A theory of medical decision making and health: fuzzy trace theory

The development and analysis of tutorial dialogues in AutoTutor Lite

The goal of intelligent tutoring systems (ITS) that interact in natural language is to emulate the benefits that a well-trained human tutor provides to students, by interpreting student answers and appropriately responding in order to encourage elaboration. BRCA Gist is an ITS developed using AutoTutor Lite, a Web-based version of AutoTutor. Fuzzy-trace theory theoretically motivated the development of BRCA Gist, which engages people in tutorial dialogues to teach them about genetic breast cancer risk. We describe an empirical method to create tutorial dialogues and fine-tune the calibration of BRCA Gist's semantic processing engine without a team of computer scientists. We created five interactive dialogues centered on pedagogic questions such as "What should someone do if she receives a positive result for genetic risk of breast cancer?" This method involved an iterative refinement process of repeated testing with different texts and successively making adjustments to the tutor's expectations and settings in order to improve performance. The goal of this method was to enable BRCA Gist to interpret and respond to answers in a manner that best facilitated learning. We developed a method to analyze the efficacy of the tutor's dialogues. We found that BRCA Gist's assessment of participants' answers was highly correlated with the quality of the answers found by trained human judges using a reliable rubric. The dialogue quality between users and BRCA Gist predicted performance on a breast cancer risk knowledge test completed after exposure to the tutor. The appropriateness of BRCA Gist's feedback also predicted the quality of answers and breast cancer risk knowledge test scores.

Gist Memory in the Unconscious-Thought Effect

The unconscious-thought effect (UTE) occurs when people are better able to make complex decisions after a period of distraction rather than immediately or after a period of conscious deliberation. This finding has often been interpreted as evidence of unconscious thinking. In two experiments, we provided the first evidence that the UTE is accompanied by enhanced memory for the gist of decision-relevant attributes and demonstrated that the cognitive demands of a distraction task moderate its effect on decision making and gist memory. It was only following a low-demand distraction task that participants chose the best alternative more often and displayed enhanced gist memory for decision-relevant attributes. These findings suggest that the UTE occurs only if cognitive resources are available and that it is accompanied by enhanced organization of information in memory, as shown by the increase in gist memory.

Can quantum probability provide a new direction for cognitive modeling?

Classical (Bayesian) probability (CP) theory has led to an influential research tradition for modeling cognitive processes. Cognitive scientists have been trained to work with CP principles for so long that it is hard even to imagine alternative ways to formalize probabilities. However, in physics, quantum probability (QP) theory has been the dominant probabilistic approach for nearly 100 years. Could QP theory provide us with any advantages in cognitive modeling as well? Note first that both CP and QP theory share the fundamental assumption that it is possible to model cognition on the basis of formal, probabilistic principles. But why consider a QP approach? The answers are that (1) there are many well-established empirical findings (e.g., from the influential Tversky, Kahneman research tradition) that are hard to reconcile with CP principles; and (2) these same findings have natural and straightforward explanations with quantum principles. In QP theory, probabilistic assessment is often strongly context- and order-dependent, individual states can be superposition states (that are impossible to associate with specific values), and composite systems can be entangled (they cannot be decomposed into their subsystems). All these characteristics appear perplexing from a classical perspective. However, our thesis is that they provide a more accurate and powerful account of certain cognitive processes. We first introduce QP theory and illustrate its application with psychological examples. We then review empirical findings that motivate the use of quantum theory in cognitive theory, but also discuss ways in which QP and CP theories converge. Finally, we consider the implications of a QP theory approach to cognition for human rationality.

Women's sun protection cognitions in response to UV photography: the role of age, cognition, and affect

This study examined the impact of ultraviolet (UV) photography, cognition versus affect, and age on women's sun-related cognitions and a proxy measure of sun protection behavior. Participants (N = 114) were recruited via public advertisements and came to the lab to view a photo showing their UV damage. In addition, some participants received instructions to focus on either their thoughts (cognition) or feelings (affect) about their photograph before completing the survey. Women in the affect condition reported the lowest perceived vulnerability to skin cancer and highest absent/exempt beliefs (beliefs that one is unlikely to develop skin cancer if she hasn't already). Condition by age interactions showed that, among those in the cognition and control (no instructions) conditions, older women reported higher perceived vulnerability and lower absent/exempt beliefs, and took more sunscreen than younger women. However, older women reported higher absent/exempt beliefs and higher sun-risk willingness than younger women in the affect condition.

Fuzzy trace theory and medical decisions by minors: differences in reasoning between adolescents and adults

Standard models of adolescent risk taking posit that the cognitive abilities of adolescents and adults are equivalent, and that increases in risk taking that occur during adolescence are the result of socio emotional differences in impulsivity, sensation seeking, and lack of self-control. Fuzzy-trace theory incorporates these socio emotional differences. However, it predicts that there are also cognitive differences between adolescents and adults, specifically that there are developmental increases in gist-based intuition that reflects understanding. Gist understanding, as opposed to verbatim-based analysis, generally has been hypothesized to have a protective effect on risk taking in adolescence. Gist understanding is also an essential element of informed consent regarding risks in medical decision- making. Evidence thus supports the argument that adolescents' status as mature minors should be treated as an exception rather than a presumption, because accuracy in verbatim analysis is not mature gist understanding. Use of the exception should be accompanied by medical experts' input on the bottom-line gist of risks involved in treatment.

Values and options in cancer care (VOICE): study design and rationale for a patient-centered communication and decision-making intervention for physicians, patients with advanced cancer, and their caregivers

BACKGROUND

Communication about prognosis and treatment choices is essential for informed decision making in advanced cancer. This article describes an investigation designed to facilitate communication and decision making among oncologists, patients with advanced cancer, and their caregivers.

