Therapeutic decision making of physicians

A game theoretic approach reveals that discretizing clinical information can reduce antibiotic misuse

The overuse of antibiotics is exacerbating the antibiotic resistance crisis. Since this problem is a classic common-goods dilemma, it naturally lends itself to a game-theoretic analysis. Hence, we designed a model wherein physicians weigh whether antibiotics should be prescribed, given that antibiotic usage depletes its future effectiveness. The physicians' decisions rely on the probability of a bacterial infection before definitive laboratory results are available. We show that the physicians' equilibrium decision rule of antibiotic prescription is not socially optimal. However, we prove that discretizing the information provided to physicians can mitigate the gap between their equilibrium decisions and the social optimum of antibiotic prescription. Despite this problem's complexity, the effectiveness of the discretization solely depends on the type of information available to the physician to determine the nature of infection. This is demonstrated on theoretic distributions and a clinical dataset. Our results provide a game-theory based guide for optimal output of current and future decision support systems of antibiotic prescription.

What a veterinary graduate should know about basic and clinical pharmacology: A Delphi study to finalize day-1 competencies

The recent changes in curricula in veterinary medicine have changed the delivery and focus on veterinary pharmacology and therapeutics, resulting in a perceived lack of knowledge of pharmacology and therapeutic decision making in recent graduates. To aid veterinary pharmacologists and clinicians teaching clinical pharmacology, core competencies were drafted by a working group. Following this process, a Delphi study was performed to come to a consensus on day-1 competencies in veterinary pharmacology and therapeutics. The described competencies could be useful to a variety of stakeholders in veterinary pharmacology, including those teaching veterinary pharmacology worldwide. Secondly, they could form the basis of vertical alignment of the subject within schools and across the world, as well as serving to frame the integration of veterinary pharmacology and therapeutics into competency-based veterinary education.

A Randomized, Crossover Pilot Study of a Novel Web-Based/Mobile Platform for Collaborative Small Group Practice in Therapeutic Reasoning

BACKGROUND AND PURPOSE

Therapeutic reasoning-the mental process of making judgments and decisions about treatment-is developed through acquisition of knowledge and application in actual or simulated experiences. Health professions education frequently uses collaborative small group work to practice therapeutic reasoning. This pilot study compared the impact of a web-based/mobile tool for collaborative case work and discussion to usual practice on student perceptions and performance on questions designed to test therapeutic knowledge and reasoning.

METHODS

In a therapeutics course that includes case-based workshops, student teams of 3 to 4 were randomly assigned to usual workshop preparation (group SOAP sheet) or preparation using the Practice Improvement using Virtual Online Training (PIVOT) platform. PIVOT was also used in the workshop to review the case and student responses. The next week, groups crossed over to the other condition. Students rated favorability with the preparatory and in-workshop experiences and provided comments about the PIVOT platform via a survey. Student performance on examination items related to the 2 workshop topics was compared.

RESULTS

One hundred and eleven students (94%) completed post-workshop surveys after both workshops. The majority of students (57%) preferred using the PIVOT platform for workshop collaboration. Favorability ratings for the in-workshop experience did not change significantly from first to second study week, regardless of sequence of exposure. There was no relationship between examination item scores and the workshop platform the students were exposed to for that content (P = .29). Student responses highlighted the efficiency of working independently before collaborating as a group and the ability to see other students' thought processes as valuable aspects of PIVOT. Students expressed frustration with the PIVOT user interface and the lack of anonymity when discussing their answers in the workshop.

CONCLUSION

A web-based/mobile platform for student team collaboration on therapeutic reasoning cases discussed in small group settings yielded favorable ratings, examination performance comparable to standard approaches, and was preferred by a majority of students. During the rapid shift to substantial online learning for the COVID-19 pandemic, virtual collaboration tools like PIVOT may help health professions teachers to better support groups working virtually on scaffolded therapeutic reasoning tasks.

'Working away in that Grey Area…' A qualitative exploration of the challenges general practitioners experience when managing behavioural and psychological symptoms of dementia

Background

general practitioners (GPs) have identified the management of behavioural and psychological symptoms of dementia (BPSD) as a particularly challenging aspect of dementia care. However, there is a paucity of research on why GPs find BPSD challenging and how this influences the care they offer to their patients with dementia.

