Hancock, Helen C; Durham, Lesley
As the extension of nursing into roles previously within the domain of medicine and the demand for evidence based practice continue to increase, the quality of decision making becomes imperative. Making accurate decisions is essential, both for the practitioner and for the patient, especially in the provision of critical care outreach (CCOR), to improve outcomes of care. With changes in health care delivery and increased accountability for practitioners' decisions, it is important to understand more about how clinical decisions are made and what factors influence them in order to inform practice. The previous paper outlined the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In this paper, the authors, a Nurse Consultant in CCOR and a research fellow, examine the process of a practitioner's decision making in the practice of CCOR, through a collaborative reflective account of a case study. From this, recommendations are made about the future development of CCOR practitioners and services.
Reddy, L. Felice; Barch, Deanna M.; Buchanan, Robert W.; Dunayevich, Eduardo; Gold, James M.; Marder, Steven R.; Wynn, Jonathan K.; Young, Jared W.; Green, Michael F.
Effort-based decision making has strong conceptual links to the motivational disturbances that define a key subdomain of negative symptoms. However, the extent to which effort-based decision-making performance relates to negative symptoms, and other clinical and functionally important variables has yet to be systematically investigated. In 94 clinically stable outpatients with schizophrenia, we examined the external validity of 5 effort-based paradigms, including the Effort Expenditure for Rewards, Balloon Effort, Grip Strength Effort, Deck Choice Effort, and Perceptual Effort tasks. These tasks covered 3 types of effort: physical, cognitive, and perceptual. Correlations between effort related performance and 6 classes of variables were examined, including: (1) negative symptoms, (2) clinically rated motivation and community role functioning, (3) self-reported motivational traits, (4) neurocognition, (5) other psychiatric symptoms and clinical/demographic characteristics, and (6) subjective valuation of monetary rewards. Effort paradigms showed small to medium relationships to clinical ratings of negative symptoms, motivation, and functioning, with the pattern more consistent for some measures than others. They also showed small to medium relations with neurocognitive functioning, but were generally unrelated to other psychiatric symptoms, self-reported traits, antipsychotic medications, side effects, and subjective valuation of money. There were relatively strong interrelationships among the effort measures. In conjunction with findings from a companion psychometric article, all the paradigms warrant further consideration and development, and 2 show the strongest potential for clinical trial use at this juncture. PMID:26209546
Horan, William P; Reddy, L Felice; Barch, Deanna M; Buchanan, Robert W; Dunayevich, Eduardo; Gold, James M; Marder, Steven R; Wynn, Jonathan K; Young, Jared W; Green, Michael F
Effort-based decision making has strong conceptual links to the motivational disturbances that define a key subdomain of negative symptoms. However, the extent to which effort-based decision-making performance relates to negative symptoms, and other clinical and functionally important variables has yet to be systematically investigated. In 94 clinically stable outpatients with schizophrenia, we examined the external validity of 5 effort-based paradigms, including the Effort Expenditure for Rewards, Balloon Effort, Grip Strength Effort, Deck Choice Effort, and Perceptual Effort tasks. These tasks covered 3 types of effort: physical, cognitive, and perceptual. Correlations between effort related performance and 6 classes of variables were examined, including: (1) negative symptoms, (2) clinically rated motivation and community role functioning, (3) self-reported motivational traits, (4) neurocognition, (5) other psychiatric symptoms and clinical/demographic characteristics, and (6) subjective valuation of monetary rewards. Effort paradigms showed small to medium relationships to clinical ratings of negative symptoms, motivation, and functioning, with the pattern more consistent for some measures than others. They also showed small to medium relations with neurocognitive functioning, but were generally unrelated to other psychiatric symptoms, self-reported traits, antipsychotic medications, side effects, and subjective valuation of money. There were relatively strong interrelationships among the effort measures. In conjunction with findings from a companion psychometric article, all the paradigms warrant further consideration and development, and 2 show the strongest potential for clinical trial use at this juncture.
Boney, Jo; Baker, Jacqueline D.
Research and a literature review suggest that nurses lack skills for effective clinical decision making. An educational program that facilitated development of critical thinking focused on four qualities: determining accuracy of information, determining bias, identifying inconsistencies in reasoning, and evaluating the strength of an argument. (SK)
Seright, Teresa J.
The purpose of this study was to develop substantive theory regarding decision making by the novice nurse in a rural hospital setting. Interviews were guided by the following research questions: What cues were used by novice rural registered nurses in order to make clinical decisions? What were the sources of feedback which influenced subsequent…
Banerjee, A.; Jadhav, S. L.; Bhawalkar, J. S.
Few clinicians grasp the true concept of probability expressed in the ‘P value.’ For most, a statistically significant P value is the end of the search for truth. In fact, the opposite is the case. The present paper attempts to put the P value in proper perspective by explaining different types of probabilities, their role in clinical decision making, medical research and hypothesis testing. PMID:21234167
I have attempted to use Feinstein's model of clinimetric indexes and his criteria as a focus for further development of measures that in physical therapy are currently considered "soft" or "subjective". I feel this development will enhance the body of knowledge by objectifying a portion of clinical assessment (eg, the patient's complaints, "subjective" portion of the POMR's SOAP format) that is in tremendous need of quantification. By making these "soft" data "hard," I feel we will enhance the decision-making power of clinicians.
Walker, Paul; Lovat, Terry
This paper is predicated on the understanding that clinical encounters between clinicians and patients should be seen primarily as inter-relations among persons and, as such, are necessarily moral encounters. It aims to relocate the discussion to be had in challenging medical decision-making situations, including, for example, as the end of life comes into view, onto a more robust moral philosophical footing than is currently commonplace. In our contemporary era, those making moral decisions must be cognizant of the existence of perspectives other than their own, and be attuned to the demands of inter-subjectivity. Applicable to clinical practice, we propose and justify a Habermasian approach as one useful means of achieving what can be described as dialogic consensus. The Habermasian approach builds around, first, his discourse theory of morality as universalizable to all and, second, communicative action as a cooperative search for truth. It is a concrete way to ground the discourse which must be held in complex medical decision-making situations, in its actual reality. Considerations about the theoretical underpinnings of the application of dialogic consensus to clinical practice, and potential difficulties, are explored.
Nurses' clinical decision-making is a complex process that holds potential to influence the quality of care provided and patient outcomes. The evolution of nurses' decision-making that occurs with experience has been well documented. In addition, literature includes numerous strategies and approaches purported to support development of nurses' clinical decision-making. There has been, however, significantly less attention given to the process of assessing nurses' clinical decision-making and novice clinical educators are often challenged with knowing how to best support nurses and nursing students in developing their clinical decision-making capacity. The Situated Clinical Decision-Making framework is presented for use by clinical educators: it provides a structured approach to analyzing nursing students' and novice nurses' decision-making in clinical nursing practice, assists educators in identifying specific issues within nurses' clinical decision-making, and guides selection of relevant strategies to support development of clinical decision-making. A series of questions is offered as a guide for clinical educators when assessing nurses' clinical decision-making. The discussion presents key considerations related to analysis of various decision-making components, including common sources of challenge and errors that may occur within nurses' clinical decision-making. An exemplar illustrates use of the framework and guiding questions. Implications of this approach for selection of strategies that support development of clinical decision-making are highlighted.
Ten Cate, Olle; Hart, Danielle; Ankel, Felix; Busari, Jamiu; Englander, Robert; Glasgow, Nicholas; Holmboe, Eric; Iobst, William; Lovell, Elise; Snell, Linda S; Touchie, Claire; Van Melle, Elaine; Wycliffe-Jones, Keith
The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis.Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article.The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.
Medicine is incorporating genetic services into all avenues of health-care, ranging from the rarest to the most common diseases. Cognitive theories of decision-making still dominate professionals' understanding of patient decision-making about how to use genetic information and whether to have testing. I discovered a conceptual model of decision-making while carrying out a phenomenological-hermeneutic descriptive study of a convenience sample of 12 couples who were interviewed while deciding whether to undergo prenatal genetic testing. Thirty-two interviews were conducted with 12 men and 12 women separately. Interviews were transcribed verbatim and all data were analyzed using three levels of coding that were sorted into 30 categories and then abstracted into three emergent meta-themes that described men's and women's attempts to make sense and find meaning in how to best use prenatal genetic technology. Their descriptions of how they thought about, communicated, and coped with their decision were so detailed it was possible to discern nine different types of thinking they engaged in while deciding to accept or decline testing. They believed that decision-making is a process of working through your own personal style of thinking. This might include only one or any combination of the following types of thinking: analytical, ethical, moral, reflective, practical, hypothetical, judgmental, scary, and second sight, as described in detail by these 12 couples.
Snethen, Julia A; Broome, Marion E; Knafl, Kathleen; Deatrick, Janet A; Angst, Denise B
The decision-making process related to a child's participation in clinical trials often involves multiple family members. The aim of this study was to compare family patterns of decision-making within and across family units in pediatric clinical trials. Participants for this secondary analysis included 14 families from a larger study of informed consent. Four distinct patterns of decision-making were identified: Exclusionary, informative, collaborative, and delegated. These patterns varied with regard to three dimensions of parents' decision-making goals, child level of involvement, and the parental role. These patterns of decision-making affect how parents and children communicate with health professionals and influence the effectiveness of health care providers interactions with the family related to the decision-making process.
Leist, James C.; Konen, Joseph C.
Four factors of clinical decision making identified by medical students include quality of care, cost, ethics, and legal concerns. This paper argues that physicians have two responsibilities in the clinical decision-making model: to be the primary advocate for quality health care and to ensure balance among the four factors, working in partnership…
Rashotte, Judy; Carnevale, F A
The aim of this article is to explore the complex forms of knowledge involved in diagnostic and interventional decision making by comparing the processes in medicine and nursing, including nurse practitioners. Many authors assert that the practice of clinical decision making involves the application of theoretical knowledge (acquired in the classroom and textbooks) as well as research evidence, upon concrete particular cases. This approach draws on various universal principles and algorithms to facilitate the task. On the other hand, others argue that this involves an intuitive form of judgement that is difficult to teach, one that is acquired principally through experience. In an exploration of these issues, this article consists of three sections. A clarification of terms commonly used when discussing decision making is provided in the first section. In the second section, an epistemological analysis of decision making is presented by examining several perspectives and comparing them for their use in the nursing and medical literature. Bunge's epistemological framework for decision making (based on scientific realism) is explored for its fit with the aims of medicine and nursing. The final section presents a discussion of knowledge utilization and decision making as it relates to the implications for the education and ongoing development of nurse practitioners. It is concluded that Donald Schön's conception of reflective practice best characterizes the skillful conduct of clinical decision making.
Jahanpour, Faezeh; Sharif, Farkhondeh; Salsali, Mahvash; Kaveh, Mohammad H; Williams, Leonie M
Clinical decision-making is the basis for professional nursing practice. This can be taught and learned through appropriate teaching and clinical experiences. Unfortunately, it has been observed that many graduates are unable to demonstrate suitable clinical decision-making skills. Research and study on the process of decision-making and factors influencing it assists educators to find the appropriate educational and clinical strategies to teach nursing students. To explore the experience of nursing students and their view points regarding the factors influencing their development of clinical decision-making skills. An exploratory qualitative approach utilizing grounded theory methods was used; focus group interviews were undertaken with 32 fourth year nursing students and data were analysed using constant comparative analysis. Four main themes emerged from the data: clinical instructor incompetency, low self-efficacy, unconducive clinical learning climate and experiencing stress. The data indicated that students could not make clinical decisions independently. The findings of this study support the need to reform aspects of the curriculum in Iran in order to increase theory-practice integration and prepare a conductive clinical learning climate that enhances learning clinical decision-making with less stress.
Dunphy, Bruce C.; Cantwell, Robert; Bourke, Sid; Fleming, Mark; Smith, Bruce; Joseph, K. S.; Dunphy, Stacey L
Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for…
Trimble, Michael; Hamilton, Paul
Diagnostic errors are responsible for a significant number of adverse events. Logical reasoning and good decision-making skills are key factors in reducing such errors, but little emphasis has traditionally been placed on how these thought processes occur, and how errors could be minimised. In this article, we explore key cognitive ideas that underpin clinical decision making and suggest that by employing some simple strategies, physicians might be better able to understand how they make decisions and how the process might be optimised.
Berger, Jeffrey T; DeRenzo, Evan G; Schwartz, Jack
The care of adult patients without decision-making abilities is a routine part of medical practice. Decisions for these patients are typically made by surrogates according to a process governed by a hierarchy of 3 distinct decision-making standards: patients' known wishes, substituted judgments, and best interests. Although this framework offers some guidance, it does not readily incorporate many important considerations of patients and families and does not account for the ways in which many patients and surrogates prefer to make decisions. In this article, the authors review the research on surrogate decision making, compare it with normative standards, and offer ways in which the 2 can be reconciled for the patient's benefit.
Grembowski, David; And Others
Senior dental students and family dental practitioners were surveyed concerning their choice of pairs of alternative treatments and the technical and patient factors influencing their decisions. Greater agreement in clinical decision-making was found among dentists than among students for all four pairs of alternative services. (MSE)
Higuchi, Kathryn A. Smith; Donald, Janet G.
Interviews with eight medical and surgical nurses and audits of patient charts investigated clinical decision-making processes. Predominant thinking processes were description of facts, selection of information, inference, syntheses, and verification, with differences between medical and surgical specialties. Exemplars of thinking processes…
Marcum, James A
What role, if any, should emotions play in clinical reasoning and decision making? Traditionally, emotions have been excluded from clinical reasoning and decision making, but with recent advances in cognitive neuropsychology they are now considered an important component of them. Today, cognition is thought to be a set of complex processes relying on multiple types of intelligences. The role of mathematical logic (hypothetico-deductive thinking) or verbal linguistic intelligence in cognition, for example, is well documented and accepted; however, the role of emotional intelligence has received less attention-especially because its nature and function are not well understood. In this paper, I argue for the inclusion of emotions in clinical reasoning and decision making. To that end, developments in contemporary cognitive neuropsychology are initially examined and analyzed, followed by a review of the medical literature discussing the role of emotions in clinical practice. Next, a published clinical case is reconstructed and used to illustrate the recognition and regulation of emotions played during a series of clinical consultations, which resulted in a positive medical outcome. The paper's main thesis is that emotions, particularly in terms of emotional intelligence as a practical form of intelligence, afford clinical practitioners a robust cognitive resource for providing quality medical care.
Davis, Derik L; Morrison, James J
Pseudotumors are a complication of hip arthroplasty. The goal of this article is to review the clinical presentation, pathogenesis, histology, and the role of diagnostic imaging in clinical decision making for treatment, and surveillance of pseudotumors. We will discuss the multimodal imaging appearances, differential diagnosis, associated complications, treatment, and prognosis of pseudotumors, as an aid to the assessment of orthopedic prostheses at the hip. PMID:27195183
Sharif, Kamal Imran; Ibrahim, Jafni Azhan; Udin, Zulkifli Mohamed
Equipment breakdown due to unavailability of spare parts is really disastrous in plant maintenance. The failure increase the cost of repair and production downtime. Therefore, it is important to understand the maintenance and inventory function in order to ensure the plant operate accordingly. Moreover, it is necessary for the plant maintenance to balance the issue of shortage and excess of inventory in plant maintenance. In view of this situation, the spare parts become a critical matters and it is good starting point to tackle the issues from looking at the perspective of spare parts inventory risk. This paper describes the development of risk technique for plant maintenance decision making purposes using the Shortage and Excess Impact Table. It also used the Breakdown Probability Table to quantify the risk for the spare part failure.
Reddy, L. Felice; Horan, William P.; Barch, Deanna M.; Buchanan, Robert W.; Dunayevich, Eduardo; Gold, James M.; Lyons, Naomi; Marder, Stephen R.; Treadway, Michael T.; Wynn, Jonathan K.; Young, Jared W.; Green, Michael F.
Impairments in willingness to exert effort contribute to the motivational deficits characteristic of the negative symptoms of schizophrenia. The current study evaluated the psychometric properties of 5 new or adapted paradigms to determine their suitability for use in clinical trials of schizophrenia. This study included 94 clinically stable participants with schizophrenia and 40 healthy controls. The effort-based decision-making battery was administered twice to the schizophrenia group (baseline, 4-week retest) and once to the control group. The 5 paradigms included 1 that assesses cognitive effort, 1 perceptual effort, and 3 that assess physical effort. Each paradigm was evaluated on (1) patient vs healthy control group differences, (2) test-retest reliability, (3) utility as a repeated measure (ie, practice effects), and (4) tolerability. The 5 paradigms showed varying psychometric strengths and weaknesses. The Effort Expenditure for Rewards Task showed the best reliability and utility as a repeated measure, while the Grip Effort Task had significant patient-control group differences, and superior tolerability and administration duration. The other paradigms showed weaker psychometric characteristics in their current forms. These findings highlight challenges in adapting effort and motivation paradigms for use in clinical trials. PMID:26142081
Reddy, L Felice; Horan, William P; Barch, Deanna M; Buchanan, Robert W; Dunayevich, Eduardo; Gold, James M; Lyons, Naomi; Marder, Stephen R; Treadway, Michael T; Wynn, Jonathan K; Young, Jared W; Green, Michael F
Impairments in willingness to exert effort contribute to the motivational deficits characteristic of the negative symptoms of schizophrenia. The current study evaluated the psychometric properties of 5 new or adapted paradigms to determine their suitability for use in clinical trials of schizophrenia. This study included 94 clinically stable participants with schizophrenia and 40 healthy controls. The effort-based decision-making battery was administered twice to the schizophrenia group (baseline, 4-week retest) and once to the control group. The 5 paradigms included 1 that assesses cognitive effort, 1 perceptual effort, and 3 that assess physical effort. Each paradigm was evaluated on (1) patient vs healthy control group differences, (2) test-retest reliability, (3) utility as a repeated measure (ie, practice effects), and (4) tolerability. The 5 paradigms showed varying psychometric strengths and weaknesses. The Effort Expenditure for Rewards Task showed the best reliability and utility as a repeated measure, while the Grip Effort Task had significant patient-control group differences, and superior tolerability and administration duration. The other paradigms showed weaker psychometric characteristics in their current forms. These findings highlight challenges in adapting effort and motivation paradigms for use in clinical trials.
Pizzorno, Joseph E
As 21st century health care moves from a disease-based approach to a more patient-centric system that can address biochemical individuality to improve health and function, clinical decision making becomes more complex. Accentuating the problem is the lack of a clear standard for this more complex functional medicine approach. While there is relatively broad agreement in Western medicine for what constitutes competent assessment of disease and identification of related treatment approaches, the complex functional medicine model posits multiple and individualized diagnostic and therapeutic approaches, most or many of which have reasonable underlying science and principles, but which have not been rigorously tested in a research or clinical setting. This has led to non-rigorous thinking and sometimes to uncritical acceptance of both poorly documented diagnostic procedures and ineffective therapies, resulting in less than optimal clinical care.
It is clear that current government policy places increasing emphasis on the need for flexible team working. This requires a shared understanding of roles and working practices. However, review of the current literature reveals that such a collaborative working environment has not as yet, been fully achieved. Role definitions and power bases based on traditional and historical boundaries continue to exist. This ethnographic study explores decision making between doctors and nurses in the intensive care environment in order to examine contemporary clinical roles in this clinical specialty. Three intensive care units were selected as field sites and data was collected through participant observation, ethnographic interviews and documentation. A key issue arising in this study is that whilst the nursing role in intensive care has changed, this has had little impact on how clinical decisions are made. Both medical and nursing staff identify conflict during patient management discussions. However, it is predominantly nurses who seek to redress this conflict area through developing specific behaviours for this clinical forum. Using this approach to resolve such team issues has grave implications if the government vision of interdisciplinary team working is to be realised.
Cornuz, Jacques; Junod, Noëlle; Pasche, Olivier; Guessous, Idris
Shared decision-making approach to uncertain clinical situations such as cancer screening seems more appropriate than ever. Shared decision making can be defined as an interactive process where physician and patient share all the stages of the decision making process. For patients who wish to be implicated in the management of their health conditions, physicians might express difficulty to do so. Use of patient decision aids appears to improve such process of shared decision making.
Zurakowski, David; Johnson, Victor M; Lee, Edward Y
Cardiothoracic radiologists are intuitively aware of sensitivity and specificity as they pertain to diagnostic tests involving clinical information. However, many cardiothoracic radiologists are unfamiliar with odds ratios, likelihood ratios, predictive values, and receiver operating characteristic (ROC) curves, which provide more information about the performance of a test. Our article will first review the fundamental concepts of sensitivity, specificity, predictive values, and likelihood ratios. The ROC curve methodology will be covered with an emphasis on creating a look-up table, a straightforward table that communicates important information to the clinician to aid in diagnosis. The article reviews sensitivity and specificity, as well as predictive values, logistic regression, and ROC curves, using conceptual principles without unnecessary mathematical rigor. We will apply principles of sensitivity and specificity to continuous measurements by constructing ROC curves in order to tie together key ideas in diagnostic decision making. Three clinical examples are presented to illustrate these fundamental statistical concepts: predictors of pulmonary embolism in children, use of dobutamine-cardiac magnetic resonance imaging to identify impaired ventricular function in patients who have suffered a myocardial infarction, and diagnostic accuracy of 64-multidetector row computed tomography to identify occluded vessels in adult patients with suspected coronary artery disease. In addition, a glossary is provided at the end of the article with key terms important in diagnostic imaging. An understanding of the concepts presented will assist cardiothoracic radiologists in critically discerning the usefulness of diagnostic tests and how these statistics can be applied to make judgments and decisions that are essential to clinical practice.
The decision making process is central to the practice of a clinician and has traditionally been described in terms of the hypothetico-deductive model. More recently, models adapted from cognitive psychology, such as the dual process and script theories have proved useful in explaining patterns of practice not consistent with purely cognitive…
Chen, Lu-Yen A; Fawcett, Tonks N
Several data-mining models have been embedded in the clinical environment to improve decision making and patient safety. Consequently, it is crucial to survey the principal data-mining strategies currently used in clinical decision making and to determine the disadvantages and advantages of using these strategies in data mining in clinical decision making. A literature review was conducted, which identified 21 relevant articles. The article findings showed that multiple models of data mining were used in clinical decision making. Although data mining is efficient and accurate, the models are limited with respect to disease and condition.
Narra, Lekha; Sahama, Tony; Stapleton, Peta
Large volumes of heterogeneous health data silos pose a big challenge when exploring for information to allow for evidence based decision making and ensuring quality outcomes. In this paper, we present a proof of concept for adopting data warehousing technology to aggregate and analyse disparate health data in order to understand the impact various lifestyle factors on obesity. We present a practical model for data warehousing with detailed explanation which can be adopted similarly for studying various other health issues.
Hudson, Donna L.; Estrin, Thelma
A computerized rule-based expert system for chest pain analysis in the emergency room has been developed as a medical decision-making tool. The rules are based on a previously established criteria mapping procedure developed for evaluating emergency room decisions. The system is implemented in PASCAL, a standardized language, and hence is machine-independent, and also has modest memory requirements. The overall design permits usage by those unfamiliar with computers.
Hruska, Pam; Hecker, Kent G.; Coderre, Sylvain; McLaughlin, Kevin; Cortese, Filomeno; Doig, Christopher; Beran, Tanya; Wright, Bruce; Krigolson, Olav
Clinical decision making requires knowledge, experience and analytical/non-analytical types of decision processes. As clinicians progress from novice to expert, research indicates decision-making becomes less reliant on foundational biomedical knowledge and more on previous experience. In this study, we investigated how knowledge and experience…
Krumwiede, Kelly A.
Developing decision-making skills is essential in education in order to be a competent nurse. The purpose of this study was to examine and compare the perceptions of clinical decision-making skills of students enrolled in accelerated and basic baccalaureate nursing programs. A comparative descriptive research design was used for this study.…
Deldar, Kolsoum; Bahaadinbeigy, Kambiz; Tara, Seyed Mahmood
Background: The goal of teleconsultation is to omit geographical and functional distance between two or more geographically separated health care providers. The purpose of present study is to review and analyze physician-physician teleconsultations. Method: The PubMed electronic database was searched. The primary search was done on January 2015 and was updated on December 2015. A fetch and tag plan was designed by the researchers using an online Zotero library. Results: 174 full-text articles of 1702 records met inclusion criteria. Teleconsultation for pediatric patients accounts for 14.36 percent of accepted articles. Surgery and general medicine were the most prevalent medical fields in the adults and pediatrics, respectively. Most teleconsultations were inland experiences (no=135), and the USA, Italy and Australia were the three top countries in this group. Non-specialists health care providers/centers were the dominant group who requested teleconsultation (no=130). Real time, store and forward, and hybrid technologies were used in 50, 31, and 16.7 percent of articles, respectively. The teleconsultation were reported to result in change in treatment plan, referral or evacuation rate, change in diagnosis, educational effects, and rapid decision making. Use of structured or semi-structured template had been noticed only in a very few articles. Conclusion: The present study focused on the recent ten years of published articles on physician-physician teleconsultations. Our findings showed that although there are positive impacts of teleconsultation as improving patient management, still have gaps that need to be repaired. PMID:27708494
Rolland, John S; Emanuel, Linda L; Torke, Alexia M
When patients are incapacitated and face serious illness, family members must make medical decisions for the patient. Medical decision sciences give only modest attention to the relationships among patients and their family members, including impact that these relationships have on the decision-making process. A review of the literature reveals little effort to systematically apply a theoretical framework to the role of family interactions in proxy decision making. A family systems perspective can provide a useful lens through which to understand the dynamics of proxy decision making. This article considers the mutual impact of family systems on the processes and outcomes of proxy decision making. The article first reviews medical decision science's evolution and focus on proxy decision making and then reviews a family systems approach, giving particular attention to Rolland's Family Systems Illness Model. A case illustrates how clinical practice and how research would benefit from bringing family systems thinking to proxy decisions. We recommend including a family systems approach in medical decision science research and clinical practices around proxy decisions making. We propose that clinical decisions could be less conflicted and less emotionally troubling for families and clinicians if family systems approaches were included. This perspective opens new directions for research and novel approaches to clinical care. (PsycINFO Database Record
Context: Highly developed critical thinking and the ability to discriminate among many possible therapeutic interventions is a core behavior for the practicing athletic trainer. However, while athletic training students receive a great deal of clinically applicable information, many are not explicitly trained in efficient methods for channeling…
Muir-Cochrane, Eimear; Gerace, Adam; Mosel, Krista; O'Kane, Debra; Barkway, Patricia; Curren, David; Oster, Candice
Risk assessment and management is a major component of contemporary mental health practice. Risk assessment in health care exists within contemporary perspectives of management and risk aversive practices in health care. This has led to much discussion about the best approach to assessing possible risks posed by people with mental health problems. In addition, researchers and commentators have expressed concern that clinical practice is being dominated by managerial models of risk management at the expense of meeting the patient's health and social care needs. The purpose of the present study is to investigate the risk assessment practices of a multidisciplinary mental health service. Findings indicate that mental health professionals draw on both managerial and therapeutic approaches to risk management, integrating these approaches into their clinical practice. Rather than being dominated by managerial concerns regarding risk, the participants demonstrate professional autonomy and concern for the needs of their clients.
... 44 Emergency Management and Assistance 1 2012-10-01 2011-10-01 true Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY GENERAL FLOODPLAIN MANAGEMENT AND PROTECTION OF WETLANDS Pt....
... 44 Emergency Management and Assistance 1 2011-10-01 2011-10-01 false Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY GENERAL FLOODPLAIN MANAGEMENT AND PROTECTION OF WETLANDS Pt....
... 44 Emergency Management and Assistance 1 2014-10-01 2014-10-01 false Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY GENERAL FLOODPLAIN MANAGEMENT AND PROTECTION OF WETLANDS Pt....
... 44 Emergency Management and Assistance 1 2010-10-01 2010-10-01 false Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY GENERAL FLOODPLAIN MANAGEMENT AND PROTECTION OF WETLANDS Pt....
... 44 Emergency Management and Assistance 1 2013-10-01 2013-10-01 false Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY GENERAL FLOODPLAIN MANAGEMENT AND PROTECTION OF WETLANDS Pt....
Légaré, France; Witteman, Holly O
For many patients, the time spent meeting with their physician-the clinical encounter-is the most opportune moment for them to become engaged in their own health through the process of shared decision making. In the United States shared decision making is being promoted for its potential to improve the health of populations and individual patients, while also helping control care costs. In this overview we describe the three essential elements of shared decision making: recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence; and incorporating the patient's values and preferences into the decision. To achieve the promise of shared decision making, more physicians need training in the approach, and more practices need to be reorganized around the principles of patient engagement. Additional research is also needed to identify the interventions that are most effective.
Teran, Felipe; Harper-Kirksey, Katrina; Jagoda, Andy
Seizures and status epilepticus are frequent neurologic emergencies in the emergency department, accounting for 1% of all emergency department visits. The management of this time-sensitive and potentially life-threatening condition is challenging for both prehospital providers and emergency clinicians. The approach to seizing patients begins with differentiating seizure activity from mimics and follows with identifying potential secondary etiologies, such as alcohol-related seizures. The approach to the patient in status epilepticus and the patient with nonconvulsive status epilepticus constitutes a special clinical challenge. This review summarizes the best available evidence and recommendations regarding diagnosis and resuscitation of the seizing patient in the emergency setting.
Clinical intuition is a common experience among counselors, yet many do not know what to do with intuition when it occurs. This article reviews the role intuition plays in clinical work and presents the research-based Clinical Intuition Exploration Guide to help counselors navigate the decision-making process. The guide consists of self-reflection…
Chipchase, S Y; Chapman, H R; Bretherton, R
Aims To develop a measure of dentists' anxiety in clinical situations; to establish if dentists' anxiety in clinical situations affected their self-reported clinical decision-making; to establish if occupational stress, as demonstrated by burnout, is associated with anxiety in clinical situations and clinical decision-making; and to explore the relationship between decision-making style and the clinical decisions which are influenced by anxiety.Design Cross-sectional study.Setting Primary Dental Care.Subjects and methods A questionnaire battery [Maslach Burnout Inventory, measuring burnout; Melbourne Decision Making Questionnaire, measuring decision-making style; Dealing with Uncertainty Questionnaire (DUQ), measuring coping with diagnostic uncertainty; and a newly designed Dentists' Anxieties in Clinical Situations Scale, measuring dentists' anxiety (DACSS-R) and change of treatment (DACSS-C)] was distributed to dentists practicing in Nottinghamshire and Lincolnshire. Demographic data were collected and dentists gave examples of anxiety-provoking situations and their responses to them.Main outcome measure Respondents' self-reported anxiety in various clinical situations on a 11-point Likert Scale (DACSS-R) and self-reported changes in clinical procedures (Yes/No; DACSS-C). The DACSS was validated using multiple t-tests and a principal component analysis. Differences in DACSS-R ratings and burnout, decision-making and dealing with uncertainty were explored using Pearson correlations and multiple regression analysis. Qualitative data was subject to a thematic analysis.Results The DACSS-R revealed a four-factor structure and had high internal reliability (Cronbach's α = 0.94). Those with higher DACSS-R scores of anxiety were more likely to report changes in clinical procedures (DACSS-C scores). DACSS-R scores were associated with decision-making self-esteem and style as measured by the MDMQ and all burnout subscales, though not with scores on the DUQ scale
Hagbaghery, Mohsen Adib; Salsali, Mahvash; Ahmadi, Fazlolah
Background Nurses' practice takes place in a context of ongoing advances in research and technology. The dynamic and uncertain nature of health care environment requires nurses to be competent decision-makers in order to respond to clients' needs. Recently, the public and the government have criticized Iranian nurses because of poor quality of patient care. However nurses' views and experiences on factors that affect their clinical function and clinical decision-making have rarely been studied. Methods Grounded theory methodology was used to analyze the participants' lived experiences and their viewpoints regarding the factors affecting their clinical function and clinical decision-making. Semi-structured interviews and participant observation methods were used to gather the data. Thirty-eight participants were interviewed and twelve sessions of observation were carried out. Constant comparative analysis method was used to analyze the data. Results Five main themes emerged from the data. From the participants' points of view, "feeling competent", "being self-confident", "organizational structure", "nursing education", and "being supported" were considered as important factors in effective clinical decision-making. Conclusion As participants in this research implied, being competent and self-confident are the most important personal factors influencing nurses clinical decision-making. Also external factors such as organizational structure, access to supportive resources and nursing education have strengthening or inhibiting effects on the nurses' decisions. Individual nurses, professional associations, schools of nursing, nurse educators, organizations that employ nurses and government all have responsibility for developing and finding strategies that facilitate nurses' effective clinical decision-making. They are responsible for identifying barriers and enhancing factors within the organizational structure that facilitate nurses' clinical decision-making. PMID
Hagbaghery, Mohsen Adib; Salsali, Mahvash; Ahmadi, Fazlolah
BACKGROUND: Nurses' practice takes place in a context of ongoing advances in research and technology. The dynamic and uncertain nature of health care environment requires nurses to be competent decision-makers in order to respond to clients' needs. Recently, the public and the government have criticized Iranian nurses because of poor quality of patient care. However nurses' views and experiences on factors that affect their clinical function and clinical decision-making have rarely been studied. METHODS: Grounded theory methodology was used to analyze the participants' lived experiences and their viewpoints regarding the factors affecting their clinical function and clinical decision-making. Semi-structured interviews and participant observation methods were used to gather the data. Thirty-eight participants were interviewed and twelve sessions of observation were carried out. Constant comparative analysis method was used to analyze the data. RESULTS: Five main themes emerged from the data. From the participants' points of view, "feeling competent", "being self-confident", "organizational structure", "nursing education", and "being supported" were considered as important factors in effective clinical decision-making. CONCLUSION: As participants in this research implied, being competent and self-confident are the most important personal factors influencing nurses clinical decision-making. Also external factors such as organizational structure, access to supportive resources and nursing education have strengthening or inhibiting effects on the nurses' decisions. Individual nurses, professional associations, schools of nursing, nurse educators, organizations that employ nurses and government all have responsibility for developing and finding strategies that facilitate nurses' effective clinical decision-making. They are responsible for identifying barriers and enhancing factors within the organizational structure that facilitate nurses' clinical decision-making.
van Baalen, Sophie; Carusi, Annamaria; Sabroe, Ian; Kiely, David G
In recent years there has been growing attention to the epistemology of clinical decision-making, but most studies have taken the individual physicians as the central object of analysis. In this paper we argue that knowing in current medical practice has an inherently social character and that imaging plays a mediating role in these practices. We have analyzed clinical decision-making within a medical expert team involved in diagnosis and treatment of patients with pulmonary hypertension (PH), a rare disease requiring multidisciplinary team involvement in diagnosis and management. Within our field study, we conducted observations, interviews, video tasks, and a panel discussion. Decision-making in the PH clinic involves combining evidence from heterogeneous sources into a cohesive framing of a patient, in which interpretations of the different sources can be made consistent with each other. Because pieces of evidence are generated by people with different expertise and interpretation and adjustments take place in interaction between different experts, we argue that this process is socially distributed. Multidisciplinary team meetings are an important place where information is shared, discussed, interpreted, and adjusted, allowing for a collective way of seeing and a shared language to be developed. We demonstrate this with an example of image processing in the PH service, an instance in which knowledge is distributed over multiple people who play a crucial role in generating an evaluation of right heart function. Finally, we argue that images fulfill a mediating role in distributed knowing in 3 ways: first, as enablers or tools in acquiring information; second, as communication facilitators; and third, as pervasively framing the epistemic domain. With this study of clinical decision-making in diagnosis and treatment of PH, we have shown that clinical decision-making is highly social and mediated by technologies. The epistemology of clinical decision-making needs
Lutz, Wolfgang; Saunders, Stephen M.; Leon, Scott C.; Martinovich, Zoran; Kosfelder, Joachim; Schulte, Dietmar; Grawe, Klaus; Tholen, Sven
In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research…
Thomson, Oliver P; Petty, Nicola J; Moore, Ann P
There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim of this research was to construct an explanatory theory of the clinical decision-making and therapeutic approaches of experienced osteopaths in the UK. Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study. Purposive and theoretical sampling was used to select participants. Data was collected using semi-structured interviews which were audio-recorded and transcribed. As the study approached theoretical sufficiency, participants were observed and video-recorded during a patient appointment, which was followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data. Data analysis resulted in the construction of three qualitatively different therapeutic approaches which characterised participants and their clinical practice, termed; Treater, Communicator and Educator. Participants' therapeutic approach influenced their approach to clinical decision-making, the level of patient involvement, their interaction with patients, and therapeutic goals. Participants' overall conception of practice lay on a continuum ranging from technical rationality to professional artistry, and contributed to their therapeutic approach. A range of factors were identified which influenced participants' conception of practice. The findings indicate that there is variation in osteopaths' therapeutic approaches to practice and clinical decision-making, which are influenced by their overall conception of practice. This study provides the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths.
The assessment and management of wounds forms a large proportion of community nurses' workload, often requiring judgment and decision-making in complex, challenging and uncertain circumstances. The processes through which nurses form judgments and make decisions within this context are reviewed in this article against existing theories on these subjects. There is variability in wound assessment and management practice which may be attributed to uncertainties within the context, a lack of knowledge in appropriate treatment choices and the inability to correctly value the importance of the clinical information presented. Nurses may be required to draw on intuition to guide their judgments and decision-making by association with experience and expertise. In addition, a step-by-step analytical approach underpinned by an evidence base may be required to ensure accuracy in practice. Developing an understanding of the different theories of judgment and decision-making may facilitate nurses' abilities to reflect on their own decision tasks, thereby enhancing the care provided.
McCullough, Laurence B
The professional medical ethics model of decision making may be applied to decisions clinicians and patients make under the conditions of clinical uncertainty that exist when evidence is low or very low. This model uses the ethical concepts of medicine as a profession, the professional virtues of integrity and candor and the patient's virtue of prudence, the moral management of medical uncertainty, and trial of intervention. These features combine to justifiably constrain clinicians' and patients' autonomy with the goal of preventing nondeliberative decisions of patients and clinicians. To prevent biased recommendations by the clinician that promote such nondeliberative decisions, medically reasonable alternatives supported by low or very low evidence should be offered but not recommended. The professional medical ethics model of decision making aims to improve the quality of decisions by reducing the unacceptable variation that can result from nondeliberative decision making by patients and clinicians when evidence is low or very low.
McGovern, Amanda R.; Alexopoulos, George S.; Yuen, Genevieve S.; Morimoto, Sarah Shizuko; Gunning, Faith M.
Objective Impairment in reward processes has been found in individuals with depression and in the aging population. The purpose of this study was twofold: 1. To use an affective neuroscience probe to identify abnormalities in reward-related decision making in late-life depression. 2. To examine the relationship of reward-related decision making abnormalities in depressed, older adults to the clinical expression of apathy in depression. We hypothesized that relative to elderly, healthy subjects, depressed, elderly patients would exhibit impaired decision making and that apathetic, depressed patients would show greater impairment in decision making than non-apathetic, depressed patients. Methods We used the Iowa Gambling Task to examine reward-related decision making in 60 non-demented, elderly patients with non-psychotic major depression and 36 elderly, psychiatrically healthy participants. Apathy was quantified using the Apathy Evaluation Scale. Of those with major depression, 18 individuals reported clinically significant apathy whereas 42 participants did not have apathy. Results Older adults with depression and healthy comparison participants did not differ in their performance on the IGT. However, apathetic, depressed older adults adopted an advantageous strategy and selected cards from the conservative decks compared to non-apathetic, depressed older adults. Non-apathetic, depressed patients showed a failure to adopt a conservative strategy and persisted in making risky decisions throughout the task. Conclusions This study indicates that apathy in older, depressed adults is associated with a conservative response style on a behavioral probe of the systems involved in reward-related decision making. This conservative response style may be the result of reduced sensitivity to rewards in apathetic individuals. PMID:25306937
Bos-Touwen, Irene D.; Trappenburg, Jaap C. A.; van der Wulp, Ineke; Schuurmans, Marieke J.; de Wit, Niek J.
Background and aim Self-management support is an integral part of current chronic care guidelines. The success of self-management interventions varies between individual patients, suggesting a need for tailored self-management support. Understanding the role of patient factors in the current decision making of health professionals can support future tailoring of self-management interventions. The aim of this study is to identify the relative importance of patient factors in health professionals’ decision making regarding self-management support. Method A factorial survey was presented to primary care physicians and nurses. The survey consisted of clinical vignettes (case descriptions), in which 11 patient factors were systematically varied. Each care provider received a set of 12 vignettes. For each vignette, they decided whether they would give this patient self-management support and whether they expected this support to be successful. The associations between respondent decisions and patient factors were explored using ordered logit regression. Results The survey was completed by 60 general practitioners and 80 nurses. Self-management support was unlikely to be provided in a third of the vignettes. The most important patient factor in the decision to provide self-management support as well as in the expectation that self-management support would be successful was motivation, followed by patient-provider relationship and illness perception. Other factors, such as depression or anxiety, education level, self-efficacy and social support, had a small impact on decisions. Disease, disease severity, knowledge of disease, and age were relatively unimportant factors. Conclusion This is the first study to explore the relative importance of patient factors in decision making and the expectations regarding the provision of self-management support to chronic disease patients. By far, the most important factor considered was patient’s motivation; unmotivated patients
Williams, Robert L.; Romney, Crystal; Kano, Miria; Wright, Randy; Skipper, Betty; Getrich, Christina; Sussman, Andrew L.; Zyzanski, Stephen J.
