Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Why the surprise?
- Richard D Colman (22 August 2004)
-
Why not test impact of gender, or at least control for it?
- Judith M Dwyer (26 August 2004)
-
Uncovering "unconscious processes" in medical decision making
- Clare Harries, Olga Kostopoulou, DoH R&D/PPP National Primary Care Postdoctoral Fellow, Department of Primary Care and General Practice, University of Birmingham (2 September 2004)
-
Re: Why not test impact of gender, or at least control for it?
- Thomas V Perneger (8 September 2004)
-
Re: Uncovering "unconscious processes" in medical decision making
- Thomas V Perneger (8 September 2004)
-
ICU admission and non clinical factors
- Alberto Giannini (16 September 2004)
|
|
|||
|
Richard D Colman, Regional Medical Officer - Corus Teeside Works, TS10 5QW
Send response to journal:
|
The fact that none medical factors influence decisions concerning patients perception of disability, or doctors consideration of what is appropriate treatment or referral, is well known. The current process of certifying and justifying sickness absence by UK GPs is an example of a particularly subjective process. Competing interests: None declared |
|||
|
|
|||
|
Judith M Dwyer, Associate Professor, Health Services Management La Trobe University, Bundoora, Victoria, 3070, Australia
Send response to journal:
|
It is disappointing that this study did not include gender of the patient as a factor of interest, given what is known about the impact of gender in decision-making about other aspects of medical care. Worse, given that patient gender is identified in 3 of the vignettes (either explicitly by the description 'woman' or implicitly by type of cancer), but obscured in others, one wonders how much the results are confounded by gender as a kind of wild card in the otherwise structured approach to allocation of variables. I wish I could say it was merely quaint that four of the patients are identified as 'patients' (one implicitly male, the other three undetermined) and two are identified as 'woman'. I wonder what assumptions the respondents made? Competing interests: None declared |
|||
|
|
|||
|
Clare Harries, Lecturer University College London, Department of Psychology, Gower Street, London, WC1E 6BT, Olga Kostopoulou, DoH R&D/PPP National Primary Care Postdoctoral Fellow, Department of Primary Care and General Practice, University of Birmingham
Send response to journal:
|
We welcome the publication of Escher and colleagues’ investigation into the influences on doctors’ decisions about admission to intensive care (1). Like clinical judgment analysis (2;3;4) this study explores both explicitly stated ratings of the relative importance of factors and also measures their tacit impact. The mismatch between these reiterates the pattern that is regularly reported both for individual doctors’ (5;6;7) and others’ (8) judgments and decisions. Whilst Escher and colleagues suggest that “unconscious processes may be at work and lead to biased decisions”, there are other explanations for this implicit-explicit mismatch (9). Firstly, a factor’s impact depends upon how much it varies across cases. Participants rating relative importance prior to judging sets of cases (as was the case in this study) don’t necessarily have access to this information and have poorer ‘self-insight’ than those rating relative importance afterwards (10). Similarly, participants whose judgments are on representative sets of vignettes (rather than carefully designed sets as here) also show better self-insight (8). Secondly, there are intra and inter- individual differences in how information is used. Group analyses may not capture the information use of any individual, but summarising across vignettes on which different cues have been used is also likely to mislead: different heuristics may drive the decisions on different cases (11) and relative importance of a factor may thus vary from case to case (12). Whilst we congratulate the authors on interesting results and a multi-method approach, conclusions that unconscious processes are afoot, may be a little premature. 1. Escher M, Perneger TV, Chevrolet J-C. National questionnaire survey on what influences doctors' decisions about admission to intensive care. British Medical Journal 2004;329:425-30. 2. Engel JD, Wigton R, LaDuca A, Blacklow R. A Social Judgment Theory Perspective on Clinical Problem Solving. Evaluation and The Health Professions 1990;13:63-78. 3. Wigton RS. Applications of Judgment Analysis and Cognitive Feedback to Medicine. In Brehmer B, Joyce CRB, eds. Human Judgment: The SJT View., North-Holland: Elsevier Science Publishers B.V., 1988. 4. Wigton RS. Social Judgement Theory and Medical Judgement. Thinking and Reasoning 1996;2:175-90. 5. Harries C, Evans JStBT, Dennis I. Measuring Doctors' Self-Insight into their Treatment Decisions. Applied Cognitive Psychology 2000;14:455- 77. 6. Evans JStBT, Harries C, Dennis I, Dean J. General Practitioners' tacit and stated policies in the prescription of lipid lowering agents. British Journal of General Practice 1995;45:15-8. 7. Kirwan JR, Chaput de Saintonge DM, Joyce CRB, Holmes J, Currey HLF. Inability of rheumatologists to describe their true policies for assessing rheumatoid arthritis. Annals of the Rheumatic Diseases 1986;45:156-61. 8. Reilly BA,.Doherty ME. The Assessment of Self-Insight in Judgment Policies. Organizational Behavior and Human Decision Processes 1992;53:285 -309. 9. Shanks D,.StJohn M. Characteristics of dissociable human learning systems. Behavioral and Brain Sciences 1994;17:367-447. 10. Reilly BA,.Doherty ME. A Note on the Assessment of Self-Insight in Judgment Research. Organizational Behavior and Human Decision Processes 1989;44:123-31. 11. Dhami MK,.Harries C. Fast and frugal versus regression models of human judgement. Thinking and Reasoning 2001;7:5-27. 12. Harries C,.Harvey N. Taking advice, using information and knowing what you are doing. Acta Psychologica 2000;104:399-416. Competing interests: None declared |
|||
|
|
|||
|
Thomas V Perneger, Professor of health services evaluation Geneva University Hospitals
Send response to journal:
|
In planning this study, we had considered many more experimental factors than we could test. We renounced testing patient sex because: a) the main focus was on cancer versus non-cancerous disease as the
underlying health problem; for some of the most frequent cancers (breast,
prostate) the patient's sex is fixed.