Objectives

to establish the challenges GPs experience when managing BPSD; to explore how these challenges influence GPs' management decisions; and to identify strategies for overcoming these challenges.

Design

qualitative study of GPs experiences of managing BPSD.

Methods

semi-structured interviews were conducted with 16 GPs in the Republic of Ireland. GPs were purposively recruited to include participants with differing levels of experience caring for people with BPSD in nursing homes and in community settings to provide maximum diversity of views. Interviews were analysed thematically.

Results

three main challenges of managing BPSD were identified; lack of clinical guidance, stretched resources and difficulties managing expectations. The lack of relevant clinical guidance available affected GPs' confidence when managing BPSD. In the absence of appropriate resources GPs felt reliant upon sedative medications. GPs believed their advocacy role was further compromised by the difficulties they experienced managing expectations of family caregivers and nursing home staff.

Conclusions

this study helps to explain the apparent discrepancy between best practice recommendations in BPSD and real-life practice. It will be used to inform the design of an intervention to support the management of BPSD in general practice.

How could undergraduate education prepare new graduates to be safer prescribers?

This review examines the extent to which undergraduate prescribing education prepares graduates for the complexities of prescribing in the workplace context. In order to prescribe safely, it is important for medical students to acquire prescribing expertise. We have developed a theoretical model, based on theories of expertise development, which acknowledges the inherent complexity of the task itself, the social context and the relationship between the two. We have examined the empirical evidence on educational interventions for prescribing by reviewing the extent to which the interventions acknowledge the different components of our theoretical model. Fifteen empirical studies met our inclusion criteria and were reviewed in detail. All the studies were conducted between 2002 and 2010, six were controlled trials, six were before and after studies and three were prospective observational studies. We found that most studies focused on improving and evaluating students' knowledge and skills, although they used different approaches to doing so. These aspects of prescribing only constitute a small part of our theoretical model of prescribing expertise. Other important components, such as social context, metacognition and training transfer, were neglected. We suggest that educational interventions need to account for the integrated nature of learning to prescribe and take a more contextualized approach which considers the task as a whole, rather than isolated constituent parts. In doing so, prescribing education could equip graduates with the necessary expertise to judge and respond to situations, enabling them to prescribe safely, or seek the help to do so, in the unpredictable and complex context of workplaces.

Customization in prescribing for bipolar disorder

For many disorders, patient heterogeneity requires physicians to customize their treatment to each patient's needs. We test for the existence of customization in physicians' prescribing for bipolar disorder, using data from a naturalistic clinical effectiveness trial of bipolar disorder treatment (STEP-BD), which did not constrain physician prescribing. Multinomial logit is used to model the physician's choice among five combinations of drug classes. We find that our observed measure of the patient's clinical status played only a limited role in the choice among drug class combinations, even for conditions such as mania that are expected to affect class choice. However, treatment of a patient with given characteristics differed widely depending on which physician was seen. The explanatory power of the model was low. There was variation within each physician's prescribing, but the results do not suggest a high degree of customization in physicians' prescribing, based on our measure of clinical status.

Treatment of asthma: Identification of the practice behavior and the deviation from the guideline recommendations

BACKGROUND

Despite an exponential development of the understanding of the disease with availability of good therapy and feasibility of good control along with availability of globally accepted guidelines, there remains a significant gap between the guidelines and prevailing practice behavior for treating asthma all over the globe. This perhaps stands as the single most deterrent factor for good asthma care worldwide. The objective of the study is to analyze the asthma prescriptions to find out the available status of the practice behaviour and the deviations from the guideline in asthma practice.

MATERIALS AND METHODS

The asthma prescriptions of the referred patients presenting to the OPD services of the IPCR, Kolkata were photocopied and collected. They were further analyzed based on the available information upon a format being prepared on four major areas as qualifications, clinical recording habit, practice of evaluating patients, and treatment habit that stands apparent from the prescribed medications. The doctors were divided into three categories as a) MBBS, b) MD/DNB (medicine and respiratory medicine), and c) DM (non respiratory sub-specialities) and statistical analysis has been performed comparing the three groups as per the performance in the four pre-decided areas.

RESULTS

All the groups fall short of any guideline or text of asthma care in all the areas involved.

CONCLUSION

The practice behaviour of our doctors for asthma care appears deficient in several areas and seems far from guideline recommendations. This needs further evaluation and adoption of appropriate interventions.