Background and objectives Health care reform aims to increase evidence based, cost-conscious, and patient-centered care. Family medicine is seen as central to these aims in part due to evidence of lower cost, comparable quality care compared with other specialties. We sought evidence that senior medical students planning family medicine residency differ from peers entering other fields in decision-making patterns relevant to these health care reform aims. Methods We conducted a national, anonymous, internet-based survey of senior medical students. Students chose one of two equivalent management options for a set of patient vignettes based on preventive care, medication selection or initial chronic disease management scenarios, representing in turn, evidence-based care, cost-conscious care, and patient-centered care. We examined differences in student recommendations, comparing those planning to enter family medicine with all others using bivariate and weighted, multilevel, multivariable analyses. Results Among 4,656 surveys received from seniors at 84 participating medical schools, students entering family medicine were significantly more likely to recommend patient management options that were more cost-conscious (p=.01) and more patient-centered (p<.001). We did not find a significant difference between the student groups in recommendations for evidence-based care vignettes. Conclusions This study provides preliminary evidence suggesting that students planning to enter family practice may already have clinical decision-making patterns that support health care reform goals to a greater extent than their peers. If confirmed by additional studies, this could have implications for medical school admission and training processes. PMID:24915476
Hruska, Pam; Hecker, Kent G; Coderre, Sylvain; McLaughlin, Kevin; Cortese, Filomeno; Doig, Christopher; Beran, Tanya; Wright, Bruce; Krigolson, Olav
Clinical decision making requires knowledge, experience and analytical/non-analytical types of decision processes. As clinicians progress from novice to expert, research indicates decision-making becomes less reliant on foundational biomedical knowledge and more on previous experience. In this study, we investigated how knowledge and experience were reflected in terms of differences in neural areas of activation. Novice and expert clinicians diagnosed simple or complex (easy, hard) cases while functional magnetic resonance imaging (fMRI) data were collected. Our results highlight key differences in the neural areas activated in novices and experts during the clinical decision-making process. fMRI data were collected from ten second year medical students (novices) and ten practicing gastroenterologists (experts) while they diagnosed sixteen (eight easy and eight hard) clinical cases via multiple-choice questions. Behavioral data were collected for diagnostic accuracy (correct/incorrect diagnosis) and time taken to assign a clinical diagnosis. Two analyses were performed with the fMRI data. First, data from easy and hard cases were compared within respective groups (easy > hard, hard > easy). Second, neural differences between novices and experts (novice > expert, expert > novice) were assessed. Experts correctly diagnosed more cases than novices and made their diagnoses faster than novices on both easy and hard cases (all p's < 0.05). Time taken to diagnose hard cases took significantly longer for both novices and experts. While similar neural areas were activated in both novices and experts during the decision making process, we identified significant hemispheric activation differences between novice and expert clinicians when diagnosing hard clinical cases. Specifically, novice clinicians had greater activations in the left anterior temporal cortex and left ventral lateral prefrontal cortex whereas expert clinicians had greater activations in the right
Owen, Gareth S.; Freyenhagen, Fabian; Martin, Wayne; David, Anthony S.
Assessment of decision-making capacity (DMC) can be difficult in acquired brain injury (ABI) particularly with the syndrome of organic personality disorder (OPD) (the “frontal lobe syndrome”). Clinical neuroscience may help but there are challenges translating its constructs to the decision-making abilities considered relevant by law and ethics. An in-depth interview study of DMC in OPD was undertaken. Six patients were purposefully sampled and rich interview data were acquired for scrutiny using interpretative phenomenological analysis. Interview data revealed that awareness of deficit and thinking about psychological states can be present. However, the awareness of deficit may not be “online” and effectively integrated into decision-making. Without this online awareness of deficit the ability to appreciate or use and weigh information in the process of deciding some matters appeared absent. We argue that the decision-making abilities discussed are: (1) necessary for DMC, (2) threatened by ABI , and (3) assessable at interview. Some advice for practically incorporating these abilities within assessments of DMC in patients with OPD is outlined. PMID:26088818
Pai, Vinay M; Rodgers, Mary; Conroy, Richard; Luo, James; Zhou, Ruixia; Seto, Belinda
In April 2012, the National Institutes of Health organized a two-day workshop entitled 'Natural Language Processing: State of the Art, Future Directions and Applications for Enhancing Clinical Decision-Making' (NLP-CDS). This report is a summary of the discussions during the second day of the workshop. Collectively, the workshop presenters and participants emphasized the need for unstructured clinical notes to be included in the decision making workflow and the need for individualized longitudinal data tracking. The workshop also discussed the need to: (1) combine evidence-based literature and patient records with machine-learning and prediction models; (2) provide trusted and reproducible clinical advice; (3) prioritize evidence and test results; and (4) engage healthcare professionals, caregivers, and patients. The overall consensus of the NLP-CDS workshop was that there are promising opportunities for NLP and CDS to deliver cognitive support for healthcare professionals, caregivers, and patients.
Adibi, Shawn; Abidi, Shawn; Bebermeyer, Richard D
Lack of transparency in funded research can compromise clinical decision-making in an evidence-based practice. Transparency can be defined as full disclosure of all financial assistance and support to authors and investigators. There is a perception that ethical principles are eroding and that research data can be biased due to conflicts of interest. These research outcomes biased or not, are used for clinical decision-making in the evidence-based practice. One suggested solution to this common ethical dilemma is to continue the dialogue on transparency in research and to create oversight bodies which include representatives from business and industry, private practice, academia, and research. There is increasing evidence of the need for more ethics education at all levels.
Taylor, Helen J
Obtaining the patient's consent is usually a prerequisite of any clinical intervention. However, some cognitively impaired patients may not be able to give valid consent. Following years of consultation and legislative review, the Mental Capacity Act 2005 (MCA) provides a statutory framework of 'best interests' decision-making on behalf of incapacitated individuals. However, confusion over the meaning and application of the 'best interests' standard persists. This paper explores the variation in judicial interpretation of the standard and the complexities of best interests decision-making in clinical practice. Prevailing confusion and risk-aversive practices mean that the rights and interests of cognitively impaired individuals continue to be compromised, with evidence to suggest that 'best interests' may be conflated with the clinician's evaluation of 'best medical interests'.
Fager, Susan; Bardach, Lisa; Russell, Susanne; Higginbotham, Jeff
Children with severe physical impairments require a variety of access options to augmentative and alternative communication (AAC) and computer technology. Access technologies have continued to develop, allowing children with severe motor control impairments greater independence and access to communication. This article will highlight new advances in access technology, including eye and head tracking, scanning, and access to mainstream technology, as well as discuss future advances. Considerations for clinical decision-making and implementation of these technologies will be presented along with case illustrations.
Johnsen, Hege Mari; Fossum, Mariann; Vivekananda-Schmidt, Pirashanthie; Fruhling, Ann; Slettebø, Åshild
The aim of this study was to design and pilot-test a serious game for teaching nursing students clinical reasoning and decision-making skills in caring for patients with chronic obstructive pulmonary disease. A video-based serious game prototype was developed. A purposeful sample of six participants tested and evaluated the prototype. Usability issues were identified regarding functionality and user-computer interface. However, overall the serious game was perceived to be useful, usable and likable to use.
Hajjaj, FM; Salek, MS; Basra, MKA; Finlay, AY
Summary This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine. PMID:20436026
Scott, P J; Altenburger, P A; Kean, J
The educational literature cites a lack of student motivation to learn how to use research evidence in clinical decision-making because the students do not observe clinicians using evidence. This lack of motivation presents a challenge to educators as they seek to instill the value of evidence-based clinical decision-making (EBCD) in students. One problem is that students in entry-level programs do not have the experience needed to know what to look for, and secondly, clinical decision-making is contextually based in a patient problem. Our approach offers one solution to bridging the gap between classroom teaching and real-world implementation of EBCD through a three-phase collaborative approach. Occupational and physical therapy students are partnered with clinicians to find and appraise evidence to answer the real-world questions posed by these therapists. This paper describes the implementation of the partnership, teaching/learning outcomes, logistics, and implications for clinicians. We found this approach increased student motivation and greatly enhanced the learning experience. Future directions include implementing a framework which allows for the assessment of the strategy on the facility and creates opportunities to integrate the use of EBCD in all aspects of facility practice.
Légaré, France; Robitaille, Hubert; Gane, Claire; Hébert, Jessica; Labrecque, Michel; Rousseau, François
Background Knowledge translation (KT) interventions are attempts to change behavior in keeping with scientific evidence. While genetic tests are increasingly available to healthcare consumers in the clinic, evidence about their benefits is unclear and decisions about genetic testing are thus difficult for all parties. Objective We sought to identify KT interventions that involved decisions about genetic testing in the clinical context and to assess their effectiveness for improving decision making in terms of behavior change, increased knowledge and wellbeing. Methods We searched for trials assessing KT interventions in the context of genetic testing up to March 2014 in all systematic reviews (n = 153) published by two Cochrane review groups: Effective Practice and Organisation of Care (EPOC) and Consumers and Communication. Results We retrieved 2473 unique trials of which we retained only 28 (1%). Two EPOC reviews yielded two trials of KT interventions: audit and feedback (n = 1) and educational outreach (n = 1). Both targeted health professionals and the KT intervention they assessed was found to be effective. Four Consumers and Communication reviews yielded 26 trials: decision aids (n = 15), communication of DNA-based disease risk estimates (n = 7), personalized risk communication (n = 3) and mobile phone messaging (n = 1). Among these, 25 trials targeted only health consumers or patients and the KT interventions were found to be effective in four trials, partly effective in seven, and ineffective in four. Lastly, only one trial targeted both physicians and patients and was found to be effective. Conclusions More research on the effectiveness of KT interventions regarding genetic testing in the clinical context may contribute to patients making informed value-based decisions and drawing the maximum benefit from clinical applications of genetic and genomic innovations. PMID:26938633
Peters, S A; Laham, S M; Pachter, N; Winship, I M
When clinicians facilitate and patients make decisions about predictive genetic testing, they often base their choices on the predicted emotional consequences of positive and negative test results. Research from psychology and decision making suggests that such predictions may often be biased. Work on affective forecasting-predicting one's future emotional states-shows that people tend to overestimate the impact of (especially negative) emotional events on their well-being; a phenomenon termed the impact bias. In this article, we review the causes and consequences of the impact bias in medical decision making, with a focus on applying such findings to predictive testing in clinical genetics. We also recommend strategies for reducing the impact bias and consider the ethical and practical implications of doing so.
Maxson, Pamela M.; Dozois, Eric J.; Holubar, Stefan D.; Wrobleski, Diane M.; Dube, Joyce A. Overman; Klipfel, Janee M.; Arnold, Jacqueline J.
OBJECTIVE: To determine whether interdisciplinary simulation team training can positively affect registered nurse and/or physician perceptions of collaboration in clinical decision making. PARTICIPANTS AND METHODS: Between March 1 and April 21, 2009, a convenience sample of volunteer nurses and physicians was recruited to undergo simulation training consisting of a team response to 3 clinical scenarios. Participants completed the Collaboration and Satisfaction About Care Decisions (CSACD) survey before training and at 2 weeks and 2 months after training. Differences in CSACD summary scores between the time points were assessed with paired t tests. RESULTS: Twenty-eight health care professionals (19 nurses, 9 physicians) underwent simulation training. Nurses were of similar age to physicians (27.3 vs 34.5 years; p=.82), were more likely to be women (95.0% vs 12.5%; p<.001), and were less likely to have undergone prior simulation training (0% vs 37.5%; p=.02). The pretest showed that physicians were more likely to perceive that open communication exists between nurses and physicians (p=.04) and that both medical and nursing concerns influence the decision-making process (p=.02). Pretest CSACD analysis revealed that most participants were dissatisfied with the decision-making process. The CSACD summary score showed significant improvement from baseline to 2 weeks (4.2 to 5.1; p<.002), a trend that persisted at 2 months (p<.002). CONCLUSION: Team training using high-fidelity simulation scenarios promoted collaboration between nurses and physicians and enhanced the patient care decision-making process. PMID:21193653
The assessment and management of wounds forms a large proportion of community nurses' workload, often requiring judgment and decision-making in complex, challenging and uncertain circumstances. The processes through which nurses form judgments and make decisions within this context are reviewed in this article against existing theories on these on these subjects. There is variability in wound assessment and management practice which may be attributed to uncertainties within the context, a lack of knowledge in appropriate treatment choices and the inability to correctly value the importance of the clinical information presented. Nurses may be required to draw on intuition to guide their judgments and decision-making by association with experience and expertise. In addition, a step-by-step analytical approach underpinned by an evidence base may be required to ensure accuracy in practice. Developing an understanding of the different theories of judgment and decision-making may facilitate nurses' abilities to reflect on their own decision tasks, thereby enhancing the care provided.
Soukup, Tayana; Petrides, Konstantinos V.; Lamb, Benjamin W.; Sarkar, Somita; Arora, Sonal; Shah, Sujay; Darzi, Ara; Green, James S. A.; Sevdalis, Nick
Abstract In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable. The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision. This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons. We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis. The exploratory factor analysis produced 4 factors, labeled “Holistic and Clinical inputs” (patient views, psychosocial aspects, patient history, comorbidities, oncologists’, nurses’, and surgeons’ inputs), “Radiology” (radiology results, radiologists’ inputs), “Pathology” (pathology results, pathologists’ inputs), and “Meeting Management” (meeting chairs’ and coordinators’ inputs). A negative cross-loading was observed from surgeons’ input on the fourth factor with a follow-up analysis showing negative correlation (r = −0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001). Hawthorne effect is the main limitation of the study. The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core
Bérubé, J; Papillon, M J; Lavoie, G; Durant, P; Fortin, J P
In the health field, clinical information is the raw material for the clinician delivering health services. Therefore, the clinical information available to the physician is often incomplete or even non¿existent upon consultation. Furthermore, the reconstruction of the medical history, which is the most important source of data for the clinician to establish a diagnosis and initiate a treatment, suffers from many constraints. The smart card, like the one used in Quebec's project, could ease the physician's decision-making by allowing fast access to accurate and pertinent data. The smart card is a major asset in the present health system.
Tanderup, Malene; Reddy, Sunita; Patel, Tulsi; Nielsen, Birgitte Bruun
As a neo-liberal economy, India has become one of the new health tourism destinations, with commercial gestational surrogacy as an expanding market. Yet the Indian Assisted Reproductive Technology (ART) Bill has been pending for five years, and the guidelines issued by the Indian Council of Medical Research are somewhat vague and contradictory, resulting in self-regulated practices of fertility clinics. This paper broadly looks at clinical ethics in reproduction in the practice of surrogacy and decision-making in various procedures. Through empirical research in New Delhi, the capital of India, from December 2011 to November 2012, issues of decision-making on embryo transfer, fetal reduction, and mode of delivery were identified. Interviews were carried out with doctors in eighteen ART clinics, agents from four agencies, and fourteen surrogates. In aiming to fulfil the commissioning parents' demands, doctors were willing to go to the greatest extent possible in their medical practice. Autonomy and decision-making regarding choice of the number of embryos to transfer and the mode of delivery lay neither with commissioning parents nor surrogate mothers but mostly with doctors. In order to ensure higher success rates, surrogates faced the risk of multiple pregnancy and fetal reduction with little information regarding the risks involved. In the globalized market of commercial surrogacy in India, and with clinics compromising on ethics, there is an urgent need for formulation of regulative law for the clinical practice and maintenance of principles of reproductive ethics in order to ensure that the interests of surrogate mothers are safeguarded.
Ota, Toshio; Yoshida, Sumiko; Tsunashima, Sousuke; Totsuka, Takao; Watanabe, Takafumi; Toyoshima, Ryoichi
Psychiatrists often have to treat patients even when the clinical information is insufficient to make a definite diagnosis. This is the case especially when we are treating first-visit outpatients or inpatients who have just been admitted. One of the causes of information insufficiency is a delay in obtaining clinical information on the patient, and another is a lack of characteristic manifestations of the disease because of an immature developmental stage. Even in such situations, however, clinicians have to make reasonable judgements using the information that is available at that time. The framework for making judgements on such occasions, or "the framework of decision-making under imperfect-information conditions", is becoming more and more important in psychiatric clinical practice in Japan for the following reasons. First, team members in charge of a patient became very heterogeneous in terms of their career and motivation after the start of the new post-graduate clinical training system in Japan several years ago, resulting in a higher risk of miscommunication. Secondly, the need for precise explanation to patients and their families has become crucial in recent years as the result of various social changes. Ota T, one of the authors, once put forward the framework of decision-making under imperfect-information conditions on the basis of Bayesian statistics. In the present paper, in consideration of the above background, we devised a sheet for visualizing the above framework so that relevant staff could share the clinical decision-making process. Specifically, we visually arranged on a sheet of paper the components and variables of the framework, so that the staff could communicate with each other explicitly and precisely about the estimated probability of each possible disease, merits and demerits of each treatment option, etc. We employed the sheet on treating patients in our acute psychiatric ward, 2 of whom are presented in the paper. Discussions were
Miller, Deborah J; Spengler, Elliot S; Spengler, Paul M
The overconfidence bias occurs when clinicians overestimate the accuracy of their clinical judgments. This bias is thought to be robust leading to an almost universal recommendation by clinical judgment scholars for clinicians to temper their confidence in clinical decision making. An extension of the Meta-Analysis of Clinical Judgment (Spengler et al., 2009) project, the authors synthesized over 40 years of research from 36 studies, from 1970 to 2011, in which the confidence ratings of 1,485 clinicians were assessed in relation to the accuracy of their judgments about mental health (e.g., diagnostic decision making, violence risk assessment, prediction of treatment failure) or psychological issues (e.g., personality assessment). Using a random effects model a small but statistically significant effect (r = .15; CI = .06, .24) was found showing that confidence is better calibrated with accuracy than previously assumed. Approximately 50% of the total variance between studies was due to heterogeneity and not to chance. Mixed effects and meta-regression moderator analyses revealed that confidence is calibrated with accuracy least when there are repeated judgments, and more when there are higher base rate problems, when decisions are made with written materials, and for earlier published studies. Sensitivity analyses indicate a bias toward publishing smaller sample studies with smaller or negative confidence-accuracy effects. Implications for clinical judgment research and for counseling psychology training and practice are discussed.
Xu, Richard H; Wong, Eliza LY
Objective This study is a preliminary exploration of the association between patient involvement in decision-making and patient socioeconomic characteristics and experience in specialist outpatient clinics (SOPCs) in Hong Kong. Methods Cross-sectional telephone interviews were conducted using the Specialist Outpatient Experience Questionnaire (SOPEQ) in 26 Hospital Authority public SOPCs in Hong Kong. The SOPEQ was designed by The School of Public Health and Primary Care at The Chinese University of Hong Kong, fully taking into account both literature review and the local context of the public specialist outpatient system in Hong Kong. A total of 22,525 eligible participants were recruited for the study. Results There were 13,966 valid responses. The results indicated that the patients who had more involvement in decision-making were younger (odds ratio [OR] =2.10; 95% CI 1.75, 2.53), more highly educated (OR =1.67; 95% CI 1.45, 1.93), less likely to be receiving a government allowance (OR =0.61; 95% CI 0.57, 0.65), and less likely to be in the new case group (OR =0.84; 95% CI 0.78, 0.92). Participants living with their families (OR =3.38; 95% CI 2.03, 5.63) or who were unemployed (OR =1.10; 95% CI 1.01, 1.21) had a more decisive role in the decision- making process. Those participants who had been more involved in decision-making and wanted to continue being more involved had greater levels of satisfaction (mean =7.94; P<0.001) and a better health status (OR =0.49; 95% CI 0.41, 0.58). Conclusion Engaging patients in their health care management remains a challenge in improving patient-centered care. Our results suggest that patient engagement is associated with perceived health status and the experience of using a health service. Understanding patients’ characteristics and roles facilitates the development of preferred styles in the decision-making model. PMID:28331297
Adult learning, critical thinking, and decision-making are fields that receive attention individually, although they are interspersed with elements of each other's theories and philosophies. In addressing adult learning precepts, it is essential to include critical thinking and decision-making. One without the other creates weakness; all must be…
Nicholson, W Reg
Objective: To demonstrate how the findings of surface electromyography (S.E.M.G.) were integrated into the clinical decision-making process. Clinical Features: This is a retrospective review of the file of a 27-year-old male suffering from mechanical low back pain. He was evaluated on 3 separate occasions over a 3 year period. History, radiography, functional outcome studies, visual-numerical pain score, pain drawing, physical examination and surface electromyography were utilized in evaluating this patient. Intervention and Outcome: The two clinical interventions of spinal manipulative therapy (S.M.T.) had positive results in that the patient achieved an asymptomatic state and returned to his position of employment. The S.E.M.G. data collected during the industrial assessment, did not provide the outcome that the patient had anticipated. Conclusion: Surface electromyography is a useful clinical tool in the author’s decision-making process for the treatment of mechanical lower back pain. Therapeutic intervention by S.M.T., therapeutic exercises and rating risk factors were influenced by the S.E.M.G. findings.
Edelen, Bonnie Gilbert; Bell, Alexandra Alice
The purpose of this study was to address the need for effective educational interventions to promote students' clinical decision making (CDM) within clinical practice environments. Researchers used a quasi-experimental, non-equivalent groups, posttest-only design to assess differences in CDM ability between intervention group students who participated in analogy-guided learning activities and control group students who participated in traditional activities. For the intervention, analogy-guided learning activities were incorporated into weekly group discussions, reflective journal writing, and questioning with clinical faculty. The researcher-designed Assessment of Clinical Decision Making Rubric was used to assess indicators of CDM ability in all students' reflective journal entries. Results indicated that the intervention group demonstrated significantly higher levels of CDM ability in their journals compared with the control group (ES(sm) = 0.52). Recommendations provide nurse educators with strategies to maximize students' development of CDM ability, better preparing students for the demands they face when they enter the profession.
Chew, Keng Sheng; Durning, Steven J; van Merriënboer, Jeroen JG
INTRODUCTION Metacognition is a cognitive debiasing strategy that clinicians can use to deliberately detach themselves from the immediate context of a clinical decision, which allows them to reflect upon the thinking process. However, cognitive debiasing strategies are often most needed when the clinician cannot afford the time to use them. A mnemonic checklist known as TWED (T = threat, W = what else, E = evidence and D = dispositional factors) was recently created to facilitate metacognition. This study explores the hypothesis that the TWED checklist improves the ability of medical students to make better clinical decisions. METHODS Two groups of final-year medical students from Universiti Sains Malaysia, Malaysia, were recruited to participate in this quasi-experimental study. The intervention group (n = 21) received educational intervention that introduced the TWED checklist, while the control group (n = 19) received a tutorial on basic electrocardiography. Post-intervention, both groups received a similar assessment on clinical decision-making based on five case scenarios. RESULTS The mean score of the intervention group was significantly higher than that of the control group (18.50 ± 4.45 marks vs. 12.50 ± 2.84 marks, p < 0.001). In three of the five case scenarios, students in the intervention group obtained higher scores than those in the control group. CONCLUSION The results of this study support the use of the TWED checklist to facilitate metacognition in clinical decision-making. PMID:26778635
Ferreira, Daian Miranda; Bezerra, Régis Otaviano França; Ortega, Cinthia Denise; Blasbalg, Roberto; Viana, Públio César Cavalcante; de Menezes, Marcos Roberto; Rocha, Manoel de Souza
Magnetic resonance imaging is a method with high contrast resolution widely used in the assessment of pelvic gynecological diseases. However, the potential of such method to diagnose vaginal lesions is still underestimated, probably due to the scarce literature approaching the theme, the poor familiarity of radiologists with vaginal diseases, some of them relatively rare, and to the many peculiarities involved in the assessment of the vagina. Thus, the authors illustrate the role of magnetic resonance imaging in the evaluation of vaginal diseases and the main relevant findings to be considered in the clinical decision making process. PMID:26379324
Falzer, Paul R
Structured professional judgment (SPJ) has received considerable attention as an alternative to unstructured clinical judgment and actuarial assessment, and as a means of resolving their ongoing conflict. However, predictive validity studies have typically relied on receiver operating characteristic (ROC) analysis, the same technique commonly used to validate actuarial assessment tools. This paper presents SPJ as distinct from both unstructured clinical judgment and actuarial assessment. A key distinguishing feature of SPJ is the contribution of modifiable factors, either dynamic or protective, to summary risk ratings. With modifiable factors, the summary rating scheme serves as a prognostic model rather than a classification procedure. However, prognostic models require more extensive and thorough predictive validity testing than can be provided by ROC analysis. It is proposed that validation should include calibration and reclassification techniques, as well as additional measures of discrimination. Several techniques and measures are described and illustrated. The paper concludes by tracing the limitations of ROC analysis to its philosophical foundation and its origin as a statistical theory of decision-making. This foundation inhibits the performance of crucial tasks, such as determining the sufficiency of a risk assessment and examining the evidentiary value of statistical findings. The paper closes by noting a current effort to establish a viable and complementary relationship between SPJ and decision-making theory.
Burns, Scott A; Mintken, Paul E; Austin, Gary P
The prevalence of lumbar and hip pathology is on the rise; however, treatment outcomes have not improved, highlighting the difficulty in identifying and treating the correct impairments. The purpose of this case report is to describe the clinical decision making in the examination and treatment of an individual with secondary hip-spine syndrome. Our case study was a 62-year-old male with low back pain with concomitant right hip pain. His Oswestry Disability Index (ODI) was 18%, back numeric pain rating scale (NPRS) was 4/10, fear avoidance beliefs questionnaire (FABQ) work subscale was 0, FABQ physical activity subscale was 18, and patient specific functional scale (PSFS) was 7.33. Physical examination revealed findings consistent with secondary hip-spine syndrome. He was treated for four visits with joint mobilization/manipulation and strengthening exercises directed at the hip. At discharge, all standardized outcome measures achieved full resolution. Clinical decision making in the presence of lumbopelvic-hip pain is often difficult. Previous literature has shown that some patients with lumbopelvic-hip pain respond favorably to manual therapy and exercise targeting regions adjacent to the lumbar spine. The findings of this case report suggest that individuals with a primary complaint of LBP with hip impairments may benefit from interventions to reduce hip impairments.
van Ryn, Michelle; Burgess, Diana J; Dovidio, John F; Phelan, Sean M; Saha, Somnath; Malat, Jennifer; Griffin, Joan M; Fu, Steven S; Perry, Sylvia
Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians' behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians' behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations.
van Ryn, Michelle; Burgess, Diana J.; Dovidio, John F.; Phelan, Sean M.; Saha, Somnath; Malat, Jennifer; Griffin, Joan M.; Fu, Steven S.; Perry, Sylvia
Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians’ behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians’ behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations. PMID:24761152
Dane, Dawn E.; Dane, Andrew B.; Crowther, Edward R.
Objective: This study explored how chiropractic interns applied evidenced-based concepts, the sources of evidence they used, and how useful they perceived these sources to be in clinical decision making. Methods: A questionnaire containing 13 items in a Likert 5-point scale was administered to 28 chiropractic interns to gather information on the evidence types they commonly accessed and their perceived usefulness of these sources in clinical decision making. The interns were in the 8th semester of the training program. Results: There was a 93% (n = 26) response rate. Clinical guidelines were rated as the most helpful resource in clinical decision making (81%), followed by lecture materials (77%), journals (54%), databases (50%), and textbooks (35%). Students recognized scientific evidence as the most important aspect in clinical decision making. They found their personal experience and the views of their clinician to be equally important and patient preference the least. Conclusion: Interns routinely employed high-quality levels of evidence in clinical decision making. They also considered their early, limited clinical experience as important as that of their clinical supervisor in decision making. This finding should be investigated further. PMID:27389528
Samalin, Ludovic; Garnier, Marion; Auclair, Candy; Llorca, Pierre-Michel
The purpose of this study was to identify clinician characteristics associated with higher prescription rates of long-acting injectable (LAI) antipsychotics, as well as the sources that influence medical decision-making regarding the treatment of schizophrenia. We surveyed 202 psychiatrists during six regional French conferences (Bordeaux, Lyon, Marseille, Nice, Paris, and Strasbourg). Data on the characteristics of practice, prescription rates of antipsychotic, and information sources about their clinical decisions were collected. Most psychiatrists used second-generation antipsychotics (SGAs), and preferentially an oral formulation, in the treatment of schizophrenia. LAI SGAs were prescribed to 30.4% of schizophrenic patients. The duration and type of practice did not influence the class or formulation of antipsychotics used. The clinicians following the higher percentage of schizophrenic patients were associated with a higher use of LAI antipsychotics and a lower use of oral SGAs. Personal experience, government regulatory approval, and guidelines for the treatment of schizophrenia were the three main contributing factors guiding clinicians’ decision-making regarding the treatment of schizophrenia. The more clinicians follow schizophrenic patients, the more they use LAI antipsychotics. The development of specialized programs with top specialists should lead to better use of LAI antipsychotics in the treatment of schizophrenia. PMID:27869767
Samalin, Ludovic; Garnier, Marion; Auclair, Candy; Llorca, Pierre-Michel
The purpose of this study was to identify clinician characteristics associated with higher prescription rates of long-acting injectable (LAI) antipsychotics, as well as the sources that influence medical decision-making regarding the treatment of schizophrenia. We surveyed 202 psychiatrists during six regional French conferences (Bordeaux, Lyon, Marseille, Nice, Paris, and Strasbourg). Data on the characteristics of practice, prescription rates of antipsychotic, and information sources about their clinical decisions were collected. Most psychiatrists used second-generation antipsychotics (SGAs), and preferentially an oral formulation, in the treatment of schizophrenia. LAI SGAs were prescribed to 30.4% of schizophrenic patients. The duration and type of practice did not influence the class or formulation of antipsychotics used. The clinicians following the higher percentage of schizophrenic patients were associated with a higher use of LAI antipsychotics and a lower use of oral SGAs. Personal experience, government regulatory approval, and guidelines for the treatment of schizophrenia were the three main contributing factors guiding clinicians' decision-making regarding the treatment of schizophrenia. The more clinicians follow schizophrenic patients, the more they use LAI antipsychotics. The development of specialized programs with top specialists should lead to better use of LAI antipsychotics in the treatment of schizophrenia.
Chambers, David W
A decision is a commitment of resources under conditions of risk in expectation of the best future outcome. The smart decision is always the strategy with the best overall expected value-the best combination of facts and values. Some of the special circumstances involved in decision making are discussed, including decisions where there are multiple goals, those where more than one person is involved in making the decision, using trigger points, framing decisions correctly, commitments to lost causes, and expert decision makers. A complex example of deciding about removal of asymptomatic third molars, with and without an EBD search, is discussed.
Morgado, P J; Alfaro, R; Morgado, P J; León, P
A retrospective study is presented of 119 patients admitted to the Central Hospital of the Venezuelan Institute of Social Security, in Caracas, between 1982 and 1990, with the diagnosis of colon trauma. Several parameters including age, etiology, time elapsed between the accident or assault and hospital admission, preoperative and postoperative hemoglobin and diastolic blood pressure, associated lesions, procedure practiced, complication rate, and hospital mortality are reviewed. The second and third decades of life appear most often involved. Most patients reached the hospital within the first four hours of the accident or assault. Anemia, sustained diastolic hypotension, and number of organs involved in addition to the colon were important prognostic factors for complications. Apparently the surgical procedure, with simple suture or resection, mostly without "protective" colostomy, was not very relevant. Hospital mortality was 2.4 percent. A staging system based on clinical conditions for decision making in the operating room was used in an attempt to inject some objectivity into the surgical approach.
Wu, Min; Yang, Jinqiu; Liu, Lingying; Ye, Benlan
This study aims to investigate the influencing factors on nurses' clinical decision-making (CDM) skills. A cross-sectional nonexperimental research design was conducted in the medical, surgical, and emergency departments of two university hospitals, between May and June 2014. We used a quantile regression method to identify the influencing factors across different quantiles of the CDM skills distribution and compared the results with the corresponding ordinary least squares (OLS) estimates. Our findings revealed that nurses were best at the skills of managing oneself. Educational level, experience, and the total structural empowerment had significant positive impacts on nurses' CDM skills, while the nurse-patient relationship, patient care and interaction, formal empowerment, and information empowerment were negatively correlated with nurses' CDM skills. These variables explained no more than 30% of the variance in nurses' CDM skills and mainly explained the lower quantiles of nurses' CDM skills distribution.
Fuller, Shannon M; Koester, Kimberly A; Guinness, Ryan R; Steward, Wayne T
Shared decision-making (SDM) is considered best practice in health care. Prior studies have explored attitudes and barriers/facilitators to SDM, with few specific to HIV care. We interviewed 53 patients in HIV primary care clinics in California to understand the factors and situations that may promote or hinder engagement in SDM. Studies in other populations have found that patients' knowledge about their diseases and their trust in providers facilitated SDM. We found these features to be more nuanced for HIV. Perceptions of personal agency, knowledge about one's disease, and trust in provider were factors that could work for or against SDM. Overall, we found that participants described few experiences of SDM, especially among those with no comorbidities. Opportunities for SDM in routine HIV care (e.g., determining antiretroviral therapy) may arise infrequently because of treatment advances. These findings yield considerations for adapting SDM to fit the context of HIV care.
Desroches, Sophie; Gagnon, Marie-Pierre; Tapp, Sylvie; Légaré, France
Background There are a growing number of dietary treatment options to choose from for the management of many chronic diseases. Shared decision making represents a promising approach to improve the quality of the decision making process needed for dietary choices that are informed by the best evidence and value-based. However, there are no studies reporting on theory-based approaches that foster the implementation of shared decision making in health professions allied to medicine. The objectives of this study are to explore the integration of shared decision making within real nutritional consultations, and to design questionnaires to assess dieticians' intention to adopt two specific behaviors related to shared decision making using the Theory of Planned Behavior. Methods Forty dieticians will audiotape one clinical encounter to explore the presence of shared decision making within the consultation. They will also participate to one of five to six focus groups that aim to identify the salient beliefs underlying the determinants of their intention to present evidence-based dietary treatment options to their patients, and clarify the values related to dietary choices that are important to their patients. These salient beliefs will be used to elaborate the items of two questionnaires. The internal consistency of theoretical constructs and the temporal stability of their measurement will be checked using the test-retest method by asking 35 dieticians to complete the questionnaire twice within a two-week interval. Discussion The proposed research project will be the first study to: provide preliminary data about the adoption of shared decision making by dieticians and theirs patients; elicit dieticians' salient beliefs regarding the intention to adopt shared decision making behaviors, report on the development of a specific questionnaire; explore dieticians' views on the implementation of shared decision making; and compare their views regarding the implementation of
Clinical decision-making (CDM) is key in learning to be a doctor as the defining activity in their clinical work. CDM is often portrayed in the literature as similar to 'trail blazing'; the doctor as the core agent, clearing away obstacles on the path towards diagnosis and treatment. However, in a fieldwork of young doctors in Denmark, it was difficult connect their practice to this image. This paper presents the exploration of this discrepancy in the heart of medical practice and how an alternative image emerged; that of a 'jam session'. The exploration is represented as a case-based hypothesis-testing: first, a theoretically and empirically informed hypothesis (H0) of how doctors perform CDM is developed. In H0, CDM is a stepwise process of reasoning about clinical data, often influenced by outside contextual factors. Then, H0 is tested against a case from ethnographic fieldwork with doctors going through internship. Although the case is chosen for characteristics that make it 'most likely' to verify the hypothesis, verification proves difficult. The case challenges preconceptions in CDM literature about chronology, context, objectivity, cognition, agency, and practice. The young doctor is found not to make decisions, but rather to participate in CDM; an activity akin to the dynamics found in a jam session. Their participation circles in and through four concurrent interrelated constructions that suggest a new conceptualization of CDM; a starting point for a deeper understanding of actual practice in a changing clinical environment.
Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity. PMID:22035338
Chessare, J B
The growth of managed care has brought a new focus on physician competency in the appropriate use of resources to help patients. The community of pediatric educators must improve residency curricula and teaching methodologies to ensure that graduates of their programs can effectively and efficiently meet the needs of children and their families. The educational approach in many pediatric residency programs is an implicit apprenticeship model, with which the residents follow the actions of attending physicians with little attention to scrutiny of the clinical evidence for and against diagnostic and treatment strategies. Evidence-based medicine stresses to the trainee the importance of the evaluation of evidence from clinical research and cautions against the use of intuition, unsystematic clinical experience, and untested pathophysiologic reasoning as sufficient for medical decision-making. Managed care also has helped to create a heightened awareness of the need to educate residents to incorporate the preferences of patients and families into diagnostic and treatment decisions. Trainees must know how to balance their duty to maximize the health of populations at the lowest resource use with their duty to each individual patient and family. Changes in the residency curriculum will bring change in educational settings and the structure of rotations. Potential barriers to implementation will include the need for faculty development and financial resources for information technology.
Exley, Catherine E; Rousseau, Nikki S; Steele, Jimmy; Finch, Tracy; Field, James; Donaldson, Cam; Thomason, J Mark; May, Carl R; Ellis, Janice S
Background The aim of this study is to examine how clinicians and patients negotiate clinical need and treatment decisions within a context of finite resources. Dental implant treatment is an effective treatment for missing teeth, but is only available via the NHS in some specific clinical circumstances. The majority of people who receive this treatment therefore pay privately, often at substantial cost to themselves. People are used to paying towards dental treatment costs. However, dental implant treatment is much more expensive than existing treatments – such as removable dentures. We know very little about how dentists make decisions about whether to offer such treatments, or what patients consider when deciding whether or not to pay for them. Methods/Design Mixed methods will be employed to provide insight and understanding into how clinical need is determined, and what influences people's decision making processes when deciding whether or not to pursue a dental implant treatment. Phase 1 will use a structured scoping questionnaire with all the General dental practitioners (GDPs) in three Primary Care Trust areas (n = 300) to provide base-line data about existing practice in relation to dental implant treatment, and to provide data to develop a systematic sampling procedure for Phase 2. Phases 2 (GDPs) and 3 (patients) use qualitative focused one to one interviews with a sample of these practitioners (up to 30) and their patients (up to 60) to examine their views and experiences of decision making in relation to dental implant treatment. Purposive sampling for phases 2 and 3 will be carried out to ensure participants represent a range of socio-economic circumstances, and choices made. Discussion Most dental implant treatment is conducted in primary care. Very little information was available prior to this study about the quantity and type of treatment carried out privately. It became apparent during phase 2 that ISOD treatment was an unusual treatment in
Moberg, Paul J; Rick, Jacqueline H
With our ageing population, the number of older adults with cognitive impairment has also increased. There is both an acute and growing need for evidence-based assessments to identify their decision making capacity and competence. In the present article we (1) present definitions of decision-making capacity and competence, (2) review cognitive functions that are central to decision-making capacity as well as the methods and procedures commonly used to assess these domains, and (3) address the communication of assessment findings to patients and their loved ones. The importance of assessing decision-making capacity in the context of specific functions and of respecting the values and interests of older adults are emphasized.
Ameneiros-Lago, E; Carballada-Rico, C; Garrido-Sanjuán, J A; García Martínez, A
Decision making in the patient with chronic advanced disease is especially complex. Health professionals are obliged to prevent avoidable suffering and not to add any more damage to that of the disease itself. The adequacy of the clinical interventions consists of only offering those diagnostic and therapeutic procedures appropriate to the clinical situation of the patient and to perform only those allowed by the patient or representative. In this article, the use of an algorithm is proposed that should serve to help health professionals in this decision making process.
Williams, Karen B; Burgardt, Grayson J; Rapley, John W; Bray, Kimberly K; Cobb, Charles M
Referral of periodontal patients requires development of a complex set of decision making skills. This study was conducted to determine criteria used by dental and dental hygiene students regarding the referral of periodontal patients for specialty care. Using mixed methods, a thirteen-item survey was developed to elicit the students' perceptions of their knowledge, confidence regarding managing patients, and clinical reasoning related to periodontal patients. The instrument was administered during the summer prior to (T1) and at the end of the students' final year (T2) of training. Seventy-nine dental students (81 percent of total class) and thirty dental hygiene students (83 percent of total class) completed T1. At T2, forty-two dental (44 percent of total class) and twenty-six dental hygiene students (87 percent of total class) completed the questionnaire. While 90 percent of dental and 96 percent of dental hygiene respondents reported a willingness to refer patients with active disease to specialists, only 40 percent of dental and 36 percent of dental hygiene respondents reported confidence in diagnosing, treating, and appropriately referring such patients. The students' ability to recognize critical disease and risk factors influencing referral was good; however, clinical application of that knowledge indicated a gap between knowledge and applied reasoning. The students' attitudes about the importance of periodontal disease and their perceived competence to identify critical disease risk factors were not significantly related (p>0.05) to correct clinical decisions in the case scenarios. The study concludes that dental and dental hygiene curricula should emphasize both the acquisition and application of knowledge regarding criteria for referral of periodontal patients.
Danielson, Carla Kmett; Cohen, Joseph R; Adams, Zachary W; Youngstrom, Eric A; Soltis, Kathryn; Amstadter, Ananda B; Ruggiero, Kenneth J
The present study aimed to utilize a Receiver Operating Characteristic (ROC) approach in order to improve clinical decision-making for adolescents at risk for the development of psychopathology in the aftermath of a natural disaster. Specifically we assessed theoretically-driven individual, interpersonal, and event-related vulnerability factors to determine which indices were most accurate in forecasting PTSD. Furthermore, we aimed to translate these etiological findings by identifying clinical cut-off recommendations for relevant vulnerability factors. Our study consisted of structured phone-based clinical interviews with 2000 adolescent-parent dyads living within a 5-mile radius of tornados that devastated Joplin, MO, and northern Alabama in Spring 2011. Demographics, tornado incident characteristics, prior trauma, mental health, and family support and conflict were assessed. A subset of youth completed two behavioral assessment tasks online to assess distress tolerance and risk-taking behavior. ROC analyses indicated four variables that significantly improved PTSD diagnostic efficiency: Lifetime depression (AUC = .90), trauma history (AUC = .76), social support (AUC = .70), and family conflict (AUC = .72). Youth were 2-3 times more likely to have PTSD if they had elevated scores on any of these variables. Of note, event-related characteristics (e.g., property damage) were not related to PTSD diagnostic status. The present study adds to the literature by making specific recommendations for empirically-based, efficient disaster-related PTSD assessment for adolescents following a natural disaster. Implications for practice and future trauma-related developmental psychopathology research are discussed.