METHODS/DESIGN

The Values and Options in Cancer Care (VOICE) Study is a National Cancer Institute sponsored randomized controlled trial conducted in the Rochester/Buffalo, NY and Sacramento, CA regions. A total of 40 oncologists, approximately 400 patients with advanced cancer, and their family/friend caregivers (one per patient, when available) are expected to enroll in the study. Drawing upon ecological theory, the intervention uses a two-pronged approach: oncologists complete a multifaceted tailored educational intervention involving standardized patient instructors (SPIs), and patients and caregivers complete a coaching intervention to facilitate prioritizing and discussing questions and concerns. Follow-up data will be collected approximately quarterly for up to three years.

DISCUSSION

The intervention is hypothesized to enhance patient-centered communication, quality of care, and patient outcomes. Analyses will examine the effects of the intervention on key elements of physician-patient-caregiver communication (primary outcomes), the physician-patient relationship, shared understanding of prognosis, patient well-being, and health service utilization (secondary outcomes).

TRIAL REGISTRATION

Clinical Trials Identifier: NCT01485627.

Direct observation of prognosis communication in palliative care: a descriptive study

CONTEXT

Palliative care (PC) consultations result in improved patient understanding of prognosis and better quality of life, yet the content and processes of prognosis communication during PC consultations remain unknown.

OBJECTIVES

To describe prognosis communication during PC consultation with seriously ill hospitalized patients.

METHODS

We audio recorded 71 sequential inpatient PC consultations (initial visit) with seriously ill patients and their families who were referred for "goals of care" clarification or help with "end-of-life decision making." Conversations were coded using reliable methods and we then linked conversation codes to clinical record and clinician interview data.

RESULTS

Ninety-three percent of consultations contained prognosis communication. Participants communicated prognoses regarding quality of life more frequently than survival; focused prognosis estimates on the unique patient more frequently than on a general population; and framed prognosis using pessimistic cues more frequently than optimistic ones. Prognoses were more commonly spoken by PC clinicians than by patients/families. The following two factors demonstrated an association with the rate of prognostic communication and with the pessimistic framing of that information: whether the patient, family, or both participated in the conversation, and shorter expected survival (as estimated by the attending physician).

CONCLUSION

Prognoses are routinely communicated in PC consultations with hospitalized patients and their families. The rate and characteristics of prognosis communication differ based on the length of time the patient is expected to live.

General Practitioners' coronary risk estimates, decisions to start lipid-lowering treatment, gender and length of clinical experience: their interactions in primary prevention

AIM

We investigated whether the risk estimates of General Practitioners (GPs) and their treatment decisions mutually influence each other and whether factors not related to the patient's risk, such as the gender and length in clinical practice, interact.

BACKGROUND

The quantitative assessment of the absolute risk of developing coronary heart disease (CHD) and the decision to start treatment with lipid-lowering drugs are crucial tasks in the primary prevention of CHD.

METHODS

Nine clinical vignettes, four rated high-risk and five rated low-risk according to the Framingham equation, were mailed to three groups of 90 randomly selected GPs in Stockholm. One group (R) was asked to estimate the risk of CHD within 10 years on a visual analogue scale. A second group (R1D) was asked to estimate the risk and to specify whether they would recommend a pharmacological lipid-lowering treatment. A third group (D) only to indicate whether they would recommend treatment.

RESULTS

Response rate ranged from 42.2% to 45.6%. The median risk estimates were higher in the R group than in the R1D group (difference not statistically significant). R1D group showed higher proportions of correct decisions to start treatment compared with the R group (86.2% versus 77.5%, P50.19). More correct decisions were made by female doctors (OR 1.77, 95% CI 1.19-2.61, P50.004) and by less experienced doctors (OR 0.97, 95% CI 0.95-0.99, P50.016).

CONCLUSIONS

The task of making CHD risk estimates and the task of making decisions whether to start lipid-lowering treatment do not seem to influence each other. The gender of physicians and the length of clinical experience seem to affect treatment decisions. Female GPs and less experienced GPs are more likely to make correct decisions. However, the relatively low response rate to the questionnaires may limit the generalizability of these results.

Children's competence or adults' incompetence: different developmental trajectories in different tasks

Dual-process theories have been proposed to explain normative and heuristic responses to reasoning and decision-making problems. Standard unitary and dual-process theories predict that normative responses should increase with age. However, research has focused recently on exceptions to this standard pattern, including developmental increases in heuristic or intuitive responses. Developmental trends for normative and heuristic responses were investigated for 2 kinds of causal reasoning (if-only and covariation) problems in 2 experiments. To investigate the role of superstitious thinking in these developmental trends, in both experiments a superstitious element was added to the problem solved by half the participants. In the first experiment, 90 fifth graders, 99 seventh graders, and 153 adults responded to an if-only problem. Children performed better than adults, with normative responses decreasing and heuristic responses increasing with age. A superstitious jinx intended to reduce heuristic responses had little effect for all age groups. In the second experiment, 276 fifth graders, 344 seventh graders, and 90 adults responded to a covariation-detection problem. When win-loss ratios were equal, adults performed better than children, with normative responses increasing and heuristic responses decreasing with age. When win-loss ratios were strikingly different, however, even the youngest children were able to solve the problems correctly; participants of all ages responded about equally well. When the normative response required recognizing that a good-luck ritual led to better team performance, participants in all age groups responded skeptically that the ritual had no effect, illustrating belief bias. These results are discussed in terms of dual-process theories and the development of heuristic (or intuitive) and analytical processes.

A theoretical framework for measuring knowledge in screening decision aid trials

OBJECTIVE

To describe a theoretical framework for assessing knowledge about the possible outcomes of participating in bowel cancer screening for the faecal occult blood test.

METHODS

The content of the knowledge measure was based on the UK General Medical Council's screening guidelines and a theory-based approach to assessing gist knowledge (Fuzzy Trace Theory). It comprised conceptual and numeric questions to assess knowledge of the underlying construct (e.g. false positive concept) and the approximate numbers affected (e.g. likelihood of a false positive). The measure was used in a randomised controlled trial involving 530 adults with low education, to compare the impact of a bowel screening decision aid with a screening information booklet developed for the Australian Government National Bowel Cancer Screening Program.

RESULTS

The numeric knowledge scale was particularly responsive to the effects of the decision aid; at follow-up decision aid participants' numeric knowledge was significantly greater than the controls (P<0.001). This contrasts with the conceptual knowledge scale which improved significantly in both groups from baseline to follow-up (P<0.001).

