A strange commentary in the Washington Times this week entitled “‘Evidence-based’ Rx miscues” makes claims about evidence-based medicine (EBM): both what the terms means and what it implies for health policy. The author suggests that EBM is equivalent to “one-size-fits-all” medicine that removes physician autonomy in pursuit of a “political imperative to cut costs - not the medical imperative to give patients the best care possible.”

Dr. Roy Poses, a well-respected physician who has done a lot of work studying physician probability judgment (one example of which is mentioned in Chapter 7 of Medical Decision Making) has posted a rebuttal on the Health Care Renewal blog. Dr. Poses demolishes the misrepresentation of EBM that appears in the original article (as well as asking some on-point questions about the author’s interests in the matter), and does it quite effectively, so I won’t repeat his criticism here. Instead, I’ll focus on some other misunderstandings in the original commentary: that cutting health care costs is at odds with the medical imperative to improve care, that patients are so biologically unique that studies of patient groups has little value, and that EBM reduces physician autonomy.

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“Buy on apples, sell on cheese” is an old proverb among wine merchants. Taking a bite of an apple before tasting wine makes it easier to detect flaws in the wine, and the buyer who does so will not as easily make the mistake of paying more than the wine is worth. Cheese, on the other hand, pairs well with wine and enhances its flavor, so a seller who offers cheese may command a higher price for the wine (and may even deserve it, if the wine is intended to be drunk with cheese).

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A bit of synchronicity strikes, as I come across two different pieces from quite different sources on the question of “even if we have a test that provides probabilities of future health states, do we really want to know?”

The first is journalistic. National Public Radio’s program Talk of the Nation did a segment on a new blood test that can diagnose early stages of Alzheimer’s diease.

The second is literary, as the science fiction podcast Escape Pod presented the story Results by Kristine Kathryn Rusch, originally written in 2000.

Very different formats, very similar ideas about patient-focused decision making. Each is well worth a listen.

The November 2007 issue of Consumer Reports features an article entitled “Treatment traps to avoid.” The article focuses on unnecessary and overused health care treatments (in the United States). One major emphasis of the report is the emphasis on the approval of new drugs and the marketing process for drugs in the U.S. in general, which includes both substantial direct-to-consumer marketing (illegal everywhere else in the world except for New Zealand), and extensive marketing to physicians — for both on-label and off-label uses — by means of gifts, samples, meals, and reprints of research sponsored by the manufacturers. Research frequently establishes a drug’s efficacy vs. placebo, but more rarely compares new drugs with the established standard of care and demonstrates incremental effectiveness, much less incremental cost-effectiveness.

As a result of a $430 million settlement between drug manufacturer Warner-Lambert and the U.S. government, several projects have been funded to study and address issues in the marketing of pharmaceuticals. One such project, Formulary Leveraged Improved Prescribing (FLIP) is centered across the street from my office, and is a joint effort between the University of Illinois at Chicago and the John H. Stroger, Jr., Hospital of Cook County.

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The 29th annual meeting of the Society for Medical Decision Making (SMDM) will be held in Pittsburgh, Pennsylvania, USA on October 24-27, 2007. All the relevant detail can be found at http://www.smdm.org.

This is the meeting to attend if you’re interested in medical decision science; presentations typically focus on clinical applications, methodological advances in decision and cost-effectiveness analysis, psychology of medical decision making, and other key topics in clinical and health policy decision science. There are also excellent short courses in the days before the meeting, providing education on MDM topics at a variety of levels (including a course on problem solving for medical educators by George, Frank Kee, and I).

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Our book approaches medical decision making primarily from the standpoint of the community of clinicians, behavior scientists, and theorists who focus on the question of “how should decisions be made in order to provide the patient with the greatest health benefit?” Another group of thinkers, including clinicians, philosophers, lawyers, and patient advocates, have asked an equally important question: “how should decisions be made in order to preserve the ethical values that mean most to us as individuals and societies?” Read the rest of this entry »

In many clinical decisions, the most ready source of additional information is diagnostic testing. Diagnostic tests include not only laboratory tests, but other sources of information about diagnosis, such as history and physical examination. Patients (and indeed, many physicians), however, do not understand how diagnostic tests are developed or how to determine the value of the information they provide.

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When I was taking my qualifying examinations for my Ph.D. in Psychology, one of my examiners asked me to address what he called the “moon question”: “If human beings are so dumb (according to decision psychology), how did we get to the moon?” The answer, of course, is that despite the predilection in cognitive psychology for inducing and examining error (because error usually provides powerful tests of process models of human behavior), most people are pretty good thinkers most of the time, and some people are very good thinkers most of the time.

Atul Gawande’s excellent 2002 collection Complications: A Surgeon’s Notes on an Imperfect Science struck a responsive chord with medical decision scientists with its insightful examination of medical error. Gawande has now collected 11 new essays in Better: A Surgeon’s Notes on Performance (Metropolitan Books, 2007), which shift the focus to how some physicians come to excel in their craft (in his terms, becoming “positive deviants”). He asks “what does it take to become good at something in which failure is so easy, so effortless?”

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Subjective confidence is usually thought of as the degree to which a person believes they are correct about a judgment and are willing to say so. Confidence can be important when there is no objective guide to accuracy; in these cases, decision makers will usually prefer to make the judgment in which they have the greatest confidence; confidence can drive further behaviors (Weber, Böckenholt et al. 2000). Accordingly, there has been some concern that decision makers have appropriate levels of confidence in their judgments.

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A major problem in all preference or utility assessment, particularly holistic assessments that require the visualization of a health state in its entirety, is that people must often be asked to assess their preferences for health states that they have not yet experienced. That is, they must predict how they will feel about future health states that may arise as a result of their decisions.

Unfortunately, people are generally poor predictors of future experiences for several reasons.

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