Karamintziou, Sofia D.; Tsirogiannis, George L.; Stathis, Pantelis G.; Tagaris, George A.; Boviatsis, Efstathios J.; Sakas, Damianos E.; Nikita, Konstantina S.
Objective. During deep brain stimulation (DBS) surgery for the treatment of advanced Parkinson's disease (PD), microelectrode recording (MER) in conjunction with functional stimulation techniques are commonly applied for accurate electrode implantation. However, the development of automatic methods for clinical decision making has to date been characterized by the absence of a robust single-biomarker approach. Moreover, it has only been restricted to the framework of MER without encompassing intraoperative macrostimulation. Here, we propose an integrated series of novel single-biomarker approaches applicable to the entire electrophysiological procedure by means of a stochastic dynamical model. Approach. The methods are applied to MER data pertinent to ten DBS procedures. Considering the presence of measurement noise, we initially employ a multivariate phase synchronization index for automatic delineation of the functional boundaries of the subthalamic nucleus (STN) and determination of the acceptable MER trajectories. By introducing the index into a nonlinear stochastic model, appropriately fitted to pre-selected MERs, we simulate the neuronal response to periodic stimuli (130 Hz), and examine the Lyapunov exponent as an indirect indicator of the clinical effectiveness yielded by stimulation at the corresponding sites. Main results. Compared with the gold-standard dataset of annotations made intraoperatively by clinical experts, the STN detection methodology demonstrates a false negative rate of 4.8% and a false positive rate of 0%, across all trajectories. Site eligibility for implantation of the DBS electrode, as implicitly determined through the Lyapunov exponent of the proposed stochastic model, displays a sensitivity of 71.43%. Significance. The suggested comprehensive method exhibits remarkable performance in automatically determining both the acceptable MER trajectories and the optimal stimulation sites, thereby having the potential to accelerate precise
Blount, Kamilah V.
This study examined the impact of accelerated nursing direct entry master's programs on the development of clinical decision-making skills of new graduate nurses that completed the Performance Based Development System (PBDS) assessment during the study period of 2008-2012 at a healthcare organization. Healthcare today is practiced in a…
Chang, Todd P; Schrager, Sheree M; Rake, Alyssa J; Chan, Michael W; Pham, Phung K; Christman, Grant
Multimedia in assessing clinical decision-making skills (CDMS) has been poorly studied, particularly in comparison to traditional text-based assessments. The literature suggests multimedia is more difficult for trainees. We hypothesize that pediatric residents score lower in diagnostic skill when clinical vignettes use multimedia rather than text for patient findings. A standardized method was developed to write text-based questions from 60 high-resolution, quality multimedia; a series of expert panels selected 40 questions with both a multimedia and text-based counterpart, and two online tests were developed. Each test featured 40 identical questions with reciprocal and alternating modality (multimedia vs. text). Pediatric residents and rising 4th year medical students (MS-IV) at a single residency were randomized to complete either test stratified by postgraduate training year (PGY). A mixed between-within subjects ANOVA analyzed differences in score due to modality and PGY. Secondary analyses ascertained modality effect in dermatology and respiratory questions using Mann-Whitney U tests, and correlations on test performance to In-service Training Exam (ITE) scores using Spearman rank. Eighty-eight residents and rising interns completed the study. Overall multimedia scores were lower than text-based scores (p = 0.047, η p(2) = 0.04), with highest disparity in rising interns (MS-IV); however, PGY had a greater effect on scores (p = 0.001, η p(2) = 0.16). Respiratory questions were not significantly lower with multimedia (n = 9, median 0.71 vs. 0.86, p = 0.09) nor dermatology questions (n = 13, p = 0.41). ITEs correlated significantly with text-based scores (ρ = 0.23-0.25, p = 0.04-0.06) but not with multimedia scores. In physician trainees with less clinical experience, multimedia-based case vignettes are associated with significantly lower scores. These results help shed light on the role of multimedia versus text-based information in
Çamlar, Seçil Arslansoyu; Deveci, Nazlı; Soylu, Alper; Türkmen, Mehmet Atilla; Özmen, Derya; Çapakaya, Gamze; Kavukçu, Salih
Hydronephrosis may be related to an obstructive cause, ureteropelvic/uretero-vesical junction obstruction or nonobstructive [vesicoureteral reflux (VUR)]. When an obstructive pathology is considered, dynamic renal scintigraphy may help to predict whether it is a true obstruction or not. In this study, we aimed to determine the contribution of dynamic renal scintigraphy with  mTc-MAG-3 to the clinical decision-making for surgery in hydronephrotic children. Files of the patients evaluated by MAG-3 scintigraphy for antenatal (AH)/postnatal (PH) hydronephrosis between 1992 and 2014 were reviewed. Gender, age, hydronephrosis (HN) grade by ultrasound (US), presence of VUR, MAG-3 result (obstructive vs. nonobstructive), ultimate diagnosis, and need for surgery were assessed. Cases with double collecting system and neurogenic bladder were excluded from the study. All of the patients had normal serum creatinine and eGFR. There were a total of 178 patients with 218 hydronephrotic renal units (mean age 34.7 ± 52.7 months; male/ female = 121/57, AH of 62%). MAG-3 was nonobstructive in 134 and obstructive in 84 hydronephrotic renal units. MAG-3 was obstructive in 47 of 121 (39%) males and 30 of 57 (53%) females (P = 0.058, odds ratio (OR) for obstruction was 1.9 for girls). MAG-3 was obstructive in 47 of 135 (35%) units with AH and 37 of 83 (45%) units with PH (P = 0.137). In 81 units with the society of fetal urology-4 HN by US, MAG-3 was obstructive in 55 (68%), and surgery was required in 52 of 55 (95%). Surgery was required for only two (7%) of the remaining 26 units with nonobstructive dilatation (P <0.001, sensitivity 96%, specificity 89%, OR 208). Antero-posterior diameter >16.5 mm was the best cutoff level for predicting obstruction by MAG-3 (sensitivity 75.2%; specificity 71%; OR 3.8). MAG-3 significantly affects clinical decision for surgery in HN. Hydronephrotic girls have more risk in terms of true obstruction. Combining MAG-3 with US improves the
Poucheret, Patrick; Fons, Françoise; Doré, Jean Christophe; Michelot, Didier; Rapior, Sylvie
Ninety percent of fatal higher fungus poisoning is due to amatoxin-containing mushroom species. In addition to absence of antidote, no chemotherapeutic consensus was reported. The aim of the present study is to perform a retrospective multidimensional multivariate statistic analysis of 2110 amatoxin poisoning clinical cases, in order to optimize therapeutic decision-making. Our results allowed to classify drugs as a function of their influence on one major parameter: patient survival. Active principles were classified as first intention, second intention, adjuvant or controversial pharmaco-therapeutic clinical intervention. We conclude that (1) retrospective multidimensional multivariate statistic analysis of complex clinical dataset might help future therapeutic decision-making and (2) drugs such as silybin, N-acetylcystein and putatively ceftazidime are clearly associated, in amatoxin poisoning context, with higher level of patient survival.
de Bie, Rob; Öner, Cumhur; Castelein, René; de Kleuver, Marinus
Objectives To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain. Design and setting Nationwide survey among spine surgeons in the Netherlands. Participants Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain. Primary and secondary outcome measures The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined. Results The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy. Conclusions The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision
Kapp-Simon, Kathleen A; Edwards, Todd; Ruta, Caroline; Bellucci, Claudia Crilly; Aspirnall, Cassandra L.; Strauss, Ronald P; Topolski, Tari D.; Rumsey, Nichola J; Patrick, Donald L
The aim of this study was to identify factors associated with youth satisfaction with surgical procedures performed to address oral cleft or craniofacial conditions (CFC). It was hypothesized that youth mental health, participation in decision-making, perceived consequences of living with a CFC, and coping strategies would be associated with satisfaction with past surgeries. Two hundred and three youth between the ages of 11 and 18 (Mean age = 14.5. SD = 2.0; 61% male; 78% oral cleft) completed a series of questionnaires measuring depression, self-esteem, participation in decision-making, condition severity, negative and positive consequences of having a CFC, coping, and satisfaction with past surgeries. Multiple Regression Analysis using boot-strapping techniques found that youth participation in decision making, youth perception of positive consequences of having a CFC, and coping accounted for 32% of the variance in satisfaction with past surgeries (p < .001). Youth age, sex, and assessment of condition severity were not significantly associated with satisfaction with surgical outcome. Depression, self-esteem, and negative consequences of having a CFC were not associated with satisfaction with past surgeries. Youth should be actively involved in the decision for craniofacial surgery. Youth who were more satisfied with their surgical outcomes also viewed themselves as having gained from the experience of living with a CFC. They felt that having a CFC made them stronger people and they believed that they were more accepting of others and more in touch with others’ feelings because of what they had been through. PMID:26114527
Abrams, Michael N; Cummings, Simone; Hage, Dana
Care paths map the critical actions and decision points across a patient's course of medical treatment; their purpose is to guide physicians in the delivery of high-quality care while reducing care costs by avoiding services that do not contribute meaningfully to positive outcomes. Each care path development initiative should be led by a respected physician champion, whose specialty is in the area of the care episode being mapped, with the support of a clinician project manager. Once the care path has been developed and implemented, the finance leader's role begins in earnest with the tracking of financial and clinical data against care paths.
Lopez, Fanny Y.; DeMeester, Rachel H.; Jia, Justin L.; Peek, Monica E.; Vela, Monica B.
Abstract Effective shared decision making (SDM) between patients and healthcare providers has been positively associated with health outcomes. However, little is known about the SDM process between Latino patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), and their healthcare providers. Our review of the literature identified unique aspects of Latino LGBTQ persons’ culture, health beliefs, and experiences that may affect their ability to engage in SDM with their healthcare providers. Further research needs to examine Latino LGBTQ patient–provider experiences with SDM and develop tools that can better facilitate SDM in this patient population. PMID:27617356
Baig, Arshiya A; Lopez, Fanny Y; DeMeester, Rachel H; Jia, Justin L; Peek, Monica E; Vela, Monica B
Effective shared decision making (SDM) between patients and healthcare providers has been positively associated with health outcomes. However, little is known about the SDM process between Latino patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), and their healthcare providers. Our review of the literature identified unique aspects of Latino LGBTQ persons' culture, health beliefs, and experiences that may affect their ability to engage in SDM with their healthcare providers. Further research needs to examine Latino LGBTQ patient-provider experiences with SDM and develop tools that can better facilitate SDM in this patient population.
Sehl, Mary; Sawhney, Rishi; Naeim, Arash
In this second article of our two-part review, we focus on age-associated physiologic changes involving the nervous, endocrine, hematologic, immune, and musculoskeletal systems, with close attention to the interconnected nature of these systems. There is a well-known connection between the neuroendocrine and immune systems via the hypothalamic-pituitary-adrenal axis and via interaction by means of cytokines, hormones, and neurotransmitters. These changes may lead to a loss of integration and resiliency with age, thus decreasing the ability of the elderly patient with cancer to adapt to stressful circumstances. Prominent changes include decline in memory and cognition, and increased susceptibility to peripheral neuropathy. Hematologic and immune changes like reduced bone marrow reserve and increased susceptibility to infections have far reaching implications for cancer care in the elderly. Gradual decline in hormone levels, and changes in muscle and body composition, can lead to functional decline and frailty. Use of the clinical interventions suggested in this article, along with an appreciation of the interplay of these age-related physiologic changes and their consequences, allows oncology professionals to customize therapy and minimize side effects in the geriatric oncology patient.
After the advent of DSM-III, operational diagnostic criteria, along with the classification of disorders using such criteria, received considerable attention, and many studies on the reliability and validity of psychiatric diagnosis were conducted worldwide. Operational methodology was applied to diagnosis and classification, especially, in the area of research, and has contributed greatly to advances in reliable and refined clinical research. Such methodology, however, has not necessarily been accepted as a guiding principle in the area of clinical practice by all psychiatrists. Rather, some psychiatrists, especially more experienced psychiatrists, took a somewhat negative attitude toward the use of operational methodology. The author contends that one of the causes for the relatively poor acceptance of operational methodology in the area of clinical practice lies in the "classification model" view of diagnosis that forms the implicit background for the methodology. From a clinical perspective, it is not from the "classification model" basis but rather, from the "decision-making model" basis that the actual process of clinical diagnosis in psychiatry is explained properly. This is a very important point, because the latter model is potentially more useful both to psychiatric patients and to researchers in psychiatry than the former model. There have been however, few reports in psychiatry that highlight the importance of this model as the clinical framework. The author analyzes the limitations of the "classification model" view, and then, based on this analysis, lists prerequisites that a model for the framework of clinical practice should possess. The prerequisites listed are: that clinical information not sufficient to meet the disease criteria should be used as effectively as possible, that diseases low in probability but high in seriousness should be considered by clinicians in the differential diagnoses; that diagnosis should be readily changed when necessary
Beisecker, Analee E.; And Others
Administered Beisecker Locus of Authority in Decision Making: Breast Cancer survey to 67 oncologists, 94 oncology nurses, and 288 patients from women's clinic. All groups believed that physicians should have dominant role in decision making. Nurses felt that patients should have more input than patients or physicians felt they should. Physicians…
Federer, Andrew E; Taylor, Dean C; Mather, Richard C
Decision making in health care has evolved substantially over the last century. Up until the late 1970s, medical decision making was predominantly intuitive and anecdotal. It was based on trial and error and involved high levels of problem solving. The 1980s gave way to empirical medicine, which was evidence based probabilistic, and involved pattern recognition and less problem solving. Although this represented a major advance in the quality of medical decision making, limitations existed. The advantages of the gold standard of the randomized controlled clinical trial (RCT) are well-known and this technique is irreplaceable in its ability to answer critical clinical questions. However, the RCT does have drawbacks. RCTs are expensive and can only capture a snapshot in time. As treatments change and new technologies emerge, new expensive clinical trials must be undertaken to reevaluate them. Furthermore, in order to best evaluate a single intervention, other factors must be controlled. In addition, the study population may not match that of another organization or provider. Although evidence-based medicine has provided powerful data for clinicians, effectively and efficiently tailoring it to the individual has not yet evolved. We are now in a period of transition from this evidence-based era to one dominated by the personalization and customization of care. It will be fueled by policy decisions to shift financial responsibility to the patient, creating a powerful and sophisticated consumer, unlike any patient we have known before. The challenge will be to apply medical evidence and personal preferences to medical decisions and deliver it efficiently in the increasingly busy clinical setting. In this article, we provide a robust review of the concepts of customized care and some of techniques to deliver it. We will illustrate this through a personalized decision model for the treatment decision after a first-time anterior shoulder dislocation.
Barnes, Andrew J; Hanoch, Yaniv; Martynenko, Melissa; Wood, Stacey; Rice, Thomas; Federman, Alex D
Many patients expect their doctor to help them choose a Medicare prescription drug plan. Whether the size of the choice set affects clinicians' decision processes and strategy selection, and the quality of their choice, as it does their older patients, is an important question with serious financial consequences. Seventy medical students and internal medicine residents completed a within-subject design using Mouselab, a computer program that allows the information-acquisition process to be examined. We examined highly numerate physician trainees' decision processes, strategy, and their ability to pick the cheapest drug plan-as price was deemed the most important factor in Medicare beneficiaries' plan choice-from either 3 or 9 drug plans. Before adjustment, participants were significantly more likely to identify the lowest cost plan when facing three versus nine choices (67.3% vs. 32.8%, p<0.01) and paid significantly less in excess premiums ($60.00 vs. $128.51, p<0.01). Compared to the three-plan condition, in the nine-plan condition participants spent significantly less time acquiring information on each attribute (p<0.05) and were more likely to employ decision strategies focusing on comparing alternate plans across a single attribute (search pattern, p<0.05). After adjusting for decision process and strategy, numeracy, and amount of medical training, the odds were 10.75 times higher that trainees would choose the lowest cost Medicare Part D drug plan when facing 3 versus 9 drug plans (p<0.05). Although employing more efficient search strategies in the complex choice environment, physician trainees experienced similar difficulty in choosing the lowest cost prescription drug plans as older patients do. Our results add further evidence that simplifications to the Medicare Part D decision environment are needed and suggest physicians' role in their patients' Part D choices may be most productive when assisting seniors with forecasting their expected medication needs
Fried, Terri R.; McGraw, Sarah; Agostini, Joseph V.; Tinetti, Mary E.
Objectives: To examine the ways in which older persons with multiple conditions think about potentially competing outcomes, in order to gain insight into how processes to elicit values regarding these outcomes can be grounded in the patient's perspective. Design: Qualitative study consisting of purposefully sampled focus groups. Setting: Community Participants: Persons age ≥ 65 years taking ≥ 5 medications. Measurements: Participants were asked their perceptions about whether their illnesses or treatment interacted with each other, goals of their treatment, and decisions to change or stop treatment. Results: Although participants were largely unaware that treatment of one condition could worsen another, many had experience with adverse medication effects as a competing outcome. Participants initially discussed their conditions in terms of disease-specific outcomes, such as achieving a target blood pressure or lipid level. In the context of decision-making, participants shifted their discussion from disease-specific to global, cross-disease health outcomes, such as survival, preservation of physical function, and relief of symptoms. Despite having some misconceptions regarding the likelihood of these outcomes, they weighed the outcomes against one another in order to consider what was most important to them. Their preference was for the treatment that would achieve the most desired outcome. Conclusions: Because of their experience with adverse medication effects, older persons with multiple morbidities can understand the concept of competing outcomes. The task of prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors who are faced with complex healthcare decisions. PMID:18771453
Thompson, Carl; Aitken, Leanne; Doran, Diane; Dowding, Dawn
Nurses' judgements and decisions have the potential to help healthcare systems allocate resources efficiently, promote health gain and patient benefit and prevent harm. Evidence from healthcare systems throughout the world suggests that judgements and decisions made by clinicians could be improved: around half of all adverse events have some kind of error at their core. For nursing to contribute to raising quality though improved judgements and decisions within health systems we need to know more about the decisions and judgements themselves, the interventions likely to improve judgement and decision processes and outcomes, and where best to target finite intellectual and educational resources. There is a rich heritage of research into decision making and judgement, both from within the discipline of nursing and from other perspectives, but which focus on nurses. Much of this evidence plays only a minor role in the development of educational and technological efforts at decision improvement. This paper presents nine unanswered questions that researchers and educators might like to consider as a potential agenda for the future of research into this important area of nursing practice, training and development.
Nierenberg, Andrew A; Smoller, Jordan W; Eidelman, Polina; Wu, Yelena P; Tilley, Claire A
Systematic biases in decision-making have been well characterized in medical and nonmedical fields but mostly ignored in clinical psychopharmacology. The purpose of this paper is to sensitize clinicians who prescribe psychiatric drugs to the issues of the psychology of risk, especially as they pertain to the risk of side effects. Specifically, the present analysis focuses on heuristic organization and framing effects that create cognitive biases in medical practice. Our purpose is to increase the awareness of how pharmaceutical companies may influence physicians by framing the risk of medication side effects to favor their products.
Grossman, Sheila; Krom, Zachary R; O'Connor, Rick
Learning to care for critically ill patients requires a high level of critical thinking, clinical decision-making ability, and a substantial knowledge base. At this nursing school, an elective Critical Care Nursing course for last-semester seniors was designed to include active learning strategies, focusing on the use of case studies to facilitate learning. Results indicate significantly improved final examination scores for those involved with the case-study pedagogy. In addition, students identified enhanced communication skills. Two complex cases are presented for others to use with their educational programs.
Thompson-Leduc, Philippe; Turcotte, Stéphane; Labrecque, Michel; Légaré, France
Objectives Unresolved clinically significant decisional conflict (CSDC) in patients following a consultation with health professionals is often the result of inadequate patient involvement in decision-making and may result in poor outcomes. We sought to identify the prevalence of CSDC in studies on decision-making in primary care and to explore its risk factors. Setting We performed a secondary analysis of existing data sets from studies conducted in Primary Care Practice-Based Research Networks in Québec and Ontario, Canada. Participants Eligible studies included a patient-reported measure on the 16-item Decisional Conflict Scale (DCS) following a decision made with a healthcare professional with no study design restriction. Primary and secondary outcome measures CSDC was defined as a score ≥25/100 on the DCS. The prevalence of CSDC was stratified by sex; and patient-level logistic regression analysis was performed to explore its potential risk factors. Data sets of studies were analysed individually and qualitatively compared. Results 5 projects conducted between 2003 and 2010 were included. They covered a range of decisions: prenatal genetic screening, antibiotics for acute respiratory infections and miscellaneous. Altogether, the 5 projects gathered data from encounters with a total of 1338 primary care patients (69% female; range of age 15–83). The prevalence of CSDC in patients varied across studies and ranged from 10.3% (95% CI 7.2% to 13.4%) to 31.1% (95% CI 26.6% to 35.6%). Across the 5 studies, risk factors of CSDC included being male, living alone and being 45 or older. Conclusions Prevalence of CSDC in patients who had enrolled in studies conducted in primary care contexts was substantial and appeared to vary according to the type of decision as well as to patient characteristics such as sex, living arrangement and age. Patients presenting risk factors of CSDC should be offered tools to increase their involvement in decision-making. PMID:27354076
Pesut, Barbara; McDonald, Heather
McCaffery's definition of pain as 'whatever the patient says it is' was truly revolutionary for nursing because of its capacity to lend credibility to the patient's pain experience. However, this definition, still widely in use, represents a particular philosophic approach to pain that has limitations for nurses' expert clinical decision making. In this paper, we trace the evolution of explanations for pain and discuss two philosophic approaches to pain that are common today. The first approach, the externalist perceptual view of pain, considers pain as a perceptual experience, one that like any perceptual experience can be 'misperceived' by the person having the experience. The second approach, the non-representational view of pain, considers pain as a holistic experience, one where physical and existential aspects necessarily coincide. These two approaches, while both emphasizing the importance of believing the patient's expression, have different implications for clinical decision making. Only the first approach permits nurses to exercise the nuanced judgement that differentiates pain from other related conditions such as anxiety, suffering or meaninglessness.
White, Krista A
Clinical decision making (CDM) is a cornerstone skill for nurses. Self-confidence and anxiety affect the learning and adeptness of CDM. This study aimed to develop and test a quantitative tool to assess undergraduate nursing students' self-confidence and anxiety during CDM. The 27-item Nursing Anxiety and Self-Confidence with Clinical Decision Making (NASC-CDM) scale is a 6-point, Likert-type tool with two subscales. Two samples of prelicensure associate and baccalaureate nursing students participated in the pilot (n = 303) and main testing (n = 242) phases of the study. Construct validity assessment, using exploratory factor analysis, produced a stable three-dimensional scale. Convergent validity assessment produced positive, moderate, and statistically significant correlations of the tool sub-scales with two existing instruments. Internal consistency reliability was assessed for each subscale (self-confidence, α = .97; anxiety, α = .96). The NASC-CDM scale may be a useful assessment tool for nurse educators to help novice clinicians improve CDM skills.
Maneval, Rhonda; Fowler, Kimberly A; Kays, John A; Boyd, Tiffany M; Shuey, Jennifer; Harne-Britner, Sarah; Mastrine, Cynthia
This study was conducted to determine whether the addition of high-fidelity patient simulation to new nurse orientation enhanced critical thinking and clinical decision-making skills. A pretest-posttest design was used to assess critical thinking and clinical decision-making skills in two groups of graduate nurses. Compared with the control group, the high-fidelity patient simulation group did not show significant improvement in mean critical thinking or clinical decision-making scores. When mean scores were analyzed, both groups showed an increase in critical thinking scores from pretest to posttest, with the high-fidelity patient simulation group showing greater gains in overall scores. However, neither group showed a statistically significant increase in mean test scores. The effect of high-fidelity patient simulation on critical thinking and clinical decision-making skills remains unclear.
Stick-Mueller, Misty; Boesch, Ron; Silverman, Steven; Carpenter, Scott; Illingworth, Robert; Countryman, James
Introduction: The physician-intern relationship can be difficult to develop. A new chiropractic intern in a teaching clinic undergoes a major transition from classroom to clinical practice and must learn to turn classroom knowledge into clinical application. The ability to start formulating clinical techniques and apply them on a patient is…
Hessinger, Jonathan D; London, Melissa J; Baer, Sheila M
The Veterans Health Administration (VHA) has continued to emphasize the availability, access, and utilization of high quality mental health care particularly in the treatment of posttraumatic stress disorder (PTSD). While dissemination and availability of evidence-based psychotherapies (EBPs) have only increased, treatment engagement and utilization have continued to be oft-noted challenges. Administrators, researchers, and individual clinicians have continued to develop and explore novel systemic and individualized interventions to address these issues. Pilot studies utilizing shared decision-making models to aid in veteran treatment selection have demonstrated the impact this approach may have on selection of and engagement in EBPs for PTSD. Based on these promising studies, a Department of Veterans Affairs (VA) outpatient PTSD clinic began to implement a shared-decision making intervention as part of a clinic redesign. In seeking to evaluate the impact of this intervention, archival clinical data from 1,056 veterans were reviewed by the authors for rates of treatment selection, EBP initiation, session attendance, and EBP completion. Time elapsed from consult until EBP initiation was also computed by the authors. These variables were then compared on the basis of whether the veteran received the shared-decision making intervention. Veterans who received the intervention were more likely to select and thus initiate an EBP for PTSD sooner than veterans who did not receive this intervention. Veterans, whether receiving the intervention or not, did not differ in therapy session attendance and completion. Implications of these findings and directions for future study are further discussed. (PsycINFO Database Record
Bergenstal, Richard M.; Ahmann, Andrew J.; Bailey, Timothy; Beck, Roy W.; Bissen, Joan; Buckingham, Bruce; Deeb, Larry; Dolin, Robert H.; Garg, Satish K.; Goland, Robin; Hirsch, Irl B.; Klonoff, David C.; Kruger, Davida F.; Matfin, Glenn; Mazze, Roger S.; Olson, Beth A.; Parkin, Christopher; Peters, Anne; Powers, Margaret A.; Rodriguez, Henry; Southerland, Phil; Strock, Ellie S.; Tamborlane, William; Wesley, David M.
Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes mellitus. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardizing the analysis and presentation of glucose monitoring data, with the initial focus on data derived from continuous glucose monitoring systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile, and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This article provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients. PMID:23567014
Jensen, Jens Dam; Peters, Christian Daugaard; Jespersen, Bente
It has been documented that preservation of residual renal function in dialysis patients improves quality of life as well as survival. Clinical trials on strategies to preserve residual renal function are clearly lacking. While waiting for more results from clinical trials, patients will benefit from clinicians being aware of available knowledge. The aim of this review was to offer an update on current evidence assisting doctors in clinical practice. PMID:25949486
Greer, Marianne L.; Kirk, Kenneth W.
A computerized, simulation-based instrument, consisting of four community practice clinical scenarios, collected information-searching data and the students' decisions. The appropriateness of the decisions, assessed by three clinical judges, and the focus of information search, based on the computer-collected process data, were the dependent…
Czaczkes, Tomer J.; Czaczkes, Benjamin; Iglhaut, Carolin; Heinze, Jürgen
Individual animals are adept at making decisions and have cognitive abilities, such as memory, which allow them to hone their decisions. Social animals can also share information. This allows social animals to make adaptive group-level decisions. Both individual and collective decision-making systems also have drawbacks and limitations, and while both are well studied, the interaction between them is still poorly understood. Here, we study how individual and collective decision-making interact during ant foraging. We first gathered empirical data on memory-based foraging persistence in the ant Lasius niger. We used these data to create an agent-based model where ants may use social information (trail pheromones), private information (memories) or both to make foraging decisions. The combined use of social and private information by individuals results in greater efficiency at the group level than when either information source was used alone. The modelled ants couple consensus decision-making, allowing them to quickly exploit high-quality food sources, and combined decision-making, allowing different individuals to specialize in exploiting different resource patches. Such a composite collective decision-making system reaps the benefits of both its constituent parts. Exploiting such insights into composite collective decision-making may lead to improved decision-making algorithms. PMID:26019155
Gupta, Rupa; Koscik, Timothy R.; Bechara, Antoine; Tranel, Daniel
Decision-making is a complex process that requires the orchestration of multiple neural systems. For example, decision-making is believed to involve areas of the brain involved in emotion (e.g., amygdala, ventromedial prefrontal cortex) and memory (e.g., hippocampus, dorsolateral prefrontal cortex). In this article, we will present findings related to the amygdala’s role in decision-making, and differentiate the contributions of the amygdala from those of other structurally and functionally connected neural regions. Decades of research have shown that the amygdala is involved in associating a stimulus with its emotional value. This tradition has been extended in newer work, which has shown that the amygdala is especially important for decision-making, by triggering autonomic responses to emotional stimuli, including monetary reward and punishment. Patients with amygdala damage lack these autonomic responses to reward and punishment, and consequently, cannot utilize “somatic marker” type cues to guide future decision-making. Studies using laboratory decision-making tests have found deficient decision-making in patients with bilateral amygdala damage, which resembles their real-world difficulties with decision-making. Additionally, we have found evidence for an interaction between sex and laterality of amygdala functioning, such that unilateral damage to the right amygdala results in greater deficits in decision-making and social behavior in men, while left amygdala damage seems to be more detrimental for women. We have posited that the amygdala is part of an “impulsive,” habit type system that triggers emotional responses to immediate outcomes. PMID:20920513
Vincent, Deborah; Hastings-Tolsma, Marie; Gephart, Sheila; Alfonzo, Paige M
Evidence-based practice is key to improving patient outcomes but can be challenging for busy nurse practitioners to implement. This article describes the process of critically appraising evidence for use in clinical practice and offers strategies for implementing evidence-based innovations and disseminating the findings.
Chu, Brian C.; Merson, Rachel A.; Zandberg, Laurie J.; Areizaga, Margaret
Comorbidity in clinical youth populations is more the rule than the exception, yet few established guidelines exist to help practicing clinicians manage complex diagnostic profiles. The current paper reviews efforts within the treatment development literature to handle comorbidity in depressed and anxious children and adolescents, including…
Hocher, Berthold; Yin, Lianghong
Preclinical studies in cell culture systems as well as in whole animal chronic kidney disease (CKD) models showed that parathyroid hormone (PTH), oxidized at the 2 methionine residues (positions 8 and 18), caused a loss of function. This was so far not considered in the development of PTH assays used in current clinical practice. Patients with advanced CKD are subject to oxidative stress, and plasma proteins (including PTH) are targets for oxidants. In patients with CKD, a considerable but variable fraction (about 70 to 90%) of measured PTH appears to be oxidized. Oxidized PTH (oxPTH) does not interact with the PTH receptor resulting in loss of biological activity. Currently used intact PTH (iPTH) assays detect both oxidized and non-oxPTH (n-oxPTH). Clinical studies demonstrated that bioactive, n-oxPTH, but not iPTH nor oxPTH, is associated with mortality in CKD patients.
The ability to reflect is becoming a core competency in many nursing educational programs. A clinical journal assignment was developed for first-semester (novice) nursing students. The aim was to see if the process of reflection-on-action through the medium of journal writing promoted fundamental clinical decision-making abilities of the first semester nursing student. This author discusses components of the clinical decision-making process used to structure six clinical journal questions for use by the first semester nursing students during their clinical rotation. Exemplars of students' self-reported reflections are included.
van Rooij, Tibor; Rix, Serena; Moore, James B; Marsh, Sharon
Background: Mobile applications (apps) providing clinical decision support (CDS) may show the greatest promise when created by and for frontline clinicians. Our aim was to create a generic model enabling healthcare providers to direct the development of CDS apps. Methods: We combined Change Management with a three-tier information technology architecture to stimulate CDS app development. Results: A Bridging Opportunities Work-frame model was developed. A test case was used to successfully develop an app. Conclusion: Healthcare providers can re-use this globally applicable model to actively create and manage regional decision support applications to translate evidence-based medicine in the use of emerging medication or novel treatment regimens. PMID:28031883
Smith, Teri; Sharp, Susan; Manzardo, Ann M.; Butler, Merlin G.
Advances made in genetic testing and tools applied to pharmacogenetics are increasingly being used to inform clinicians in fields such as oncology, hematology, diabetes (endocrinology), cardiology and expanding into psychiatry by examining the influences of genetics on drug efficacy and metabolism. We present a clinical case example of an adolescent male with anxiety, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder who did not tolerate numerous medications and dosages over several years in attempts to manage his symptoms. Pharmacogenetics testing was performed and DNA results on this individual elucidated the potential pitfalls in medication use because of specific pharmacodynamic and pharmacokinetic differences specifically involving polymorphisms of genes in the cytochrome p450 enzyme system. Future studies and reports are needed to further illustrate and determine the type of individualized medicine approach required to treat individuals based on their specific gene patterns. Growing evidence supports this biological approach for standard of care in psychiatry. PMID:25710722
Weed, L L; Zimny, N J
The information tool to aid us in making the clinical decisions discussed in this presentation is called the PKC. Our goal with patients should be to couple the knowledge of the unique patient to the knowledge in the literature and get the best possible match. This approach requires combinatorial versus probabilistic thinking. In the real world, ideal matches are not found. Therefore, it is critical to exhaust the patient's uniqueness first and only then use probabilities to settle further uncertainties. It is an error to teach people how to deal with uncertainty instead of teaching them to clean up a great deal of the uncertainty first. Patients must be involved in this endeavor. In essence, they have a PhD in their own uniqueness, and it is this uniqueness that is very powerful in solving complex problems. This method of patient evaluation and management cannot be used with the unaided mind. It requires new and powerful information tools like the PKC. All information that is relevant to a problem should be included in the coupler. It should encompass differing points of view, and the rationale should be made explicit to clinician and patient alike. When complete, the coupler should represent an interdisciplinary compilation of questions and tests that are expected to be collected every time in the clinic for the type of problem the coupler represents. This method will provide a basis for quality control because the contents of the coupler now have defined what we expect to occur in every patient encounter.(ABSTRACT TRUNCATED AT 250 WORDS)
Davies, B J B; Macfarlane, F
In April 2006 a new contract was introduced that governed how NHS General Dental Practitioners would be funded for the services they provide. This study looks at the impact that the contract has had in the three years since its introduction, evaluating its influence on the clinical care that patients receive and the clinical decisions that dentists are making. This qualitative service evaluation involved interviewing 12 dentists representative of a range of NHS dentists involved with the new NHS dental contract using a semi-structured approach. We found evidence that the new contract has led to dentists making different decisions in their daily practice and sometimes altering their treatment plans and referral patterns to ensure that their business is not disadvantaged. Access to care for some patients without a regular dentist can be compromised by the new contract as it can be financially challenging for a dentist to accept to care for a new patient who has an unknown and potentially large need for treatment. Cherry-picking of potentially more profitable patients may be common. The incentive is to watch borderline problems rather than to treat if a treatment band threshold has already been crossed and treatment may be delayed until a later course of treatment for the same reason. Dentists often feel that complex treatments (for example, endodontic treatments) are financially unviable. Some dentists are referring difficult cases that might previously have been treated 'in house', such as extractions, to another provider, as this enables offloading of costs while potentially retaining full fees. Younger and less experienced dentists may be further pressured.
Thompson, Steven; Varvel, Stephen; Sasinowski, Maciek; Burke, James P
Big data and advances in analytical processes represent an opportunity for the healthcare industry to make better evidence-based decisions on the value generated by various tests, procedures, and interventions. Value-based reimbursement is the process of identifying and compensating healthcare providers based on whether their services improve quality of care without increasing cost of care or maintain quality of care while decreasing costs. In this article, we motivate and illustrate the potential opportunities for payers and providers to collaborate and evaluate the clinical and economic efficacy of different healthcare services. We conduct a case study of a firm that offers advanced biomarker and disease state management services for cardiovascular and cardiometabolic conditions. A value-based analysis that comprised a retrospective case/control cohort design was conducted, and claims data for over 7000 subjects who received these services were compared to a matched control cohort. Study subjects were commercial and Medicare Advantage enrollees with evidence of CHD, diabetes, or a related condition. Analysis of medical claims data showed a lower proportion of patients who received biomarker testing and disease state management services experienced a MI (p < 0.01) or diabetic complications (p < 0.001). No significant increase in cost of care was found between the two cohorts. Our results illustrate the opportunity healthcare payers such as Medicare and commercial insurance companies have in terms of identifying value-creating healthcare interventions. However, payers and providers also need to pursue system integration efforts to further automate the identification and dissemination of clinically and economically efficacious treatment plans to ensure at-risk patients receive the treatments and interventions that will benefit them the most.
Krieger, Janice L; Palmer-Wackerly, Angela; Dailey, Phokeng M; Krok-Schoen, Jessica L; Schoenberg, Nancy E; Paskett, Electra D
Comprehension of randomization is a vital, but understudied, component of informed consent to participate in cancer randomized clinical trials (RCTs). This study examines patient comprehension of the randomization process as well as sources of ongoing uncertainty that may inhibit a patient's ability to provide informed consent to participate in RCTs. Cancer patients living in rural Appalachia who were offered an opportunity to participate in a cancer treatment RCT completed in-depth interviews and a brief survey. No systematic differences in randomization comprehension between patients who consented and those who declined participation in a cancer RCT were detected. Comprehension is conceptually distinct from uncertainty, with patients who had both high and low comprehension experiencing randomization-related uncertainty. Uncertainty about randomization was found to have cognitive and affective dimensions. Not all patients enrolling in RCTs have a sufficient understanding of the randomization process to provide informed consent. Healthcare providers need to be aware of the different types of randomization-related uncertainty. Efforts to improve informed consent to participate in RCTs should focus on having patients teach back their understanding of randomization. This practice could yield valuable information about the patient's cognitive and affective understanding of randomization as well as opportunities to correct misperceptions. Education about RCTs should reflect patient expectations of individualized care by explaining how all treatments being compared are appropriate to the specifics of a patient's disease.
Krieger, Janice L.; Palmer-Wackerly, Angela; Dailey, Phokeng M.; Krok-Schoen, Jessica L.; Schoenberg, Nancy E.; Paskett, Electra D.
Objective Comprehension of randomization is a vital, but understudied, component of informed consent to participate in cancer randomized clinical trials (RCTs). This study examines patient comprehension of the randomization process as well as sources of ongoing uncertainty that may inhibit a patient's ability to provide informed consent to participate in RCTs. Methods Cancer patients living in rural Appalachia who were offered an opportunity to participate in cancer treatment RCT completed in-depth interviews and a brief survey. Results No systematic differences in randomization comprehension between patients who consented and those who declined participation in a cancer RCT were detected. Comprehension is conceptually distinct from uncertainty, with patients who had both high and low comprehension experiencing randomization-related uncertainty. Uncertainty about randomization was found to have cognitive and affective dimensions. Conclusion Not all patients enrolling in RCTs have sufficient understanding of the randomization process to provide informed consent. Healthcare providers need to be aware of the different types of randomization-related uncertainty. Efforts to improve informed consent to participate in RCTs should focus on having patients “teach back” their understanding of randomization. This practice could yield valuable information about the patient's cognitive and affective understanding of randomization as well as opportunities to correct misperceptions. Education about RCTs should reflect patient expectations of individualized care by explaining how all treatments being compared are appropriate to the specifics of a patient's disease. PMID:25608719
Schor, N F; Troen, P; Adler, S; Williams, J G; Kanter, S L; Mahling, D E; Sorrows, B; Skogseid, I; Bernier, G M
This article describes a novel course that was designed to bridge the gap between the basic science years and clinical experiences in medical school by using information science and computer technology as major components of problem-based learning (PBL) sessions. The course, Integrated Case Studies and Medical Decision Making, was first given to second-year students at the University of Pittsburgh School of Medicine in the spring of 1994. It consists of 13 PBL exercises, each of which explores a clinical case. The cases, including images and gated access to information, are housed on a computer. Using one of 16 networked terminals in specially designed small-group rooms, groups of nine students progress through the cases with a faculty facilitator. The responses of students and faculty to the initial year of the course were favorable. In comparison with traditional PBL sessions, enhanced quality of and access to images and accountability for accessing case information in sequential fashion were cited as major strengths of the course. Juxtaposition of basic science and clinical material and utility in reviewing for the United States Medical Licensing Examination were also cited as strengths. The diversity of the basic science material involved in completing the cases drew overwhelming enthusiasm from students and facilitators alike. In conclusion, the course successfully employs computer and information science technology, which will be of increasing importance to future physicians. The course also serves as an effective bridge to the clinical years of medical school and as a study adjunct for the USMLE.