CONCLUSION

Our theory-based knowledge measure was responsive to change in conceptual knowledge and to the effect on numeric knowledge of a decision aid.

PRACTICE IMPLICATIONS

This theoretical framework has the potential to guide the development of knowledge measures in other screening settings.

Supporting shared decision making when clinical evidence is low

Shared decision making (SDM) is the process of providing the patient with critical information that can support his or her informed participation in decision making. Shared decision making has become accepted as an important component of quality health care. Influenced by its foundations in law and ethics and by empirical work on its value as a tool to reduce variability in care, a perception has developed that SDM is relevant primarily to clinical situations with high-quality clinical evidence. This raises the question of the role of SDM in situations when clinical evidence is lacking or of low quality. This article posits that SDM is equally relevant and important to low-evidence situations in four ways--SDM fosters shared acceptance of uncertainty, closes the gap in knowledge between patient and physician, promotes patient empowerment, and enhances trust through transparent communication.

Good decision making requires good communication

The methods used for regulatory decisions must facilitate three kinds of communication: (i) with individual experts who must translate their knowledge into usable form; (ii) among the experts whose pooled knowledge informs those choices; and (iii) between regulators and those affected by their choices. Decision-making methods vary in their reliance on expert judgement and computational methods and, hence, in their ability to meet the goals of sound decision making: breadth, depth, precision, neutrality, evaluability and transparency. An approach developed by the US FDA, the Benefit-Risk Framework, integrates judgement and computation, cognizant of their strengths and weaknesses. Its application both requires and facilitates good communication about risks and benefits.

Decision tool to improve the quality of care in rheumatoid arthritis

OBJECTIVE

Despite the importance of achieving tight control, many patients with rheumatoid arthritis (RA) are not effectively treated with disease-modifying antirheumatic drugs. The objective of this study was to develop a decision support tool to inform RA patients with ongoing active disease about the risks and benefits related to biologic therapy.

METHODS

We developed a balanced, web-based, decision support tool. Options, values, and probabilistic information were described using theoretically supported formulations. We conducted a pre-/posttest study to assess preliminary evidence of the tool's efficacy in improving knowledge related to biologics, clarity of values, willingness to take a biologic, and informed choice.

RESULTS

We interviewed 104 subjects (mean age 62 years, 84% women, 87% white, and median duration of RA 8 years). Knowledge (coded on a 0-20 scale) and willingness to take a biologic (coded on a 0-10 scale) significantly increased after viewing the tool (mean differences 2.3 and 1.4, respectively; P < 0.0001 for both). Perceived knowledge and values clarity (coded on 0-100 scales) also significantly improved (mean differences 20.4 and 20.8, respectively; P < 0.0001 for both). The proportion of subjects making an informed value-concordant choice increased substantially from 35% to 64%.

CONCLUSION

A tool designed to effectively communicate the risks and benefits associated with biologic therapy increased knowledge, patient willingness to escalate care, and the likelihood of making an informed choice. The results of this study support the need for a clinical trial to examine the impact of the tool in clinical practice.

What Is Shared in Shared Decision Making? Complex Decisions When the Evidence Is Unclear

Patient involvement in decisions is central to patient-centered care. Yet many important decisions must be made in complex, ambiguous clinical situations in which all possible options cannot be known, evidence is inadequate to inform patients’ preferences fully, and/or patients are unclear about their desired level of involvement. In these situations, preferences are shaped by affect, framing, and “collaborative cognition” among clinicians, patients, and their families; thus, decisions are often relational, dynamic, iterative, provisional, and/or conditional. Clinicians can help patients achieve greater autonomy by engaging both intuitive and deliberative decision-making processes (“whole mind”) and involving others in exploring, clarifying, and co-constructing patients’ preferences (“shared mind”). Clinical and interpersonal relationships can promote effective decision making through developing a shared attentional focus, tailoring information, and identifying conditions under which provisional preferences might change. Information technology and health systems offer untapped potential to deepen the relationships and conversations within which decisions are made.

Individual Differences in Numeracy and Cognitive Reflection, with Implications for Biases and Fallacies in Probability Judgment

Despite evidence that individual differences in numeracy affect judgment and decision making, the precise mechanisms underlying how such differences produce biases and fallacies remain unclear. Numeracy scales have been developed without sufficient theoretical grounding, and their relation to other cognitive tasks that assess numerical reasoning, such as the Cognitive Reflection Test (CRT), has been debated. In studies conducted in Brazil and in the USA, we administered an objective Numeracy Scale (NS), Subjective Numeracy Scale (SNS), and the CRT to assess whether they measured similar constructs. The Rational-Experiential Inventory, inhibition (go/no-go task), and intelligence were also investigated. By examining factor solutions along with frequent errors for questions that loaded on each factor, we characterized different types of processing captured by different items on these scales. We also tested the predictive power of these factors to account for biases and fallacies in probability judgments. In the first study, 259 Brazilian undergraduates were tested on the conjunction and disjunction fallacies. In the second study, 190 American undergraduates responded to a ratio-bias task. Across the different samples, the results were remarkably similar. The results indicated that the CRT is not just another numeracy scale, that objective and subjective numeracy scales do not measure an identical construct, and that different aspects of numeracy predict different biases and fallacies. Dimensions of numeracy included computational skills such as multiplying, proportional reasoning, mindless or verbatim matching, metacognitive monitoring, and understanding the gist of relative magnitude, consistent with dual-process theories such as fuzzy-trace theory.