Therapeutic reasoning: from hiatus to hypothetical model

Rationale Extensive research has been conducted on clinical reasoning to gain better understanding of this process. Clinical reasoning has been defined as the process of thinking critically about the diagnosis and patient management. However, most research has focused on the process of diagnostic reasoning. Because of the lack of understanding regarding therapeutic reasoning, education in patient management decisions lacks a solid theoretical basis. Aims and objective To improve medical education, training and refresher courses with regard to therapeutic decision making. Methods A search on the literature about clinical reasoning has been conducted. Based on this literature a hypothetical model of therapeutic reasoning is developed. Results It is assumed on the literature about diagnostic and therapeutic reasoning that after the diagnosis has been formulated, the process of determining the therapy is initiated by a concept called the therapy script. Patient cases unconsciously elicit such scripts and they consist of relevant treatments, knowledge and clinical experiences. Analytical and non-analytical processes determine the final choice of therapy. Subsequently, these processes adapt the therapy script continuously. Conclusions A hypothetical model of therapeutic reasoning has been developed in order to improve medical education, training and refresher courses with regard to therapeutic decision making. Future research should empirically test the validity of this hypothetical model in different phases of the medical education continuum.

Teaching clinical pharmacology and therapeutics with an emphasis on the therapeutic reasoning of undergraduate medical students

BACKGROUND

The rational prescribing of drugs is an essential skill of medical doctors. Clinical pharmacologists play an important role in the development of these skills by teaching clinical pharmacology and therapeutics (CP&T) to undergraduate medical students. Although the approaches to teaching CP&T have undergone many changes over the last decennia, it is essential that the actual teaching of CP&T continues to be a major part of the undergraduate medical curriculum.

OBJECTIVES

The learning objectives of CP&T teaching in terms of developing the therapeutic competencies of undergraduate medical students are described, with an emphasis on therapeutic decision-making. On the basis of current theories of cognitive psychology and medical education, context-learning is presented as an effective approach by which to achieve therapeutic competencies. An example of a CP&T curriculum is presented.

Evaluation of a pharmacotherapy context-learning programme for preclinical medical students

AIM

To evaluate a context-learning pharmacotherapy programme for approximately 750 2nd, 3rd and 4th year preclinical medical students with respect to mastering cognitive pharmacotherapeutic skills, i.e. choosing a (drug) treatment and determining patient information.

METHODS

The context-learning pharmacotherapy programme consists of weekly organized role play sessions in the form of consulting hours. Fourth year students sit for a therapeutic Objective Structured Clinical Examination (OSCE) in the form of consulting hours at the outpatient clinic. Sixty-one 2nd, 74 3rd and 49 4th year medical students who attended the role play sessions and the OSCE were randomly selected. Their performances were assessed by clinical examiners and clinical experts and compared with a reference group of 6th year graduated students. Additionally, the scores of a questionnaire on study load and appreciation were collected.

RESULTS

The level of the pharmacotherapeutic skills of the 4th year students who followed the pharmacotherapy context-learning programme was not far below that of 6th year graduates who had finished their clinical clerkships, but had not followed the pharmacotherapy programme. The time spent on the programme was about 1% of the total study load per year. The students appreciated the role play sessions and OSCE by around 80% and 99% of the maximum possible scores.

CONCLUSIONS

Preclinical pharmacotherapy context learning has a modest but positive effect on learning cognitive pharmacotherapeutic skills, i.e. choosing a drug treatment and determining patient information. This effect has been obtained with role play sessions, a suboptimal form of context learning, with a minimal study load and a high appreciation by students.

Physician decisions to discontinue long-term medications using a two-stage framework: the case of growth hormone therapy

BACKGROUND

Physician decisions to discontinue prescription medications for chronic conditions are fundamental determinants of drug use but have been inadequately studied. The decision to stop growth hormone (GH) therapy is an important example because of high cost (approximately $26,000/y for a 48-kg child), complexity of treatment options, and expansion of patient populations.

AIM

The aim of this study was to identify the factors that influence physician recommendations in the process of discontinuing therapy.

DESIGN

A random sample of half of U.S. pediatric endocrinologists (n = 265) was mailed a survey that included case scenarios of GH-deficient adolescents. Decision options involved a 2-stage framework to 1) initiate change in ongoing GH therapy (by discussing discontinuing GH with the family but not yet stopping treatment), and 2) take action to discontinue ongoing GH therapy (by terminating GH or reducing the dose to adult maintenance level).