Kargi, Atil Y.; Bustamante, Marcela Perez; Gulec, Seza
In recent years there has been an increased awareness of the genetic alterations underlying both benign and malignant neoplasms of the thyroid. Next-generation sequencing (NGS) is an emerging technology that allows for rapid detection of a large number of genetic mutations in thyroid fine-needle aspiration (FNA) specimens. NGS for targeted mutational analysis in thyroid tumors has been proposed as a tool to assist in the diagnosis of thyroid nodules with indeterminate FNA cytology. Results of genomic testing of thyroid nodules and thyroid cancers could also have prognostic implications and play a role in determining optimal treatment strategies including targeted therapies. We provide a critical review of existing studies assessing the performance of the ThyroSeq NGS test for the diagnosis and management of patients with thyroid nodules with indeterminate cytopathology and discuss the applicability of findings from these studies to clinical practice. While there are early indications to suggest a possible utility of data obtained from NGS to aid in prognostication and therapeutic decision-making in thyroid cancer, we recommend judicious use and cautious interpretation of such molecular testing until results of ongoing clinical trials become available. Lastly, we discuss recommendations provided from clinical practice guidelines regarding the use of mutation detection via NGS in the diagnostic evaluation of thyroid nodules. PMID:28117287
Lessard, Chantale; Contandriopoulos, André-Pierre; Beaulieu, Marie-Dominique
Despite increasing interest in health economic evaluation, investigations have shown limited use by micro (clinical) level decision-makers. A considerable amount of health decisions take place daily at the point of the clinical encounter; especially in primary care. Since every decision has an opportunity cost, ignoring economic information in family physicians' (FPs) decision-making may have a broad impact on health care efficiency. Knowledge translation of economic evaluation is often based on taken-for-granted assumptions about actors' interests and interactions, neglecting much of the complexity of social reality. Health economics literature frequently assumes a rational and linear decision-making process. Clinical decision-making is in fact a complex social, dynamic, multifaceted process, involving relationships and contextual embeddedness. FPs are embedded in complex social networks that have a significant impact on skills, attitudes, knowledge, practices, and on the information being used. Because of their socially constructed nature, understanding preferences, professional culture, practices, and knowledge translation requires serious attention to social reality. There has been little exploration by health economists of whether the problem may be more fundamental and reside in a misunderstanding of the process of decision-making. There is a need to enhance our understanding of the role of economic evaluation in decision-making from a disciplinary perspective different than health economics. This paper argues for a different conceptualization of the role of economic evaluation in FPs' decision-making, and proposes Bourdieu's sociological theory as a research framework. Bourdieu's theory of practice illustrates how the context-sensitive nature of practice must be understood as a socially constituted practical knowledge. The proposed approach could substantially contribute to a more complex understanding of the role of economic evaluation in FPs' decision-making.
Mehallis, Mantha, Ed.
This collection of essays focuses on the importance of accurate and timely information for effective decision making. First, Ivan Lach considers the proliferation of statewide planning and policy formation and discusses problems with and ways to improve statewide research. Next, Cheryl Opacinch focuses on decision making for federal postsecondary…
Elbogen, Eric B.; Fuller, Sara; Johnson, Sally C.; Brooks, Stephanie; Kinneer, Patricia; Calhoun, Patrick; Beckham, Jean C.
Despite increased media attention on violent acts against others committed by military Veterans, few models have been developed to systematically guide violence risk assessment among Veterans. Ideally, a model would identify which Veterans are most at risk for violence and increased attention could then be turned to determining what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A list was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veteran’s violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Veteran Administration settings and in the broader community. It is likely that the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment, and help reduce violence among Veterans. PMID:20627387
Elbogen, Eric B; Fuller, Sara; Johnson, Sally C; Brooks, Stephanie; Kinneer, Patricia; Calhoun, Patrick S; Beckham, Jean C
Increased media attention to post-deployment violence highlights the need to develop effective models to guide risk assessment among military Veterans. Ideally, a method would help identify which Veterans are most at risk for violence so that it can be determined what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A checklist was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veteran's violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Department of Veteran Affairs settings and in the broader community. Research is needed to test the predictive validity of risk assessment models. Ultimately, the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment and potentially help prevent violence among Veterans.
Tonry, Claire L.; Leacy, Emma; Raso, Cinzia; Finn, Stephen P.; Armstrong, John; Pennington, Stephen R.
Prostate Cancer (PCa) is the second most commonly diagnosed cancer in men worldwide. Although increased expression of prostate-specific antigen (PSA) is an effective indicator for the recurrence of PCa, its intended use as a screening marker for PCa is of considerable controversy. Recent research efforts in the field of PCa biomarkers have focused on the identification of tissue and fluid-based biomarkers that would be better able to stratify those individuals diagnosed with PCa who (i) might best receive no treatment (active surveillance of the disease); (ii) would benefit from existing treatments; or (iii) those who are likely to succumb to disease recurrence and/or have aggressive disease. The growing demand for better prostate cancer biomarkers has coincided with the development of improved discovery and evaluation technologies for multiplexed measurement of proteins in bio-fluids and tissues. This review aims to (i) provide an overview of these technologies as well as describe some of the candidate PCa protein biomarkers that have been discovered using them; (ii) address some of the general limitations in the clinical evaluation and validation of protein biomarkers; and (iii) make recommendations for strategies that could be adopted to improve the successful development of protein biomarkers to deliver improvements in personalized PCa patient decision making. PMID:27438858
Wood, Stacey; Hanoch, Yaniv; Barnes, Andrew; Liu, Pi-Ju; Cummings, Janet; Bhattacharya, Chandrima; Rice, Thomas
Studies on decision making have come to challenge the idea that having more choice is necessarily better. The Medicare prescription drug program (Part D) has been designed to maximize choice for the consumer but has simultaneously created a highly complex decision task with dozens of options. In this study, in a sample of 121 adults, we examined the impact that increasing choice options has on decision-making abilities in older versus younger adults. Consistent with our hypotheses, we found that participants performed better with less choice versus more choice, and that older adults performed worse than younger adults across conditions. We further examined the role that numeracy may play in making these decisions and the role of more traditional cognitive variables such as working memory, executive functioning, intelligence, and education. Finally, we examined how personality style may interact with cognitive variables and age in decision making. Regression analysis revealed that numeracy is related to performance across the lifespan. When controlling for additional measures of cognitive ability, we found that although age was no longer associated with performance, numeracy remained significant. In terms of decision style, personality characteristics were not related to performance. Our results add to the mounting evidence for the critical role of numeracy in decision making across decision domains and across the lifespan.
Jibril, Farah; Sharaby, Sherif; Mohamed, Ahmed; Wilby, Kyle J
Background: Intravenous (IV) acetaminophen is increasingly used around the world for pain control for a variety of indications. However, it is unclear whether IV administration offers advantages over oral administration. Objective: To identify, summarize, and critically evaluate the literature comparing analgesic efficacy, safety, and pharmacokinetics for IV and oral dosage forms of acetaminophen. Data Sources: A literature search of the PubMed, Embase, and International Pharmaceutical Abstracts databases was supplemented with keyword searches of Science Direct, Wiley Library Online, and Springer Link databases for the period 1948 to November 2014. The reference lists of identified studies were searched manually. Study Selection and Data Extraction: Randomized controlled trials comparing IV and oral dosage forms of acetaminophen were included if they assessed an efficacy, safety, or pharmacokinetic outcome. For each study, 2 investigators independently extracted data (study design, population, interventions, follow-up, efficacy outcomes, safety outcomes, pharmacokinetic outcomes, and any other pertinent information) and completed risk-of-bias assessments. Data Synthesis: Six randomized clinical trials were included. Three of the studies reported outcomes pertaining to efficacy, 4 to safety, and 4 to pharmacokinetics. No clinically significant differences in efficacy were found between the 2 dosage forms. Safety outcomes were not reported consistently enough to allow adequate assessment. No evidence was found to suggest that increased bioavailability of the IV formulation enhances efficacy outcomes. For studies reporting clinical outcomes, the results of risk-of-bias assessments were largely unclear. Conclusions: For patients who can take an oral dosage form, no clear indication exists for preferential prescribing of IV acetaminophen. Decision-making must take into account the known adverse effects of each dosage form and other considerations such as convenience and
Huang, Rongchong; Song, Xiantao; Wu, Jian; Huang, Wei; Leppin, Aaron L; Gionfriddo, Michael R; Liu, Yongxian; Boehmer, Kasey R; Ting, Henry H; Montori, Victor M
Background The aim of this study was to evaluate the feasibility of using the Statin Choice decision aid to have discussions about starting a statin medication for cardiovascular risk reduction in Chinese patients with stable coronary artery diseases. Methods A prospective, pilot study of the Statin Choice decision aid in two teaching hospitals in Northern China was conducted. A total of seven clinicians were enrolled and underwent a 12-hour, group-based, in-person training on shared decision making (SDM) and the Statin Choice decision aid. Then, these clinicians used the Statin Choice decision aid in patients during a clinical encounter. A total of 86 patients aged 40−80 years, who had stable angina, were enrolled. All clinical encounters were video recorded. A team of three researchers viewed and scored all the encounter recordings to evaluate the SDM process and fidelity to the intervention using the OPTION scale and Fidelity scale, respectively. All the patients were followed up for 12 months to record adherence to statin and any major adverse cardiac events (MACEs). Results The average scores on the OPTION normalized score and Fidelity scale were 21 (range, 3–32; out of a possible, 48) and 10 (range, 6–10; out of a possible, 10), respectively. This suggested that Chinese clinicians who were using Statin Choice in their patients were able to exhibit behaviors consistent with SDM at a level that is similar to that reported in Western countries. After SDM, the statin adherence was 94.5% (69/73), and the proportion of MACEs was 2.9% (2/69). Conclusion Using an encounter decision aid developed in the US, it was feasible to implement SDM in a referral cardiology practice in Mainland China. Further work to ensure that the encounter aid is pertinent to the Chinese population and that SDM is tested in at-risk patients could contribute to the implementation of SDM across Mainland China. PMID:27881912
This article seeks to critically examine whether the reliance upon clinical judgment in decision-making under the Mental Health Act 1986 (Vic.) (MHA) and the Mental Health Review Board (MHRB) assists or hinders Parliament's key objective in passing the current MHA in 1986: least restrictive treatment.
Baker-Ericzén, Mary J.; Jenkins, Melissa M.; Park, Soojin; Garland, Ann F.
Background: Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities. Objective: The present study explored the role of prior training in evidence-based treatments (EBTs) on clinicians' assessment and treatment formulations using…
Allegue, Catarina; Coll, Mònica; Mates, Jesus; Campuzano, Oscar; Iglesias, Anna; Sobrino, Beatriz; Brion, Maria; Amigo, Jorge; Carracedo, Angel; Brugada, Pedro; Brugada, Josep; Brugada, Ramon
purposes due to the large amount of data generated. The identification of these genetic variants opens new perspectives on the implications of genetic background in the arrhythmogenic substrate for research purposes. Conclusions As a paradigm for other arrhythmogenic diseases and for unexplained sudden death, our data show that clinical genetic diagnosis is justified in a family perspective for confirmation of genetic causality. In the era of personalized medicine using high-throughput tools, clinical decision-making is increasingly complex. PMID:26230511
Wise, H F; Smith, L K; Einsweiler, R C; Jensen, D E
This part of the handbook addresses the basic how to do it - how states and local governments can identify complex and cross-cutting issues and develop and manage scientific and technical resources in seeking policy solutions to such issues. The following subjects are discussed: background statement of the issue; the research/decision-making process; defining problems and identifying research components; research and decision-making strategies; how to identify existing knowledge or ongoing research in the area of policy concern; and managing multi-disciplinary research. The fourteen agencies involved in this effort include: US Departments of Energy, Agriculture, Transportation, Housing and Urban Development, Environmental Protection Agency, and National Science Foundation. (PSB)
Dolan, James G.
Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers. Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine “hard data” with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings. The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP) PMID:21394218
Shakespeare, Thomas P. . E-mail: ThomasShakespeare@gmail.com; Back, Michael F.; Lu, Jiade J.; Lee, Khai Mun; Mukherjee, Rahul K.
Purpose: The external audit of oncologist clinical practice is increasingly important because of the incorporation of audits into national maintenance of certification (MOC) programs. However, there are few reports of external audits of oncology practice or decision making. Our institution (The Cancer Institute, Singapore) was asked to externally audit an oncology department in a developing Asian nation, providing a unique opportunity to explore the feasibility of such a process. Methods and Materials: We audited 100 randomly selected patients simulated for radiotherapy in 2003, using a previously reported audit instrument assessing clinical documentation/quality assurance and medical decision making. Results: Clinical documentation/quality assurance, decision making, and overall performance criteria were adequate 74.4%, 88.3%, and 80.2% of the time, respectively. Overall 52.0% of cases received suboptimal management. Multivariate analysis revealed palliative intent was associated with improved documentation/clinical quality assurance (p = 0.07), decision making (p 0.007), overall performance (p = 0.003), and optimal treatment rates (p 0.07); non-small-cell lung cancer or central nervous system primary sites were associated with better decision making (p = 0.001), overall performance (p = 0.03), and optimal treatment rates (p = 0.002). Conclusions: Despite the poor results, the external audit had several benefits. It identified learning needs for future targeting, and the auditor provided facilitating feedback to address systematic errors identified. Our experience was also helpful in refining our national revalidation audit instrument. The feasibility of the external audit supports the consideration of including audit in national MOC programs.
Green, Andrew R; Soria, Daniele; Stephen, Jacqueline; Powe, Desmond G; Nolan, Christopher C; Kunkler, Ian; Thomas, Jeremy; Kerr, Gillian R; Jack, Wilma; Cameron, David; Piper, Tammy; Ball, Graham R; Garibaldi, Jonathan M; Rakha, Emad A; Bartlett, John Ms; Ellis, Ian O
The Nottingham Prognostic Index Plus (NPI+) is a clinical decision making tool in breast cancer (BC) that aims to provide improved patient outcome stratification superior to the traditional NPI. This study aimed to validate the NPI+ in an independent series of BC. Eight hundred and eighty five primary early stage BC cases from Edinburgh were semi-quantitatively assessed for 10 biomarkers [Estrogen Receptor (ER), Progesterone Receptor (PgR), cytokeratin (CK) 5/6, CK7/8, epidermal growth factor receptor (EGFR), HER2, HER3, HER4, p53, and Mucin 1] using immunohistochemistry and classified into biological classes by fuzzy logic-derived algorithms previously developed in the Nottingham series. Subsequently, NPI+ Prognostic Groups (PGs) were assigned for each class using bespoke NPI-like formulae, previously developed in each NPI+ biological class of the Nottingham series, utilising clinicopathological parameters: number of positive nodes, pathological tumour size, stage, tubule formation, nuclear pleomorphism and mitotic counts. Biological classes and PGs were compared between the Edinburgh and Nottingham series using Cramer's V and their role in patient outcome prediction using Kaplan-Meier curves and tested using Log Rank. The NPI+ biomarker panel classified the Edinburgh series into seven biological classes similar to the Nottingham series (p > 0.01). The biological classes were significantly associated with patient outcome (p < 0.001). PGs were comparable in predicting patient outcome between series in Luminal A, Basal p53 altered, HER2+/ER+ tumours (p > 0.01). The good PGs were similarly validated in Luminal B, Basal p53 normal, HER2+/ER- tumours and the poor PG in the Luminal N class (p > 0.01). Due to small patient numbers assigned to the remaining PGs, Luminal N, Luminal B, Basal p53 normal and HER2+/ER- classes could not be validated. This study demonstrates the reproducibility of NPI+ and confirmed its prognostic value in an independent cohort
Orasanu, Judith; Statler, Irving C. (Technical Monitor)
The importance of decision-making to safety in complex, dynamic environments like mission control centers and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. A similar observation has been made in nuclear power plants. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multidimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication
Lindelow, John; And Others
Chapter 6 in a volume on school leadership, this chapter makes a case for the use of participative decision-making (PDM) at the school-site level, outlines guidelines for its implementation, and describes the experiences of some schools with PDM systems. It begins by citing research indicating the advantages of PDM, including better decisions,…
Eight psychometric instruments were administered to 10 elite male Portuguese orienteers. The cognitive process involved in decision making did not differ between the best orienteers and the others. This group of athletes had a high capacity for work realization and a strong need to be in control of interpersonal situations. (Author/SV)
With sustainability as the “true north” for EPA research, a premium is placed on the ability to make decisions under highly complex and uncertain conditions. The primary challenge is reconciling disparate criteria toward credible and defensible decisions. Making decisions on on...
Warner, Linda Sue
In contrast to European cultures, many American Indian societies have been matriarchal. Indian women have had a great deal of power, both as individuals and as groups, and have held various leadership roles within their tribes. Traditionally, Indian women have worked in partnership with men, and decision-making has been related to consensus…
Jonassen, David H.
Decision making is the most common kind of problem solving. It is also an important component skill in other more ill-structured and complex kinds of problem solving, including policy problems and design problems. There are different kinds of decisions, including choices, acceptances, evaluations, and constructions. After describing the centrality…
In shared decision making (SDM), principals collaborate with teachers and sometimes parents to take actions aimed at improving instruction and school climate. While research on SDM outcomes is still inconclusive, the literature shows that SDM brings both benefits and problems, and that the principal is a key figure. This brief offers a sampling of…
Bowen, Leah; Shaw, Alison; Lyttle, Mark D; Purdy, Sarah
Background Rates of unplanned paediatric admissions are persistently high. Many admissions are short-stay events, lasting less than 48 hours. Objective This qualitative research explores factors that influence clinical decision making in the paediatric ED (PED) for children under 5 attending with acute respiratory conditions, focusing on how management decisions adapt with increasing experience. Method Semi-structured interviews were conducted with 15 PED clinicians (doctors, emergency nurse practitioners and registered nurses) with varying levels of experience in paediatric emergency medicine (PEM), emergency medicine or paediatrics. Audio-recorded interviews were transcribed and analysed thematically. Results There were clear differences in decision-making approaches between experienced clinicians and junior staff. The latter were more risk adverse, relying heavily on guidelines, set admission criteria, clinical theory and second opinions. This was particularly true for doctors. ‘Informal’ learning was apparent in accounts from less-experienced doctors and nurses, whereby tacit knowledge and risk management played an increasing role in the development of clinical intuition that permitted rapid assessment and treatment of young patients. Conclusions The emergence of intuition entwined with approaches to risk management and the role of these skills in clinical decision making, carry implications for the development of training programmes for clinicians working in PEM. Enhanced training for such groups to permit development of the supplementary skills described in this study could have the ability to improve care delivery and even reduce paediatric admissions. PMID:27496899
Martin-Sanchez, Fernando; Turner, Maureen; Johnstone, Alice; Heffer, Leon; Rafael, Naomi; Bakker, Tim; Thorne, Natalie; Macciocca, Ivan; Gaff, Clara
Despite widespread use of genomic sequencing in research, there are gaps in our understanding of the performance and provision of genomic sequencing in clinical practice. The Melbourne Genomics Health Alliance (the Alliance), has been established to determine the feasibility, performance and impact of using genomic sequencing as a diagnostic tool. The Alliance has partnered with BioGrid Australia to enable the linkage of genomic sequencing, clinical treatment and outcome data for this project. This integrated dataset of genetic, clinical and patient sourced information will be used by the Alliance to evaluate the potential diagnostic value of genomic sequencing in routine clinical practice. This project will allow the Alliance to provide recommendations to facilitate the integration of genomic sequencing into clinical practice to enable personalised disease treatment.
Gong, Jingjing; Zhang, Yan; Feng, Jun; Huang, Yonghua; Wei, Yazhou; Zhang, Weiwei
Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision making. Unfortunately, research is still inconsistent as to how so many variables impact framing effects in medical decision making. Additionally, much attention should be paid to the framing effect not only in hypothetical scenarios but also in clinical experience. PMID:27034630
Decision making in midwifery is a complex process that shapes and underpins clinical practice and determines, to a large extent, the quality of care. Effective decision making and professional accountability are central to clinical governance, and being able.to justify all decisions is a professional and legal requirement. At the same time, there is an emphasis in midwifery on shared decision making, and keeping women at the centre of their care, and research reveals that feelings of choice, control and autonomy are central to a positive birth experience. However the extent to which decisions are really shared and care truly woman-centred is debatable and affected by environment and culture. Using a case study of a decision made in clinical practice around amniotomy, this article explores the role of the intuitive thinking system in midwifery decision making, and highlights the importance of involving women in the decision making process.
Campbell, Stephen M; Renfrew, Megan R; Marceau, Lisa D; Roland, Martin; McKinlay, John B
Variations in medical practice have been widely documented and are a linchpin in explanations of health disparities. Evidence shows that clinical decision making varies according to patient, provider and health system characteristics. However, less is known about the processes underlying these aggregate associations and how physicians interpret various patient attributes. Verbal protocol analysis (otherwise known as ‘think-aloud’) techniques were used to analyze open-ended data from 244 physicians to examine which patient characteristics physicians identify as relevant for their decision making. Data are from a vignette-based factorial experiment measuring the effects of: (a) patient attributes (age, gender, race and socioeconomic status); (b) physician characteristics (gender and years of clinical experience); and (c) features of the healthcare system in two countries (USA, United Kingdom) on clinical decision making for diabetes. We find that physicians used patients’ demographic characteristics only as a starting point in their assessments, and proceeded to make detailed assessments about cognitive ability, motivation, social support and other factors they consider predictive of adherence with medical recommendations and therefore relevant to treatment decisions. These non-medical characteristics of patients were mentioned with much greater consistency than traditional biophysiologic markers of risk such as race, gender, and age. Types of explanations identified varied somewhat according to patient characteristics and to the country in which the interview took place. Results show that basic demographic characteristics are inadequate to the task of capturing information physicians draw from doctor-patient encounters, and that in order to fully understand differential clinical decision making there is a need to move beyond documentation of aggregate associations and further explore the mental and social processes at work. PMID:18703267
Medical ethical analysis remains dominated by the principlist account first proposed by Beauchamp and Childress. This paper argues that the principlist model is unreflective of how ethical decisions are taken in clinical practice. Two kinds of medical ethical decisions are distinguished: biosocial ethics and clinical ethics. It is argued that principlism is an inappropriate model for clinical ethics as it is neither sufficiently action-guiding nor does it emphasise the professional integrity of the clinician. An alternative model is proposed for decision making in the realm of clinical ethics.
Stergiou, G S; Lourida, P; Tzamouranis, D
Oscillometric devices are being widely used for ambulatory, home and office blood pressure (BP) measurement, and several of them have been validated using established protocols. This cross-sectional study assessed the impact on antihypertensive treatment decisions of replacing the mercury sphygmomanometer by a validated oscillometric device. Consecutive subjects attending a hypertension clinic had triplicate simultaneous same-arm BP measurements using a mercury sphygmomanometer and a validated professional oscillometric device. For each device, uncontrolled hypertension was defined as average BP ≥140/90 mm Hg (systolic/diastolic). A total of 5108 simultaneous BP measurements were obtained from 763 subjects in 1717 clinic visits. In 24% of all visits, the mercury and the oscillometric BP measurements led to different conclusion regarding the diagnosis of uncontrolled hypertension. In 4.9% of the visits, the diagnostic disagreement was considered as 'clinically important' (BP exceeding the diagnostic threshold by >5 mm Hg). These data suggest that the replacement of the mercury sphygmomanometer by a validated professional oscillometric device will result into different treatment decisions in about 5% of the cases. Therefore, and because of the known problems when using mercury devices and the auscultatory technique in clinical practise, the oscillometric devices are regarded as reliable alternatives to the mercury sphygmomanometer for office use.
van der Veeken, Frida C. A.
Background Rehabilitation in forensic psychiatry is achieved gradually with different leave modules, in line with the Risk Need Responsivity model. A forensic routine outcome monitoring tool should measure treatment progress based on the rehabilitation theory, and it should be predictive of important treatment outcomes in order to be usable in decision-making. Therefore, this study assesses the predictive validity for both positive (i.e., leave) and negative (i.e., inpatient incidents) treatment outcomes with the Instrument for Forensic Treatment Evaluation (IFTE). Methods Two-hundred and twenty-four patients were included in this study. ROC analyses were conducted with the IFTE factors and items for three leave modules: guided, unguided and transmural leave for the whole group of patients. Predictive validity of the IFTE for aggression in general, physical aggression specifically, and urine drug screening (UDS) violations was assessed for patients with the main diagnoses in Dutch forensic psychiatry, patients with personality disorders and the most frequently occurring co-morbid disorders: those with combined personality and substance use disorders. Results and Conclusions Results tentatively imply that the IFTE has a reasonable to good predictive validity for inpatient aggression and a marginal to reasonable predictive value for leave approvals and UDS violations. The IFTE can be used for information purposes in treatment decision-making, but reports should be interpreted with care and acknowledge patients’ personal risk factors, strengths and other information sources. PMID:27517721
of a DDM Testbed 69 4.3.2 Design of Experiments on Distributed 71 Mission Planning 5. AUTOMATED DECISION MAKING TECHNIQUES 76 5.1 SEQUENTIAL...missile assignment scenario. A sequential assignment algorithm has been fully computer implemented and preliminary experiments with it have been run. An...implementation of a distributed version in which several humans can participate in experiments simultaneously. The distributed version will allow L1 us to
Edwards, Ian; Delany, Clare M; Townsend, Anne F; Swisher, Laura Lee
This is the second of 2 companion articles in this issue. The first article explored the clinical and ethical implications of new emphases in physical therapy codes of conduct reflecting the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. The first article was theoretically oriented and proposed that a re-thinking of ethical frameworks expressed in codes of ethics could both inform and underpin practical strategies for working in primary health care. A review of the ethical principle of "justice," which, arguably, remains the least consensually understood and developed principle in the ethics literature of physical therapy, was provided, and a more recent perspective-the capability approach to justice-was discussed. The current article proposes a clinical and ethical decision-making framework, the ethical reasoning bridge (ER bridge), which can be used to assist physical therapy practitioners to: (1) understand and implement the capability approach to justice at a clinical level; (2) reflect on and evaluate both the fairness and influence of beliefs, perspectives, and context affecting health and disability through a process of "wide reflective equilibrium" and assist patients to do this as well; and (3) nurture the development of moral agency, in partnership with patients, through a transformative learning process manifest in a mutual "crossing" and "re-crossing" of the ER bridge. It is proposed that the development and exercise of moral agency represent an enacted justice that is the result of a shared reasoning and learning experience on the part of both therapists and patients.
Dunphy, Bruce C; Cantwell, Robert; Bourke, Sid; Fleming, Mark; Smith, Bruce; Joseph, K S; Dunphy, Stacey L
Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for ambiguity, state-trait anxiety and metacognitive awareness were assessed for obstetricians (n = 12) who provided intra-partum care to 4,149 women. Outcome measures included delivery mode and intrapartum asphyxia. Analysis was carried out using logistic regression and tree-based classification. Obstetricians with high RC scores were more likely to perform a caesarean section (OR 1.59, p < 0.0001), less likely undertake a mid-forceps or low forceps delivery (OR 0.41, p < 0.0001; OR 0.49, p < 0.0001), and more likely to supervise a spontaneous vaginal delivery (OR 1.17, p = 0.08). Obstetricians with high NFC scores were more likely to perform a caesarean section (OR 1.53, p = 0.03), more likely to undertake a vacuum delivery (OR 5.8, p = 0.001), less likely undertake a mid-forceps delivery (OR 0.45, p = 0.02) and less likely to supervise a spontaneous vaginal delivery (OR 0.47, p < 0.0001). Obstetricians high in trait anxiety were more likely to perform a mid forceps delivery (OR 2.49, p = 0.01) or a vacuum delivery (OR 5.08, p = 0.003), and less likely to supervise a spontaneous vaginal delivery (OR 0.38, p < 0.0001). NFC was negatively associated (OR 0.10, p < 0.001) and trait anxiety was positively associated with intrapartum asphyxia (p < 0.05, rho = 0.582). In summary, physician cognitive processes and affect have a significant impact on patient outcomes, particularly in situations where there is a higher level of clinical unpredictability.
French, Jennifer A.
One-hundred and eleven graduate students enrolled in a clinical psychology training program (PsyD) participated in a research study that examined the ethical decision-making processes and factors that have been proposed to influence behavior (Smith, McGuire, Abbott, & Blau, 1991). Using a two-part questionnaire, data regarding the ethical…
Paterlini, G; Tagliabue, P
The field of neonatology presents a fascinating context in which hugely important decisions have to be made on the basis of physicians' assessments of the long term consequences of various possible choices. In many cases such assessments cannot be derived from a consensual professional opinion; the situation is characterized by a high level of uncertainty. A sample of neonatologists in different countries received a questionnaire including vignette cases for which no clear consensus exists regarding the (probabilistic) prognosis. They were asked to (I) assess the probability of various outcomes (death, severe impairment) and (II) choose a treatment to be offered to the parents. Information on the physicians' professional and socio-demographic characteristics and their ethical "values" was also collected. The goal of this international survey is to understand the prognosis and to analyze decision making by professionals in the context of life and death in medicine. The availability of an identical technology in different social and institutional contexts should help identifying the convergences and differences under consideration. Seventy percent of those invited responded to the questionnaire (International 60-80%). Italian neonatologists seem to be quite pessimistic about the prognosis of infants at high risk of death or long term disabilities, they show a pro-life attitude, but in a certain proportion are willing to change their minds if requested by parents. Furthermore personal opinions predominate in the decision-making process and the contribution of team meeting and/or ethic consultation seem not significantly modify the decisions.
Efficace, Fabio; Kemmler, Georg; Vignetti, Marco; Mandelli, Franco; Molica, Stefano; Holzner, Bernhard
Health-related quality of life (HRQOL) is increasingly reported as an important outcome in cancer clinical trials. However, very little evidence exists on the impact of such evaluation in randomised controlled trials (RCTs) of leukaemia patients. A systematic search of the literature from 1980 to 2007 was undertaken and studies were identified and evaluated independently, according to a pre-defined coding scheme, by three reviewers. Both HRQOL outcomes and traditional clinical reported outcomes were systematically analysed to evaluate their consistency and their relevance for supporting clinical decision making. Nine RCTs were identified, involving 3838 patients overall. There were four RCTs involving acute myeloid leukaemia patients (AML), three with chronic myeloid leukaemia (CML) and two with chronic lymphocytic leukaemia (CLL). Six studies were published after 2000 and provided fairly robust methodological quality. Imatinib greatly improved HRQOL compared to interferon based treatments in CML patients and fludarabine plus cyclophosphamide does not seem to have a deleterious impact on patient's HRQOL when compared to fludarabine alone or chlorambucil in CLL patients. This study revealed the paucity of HRQOL research in leukaemia patients. Nonetheless, HRQOL assessment is feasible in RCTs and has the great potential of providing valuable outcomes to further support clinical decision making.
van der Sanden, Wil J M; Mettes, Dirk G; Plasschaert, Alphons J M; Grol, Richard P T M; Mulder, Jan; Verdonschot, Emiel H
The objective of this study was twofold, namely to evaluate the effectiveness of a dental clinical practice guideline on the management of asymptomatic impacted lower third molars (i) on referral rates and (ii) on dentists' change in knowledge. A two-arm cluster randomized controlled trial, with pre- and post-test assessments, was conducted. A guideline was implemented by multifaceted interventions (i.e. feedback, reminders, and an interactive meeting). The effect was evaluated after 1 yr by repeating the baseline questionnaire and by monitoring the number of patients who were referred for removal of their asymptomatic impacted mandibular third molars. Instruments were questionnaires for detecting changes in knowledge, patient records, and panoramic radiographs. The knowledge of dentists regarding asymptomatic mandibular third molar management was found to increase significantly in the intervention group as compared to the control group. There was no statistically significant difference between the groups in guideline-consistent patient referral rates at the post-test assessment. It was concluded that the methodology employed for dissemination and implementation of a clinical practice guideline on asymptomatic mandibular third molar management improves dentists' knowledge on this topic and is effective in improving decision-making in simulated cases; however, no clinical effect was demonstrated.
Lee, Daeyeol; Seo, Hyojung
Human choice behaviors during social interactions often deviate from the predictions of game theory. This might arise partly from the limitations in the cognitive abilities necessary for recursive reasoning about the behaviors of others. In addition, during iterative social interactions, choices might change dynamically as knowledge about the intentions of others and estimates for choice outcomes are incrementally updated via reinforcement learning. Some of the brain circuits utilized during social decision making might be general-purpose and contribute to isomorphic individual and social decision making. By contrast, regions in the medial prefrontal cortex (mPFC) and temporal parietal junction (TPJ) might be recruited for cognitive processes unique to social decision making.
Santos, Adriano A; Moura, J Antão B; de Araújo, Joseana Macêdo Fechine Régis
Mitigating uncertainty and risks faced by specialist physicians in analysis of rare clinical cases is something desired by anyone who needs health services. The number of clinical cases never seen by these experts, with little documentation, may introduce errors in decision-making. Such errors negatively affect well-being of patients, increase procedure costs, rework, health insurance premiums, and impair the reputation of specialists and medical systems involved. In this context, IT and Clinical Decision Support Systems (CDSS) play a fundamental role, supporting decision-making process, making it more efficient and effective, reducing a number of avoidable medical errors and enhancing quality of treatment given to patients. An investigation has been initiated to look into characteristics and solution requirements of this problem, model it, propose a general solution in terms of a conceptual risk-based, automated framework to support rare-case medical diagnostics and validate it by means of case studies. A preliminary validation study of the proposed framework has been carried out by interviews conducted with experts who are practicing professionals, academics, and researchers in health care. This paper summarizes the investigation and its positive results. These results motivate continuation of research towards development of the conceptual framework and of a software tool that implements the proposed model.
Labrecque, Michel; Ratté, Stéphane; Frémont, Pierre; Cauchon, Michel; Ouellet, Jérôme; Hogg, William; McGowan, Jessie; Gagnon, Marie-Pierre; Njoya, Merlin; Légaré, France
Abstract Objective To compare the ability of users of 2 medical search engines, InfoClinique and the Trip database, to provide correct answers to clinical questions and to explore the perceived effects of the tools on the clinical decision-making process. Design Randomized trial. Setting Three family medicine units of the family medicine program of the Faculty of Medicine at Laval University in Quebec city, Que. Participants Fifteen second-year family medicine residents. Intervention Residents generated 30 structured questions about therapy or preventive treatment (2 questions per resident) based on clinical encounters. Using an Internet platform designed for the trial, each resident answered 20 of these questions (their own 2, plus 18 of the questions formulated by other residents, selected randomly) before and after searching for information with 1 of the 2 search engines. For each question, 5 residents were randomly assigned to begin their search with InfoClinique and 5 with the Trip database. Main outcome measures The ability of residents to provide correct answers to clinical questions using the search engines, as determined by third-party evaluation. After answering each question, participants completed a questionnaire to assess their perception of the engine’s effect on the decision-making process in clinical practice. Results Of 300 possible pairs of answers (1 answer before and 1 after the initial search), 254 (85%) were produced by 14 residents. Of these, 132 (52%) and 122 (48%) pairs of answers concerned questions that had been assigned an initial search with InfoClinique and the Trip database, respectively. Both engines produced an important and similar absolute increase in the proportion of correct answers after searching (26% to 62% for InfoClinique, for an increase of 36%; 24% to 63% for the Trip database, for an increase of 39%; P = .68). For all 30 clinical questions, at least 1 resident produced the correct answer after searching with either
Rosenbloom, Michael H; Schmahmann, Jeremy D; Price, Bruce H
Decision-making is a complex executive function that draws on past experience, present goals, and anticipation of outcome, and which is influenced by prevailing and predicted emotional tone and cultural context. Functional imaging investigations and focal lesion studies identify the orbitofrontal, anterior cingulate, and dorsolateral prefrontal cortices as critical to decision-making. The authors review the connections of these prefrontal regions with the neocortex, limbic system, basal ganglia, and cerebellum, highlight current ideas regarding the cognitive processes of decision-making that these networks subserve, and present a novel integrated neuroanatomical model for decision-making. Finally, clinical relevance of this circuitry is illustrated through a discussion of frontotemporal dementia, traumatic brain injury, and sociopathy.
Decision making is aided by emotions. Bodily responses, such as sweating, heartbeat, and visceral sensation, are used to monitor the emotional state during decision making. Because decision making in dairy life is complicated and cognitively demanding, these bodily signals are thought to facilitate the decision making process by assigning positive or negative values for each of the behavioral options. The sweat response in a decision making task is measured by skin conductance response (SCR). SCR in decision making is divided into two categories: anticipatory SCR is observed before making decisions, and reward/punishment SCR is observed after the outcome of the decision is perceived. Brain lesion studies in human revealed that the amygdala and ventromedial prefrontal cortex are important in decision making. Patients with lesinon in the amygdala exhibit neither the anticipatory nor reward/punishment SCRs, while patients with the ventromedial prefrontal lesions have deficits only in the anticipatory SCRs. Decision making tasks and SCR analysis have contributed to reveal the implicit aspects of decision making. Further research is necessary for clarifying the role of explicit process of decision making and its relationship with the implicit process.
Gleichgerrcht, Ezequiel; Torralva, Teresa; Roca, María; Szenkman, Daniela; Ibanez, Agustin; Richly, Pablo; Pose, Mariángeles; Manes, Facundo
We sought to investigate the decision making profile of Primary Progressive Aphasia (PPA) by assessing patients diagnosed with this disease (n = 10), patients diagnosed with behavioral variant frontotemporal dementia (bvFTD, n = 35), and matched controls (n = 14) using the Iowa Gambling Task, a widely used test that mimics real-life decision making. Participants were also evaluated with a complete neuropsychological battery. Patients with PPA were unable to adopt an advantageous strategy on the IGT, which resulted in a flat performance, different to that exhibited by both controls (who showed advantageous decision making) and bvFTD patients (who showed risk-appetitive behavior). The decision making profile of PPA patients was not associated with performance on language tasks and did not differ between sub-variants of the disease (namely, semantic dementia and progressive nonfluent aphasia). Investigating decision making in PPA is crucial both from a theoretical perspective, as it can shed light about the way in which language interacts with other cognitive functions, as well as a clinical standpoint, as it could lead to a more objective detection of impairments of decision making deficits in this condition.
Gleichgerrcht, Ezequiel; Torralva, Teresa; Roca, María; Szenkman, Daniela; Ibanez, Agustin; Richly, Pablo; Pose, Mariángeles; Manes, Facundo
We sought to investigate the decision making profile of Primary Progressive Aphasia (PPA) by assessing patients diagnosed with this disease (n = 10), patients diagnosed with behavioral variant frontotemporal dementia (bvFTD, n = 35), and matched controls (n = 14) using the Iowa Gambling Task, a widely used test that mimics real-life decision making. Participants were also evaluated with a complete neuropsychological battery. Patients with PPA were unable to adopt an advantageous strategy on the IGT, which resulted in a flat performance, different to that exhibited by both controls (who showed advantageous decision making) and bvFTD patients (who showed risk-appetitive behavior). The decision making profile of PPA patients was not associated with performance on language tasks and did not differ between sub-variants of the disease (namely, semantic dementia and progressive nonfluent aphasia). Investigating decision making in PPA is crucial both from a theoretical perspective, as it can shed light about the way in which language interacts with other cognitive functions, as well as a clinical standpoint, as it could lead to a more objective detection of impairments of decision making deficits in this condition. PMID:22207422
Arnaboldi, Paola; Riva, Silvia; Vadilonga, Valeria; Tadini, Liliana; Magon, Giorgio; Pravettoni, Gabriella
Introduction: The Distress Thermometer (DT) was built and validated for screening cancer patients for distress, as suggested by the National Comprehensive Cancer Network. The current work was designed to measure the rates of distress in a sample of patients being hospitalized in a multidisciplinary outpatient surgery clinic. Objective: To measure the rates of distress in a sample of patients referring to a multidisciplinary day surgery division in a comprehensive cancer center based in Northern Italy. Methods: A total of 177 patients were asked to fill in the (DT) before surgery. Results: Out of 177 patients, 154 (87%) patients completed the DT. While 13% of the patients indicated a total absence of distress, more than half of the sample declared a moderate or high distress. A total of 55% of patients presented at least three difficulties in the Problem List Checklist. Distress was not correlated with age or other medical and clinical variables. Number of emotional problems was the best predictor of distress at admission (β = 0.655, p = 0.000). Conclusion: Screening for distress in a day surgery multidisciplinary oncology division is feasible and a relevant percentage of patients can be identified as clinically distressed. Outcomes also highlight the impact of age and precise physical and psycho-social signs as prognostic indicators of clinically significant distress. Measurement of distress and associated problems list represent the preliminary endpoint toward adequate recommendations that contribute to taking care of distress in cancer patients in cost-effective clinical setting. PMID:28082946
Divall, Pip; Camosso-Stefinovic, Janette; Baker, Richard
Ownership of personal digital assistants (PDAs) and smartphones by health professionals is increasingly common. Providing the best available evidence at the point of care is important for time-poor clinical staff and may lead to benefits in the processes and outcomes of clinical care. This review was performed to investigate the usefulness of PDAs in the clinical setting. MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials were searched from 2000 to March 2010. Randomised controlled trials that evaluated the effects on the processes or outcomes of clinical care of using PDAs compared with not using a PDA were included. Two reviewers independently reviewed citations and abstracts, assessed full text articles and abstracted data from the studies. Seven trials met the review inclusion criteria, of which only three were of satisfactory quality. Studies investigated the use of PDAs either in recording patient information or in decision support for diagnoses or treatment. An increase in data collection quality was reported, and the appropriateness of diagnosis and treatment decisions was improved. PDAs appear to have potential in improving some processes and outcomes of clinical care, but the evidence is limited and reliable conclusions on whether they help, in what circumstances and how they should be used are not possible. Further research is required to assess their value and ensure full benefits from their widespread use, but the pace of technological development creates problems for the timely evaluation of these devices and their applications.