Younger and Older Adults’ Comprehension of Health Risk Probabilities: Understanding the Relationship between Format and Numeracy

The format in which a probability is presented and a person’s numeracy can influence comprehension of health risk probabilities (e.g., Galesic, Gigerenzer, & Straubinger, 2009). Many people, especially older adults, have inadequate numeracy (Kutner, Greenberg, & Baer, 2005), which may interact with comprehension of different formats (e.g., frequency, percent, or words). The relationship between probability format and numeracy on comprehension of health risk probabilities was investigated via questions and delayed tests of recall for 36 younger adults’ ( Mage=20.0, SD=2.2, range=18-27) and 36 older adults’ ( Mage=71.1, SD=2.4, range=66-75). No interaction between numeracy and format was identified; higher numeracy was positively correlated with higher accuracy on comprehension questions across all formats. The results suggest that percent format best supports comprehension and recall of health risk probabilities for younger and older adults in a probability comparison task.

A methodological approach to ratio bias

The ratio-bias (RB) phenomenon is considered to provide systematic evidence of irrationality. When judging the probability of a low-probability event, many people judge it as less likely when it is expressed as a ratio of small numbers (e.g., 1-in-10) than when it is expressed as a ratio of large numbers (e.g., 10-in-100). Four experiments show that the phenomenon is increased by the experimental paradigm, which misleads subjects regarding the aim of the task by inducing equal-ratio neglect. One factor is constant across the texts of the Experiment 1–3: a particular sentence that induces subjects to neglect the equal ratio and invites them to express feelings about the outcome of the target event rather than giving a rational answer. This intent is strengthened by the formulation of the question (Experiment 1), which explicitly asks the subject to express the feeling connected to the lotteries and the absence of a third option (Experiment 1, 4), the right one, which expresses the “indifference” between the two options. In Experiment 4, the task lacks only the third option, and, simply by adding the option that allows subjects to express the correct answer, the RB disappears.

Patient-centered, comparative effectiveness of esophageal cancer screening: protocol for a comparative effectiveness research study to inform guidelines for evidence-based approach to screening and surveillance endoscopy

BACKGROUND

The comparative effectiveness (CE) of endoscopic screening (versus no screening) for Barrett's esophagus (BE) in patients with GERD symptoms, or among different endoscopic surveillance strategies in patients with BE, for the early detection of esophageal adenocarcinoma (EA) is unknown. Furthermore, it is unclear if patients or providers have or will adopt any of these strategies (screening only, screening and surveillance, vs. none), irrespective of their effectiveness. Endoscopic screening and surveillance is expensive and can be risky. Therefore, it is imperative to establish the CE and acceptability about the risks and outcomes related to these practices to better inform expert recommendations and provider-patient decisions.

METHODS/RESULTS

We propose a mixed methods study which will involve: (1) an analysis of secondary databases (VA and VA-Medicare linked datasets for 2004-09) to examine CE of endoscopic screening and surveillance in an observational study cohort (an estimated 680,000 patients with GERD; 25,000-30,000 with BE; and 3,000 with EA); (2) a structured electronic medical record (EMR) review on a national sample of patients using VA EMRs to verify all EA cases, identify cancer stage, cancer-targeted therapy, and validate the screening and surveillance endoscopy; and (3) qualitative in depth interviews with patients and providers to elicit preferences, norms, and behaviors to explain clinical contexts of these findings and address gaps arising from the CE study.

CONCLUSION

This study will compare clinical strategies for detecting and monitoring BE, a pre-cancerous lesion. Additionally, by eliciting acceptability of these strategies for patients and providers, we will be able to propose effective and feasible strategies that are likely to be implemented in routine use. Findings will inform recommendations for clinical practice guidelines. Our innovative approach is consistent with the methodological standards of patient-centered outcomes research, and our findings will offer a significant contribution to the literature on cancer surveillance.

Testing different communication formats on responses to imagined risk of having versus missing the GSTM1 gene

Genetic markers of lung cancer susceptibility, such as the common variant of the glutathione S-transferase Mu 1 gene (GSTM1-null), confer small probabilities of disease risk. The authors explored the influence of different approaches to communicating the small variations in risk associated with this biomarker. College smokers (N = 128) imagined that they had the GSTM1 wild-type variant versus the GSTM1 null-type variant. The authors presented lung cancer risk in 6 ways that varied the risk format (absolute risk vs. incremental risk) and the presentation style of the information (no graphics vs. graphic display of foreground only vs. graphic display of foreground + background). Presentation style had minor effects. However, absolute risk information increased negative emotions more than did incremental risk information. Perceptions of risk and negative emotions were most profoundly affected by the difference between having the GSTM1 wild-type variant versus the GSTM1 null-type variant. The authors discuss implications for conveying small probabilities related to genetic risk.

Decision making and coping in healthcare: the Coping in Deliberation (CODE) framework

OBJECTIVE

To develop a framework of decision making and coping in healthcare that describes the twin processes of appraisal and coping faced by patients making preference-sensitive healthcare decisions.

METHODS

We briefly review the literature for decision making theories and coping theories applicable to preference-sensitive decisions in healthcare settings. We describe first decision making, then coping and finally attempt to integrate these processes by building on current theory.

RESULTS

Deliberation in healthcare may be described as a six step process, comprised of the presentation of a health threat, choice, options, preference construction, the decision itself and consolidation post-decision. Coping can be depicted in three stages, beginning with a threat, followed by primary and secondary appraisal and ultimately resulting in a coping effort.

CONCLUSIONS

Drawing together concepts from prominent decision making theories and coping theories, we propose a multidimensional, interactive framework which integrates both processes and describes coping in deliberation.

PRACTICE IMPLICATIONS

The proposed framework offers an insight into the complexity of decision making in preference-sensitive healthcare contexts from a patient perspective and may act as theoretical basis for decision support.

Looking at Patients’ Choices through the Lens of Expected Utility

The expected utility framework underlies much research in medical decision making. Because the framework requires decisions to be decomposed into probabilities of states and the values of those states, researchers have investigated the two components separately from each other and from patients’ actual decisions. The authors propose that it would be productive to focus more research on the relationships among risk perceptions, outcome valuations, and choices in the same decision makers. They outline exploratory analyses based on two existing national surveys, the Medical Expenditure Panel Survey and the Joint Canada/United States Survey of Health.