MAIN OUTCOME MEASURE

Physician recommendations.

RESULTS

The response rate was 83.8%. Physiological indices of growth potential (growth velocity, bone age) significantly influenced discontinuation decisions (both P < 0.001). However, family preference, child's height, and physician attitudes exerted independent effects (each P < 0.05). Treatment price had little influence. Together, these variables accounted for 60% to 70% of the variation in recommendations. Their relative influence differed by stage in the discontinuation process.

CONCLUSION

The variables in our framework substantially explain discontinuation decisions. The data demonstrate the importance of both physiological and nonphysiological factors. The results suggest that physicians value even small gains as final height approaches, although an additional 20% expenditure may be needed to gain the last 1% to 3% of adult height.

Factors that influence prescribing decisions

BACKGROUND

Strategies to control the quality and cost of medication use are largely dependent on the ability to alter selection of medications. Previous models of prescribing behavior have focused on physicians. In the hospital setting, clinical pharmacists and formulary committee members are also key players in drug therapy decision-making. Differences between physicians, formulary committee members, and clinical pharmacists have not been compared. Knowledge of these differences could have importance in predicting the effectiveness of strategies designed to influence drug use in this setting.

OBJECTIVE

To describe and compare the opinions of physicians, clinical pharmacists, and formulary committee members with respect to key factors that influence medication prescribing in community hospitals.

METHODS

Physicians, clinical pharmacists, and formulary committee members were solicited to participate. A trained interviewer administered a standardized questionnaire designed to elicit opinions of participants regarding the importance of factors thought to influence drug prescribing. Responses were described using descriptive statistics, and differences between the groups were determined by post hoc analysis.

RESULTS

A total of 150 individuals participated in the study. Safety, effectiveness, formulary status, and restrictions on prescribing were considered highly influential by all participants. Physicians rated the availability of drug samples and personal experience higher (more influential on prescribing) than clinical pharmacists and formulary committee members. Clinical pharmacists and formulary committee members rated the influence of recommendations by clinical pharmacists, prescribing guidelines, and cost or cost comparisons higher than physicians. Factors that were drug-related or that involved policy-related programs tended to be more influential than indirect factors.

CONCLUSIONS

Those who seek to implement programs to alter medication use should recognize and employ factors that are most influential in the decision-making process. Further, it may be important to consider differences that exist between key participants in the medication use process.

'Health repertories': an understanding of lay management of minor ailments

Data from a programme of research exploring information channels about health and medicines used by young adults (16-24 years old) in the UK were considered, in the light of existing schema and memory theory, to provide a concept of 'health repertories' for self-medication of minor ailments. Focus groups comprising a total of 48 young adults were conducted, followed by structured interviews with 76 young adults who visited a community pharmacy to purchase non-prescription medicines or to ask for advice, and case studies from this cohort. We propose that young adults develop a dynamic 'health repertory' of information for management of minor illness episodes, comprising a number of 'entries', and that these repertories are consistent with schema theory. Each 'repertory' includes description/labelling of symptoms, one or more self-medication strategies, and contingency plans (including formal health care intervention), if these strategies fail. Information in the repertory is drawn from both lay and professional channels.

Scope and nature of prescribing decisions made by general practitioners

BACKGROUND

This study describes cognitive processes of doctors who are deciding on the treatment for a patient. This helps to uncover how prescribing decisions could benefit from (computerised) support.

METHODS

While thinking aloud, 61 general practitioners made prescribing decisions for five patients with urinary tract infections or stomach complaints. The resulting 305 transcripts were analysed to determine the scope and nature of the decision processes. Differences in the process were related to case or doctor characteristics, and to differences in the quality of prescribing behaviour.

RESULTS

The decision processes were not extensive, particularly for patients with a urinary tract infection. The doctors did not actively consider all possible relevant information. Considerations referring to core aspects of the treatment were made in 159 cases (52%) and to contextual aspects in 111 cases (36%). Habitual behaviour, defined as making a treatment decision without any specific contemplation, was observed in 118 cases (40%) and resulted in prescribing first choice as well as second choice drugs. For stomach complaints, second choice drugs were often prescribed after considering other treatments or in view of specific circumstances. Experience of the doctor was not related to the type of decision process.