Roman, Matthew; Brown, Christopher; Richardson, William; Isaacs, Robert; Howes, Cameron; Cook, Chad
The clinical diagnosis of an osteoporotic vertebral compression fracture (OVCF) is challenging and requires detailed assessment using comprehensive imaging methods. Further complicating matter is that the clinical sequelae associated with OVCF typically involves asymptomatic findings and variable pain patterns. The purpose of this study was to identify clinical characteristics and assessment findings that were associated with a diagnosis of OVCF. The study evaluated routine clinical findings in over 1400 subjects seen at an adult spine surgery clinic for thoracolumbar spine-related conditions within the years 2005-2009. All patients underwent a standardized clinical examination that included a self-report, observational, physical examination and imaging assessment. The diagnosis of OVCF was made after assessment of radiographic findings in sagittal alignment, vertebral body compression, and spinal canal dimensions. Data from the patient history and observational findings were then statistically analyzed and compared between those patients with a diagnosis of OVCF and those with an alternative diagnosis. Based on the results, a diagnostic support tool was created to predict the likelihood of OVCF. The most diagnostic combination included a cluster of: (1) age > 52 years; (2) no presence of leg pain; (3) body mass index ⩽ 22; (4) does not exercise regularly; and (5) female gender. A finding of two of five positive tests or less demonstrated high sensitivity of 0.95 (95% CI = 0.83-0.99) and low negative likelihood ratio of 0.16 (95% CI = 0.04-0.51), providing moderate value to rule out OVCF. Four of five yielded a positive likelihood ratio (LR+) of 9.6 (95% CI = 3.7-14.9) providing moderate value in ruling in the diagnosis of OVCF. Further validation is necessary prospectively to determine the value of these findings on a disparate sample of patients in other unique environments.
Gillam, Ronald B.
This article critiques the theoretical basis of the Fast ForWord program, a computer-assisted language intervention program for children with language-learning impairments. It notes undocumented treatment outcomes and questions the clinical methods associated with the procedures. Fifteen cautionary statements are provided that clinicians may want…
Germini, Federico; Agnelli, Giancarlo; Fedele, Marta; Galli, Maria Giulia; Giustozzi, Michela; Marcucci, Maura; Paganelli, Gloria; Pinotti, Emanuele; Becattini, Cecilia
The Padua prediction score (PPS) has been suggested as the best available model for the assessment of the risk of venous thromboembolism (VTE) in hospitalized medical patients. The impact of its use in clinical practice has never been prospectively evaluated. According to a quasi-randomized study design, consecutive patients admitted to Internal Medicine Section 1 were allocated to a PPS-based decisional strategy suggesting thromboprophylaxis in patients with PPS score ≥4, and those admitted to Section 2 to a clinical judgment-based strategy. Study patients underwent complete compression ultrasonography of the lower limbs at discharge. The primary outcome was symptomatic or asymptomatic VTE during hospital stay. Secondary outcomes were VTE excluding isolated distal deep vein thrombosis, bleedings, and appropriate thromboprophylaxis. 628 patients were included in the analysis, 235 in the PPS group, and 393 in the clinical judgment group. The two groups differed for length of hospital stay, prevalence of recent trauma or surgery, and stroke. Compared with control, the PPS group had a significantly lower incidence of VTE (8.5 vs. 15.5 %, OR 0.51, 95 % CI 0.30-0.86), also after adjusting for thromboprophylaxis use and patient PPS-risk category (OR 0.54, 95 % CI 0.31-0.94). In conclusion, the use of PPS was associated with a higher rate of appropriate thromboprophylaxis prescription; no significant differences were found in the other secondary outcomes. The use of PPS for the assessment of risk for VTE is associated with a reduced incidence of VTE compared with the clinical judgment. These result needs to be confirmed in future studies.
Kloos, Richard T.
Thyroid fine-needle aspiration biopsy results are cytologically indeterminate in 15-30% of cases. When these nodules undergo diagnostic surgery, approximately three-quarters are histologically benign. These unnecessary surgeries diminish quality of life, generate complications, and increase healthcare costs. The Afirma gene expression classifier (GEC) is validated to pre-operatively identify cytologically indeterminate nodules likely to be truly benign so that surgery can be avoided. Its performance is supported by robust multicenter prospective and blinded clinical validation studies, and supported by extensive independent clinical utility publications which show a marked reduction in surgery among patients with benign Afirma GEC results. To rule-out cancer and avoid unnecessary diagnostic surgery, Afirma’s quality and depth of validation stand alone. The accuracy of a benign result is the negative predictive value (NPV). Afirma achieves an NPV ≥94% among cytologically indeterminate nodules (Bethesda III or IV). Thirteen clinical utility studies describing 1468 GEC benign patients demonstrate that few Afirma GEC benign nodules undergo surgery, including after 3 years of follow-up. With a specificity of 52%, over half of the truly benign nodules with indeterminate cytology receive a benign GEC result. High test sensitivity is critical to safely rule out cancer. The Afirma GEC’s 90% sensitivity means that regardless of the pre-test risk of malignancy, 90% of all malignant nodules are GEC suspicious. The Afirma GEC has transformed patient care. Where the majority of cytologically indeterminate patients were once operated to determine if the nodule was benign or malignant, now nearly half of these surgeries can be avoided. PMID:28117288
Van Meter, Anna; Youngstrom, Eric; Youngstrom, Jennifer Kogos; Ollendick, Thomas; Demeter, Christine; Findling, Robert L
Anxiety disorders are common among children but can be difficult to diagnose. An actuarial approach to the diagnosis of anxiety may improve the efficiency and accuracy of the process. The objectives of this study were to determine the clinical utility of the Achenbach Child Behavior Checklist (CBCL) and Youth Self Report (YSR), two widely used assessment tools, for diagnosing anxiety disorders in youth and to aid clinicians in incorporating scale scores into an actuarial approach to diagnosis through a clinical vignette. Demographically diverse youth, 5 to 18 years of age, were drawn from two samples; one (N = 1,084) was recruited from a research center, and the second (N = 651) was recruited from an urban community mental health center. Consensus diagnoses integrated information from semistructured interview, family history, treatment history, and clinical judgment. The CBCL and YSR internalizing problems T scores discriminated cases with any anxiety disorder or with generalized anxiety disorder from all other diagnoses in both samples (ps < .0005); the two scales had equivalent discriminative validity (ps > .05 for tests of difference). No other scales, nor any combination of scales, significantly improved on the performance of the Internalizing scale. In the highest risk group, Internalizing scores greater than 69 (CBCL) or greater than 63 (YSR) resulted in a Diagnostic Likelihood Ratio of 1.5; low scores reduced the likelihood of anxiety disorders by a factor of 4. Combined with other risk factor information in an actuarial approach to assessment and diagnosis, the CBCL and YSR Internalizing scales provide valuable information about whether a youth is likely suffering from an anxiety disorder.
Beam, Andrew L.; Kartoun, Uri; Pai, Jennifer K.; Chatterjee, Arnaub K.; Fitzgerald, Timothy P.; Shaw, Stanley Y.; Kohane, Isaac S.
Insomnia remains under-diagnosed and poorly treated despite its high economic and social costs. Though previous work has examined how patient characteristics affect sleep medication prescriptions, the role of physician characteristics that influence this clinical decision remains unclear. We sought to understand patient and physician factors that influence sleep medication prescribing patterns by analyzing Electronic Medical Records (EMRs) including the narrative clinical notes as well as codified data. Zolpidem and trazodone were the most widely prescribed initial sleep medication in a cohort of 1,105 patients. Some providers showed a historical preference for one medication, which was highly predictive of their future prescribing behavior. Using a predictive model (AUC = 0.77), physician preference largely determined which medication a patient received (OR = 3.13; p = 3 × 10−37). In addition to the dominant effect of empirically determined physician preference, discussion of depression in a patient’s note was found to have a statistically significant association with receiving a prescription for trazodone (OR = 1.38, p = 0.04). EMR data can yield insights into physician prescribing behavior based on real-world physician-patient interactions. PMID:28181568
Beam, Andrew L.; Kartoun, Uri; Pai, Jennifer K.; Chatterjee, Arnaub K.; Fitzgerald, Timothy P.; Shaw, Stanley Y.; Kohane, Isaac S.
Insomnia remains under-diagnosed and poorly treated despite its high economic and social costs. Though previous work has examined how patient characteristics affect sleep medication prescriptions, the role of physician characteristics that influence this clinical decision remains unclear. We sought to understand patient and physician factors that influence sleep medication prescribing patterns by analyzing Electronic Medical Records (EMRs) including the narrative clinical notes as well as codified data. Zolpidem and trazodone were the most widely prescribed initial sleep medication in a cohort of 1,105 patients. Some providers showed a historical preference for one medication, which was highly predictive of their future prescribing behavior. Using a predictive model (AUC = 0.77), physician preference largely determined which medication a patient received (OR = 3.13 p = 3 × 10‑37). In addition to the dominant effect of empirically determined physician preference, discussion of depression in a patient’s note was found to have a statistically significant association with receiving a prescription for trazodone (OR = 1.38, p = 0.04). EMR data can yield insights into physician prescribing behavior based on real-world physician-patient interactions.
Background This paper reports the findings of a study of how midwifery students responded to a simulated post partum haemorrhage (PPH). Internationally, 25% of maternal deaths are attributed to severe haemorrhage. Although this figure is far higher in developing countries, the risk to maternal wellbeing and child health problem means that all midwives need to remain vigilant and respond appropriately to early signs of maternal deterioration. Methods Simulation using a patient actress enabled the research team to investigate the way in which 35 midwifery students made decisions in a dynamic high fidelity PPH scenario. The actress wore a birthing suit that simulated blood loss and a flaccid uterus on palpation. The scenario provided low levels of uncertainty and high levels of relevant information. The student's response to the scenario was videoed. Immediately after, they were invited to review the video, reflect on their performance and give a commentary as to what affected their decisions. The data were analysed using Dimensional Analysis. Results The students' clinical management of the situation varied considerably. Students struggled to prioritise their actions where more than one response was required to a clinical cue and did not necessarily use mnemonics as heuristic devices to guide their actions. Driven by a response to single cues they also showed a reluctance to formulate a diagnosis based on inductive and deductive reasoning cycles. This meant they did not necessarily introduce new hypothetical ideas against which they might refute or confirm a diagnosis and thereby eliminate fixation error. Conclusions The students response demonstrated that a number of clinical skills require updating on a regular basis including: fundal massage technique, the use of emergency standing order drugs, communication and delegation of tasks to others in an emergency and working independently until help arrives. Heuristic devices helped the students to evaluate their
Murdach, A D
Social workers increasingly are being required to assist clients in emergency situations. Such conditions typically require rapid decision making and quick action. In this article, the processes practitioners use in their interventions in psychiatric emergencies are examined. This examination is based on concepts derived from cognitive psychology and decision-making theory. Implications for practice and training also are discussed.
decision- making. 14. SUBJECT TERMS optimal decision-making, regret, Iowa gambling task, exponentially weighted moving average, change point...Iowa Gambling Task ......................................................... 3 2. Convoy Task...81 ix LIST OF FIGURES Figure 1. The Iowa Gambling Task screenshot (from Sacchi, 2014
Lamb, B; Green, J S A; Vincent, C; Sevdalis, N
Decisions in surgical oncology are increasingly being made by multi-disciplinary teams (MDTs). Although MDTs have been widely accepted as the preferred model for cancer service delivery, the process of decision making has not been well described and there is little evidence pointing to the ideal structure of an MDT. Performance in surgery has been shown to depend on non-technical skills, such as decision making, as well as patient factors and the technical skills of the healthcare team. Application of this systems approach to MDT working allows the identification of factors that affect the quality of decision making for cancer patients. In this article we review the literature on decision making in surgical oncology and by drawing from the systems approach to surgical performance we provide a framework for understanding the process of decision making in MDTs. Technical factors that affect decision making include the information about patients, robust ICT and video-conferencing equipment, a minimum dataset with expert review of radiological and pathological information, implementation and recording of the MDTs decision. Non-technical factors with an impact on decision making include attendance of team members at meetings, leadership, teamwork, open discussion, consensus on decisions and communication with patients and primary care. Optimising these factors will strengthen the decision making process and raise the quality of care for cancer patients.
Feldman, M. S.; Sarbaugh-Thompson, M.
Electronic communication can either facilitate or sabotage decision-making contexts. This article formulates recommendations about when and how to use electronic communication to enhance decision making and describes various decision contexts. Solutions to communication problems such as groupthink, social deadlock, bureaucratic isolation from…
Duryea, Elias J.
A position statement is offered that clarifies the function, role, and emphasis of decision making within the field of health education, and a rationale that proposes that health decision-making efforts be limited to areas where evidence links a health behavior (i.e., smoking) to a health problem (i.e., lung cancer) is presented. (Author/CJ)
Paddock, Susan C.; Sferra, Bobbie A.
This handbook for parents defines and describes the process of citizen participation in educational decision making. After describing the history of citizen involvement, the booklet answers questions regarding why and how community members can become involved in policy formation. Problems in participatory decision making and strategies for…
Gillam, Ronald B
A computer-assisted language intervention program called Fast ForWord® (Scientific Learning Corporation, 1998) has received a great deal of attention at professional meetings and in the popular media. Newspaper and magazine articles about this program contain statements like, "On average, after only 6 to 7 weeks of training, language-learning impaired children ages 4 to 12 showed improvement of more than one and a half years in speech processing and language ability." (Scientific Learning Corporation, 1997). Are the claims that are being made about this intervention approach just a matter of product promotion, or is this really a scientifically proven remedy for language-learning impairments? This article critiques the theoretical basis of Fast ForWord®, the documented treatment outcomes, and the clinical methods associated with the procedure. Fifteen cautionary statements are provided that clinicians may want to consider before they recommend Fast ForWord® intervention for the children they serve.
Heiberg, J; El-Ansary, D; Canty, D J; Royse, A G; Royse, C F
Focused echocardiography is becoming a widely used tool to aid clinical assessment by anaesthetists and critical care physicians. At the present time, most physicians are not yet trained in focused echocardiography or believe that it may result in adverse outcomes by delaying, or otherwise interfering with, time-critical patient management. We performed a systematic review of electronic databases on the topic of focused echocardiography in anaesthesia and critical care. We found 18 full text articles, which consistently reported that focused echocardiography may be used to identify or exclude previously unrecognised or suspected cardiac abnormalities, resulting in frequent important changes to patient management. However, most of the articles were observational studies with inherent design flaws. Thirteen prospective studies, including two that measured patient outcome, were supportive of focused echocardiography, whereas five retrospective cohort studies, including three outcome studies, did not support focused echocardiography. There is an urgent requirement for randomised controlled trials.
Kieslich, Katharina; Littlejohns, Peter
Introduction Clinical commissioning groups (CCGs) in England are tasked with making difficult decisions on which healthcare services to provide against the background of limited budgets. The question is how to ensure that these decisions are fair and legitimate. Accounts of what constitutes fair and legitimate priority setting in healthcare include Daniels’ and Sabin's accountability for reasonableness (A4R) and Clark's and Weale's framework for the identification of social values. This study combines these accounts and asks whether the decisions of those CCGs that adhere to elements of such accounts are perceived as fairer and more legitimate by key stakeholders. The study addresses the empirical gap arising from a lack of research on whether frameworks such as A4R hold what they promise. It aims to understand the criteria that feature in CCG decision-making. Finally, it examines the usefulness of a decision-making audit tool (DMAT) in identifying the process and content criteria that CCGs apply when making decisions. Methods and analysis The adherence of a sample of CCGs to criteria emerging from theories of fair priority setting will be examined using the DMAT developed by PL. The results will be triangulated with data from semistructured interviews with key stakeholders in the CCG sample to ascertain whether there is a correlation between those CCGs that performed well in the DMAT exercise and those whose decisions are perceived positively by interviewees. Descriptive statistical methods will be used to analyse the DMAT data. A combination of quantitative and qualitative content analysis methods will be used to analyse the interview transcripts. Ethics and dissemination Full ethics approval was received by the King's College London Biomedical Sciences, Dentistry, Medicine and Natural and Mathematical Sciences Research Ethics Subcommittee. The results of the study will be disseminated through publications in peer review journals. PMID:26163034
McMinn, Bryan G; Lewin, Terry J; Savio, Naveen; Matters, Dawn; Smith, Carol
Prior to introduction of the Health of the Nation Outcome Scale 65+ (HoNOS65) as a mandated measure, the three subacute mental health units for older people in the present study routinely used the Care Planning Assessment Tool (CPAT) for clinical review and discharge planning. The aims of the present study were to compare these two measures of behavioural change during subacute admissions, to examine associations with discharge readiness, and to assess their overall contributions to discharge planning decisions. This is a prospective, comparative measurement study. HoNOS65 (severity) and CPAT (frequency) behavioural subscale ratings were collected from admission to discharge for older patients with very severe and persistent behavioural and psychological symptoms of dementia. Readiness for discharge data (yes/no), collected from multidisciplinary review meetings, was used as the outcome in all analyses. In combination, these measures achieved only modest positive predictive value (52.8%) but good negative predictive value (90.4%). Consequently, patients above the cut-point on both measures are reasonably unlikely to be discharge ready. The combined use of a standard outcome measure of severity along with a specialized measure of frequency is recommended to support and enhance discharge planning decisions in this population.
Background Falls in the elderly is a major problem. Although falls have a multifactorial etiology, a commonly cited cause of falls in older people is poor vision. This study proposes a method to discriminate fallers and non-fallers among ophthalmic patients, based on data-mining algorithms applied to health and socio-demographic information. Methods A group of 150 subjects aged 55 years and older, recruited at the Eye Clinic of the Second University of Naples, underwent a baseline ophthalmic examination and a standardized questionnaire, including lifestyles, general health, social engagement and eyesight problems. A subject who reported at least one fall within one year was considered as faller, otherwise as non-faller. Different tree-based data-mining algorithms (i.e., C4.5, Adaboost and Random Forest) were used to develop automatic classifiers and their performances were evaluated by assessing the receiver-operator characteristics curve estimated with the 10-fold-crossvalidation approach. Results The best predictive model, based on Random Forest, enabled to identify fallers with a sensitivity and specificity rate of 72.6% and 77.9%, respectively. The most informative variables were: intraocular pressure, best corrected visual acuity and the answers to the total difficulty score of the Activities of Daily Vision Scale (a questionnaire for the measurement of visual disability). Conclusions The current study confirmed that some ophthalmic features (i.e. cataract surgery, lower intraocular pressure values) could be associated with a lower fall risk among visually impaired subjects. Finally, automatic analysis of a combination of visual function parameters (either self-evaluated either by ophthalmological tests) and other health information, by data-mining algorithms, could be a feasible tool for identifying fallers among ophthalmic patients. PMID:26391731
Arthur, R.; Sibani, P.
We discuss fitness landscapes and how they can be modified to account for co-evolution. We are interested in using the landscape as a way to model rational decision making in a toy economic system. We develop a model very similar to the Tangled Nature Model of Christensen et al. that we call the Tangled Decision Model. This is a natural setting for our discussion of co-evolutionary fitness landscapes. We use a Monte Carlo step to simulate decision making and investigate two different decision making procedures.
Goulet-Kennedy, Julie; Labbe, Sara; Fecteau, Shirley
Decision making has been extensively studied in the context of economics and from a group perspective, but still little is known on individual decision making. Here we discuss the different cognitive processes involved in decision making and its associated neural substrates. The putative conductors in decision making appear to be the prefrontal cortex and the striatum. Impaired decision-making skills in various clinical populations have been associated with activity in the prefrontal cortex and in the striatum. We highlight the importance of strengthening the degree of integration of both cognitive and neural substrates in order to further our understanding of decision-making skills. In terms of cognitive paradigms, there is a need to improve the ecological value of experimental tasks that assess decision making in various contexts and with rewards; this would help translate laboratory learnings into real-life benefits. In terms of neural substrates, the use of neuroimaging techniques helps characterize the neural networks associated with decision making; more recently, ways to modulate brain activity, such as in the prefrontal cortex and connected regions (eg, striatum), with noninvasive brain stimulation have also shed light on the neural and cognitive substrates of decision making. Together, these cognitive and neural approaches might be useful for patients with impaired decision-making skills. The drive behind this line of work is that decision-making abilities underlie important aspects of wellness, health, security, and financial and social choices in our daily lives. PMID:27069380
Goulet-Kennedy, Julie; Labbe, Sara; Fecteau, Shirley
Decision making has been extensively studied in the context of economics and from a group perspective, but still little is known on individual decision making. Here we discuss the different cognitive processes involved in decision making and its associated neural substrates. The putative conductors in decision making appear to be the prefrontal cortex and the striatum. Impaired decision-making skills in various clinical populations have been associated with activity in the prefrontal cortex and in the striatum. We highlight the importance of strengthening the degree of integration of both cognitive and neural substrates in order to further our understanding of decision-making skills. In terms of cognitive paradigms, there is a need to improve the ecological value of experimental tasks that assess decision making in various contexts and with rewards; this would help translate laboratory learnings into real-life benefits. In terms of neural substrates, the use of neuroimaging techniques helps characterize the neural networks associated with decision making; more recently, ways to modulate brain activity, such as in the prefrontal cortex and connected regions (eg, striatum), with noninvasive brain stimulation have also shed light on the neural and cognitive substrates of decision making. Together, these cognitive and neural approaches might be useful for patients with impaired decision-making skills. The drive behind this line of work is that decision-making abilities underlie important aspects of wellness, health, security, and financial and social choices in our daily lives.
Pearson, John M; Watson, Karli K; Platt, Michael L
Neuroeconomics applies models from economics and psychology to inform neurobiological studies of choice. This approach has revealed neural signatures of concepts like value, risk, and ambiguity, which are known to influence decision making. Such observations have led theorists to hypothesize a single, unified decision process that mediates choice behavior via a common neural currency for outcomes like food, money, or social praise. In parallel, recent neuroethological studies of decision making have focused on natural behaviors like foraging, mate choice, and social interactions. These decisions strongly impact evolutionary fitness and thus are likely to have played a key role in shaping the neural circuits that mediate decision making. This approach has revealed a suite of computational motifs that appear to be shared across a wide variety of organisms. We argue that the existence of deep homologies in the neural circuits mediating choice may have profound implications for understanding human decision making in health and disease.
Deco, Gustavo; Rolls, Edmund T.; Romo, Ranulfo
During decision making between sequential stimuli, the first stimulus must be held in memory and then compared with the second. Here, we show that in systems that encode the stimuli by their firing rate, neurons can use synaptic facilitation not only to remember the first stimulus during the delay but during the presentation of the second stimulus so that they respond to a combination of the first and second stimuli, as has been found for “partial differential” neurons recorded in the ventral premotor cortex during vibrotactile flutter frequency decision making. Moreover, we show that such partial differential neurons provide important input to a subsequent attractor decision-making network that can then compare this combination of the first and second stimuli with inputs from other neurons that respond only to the second stimulus. Thus, both synaptic facilitation and neuronal attractor dynamics can account for sequential decision making in such systems in the brain. PMID:20360555
Pearson, John M.; Watson, Karli K.; Platt, Michael L.
Neuroeconomics applies models from economics and psychology to inform neurobiological studies of choice. This approach has revealed neural signatures of concepts like value, risk, and ambiguity, which are known to influence decision-making. Such observations have led theorists to hypothesize a single, unified decision process that mediates choice behavior via a common neural currency for outcomes like food, money, or social praise. In parallel, recent neuroethological studies of decision-making have focused on natural behaviors like foraging, mate choice, and social interactions. These decisions strongly impact evolutionary fitness and thus are likely to have played a key role in shaping the neural circuits that mediate decision-making. This approach has revealed a suite of computational motifs that appear to be shared across a wide variety of organisms. We argue that the existence of deep homologies in the neural circuits mediating choice may have profound implications for understanding human decision-making in health and disease. PMID:24908481
Marzorati, Chiara; Pravettoni, Gabriella
In the last 10 years, value has played a key role in the health care system. In this concept, innovations in medical practice and the increasing importance of patient centeredness have contributed to draw the attention of the medical community. Nonetheless, a large consensus on the meaning of “value” is still lacking: patients, physicians, policy makers, and other health care professionals have different ideas on which component of value may play a prominent role. Yet, shared clinical decision-making and patient empowerment have been recognized as fundamental features of the concept of value. Different paradigms of health care system embrace different meanings of value, and the absence of common and widely accepted definition does not help to identify a unique model of care in health care system. Our aim is to provide an overview of those paradigms that have considered value as a key theoretical concept and to investigate how the presence of value can influence the medical practice. This article may contribute to draw attention toward patients and propose a possible link between health care system based on “value” and new paradigms such as patient-centered system (PCS), patient empowerment, and P5 medicine, in order to create a predictive, personalized, preventive, participatory, and psycho-cognitive model to treat patients. Indeed, patient empowerment, value-based system, and P5 medicine seem to shed light on different aspects of a PCS, and this allows a better understanding of people under care. PMID:28356752
Marzorati, Chiara; Pravettoni, Gabriella
In the last 10 years, value has played a key role in the health care system. In this concept, innovations in medical practice and the increasing importance of patient centeredness have contributed to draw the attention of the medical community. Nonetheless, a large consensus on the meaning of "value" is still lacking: patients, physicians, policy makers, and other health care professionals have different ideas on which component of value may play a prominent role. Yet, shared clinical decision-making and patient empowerment have been recognized as fundamental features of the concept of value. Different paradigms of health care system embrace different meanings of value, and the absence of common and widely accepted definition does not help to identify a unique model of care in health care system. Our aim is to provide an overview of those paradigms that have considered value as a key theoretical concept and to investigate how the presence of value can influence the medical practice. This article may contribute to draw attention toward patients and propose a possible link between health care system based on "value" and new paradigms such as patient-centered system (PCS), patient empowerment, and P5 medicine, in order to create a predictive, personalized, preventive, participatory, and psycho-cognitive model to treat patients. Indeed, patient empowerment, value-based system, and P5 medicine seem to shed light on different aspects of a PCS, and this allows a better understanding of people under care.
Dunger, Christine; Schnell, Martin W; Bausewein, Claudia
Introduction Decision-making (DM) in healthcare can be understood as an interactive process addressing decision makers' reasoning as well as their visible behaviour after the decision is made. Other key elements of DM are ethical aspects and the role as well as the treatment options of the examined professions. Nurses' DM to choose interventions in situations of severe breathlessness is such interactions. They are also ethically relevant regarding the vulnerability of affected patients and possible restrictions or treatment options. The study aims to explore which factors influence nurses' DM to use nursing interventions in situations where patients suffer from severe breathlessness. Methods and analysis Qualitative study including nurses in German hospital wards and hospices. A triangulation of different methods of data collection—participant observation and qualitative expert interviews—and analysis merge in a reflexive grounded theory approach which integrates Goffman's framework analysis. It allows an analysis of nurses' self-statements about DM, their behaviour in relevant clinical situations and its influences. Data collection and analysis will be examined simultaneously. Ethics and dissemination Informed consent will be gained from all participants and the institutional stakeholders. Ongoing consent has to be ensured since observations will take place in healthcare institutions and many patients will be highly vulnerable. The study has been evaluated and approved by the Witten/Herdecke University Ethics Committee, Witten, Germany. Results of the study will be published at congresses and in journal papers.
Kustusch, Mary Bridget; Ptak, Corey; Sayre, Eleanor C.; Franklin, Scott V.
It is increasingly common in physics classes for students to work together to solve problems and perform laboratory experiments. When students work together, they need to negotiate the roles and decision making within the group. We examine how a large group of students negotiates authority as part of their two week summer College Readiness Program at Rochester Institute of Technology. The program is designed to develop metacognitive skills in first generation and Deaf and hard-of-hearing (DHH) STEM undergraduates through cooperative group work, laboratory experimentation, and explicit reflection exercises. On the first full day of the program, the students collaboratively developed a sign for the word ``metacognition'' for which there is not a sign in American Sign Language. This presentation will focus on three aspects of the ensuing discussion: (1) how the instructor communicated expectations about decision making; (2) how the instructor promoted student-driven decision making rather than instructor-driven policy; and (3) one student's shifts in decision making behavior. We conclude by discussing implications of this research for activity-based physics instruction.
Orasanu, Judith; Shafto, Michael G. (Technical Monitor)
The Importance of decision-making to safety in complex, dynamic environments like mission control centers, aviation, and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. Yet laboratory research on decision making has not proven especially helpful In improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multi-dimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication contributes to performance because it assures that
König, Niklas; Singh, Navrag B.; Baumann, Christian R.; Taylor, William R.
A disturbed, inconsistent walking pattern is a common feature of patients with Parkinson's disease (PwPD). Such extreme variability in both temporal and spatial parameters of gait has been associated with unstable walking and an elevated prevalence of falls. However, despite their ability to discretise healthy from pathological function, normative variability values for key gait parameters are still missing. Furthermore, an understanding of each parameter's response to pathology, as well as the inter-parameter relationships, has received little attention. The aim of this systematic literature review and meta-analysis was therefore to define threshold levels for pathological gait variability as well as to investigate whether all gait parameters are equally perturbed in PwPD. Based on a broader systematic literature search that included 13′195 titles, 34 studies addressed Parkinson's disease, presenting 800 PwPD and 854 healthy subjects. Eight gait parameters were compared, of which six showed increased levels of variability during walking in PwPD. The most commonly reported parameter, coefficient of variation of stride time, revealed an upper threshold of 2.4% to discriminate the two groups. Variability of step width, however, was consistently lower in PwPD compared to healthy subjects, and therefore suggests an explicit sensory motor system control mechanism to prioritize balance during walking. The results provide a clear functional threshold for monitoring treatment efficacy in patients with Parkinson's disease. More importantly, however, quantification of specific functional deficits could well provide a basis for locating the source and extent of the neurological damage, and therefore aid clinical decision-making for individualizing therapies. PMID:27445759
Business educators should give students specific training in a methodology which will enable them to make logical, systematic, and rational decisions. Kepner-Tregoe Analysis (KTA), a decision making model, is described and illustrated with an example of a student buying his first car. (SC)
Thompson, Bertha Boya
Suggests a decision-making model that can be applied by high school students to a variety of environmental problems, and illustrates how the model can be used to make decisions concerning future energy shortages. Provides criteria for judging allocation priorities of limited resources and stimulates awareness of alternative solutions to energy…
Szu, Harold; Jung, TP; Makeig, Scott
We propose to enhance the decision making of pilot, co-pilot teams, over a range of vehicle platforms, with the aid of neuroscience. The goal is to optimize this collaborative decision making interplay in time-critical, stressful situations. We will research and measure human facial expressions, personality typing, and brainwave measurements to help answer questions related to optimum decision-making in group situations. Further, we propose to examine the nature of intuition in this decision making process. The brainwave measurements will be facilitated by a University of California, San Diego (UCSD) developed wireless Electroencephalography (EEG) sensing cap. We propose to measure brainwaves covering the whole head area with an electrode density of N=256, and yet keep within the limiting wireless bandwidth capability of m=32 readouts. This is possible because solving Independent Component Analysis (ICA) and finding the hidden brainwave sources allow us to concentrate selective measurements with an organized sparse source -->s sensing matrix [Φs], rather than the traditional purely random compressive sensing (CS) matrix[Φ].
Abdullah, Suhaily; Majid, Faizah Abd
Teacher decision making involves a selection of options that leads to thinking processes, underlying teaching in language classroom contexts. Due to this, as a small part of an on-going postgraduate research, this exploratory case study shares the initial findings on the lecturers' decision-making effects on their classroom orientation. Four…
Kabler, Michael L.; Genshaft, Judy L.
Three areas related to decision making are discussed: (1) a research survey summary of multidisciplinary team decision making (MTD); (2) four approaches for structuring MTD decision making; and (3) styles of leadership as a factor that impacts on the decision-making teams. (Author/PN)
With the dissemination of non-invasive human neuroimaging techniques such as fMRI and the advancement of cognitive science, neuroimaging studies focusing on emotions and social cognition have become established. Along with this advancement, behavioral economics taking emotional and social factors into account for economic decisions has been merged with neuroscientific studies, and this interdisciplinary approach is called neuroeconomics. Past neuroeconomics studies have demonstrated that subcortical emotion-related brain structures play an important role in "irrational" decision-making. The research field that investigates the role of central neurotransmitters in this process is worthy of further development. Here, we provide an overview of recent molecular neuroimaging studies to further the understanding of the neurochemical basis of "irrational" or emotional decision-making and the future direction, including clinical implications, of the field.
García-Altés, Anna; Argimon, Josep M
Improving the quality and transparency of governmental healthcare decision-making has an impact on the health of the population through policies, organisational management and clinical practice. Moreover, the comparison between healthcare centres and the transparent feedback of results to professionals and to the wider public contribute directly to improved results. The "Results Centre" of the Catalan healthcare system measures and disseminates the results achieved by the different healthcare centres in order to facilitate a shared decision-making process, thereby enhancing the quality of healthcare provided to the population of Catalonia (Spain). This is a pioneering initiative in Spain and is aligned with the most advanced countries in terms of policies of transparency and accountability.
Kerr, Norbert L; Tindale, R Scott
Theory and research on small group performance and decision making is reviewed. Recent trends in group performance research have found that process gains as well as losses are possible, and both are frequently explained by situational and procedural contexts that differentially affect motivation and resource coordination. Research has continued on classic topics (e.g., brainstorming, group goal setting, stress, and group performance) and relatively new areas (e.g., collective induction). Group decision making research has focused on preference combination for continuous response distributions and group information processing. New approaches (e.g., group-level signal detection) and traditional topics (e.g., groupthink) are discussed. New directions, such as nonlinear dynamic systems, evolutionary adaptation, and technological advances, should keep small group research vigorous well into the future.
Rabinovich, Mikhail I.; Huerta, Ramón; Afraimovich, Valentin
We suggest a new paradigm for intelligent decision-making suitable for dynamical sequential activity of animals or artificial autonomous devices that depends on the characteristics of the internal and external world. To do it we introduce a new class of dynamical models that are described by ordinary differential equations with a finite number of possibilities at the decision points, and also include rules solving this uncertainty. Our approach is based on the competition between possible cognitive states using their stable transient dynamics. The model controls the order of choosing successive steps of a sequential activity according to the environment and decision-making criteria. Two strategies (high-risk and risk-aversion conditions) that move the system out of an erratic environment are analyzed.
Garcia, Luiz Henrique Costa; Ferreira, Bruna Cortez
The present study was aimed at proposing a systematic evaluation of cranial computed tomography, identifying the main aspects to be analyzed in order to facilitate the decision making process regarding diagnosis and management in emergency settings. The present descriptive study comprised a literature review at the following databases: Access Medicine and Access Emergency Medicine (McGraw- Hill Education); British Medical Journal Evidence Center; UptoDate; Bireme; PubMed; Lilacs; SciELO; ProQuest; Micromedex (Thomson Reuters); Embase. Once the literature review was completed, the authors identified the main diseases with tomographic repercussions and proposed the present system to evaluate cranial computed tomography images. An easy-to-memorize ABC system will facilitate the decision making in emergency settings, as it covers the main diseases encountered by intensivists and emergency physicians, and provides a sequential guidance about anatomical structures to be investigated as well as their respective alterations. PMID:25987751
Garcia, Luiz Henrique Costa; Ferreira, Bruna Cortez
The present study was aimed at proposing a systematic evaluation of cranial computed tomography, identifying the main aspects to be analyzed in order to facilitate the decision making process regarding diagnosis and management in emergency settings. The present descriptive study comprised a literature review at the following databases: Access Medicine and Access Emergency Medicine (McGraw- Hill Education); British Medical Journal Evidence Center; UptoDate; Bireme; PubMed; Lilacs; SciELO; ProQuest; Micromedex (Thomson Reuters); Embase. Once the literature review was completed, the authors identified the main diseases with tomographic repercussions and proposed the present system to evaluate cranial computed tomography images. An easy-to-memorize ABC system will facilitate the decision making in emergency settings, as it covers the main diseases encountered by intensivists and emergency physicians, and provides a sequential guidance about anatomical structures to be investigated as well as their respective alterations.
Simons, Pascale; Benders, Jos; Bergs, Jochen; Marneffe, Wim; Vandijck, Dominique
Purpose - Sustainable improvement is likely to be hampered by ambiguous objectives and uncertain cause-effect relations in care processes (the organization's decision-making context). Lean management can improve implementation results because it decreases ambiguity and uncertainties. But does it succeed? Many quality improvement (QI) initiatives are appropriate improvement strategies in organizational contexts characterized by low ambiguity and uncertainty. However, most care settings do not fit this context. The purpose of this paper is to investigate whether a Lean-inspired change program changed the organization's decision-making context, making it more amenable for QI initiatives. Design/methodology/approach - In 2014, 12 professionals from a Dutch radiotherapy institute were interviewed regarding their perceptions of a Lean program in their organization and the perceived ambiguous objectives and uncertain cause-effect relations in their clinical processes. A survey (25 questions), addressing the same concepts, was conducted among the interviewees in 2011 and 2014. The structured interviews were analyzed using a deductive approach. Quantitative data were analyzed using appropriate statistics. Findings - Interviewees experienced improved shared visions and the number of uncertain cause-effect relations decreased. Overall, more positive (99) than negative Lean effects (18) were expressed. The surveys revealed enhanced process predictability and standardization, and improved shared visions. Practical implications - Lean implementation has shown to lead to greater transparency and increased shared visions. Originality/value - Lean management decreased ambiguous objectives and reduced uncertainties in clinical process cause-effect relations. Therefore, decision making benefitted from Lean increasing QI's sustainability.
Souther, J. W.
The need to teach informational writing as a decision-making process is discussed. Situational analysis, its relationship to decisions in writing, and the need for relevant assignments are considered. Teaching students to ask the right questions is covered. The need to teach writing responsiveness is described. Three steps to get started and four teaching techniques are described. The information needs of the 'expert' and the 'manager' are contrasted.
Einhom and Hogarth (1979) Mynatt , Doherty, and Tweney (1977) Wason and Johnson-Laird (1972) 2. Decision making Models: These are not usually mathematical...395-416. Mynatt , C. R., M. E. Doherty, and R. D. Tweney. "Confirmation bias in a simulated research environment: an experimental study of scientific...Telephone Interview, 1998. Mynatt , C. R., M. E. Doherty, and R. D. Tweney. "Confirmation bias in a simulated research environment: an experimental
Insabato, Andrea; Pannunzi, Mario; Rolls, Edmund T; Deco, Gustavo
Neurons have been recorded that reflect in their firing rates the confidence in a decision. Here we show how this could arise as an emergent property in an integrate-and-fire attractor network model of decision making. The attractor network has populations of neurons that respond to each of the possible choices, each biased by the evidence for that choice, and there is competition between the attractor states until one population wins the competition and finishes with high firing that represents the decision. Noise resulting from the random spiking times of individual neurons makes the decision making probabilistic. We also show that a second attractor network can make decisions based on the confidence in the first decision. This system is supported by and accounts for neuronal responses recorded during decision making and makes predictions about the neuronal activity that will be found when a decision is made about whether to stay with a first decision or to abort the trial and start again. The research shows how monitoring can be performed in the brain and this has many implications for understanding cognitive functioning.
A number of different types of health decisions and choices can be distinguished from a wide range: individual decisions, health policy decisions, health action decisions, regulatory decisions regarding the health system, micro-level health decisions and decisions made outside of the health sector. With regard to health-related matters, decision-making is characterised by the level of uncertainty, the complexity of the health system and its structure, the role of urgency and the obligation to act; however, there is a significant emotional factor in these decisions and the supremacy of the individual in the decision-making process. On the policy side, health-related decision-making poses questions concerning the role of expertise and necessitates the development of public debate. The issue of a better balance between the quest for security and safety and respect for civil liberties and rights should be more and more acute in the future. As for the matter of health financing, namely through social security and insurance, it calls for a re-examination of the economic analysis of health decisions and policy and the development of a more coherent position on the right to health versus the right to universal coverage.
Adida, M; Maurel, M; Kaladjian, A; Fakra, E; Lazerges, P; Da Fonseca, D; Belzeaux, R; Cermolacce, M; Azorin, J-M
Abnormalities involving the prefrontal cortex (PFC) have long been postulated to underpin the pathophysiology of schizophrenia. Investigations of PFC integrity have focused mainly on the dorsolateral PFC (DLPFC) and abnormalities in this region have been extensively documented. However, defects in schizophrenia may extend to other prefrontal regions, including the ventromedial PFC (VMPFC), and evidence of VMPFC abnormalities comes from neuropathological, structural and functional studies. Patients with acquired brain injury to the VMPFC display profound disruption of social behaviour and poor judgment in their personal lives. The Iowa Gambling Task (IGT) was developed to assess decision-making in these neurological cases : it presents a series of 100 choices from four card decks that differ in the distribution of rewarding and punishing outcomes. Whilst healthy volunteers gradually develop a preference for the two "safe" decks over the course of the task, patients with VMPFC lesions maintain a preference for the two "risky" decks which are associated with high reinforcement in the short term, but significant long-term debt. Interestingly, damage to VMPFC may cause both poor performance on the IGT and lack of insight concerning the acquired personality modification. Recently, our group reported a trait-related decisionmaking impairment in the three phases of bipolar disorder. In a PET study, VMPFC dysfunction was shown in bipolar manic patients impaired on a decision-making task and an association between decision-making cognition and lack of insight was described in mania. A quantitative association between grey matter volume of VMPFC and memory impairment was previously reported in schizophrenia. Research suggests that lack of insight is a prevalent feature in schizophrenia patients, like auditory hallucinations, paranoid or bizarre delusions, and disorganized speech and thinking. Because schizophrenia is associated with significant social or occupational
Gleichgerrcht, Ezequiel; Ibáñez, Agustín; Roca, María; Torralva, Teresa; Manes, Facundo
A large proportion of human social neuroscience research has focused on the issue of decision-making. Impaired decision-making is a symptomatic feature of a number of neurodegenerative diseases, but the nature of these decision-making deficits depends on the particular disease. Thus, examining the qualitative differences in decision-making impairments associated with different neurodegenerative diseases could provide valuable information regarding the underlying neural basis of decision-making. Nevertheless, few comparative reports of decision-making across patient groups exist. In this Review, we examine the neuroanatomical substrates of decision-making in relation to the neuropathological changes that occur in Alzheimer disease, frontotemporal dementia, Parkinson disease and Huntington disease. We then examine the main findings from studies of decision-making in these neurodegenerative diseases. Finally, we suggest a number of recommendations that future studies could adopt to aid our understanding of decision-making cognition.