An international comparative family medicine study of the Transition Project data from the Netherlands, Malta and Serbia. Is family medicine an international discipline? Comparing diagnostic odds ratios across populations

INTRODUCTION

This is an international study of the epidemiology of family medicine (FM) in three practice populations from the Netherlands, Malta and Serbia. Diagnostic associations between common reasons for encounter (RfEs) and episodes titles are compared and similarities and differences are described and analysed.

METHODOLOGY

Participating family doctors (FDs) recorded details of all their patient contacts in an 'episode of care (EoC)' structure using the International Classification of Primary Care (ICPC). RfEs presented by the patient and episode titles (diagnostic labels of EoCs) were classified with ICPC. The relationships between RfEs and episode titles were studied with Bayesian methods.

RESULTS

Distributions of diagnostic odds ratios (ORs) from the three population databases are presented and compared.

CONCLUSIONS

ICPC, the RfE and the EoC data model are appropriate tools to study the process of diagnosis in FM. Distributions of diagnostic associations between RfEs and episode titles in the Transition Project international populations show remarkable similarities and congruencies in the process of diagnosis from both the RfE and the episode title perspectives. The congruence of diagnostic associations between populations supports the use of such data from one population to inform diagnostic decisions in another. Differences in the magnitude of such diagnostic associations are significant, and population-specific data are therefore desirable. We propose that both an international (common) and a local (health care system specific) content of FM exist and that the empirical distributions of diagnostic associations presented in this paper are a reflection of both these effects. We also observed that the frequency of exposure to such diagnostic challenges had a strong effect on the confidence intervals of diagnostic ORs reflecting these diagnostic associations. We propose that this constitutes evidence that expertise in FM is associated with frequency of exposure to diagnostic challenges.

Improving communication of breast cancer recurrence risk

Doctors commonly use genomic testing for breast cancer recurrence risk. We sought to assess whether the standard genomic report provided to doctors is a good approach for communicating results to patients. During 2009-2010, we interviewed 133 patients with stages I or II, node-negative, hormone receptor-positive breast cancer and eligible for the Oncotype DX genomic test. In a randomized experiment, patients viewed six vignettes that presented hypothetical recurrence risk test results. Each vignette described a low, intermediate, or high chance of breast cancer recurrence in 10 years. Vignettes used one of five risk formats of increasing complexity that we derived from the standard report that accompanies the commercial assay or a sixth format that used an icon array. Among women who received the genomic recurrence risk test, 63% said their doctors showed them the standard report. The standard report format yielded among the most errors in identification of whether a result was low, intermediate, or high risk (i.e., the gist of the results), whereas a newly developed risk continuum format yielded the fewest errors (17% vs. 5%; OR 0.23; 95% CI 0.10-0.52). For high recurrence risk results presented in the standard format, women made errors 35% of the time. Women rated the standard report as one of the least understandable and least-liked formats, but they rated the risk continuum format as among the most understandable and most liked. Results differed little by health literacy, numeracy, prior receipt of genomic test results during clinical care, and actual genomic test results. The standard genomic recurrence risk report was more difficult for women to understand and interpret than the other formats. A less complex report, potentially including the risk continuum format, would be more effective in communicating test results to patients.

Efficacy of a computerized simulation in promoting walking in individuals with diabetes

BACKGROUND

Regular walking is a recommended but underused self-management strategy for individuals with type 2 diabetes mellitus (T2DM).

OBJECTIVE

To test the impact of a simulation-based intervention on the beliefs, intentions, knowledge, and walking behavior of individuals with T2DM. We compared two versions of a brief narrated simulation. The experimental manipulation included two components: the presentation of the expected effect of walking on the glucose curve; and the completion of an action plan for walking over the next week. Primary hypotheses were (1) intervention participants' walking (minutes/week) would increase more than control participants' walking, and (2) change in outcome expectancies (beliefs) would be a function of the discrepancy between prior beliefs and those presented in the simulation. Secondary hypotheses were that, overall, behavioral intentions to walk in the coming week and diabetes-related knowledge would increase in both groups.

METHODS

Individuals were randomly assigned to condition. Preintervention measures included self-reported physical activity (International Physical Activity Questionnaire [IPAQ] 7-day), theory of planned behavior-related beliefs, and knowledge (Diabetes Knowledge Test). During the narrated simulation we measured individuals' outcome expectancies regarding the effect of exercise on glucose with a novel drawing task. Postsimulation measures included theory of planned behavior beliefs, knowledge, and qualitative impressions of the narrated simulation. The IPAQ 7-day was readministered by phone 1 week later. We used a linear model that accounted for baseline walking to test the main hypothesis regarding walking. Discrepancy scores were calculated between the presented outcome and individuals' prior expectations (measured by the drawing task). A linear model with an interaction between intervention status and the discrepancy score was used to test the hypothesis regarding change in outcome expectancy. Pre-post changes in intention and knowledge were tested using paired t tests.

RESULTS

Of 65 participants, 33 were in the intervention group and 32 in the control group. We excluded 2 participants from analysis due to being extreme outliers in baseline walking. After adjustment for baseline difference in age and intentions between groups, intervention participants increased walking by 61.0 minutes/week (SE 30.5, t(58 = 1.9, )P = .05) more than controls. The proposed interaction between the presented outcome and the individual's prior beliefs was supported: after adjustment for baseline differences in age and intentions between groups, the coefficient for the interaction was -.25, (SE 0.07, t(57 = -3.2, )P < .01). On average participants in both groups improved significantly from baseline in intentions (mean difference 0.66, t(62 = 4.5, )P < .001) and knowledge (mean difference 0.38, t(62 = 2.4, )P = .02).

CONCLUSIONS

This study suggests that a brief, Internet-ready, simulation-based intervention can improve knowledge, beliefs, intentions, and short-term behavior in individuals with T2DM.