CONCLUSIONS

The processes observed deviate from the decision theoretic norm of thoroughly evaluating all possible options, but these deviations do not always result in suboptimal prescribing. Decision support is useful for bringing pertinent information and first choice treatments to the prescriber's attention. In particular, information about relevant contraindications, interactions, and costs could improve the quality of prescribing.

Evaluating an educational intervention to improve the treatment of asthma in four European countries. Drug Education Project Group

In the international Drug Education Project, a new educational program for peer groups of doctors was developed and tested to improve the treatment of asthma patients in The Netherlands, Norway, Sweden, and Slovakia. Individualized feedback on prescribing and the underlying decision strategy was presented and discussed within the group of doctors, in relation to existing guidelines. In a parallel, randomized controlled design the effect on competence and actual prescribing was tested. Results were related to national guidelines. In general, the program improved the doctors' attitudes as well as some of their prescribing behavior. The proportion of patients treated with inhaled corticosteroids significantly improved in The Netherlands (effect size 1.27), and the proportion of oral corticosteroid use for exacerbation treatment increased both in The Netherlands and in Norway (effect sizes 1.99 and 0.87, respectively). Overall attitudes of Dutch and Norwegian doctors also improved significantly (effect sizes 1.06 and 0.87, respectively), as did both knowledge (effect size 1.06) and attitudes (effect size 1.49) concerning exacerbation treatment in Slovakia. In Sweden no significant improvements could be measured. Conclusively, improvements in asthma treatment are possible with an educational program based on self-learning in small peer groups, although effects in one health care setting may not occur in another health care setting. Possible explaining factors may be different attitudes to and experiences with guidelines as well as with continuing medical education programs, and differences in the opportunities for change, including prevailing trends in prescribing behavior.

The System of Objectified Judgement Analysis (SOJA). A tool in rational drug selection for formulary inclusion

Rational drug selection for formulary purposes is important. Besides rational selection criteria, other factors play a role in drug decision making, such as emotional, personal financial and even unconscious criteria. It is agreed that these factors should be excluded as much as possible in the decision making process. A model for drug decision making for formulary purposes is described, the System of Objectified Judgement Analysis (SOJA). In the SOJA method, selection criteria for a given group of drugs are prospectively defined and the extent to which each drug fulfils the requirements for each criterion is determined. Each criterion is given a relative weight, i.e. the more important a given selection criterion is considered, the higher the relative weight. Both the relative scores for each drug per selection criterion and the relative weight of each criterion are determined by a panel of experts in this field. The following selection criteria are applied in all SOJA scores: clinical efficacy, incidence and severity of adverse effects, dosage frequency, drug interactions, acquisition cost, documentation, pharmacokinetics and pharmaceutical aspects. Besides these criteria, group specific criteria are also used, such as development of resistance when a SOJA score was made for antimicrobial agents. The relative weight that is assigned to each criterion will always be a subject of discussion. Therefore, interactive software programs for use on a personal computer have been developed, in which the user of the system may enter their own personal relative weight to each selection criterion and make their own personal SOJA score. The main advantage of the SOJA method is that all nonrational selection criteria are excluded and that drug decision making is based solely on rational criteria. The use of the interactive SOJA discs makes the decision process fully transparent as it becomes clear on which criteria and weighting decisions are based. We have seen that the use of this method for drug decision making greatly aids the discussion in the formulary committee, as discussion becomes much more concrete. The SOJA method is time dependent. Documentation on most products is still increasing and the score for this criterion will therefore change continuously. New products are introduced and prices are also subject to change. To overcome the time-dependence of the SOJA method, regular updates of interactive software programs are being made, in which changes in acquisition cost, documentation or a different weighting of criteria are included, as well as newly introduced products. The possibility of changing the official acquisition cost into the actual purchasing costs for the hospital in question provides a tailor-made interactive program.

The use of drug information sources by physicians: development of a data-generating methodology

The aim of this study was: (1) to develop and evaluate a methodology to determine hospital physician's use of personal drug information sources; (2) a preliminary insight into the use personal drug information sources. Written case simulations appeared to be the most appropriate method. To construct the written case simulations a step-wise procedure was developed. In the first stage 5 internists formulated 35 complex cases from their daily practice in which they consulted drug information sources; after an evaluation by experts 20 cases were left over. Next, using a written questionnaire, these 20 cases were evaluated in a random sample of 50 internists according to criteria concerning aspects of the process, the contents and the context. Finally, we analyzed these ratings using an elimination-by-aspects decision rule, with the dominant criterion 'need for consultation'. After this selection programme, two cases for each stage in the decision-making process of hospital physicians were selected which met the criteria. In general the colleague internist was the most frequently mentioned information source. Subspecialists and supporting specialists were considered less often and varied per stage in the decision-making process of physicians. The hospital pharmacist was hardly mentioned as a possible information source. The representatives of the pharmaceutical industry were not mentioned at all by the respondents.