Marino, Patricia; Siani, Carole; Bertucci, François; Roche, Henri; Martin, Anne-Laure; Viens, Patrice; Seror, Valérie
The use of taxanes to treat node-positive (N+) breast cancer patients is associated with heterogeneous benefits as well as with morbidity and financial costs. This study aimed to assess the economic impact of using gene expression profiling to guide decision-making about chemotherapy, and to discuss the coverage/reimbursement issues involved. Retrospective data on 246 patients included in a randomised trial (PACS01) were analyzed. Tumours were genotyped using DNA microarrays (189-gene signature), and patients were classified depending on whether or not they were likely to benefit from chemotherapy regimens without taxanes. Standard anthracyclines plus taxane chemotherapy (strategy AT) was compared with the innovative strategy based on genomic testing (GEN). Statistical analyses involved bootstrap methods and sensitivity analyses. The AT and GEN strategies yielded similar 5-year metastasis-free survival rates. In comparison with AT, GEN was cost-effective when genomic testing costs were less than 2,090€. With genomic testing costs higher than 2,919€, AT was cost-effective. Considering a 30% decrease in the price of docetaxel (the patent rights being about to expire), GEN was cost-effective if the cost of genomic testing was in the 0€-1,139€, range; whereas AT was cost-effective if genomic testing costs were higher than 1,891€. The use of gene expression profiling to guide decision-making about chemotherapy for N+ breast cancer patients is potentially cost-effective. Since genomic testing and the drugs targeted in these tests yield greater well-being than the sum of those resulting from separate use, questions arise about how to deal with extra well-being in decision-making about coverage/reimbursement.
Carpenter, Stephanie M.; Yoon, Carolyn
Research on consumer decision making and aging is especially important for fostering a better understanding of ways to maintain consumer satisfaction and high decision quality across the life span. We provide a review of extant research on the effects of normal aging on cognition and decision processes and how these age-related processes are influenced by task environment, meaningfulness of the task, and consumer expertise. We consider how research centered on these topics generates insights about changes in consumption decisions that occur with aging and identify a number of gaps and directions for future research. PMID:22360794
Forsythe, J. Chris; Speed, Ann E.; Jordan, Sabina E.; Xavier, Patrick G.
A method for computer emulation of human decision making defines a plurality of concepts related to a domain and a plurality of situations related to the domain, where each situation is a combination of at least two of the concepts. Each concept and situation is represented in the computer as an oscillator output, and each situation and concept oscillator output is distinguishable from all other oscillator outputs. Information is input to the computer representative of detected concepts, and the computer compares the detected concepts with the stored situations to determine if a situation has occurred.
Fessler, J F; Adams, S B
Decision making in ruminant orthopedics is determined by many factors, the most of important of which is age, size, and value of the patient, the nature of the injury, the prognosis for effective treatment and satisfactory healing, the intentions of the client, and the experiences of the veterinarian. Ruminant orthopedics currently is expanding to include the treatment of llamas and small ruminants as companion animals in addition to the treatment of valuable livestock. The future promises increasing sophistication in treatments and an ever higher quality of patient care.
Chen, Stephanie Y.; Ross, Brian H.; Murphy, Gregory L.
Two experiments investigated how category information is used in decision making under uncertainty and whether the framing of category information influences how it is used. Subjects were presented with vignettes in which the categorization of a critical item was ambiguous and were asked to choose among a set of actions with the goal of attaining the desired outcome for the main character in the story. The normative decision making strategy was to base the decision on all possible categories; however, research on a related topic, category-based induction, has found that people often only consider a single category when making predictions when categorization is uncertain. These experiments found that subjects tend to consider multiple categories when making decisions, but do so both when it is and is not appropriate, suggesting that use of multiple categories is not driven by an understanding of whether categories are relevant to the decision. Similarly, although a framing manipulation increased the rate of multiple-category use, it did so in situations in which multiple-category use both was and was not appropriate. PMID:25309475
Keller, Sara R; Hayes, Gillian R; Dorr, David A; Ash, Joan S; Sittig, Dean F
Background Patient-generated health data (PGHD) are health-related data created or recorded by patients to inform their self-care and understanding about their own health. PGHD is different from other patient-reported outcome data because the collection of data is patient-driven, not practice- or research-driven. Technical applications for assisting patients to collect PGHD supports self-management activities such as healthy eating and exercise and can be important for preventing and managing disease. Technological innovations (eg, activity trackers) are making it more common for people to collect PGHD, but little is known about how PGHD might be used in outpatient clinics. Objective The objective of our study was to examine the experiences of health care professionals who use PGHD in outpatient clinics. Methods We conducted an evaluation of Project HealthDesign Round 2 to synthesize findings from 5 studies funded to test tools designed to help patients collect PGHD and share these data with members of their health care team. We conducted semistructured interviews with 13 Project HealthDesign study team members and 12 health care professionals that participated in these studies. We used an immersion-crystallization approach to analyze data. Our findings provide important information related to health care professionals’ attitudes toward and experiences with using PGHD in a clinical setting. Results Health care professionals identified 3 main benefits of PGHD accessibility in clinical settings: (1) deeper insight into a patient’s condition; (2) more accurate patient information, particularly when of clinical relevance; and (3) insight into a patient’s health between clinic visits, enabling revision of care plans for improved health goal achievement, while avoiding unnecessary clinic visits. Study participants also identified 3 areas of consideration when implementing collection and use of PGHD data in clinics: (1) developing practice workflows and protocols
Weber, Elke U; Johnson, Eric J
A full range of psychological processes has been put into play to explain judgment and choice phenomena. Complementing work on attention, information integration, and learning, decision research over the past 10 years has also examined the effects of goals, mental representation, and memory processes. In addition to deliberative processes, automatic processes have gotten closer attention, and the emotions revolution has put affective processes on a footing equal to cognitive ones. Psychological process models provide natural predictions about individual differences and lifespan changes and integrate across judgment and decision making (JDM) phenomena. "Mindful" JDM research leverages our knowledge about psychological processes into causal explanations for important judgment and choice regularities, emphasizing the adaptive use of an abundance of processing alternatives. Such explanations supplement and support existing mathematical descriptions of phenomena such as loss aversion or hyperbolic discounting. Unlike such descriptions, they also provide entry points for interventions designed to help people overcome judgments or choices considered undesirable.
Focuses on the use of graphic representations to enable students to improve their decision making skills in the social studies. Explores three visual aids used in assisting students with decision making: (1) the force field; (2) the decision tree; and (3) the decision making grid. (CMK)
Amir, Tami; Gati, Itamar
The present research investigated the relations among the measured and the expressed career decision-making difficulties in a sample of 299 young adults who intended to apply to college or university. As hypothesised, the correlations between career decision-making difficulties, as measured by the Career Decision-Making Difficulties Questionnaire…
Montyla, Timo; Still, Johanna; Gullberg, Stina; Del Missier, Fabio
Objectives: This study examined decision-making competence in ADHD by using multiple decision tasks with varying demands on analytic versus affective processes. Methods: Adults with ADHD and healthy controls completed two tasks of analytic decision making, as measured by the Adult Decision-Making Competence (A-DMC) battery, and two affective…
Bridge, Jeffrey A.; McBee-Strayer, Sandra M.; Cannon, Elizabeth A.; Sheftall, Arielle H.; Reynolds, Brady; Campo, John V.; Pajer, Kathleen A.; Barbe, Remy P.; Brent, David A.
Objective: Decision-making deficits have been linked to suicidal behavior in adults. However, it remains unclear whether impaired decision making plays a role in the etiopathogenesis of youth suicidal behavior. The purpose of this study was to examine decision-making processes in adolescent suicide attempters and never-suicidal comparison…
Use of statistical and pharmacokinetic-pharmacodynamic modeling and simulation to improve decision-making: A section summary report of the trends and innovations in clinical trial statistics conference.
Kimko, Holly; Berry, Seth; O'Kelly, Michael; Mehrotra, Nitin; Hutmacher, Matthew; Sethuraman, Venkat
The application of modeling and simulation (M&S) methods to improve decision-making was discussed during the Trends & Innovations in Clinical Trial Statistics Conference held in Durham, North Carolina, USA on May 1-4, 2016. Uses of both pharmacometric and statistical M&S were presented during the conference, highlighting the diversity of the methods employed by pharmacometricians and statisticians to address a broad range of quantitative issues in drug development. Five presentations are summarized herein, which cover the development strategy of employing M&S to drive decision-making; European initiatives on best practice in M&S; case studies of pharmacokinetic/pharmacodynamics modeling in regulatory decisions; estimation of exposure-response relationships in the presence of confounding; and the utility of estimating the probability of a correct decision for dose selection when prior information is limited. While M&S has been widely used during the last few decades, it is expected to play an essential role as more quantitative assessments are employed in the decision-making process. By integrating M&S as a tool to compile the totality of evidence collected throughout the drug development program, more informed decisions will be made.
Flight crews must make decisions and take action when systems fail or emergencies arise during flight. These situations may involve high stress. Full-missiion flight simulation studies have shown that crews differ in how effectively they cope in these circumstances, judged by operational errors and crew coordination. The present study analyzed the problem solving and decision making strategies used by crews led by captains fitting three different personality profiles. Our goal was to identify more and less effective strategies that could serve as the basis for crew selection or training. Methods: Twelve 3-member B-727 crews flew a 5-leg mission simulated flight over 1 1/2 days. Two legs included 4 abnormal events that required decisions during high workload periods. Transcripts of videotapes were analyzed to describe decision making strategies. Crew performance (errors and coordination) was judged on-line and from videotapes by check airmen. Results: Based on a median split of crew performance errors, analyses to date indicate a difference in general strategy between crews who make more or less errors. Higher performance crews showed greater situational awareness - they responded quickly to cues and interpreted them appropriately. They requested more decision relevant information and took into account more constraints. Lower performing crews showed poorer situational awareness, planning, constraint sensitivity, and coordination. The major difference between higher and lower performing crews was that poorer crews made quick decisions and then collected information to confirm their decision. Conclusion: Differences in overall crew performance were associated with differences in situational awareness, information management, and decision strategy. Captain personality profiles were associated with these differences, a finding with implications for crew selection and training.
Gartlehner, Gerald; Matyas, Nina
Shared decision making in medicine has become a widely promoted approach. The goal is for patients and physicians to reach a mutual, informed decision by taking into consideration scientific evidence, clinical experience, and the patient's personal values or preferences. Shared decision making, however, is not a straightforward process. In practice, it might fall short of what it promises and might even be misused to whitewash monetary motives. In this article, which summarizes a presentation given at the 17(th) Annual Conference of the German Network Evidence-based Medicine on March 4(th), 2016 in Cologne, Germany, we discuss three contextual factors that in our opinion can have a tremendous impact on any informed decision making: 1) opinions and convictions of physicians or other clinicians; 2) uncertainty of the evidence regarding benefits and harms; 3) uncertainty of patients about their own values and preferences. But despite barriers and shortcomings, modern medicine currently does not have an alternative to shared decision making. Shared decision making has become a central theme in good quality health care because it has a strong ethical component. Advocates of shared decision making, however, must realize that not all patients prefer to participate in decision making. For those who do, however, we must ensure that shared decisions can be made in a neutral environment as free of biases and conflicts of interest as possible.
Sokol-Hessner, Peter; Raio, Candace M; Gottesman, Sarah P; Lackovic, Sandra F; Phelps, Elizabeth A
The ubiquitous and intense nature of stress responses necessitate that we understand how they affect decision-making. Despite a number of studies examining risky decision-making under stress, it is as yet unclear whether and in what way stress alters the underlying processes that shape our choices. This is in part because previous studies have not separated and quantified dissociable valuation and decision-making processes that can affect choices of risky options, including risk attitudes, loss aversion, and choice consistency, among others. Here, in a large, fully-crossed two-day within-subjects design, we examined how acute stress alters risky decision-making. On each day, 120 participants completed either the cold pressor test or a control manipulation with equal probability, followed by a risky decision-making task. Stress responses were assessed with salivary cortisol. We fit an econometric model to choices that dissociated risk attitudes, loss aversion, and choice consistency using hierarchical Bayesian techniques to both pool data and allow heterogeneity in decision-making. Acute stress was found to have no effect on risk attitudes, loss aversion, or choice consistency, though participants did become more loss averse and more consistent on the second day relative to the first. In the context of an inconsistent previous literature on risk and acute stress, our findings provide strong and specific evidence that acute stress does not affect risk attitudes, loss aversion, or consistency in risky monetary decision-making.
The cognitive and individual framing of clinical decision-making has been undermined in the social sciences by attempts to reframe decision-making as being distributed. In various ways, shifts in understanding in social science research and theorising have wrested clinical decision-making away from the exclusive domain of medical practice and shared it throughout the healthcare disciplines. The temporality of decision-making has been stretched from discrete moments of cognition to being incrementally built over many instances of time and place, and the contributors towards decision-making have been expanded to include non-humans such as policies, guidelines and technologies. However, frameworks of accountability fail to recognise this distributedness and instead emphasise independence of thought and autonomy of action. In this article I illustrate this disparity by contrasting my ethnographic accounts of clinical practice with the professional codes of practice produced by the General Medical Council and the Nursing and Midwifery Council. I argue that a 'thicker' concept of accountability is needed; one that can accommodate the diffuseness of decision-making and the dependencies incurred in collaborative work.
Booister, Nikéh; Verkade, Jan; Werner, Micha; Cranston, Michael; Cumiskey, Lydia; Zevenbergen, Chris
flood event management, the more damage can be reduced. And with decisions based on probabilistic forecasts, partial decisions can be made earlier in time (with a lower probability) and can be scaled up or down later in time when there is more certainty; whether the event takes place or not. Partial decisions are often more cheap, or shorten the final mitigation-time at the moment when there is more certainty. The proposed method is tested on Stonehaven, on the Carron River in Scotland. Decisions to implement demountable defences in the town are currently made based on a very short lead-time due to the absence of certainty. Application showed that staged decision making is possible and gives the decision maker more time to respond to a situation. The decision maker is able to take a lower regret decision with higher uncertainty and less related negative consequences. Although it is not possible to quantify intangible effects, it is part of the analysis to reduce these effects. Above all, the proposed approach has shown to be a possible improvement in economic terms and opens up possibilities of more flexible and robust decision making.
Orasanu, Judith; Shafto, Michael G. (Technical Monitor)
This paper describes the implications of a naturalistic decision making (NDM) perspective for training air crews to make flight-related decisions. The implications are based on two types of analyses: (a) identification of distinctive features that serve as a basis for classifying a diverse set of decision events actually encountered by flight crews, and (b) performance strategies that distinguished more from less effective crews flying full-mission simulators, as well as performance analyses from NTSB accident investigations. Six training recommendations are offered: (1) Because of the diversity of decision situations, crews need to be aware that different strategies may be appropriate for different problems; (2) Given that situation assessment is essential to making a good decision, it is important to train specific content knowledge needed to recognize critical conditions, to assess risks and available time, and to develop strategies to verify or diagnose the problem; (3) Tendencies to oversimplify problems may be overcome by training to evaluate options in terms of goals, constraints, consequences, and prevailing conditions; (4) In order to provide the time to gather information and consider options, it is essential to manage the situation, which includes managing crew workload, prioritizing tasks, contingency planning, buying time (e.g., requesting holding or vectors), and using low workload periods to prepare for high workload; (5) Evaluating resource requirements ("What do I need?") and capabilities ("'What do I have?" ) are essential to making good decisions. Using resources to meet requirements may involve the cabin crew, ATC, dispatchers, and maintenance personnel; (6) Given that decisions must often be made under high risk, time pressure, and workload, train under realistic flight conditions to promote the development of robust decision skills.
McLaughlin, Jacqueline E.; Cox, Wendy C.; Shepherd, Greene
Objective. To determine if student pharmacists’ preferences towards experiential and rational thinking are associated with performance on advanced pharmacy practice experiences (APPEs) and whether thinking style preference changes following APPEs. Methods. The Rational Experiential Inventory (REI), a validated survey of thinking style, was administered to student pharmacists before starting APPEs and re-administered after completing APPEs. APPE grades were compared to initial REI scores. Results. Rational Experiential Inventory scores remained consistent before and after APPEs. Overall, APPE grades were independent of REI scores. In a regression model, the REI experiential score was a significant negative predictor of hospital APPE grades. Conclusion. These findings suggest that overall APPE performance is independent of decision-making preference, and decision-making style does not change following immersion into APPEs. Instead of targeting teaching strategies towards a specific decision-making style, preceptors may use pedagogical approaches that promote sound clinical decision-making skills through critical thinking and reflection. PMID:27756927
Holder, A R
Failure to obtain "adequate" medical care for a child constitutes child neglect, which may be used as the basis for prosecution of parents, removal of the child from the home, or court-ordered medical treatment. "Adequate" care is usually construed as that which is given by a licensed physician, but, in case of dispute, courts almost never engage in choosing one medical approach over another. The principle that parents may not refuse medical care, however, is made very difficult when children have malignancies--the long-term nature of the treatment means that, if the child is left at home, court order or not, the parents may flee with their child. Removing the child from the home, however, adds that trauma to the ill child's burdens. Questions should be asked before making a request to a court to order a therapy which will prolong but not save a child's life if the parents would prefer to spare their child the side effects. Parents, however, may always refuse to permit their child to participate in research studies, no matter how promising. Adolescents are increasingly believed to be capable of medical decision making; most courts, however, would not allow an adolescent to refuse life-saving treatment.
Decisions relating to wildfire management are subject to multiple sources of uncertainty, and are made by a broad range of individuals, across a multitude of environmental and socioeconomic contexts. In this presentation I will review progress towards identification and characterization of uncertainties and how this information can support wildfire decision-making. First, I will review a typology of uncertainties common to wildfire management, highlighting some of the more salient sources of uncertainty and how they present challenges to assessing wildfire risk. This discussion will cover the expanding role of burn probability modeling, approaches for characterizing fire effects, and the role of multi-criteria decision analysis, and will provide illustrative examples of integrated wildfire risk assessment across a variety of planning scales. Second, I will describe a related uncertainty typology that focuses on the human dimensions of wildfire management, specifically addressing how social, psychological, and institutional factors may impair cost-effective risk mitigation. This discussion will encompass decision processes before, during, and after fire events, with a specific focus on active management of complex wildfire incidents. An improved ability to characterize uncertainties faced in wildfire management could lead to improved delivery of decision support, targeted communication strategies, and ultimately to improved wildfire management outcomes.
Park, Vicki; Datnow, Amanda
Despite data-driven decision making being a ubiquitous part of policy and school reform efforts, little is known about how teachers use data for instructional decision making. Drawing on data from a qualitative case study of four elementary schools, we examine the logic and patterns of teacher decision making about differentiation and ability…
Starcke, Katrin; Brand, Matthias
Many decisions must be made under stress, and many decision situations elicit stress responses themselves. Thus, stress and decision making are intricately connected, not only on the behavioral level, but also on the neural level, i.e., the brain regions that underlie intact decision making are regions that are sensitive to stress-induced changes. The purpose of this review is to summarize the findings from studies that investigated the impact of stress on decision making. The review includes those studies that examined decision making under stress in humans and were published between 1985 and October 2011. The reviewed studies were found using PubMed and PsycInfo searches. The review focuses on studies that have examined the influence of acutely induced laboratory stress on decision making and that measured both decision-making performance and stress responses. Additionally, some studies that investigated decision making under naturally occurring stress levels and decision-making abilities in patients who suffer from stress-related disorders are described. The results from the studies that were included in the review support the assumption that stress affects decision making. If stress confers an advantage or disadvantage in terms of outcome depends on the specific task or situation. The results also emphasize the role of mediating and moderating variables. The results are discussed with respect to underlying psychological and neural mechanisms, implications for everyday decision making and future research directions.
Krieger, Janice L; Krok-Schoen, Jessica L; Dailey, Phokeng M; Palmer-Wackerly, Angela L; Schoenberg, Nancy; Paskett, Electra D; Dignan, Mark
Distributed cognition occurs when cognitive and affective schemas are shared between two or more people during interpersonal discussion. Although extant research focuses on distributed cognition in decision making between health care providers and patients, studies show that caregivers are also highly influential in the treatment decisions of patients. However, there are little empirical data describing how and when families exert influence. The current article addresses this gap by examining decisional support in the context of cancer randomized clinical trial (RCT) decision making. Data are drawn from in-depth interviews with rural, Appalachian cancer patients (N = 46). Analysis of transcript data yielded empirical support for four distinct models of health decision making. The implications of these findings for developing interventions to improve the quality of treatment decision making and overall well-being are discussed.
Wahlqvist, Mark L; Tanaka, Kiyoshi; Tzeng, Bing-Hsiean
Coronary artery calcification is a recognised risk factor for ischaemic heart disease and mortality. Evidence is now strong that Mönckeberg's arteriosclerosis, a form of vascular calcification, can be attributable to vitamin K deficiency, but that vitamin K-2, especially the MK-4 form from foods like cheese can be protective. Warfarin blocks the recycling of hepatic and peripheral vitamin K leading to secondary vitamin K deficiency with adverse effects on vasculature, bone, kidneys, brain and other tissues and systems (inflammatory, immune function and neoplasia at least). There is individual susceptibility to vitamin K deficiency and warfarin sensitivity, partly explicable in terms of genetic polymorphisms, epigenetics, diet and pharmacotherapy. The emergence of extensive coronary calcification in a man with atrial fibrillation treated for a decade with warfarin is described by way of illustration and to raise the present clinical management conundrums. Finally, a putative set of recommendations is provided.
Wang, Yishen; Bajorek, Beata
Background For stroke prevention in patients with atrial fibrillation (AF), the decision-making around antithrombotic therapy has been complicated by older age, multiple comorbidities, polypharmacy and the different pharmacological properties of warfarin and the nonvitamin K antagonist oral anticoagulants (NOACs). The complexity of decision-making has been associated with a reluctance by health professionals to use antithrombotic therapy, leading to poor clinical outcomes. In order to improve stroke prevention in patients with AF, the contemporary perspectives of health professionals on the decision-making around antithrombotic therapy needs exploration. Objective To elicit emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Setting Sydney metropolitan area of New South Wales, Australia. Method A qualitative study based on face-to-face interviews was conducted from August to October 2014. Seven pharmacists, seven specialists, six general practitioners and six nurses practising in the Sydney metropolitan area and managing antithrombotic therapy for AF were interviewed until theme saturation was achieved in each subgroup. Interview transcripts were analysed using manual inductive coding. Main outcome measure Emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Results Three overarching themes emerged. (1) Comprehensive assessment is necessary for decision-making but is not always implemented. Health professionals mostly focused on stroke risk assessment, not on the bleeding risk and medication safety issues. (2) Health professionals from different disciplines have different preferences for antithrombotic therapies. Although the majority of health professionals considered warfarin as the first-line therapy, NOACs were preferred by neurologists and
Pahwa, Rohini; Fulginiti, Anthony; Brekke, John S; Rice, Eric
Disclosure related to mental illness has been linked to various positive outcomes, including better mental health. However, many individuals with serious mental illness (SMI) continue to practice non-disclosure. Even though disclosure inherently occurs within the context of one's social relationships, research has generally conceptualized mental illness disclosure as an individual level phenomenon and neglected to consider preferences concerning to whom an individual discloses and the factors that influence this decision. The current study uses the disclosure decision-making model (DD-MM) by Greene (2009) to better understand the processes of mental illness disclosure preference and selective disclosure for individuals with SMI (n = 60) using multivariate random intercept logistic regression with an emphasis on the constituent factors of disclosure preference at both individual and relational levels. The majority of participants were found to practice selective disclosure, with 68% of the participants identifying at least 1 network member to whom they could disclose. Family members and friends were central to the selective disclosure process, comprising the greatest proportion of network members who, both were and were not identified as preferred confidants. Women were found to show higher odds of preference for mental illness disclosure than men. Having lower perceived social support was associated with lower odds of disclosure preference. Among relational factors, greater relationship availability and lower dyadic tangible social support were associated with lower odds of disclosure preference. Practice and research implications of using social network analysis to get a deeper understanding of disclosure and disclosure preference are discussed, including implications for future interventions targeting stigma reduction. (PsycINFO Database Record
Rustad, James K; Musselman, Dominique L; Skyler, Jay S; Matheson, Della; Delamater, Alan; Kenyon, Norma S; Cáceda, Ricardo; Nemeroff, Charles B
Decreased treatment adherence in patients with diabetes mellitus type 1 (type 1 DM) may reflect impairments in decision-making and underlying associated deficits in working memory and executive functioning. Other factors, including comorbid major depression, may also interfere with decision-making. The authors sought to review the clinically relevant characteristics of decision-making in type 1 DM by surveying the literature on decision-making by patients with type 1 DM. Deficiencies in decision-making in patients with type 1 DM or their caregivers contribute to treatment nonadherence and poorer metabolic control. Animal models of type 1 DM reveal deficits in hippocampal-dependent memory tasks, which are reversible with insulin. Neurocognitive studies of patients with type 1 DM reveal lowered performance on ability to apply knowledge to solve problems in a new situation and acquired scholarly knowledge, psychomotor efficiency, cognitive flexibility, visual perception, speed of information-processing, and sustained attention. Other factors that might contribute to poor decision-making in patients with type 1 DM, include "hypoglycemia unawareness" and comorbid major depression (given its increased prevalence in type 1 DM). Future studies utilizing novel treatment strategies to help patients with type 1 DM make better decisions about their disease may improve their glycemic control and quality of life, while minimizing the impact of end-organ disease.
Carver, Jeffrey S.
The instructional decision-making processes of high school science teachers have not been well established in the literature. Several models for decision-making do exist in other teaching disciplines, business, computer game programming, nursing, and some fields of science. A model that incorporates differences in science teaching that is consistent with constructivist theory as opposed to conventional science teaching is useful in the current climate of standards-based instruction that includes an inquiry-based approach to teaching science. This study focuses on three aspects of the decision-making process. First, it defines what factors, both internal and external, influence high school science teacher decision-making. Second, those factors are analyzed further to determine what instructional decision-making processes are articulated or demonstrated by the participants. Third, by analyzing the types of decisions that are made in the classroom, the classroom learning environments established as a result of those instructional decisions are studied for similarities and differences between conventional and constructivist models. While the decision-making process for each of these teachers was not clearly articulated by the teachers themselves, the patterns that establish the process were clearly exhibited by the teachers. It was also clear that the classroom learning environments that were established were, at least in part, established as a result of the instructional decisions that were made in planning and implementation of instruction. Patterns of instructional decision-making were different for each teacher as a result of primary instructional goals that were different for each teacher. There were similarities between teachers who exhibited more constructivist epistemological tendencies as well as similarities between teachers who exhibited a more conventional epistemology. While the decisions that will result from these two camps may be different, the six step
editor at Harvard Business Review , wrote an essay called, When to Trust Your Gut. The essay describes intuitive decision-making in business leaders...9 Peter F. Drucker, "The Effective Decision," in Harvard Business Review on Decision Making, Boston, MA: Harvard Business School Publishing, 2001, pp...2-3. Hereafter cited as Drucker, HBR. 10 Drucker, HBR, p. 2. 11 Amitai Etzioni, "Humble Decision Making," in Harvard Business Review on Decision
Bogdan-Lovis, Elizabeth Libby; Holmes-Rovner, Margaret
In its brief tenure evidence-based medicine (EBM) has proven to be a powerful magnet for criticism, while at the same time it has demonstrated impressive resilience. Located within the ongoing critical discourse surrounding the strengths and weaknesses of an EBM approach is the persistent question of the proper place of the social sciences relative to other disciplinary perspectives. This article considers one way the social sciences might usefully illuminate EBM-mediated human interactions to influence policy. We focus on the ethical nexus of the human impulse for unlimited consumption of health care resources in those situations where there exist competing clinical management options and suggest strategies for resource-preserving shared decision making. We conclude that a frugal default option is a fruitful avenue for future exploration in such situations.
Hartmann, David J; Van Valey, Thomas; Fuqua, Wayne
This paper presents methods and challenges attendant on the use of protocol analysis to develop a model of heuristic processing applied to research ethics. Participants are exposed to ethically complex scenarios and asked to verbalize their thoughts as they formulate a requested decision. The model identifies functional parts of the decision-making task: interpretation, retrieval, judgment and editing and seeks to reliably code participant verbalizations to those tasks as well as to a set of cognitive tools generally useful in such work. Important difficulties in the reliability and external validity of measurement are evaluated and a small set of illustrative data is used in support of that discussion. Results indicate that both intuitive emotional but also more deliberative cognition is present which is consistent with work in related literatures in expertise and in neuropsychology. Finally, the theoretical and practical potential of the approach is elaborated, particularly through links to a framing in Aristotelian ethics.
Critical examination of the processes by which we as nurses judge and reach clinical decisions is important. It facilitates the maintenance and refinement of good standards of nursing care and the pinpointing of areas where improvement is needed. In turn this potentially could support broader validation of nurse expertise and contribute to emancipation of the nursing profession. As pure theory, clinical decision-making may appear abstract and alien to nurses struggling in 'the swampy lowlands' (Schon 1983) of the realities of practice. This paper explores some of the key concepts in decision-making theory by introducing, then integrating, them in a reflective case study. The case study, which examines a 'snapshot' of the patient and practitioner's journey, interwoven with theory surrounding clinical decision-making, may aid understanding and utility of concepts and theories in practice.
Kortas, Linda; And Others
The Career Decision Scale, Assessment of Career Decision Making, and Cognitive Differentiation Grid were administered to 598 community college students. Results indicated a relationship between decision-making styles and vocational construct structure. Poorly developed vocational schemas predispose individuals toward dependent and intuitive…
HILTON, THOMAS L.; AND OTHERS
THE PROBLEM OF THIS LONGITUDINAL STUDY WAS TO IDENTIFY THE COGNITIVE PROCESSES WHICH ARE INVOLVED IN CAREER DECISION-MAKING AND THE LONG-TERM EFFECTS OF THESE PROCESSES ON CAREER DEVELOPMENT. AREAS OF CONCERN WERE (1) IDENTIFICATION OF STRATEGIES BY WHICH AN INDIVIDUAL CAN OVERCOME DECISION-MAKING DIFFICULTY, (2) ASSESSMENT OF THE SHORT-TERM…
Goldberg, Alvin A.; Hannegan, David W., Jr.
This paper applies some of the research done on small group decision-making to the process of identification and selection of colleges by high school students. It argues that, since the decisions that are reached are often group decisions, or are at least strongly influenced by groups, an understanding of group decision-making processes can be…
Wales, Charles E.; And Others
Defines education's new paradigm as schooling based on decision making, the critical thinking skills serving it, and the knowledge base supporting it. Outlines a model decision-making process using a hypothetical breakfast problem; a late riser chooses goals, generates ideas, develops an action plan, and implements and evaluates it. (4 references)…
Morey, Janis T.; Dansereau, Donald F.
College students' decision making is often less than optimal and sometimes leads to negative consequences. The effectiveness of two strategies for improving student decision making--node-link mapping and social perspective taking (SPT)--are examined. Participants using SPT were significantly better able to evaluate decision options and develop…
Tunney, Richard J; Ziegler, Fenja V
In everyday life, many of the decisions that we make are made on behalf of other people. A growing body of research suggests that we often, but not always, make different decisions on behalf of other people than the other person would choose. This is problematic in the practical case of legally designated surrogate decision makers, who may not meet the substituted judgment standard. Here, we review evidence from studies of surrogate decision making and examine the extent to which surrogate decision making accurately predicts the recipient's wishes, or if it is an incomplete or distorted application of the surrogate's own decision-making processes. We find no existing domain-general model of surrogate decision making. We propose a framework by which surrogate decision making can be assessed and a novel domain-general theory as a unifying explanatory concept for surrogate decisions.
Moser, Albine; Houtepen, Rob; van der Bruggen, Harry; Spreeuwenberg, Cor; Widdershoven, Guy
This article examines how people with type 2 diabetes perceive autonomous decision making and which moral capacities they consider important in diabetes nurses' support of autonomous decision making. Fifteen older adults with type 2 diabetes were interviewed in a nurse-led unit. First, the data were analysed using the grounded theory method. The participants described a variety of decision-making processes in the nurse and family care-giver context. Later, descriptions of the decision-making processes were analysed using hermeneutic text interpretation. We suggest first- and second-order moral capacities that nurses specializing in diabetes need to promote the autonomous decision making of their patients. We recommend nurses to engage in ongoing, interactive reflective practice to further develop these moral capacities.
Tsaloglidou, A; Rammos, K; Kiriklidis, K; Zourladani, A; Matziari, C
This study provides an insight into the process of ethical decision-making regarding the initiation or withdrawal of artificial nutritional support of seriously ill patients and explores the nursing involvement in it. Fifteen health carers were recruited from a clinical nutrition unit in the UK and qualitative research methods were used to gather data. The findings of the study indicate that nursing contribution to decision-making appeared to be in the 'back room' as the nurses feel that the decisions about difficult ethical dilemmas are 'out of their hands' because of lack of knowledge, experience and confidence. The medical staff and the clinical nurse specialist appear to be primarily responsible for making important decisions. It is clear from the study that to become more effective in the process, nurses need to enhance their knowledge in nutritional support and to develop their practical skills in ethical decision-making through experience and research.
Luby, Marie; Warach, Steven J; Albers, Gregory W; Baron, Jean-Claude; Cognard, Christophe; Dávalos, Antoni; Donnan, Geoffrey A; Fiebach, Jochen B; Fiehler, Jens; Hacke, Werner; Lansberg, Maarten G; Liebeskind, David S; Mattle, Heinrich P; Oppenheim, Catherine; Schellinger, Peter D; Wardlaw, Joanna M; Wintermark, Max
Background and Purpose The purpose of this study was to collect precise information on the typical imaging decisions given specific clinical acute stroke scenarios. Stroke centers worldwide were surveyed regarding typical imaging used to work up representative acute stroke patients, make treatment decisions, and willingness to enroll in clinical trials. Methods STroke Imaging Research and Virtual International Stroke Trials Archive-Imaging circulated an online survey of clinical case vignettes through its website, the websites of national professional societies from multiple countries as well as through email distribution lists from STroke Imaging Research and participating societies. Survey responders were asked to select the typical imaging work-up for each clinical vignette presented. Actual images were not presented to the survey responders. Instead, the survey then displayed several types of imaging findings offered by the imaging strategy, and the responders selected the appropriate therapy and whether to enroll into a clinical trial considering time from onset, clinical presentation, and imaging findings. A follow-up survey focusing on 6 h from onset was conducted after the release of the positive endovascular trials. Results We received 548 responses from 35 countries including 282 individual centers; 78% of the centers originating from Australia, Brazil, France, Germany, Spain, United Kingdom, and United States. The specific onset windows presented influenced the type of imaging work-up selected more than the clinical scenario. Magnetic Resonance Imaging usage (27–28%) was substantial, in particular for wake-up stroke. Following the release of the positive trials, selection of perfusion imaging significantly increased for imaging strategy. Conclusions Usage of vascular or perfusion imaging by Computed Tomography or Magnetic Resonance Imaging beyond just parenchymal imaging was the primary work-up (62–87%) across all clinical vignettes and time windows
Brown, Edwina A; Bekker, Hilary L; Davison, Sara N; Koffman, Jonathan; Schell, Jane O
Historic migration and the ever-increasing current migration into Western countries have greatly changed the ethnic and cultural patterns of patient populations. Because health care beliefs of minority groups may follow their religion and country of origin, inevitable conflict can arise with decision making at the end of life. The principles of truth telling and patient autonomy are embedded in the framework of Anglo-American medical ethics. In contrast, in many parts of the world, the cultural norm is protection of the patient from the truth, decision making by the family, and a tradition of familial piety, where it is dishonorable not to do as much as possible for parents. The challenge for health care professionals is to understand how culture has enormous potential to influence patients' responses to medical issues, such as healing and suffering, as well as the physician-patient relationship. Our paper provides a framework of communication strategies that enhance crosscultural competency within nephrology teams. Shared decision making also enables clinicians to be culturally competent communicators by providing a model where clinicians and patients jointly consider best clinical evidence in light of a patient's specific health characteristics and values when choosing health care. The development of decision aids to include cultural awareness could avoid conflict proactively, more productively address it when it occurs, and enable decision making within the framework of the patient and family cultural beliefs.
) Analyze existing climate assessments and translate projected impacts into possible, probable, and effectively certain impacts. 4) Improve climate projections with respect to precipitation (timing, amount, and intensity), extreme events, and tails of probability distributions (i.e., low-probability but high-consequence events). 5) Increase spatial resolution of climate projections in order to provide climate information at the scale most relevant to financial investments. 6) Improve projections of the societal consequences of climate impacts through integrated assessments of physical, natural, and social sciences. 7) Create a user-friendly information repository and portal that provides easy access to information relevant to financial decision making. 8) Create and maintain opportunities to bring together financial decision makers, scientists, and service providers. Near-term financial decisions have long-term implications for the United States’ social and economic well-being that depend, in part, on climate variability and change. Investments will be most successful, and will advance the interests of society most effectively, if they are grounded in the best available knowledge & understanding.
Barg, S.; Fletcher, T.; Mechling, J.; Tonn, B.; Turner, R.
This report presents a summary of the Information Technology and Environmental Decision Making Workshop that was held at Harvard University, October 1-3, 1998. Over sixty participants from across the US took part in discussions that focused on the current practice of using information technology to support environmental decision making and on future considerations of information technology development, information policies, and data quality issues in this area. Current practice is focusing on geographic information systems and visualization tools, Internet applications, and data warehousing. In addition, numerous organizations are developing environmental enterprise systems to integrate environmental information resources. Plaguing these efforts are issues of data quality (and public trust), system design, and organizational change. In the future, much effort needs to focus on building community-based environmental decision-making systems and processes, which will be a challenge given that exactly what needs to be developed is largely unknown and that environmental decision making in this arena has been characterized by a high level of conflict. Experimentation and evaluation are needed to contribute to efficient and effective learning about how best to use information technology to improve environmental decision making.
Hill, Marie C; Cox, Carol L
Immunisation decision making is not a straightforward process for parents. Many factors influence parental decision making on whether they immunise their child with the measles, mumps and rubella (MMR) vaccine. The feasibility study described in this article provides insight into influencing factors associated with decisions regarding the immunisation of children by parents. The study findings suggest that the practice nurse is a credible source of information for parents seeking informed decision making. At a time when the incidence of measles and mumps is rising in the UK, the provision of appropriate information by the practice nurse has the potential to increase uptake of the MMR vaccine.
Patrick, Nicholas J. M.
Our scientific goal is to understand the process of human decision-making. Specifically, a model of human decision-making in piloting modern commercial aircraft which prescribes optimal behavior, and against which we can measure human sub-optimality is sought. This model should help us understand such diverse aspects of piloting as strategic decision-making, and the implicit decisions involved in attention allocation. Our engineering goal is to provide design specifications for (1) better computer-based decision-aids, and (2) better training programs for the human pilot (or human decision-maker, DM).
Mosqueda-Díaz, Angélica; Mendoza-Parra, Sara; Jofré-Aravena, Viviane
Decision making in health is a frequent situation, although potentially difficult, depending on patient/user characteristics and the context or the situation of health. This causes decisional conflicts in patients/users. The present study proposes to analyze the decision making process in health, conceptually, and nurses' contributions to understand and confront the phenomenon. The Ottawa the Model of Decisions Making in Health, proposed by Annette O'Connor, arises as a useful tool that enables nurses to carry out effective interventions with persons who face decision problems. Patients/users can assume a more active participation in the decisions on their own health.
Salkovskis, Paul M; Wroe, Abigail L; Rees, Margaret C P
The growing influence of the mass media on public understanding of health care matters has increased both information and misinformation in patients seeking help with menopausal symptoms. The use of shared decision-making strategies provides the opportunity to engage the patient in taking some responsibility for their own treatment. It also allows the identification and correction of any distortions in the perceived balance of evidence for and against any particular treatment. Shared decision-making balances the need to respect patients' values and autonomy with the drive towards evidence-based medicine and clinical cost-effectiveness. Although ways of achieving such a balance are much discussed, the current need is for research which can identify effective strategies that allow the principles of "shared decision-making" and "evidence-based patient choice" to be validated and applied in clinical practice. Previous research focused on hormone replacement therapy indicates that the patient's decision is the outcome of the way they balance the pros and cons of taking (or not taking) it, and that their satisfaction with the decision is strongly associated with the perception that they have been given information about the full range of treatment available. It therefore seems likely that patients will respond more positively to consultations which include discussion of hormone replacement therapy alongside alternative strategies such as natural remedies and dietary/lifestyle changes. Psychological factors influencing treatment choice and the decision making process are discussed, and clinical and research implications for clinical practice in the menopause clinic examined.
