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

Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight?

OBJECTIVE

The authors examined whether physicians' use of computerized decision aids affects patient satisfaction and/or blame for medical outcomes.

METHOD

Experiment 1: Fifty-nine undergraduates read about a doctor who made either a correct or incorrect diagnosis and either used a decision aid or did not. All rated the quality of the doctor's decision and the likelihood of recommending the doctor. Those receiving a negative outcome also rated negligence and likelihood of suing. Experiment 2: One hundred sixty-six medical students and 154 undergraduates read negative-outcome scenarios in which a doctor either agreed with the aid, heeded the aid against his own opinion, defied the aid in favor of his own opinion, or did not use a decision aid. Subjects rated doctor fault and competence and the appropriateness of using decision aids in medicine. Medical students made judgments for themselves and for a layperson.

RESULTS

Experiment 1: Using a decision aid caused a positive outcome to be rated less positively and a negative outcome to be rated less negatively. Experiment 2: Agreeing with or heeding the aid was associated with reduced fault, whereas defying the aid was associated with roughly the same fault as not using one at all. Medical students were less harsh than undergraduates but accurately predicted undergraduate's responses.

CONCLUSION

Agreeing with or heeding a decision aid, but not defying it, may reduce liability after an error. However, using an aid may reduce favorability after a positive outcome.

Emerging paradigms of cognition in medical decision-making

The limitations of the classical or traditional paradigm of decision research are increasingly apparent, even though there has been a substantial body of empirical research on medical decision-making over the past 40 years. As decision-support technology continues to proliferate in medical settings, it is imperative that "basic science" decision research develop a broader-based and more valid foundation for the study of medical decision-making as it occurs in the natural setting. This paper critically reviews both traditional and recent approaches to medical decision making, considering the integration of problem-solving and decision-making research paradigms, the role of conceptual knowledge in decision-making, and the emerging paradigm of naturalistic decision-making. We also provide an examination of technology-mediated decision-making. Expanding the scope of decision research will better enable us to understand optimal decision processes, suitable coping mechanisms under suboptimal conditions, the development of expertise in decision-making, and ways in which decision-support technology can successfully mediate decision processes.

Management choices for patients with "squamous atypia" on Papanicolaou smear. A toss up?

Appropriate management of borderline abnormalities on Papanicolaou (Pap smears is controversial. This decision analysis compared two strategies for management of women with the Pap smear result of "squamous atypia." A policy of immediate colposcopy and biopsy was compared with repeating the cervical smear at 6-month intervals. Relevant probabilities and ranges were extracted from published studies in the English language medical literature from 1966 to 1993. When no relevant studies could be located, probabilities with a plausible range were determined through consensus of a panel of experts. Outcome values were assigned for the analysis to contrast the time period (approximately 2 years) covered by the analysis. Using baseline estimates, either policy resulted in an essentially equivalent probability of invasive cervical cancer. The estimated likelihood of remaining free of invasive cervical cancer was .9974 for follow-up by repeat smear versus .9976 for immediate colposcopy and biopsy. In sensitivity analysis, very high probabilities of progression to invasive cervical cancer favored the policy of immediate colposcopy and biopsy. Follow-up of squamous atypia on cervical smear by repeating the smear at 6-month intervals is unlikely to result in a detectable increase in invasive cervical cancers.