult↗
Use of expert judgment in exposure assessment. Part I. Characterization of personal exposure to benzene.
This paper presents the results of the first phase of a study, conducted as an element of the National Human Exposure Assessment Survey (NHEXAS), to demonstrate the use of expert subjective judgment elicitation techniques to characterize the magnitude of and uncertainty in environmental exposure to benzene. In decisions about the value of exposure research or of regulatory controls, the characterization of uncertainty can play an influential role. Classical methods for characterizing uncertainty may be sufficient when adequate amounts of relevant data are available. Frequently, however, data are neither abundant nor directly relevant, making it necessary to rely to varying degrees on subjective judgment. Since the 1950s, methods to elicit and quantify subjective judgments have been explored but have rarely been applied to the field of environmental exposure assessment. In this phase of the project, seven experts in benzene exposure assessment were selected through a peer nomination process, participated in a 2-day workshop, and were interviewed individually to elicit their judgments about the distributions of residential ambient, residential indoor, and personal air benzene concentrations (6-day integrated average) experienced by both the non-smoking, non-occupationally exposed target and study populations of the US EPA Region V pilot study. Specifically, each expert was asked to characterize, in probabilistic form, the arithmetic means and the 90th percentiles of these distributions. This paper presents the experts' judgments about the concentrations of benzene encountered by the target population. The experts' judgments about levels of benzene in personal air were demonstrative of patterns observed in the judgments about the other distributions. They were in closest agreement about their predictions of the mean; with one exception, their best estimates of the mean fell within 7-11 microg/m(3) although they exhibited striking differences in the degree of uncertainty expressed. Their estimates of the 90th percentile were more varied with the best estimates ranging from 12 to 26 microg/m(3) for all but one expert. However, their predictions of the 90th percentile were far more uncertain. The paper demonstrates that coherent subjective judgments can be elicited from exposure assessment scientists and critically examines the challenges and potential benefits of a subjective judgment approach. The results of the second phase of the project, in which measurements from the NHEXAS field study in Region V are used to calibrate the experts' judgments about the benzene exposures in the study population, will be presented in a second paper.
Benzene↗
Living wills and substituted judgments: a critical analysis.
In the literature three mechanisms are commonly distinguished to make decisions about the care of incompetent patients: A living will, a substituted judgment by a surrogate (who may or may not hold the "power of attorney"), and a best interest judgment. Almost universally, the third mechanism is deemed the worst possible of the three, to be invoked only when the former two are unavailable. In this article, I argue in favor of best interest judgments. The ever more common aversion of best interest judgments entails a risk that health care providers withdraw from the decision-making process, abandoning patients (or their family members) to these most difficult of decisions about life and death. My approach in this article is primarily negative, that is, I criticize the alleged superiority of the living will and substituted judgment. The latter two mechanisms gain their alleged superiority because they are supposedly morally neutral, whereas the best interest judgment entails a value judgment on behalf of the patient. I argue that on closer inspection living wills and substituted judgments are not morally neutral; indeed, they generally rely on best interest judgments, even if those are not made explicit.
Decision Making↗
Context, feedback, and the calibration and resolution of confidence in perceptual judgments.
The effects of variations in the global task difficulty context on judgmental confidence and confidence calibration were investigated in two experiments requiring perceptual comparisons. In Experiment 1, target judgments of moderate difficulty were embedded in a larger set of more difficult (hard context) or less difficult (easy context) judgments. Decisional response time on the target items was longer in the hard context condition, but there was no effect of difficulty context on target judgment confidence, accuracy, over/underconfidence, calibration, or resolution. In Experiment 2, each subject was exposed to three levels of local judgment difficulty. The global contextual difficulty manipulation involved varying the frequency with which the hard and easy judgments appeared, and the presence or absence of trial-by-trial response feedback was manipulated between subjects. As in Experiment 1, contextual difficulty affected decisional response times but not mean confidence ratings or accuracy. However, we found that providing feedback on a globally difficult task makes calibration worse. Also, resolution (the ability to differentiate correct from incorrect judgments) was found to be superior for easy judgments in a difficult context and for difficult judgments in an easy context. We discuss the implication of these findings for research on confidence and confidence calibration.