Severo, Milton; Silva-Pereira, Fernanda; Ferreira, Maria Amelia
Several studies have shown that the standard error of measurement (SEM) can be used as an additional “safety net” to reduce the frequency of false-positive or false-negative student grading classifications. Practical examinations in clinical anatomy are often used as diagnostic tests to admit students to course final examinations. The aim of this…
Kostagiolas, Petros; Martzoukou, Konstantina; Georgantzi, Georgia; Niakas, Dimitris
Introduction: This study investigated the information seeking behaviour and needs of parents of paediatric patients and their motives for seeking Internet-based information. Method: A questionnaire survey of 121 parents was conducted in a paediatric clinic of a Greek university hospital. Analysis: The data were analysed using SPSS; descriptive…
Payne, Lesle Karns
The author in this article presents a theory of decision-making in nursing, specifically a middle-range theory of intuitive decision-making in nursing created through the synthesis of Patricia Benner's model of skill acquisition in nursing and Damasio's somatic marker hypothesis. The author proposes that Damasio's somatic state is equivalent to what Benner has identified as intuition. When a nurse is faced with a decision, intuition, if developed, is a somatic state that creates a measurable physiological biasing signal (skin conductive response) that helps in making an advantageous decision. Research, educational, clinical and theoretical implications are discussed.
Mitchell, Teri M.; Beal, Claudia
ABSTRACT It is important that expectant parents receive accurate information about the benefits and risks of circumcision as well as the benefits and risks of having an intact foreskin when making a decision about routine infant circumcision (RIC). A pilot study was conducted using the shared decision making (SDM) conceptual model to guide expectant parents through a 3-phase decision-making program about RIC as part of their childbirth education class. The participants showed a high level of preparedness following each of the 3 phases. Preparedness score were highest for those who decided to keep their expected sons’ penises natural. This SDM program was an effective way of guiding expectant parents through the decision-making process for RIC. PMID:26834440
Prochaska, James O
Decision making is an integral part of the transtheoretical model of behavior change. Stage of change represents a temporal dimension for behavior change and has been the key dimension for integrating principles and processes of change from across leading theories of psychotherapy and behavior change. The decision-making variables representing the pros and cons of changing have been found to have systematic relationships across the stages of change for 50 health-related behaviors. Implications of these patterns of relationships are discussed in the context of helping patients make more effective decisions to decrease health risk behaviors and increase health-enhancing behaviors.
Levinson, Wendy; Kao, Audiey; Kuby, Alma; Thisted, Ronald A
BACKGROUND The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation. OBJECTIVES 1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people's preferences for participation in decision making. DESIGN AND PARTICIPANTS A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N= 2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences. MAIN RESULTS Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined. CONCLUSION This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly. PMID:15987329
Reduction in prices now makes it possible for almost any institution to use computer graphics for administrative decision making and research. Current and potential uses of computer graphics in these two areas are discussed. (JN)
Bolhuis, Erik; Schildkamp, Kim; Voogt, Joke
Data use is becoming more important in higher education. In this case study, a team of teachers from a teacher education college was supported in data-based decision making by means of the data team procedure. This data team studied the reasons why students drop out. A team's success depends in part on whether the team is able to develop and apply…
Part of a collection of papers commissioned by Foundations, a project designed to identify the career development needs of students entering the National Technical Institute for the Deaf, this paper examines research on problem solving and decision making. The section on problem solving reviews various models and concepts associated with problem…
Wu, Shu-Chieh; Gooding, Cary L.; Shelley, Alexandra E.; Duong, Constance G.; Johnson, Walter W.
The present research investigates characteristics exhibited in pilot convective weather decision making in en route airspace. In a part-task study, pilots performed weather avoidance under various encounter scenarios. Results showed that the margins of safety that pilots maintain from storms are as fluid as deviation decisions themselves.
Shaposhnikov, A V
The article covers modern principles of the decision-making method, used in medicine and gastroenterology, in particular. These principles are based upon taking into consideration psychosocial features of a doctor and a patient, types of doctor's thinking and pathologic processes, as well as the effect of a range of negative factors, such as conformism, engageness of a doctor, neurotism etc. The author pioneers the treatment of decision-making in medicine.
requirements 1.2 - Agile Wargames, 2.6 - Mission Command Processes and decision-making, and 2.2 - Enhancing Subject Matter Expert ( SME ) Elicitation...Raymond, 1989). In the aviation domain, pilots exhibit different visual scanning patterns during various phases of flying under instrument flight rules ( IFR ... SME ) Elicitation Techniques, and 2.2 Mission Command Processes and decision-making (Alt et al., 2013). ARO research interests are defined by the
Agostoni, Pierfrancesco; Kedhi, Elvin; Verheye, Stefan; Vermeersch, Paul; Van Langenhove, Glenn
We discuss two cases of non-occlusive sub-acute/late stent thrombosis, one correctly diagnosed (with the help of intravascular ultrasound) 12 days after implantation of a sirolimus eluting stent, the other erroneously non recognized 17 days after implantation of a bare metal stent and evolving 6 weeks later in total thrombotic occlusion of the stent itself. We believe that our clinical judgment, accurate in case of sirolimus eluting stent thrombosis, but wrong in case of bare metal stent thrombosis, was largely influenced by the recent literature giving overwhelming attention, in the drug-eluting stent era, to an issue (late stent thrombosis) that was already present but under-considered, also in the bare metal stent era.
Martínez-Tur, Vicente; Peñarroja, Vicente; Serrano, Miguel A.; Hidalgo, Vanesa; Moliner, Carolina; Salvador, Alicia; Alacreu-Crespo, Adrián; Gracia, Esther; Molina, Agustín
The literature has been relatively silent about post-conflict processes. However, understanding the way humans deal with post-conflict situations is a challenge in our societies. With this in mind, we focus the present study on the rationality of cooperative decision making after an intergroup conflict, i.e., the extent to which groups take advantage of post-conflict situations to obtain benefits from collaborating with the other group involved in the conflict. Based on dual-process theories of thinking and affect heuristic, we propose that intergroup conflict hinders the rationality of cooperative decision making. We also hypothesize that this rationality improves when groups are involved in an in-group deliberative discussion. Results of a laboratory experiment support the idea that intergroup conflict –associated with indicators of the activation of negative feelings (negative affect state and heart rate)– has a negative effect on the aforementioned rationality over time and on both group and individual decision making. Although intergroup conflict leads to sub-optimal decision making, rationality improves when groups and individuals subjected to intergroup conflict make decisions after an in-group deliberative discussion. Additionally, the increased rationality of the group decision making after the deliberative discussion is transferred to subsequent individual decision making. PMID:25461384
Toorians, A W; Strack van Schijndel, R J
A man aged 73, admitted because of unstable angina pectoris also had a anaemia with a haemoglobin concentration of 2.8 mmol/l. The department of Consultative Internal Medicine was asked to elucidate this anaemia. The anamnesis proved to contain extensive diagnostic tests concerning the anaemia which had had no results. In spite of a negative anamnesis, the low serum iron level had prompted an unsuccessful search for a source of haemorrhage in the proximal and distal parts of the digestive tract. The bone marrow had been examined three times without a clear diagnosis. It was also found that there had been a deviation from the classification of anaemia which should be guided by the size of the erythrocyte and the reticulocyte count. This had resulted in diagnostics that where inconvenient to the patient; also the patient had been treated without success with ferrofumarate. Ultimately, he proved to suffer from autoimmune hypothyroidism; the anaemia was resolved by substitution therapy.
Gilou, Sotiria; Billis, Antonis; Karagianni, Maria; Bratsas, Charalampos D.
Recent neuroscientific studies focused on the identification of pathological neurophysiological patterns (emotions, geriatric depression, memory impairment and sleep disturbances) through computerised clinical decision-support systems. Almost all these research attempts employed either resting-state condition (e.g. eyes-closed) or event-related potentials extracted during a cognitive task known to be affected by the disease under consideration. This Letter reviews existing data mining techniques and aims to enhance their robustness by proposing a holistic decision framework dealing with comorbidities and early symptoms’ identification, while it could be applied in realistic occasions. Multivariate features are elicited and fused in order to be compared with average activities characteristic of each neuropathology group. A proposed model of the specific cognitive function which may be based on previous findings (a priori information) and/or validated by current experimental data should be then formed. So, the proposed scheme facilitates the early identification and prevention of neurodegenerative phenomena. Neurophysiological semantic annotation is hypothesised to enhance the importance of the proposed framework in facilitating the personalised healthcare of the information society and medical informatics research community. PMID:27222732
Graziano, David L.; Nitsch, Wanda; Huijbregts, Peter A.
This case report describes the diagnosis and management of a 43-year-old female patient who had sustained an injury to her neck in a motor-vehicle accident two years earlier. The major symptoms described by the patient included headache and neck pain, but history and examination also revealed signs and symptoms potentially indicative of cervical artery compromise. Physical therapy management initially consisted of soft tissue and non-thrust joint manipulation of the lower cervical and thoracic spine, specific exercise prescription, and superficial heat. Cervical vascular compromise was re-evaluated by way of the sustained extension-rotation test. When at the fifth visit this test no longer produced symptoms potentially indicative of vascular compromise, upper cervical diagnosis and management consisting of soft tissue and non-thrust joint manipulation was added. A positive outcome was achieved both at the impairment level and with regard to limitations in activities, the latter including increased performance at work, a return to previous reading activities, improved length and quality of sleep, and greater comfort while driving. At discharge, the patient reported only occasional pain and mild limitations in activities. This report describes the positive outcomes in a patient with chronic whiplash syndrome; however, its main emphasis lies in the discussion and critical evaluation of clinical reasoning in the presence of diagnostic uncertainty with regard to cervical artery compromise. PMID:19066653
Frantzidis, Christos A; Gilou, Sotiria; Billis, Antonis; Karagianni, Maria; Bratsas, Charalampos D; Bamidis, Panagiotis
Recent neuroscientific studies focused on the identification of pathological neurophysiological patterns (emotions, geriatric depression, memory impairment and sleep disturbances) through computerised clinical decision-support systems. Almost all these research attempts employed either resting-state condition (e.g. eyes-closed) or event-related potentials extracted during a cognitive task known to be affected by the disease under consideration. This Letter reviews existing data mining techniques and aims to enhance their robustness by proposing a holistic decision framework dealing with comorbidities and early symptoms' identification, while it could be applied in realistic occasions. Multivariate features are elicited and fused in order to be compared with average activities characteristic of each neuropathology group. A proposed model of the specific cognitive function which may be based on previous findings (a priori information) and/or validated by current experimental data should be then formed. So, the proposed scheme facilitates the early identification and prevention of neurodegenerative phenomena. Neurophysiological semantic annotation is hypothesised to enhance the importance of the proposed framework in facilitating the personalised healthcare of the information society and medical informatics research community.
Strain, W David; Agarwal, Abhijit S; Paldánius, Päivi M
We tested the feasibility of setting individualized glycemic goals and factors influencing targets set in a clinical trial in elderly patients with type 2 diabetes.A 24-week, randomized, double-blind, placebo-controlled study was conducted in 45 outpatient centers in seven European countries. 278 drug-naïve or inadequately controlled (mean HbA1c 7.9%) patients with type 2 diabetes aged ≥70 years with HbA1c levels ≥7.0% and ≤10.0% were enrolled. Investigator-defined individualized HbA1c targets and the impact of baseline characteristics on individualized treatment targets was evaluated.The average individualized HbA1c target was set at 7.0%. HbA1c at baseline predicted a target setting such that higher the HbA1c, more aggressive was the target (P<0.001). Men were more likely to be set aggressive targets than women (P=0.026). Frailty status of patients showed a trend towards significance (P=0.068), whereas diabetes duration, age, or polypharmacy did not. There was heterogeneity between countries regarding how baseline factors were viewed.Despite training and guidance to individualize HbA1c goals, targets were still set in line with conventional values. A strong influence of country-specific guidelines on target setting was observed; confirming the importance of further education to implement new international guidelines in older adults.
Bulsiewicz, W J; Dellon, E S; Rogers, A J; Pasricha, S; Madanick, R D; Grimm, I S; Shaheen, N J
The clinical utility of endoscopic ultrasound (EUS) for staging patients with Barrett's esophagus and high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) prior to endoscopic therapy is unclear. We performed a retrospective analysis of patients with HGD or IMC referred to an American medical center for endoscopic treatment between 2004 and 2010. All patients had pretreatment staging by EUS. We examined the frequency that EUS findings consistent with advanced disease (tumor invasion into the submucosa, lymph node involvement, or regional metastasis) led to a change in management. The analysis was stratified by nodularity and pre-EUS histology. We identified one hundred thirty-five patients with HGD (n = 106, 79%) or IMC (n = 29, 21%) had staging by EUS (79 non-nodular, 56 nodular). Pathologic lymph nodes or metastases were not found by EUS. There were no endosonographic abnormalities noted in any patient with non-nodular mucosa (0/79). Abnormal EUS findings were present in 8/56 patients (14%) with nodular neoplasia (five IMC, three HGD). Endoscopic mucosal resection was performed in 44 patients with a nodule, with 13% (6/44) having invasive cancer. In nodular neoplasia, the EUS and endoscopic mucosal resection were abnormal in 24% (5/21) and 40% (6/15) of those with IMC and 9% (3/35) and 0% (0/29) of those with HGD, respectively. In this study we found that EUS did not alter management in patients with non-nodular HGD or IMC. Because the diagnostic utility of EUS in subjects with non-nodular Barrett's esophagus is low, the value of performing endoscopic mucosal resection in this setting is questionable. For patients with nodular neoplasia, resection of the nodule with histological examination had greater utility than staging by EUS.
Souliotis, Kyriakos; Agapidaki, Eirini; Peppou, Lily Evangelia; Tzavara, Chara; Samoutis, George; Theodorou, Mamas
Although the importance of patient participation in the design and evaluation of health programs and services is well-documented, there is scarcity of research with regard to patient association (PA) participation in health policy decision-making processes. To this end, the present study aimed to validate further a previously developed instrument as well as to investigate the degree of PA participation in health policy decision-making in Cyprus. A convenient sample of 114 patients-members of patients associations took part in the study. Participants were recruited from an umbrella organization, the Pancyprian Federation of Patient Associations and Friends (PFPA). PA participation in health policy decision-making was assessed with the Health Democracy Index (HDI), an original 8-item tool. To explore its psychometric properties, Cronbach α was computed as regards to its internal consistency, while its convergent validity was tested against a self-rated question enquiring about the degree of PA participation in health policy decision-making. The findings revealed that the HDI has good internal consistency and convergent validity. Furthermore, PAs were found to participate more in consultations in health-related organizations and the Ministry of Health (MoH) as well as in reforms or crucial decisions in health policy. Lower levels were documented with regard to participation in hospital boards, ethics committees in clinical trials and health technology assessment (HTA) procedures. Overall, PA participation levels were found to be lower than the mid-point of the scale. Targeted interventions aiming to facilitate patients’ involvement in health policy decision-making processes and to increase its impact are greatly needed in Cyprus. PMID:27694659
Souliotis, Kyriakos; Agapidaki, Eirini; Peppou, Lily Evangelia; Tzavara, Chara; Samoutis, George; Theodorou, Mamas
Although the importance of patient participation in the design and evaluation of health programs and services is well-documented, there is scarcity of research with regard to patient association (PA) participation in health policy decision-making processes. To this end, the present study aimed to validate further a previously developed instrument as well as to investigate the degree of PA participation in health policy decision-making in Cyprus. A convenient sample of 114 patients-members of patients associations took part in the study. Participants were recruited from an umbrella organization, the Pancyprian Federation of Patient Associations and Friends (PFPA). PA participation in health policy decision-making was assessed with the Health Democracy Index (HDI), an original 8-item tool. To explore its psychometric properties, Cronbach α was computed as regards to its internal consistency, while its convergent validity was tested against a self-rated question enquiring about the degree of PA participation in health policy decision-making. The findings revealed that the HDI has good internal consistency and convergent validity. Furthermore, PAs were found to participate more in consultations in health-related organizations and the Ministry of Health (MoH) as well as in reforms or crucial decisions in health policy. Lower levels were documented with regard to participation in hospital boards, ethics committees in clinical trials and health technology assessment (HTA) procedures. Overall, PA participation levels were found to be lower than the mid-point of the scale. Targeted interventions aiming to facilitate patients' involvement in health policy decision-making processes and to increase its impact are greatly needed in Cyprus.
This paper assesses the decision making patterns in medical ethics: the formalized pattern of decision science, the meditative pattern of an art of judgement and lastly the still-to-be-elaborated pattern of kairology or sense of the right time. The ethical decision is to be thought out in the conditions of medical action while resorting to the philosophical concepts that shed light on the issue. And it is precisely where medicine and philosophy of human action meet that the Greek notion of kairos, or "propitious moment", evokes the critical point where decision has to do with what is vital. Reflection shows that this kairos can be thought out outside the sacrificial pattern (deciding comes down to killing a possibility) by understanding the opportune moment as a sign of ethical action, as the condition for the formation of the subject (making a decision) and finally as a new relationship to time, including in the context of medical urgency. Thus with an approach to clinical ethics centred on the relation to the individual, the focus is less on the probabilistic knowledge of the decidable than on the meaning of the decision, and the undecidable comes to be accepted as an infinite dimension going beyond the limits of our acts, which makes the contingency and the grandeur of human responsibility.
Ga-68 DOTANOC PET/CT imaging in detection of primary site in patients with metastatic neuroendocrine tumours of unknown origin and its impact on clinical decision making: experience from a tertiary care centre in India
Pankaj, Promila; Verma, Ritu; Jain, Anjali; Belho, Ethel S.; Mahajan, Harsh
Background Neuroendocrine tumours (NETs) are rare, heterogeneous group of tumours which usually originate from small, occult primary sites and are characterized by over-expression of somatostatin receptors (SSTRs). Positron emission tomography/computed tomography (PET/CT) using Ga-68-labeled-somatostatin-analogues have shown superiority over other modalities for imaging of NETs. The objective of the study was to retrospectively evaluate the efficacy of Ga-68 DOTANOC PET/CT imaging in detecting the primary site in patients with metastatic NETs of unknown origin and its impact on clinical decision making in such patients. Methods Between December 2011 and September 2014, a total of 263 patients underwent Ga-68 DOTANOC PET/CT study in our department for various indications. Out of them, 68 patients (45 males, 23 females; mean age, 54.9±10.7 years; range, 31–78 years) with histopathologically proven metastatic NETs and unknown primary site (CUP-NET) on conventional imaging, who underwent Ga-68 DOTANOC PET/CT scan as part of their clinical work-up were included for analyses. Histopathology (wherever available) and/or follow-up imaging were taken as reference standard. Quantitative estimation of SSTR expression in the form of maximal standardized uptake value (SUVmax) of detected primary and metastatic sites was calculated. Follow-up data of individual patients was collected through careful survey of hospital medical records and telephonic interviews. Results Maximum patients presented to our department with hepatic metastasis (50 out of 68 patients) and grade I NETs (>50%). Ga-68 DOTANOC PET/CT scan identified primary sites in 40 out of these 68 patients i.e., in approximately 59% patients. Identified primary sites were: small intestine , rectum , pancreas , stomach , lung  and one each in rare sites in kidney and prostate. In one patient, 2 primary sites were identified (one each in stomach and duodenum). Mean SUVmax of the detected primary sites was
Orasanu, Judith; Statler, Irving C. (Technical Monitor)
The importance of crew decision making to aviation safety has been well established through NTSB accident analyses: Crew judgment and decision making have been cited as causes or contributing factors in over half of all accidents in commercial air transport, general aviation, and military aviation. Yet the bulk of research on decision making has not proven helpful in improving the quality of decisions in the cockpit. One reason is that traditional analytic decision models are inappropriate to the dynamic complex nature of cockpit decision making and do not accurately describe what expert human decision makers do when they make decisions. A new model of dynamic naturalistic decision making is offered that may prove more useful for training or aiding cockpit decision making. Based on analyses of crew performance in full-mission simulation and National Transportation Safety Board accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation and reflect the crew's metacognitive skill. Effective crew decision making and overall performance are mediated by crew communication. Communication contributes to performance because it assures that all crew members have essential information, but it also regulates and coordinates crew actions and is the medium of collective thinking in response to a problem. This presentation will examine the relation between communication that serves to build performance. Implications of these findings for crew training will be discussed.
Background Public health professionals are increasingly expected to engage in evidence-informed decision making to inform practice and policy decisions. Evidence-informed decision making involves the use of research evidence along with expertise, existing public health resources, knowledge about community health issues, the local context and community, and the political climate. The National Collaborating Centre for Methods and Tools has identified a seven step process for evidence-informed decision making. Tools have been developed to support public health professionals as they work through each of these steps. This paper provides an overview of tools used in three Canadian public health departments involved in a study to develop capacity for evidence-informed decision making. Methods As part of a knowledge translation and exchange intervention, a Knowledge Broker worked with public health professionals to identify and apply tools for use with each of the steps of evidence-informed decision making. The Knowledge Broker maintained a reflective journal and interviews were conducted with a purposive sample of decision makers and public health professionals. This paper presents qualitative analysis of the perceived usefulness and usability of the tools. Results Tools were used in the health departments to assist in: question identification and clarification; searching for the best available research evidence; assessing the research evidence for quality through critical appraisal; deciphering the ‘actionable message(s)’ from the research evidence; tailoring messages to the local context to ensure their relevance and suitability; deciding whether and planning how to implement research evidence in the local context; and evaluating the effectiveness of implementation efforts. Decision makers provided descriptions of how the tools were used within the health departments and made suggestions for improvement. Overall, the tools were perceived as valuable for advancing
Public health, prevention, health education and health promotion are inseparable from the concepts of information and communication. Information should respond as much as possible to the needs of professionals, decision-makers, and consumers who are more and more concerned and conscious of its importance in light of "information overload", various dissemination channels and the multiplicity of its sources. There are numerous issues at stake ranging from comprehension, to the validation of health information, health education, health promotion, prevention, decision-making, as well as issues related to knowledge and power. Irrespective of the type of choice to be made, the need for information, knowledge, and know-how is inseparable from that of other tools or regulatory measures required for decision-making. Information is the same as competence, epidemiological and population data, health data, scientific opinion, and expert conferences--all are needed to assist in decision-making. Based on the principle of precaution, information must increasingly take into account the rejection of a society which often reasons on the basis of a presumption of zero-risk, in an idealistic manner, and which also excludes the possibility of new risks. The consumer positions himself as the regulator of decisions, specifically those with regard to the notion of acceptable level of risk. All of the actors involved in the health system are or become at one moment or another public health decision-makers. Their decision might be based either on an analytical approach, or on an intuitive approach. Although the act of decision-making is the least visible part of public health policy, it is certainly the driving force. This process should integrate the perspective of all of the relevant players, including consumers, who are currently situated more and more frequently at the heart of the health system. Public health decision-making is conducted as a function of political, strategic and
Lipman, Hannah I; Kalra, Ankur; Kirkpatrick, James N
In order to help older adults with cardiovascular disease navigate complex decisions, clinicians must know tenets of medical ethics and have good communication skills. The elements of decision making capacity and informed consent are reviewed, using relevant clinical examples to illustrate the basic concepts. The shared decision making model, by which clinician and patient work together to determine the plan of care, is described. Useful communication techniques to implement shared decision making are suggested.
Sinayev, Aleksandr; Peters, Ellen
Scores on the three-item Cognitive Reflection Test (CRT) have been linked with dual-system theory and normative decision making (Frederick, 2005). In particular, the CRT is thought to measure monitoring of System 1 intuitions such that, if cognitive reflection is high enough, intuitive errors will be detected and the problem will be solved. However, CRT items also require numeric ability to be answered correctly and it is unclear how much numeric ability vs. cognitive reflection contributes to better decision making. In two studies, CRT responses were used to calculate Cognitive Reflection and numeric ability; a numeracy scale was also administered. Numeric ability, measured on the CRT or the numeracy scale, accounted for the CRT's ability to predict more normative decisions (a subscale of decision-making competence, incentivized measures of impatient and risk-averse choice, and self-reported financial outcomes); Cognitive Reflection contributed no independent predictive power. Results were similar whether the two abilities were modeled (Study 1) or calculated using proportions (Studies 1 and 2). These findings demonstrate numeric ability as a robust predictor of superior decision making across multiple tasks and outcomes. They also indicate that correlations of decision performance with the CRT are insufficient evidence to implicate overriding intuitions in the decision-making biases and outcomes we examined. Numeric ability appears to be the key mechanism instead. PMID:25999877
Sinayev, Aleksandr; Peters, Ellen
Scores on the three-item Cognitive Reflection Test (CRT) have been linked with dual-system theory and normative decision making (Frederick, 2005). In particular, the CRT is thought to measure monitoring of System 1 intuitions such that, if cognitive reflection is high enough, intuitive errors will be detected and the problem will be solved. However, CRT items also require numeric ability to be answered correctly and it is unclear how much numeric ability vs. cognitive reflection contributes to better decision making. In two studies, CRT responses were used to calculate Cognitive Reflection and numeric ability; a numeracy scale was also administered. Numeric ability, measured on the CRT or the numeracy scale, accounted for the CRT's ability to predict more normative decisions (a subscale of decision-making competence, incentivized measures of impatient and risk-averse choice, and self-reported financial outcomes); Cognitive Reflection contributed no independent predictive power. Results were similar whether the two abilities were modeled (Study 1) or calculated using proportions (Studies 1 and 2). These findings demonstrate numeric ability as a robust predictor of superior decision making across multiple tasks and outcomes. They also indicate that correlations of decision performance with the CRT are insufficient evidence to implicate overriding intuitions in the decision-making biases and outcomes we examined. Numeric ability appears to be the key mechanism instead.
Carr, Priyanka B; Steele, Claude M
The research presented in this article provides the first evidence that one's decision making can be influenced by concerns about stereotypes and the devaluation of one's identity. Many studies document gender differences in decision making, and often attribute these differences to innate and stable factors, such as biological and hormonal differences. In three studies, we found that stereotype threat affected decision making and led to gender differences in loss-aversion and risk-aversion behaviors. In Study 1, women subjected to stereotype threat in academic and business settings were more loss averse than both men and women who were not facing the threat of being viewed in light of negative stereotypes. We found no gender differences in loss-aversion behavior in the absence of stereotype threat. In Studies 2a and 2b, we found the same pattern of effects for risk-aversion behavior that we had observed for loss-aversion behavior. In addition, in Study 2b, ego depletion mediated the effects of stereotype threat on women's decision making. These results suggest that individuals' decision making can be influenced by stereotype concerns.
Background Patient-centered diabetes care requires shared decision making (SDM). Decision aids promote SDM, but their efficacy in nonacademic and rural primary care clinics is unclear. Methods We cluster-randomized 10 practices in a concealed fashion to implement either a decision aid (DA) about starting statins or one about choosing antihyperglycemic agents. Each practice served as a control group for another practice implementing the other type of DA. From April 2011 to July 2012, 103 (DA=53) patients with type 2 diabetes participated in the trial. We used patient and clinician surveys administered after the clinical encounter to collect decisional outcomes (patient knowledge and comfort with decision making, patient and clinician satisfaction). Medical records provided data on metabolic control. Pharmacy fill profiles provided data for estimating adherence to therapy. Results Compared to usual care, patients receiving the DA were more likely to report discussing medications (77% vs. 45%, p<.001), were more likely to answer knowledge questions correctly (risk reduction with statins 61% vs. 33%, p=.07; knowledge about options 57% vs. 33%, p=.002) and were more engaged by their clinicians in decision making (50. vs. 28, difference 21.4 (95% CI 6.4, 36.3), p=.01). We found no significant impact on patient satisfaction, medication starts, adherence or clinical outcomes, in part due to limited statistical power. Conclusion DAs improved decisional outcomes without significant effect on clinical outcomes. DAs designed for point-of-care use with type 2 diabetes patients promoted shared decision making in nonacademic and rural primary care practices. Trial Registration NCT01029288 PMID:23927490
Santema, T B Katrien; Stoffer, E Anniek; Kunneman, Marleen; Koelemay, Mark J W; Ubbink, Dirk T
Objectives Shared decision-making (SDM) has been advocated as the preferred method of choosing a suitable treatment option. However, patient involvement in treatment decision-making is not yet common practice in the field of vascular surgery. The aim of this mixed-methods study was to explore patients' decision-making preferences and to investigate which facilitators and barriers patients perceive as important for the application of SDM in vascular surgery. Design and setting Patients were invited to participate after visiting the vascular surgical outpatient clinic of an Academic Medical Center in the Netherlands. A treatment decision was made during the consultation for an abdominal aortic aneurysm or peripheral arterial occlusive disease. Patients filled in a number of questionnaires (quantitative part) and a random subgroup of patients participated in an in-depth interview (qualitative part). Results A total of 67 patients participated in this study. 58 per cent of them (n=39) indicated that they preferred a shared role in decision-making. In more than half of the patients (55%; n=37) their preferred role was in disagreement with what they had experienced. 31 per cent of the patients (n=21) preferred a more active role in the decision-making process than they had experienced. Patients indicated a good patient–doctor relationship as an important facilitator for the application of SDM. Conclusions The vast majority of vascular surgical patients preferred, but did not experience a shared role in the decision-making process, although the concept of SDM was insufficiently clear to some patients. This emphasises the importance of explaining the concept of SDM and implementing it in the clinical encounter. PMID:28188153
The purpose of this discussion is to present triage decision making research within the context of the Revised Cognitive Continuum Theory. Triage is an essential clinical skill in emergency nursing. Understanding the best way to facilitate this skill is vital when educating new nurses or providing continuing education to practicing nurses. Delineating research evidence within a theory allows clinical educators to understand practices that foster successful triage skills and permits the grounding of educational strategies within a theoretical framework.
Stiegler, Marjorie Podraza; Tung, Avery
The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology.Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame.Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making.
Parker, Francine M; Morris, Arlene H
Shared decision-making is an effective management strategy that may have positive implications for nurse educators facing curricular and course delivery issues. Use of shared or participative decision-making recognizes that decisions made for the overall good of the organization should include those integrally involved, i.e., faculty, students and administration. Ultimately, effective student learning should be the outcome of decisions related to curricular and content delivery. In this anecdotal paper, the authors present shared decision-making (SDM) as a management strategy that may be effectively utilized in a range of situations in educational settings. An exemplar is presented regarding changes in course delivery methods at two sister schools of nursing. Strategies to promote successful implementation, as well as challenges in initiating SDM, are discussed. The information presented in this paper can benefit nurse educators by offering a collaborative approach to the issues of evolving nursing curricula and content delivery.
Yu, Jai Y; Frank, Loren M
When making a decision it is often necessary to consider the available alternatives in order to choose the most appropriate option. This deliberative process, where the pros and cons of each option are considered, relies on memories of past actions and outcomes. The hippocampus and prefrontal cortex are required for memory encoding, memory retrieval and decision making, but it is unclear how these areas support deliberation. Here we examine the potential neural substrates of these processes in the rat. The rat is a powerful model to investigate the network mechanisms underlying deliberation in the mammalian brain given the anatomical and functional conservation of its hippocampus and prefrontal cortex to other mammalian systems. Importantly, it is amenable to large scale neural recording while performing laboratory tasks that exploit its natural decision-making behavior. Focusing on findings in the rat, we discuss how hippocampal-cortical interactions could provide a neural substrate for deliberative decision making.
Case study and case-based research in emergency nursing and care: Theoretical foundations and practical application in paramedic pre-hospital clinical judgment and decision-making of patients with mental illness.
Shaban, Ramon Z; Considine, Julie; Fry, Margaret; Curtis, Kate
Generating knowledge through quality research is fundamental to the advancement of professional practice in emergency nursing and care. There are multiple paradigms, designs and methods available to researchers to respond to challenges in clinical practice. Systematic reviews, randomised control trials and other forms of experimental research are deemed the gold standard of evidence, but there are comparatively few such trials in emergency care. In some instances it is not possible or appropriate to undertake experimental research. When exploring new or emerging problems where there is limited evidence available, non-experimental methods are required and appropriate. This paper provides the theoretical foundations and an exemplar of the use of case study and case-based research to explore a new and emerging problem in the context of emergency care. It examines pre-hospital clinical judgement and decision-making of mental illness by paramedics. Using an exemplar the paper explores the theoretical foundations and conceptual frameworks of case study, it explains how cases are defined and the role researcher in this form of inquiry, it details important principles and the procedures for data gathering and analysis, and it demonstrates techniques to enhance trustworthiness and credibility of the research. Moreover, it provides theoretically and practical insights into using case study in emergency care.
Friedberg, Mark W; Van Busum, Kristin; Wexler, Richard; Bowen, Megan; Schneider, Eric C
Recent developments in health reform related to the passage of the Affordable Care Act and ensuing regulations encourage delivery systems to engage in shared decision making, in which patients and providers together make health care decisions that are informed by medical evidence and tailored to the specific characteristics and values of the patient. To better understand how delivery systems can implement shared decision making, we interviewed representatives of eight primary care sites participating in a demonstration funded and coordinated by the Informed Medical Decisions Foundation. Barriers to shared decision making included overworked physicians, insufficient provider training, and clinical information systems incapable of prompting or tracking patients through the decision-making process. Methods to improve shared decision making included using automatic triggers for the distribution of decision aids and engaging team members other than physicians in the process. We conclude that substantial investments in provider training, information systems, and process reengineering may be necessary to implement shared decision making successfully.
Payne, Leslie Karns
The ability to make sound clinical decisions is the cornerstone of excellent nursing care and the goal of continuing nurse educators. Research has revealed that expert nurses make fewer errors in decision making; it also has shown differences in the decision-making process of expert nurses, compared with novice nurses. Specifically, expert nurses report a greater use of intuitive decision making. Accordingly, an important goal for continuing nurse educators is the development of intuitive decision making by nurses. This article proposes a pattern-based, constructivist educational framework that synthesizes Benner's novice to expert (NTE) theory, Damascio's somatic marker hypothesis (SMH), and Hammond's cognitive continuum theory (CCT). This framework provides a foundation for continuing education that fosters the development of intuitive decision making in nurses. Although this framework needs further empirical validation, it is theoretically sound and applicable to all areas of nursing, and its implementation could help reduce errors in decision making by nurses, thus improving patient outcomes.
Gevarter, William B.
Models of human decision making are reviewed. Models which treat just the cognitive aspects of human behavior are included as well as models which include motivation. Both models which have associated computer programs, and those that do not, are considered. Since flow diagrams, that assist in constructing computer simulation of such models, were not generally available, such diagrams were constructed and are presented. The result provides a rich source of information, which can aid in construction of more realistic future simulations of human decision making.
Yang, Chyan; Wu, Chia-Chun
The purpose of this research is to provide managers of shopping websites information regarding consumer purchasing decisions based on the Consumer Styles Inventory (CSI). According to the CSI, one can capture what decision-making styles online shoppers use. Furthermore, this research also discusses the gender differences among online shoppers. Exploratory factor analysis (EFA) was used to understand the decision-making styles and discriminant analysis was used to distinguish the differences between female and male shoppers. The result shows that there are differences in purchasing decisions between online female and male Internet users.
Keuken, Max C.; Müller-Axt, Christa; Langner, Robert; Eickhoff, Simon B.; Forstmann, Birte U.; Neumann, Jane
In the recent perceptual decision-making literature, a fronto-parietal network is typically reported to primarily represent the neural substrate of human perceptual decision-making. However, the view that only cortical areas are involved in perceptual decision-making has been challenged by several neurocomputational models which all argue that the basal ganglia play an essential role in perceptual decisions. To consolidate these different views, we conducted an Activation Likelihood Estimation (ALE) meta-analysis on the existing neuroimaging literature. The results argue in favor of the involvement of a frontal-parietal network in general perceptual decision-making that is possibly complemented by the basal ganglia, and modulated in substantial parts by task difficulty. In contrast, expectation of reward, an important aspect of many decision-making processes, shows almost no overlap with the general perceptual decision-making network. PMID:24994979
Gati, Itamar; Landman, Shiri; Davidovitch, Shlomit; Asulin-Peretz, Lisa; Gadassi, Reuma
Previous research on individual differences in career decision-making processes has often focused on classifying individuals into a few types of decision-making "styles" based on the most dominant trait or characteristic of their approach to the decision process (e.g., rational, intuitive, dependent; Harren, 1979). In this research, an…
The research reported in this paper aimed to examine the relationships between decisiveness in social relationships, and the decision-making styles of a group of university students and to investigate the contributions of decision-making styles in predicting decisiveness in social relationship (conflict resolution, social relationship selection…
Placek, Rita; Pearson, Kaye
A program for improving adolescents' decision-making skills to reduce the number of inappropriate behavioral choices related to wellness is described. The targeted population consisted of seventh and tenth grade students in a rural, middle class community. Data from local law enforcement records and school-based program referrals supported…
Purcell, Braden A.; Heitz, Richard P.; Cohen, Jeremiah Y.; Schall, Jeffrey D.; Logan, Gordon D.; Palmeri, Thomas J.
Stochastic accumulator models account for response time in perceptual decision-making tasks by assuming that perceptual evidence accumulates to a threshold. The present investigation mapped the firing rate of frontal eye field (FEF) visual neurons onto perceptual evidence and the firing rate of FEF movement neurons onto evidence accumulation to…
El-Mallakh, Rif; Zinner, Jill; Mackey, Amanda; Tamas, Rebecca L.; Martin, Chanley M.; Dalton, Jerad; Dhaliwal, Nitu; Luddington, Nicole; Numan, Farhad U.; Nunes, Ross; Taylor, Stephen; Ye, Lu
Objective: Several conspiring factors have resulted in an increase in the level of medical burden in psychiatric patients. Psychiatry residents require increasing levels of medical sophistication. To assess the medical decision-making of psychiatry residents, the authors examined the outcome in subjects initially seen in the emergency psychiatric…
Rogerson, Mark D.; Gottlieb, Michael C.; Handelsman, Mitchell M.; Knapp, Samuel; Younggren, Jeffrey
Most current ethical decision-making models provide a logical and reasoned process for making ethical judgments, but these models are empirically unproven and rely upon assumptions of rational, conscious, and quasi-legal reasoning. Such models predominate despite the fact that many nonrational factors influence ethical thought and behavior,…
Winter, Scott R.
The purpose of this study was to determine if a reflexive learning treatment utilizing select case studies could enhance the decision-making of pilots who encounter an irreversible emergency. Participants, who consisted of members of the subject university's professional pilot program, were divided into either a control or experimental group and…
Franks, Nigel R; Dornhaus, Anna; Fitzsimmons, Jon P; Stevens, Martin
We demonstrate a speed versus accuracy trade-off in collective decision making. House-hunting ant colonies choose a new nest more quickly in harsh conditions than in benign ones and are less discriminating. The errors that occur in a harsh environment are errors of judgement not errors of omission because the colonies have discovered all of the alternative nests before they initiate an emigration. Leptothorax albipennis ants use quorum sensing in their house hunting. They only accept a nest, and begin rapidly recruiting members of their colony, when they find within it a sufficient number of their nest-mates. Here we show that these ants can lower their quorum thresholds between benign and harsh conditions to adjust their speed-accuracy trade-off. Indeed, in harsh conditions these ants rely much more on individual decision making than collective decision making. Our findings show that these ants actively choose to take their time over judgements and employ collective decision making in benign conditions when accuracy is more important than speed. PMID:14667335
Cone, W. Henry
Administrators cannot afford to remain ignorant of the work of neuroscientists over the last 30 years. The findings of brain research can help administrators gain a better understanding of decision making. The author lists four benefits to education that administrators can provide through greater knowledge of the brain. (WD)
Dunwell, Robert R.
The author examines the traditional, academic, decision-making processes in light of humanistic pressures that have evolved in the past three decades and concludes that these processes must undergo fundamental changes to include those participants who should be enfranchised. (MB)
Utility Theory ( MAUT ). iv Multiattribute Methodologies for Decision Making in COEAs Table of Contents 1. Purpose... Multiattribute Utility Theory a. As with AHP the application of MAUT begins with hierarchical decomposition illustrated in Figure 1. The complete demonstration...Analytic Hierarchy Process (AHP), (4) Multiattribute Value Theory (I4AVT), and (5) Multiattribute Utility Theory ( MAUT ). Each of these techniques
Lusby, Linda A.
This document examines the underlying rationale for the development of a global approach in consumer studies. The concept of consumer ethics is discussed and the consumer decision-making process is placed within an ecosystem perspective of the marketplace. The model developed introduces educators, marketers, and consumers to a more global…
Ross-Gillespie, Adin; Kümmerli, Rolf
Microbes are intensely social organisms that routinely cooperate and coordinate their activities to express elaborate population level phenotypes. Such coordination requires a process of collective decision-making, in which individuals detect and collate information not only from their physical environment, but also from their social environment, in order to arrive at an appropriately calibrated response. Here, we present a conceptual overview of collective decision-making as it applies to all group-living organisms; we introduce key concepts and principles developed in the context of animal and human group decisions; and we discuss, with appropriate examples, the applicability of each of these concepts in microbial contexts. In particular, we discuss the roles of information pooling, control skew, speed vs. accuracy trade-offs, local feedbacks, quorum thresholds, conflicts of interest, and the reliability of social information. We conclude that collective decision-making in microbes shares many features with collective decision-making in higher taxa, and we call for greater integration between this fledgling field and other allied areas of research, including in the humanities and the physical sciences. PMID:24624121
Brazer, S. David; Rich, William; Ross, Susan A.
Purpose: The dual purpose of this paper is to determine how superintendents in US school districts work with stakeholders in the decision-making process and to learn how different choices superintendents make affect decision outcomes. Design/methodology/approach: This multiple case study of three school districts employs qualitative methodology to…
Ashford-Rowe, Kevin H.; Holt, Marnie
The "emerging educational institutional decision-making matrix" is developed to allow educational institutions to adopt a rigorous and consistent methodology of determining which of the myriad of emerging educational technologies will be the most compelling for the institution, particularly ensuring that it is the educational or pedagogical but…
Shankar, Karthik H
How realistic is it to adopt a quantum random walk model to account for decisions involving two choices? Here, we discuss the neural plausibility and the effect of initial state and boundary thresholds on such a model and contrast it with various features of the classical random walk model of decision making.
