A little history for the non-US readers: the U.S. Preventive Services Task Force (USPSTF) is an independent panel that reviews evidence and issues recommendations for preventive health care services.  They are sponsored by the U.S. Agency for Healthcare Research and Quality (AHRQ) but the panelists are physicians, nurses, and public health researchers  employed by universities and state health departments.

From 1989-2002, annual screening mammography was recommended for women at low risk of breast cancer starting at age 50 in the US. In 2002, USPSTF changed that recommendation to recommend mammography every 1-2 years for women starting at age 40. This change was scientifically contentious – there were questions about the data – but endorsed by cancer organizations. This month, USPSTF changed the recommendation back to starting at age 50. You can read the published recommendation here. This change is less scientifically contentious, but has been even more upsetting to cancer organizations and, in many cases, to women.

I’m going to tackle just a few of the key decision making questions here to try to clarify what’s going on. For example, I’m going to set aside questions of cost and of insurance coverage, which are significant issues, to focus only on the health questions, and only on women at low risk for breast cancer.
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The 2008 annual meetings of the Society for Judgment and Decision Making (SJDM) and the Society for Medical Decision Making (SMDM) included a “symposium exchange”. A symposium by SJDM members was presented at SMDM 2008 (Pennsylvania, PA) and a symposium by SMDM members was presented at SJDM 2008 (Chicago, IL). At least one of the talks reported on a study of behavioral economics for weight loss that has recently received considerable media attention.

Videorecordings of the symposia are now available. You can find links at http://www.sjdm.org/content/video-recordings-2008-sjdmsmdm-symposia

I’m writing from Philadelphia, at the annual meeting of the Society for Medical Decision Making. I’ve just had the pleasure of attending a great short course entitled “How to discuss evidence-based diagnosis with experienced clinicians (and avoid giving EBM at bad name)”, taught by Tom Newman and Mike Kohn from UCSF.

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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.

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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One major strategy for managing uncertainty is seeking additional information about the likelihood of outcomes. New information may enable a patient to reduce their uncertainty directly, as when new research studies provide more insight into patient outcomes and suggest increase the likelihood that a particular treatment will or will not be beneficial. Even when new information does not yield greater certainty about outcomes, however, it may serve to narrow the range of the uncertainty.

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