Adult↗
Diagnostic judgments of nurse practitioners providing primary gynecologic care: a quantitative analysis.
OBJECTIVES: To determine the accuracy of experienced nurse practitioners' judgments of the probability of chlamydial infection of the cervix, to identify the clinical factors ("cues") related to the judgments, and to discern likely sources of judgment error. DESIGN: Cross-sectional study with prospective data collection. SETTING: Urban hospital-based clinic. PATIENTS: 492 nonpregnant women receiving primary gynecologic care. INTERVENTIONS: Four nurse practitioners recorded clinical data, tested women for chlamydial infection, and judged the probability of chlamydial infection using six categories: less than 1%, 1-4%, 5-9%, 10-24%, 25-50%, and greater than 50%. MEASUREMENTS AND MAIN RESULTS: Chlamydial infection was detected by immunofluorescent assay in 31 (6%) of the 492 women. Although the median probability judgment was 5-9%, judgments were only weakly related (p = 0.08) to actual rates of infection. In a multivariate analysis, eight clinical cues were independently (p less than 0.05) related to nurse practitioners' probability judgments: age less than 20 years; past chlamydial or gonococcal infection; new sex partner; partner with suspected genital infection; genito-urinary symptoms; cervicitis, purulent vaginal discharge; and malodorous vaginal discharge. A linear model based on the eight cues, weighted according to their regression coefficients, predicted chlamydial infection more accurately than did the nurse practitioners' actual judgments (ROC curve areas 0.69 vs. 0.58, respectively; p less than 0.05). However, only two of the eight cues (age less than 20 years and purulent vaginal discharge) were actually related to chlamydial infection in a second multivariate model; this model bad accuracy similar to that of an empirically derived prediction rule (ROC curve areas 0.77 and 0.80, p = 0.27). CONCLUSIONS: Nurse practitioners were often inaccurate in their diagnostic judgments. Our analyses suggest that this inaccuracy stemmed from both the inconsistent use of clinical cues and the use of cues that were not related to chlamydial infection. Therefore, interventions such as algorithms that promote consistency and accuracy in diagnostic use of relevant cues would be likely to improve their diagnostic judgments.
Adult↗
Effects of social influences and waiting on time judgment.
Utilizing social judgment theory, the relationships of three social cues to time judgment under low physical temporal-cue conditions were explored. These social influences were as follows: being free to interact with another person, being told by the experimenter to expect to wait a specified period of time, and seeing another person's time judgment. 72 college students, randomly assigned to conditions of free social interaction (alone-interactive) and of waiting expectancy (expected-unexpected), made time estimates after 4 min., 7 sec. Each person under interactive conditions made another judgment after seeing a partner's judgment. Mean estimation was lower alone than under interactive conditions and lower under expected than unexpected waiting conditions. Under interactive conditions, correlations were positive between the individual's first and second judgments, between the partners' second judgments, and between the individual's second and the partner's first judgments. Social cues may influence time judgment.
Adult↗
Interpreting the judgment of surgical faculty regarding resident competence.
BACKGROUND: It is reasonable to propose that competence is a multifaceted characteristic defined in part by some minimum level of knowledge and skill. In this study we examined the relationship between surgical faculty's judgment of clinical competence, as measured by a surgical resident objective structured clinical examination (OSCE), and the residents' objective performance on the skills being tested. METHODS: Fifty-six general surgery residents at all levels of training participated in a 30-station OSCE. At the completion of each station, the faculty proctor made several overall judgments regarding each resident's performance, including a global judgment of competent or not competent. The competence judgment was applied to the objective percentage performance score in three different ways to construct methods for determining competence based solely upon this objective percentage score. RESULTS: The average mean competent score (MCS) across the stations was 61%, and the average mean noncompetent score (MNCS) was 38%. The difference between MCS and MNCS for each station was very consistent. Upper threshold scores above which a judgment of competent was always made, and lower threshold scores below which a judgment of noncompetent was always made were observed. Overall, the average mean and threshold scores for competent and noncompetent groups were remarkably similar. For performance scores in the range between the threshold competent and noncompetent scores at each station, measures other than objective performance on the skills being evaluated determined the judgment of competent or not competent. CONCLUSIONS: Empirically determined minimum acceptable standards for objective performance in clinical skills and knowledge appeared to have been subconsciously applied to the competence judgment by the faculty evaluators in this study. Other factors appeared to have become determinate when the objective performance score fell within a range of uncertainty.