A new intuitionism: Meaning, memory, and development in Fuzzy-Trace Theory

Combining meaning, memory, and development, the perennially popular topic of intuition can be approached in a new way. Fuzzy-trace theory integrates these topics by distinguishing between meaning-based gist representations, which support fuzzy (yet advanced) intuition, and superficial verbatim representations of information, which support precise analysis. Here, I review the counterintuitive findings that led to the development of the theory and its most recent extensions to the neuroscience of risky decision making. These findings include memory interference (worse verbatim memory is associated with better reasoning); nonnumerical framing (framing effects increase when numbers are deleted from decision problems); developmental decreases in gray matter and increases in brain connectivity; developmental reversals in memory, judgment, and decision making (heuristics and biases based on gist increase from childhood to adulthood, challenging conceptions of rationality); and selective attention effects that provide critical tests comparing fuzzy-trace theory, expected utility theory, and its variants (e.g., prospect theory). Surprising implications for judgment and decision making in real life are also discussed, notably, that adaptive decision making relies mainly on gist-based intuition in law, medicine, and public health.

A new intuitionism: Meaning, memory, and development in Fuzzy-Trace Theory

Combining meaning, memory, and development, the perennially popular topic of intuition can be approached in a new way. Fuzzy-trace theory integrates these topics by distinguishing between meaning-based gist representations, which support fuzzy (yet advanced) intuition, and superficial verbatim representations of information, which support precise analysis. Here, I review the counterintuitive findings that led to the development of the theory and its most recent extensions to the neuroscience of risky decision making. These findings include memory interference (worse verbatim memory is associated with better reasoning); nonnumerical framing (framing effects increase when numbers are deleted from decision problems); developmental decreases in gray matter and increases in brain connectivity; developmental reversals in memory, judgment, and decision making (heuristics and biases based on gist increase from childhood to adulthood, challenging conceptions of rationality); and selective attention effects that provide critical tests comparing fuzzy-trace theory, expected utility theory, and its variants (e.g., prospect theory). Surprising implications for judgment and decision making in real life are also discussed, notably, that adaptive decision making relies mainly on gist-based intuition in law, medicine, and public health.

Toxics, Toyotas, and terrorism: the behavioral economics of fear and stigma

Economists have traditionally viewed the behavioral response to risk as continuous and proportional. In contrast, psychologists have often contended that people have little control over their response to risk that is dichotomous, nonproportional, visceral, and fear based. In extreme cases, this automatic response results in the stigmatization of a product, technology, or choice, which seemingly cannot be eliminated or reduced. In resolving these contrasting perspectives, we review four recent studies that blend behavioral economics and psychology. Together, they provide evidence for a dual-process decision model for risk that incorporates both reason and fear. They show consumers' responses to perceived risk as a mix of proportional and dichotomous (safe/unsafe) responses that are relatively more continuous in situations where deliberation is possible, and more dichotomous in emotional or stressful circumstances. These findings reconcile mixed results in past studies, and, more importantly, the dual-process model allows a clear definition of stigma, and suggests new ways to mitigate stigma and to help manage potentially damaging overreactions to it.

Surrogate decision makers' interpretation of prognostic information: a mixed-methods study

BACKGROUND

Little is known about why surrogate decision makers for patients with advanced illness often have overly optimistic expectations about prognosis.

OBJECTIVE

To determine how surrogates interpret prognostic statements and to explore factors influencing surrogates' interpretations of grim prognostic information.

DESIGN

Multicenter, mixed-methods study.

SETTING

Intensive care units of 3 hospitals in San Francisco, California.

PARTICIPANTS

80 surrogates of critically ill patients.

MEASUREMENTS

Participants recorded their interpretation of 16 prognostic statements using a standard probability scale. Generalized estimating equations were used to determine whether participants interpreted statements more optimistically as the expressed probability of survival decreased. Fifteen surrogates whose responses exhibited this trend participated in a semistructured interview.

RESULTS

Participants' interpretations of prognostic statements expressing a low risk for death were relatively accurate, but interpretations of statements conveying a high risk for death were more optimistic than the actual meaning (P < 0.001; generalized estimating equation model). Interpretations of the statement "90% chance of surviving" did not differ from the actual meaning, but interpretations of "5% chance of surviving" were more optimistic and showed substantial variability (median, 90% [interquartile range, 90% to 95%; P = 0.11] vs. 15% [interquartile range, 5% to 40%; P < 0.001], respectively). Two main themes from the interviews explained this trend: surrogates' need to register optimism in the face of a poor prognosis and surrogates' belief that patient attributes unknown to the physician would lead to better-than-predicted outcomes.

LIMITATION

Surrogates' interpretations were elicited in an experimental setting rather than during actual clinician-surrogate conversations.

CONCLUSION

Inaccurate interpretations of physicians' prognostications by surrogates arise partly from optimistic biases rather than simply from misunderstandings.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

An experimental evaluation of patient decision aid design to communicate the effects of medications on the rate of progression of structural joint damage in rheumatoid arthritis

OBJECTIVE

To explore how effectively information presentation formats used in a patient decision aid communicated the ability of a disease modifying anti-rheumatic drug to slow the rate of progression of rheumatoid arthritis related structural joint damage (SJD).

METHODS

91 first year psychology students and 91 RA patients participated in a prospective randomized, single blind, factorial experimental design evaluating the effect of four information formats on: satisfaction with risk communication, verbatim and gist recall of a hypothetical anti-rheumatic drug's ability to slow the rate of progression of SJD.

RESULTS

Both groups underestimated the hypothetical drug's ability to slow SJD. Formats that supported the narrative statement with a reinforcing graphic element resulted in recall closer to the true value. Comparison of the results from testing of RA patients and college students were remarkably similar across formats.

CONCLUSION

Rate of progression as communicated by narrative statement plus a graphic element (i.e. speedometer metaphor or pictograph) aided recall better than a narrative statement alone. Our results suggest that testing decision aid components with non-patients may provide data generalizable to patient populations.

PRACTICE IMPLICATIONS

Graphics must be used carefully in patient decision aids as they can enhance recall, but may also introduce unintended recall bias.

Remembering and diagnosing clients: does experience matter?