Pharmacist-physician co-operation at a regional level

In the Dutch region of "Betuwe" the hospital pharmacists and community pharmacists together provide short drug letters about new drugs, which are sent bimonthly to all the practising general practitioners (n = 83) and medical specialists (n = 50) in this region. A survey was conducted among these physicians in order to investigate their opinion about and reported use of the drug letters in comparison with other drug-information sources. The majority of the responding physicians (response rate 68%) was found to read the drug letter frequently and evaluated the drug letter as a useful source of information about drugs, especially its section about the advantages and disadvantages of the new drug compared to other drugs. With respect to the different stages of the drug-adoption process, the drug letter was found to be the most frequently used information source at the decision stage. At the introduction stage the pharmaceutical industry representative seems to be the most frequently used source of information, while at the information stage it is the "Geneesmiddelenbulletin" (Drug Bulletin). The majority of the responding general practitioners reported to participate in local group meetings with pharmacists. However, in only 20% of these group meetings attention is given to the drug letter. Since it is known that written information has only a limited influence on the physician's behaviour, the influence of the "Betuwe Circulaire" may increase when attention is paid to it in the local contacts between pharmacists and physicians.

Drug expectations and drug choices of hospital physicians

OBJECTIVES

To assess whether differences in drug choices of hospital physicians are related to differences in the underlying decision-making process.

DESIGN

A survey study was conducted addressing drug choices in six therapeutic fields with existing interprescriber variations; prescribers and non-prescribers of drugs of which the merits were not sufficiently proven (i.e. the 'target drugs') were compared.

SETTING

A 1000-bed university hospital in The Netherlands.

SUBJECTS

All 85 hospital physicians working in specialities involving one of the selected fields were asked to participate; 72 physicians completed the interviews.

MAIN OUTCOME MEASURES

Comparisons were made regarding three elements of the decision-making process: (1) the physicians' expectations of the target drugs and frequently used alternatives, (2) the weights attached to the principal treatment aspects, and (3) the extent to which their actual choice is based on these expectations and weights.

RESULTS

In three fields, i.e. anti-emetics, vasodilators, and platelet inhibitors, the prescribers of the less desirable target drugs had higher expectations of these drugs in comparison to the non-prescribers. In the other therapeutic fields, choosing target drugs was related either to attaching less importance to side-effects and costs, or to attaching less importance to reports from clinical trials. Twenty of the 46 treatment choices of the prescribers of target drugs could not be predicted from their expressed views as opposed to 5 of the 36 choices of the non-prescribers (P < 0.05).

CONCLUSIONS

Choosing less desirable drugs is not always related to having too high expectations of the drug. Assigning a different importance to certain aspects of the drug and resorting to decision strategies that do not include the weighing of all pros and cons provide alternative explanations for such treatment choices.

Physician prescribing decisions: the effects of situational involvement and task complexity on information acquisition and decision making

This research utilized conjoint analysis and an analysis of information acquisition to examine the effects of situational involvement and task complexity on physician's decision-making process. The predictive accuracy of the linear model in predicting drug choice across situations was also assessed. A contingency model for the selection of decision strategies was used as a framework in the study. A sample of forty-eight physicians was asked to indicate their preferences and choices for hypothetical anti-infective drugs. Situational involvement was manipulated by telling physicians in the experimental group via the written scenario to assume that his/her decision would be reviewed and evaluated by peers and (s)he would be asked to justify drug choice. Task complexity was manipulated by varying the number of drug alternatives in a choice set. Results of the study indicated that physicians shifted from using compensatory to noncompensatory decision-making processes when task complexity increased. The effect of situational involvement on the decision-making process was not supported. However, physicians in the two groups were found to differ in choice outcomes and the attention given to specific drug attribute information. Finally, the linear model was found to be robust in predicting drug choice across contexts.