Do physician outcome judgments and judgment biases contribute to inappropriate use of treatments? Study protocol

<p>Abstract</p> <p>Background</p> <p>There are many examples of physicians using treatments inappropriately, despite clear evidence about the circumstances under which the benefits of such treatments outweigh their harms. When such over- or under- use of treatments occurs for common diseases, the burden to the healthcare system and risks to patients can be substantial. We propose that a major contributor to inappropriate treatment may be how clinicians judge the likelihood of important treatment outcomes, and how these judgments influence their treatment decisions. The current study will examine the role of judged outcome probabilities and other cognitive factors in the context of two clinical treatment decisions: 1) prescription of antibiotics for sore throat, where we hypothesize overestimation of benefit and underestimation of harm leads to over-prescription of antibiotics; and 2) initiation of anticoagulation for patients with atrial fibrillation (AF), where we hypothesize that underestimation of benefit and overestimation of harm leads to under-prescription of warfarin.</p> <p>Methods</p> <p>For each of the two conditions, we will administer surveys of two types (Type 1 and Type 2) to different samples of Canadian physicians. The primary goal of the Type 1 survey is to assess physicians' perceived outcome probabilities (both good and bad outcomes) for the target treatment. Type 1 surveys will assess judged outcome probabilities in the context of a representative patient, and include questions about how physicians currently treat such cases, the recollection of rare or vivid outcomes, as well as practice and demographic details. The primary goal of the Type 2 surveys is to measure the specific factors that drive individual clinical judgments and treatment decisions, using a 'clinical judgment analysis' or 'lens modeling' approach. This survey will manipulate eight clinical variables across a series of sixteen realistic case vignettes. Based on the survey responses, we will be able to identify which variables have the greatest effect on physician judgments, and whether judgments are affected by inappropriate cues or incorrect weighting of appropriate cues. We will send antibiotics surveys to family physicians (300 per survey), and warfarin surveys to both family physicians and internal medicine specialists (300 per group per survey), for a total of 1,800 physicians. Each Type 1 survey will be two to four pages in length and take about fifteen minutes to complete, while each Type 2 survey will be eight to ten pages in length and take about thirty minutes to complete.</p> <p>Discussion</p> <p>This work will provide insight into the extent to which clinicians' judgments about the likelihood of important treatment outcomes explain inappropriate treatment decisions. This work will also provide information necessary for the development of an individualized feedback tool designed to improve treatment decisions. The techniques developed here have the potential to be applicable to a wide range of clinical areas where inappropriate utilization stems from biased judgments.</p

Nurses joining family doctors in primary care practices: perceptions of patients with multimorbidity

<p>Abstract</p> <p>Background</p> <p>Among the strategies used to reform primary care, the participation of nurses in primary care practices appears to offer a promising avenue to better meet the needs of vulnerable patients. The present study explores the perceptions and expectations of patients with multimorbidity regarding nurses' presence in primary care practices.</p> <p>Methods</p> <p>18 primary (health) care patients with multimorbidity participated in semi-directed interviews, in order to explore their perceptions and expectations in regard to the involvement of nurses in primary care practices. Interviews were audio-recorded and transcribed. After reviewing the transcripts, the principal investigator and research assistants performed thematic analysis independently and reached consensus on the retained themes.</p> <p>Results</p> <p>Patients with multimorbidity were open to the participation of nurses in primary care practices. They expected greater accessibility, for both themselves and for new patients. However, the issue of shared roles between nurses and doctors was a source of concern. Many patients held the traditional view of the nurse's role as an assistant to the doctor in his or her various duties. In general, participants said they were confident about nurses' competency but expressed concern about nurses performing certain acts that their doctor used to, notwithstanding a close collaboration between the two professionals.</p> <p>Conclusion</p> <p>Patients with multimorbidity are open to the involvement of nurses in primary care practices. However, they expect this participation to be established using clear definitions of professional roles and fields of practice.</p

Evaluating and Combining Physicians' Probabilities of Survival in an Intensive Care Unit

In this paper, probabilities of survival assessed by physicians for patients admitted to an intensive care unit are studied. The probabilities from each of four types of physicians are evaluated on an overall basis and in terms of specific attributes, and the groups are compared. The physicians with the most experience and expertise perform better overall. All four groups appear to be reasonably well calibrated, and the key factor in relative overall performance is the level of discrimination provided by the probabilities. Averages of two, three, and four probabilities for each individual patient are also analyzed. As the number of the probabilities in the average increases, performance improves on average on all dimensions, although the best overall performance is exhibited by a combination of probabilities from the two physician types performing best individually. Some comparisons are made with previous work, and implications for probability assessment and combination in medicine and more generally in other areas of application are discussed. Important characteristics of the study are the fact that it was conducted on-line in a real setting, the involvement of individuals with different levels of expertise, the use of a true predictive situation with a clearly-defined event, the consideration of multiple dimensions of the quality of judgments, and the collection of multiple probabilities for each case to permit the investigation of a variety of possible combinations of probabilities.probability assessment, combining probabilities, physicians' judgments, diagnostic probability evaluation, expertise

Can Physicians Be Rational About Diagnostic Tests?

Concerns about diagnostic test utilization have led to interest in the role of tests in clinical decision-making, and researchers have developed guidelines for interpreting the results of diagnostic tests using Bayesian probability revision and decision analysis. Although it acknowledges the importance of these quantitative models in medical education, this article identifies major obstacles that limit their application, demonstrating that rational decision-making may not be rational or optimal in clinical practice