Experienced mental health clinicians often do not outperform novices in diagnostic decision making. In this paper we look for an explanation of this phenomenon by testing differences in memory processes. In two studies we aimed to look at differences in accuracy of diagnoses in relation to free recall of client information between mental health clinicians with different levels of experience. Clinicians were presented with two cases, and were asked afterwards, either directly (Study 1) or after 1 week (Study 2), to give the appropriate diagnoses and to write down what they remembered of the cases. We found in Study 1 that the accuracy of the diagnoses was the same for all levels of experience, as was the amount of details recalled. Very experienced clinicians did remember more higher-order concepts, that is, abstractions from the presented information. In Study 2 we found that the very experienced clinicians were less accurate in their diagnoses and remembered fewer details than the novices. In response to these findings we further discuss their implications for psychodiagnostic practice.

Multi-media support for informed/shared decision-making before and after a cancer diagnosis

OBJECTIVES

To define and distinguish informed decision-making (IDM) from shared decision-making (SDM) and review the evidence for technology-based interventions designed to facilitate informed decisions about cancer screening and treatment.

DATA SOURCES

Peer-reviewed research articles from Medline and other data sources accessible through pubmed.gov.

CONCLUSION

There is evidence that multi-media decision aids (DAs) or support systems can improve quality of decision-making in terms of enhancing knowledge relevant to decision-making, reducing decisional conflict, and customizing education and coaching of patients with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses have a key role to play in designing, deploying, monitoring, and evaluating multi-media DAs in oncology practice settings. DAs are an adjunct to interpersonal education, providing information to patients in both the clinical setting and in more familiar settings without the time constraints of clinical encounters. Nurses can adopt such DAs and support systems and work with patients to ensure that information has been comprehended, that values have been considered, and that patients play an active role in the decision-making process as they desire.

Varieties of uncertainty in health care: a conceptual taxonomy

Uncertainty is a pervasive and important problem that has attracted increasing attention in health care, given the growing emphasis on evidence-based medicine, shared decision making, and patient-centered care. However, our understanding of this problem is limited, in part because of the absence of a unified, coherent concept of uncertainty. There are multiple meanings and varieties of uncertainty in health care that are not often distinguished or acknowledged although each may have unique effects or warrant different courses of action. The literature on uncertainty in health care is thus fragmented, and existing insights have been incompletely translated to clinical practice. This article addresses this problem by synthesizing diverse theoretical and empirical literature from the fields of communication, decision science, engineering, health services research, and psychology and developing a new integrative conceptual taxonomy of uncertainty. A 3-dimensional taxonomy is proposed that characterizes uncertainty in health care according to its fundamental sources, issues, and locus. It is shown how this new taxonomy facilitates an organized approach to the problem of uncertainty in health care by clarifying its nature and prognosis and suggesting appropriate strategies for its analysis and management.

Development of a tool to improve the quality of decision making in atrial fibrillation

Background

Decision-making about appropriate therapy to reduce the stroke risk associated with non-valvular atrial fibrillation (NVAF) involves the consideration of trade-offs among the benefits, risks, and inconveniences of different treatment options. The objective of this paper is to describe the development of a decision support tool for NVAF based on the provision of individualized risk estimates for stroke and bleeding and on preparing patients to communicate with their physicians about their values and potential treatment options.

Methods

We developed a tool based on the principles of the International Patient Decision Aids Standards. The tool focuses on the patient-physician dyad as the decision-making unit and emphasizes improving the interaction between the two. It is built on the recognition that the application of patient values to a specific treatment decision is complex and that the final treatment choice is best made through a process of patient-clinician communication.

Results

The tool provides education incorporating patients ' illness perceptions to explain the relationship between NVAF and stroke, and then presents individualized risk estimates, derived using separate risk calculators for stroke and bleeding over a clinically meaningful time period (5 years) associated with no treatment, aspirin, and warfarin. Sequelae of both stroke and bleeding outcomes are also described. Patients are encouraged to verbalize how they value the incremental risks and benefits associated with each option and write down specific concerns to address with their physician. A physician prompt to encourage patients to discuss their opinions is included as part of the decision support tool. In pilot testing with 11 participants (mean age 78 ± 9 years, 64% with ≤ high-school education), 8 (72%) rated ease of completion as "very easy," and 9 (81%) rated amount of information as "just right."

Conclusions

The risks and benefits of different treatment options for reduction of stroke in NVAF vary widely according to patients' comorbidities. This tool facilitates the provision of individualized outcome data and encourages patients to communicate with their physicians about these risks and benefits. Future studies will examine whether use of the tool is associated with improved quality of decision making.

Gist reasoning training in cognitively normal seniors

OBJECTIVE

Cognitive impairment is a key factor that threatens functionality and quality of life in seniors. Given the projection that the population of individuals 65 years of age and older will double within the next 25 years, a critical need exists to identify and test effectiveness of protocols that target higher-order cognitive skills such as gist reasoning to maximize cognitive capacity in later life.

METHODS

This study examined the effects of eight hours of gist reasoning training in 26 cognitively normal seniors between the ages of 64-85 years (M = 74.23, SD = 6.67).

RESULTS

Findings suggest that top-down strategy-based gist reasoning training significantly improved abstraction ability, a skill relevant to everyday life, as well as generalized to untrained measures of executive function including concept abstraction, cognitive switching, and verbal fluency. Individuals with lower baseline ability to abstract gist showed the greatest gain in the target domain trained.

CONCLUSIONS

These findings highlight the potential value of engaging in cognitively challenging activities that involve gist reasoning, to strengthen and preserve cognitive capacity with aging.

Addiction, adolescence, and the integration of control and motivation

The likelihood of initiating addictive behaviors is higher during adolescence than during any other developmental period. The differential developmental trajectories of brain regions involved in motivation and control processes may lead to adolescents' increased risk taking in general, which may be exacerbated by the neural consequences of drug use. Neuroimaging studies suggest that increased risk-taking behavior in adolescence is related to an imbalance between prefrontal cortical regions, associated with executive functions, and subcortical brain regions related to affect and motivation. Dual-process models of addictive behaviors are similarly concerned with difficulties in controlling abnormally strong motivational processes. We acknowledge concerns raised about dual-process models, but argue that they can be addressed by carefully considering levels of description: motivational processes and top-down biasing can be understood as intertwined, co-developing components of more versus less reflective states of processing. We illustrate this with a model that further emphasizes temporal dynamics. Finally, behavioral interventions for addiction are discussed. Insights in the development of control and motivation may help to better understand - and more efficiently intervene in - vulnerabilities involving control and motivation.