Regarding the terms used in the paper and the identification of the patients' sex, any ambiguity exists only in English. The vignettes were written in French and German, and all used gendered terms: "patient"(M) or "patiente"(F), "Patient"(M) or "Patientin"(F). This also means that the study results are adjusted for the hypothetical patients' sex. Competing interests: Co-author of paper |
|||
|
|
|||
|
Thomas V Perneger, Professor of health services evaluation Geneva University Hospitals
Send response to journal:
|
Dr Harries provides a useful perspective on the psychological mechanisms that may explain some of our results. She notes that "a factor’s impact depends upon how much it varies across cases." Meaning, I suppose, that real life variability (say, in the proportions of cheerful and gloomy patients) may be less than the 50/50 used in the experimental design. That would be correct. However, we did not ask respondents about the (quantitative) importance of a given factor in the paptient population they see, but about the (qualitative) importance of a given factor when deciding whether to admit or not a given individual. So if doctors say in essence "no, we do not use the patient's emotional state when deciding on an admission", but the vignette analysis suggests they do (as a group), I do not think that factor variability can explain this. Dr Harries also warns against inferring too much from grouped analyses to individual decisions. Agreed. The grouped analysis might point to potential problems or issues that may require consideration by the profession or by society at large, but will not necessarily help in deciding about the best care for Mr A or Mrs X. Competing interests: Co-author of the paper |
|||
|
|
|||
|
Alberto Giannini, intensivist Intensive Care Unit, Istituti Clinici di Perfezionamento - Via della Commenda, 9 20122 Milano, Italy
Send response to journal:
|
Dear Sir, the decision to admit a patient to the intensive care unit (ICU) is only one link in a chain of events [1], and nowadays we are inclined to think that the decision process regarding admission to ICU is frequently not a purely objective one based on medical suitability but is often influenced by non clinical factors. In the interesting article by Escher and co-workers [2] on the subject of the factors influencing doctors’ decisions to admit a patient to ICU, the authors consider a number of factors based on the literature and on their own experience. The list of factors considered is certainly wide, but it may be worth mentioning at least two further elements which have proved to exert some considerable influence on the choices of ICU doctors. The first is pressure in connection with economic factors: there are data suggesting that income maximization may sometimes influence bed allocation more than patient need [3]. The second element is pressure from colleagues: a Europe-wide survey [4] found that 78% of ICU physicians acknowleged that, although shortage of ICU beds is a common state of affairs, they admitted patients with only a limited chance of survival beyond a few days, and 64% admitted patients with no chance of survival. This behaviour was attributed in part to pressure from the patients’ primary care physicians [5]. Recent Italian data also show that ICU physicians consider their admission decisions may be influenced by pressure “from above” and by pressure from the referring clinician [6]. I believe it is crucial to continue to gather all data possible relating to ICU admission in order to obtain an overall “snapshot” of the situation, to gain a more precise picture of circumstances which are complex and variegated. This is an important starting point for improving the decision-making processes and therefore the allocation of ICU resources. Refrences: 1.Levin PD, Sprung CL. The process of intensive care triage. Intensive Care Med 2001;27:1441-1445 2.Escher M, Perneger TV, Chevrolet JC. National questionnaire survey on what influences doctors’ decisions about admission to intensive care. BMJ 2004;329: 3.Marshall MF, Schwenzer KJ, Orsina M et al. Influence of political power, medical provincialism, and economic incentives on the rationing of surgical intensive care unit beds. Crit Care Med 1992;20:387-394 4.Vincent JL. European attitudes towards ethical problems in intensive care medicine: results of an ethical questionnaire. Intensive Care Med 1990;16:256-264 5.Vincent JL. Ethical issues in critical care medicine: United States and European views and differences. Intensive Care World 1996;13:142-144 6.Giannini A, Sgamma D, Izzo F, Moneta A. Physicians perceptions of inappropriate admissions to intensive care units. Eur J Aneasthesiol 2004:21 (Suppl 32):A712 Competing interests: None declared |
|||