Doctors and decision analysis

Use of formal methods in medical decision making: a survey and analysis

Apparent low usage of formal decision techniques by general clinicians has raised questions about dissemination methods and about the techniques' perceived usefulness. Two literature searches examined whether use of formal decision techniques among clinicians had indeed failed to increase from the 1970s to the 1980s. A general MEDLINE search for the period 1983-87 relative to 1973-77 indicated that usage of formal decision techniques had more than doubled. This increase, however, was due to increased coverage of formal decision techniques in specialist methods journals. A manual search of seven major clinical journals and a MEDLINE search restricted to the clinical journals of the manual search disclosed no increase in overall usage for the same time periods. MEDLINE detected only a small subset of the actual instances of formal method usage found by the manual search. Individual medical subspecialties were found to utilize different formal decision techniques to different degrees. The authors suggest interventions that may increase the usage of formal decision techniques among general clinicians.

The limits of decision analysis for rapid decision making in ICU nursing

In a study examining rapid decisions in ICU nursing in the context of decision analysis, 40 nurses in 2 ICUs were asked to describe their decisions for six pretested vignettes, suggest alternatives and answer questions about case characteristics. Later, ICU charge nurses and educators were asked to rate the nurses' responses using a modified Q-sort. The nurses did not perceive a finite set of alternatives; the 40 nurses gave 36 to 40 unique sequences that did not cluster. The experts could not agree on which alternatives were good (no "gold standard"). The assumptions of decision analysis appear to be violated when (a) there is not a small finite set of mutually exclusive alternatives; (b) the merit of an intervention cannot be agreed on; or (c) the link between intervention and outcome is unclear. Not only nursing but other process-oriented areas of medical care as well may not fit the decision analysis model.