Patient decision making among older individuals with cancer

Patient decision making is an area of increasing inquiry. For older individuals experiencing cancer, variations in health and functional status, physiologic aspects of aging, and tension between quality and quantity of life present unique challenges to treatment-related decision making. We used the pragmatic utility method to analyze the concept of patient decision making in the context of older individuals with cancer. We first evaluated its maturity in existing literature and then posed analytical questions to clarify aspects found to be only partially mature. In this context, we found patient decision making to be an ongoing process, changing with time, reflecting individual and relational components, as well as analytical and emotional ones. Assumptions frequently associated with patient decision making were not consistent with the empirical literature. Careful attention to the multifaceted components of patient decision making among older individuals with cancer provides guidance for research, supportive interventions, and targeted follow-up care.

Preserving the self: the process of decision making about hereditary breast cancer and ovarian cancer risk reduction

Women who carry BRCA1 or BRCA2 (BRCA1/2) gene mutations have up to an 88% lifetime risk of breast cancer and up to a 65% lifetime risk of ovarian cancer. Strategies to address these risks include cancer screening and risk-reducing surgery (i.e., mastectomy and salpingo-oophorectomy). We conducted a grounded theory study with 22 BRCA1/2 mutation-carrier women to understand how women make decisions about these risk-reducing strategies. Preserving the self was the overarching decision-making process evident in the participants' descriptions. This process was shaped by contextual conditions including the characteristics of health services, the nature of hereditary breast and ovarian cancer risk-reduction decisions, gendered roles, and the women's perceived proximity to cancer. The women engaged in five decision-making styles, and these were characterized by the use of specific decision-making approaches. These findings provide theoretical insights that could inform the provision of decisional support to BRCA1/2 carriers.

Effects of benefits and harms on older persons' willingness to take medication for primary cardiovascular prevention

BACKGROUND

Quality-assurance initiatives encourage adherence to evidenced-based guidelines based on a consideration of treatment benefit. We examined older persons' willingness to take medication for primary cardiovascular disease prevention according to benefits and harms.

METHODS

In-person interviews were performed with 356 community-living older persons. Participants were asked about their willingness to take medication for primary prevention of myocardial infarction (MI) with varying benefits in terms of absolute 5-year risk reduction and varying harms in terms of type and severity of adverse effects.

RESULTS

Most (88%) would take medication, providing an absolute benefit of 6 fewer persons with MI out of 100, approximating the average risk reduction of currently available medications. Of participants who would not take it, 17% changed their preference if the absolute benefit was increased to 10 fewer persons with MI, and, of participants who would take it, 82% remained willing if the absolute benefit was decreased to 3 fewer persons with MI. In contrast, large proportions (48%-69%) were unwilling or uncertain about taking medication with average benefit causing mild fatigue, nausea, or fuzzy thinking, and only 3% would take medication with adverse effects severe enough to affect functioning.

CONCLUSIONS

Older persons' willingness to take medication for primary cardiovascular disease prevention is relatively insensitive to its benefit but highly sensitive to its adverse effects. These results suggest that clinical guidelines and decisions about prescribing these medications to older persons need to place emphasis on both benefits and harms.

Esophageal adenocarcinoma incidence in individuals with gastroesophageal reflux: synthesis and estimates from population studies

OBJECTIVES

Recent advances in the management of Barrett's esophagus may kindle enthusiasm for screening for esophageal adenocarcinoma (EAC). Symptoms of gastroesophageal reflux disease (GERD) are recognized as relative risks for EAC. However, the absolute incidence of EAC in specific populations with GERD is unknown. We aimed to estimate the symptom-, age-, and sex-specific incidences of EAC, and place these incidences in the perspective of other cancers for which screening is endorsed.

METHODS

A Markov computer model utilizing published and publicly available data was created to estimate the age- and sex-specific incidences of EAC in American white non-Hispanics with GERD symptoms.

RESULTS

The incidence of EAC in men younger than 50 years with GERD symptoms is very low (for instance, at the age of 35 years, incidence=1.0/100,000), and their incidence of colorectal cancer is relatively much higher (for instance, at the age of 35 years, incidence of colorectal cancer is 6.7-fold greater). The incidence of EAC in older men with weekly GERD symptoms is substantial (for instance, at the age of 70 years, incidence=60.8/100,000 person-years), but their incidence of colorectal cancer is at least threefold greater. The incidence of EAC in women with GERD is extremely low, and similar to that of breast cancer in men (for instance, 3.9/100,000 person-years at the age of 60 years).

CONCLUSIONS

Screening for EAC should not be performed in men younger than 50 years or in women because of very low incidences of cancer, regardless of the frequency of GERD symptoms. In white men with weekly GERD over the age of 60 years, the incidence of EAC is substantial, and might warrant screening if that practice is particularly accurate, safe, effective, and inexpensive.

Varieties of Uncertainty in Health Care

Uncertainty is a pervasive and important problem that has attracted increasing attention in health care, given the growing emphasis on evidence-based medicine, shared decision making, and patient-centered care. However, our understanding of this problem is limited, in part because of the absence of a unified, coherent concept of uncertainty. There are multiple meanings and varieties of uncertainty in health care that are not often distinguished or acknowledged although each may have unique effects or warrant different courses of action. The literature on uncertainty in health care is thus fragmented, and existing insights have been incompletely translated to clinical practice. This article addresses this problem by synthesizing diverse theoretical and empirical literature from the fields of communication, decision science, engineering, health services research, and psychology and developing a new integrative conceptual taxonomy of uncertainty. A 3-dimensional taxonomy is proposed that characterizes uncertainty in health care according to its fundamental sources, issues, and locus. It is shown how this new taxonomy facilitates an organized approach to the problem of uncertainty in health care by clarifying its nature and prognosis and suggesting appropriate strategies for its analysis and management.