Animals↗
Loci of contextual effects in judgment.
Three experiments investigated the loci of contextual effects in judgment. Experiment 1 demonstrated the effect of stimulus spacing on category ratings and magnitude estimations of the darkness of dot patterns. Variations in the stimulus spacing were shown to affect both category ratings and magnitude estimations in a similar fashion. Experiment 2 was designed to determine whether contextual effects due to stimulus spacing influence the scale values or the judgment function. Subjects judged "differences" and "ratios" of the subjective darkness of dot patterns. Differences in mean judgments of single stimuli from Experiment 1 did not predict the rank order of judged "differences" and "ratios" from Experiment 2. The estimated scale values of the stimuli appeared to be independent of stimulus spacing. These findings suggest that contextual effects due to the stimulus spacing occur in the judgment function for within-modality judgments. Experiment 3 examined contextual effects in cross-modality judgments. Stimulus spacing and stimulus range were manipulated for "difference" and "total" judgments. Unlike the within-modality results, the stimulus range and spacing influenced the scale values. A contextual theory of within- and cross-modality judgment is presented.
Discrimination Learning↗
Life-satisfaction is a momentary judgment and a stable personality characteristic: the use of chronically accessible and stable sources.
Social cognition research indicates that life-satisfaction judgments are based on a selected set of relevant information that is accessible at the time of the life-satisfaction judgment. Personality research indicates that life-satisfaction judgments are quite stable over extended periods of time and predicted by personality traits. The present article integrates these two research traditions. We propose that people rely on the same sources to form repeated life-satisfaction judgments over time. Some of these sources (e.g., memories of emotional experiences, academic performance) provide stable information that explains the stability in life-satisfaction judgments. Second, we propose that the influence of personality traits on life satisfaction is mediated by the use of chronically accessible sources because traits produce stability of these sources. Most important, the influence of extraversion and neuroticism is mediated by use of memories of past emotional experiences. To test this model, participants repeatedly judged life-satisfaction over the course of a semester. After each assessment, participants reported sources that they used for these judgments. Changes in reported sources were related to changes in life-satisfaction judgments. A path model demonstrated that chronically accessible and stable sources are related to stable individual differences in life-satisfaction. Furthermore, the model supported the hypothesis that personality effects were mediated by chronically accessible and stable sources. In sum, the results are consistent with our theory that life-satisfaction judgments are based on chronically accessible sources.
Cognition↗
Judgments of personal and environmental risks of consumer products--do they differ?
Many psychometric studies have investigated judgments concerning personal risks from technologies, activities or consumer products, but only a few studies have included judgments of risk to the environment. Thus, little is known about this aspect of environmental risk perception, and whether it differs from personal risk perception. This study investigates risk judgments for 30 consumer products of various types such as herbal remedies, mobile telephones, genetically engineered drugs, or garden pesticides. A survey was conducted in two German cities: Leipzig and West Berlin. In total, 408 subjects evaluated the consumer products with regard to personal and environmental risk (and other risk-related aspects) and whether they would recommend the product to others. The findings show statistically significant differences between the mean values of perceived personal risk and environmental risk for most products. Despite these differences, the rank order of mean personal risk and environmental risk judgments for the products is quite similar. However, separate analyses for each product reveal that correlations between perceived personal and environmental risk vary strongly across products. Multiple regression analyses with personal and environmental risk judgments as predictors and product recommendation as criterion, run separately for each consumer product, show that it is mainly the judgment of perceived personal risk that explains product recommendation. Perceived risk to the environment adds little explanatory power. The study also explores differences in judgments of personal and environmental risk with regard to two sociodemographic variables: location (former East Germany vs. West Germany) and gender. Differences in both types of risk judgments are found with regard to location but not for gender.
Adolescent↗