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

Relation of Physician Specialty and HIV/AIDS Experience to Choice of Guideline-Recommended Antiretroviral Therapy

BACKGROUND: Controversy exists regarding who should provide care for those with HIV/AIDS. While previous studies have found an association between physician HIV experience and patient outcomes, less is known about the relationship of physician specialty to HIV/AIDS outcomes or quality of care. OBJECTIVE: To examine the relationship between choice of appropriate antiretroviral therapy (ART) to physician specialty and HIV/AIDS experience. DESIGN: Self-administered physician survey. PARTICIPANTS: Random sample of 2,478 internal medicine (IM) and infectious disease (ID) physicians. MEASUREMENTS: Choice of guideline-recommended ART. RESULTS: Two patients with HIV disease, differing only by CD4+ count and HIV RNA load, were presented. Respondents were asked whether ART was indicated, and if so, what ART regimen they would choose. Respondents' ART choices were categorized as “recommended” or not by Department of Health and Human Services guidelines. Respondents' HIV/AIDS experience was categorized as moderate to high (MOD/HI) or none to low (NO/LO). For Case 1, 72.9% of responding physicians chose recommended ART. Recommended ART was more likely (P < .01) to be chosen by ID physicians (88.2%) than by IM physicians (57.1%). Physicians with MOD/HI experience were also more likely (P < .01) to choose recommended ART than those with NO/LO experience. Finally, choice of ART was examined using logistic regression: specialty and HIV experience were found to be independent predictors of choosing recommended ART (for ID physicians, odds ratio [OR], 4.66; 95% confidence interval [95% CI], 3.15 to 6.90; and for MOD/HI experience, OR, 2.05; 95% CI, 1.33 to 3.16). Results for Case 2 were similar. When the analysis was repeated excluding physicians who indicated they would refer the HIV “patient,” specialty and HIV experience were not significant predictors of choosing recommended ART. CONCLUSIONS: Guideline-recommended ART appears to be less likely to be chosen by generalists and physicians with less HIV/AIDS experience, although many of these physicians report they would refer these patients in clinical practice. These results lend support to current recommendations for routine expert consultant input in the management of those with HIV/AIDS