Reports generalizations about specific patterns emerging from a panel employing a decision-making Delphi process that attempted to forecast the long-range general environment for higher education in Michigan. Participating were 24 influential persons with knowledge of factors important within the state. (Author/RH)
Discusses the impact of public opinion on government decision-making, and develops a model that describes how certain input or control factors can combine to produce discontinuous or divergent policy decisions. Available from: Elsevier Scientific Publishing Company, Box 211, Amsterdam, the Netherlands, single copies available. (Author/JG)
Brower, Robert E.; Balch, Bradley V.
It is essential for every school leader to possess the savvy to effect positive change, raise achievement levels, and foster a positive school climate. Now it seems that the struggle for school leaders to make productive decisions has become clouded with ever-growing uncertainty and skepticism. "Transformational Leadership & Decision Making in…
BAILEY, STEPHEN K.
THE AUTHOR EXAMINES THE VARIOUS WAYS IN WHICH THE UNIVERSITY CAN AND SHOULD INFLUENCE URBAN DECISION MAKING. THE CENTRAL UNIVERSITY ROLE IS SENSITIZING THE DECISION MAKERS AND THE CITIZENS TO HUMAN MISERY, SUCH AS BIGOTRY, SQUALOR, DISEASE, UGLINESS, POVERTY, AND IGNORANCE. LONG-RANGE ROLES ARE PINPOINTING THE PROBLEMS URBAN DECISION MAKERS SHOULD…
We propose a model of vocational choice that can be used for analyzing and guiding the decision processes underlying career and job choices. Our model is based on research in behavioral decision making (BDM), in particular the choice goals framework developed by Bettman, Luce, and Payne (1998). The basic model involves two major processes. First,…
Butow, Phyllis; Tattersall, Martin
Cancer treatment outcomes have improved over the past 20 years, but treatment decision making in this context remains complex. There are often a number of reasonable treatment alternatives, including no treatment in some circumstances. Patients and doctors often have to weigh up uncertain benefits against uncertain costs. Shared decision making…
This study considers how ABCS (Army Battle Command System) capabilities achieve information dominance and how they influence the military decision...making process. The work examines how ABCS enables commanders and staffs to achieve information dominance at the brigade and battalion levels. Further...future digitized systems that will gain information dominance for the future commander. It promotes the continued development information dominance technologies
Karl, Herman A.; Turner, Christine E.
Alan Leshner's Editorial “Public engagement with science” (14 Feb., p. 977) highlights a conundrum: Why is science often ignored in important societal decisions, even as the call for decisions based on sound science escalates? One reason is that decision-making is often driven by a variety of nonscientific, adversarial, and stakeholder dynamics
Lapenta, William; Irwin, Dan
SERVIR is a regional visualization and monitoring system for Mesoamerica that integrates satellite and other geospatial data for improved scientific knowledge and decision making by managers, researchers, students, and the general public. SERVIR addresses the nine societal benefit areas of the Global Earth Observation System of Systems (GEOSS). This talk will provide an overview of products and services available through SERVIR.
2, Modelisation et Application, Masson, Paris. Chyen, G. H-L., and A.H. Levis, 1985, "Analysis of Preprocessors and Decision Aids in Organizations...34Decision Aiding and Coordination in Decision-making Organizations," S.M. Thesis , LIDS-TH-1737, Laboratory for Information and Decision Systems, MIT
This paper suggests an innovative idea of using the "technology fair" as a means for promoting pre-service teachers (university students) decision-making skills. The purpose of the study was to investigate the influence of a procedure of working with primary school children to complete and present a technology fair project, on the decision-making…
Albert, Dustin; Steinberg, Laurence
In this article, we review the most important findings to have emerged during the past 10 years in the study of judgment and decision making (JDM) in adolescence and look ahead to possible new directions in this burgeoning area of research. Three inter-related shifts in research emphasis are of particular importance and serve to organize this…
AFOSR: 1.8 BRIEF DESCRIPTION OF PORTFOLIO Support experimental and computational modeling work in: 1. Understanding cognitive...AREAS IN PORTFOLIO 1. Mathematical and Computational Cognition 2. Robust Decision Making in Human-System Interface 3. Computational and Machine...Interactions with Other Organizations ONR (Paul Bello) • Perception, Metacognition , and Cognitive Control Program ONR (Tom McKenna) • Computational
Lee, Michael D.; Dry, Matthew J.
We study human decision making in a simple forced-choice task that manipulates the frequency and accuracy of available information. Empirically, we find that people make decisions consistent with the advice provided, but that their subjective confidence in their decisions shows 2 interesting properties. First, people's confidence does not depend…
Kenward, Ben; Folke, Sara; Holmberg, Jacob; Johansson, Alexandra; Gredeback, Gustaf
The term "goal directed" conventionally refers to either of 2 separate process types--motor processes organizing action oriented toward physical targets and decision-making processes that select these targets by integrating desire for and knowledge of action outcomes. Even newborns are goal directed in the first sense, but the status of…
van Ravenzwaaij, Don; van der Maas, Han L. J.; Wagenmakers, Eric-Jan
In their influential "Psychological Review" article, Bogacz, Brown, Moehlis, Holmes, and Cohen (2006) discussed optimal decision making as accomplished by the drift diffusion model (DDM). The authors showed that neural inhibition models, such as the leaky competing accumulator model (LCA) and the feedforward inhibition model (FFI), can mimic the…
The study investigated the relationship of nature of science (NOS) instruction and students' decision-making (DM) related to a controversial socioscientific issue about genetically modified food. Participants were ninth-grade students in four intact sections (two regulars and two honors) in a public high school in the Midwest. All four groups were…
Cubillo, Jose Maria; Sanchez, Joaquin; Cervino, Julio
Purpose--The purpose of this paper is to propose a theoretical model that integrates the different groups of factors which influence the decision-making process of international students, analysing different dimensions of this process and explaining those factors which determine students' choice. Design/methodology/approach--A hypothetical model…
Waldrop, Deborah P.; Meeker, Mary Ann
Purpose: This study explored the process of decision making about hospice enrollment and identified factors that influence the timing of that decision. Methods: This study employed an exploratory, descriptive, cross-sectional design and was conducted using qualitative methods. In-depth in-person semistructured interviews were conducted with 36…
Moore, J. William; And Others
Undergraduates (n=142) participated in study on decision making in which prospective administrators made monetary commitments to long-term goals under varying conditions. Found significant negative correlation between anxiety level and commitments to previously chosen courses of action; no significant effects of job security on commitment; and…
Leet, Don R.; Charkins, R. J.; Lang, Nancy A.; Lopus, Jane S.; Tamaribuchi, Gail
This book highlights and examines basic economic concepts as they relate to consumer, business, social, and personal choices. Students are shown connections between their classroom learning and their real-world experiences in budgeting, career planning, credit management, and housing. The set of 15 lessons include: (1) "Decision Making: Scarcity,…
This paper seeks to investigate the extent of influence of corporate (or organisational) responsibility on university students' career decision-making. It reports on a pilot study conducted at the University of Sydney which aims to: explore students' ethical, professional and social understanding regarding corporate responsibility; determine the…
Veksler, Vladislav D.; Gray, Wayne D.; Schoelles, Michael J.
Reinforcement learning (RL) models of decision-making cannot account for human decisions in the absence of prior reward or punishment. We propose a mechanism for choosing among available options based on goal-option association strengths, where association strengths between objects represent previously experienced object proximity. The proposed…
Yurtseven, M. Kudret; Buchanan, Walter W.
Decision making in most universities is taught within the conventional OR/MS (Operations Research/Management Science) paradigm. This paradigm is known to be "hard" since it is consisted of mathematical tools, and normally suitable for solving structured problems. In complex situations the conventional OR/MS paradigm proves to be…
Zamarian, Laura; Höfler, Julia; Kuchukhidze, Giorgi; Delazer, Margarete; Bonatti, Elisabeth; Kemmler, Georg; Trinka, Eugen
Recent neuroimaging studies have reported structural and functional brain abnormalities in patients with juvenile myoclonic epilepsy (JME), which may also involve cortical and subcortical networks that are important for decision making. This study is the first attempt to examine decision making in JME. Twenty-two patients with JME (median age 26.00, range 18-50) and 33 healthy controls (median age 26.00, range 18-57) participated in the study. For the JME group, the median age at seizure onset was 14.00 years (range 1-20); the median epilepsy duration was 11.50 years (range 3-45). Eleven patients (50 %) had pharmacoresistant seizures. All participants completed the Iowa Gambling Task (IGT), a widely used standard task of decision making. In this task, contingencies are not explained and feedback on previous decisions has to be used in order to learn to choose the advantageous alternatives. In the IGT, patients with JME showed difficulty in learning to choose advantageously compared to healthy controls. Difficulty was enhanced for the patients with pharmacoresistant seizures. A correlation analysis revealed an association between decision-making performance of patients with JME and executive functions. Results indicate that patients with JME have difficulty in making advantageous decisions and that persistence of seizures might be a critical factor for cognitive functioning. Findings of this study add a new aspect to the neuropsychological profile of JME. Difficulty in decision making may impair functioning of patients with JME in everyday life and affect their adherence to treatment plans.
Li, W; Zhang, R S; Zhang, L Q; Lu, B G; Fu, W H
Objective: To analyze the clinical value of SPECT/CT in diagnosis of skull base bone invasion and clinical decision-making for nasopharyngeal carcinoma (NPC), and to compare their diagnostic value with SPECT/CT, CT, MRI, and MRI combined with SPECT (MRI-SPECT) for skull base bone invasion. Methods: Before treatment, among 348 newly diagnosed NPC patients, CT scan was performed in 186 patients (group A) and the remaining 162 patients received MRI scan (group B). Clinical doctors then made clinical management decisions according to the CT or MRI results. After that, all patients underwent (99)Tc(m)-MDP SPECT/CT examination for nasopharyngeal local tomography, and the results were provided to the clinical doctors to make clinical management decisions again. The changes between the two clinical management decisions were scored according to diagnosis, range of lesion, staging, treatment regimens, and auxiliary examination. The diagnostic value of CT scan, MRI scan, SPECT/CT and MRI-SPECT for skull base bone invasion was then evaluated and compared. Results: In terms of changes in scores of clinical management decisions, the score of group A was 1.387 and group B was 0.951, showing a significant difference between the two groups by Wilcoxon test (Z=6.570, P<0.001). By χ(2) test, there were correlations between CT and SPECT/CT (χ(2) =98.495, P<0.001), and between MRI and SPECT/CT (χ(2) =32.662, P<0.001). The consistency of CT and SPECT/CT (Kappa=0.713) was greater than MRI and SPECT (Kappa=0.449). The sensitivity of CT, MRI, SPECT/CT and MRI-SPECT was 67.1%, 84.5%, 90.8% and 100%, the specificity was 73.3%, 92.3%, 85.6% and 84.6%, and the area under the ROC curve was 0.702, 0.884, 0.882 and 0.923, respectively. Conclusions: SPECT/CT has important impact on clinical management decision for NPC. In the judgement of skull base invasion, the diagnostic value of SPECT/CT is significantly higher than CT and approximately equal to MRI. SPECT/CT should be one of the routine
Masters, James R.; Dorwart, James P.
Instruments to measure decision-making skills of grade 5, 8, and 11 students were developed as a part of Pennsylvania's statewide assessment program. A decision-making model was formulated based upon John Dewey's five major steps of the critical thinking process: (1) identify the problem; (2) establish the facts; (3) formulate the hypothesis; (4)…
Association of California School Administrators.
This report raises fundamental issues that must be explored by educators considering participative decision-making as part of an educational restructuring initiative. In analyzing district readiness to implement a shared decision-making model, several factors must be considered, including school culture and climate, leadership style and attitude,…
Hung, M.-L. . E-mail: email@example.com; Ma Hwongwen . E-mail: firstname.lastname@example.org; Yang, W.-F. . E-mail: email@example.com
This paper reviews several models developed to support decision making in municipal solid waste management (MSWM). The concepts underlying sustainable MSWM models can be divided into two categories: one incorporates social factors into decision making methods, and the other includes public participation in the decision-making process. The public is only apprised or takes part in discussion, and has little effect on decision making in most research efforts. Few studies have considered public participation in the decision-making process, and the methods have sought to strike a compromise between concerned criteria, not between stakeholders. However, the source of the conflict arises from the stakeholders' complex web of value. Such conflict affects the feasibility of implementing any decision. The purpose of this study is to develop a sustainable decision making model for MSWM to overcome these shortcomings. The proposed model combines multicriteria decision making (MCDM) and a consensus analysis model (CAM). The CAM is built up to aid in decision-making when MCDM methods are utilized and, subsequently, a novel sustainable decision making model for MSWM is developed. The main feature of CAM is the assessment of the degree of consensus between stakeholders for particular alternatives. A case study for food waste management in Taiwan is presented to demonstrate the practicality of this model.
Zhang, Long; Wang, Kai; Zhu, Chunyan; Yu, Fengqiong; Chen, Xingui
Previous studies have reported that trait anxiety (TA) affects decision making. However, results remain largely inconsistent across studies. The aim of the current study was to further address the interaction between TA and decision making. 304 subjects without depression from a sample consisting of 642 participants were grouped into high TA (HTA), medium TA (MTA) and low TA (LTA) groups based on their TA scores from State Trait Anxiety Inventory. All subjects were assessed with the Iowa Gambling Task (IGT) that measures decision making under ambiguity and the Game of Dice Task (GDT) that measures decision making under risk. While the HTA and LTA groups performed worse on the IGT compared to the MTA group, performances on the GDT between the three groups did not differ. Furthermore, the LTA and HTA groups showed different individual deck level preferences in the IGT: the former showed a preference for deck B indicating that these subjects focused more on the magnitude of rewards, and the latter showed a preference for deck A indicating significant decision making impairment. Our findings suggest that trait anxiety has effect on decision making under ambiguity but not decision making under risk and different levels of trait anxiety related differently to individual deck level preferences in the IGT. PMID:26000629
Clinical decisions and clinical judgements are important elements of nursing practice because they have a direct effect on patient care. A four-stage information processing framework was used to critique a decision to carry out chest examination and auscultation during the routine assessment of a child's asthma status. The use of this process demonstrates that nurses apply a combination of analytical and intuitive strategies when making decisions. Nurses who manage the care of patients in nurse-led clinics need to acquire advanced assessment skills to support their clinical decision making.
Taylor, Stephanie D; Bagozzi, Richard P; Gaither, Caroline A
We compare the ability of two social psychological models to explain self-regulation decisions to control hypertension by 208 patients at a hospital clinic: the theory of planned behaviour (TPB) and the model of goal-directed behaviour (MGB). The sample was drawn from patients at a large research hospital in North America. The findings show that the MGB not only explains significantly more variance in decision making than the TPB, but it provides an account for how reasons for acting become integrated and transformed into intentions to act, which the TPB does not address. The MGB does this in part by introducing the variable, desire, as an essential mediator between reasons for acting and intentions. The MGB also incorporates the effects of anticipated emotions on decision making, which are forms of forward-looking counterfactual thinking with respect to goals. In addition, the present study reconceptualized instrumental behaviour to encompass how hard one tries to act in the senses of (1) devoting time to planning with respect to reducing/maintaining blood pressure, (2) expending mental/physical energy to reduce/maintain blood pressure, (3) maintaining will power to reduce/maintain blood pressure, and (4) sustaining self-discipline (e.g. in overcoming obstacles) to reduce/maintain blood pressure. Key differences, as well as commonalities, in decision making are pointed-out between men and women and between people whose goal is to reduce versus maintain blood pressure.
Glasdam, Stinne; Oeye, Christine; Thrysoee, Lars
This article focuses on patients' participation in decision-making in meetings with healthcare professionals in a healthcare system, based on neoliberal regulations and ideas. Drawing on two constructed empirical cases, primarily from the perspective of patients, this article analyses and discusses the clinical practice around decision-making meetings within a Foucauldian perspective. Patients' participation in decision-making can be seen as an offshoot of respect for patient autonomy. A treatment must be chosen, when patients consult physicians. From the perspective of patients, there is a tendency for healthcare professionals to supply the patients with the information that they think are necessary for them to make their own decision. But patients do not always want to be a 'customer' in the healthcare system; they want to be a patient, consulting an expert for help and advice, which creates resistance to some parts of the decision-making process. Both professionals and patients are subject to the structural frame of the medical field, formed of both neoliberal framework and medical logic. The decision-making competence in relation to the choice of treatment is placed away from the professionals and seen as belonging to the patient. A 'projectification' of the patient occurs, whereby the patient becomes responsible for his/her choices in treatment and care and the professionals support him/her with knowledge, preferences, and alternative views, out of which he/she must make his/her own choices, and the responsibility for those choices now and in the future. At the same time, there is a tendency towards de-professionalization. In that light, participation of patients in decision-making can be regarded as a tacit governmentality strategy that shapes the location of responsibility between individual and society, and independent patients and healthcare professionals, despite the basically desirable, appropriate, and necessary idea of involving patients in their own
... 43 Public Lands: Interior 2 2014-10-01 2014-10-01 false Decision-making procedures. 10010.48... POLICY ACT Relationship to Decision-Making § 10010.48 Decision-making procedures. (a) Procedures by which... in its formal decision-making procedures provisions for consideration of environmental factors...
... 36 Parks, Forests, and Public Property 3 2011-07-01 2011-07-01 false Trust decision-making... § 1010.13 Trust decision-making procedures. To ensure that at major decision-making points all relevant... to being prepared at the earliest point in the decision-making process, shall accompany the...
... 36 Parks, Forests, and Public Property 3 2013-07-01 2012-07-01 true Trust decision-making... § 1010.13 Trust decision-making procedures. To ensure that at major decision-making points all relevant... to being prepared at the earliest point in the decision-making process, shall accompany the...
... 36 Parks, Forests, and Public Property 3 2012-07-01 2012-07-01 false Trust decision-making... § 1010.13 Trust decision-making procedures. To ensure that at major decision-making points all relevant... to being prepared at the earliest point in the decision-making process, shall accompany the...
... 43 Public Lands: Interior 2 2013-10-01 2013-10-01 false Decision-making procedures. 10010.48... POLICY ACT Relationship to Decision-Making § 10010.48 Decision-making procedures. (a) Procedures by which... in its formal decision-making procedures provisions for consideration of environmental factors...
... 43 Public Lands: Interior 2 2012-10-01 2012-10-01 false Decision-making procedures. 10010.48... POLICY ACT Relationship to Decision-Making § 10010.48 Decision-making procedures. (a) Procedures by which... in its formal decision-making procedures provisions for consideration of environmental factors...
... 36 Parks, Forests, and Public Property 3 2014-07-01 2014-07-01 false Trust decision-making... § 1010.13 Trust decision-making procedures. To ensure that at major decision-making points all relevant... to being prepared at the earliest point in the decision-making process, shall accompany the...
... 43 Public Lands: Interior 2 2011-10-01 2011-10-01 false Decision-making procedures. 10010.48... POLICY ACT Relationship to Decision-Making § 10010.48 Decision-making procedures. (a) Procedures by which... in its formal decision-making procedures provisions for consideration of environmental factors...
Lighthall, Geoffrey K.; Vazquez-Guillamet, Cristina
Background Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action. Rationale There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature. Content This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition. PMID:26387708
Leisti, Tuomas; Radun, Jenni; Virtanen, Toni; Nyman, Göte; Häkkinen, Jukka
The verbalization of one's thoughts has been shown to impair judgment and decision making in some cases, particularly when targets are perceptual. This finding has been attributed to the fact that non-verbal processes are sometimes difficult to verbalize, which may cause a shift in processing that is maladaptive to the task. The study shows that concurrent written explanations can also enhance judgment and decision making in certain visual choice tasks. This finding suggests that the effect of verbalization on perceptual tasks is not dependent on whether the targets of the judgment are verbal or perceptual but rather on whether there is adequate vocabulary to execute the task and whether the task benefits from a more analytic approach.
Churchland, Anne K.; Kiani, Roozbeh; Shadlen, Michael N.
Simple perceptual tasks have laid the groundwork for understanding the neurobiology of decision making. Here, we challenge this foundation to explain how decision-making circuitry adjusts to a more difficult task. We measured behavioral and physiological responses on a 2- and 4-choice direction discrimination decision task. For both tasks, firing rates in the lateral intraparietal area appeared to reflect the accumulation of evidence for or against each choice. Evidence accumulation began at a lower firing rate for the 4-choice task, but reached a common level at the end of the decision process. The larger excursion suggests that subjects required more evidence before making a choice. Further, on both tasks, we observed a time-dependent rise in firing rates that may impose a deadline for deciding. These physiological observations constitute an effective strategy for handling increased task difficulty. The differences appear to explain subjects’ accuracy and reaction times. PMID:18488024
Yearsley, James M.; Pothos, Emmanuel M.
Classical probability theory has been influential in modelling decision processes, despite empirical findings that have been persistently paradoxical from classical perspectives. For such findings, some researchers have been successfully pursuing decision models based on quantum theory (QT). One unique feature of QT is the collapse postulate, which entails that measurements (or in decision-making, judgements) reset the state to be consistent with the measured outcome. If there is quantum structure in cognition, then there has to be evidence for the collapse postulate. A striking, a priori prediction, is that opinion change will be slowed down (under idealized conditions frozen) by continuous judgements. In physics, this is the quantum Zeno effect. We demonstrate a quantum Zeno effect in decision-making in humans and so provide evidence that advocates the use of quantum principles in decision theory, at least in some cases. PMID:27053743
Yearsley, James M; Pothos, Emmanuel M
Classical probability theory has been influential in modelling decision processes, despite empirical findings that have been persistently paradoxical from classical perspectives. For such findings, some researchers have been successfully pursuing decision models based on quantum theory (QT). One unique feature of QT is the collapse postulate, which entails that measurements (or in decision-making, judgements) reset the state to be consistent with the measured outcome. If there is quantum structure in cognition, then there has to be evidence for the collapse postulate. A striking, a prioriprediction, is that opinion change will be slowed down (under idealized conditions frozen) by continuous judgements. In physics, this is the quantum Zeno effect. We demonstrate a quantum Zeno effect in decision-making in humans and so provide evidence that advocates the use of quantum principles in decision theory, at least in some cases.
The area of judgment and decision making has given rise to the study of many interesting phenomena, including reasoning fallacies, which are also of interest to behavior analysts. Indeed, techniques and principles of behavior analysis may be applied to study these fallacies. This article reviews research from a behavioral perspective that suggests that humans are not the information-seekers we sometimes suppose ourselves to be. Nor do we utilize information effectively when it is presented. This is shown from the results of research utilizing matching to sample and other behavioral tools (monetary reward, feedback, instructional control) to study phenomena such as the conjunction fallacy, base-rate neglect, and probability matching. Research from a behavioral perspective can complement research from other perspectives in furthering our understanding of judgment and decision making. PMID:22478308
Today, the assessment of liver function in patients suffering from acute or chronic liver disease is based on liver biopsy and blood tests including synthetic function, liver enzymes and viral load, most of which provide only circumstantial evidence as to the degree of hepatic impairment. Most of these tests lack the degree of sensitivity to be useful for follow-up of these patients at the frequency that is needed for decision making in clinical hepatology. Accurate assessment of liver function is essential to determine both short- and long-term prognosis, and for making decisions about liver and non-liver surgery, TIPS, chemoembolization or radiofrequency ablation in patients with chronic liver disease. Liver function tests can serve as the basis for accurate decision-making regarding the need for liver transplantation in the setting of acute failure or in patients with chronic liver disease. The liver metabolic breath test relies on measuring exhaled (13) C tagged methacetin, which is metabolized only by the liver. Measuring this liver-specific substrate by means of molecular correlation spectroscopy is a rapid, non-invasive method for assessing liver function at the point-of-care. The (13) C methacetin breath test (MBT) is a powerful tool to aid clinical hepatologists in bedside decision-making. Our recent findings regarding the ability of point-of-care (13) C MBT to assess the hepatic functional reserve in patients with acute and chronic liver disease are reviewed along with suggested treatment algorithms for common liver disorders.
Virtually all of the longer decisions are from incidents #30--32, a pumping station fire. This was a unique case in our interviews. First, it took almost...select one. In other words, we found virtually no Instances of the standard laboratory paradigm for decision making: conscious and deliberate...Heidi L. (1985). Eyewitness Memory Enhancement in the Police Interview: Cognitive Retrieval Mnemonics Versus Hypnosis . Journal of Applied Psychology, 70
793–810. 39. Wagatsuma H, Yamaguchi Y (2007) Neural dynamics of the cognitive map in the hippocampus. Cognitive Neurodynamics 1: 119–141. 40. Kifer Y...Transient Cognitive Dynamics, Metastability, and Decision Making Mikhail I. Rabinovich1*, Ramón Huerta1,2, Pablo Varona2, Valentin S. Afraimovich3 1...Óptica, UASLP, San Luis de Potosı́, Mexico Abstract The idea that cognitive activity can be understood using nonlinear dynamics has been intensively
Decisionproe-ssr-Deci-sion outcomes, Organizational Learning , Strategic Management, Decision Models, Culture, Group Think, Decision Errors, Industrial...in the process mode. a~q REFERENCES Argyris, C. and Schon, D.A. Organizational Learning : A Theory of Action Perspectives. Reading, MA: Addison Wesley...process of strategic decision making. Richard Normann, associated with the Service Management Group, Paris, provides a framework for organizational
Sandman, Lars; Munthe, Christian
In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, different versions of SDM are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship.
of this effort to establish a universal CRM evaluation methodology useful throughout the 7 Codes icd/or AA industry. The author’s participation in the...on communication) to the decision training and evaluation being offered to the single-person cockpit elsewhere described as ADM. From a historical...risk assessment skills. 5) Learning to consider all resources available. 6) Learning to how evaluate your flight and decision making skills. Recent
tools . Decision support tools are systems designed to support and even enhance human decision making augmenting the amount of information that...well short of an reverse engineering system . IDA Pro was chosen because it is a commonly used reverse engineering tool and also used by the reverse...reason. A debugger is a tool designed for human use. For an artificial agent system , the interface provided by the debug tool unnecessarily limits
the group process during the experiment and the influence of the MBTI. 7 Subsidiary Research Ouestions and Hypothesis The research objectives were...members’ contributions. Margolis explained how defensive feelings can influence the group members: Feeling defensive, individuals protect themselves and...encouraging diversity and nonconformity during group decision making" (18:449). Another way to guard against groupthink.is to pick someone in the group who will
Nicolis, Grégoire; Nicolis, Stamatios C.
A probabilistic approach to decision-making is developed in which the states of the underlying stochastic process, assumed to be of the Markov type, represent the competing options. The principal parameters determining the dominance of a particular option versus the others are identified and the transduction of information associated to the transitions between states is quantified using a set of entropy-like quantities.
Bexkens, Anika; Jansen, Brenda R J; Van der Molen, Maurits W; Huizenga, Hilde M
Adolescents with Behavior Disorders (BD), Mild-to-Borderline Intellectual Disability (MBID), and with both BD and MBID (BD + MBID) are known to take more risks than normal controls. To examine the processes underlying this increased risk-taking, the present study investigated cool decision-making strategies in 479 adolescents (12-18 years, 55.9 % male) from these four groups. Cool decision-making was assessed with the paper-and-pencil Gambling Machine Task. This task, in combination with advanced latent group analysis, allows for an assessment of decision strategies. Results indicated that adolescents with BD and controls were almost equivalent in their decision-making strategies, whereas adolescents with MBID and adolescents with BD + MBID were characterized by suboptimal decision-making strategies, with only minor differences between these two clinical groups. These findings may have important clinical implications, as they suggest that risk taking in adolescents with MBID and in adolescents with BD + MBID can be (partly) attributed to the strategies that these adolescents use to make their decisions. Interventions may therefore focus on an improvement of these strategies.
Polezzi, David; Sartori, Giuseppe; Rumiati, Rino; Vidotto, Giulio; Daum, Irene
Understanding the neurocognitive basis of risk-taking behavior is an important issue, especially in economic decision-making. Classical behavioral studies have shown that risk-attitude changes across different contexts, but little is so far known about the brain correlates of processing of outcomes across such context shifts. In this study, EEG was recorded while subjects performed a gambling task. Participants could choose between a risky and a safer option, within two different contexts: one in which options yielded gains and losses of the same magnitude (Zero Expected Value context) and another in which gains were larger than losses (Positive Expected Value context). Based on their risk-attitude, two groups were compared: subjects who are risk-seekers in the zero Expected Value context (Zero-Oriented group) and subjects who are risk-seekers in the positive Expected Value condition (Positive-Oriented group). The Feedback Related Negativity (FRN) reflects this distinction, with each group being insensitive to magnitude of outcomes in the condition in which they were risk-prone. P300 amplitude mirrored the behavioral results, with larger amplitudes in the condition in which each group showed a higher risk-tendency. Source analyses highlighted the involvement of posterior cingulate cortex in risky decision-making. Taken together, the findings make a contribution to the clarification of the neurocognitive substrates of risky decision-making.
Shenoy, Pradeep; Yu, Angela J.
An important aspect of cognitive flexibility is inhibitory control, the ability to dynamically modify or cancel planned actions in response to changes in the sensory environment or task demands. We formulate a probabilistic, rational decision-making framework for inhibitory control in the stop signal paradigm. Our model posits that subjects maintain a Bayes-optimal, continually updated representation of sensory inputs, and repeatedly assess the relative value of stopping and going on a fine temporal scale, in order to make an optimal decision on when and whether to go on each trial. We further posit that they implement this continual evaluation with respect to a global objective function capturing the various reward and penalties associated with different behavioral outcomes, such as speed and accuracy, or the relative costs of stop errors and go errors. We demonstrate that our rational decision-making model naturally gives rise to basic behavioral characteristics consistently observed for this paradigm, as well as more subtle effects due to contextual factors such as reward contingencies or motivational factors. Furthermore, we show that the classical race model can be seen as a computationally simpler, perhaps neurally plausible, approximation to optimal decision-making. This conceptual link allows us to predict how the parameters of the race model, such as the stopping latency, should change with task parameters and individual experiences/ability. PMID:21647306
Wemm, Stephanie E; Wulfert, Edelgard
The study examined the effects of a social stressor (Trier Social Stress Test) on 24 male and 32 female college students' affective and physiological reactivity and their subsequent performance on a decision-making task (Iowa Gambling Task). The 56 participants were randomly assigned to a social stressor or a control condition. Compared to controls, participants in the stress condition responded with higher heart rates and skin conductance responses, reported more negative affect, and on the decision-making task made less advantageous choices. An exploratory regression analysis revealed that among men higher levels of heart rate were positively correlated with riskier choices on the Iowa Gambling Task, whereas for women this relationship was curvilinear. Exploratory correlational analyses showed that lower levels of skin conductance within the stress condition were associated with greater levels of substance use and gambling. The results suggest that the presence of a stressor may generally result in failure to attend to the full range of possible consequences of a decision. The relationship pattern between the degree of stress responding and successful decision making may be different for men and women.
Temel, Veysel; Birol, Sefa Sahan; Nas, Kazim; Akpinar, Selahattin; Tekin, Murat
The aim of the study was to examine the self-esteem in decision-making and decision-making styles of the teachers in various branches of Çat town of Erzurum Province, Turkey in terms of some variables in 2014-2015 year. A total of 153 teachers (84 females and 69 males) (age (? = 1.6536 ± 0.72837) from different departments participated in the…
Han, Paul K. J.; Kobrin, Sarah; Breen, Nancy; Joseph, Djenaba A.; Li, Jun; Frosch, Dominick L.; Klabunde, Carrie N.
PURPOSE Recent clinical practice guidelines on prostate cancer screening using the prostate-specific antigen (PSA) test (PSA screening) have recommended that clinicians practice shared decision making—a process involving clinician-patient discussion of the pros, cons, and uncertainties of screening. We undertook a study to determine the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making. METHODS A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past 5 years), and sociodemographic and health-related characteristics. RESULTS Nearly two-thirds (64.3%) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (no shared decision making); 27.8% reported discussion of 1 to 2 elements only (partial shared decision making); 8.0% reported discussion of all 3 elements (full shared decision making). Nearly one-half (44.2%) reported no PSA screening, 27.8% reported low-intensity (less-than-annual) screening, and 25.1% reported high-intensity (nearly annual) screening. Absence of shared decision making was more prevalent in men who were not screened; 88% (95% CI, 86.2%–90.1%) of nonscreened men reported no shared decision making compared with 39% (95% CI, 35.0%–43.3%) of men undergoing high-intensity screening. Extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial vs no or full shared
Smith, Anita J
Triage decision making and prioritizing nursing care are essential nursing skills in all clinical settings. The purpose of this study was to evaluate the psychometric properties of the Triage Decision Making Inventory in a sample of Navy and civilian nurses with diverse clinical specialties and years of clinical experience. Establishing reliability and validity allows staff development educators to evaluate training strategies that promote confidence in decision making among nurses of all specialty practices.
Perestelo-Perez, Lilisbeth; Rivero-Santana, Amado; Perez-Ramos, Jeanette; Gonzalez-Lorenzo, Marien; Roman, Javier Gracia-San; Serrano-Aguilar, Pedro
In the last two decades there has been a growing recognition in the Spanish National Health System (NHS) of the importance of considering patients' values and preferences in clinical decisions. Patient participation in shared decision making (SDM) is gaining importance as a suitable approach to patient-health professional communication and decision making in Spain. In addition, the NHS is funding the development of patients' decision aids (PtDAs) for shared decision making (SDM) by Health Technology Assessment Agencies. However, the NHS has still not incorporated reforms in law that includes SDM and PtDAs as a key component of health care services and professional curricula, nor is there a standardised implementation of interventions to support decisions in routine care. Most patients are not very familiar with their rights to be kept informed and participate in their own health care decisions. Most professionals are not familiar with or educated about patients' rights to be kept informed and participate in health care decisions either. The future of SDM in Spain is promising. The next course of action should be to maintain the production and adaptation of high-quality PtDAs while at the same time reinforcing effective dissemination strategies among patients and training programmes for professionals focused on SDM.
Boland, Laura; McIsaac, Daniel I; Lawson, Margaret L
OBJECTIVE: To explore multiple stakeholders’ perceived barriers to and facilitators of implementing shared decision making and decision support in a tertiary paediatric hospital. METHODS: An interpretive descriptive qualitative study was conducted using focus groups and interviews to examine senior hospital administrators’, clinicians’, parents’ and youths’ perceived barriers to and facilitators of shared decision making and decision support implementation. Data were analyzed using inductive thematic analysis. RESULTS: Fifty-seven stakeholders participated. Six barrier and facilitator themes emerged. The main barrier was gaps in stakeholders’ knowledge of shared decision making and decision support. Facilitators included compatibility between shared decision making and the hospital’s culture and ideal practices, perceptions of positive patient and family outcomes associated with shared decision making, and positive attitudes regarding shared decision making and decision support. However, youth attitudes regarding the necessity and usefulness of a decision support program were a barrier. Two themes were both a barrier and a facilitator. First, stakeholder groups were uncertain which clinical situations are suitable for shared decision making (eg, new diagnoses, chronic illnesses, complex decisions or urgent decisions). Second, the clinical process may be hindered if shared decision making and decision support decrease efficiency and workflow; however, shared decision making may reduce repeat visits and save time over the long term. CONCLUSIONS: Specific knowledge translation strategies that improve shared decision making knowledge and match specific barriers identified by each stakeholder group may be required to promote successful shared decision making and decision support implementation in the authors’ paediatric hospital. PMID:27398058
Mollica, Michelle A; Underwood, Willie; Homish, Gregory G; Homish, D Lynn; Orom, Heather
This study examined whether spiritual beliefs are associated with greater decision-making satisfaction, lower decisional conflict and decision-making difficulty with the decision-making process in newly diagnosed men with prostate cancer. Participants were 1114 men diagnosed with localized prostate cancer who had recently made their treatment decision, but had not yet been treated. We used multivariable linear regression to analyze relationships between spirituality and decision-making satisfaction, decisional conflict, and decision-making difficulty, controlling for optimism and resilience, and clinical and sociodemographic factors. Results indicated that greater spirituality was associated with greater decision-making satisfaction (B = 0.02; p < 0.001), less decisional conflict (B = -0.42; p < 0.001), and less decision-making difficulty (B = -0.08; p < 0.001). These results confirm that spiritual beliefs may be a coping resource during the treatment decision-making process. Providing opportunities for patients to integrate their spiritual beliefs and their perceptions of their cancer diagnosis and trajectory could help reduce patient uncertainty and stress during this important phase of cancer care continuum.
Bui, Thanh C; Krieger, Heather A; Blumenthal-Barby, Jennifer S
This study aimed to assess physicians' susceptibility to framing effects in clinical judgment and decision making. A survey was administered online to 159 general internists in the United States. Participants were randomized into two groups, in which clinical scenarios varied in their framings: frequency vs percentage, with cost information vs without, female patient vs male patient, and mortality vs survival. Results showed that physicians' recommendations for patients in hypothetical scenarios were significantly different when the predicted probability of the outcomes was presented in frequency versus percentage form and when it was presented in mortality rate vs survival rate of the same magnitude. Physicians' recommendations were not different for other framing effects.
Korn, Christoph W; Bach, Dominik R
Living organisms need to maintain energetic homeostasis. For many species, this implies taking actions with delayed consequences. For example, humans may have to decide between foraging for high-calorie but hard-to-get, and low-calorie but easy-to-get food, under threat of starvation. Homeostatic principles prescribe decisions that maximize the probability of sustaining appropriate energy levels across the entire foraging trajectory. Here, predictions from biological principles contrast with predictions from economic decision-making models based on maximizing the utility of the endpoint outcome of a choice. To empirically arbitrate between the predictions of biological and economic models for individual human decision-making, we devised a virtual foraging task in which players chose repeatedly between two foraging environments, lost energy by the passage of time, and gained energy probabilistically according to the statistics of the environment they chose. Reaching zero energy was framed as starvation. We used the mathematics of random walks to derive endpoint outcome distributions of the choices. This also furnished equivalent lotteries, presented in a purely economic, casino-like frame, in which starvation corresponded to winning nothing. Bayesian model comparison showed that--in both the foraging and the casino frames--participants' choices depended jointly on the probability of starvation and the expected endpoint value of the outcome, but could not be explained by economic models based on combinations of statistical moments or on rank-dependent utility. This implies that under precisely defined constraints biological principles are better suited to explain human decision-making than economic models based on endpoint utility maximization.
Korn, Christoph W.; Bach, Dominik R.
Living organisms need to maintain energetic homeostasis. For many species, this implies taking actions with delayed consequences. For example, humans may have to decide between foraging for high-calorie but hard-to-get, and low-calorie but easy-to-get food, under threat of starvation. Homeostatic principles prescribe decisions that maximize the probability of sustaining appropriate energy levels across the entire foraging trajectory. Here, predictions from biological principles contrast with predictions from economic decision-making models based on maximizing the utility of the endpoint outcome of a choice. To empirically arbitrate between the predictions of biological and economic models for individual human decision-making, we devised a virtual foraging task in which players chose repeatedly between two foraging environments, lost energy by the passage of time, and gained energy probabilistically according to the statistics of the environment they chose. Reaching zero energy was framed as starvation. We used the mathematics of random walks to derive endpoint outcome distributions of the choices. This also furnished equivalent lotteries, presented in a purely economic, casino-like frame, in which starvation corresponded to winning nothing. Bayesian model comparison showed that—in both the foraging and the casino frames—participants’ choices depended jointly on the probability of starvation and the expected endpoint value of the outcome, but could not be explained by economic models based on combinations of statistical moments or on rank-dependent utility. This implies that under precisely defined constraints biological principles are better suited to explain human decision-making than economic models based on endpoint utility maximization. PMID:26024504
Wolfe, A.K.; Vogt, D.P.; Hwang, Ho-Ling
Executive Order 12898, signed on February 11, 1994, broadly states that federal activities, programs, and policies should not produce disproportionately high and adverse impacts on minority and low-income populations. Moreover, the Order indicates that these populations should not be denied the benefits of, or excluded from participation in, these activities, programs, and policies. Because a presidential memorandum accompanying the order said that National Environmental Policy Act (NEPA) documents should begin to address environmental justice immediately, much attention has been paid to assessment-related issues. Also important, a topic that appears to have received relatively little attention, is how decision makers should be expected to use information about environmental justice in their decision making. This paper discusses issues surrounding the use of environmental justice information in the decision-making process by focusing on the following five main topics: (1) the importance, or weight, attached to environmental justice within larger decision-making contexts; (2) the potential tension between localized environmental justice issues and regional or national issues and needs; (3) the use of environmental justice information to develop (perhaps in concert with affected minority and low-income communities) appropriate mitigation strategies, or to establish conditions under which activities, programs, and policies may be accepted locally; (4) the general implications of shifting the distribution of broadly defined risks, costs, and benefits among different population groups; and (5) the implications of implementing environmental justice on an individual, ad hoc basis rather than within a larger environmental justice framework. This paper raises the issues and discusses the implications of alternative approaches to them.
theme is the work on novice-expert differences in problem-solving, which goes back to deGroot . 1I As Newell2 notes, decision-making is a form of problem...26 REFERENCES (Cont’d) 11. A.D. deGroot , Thought and Choice in Chess, Mouton, The Hague, Nether- lands, 1965. 12. A. Newell, "Reasoning, Problem...Gentner and A.L. Stevens (eds.), Erlbaum, Hillsdale, NJ, 1983. 26. W.B. Rouse and N.M. Morris , "On Looking into the Black Box: Prospects and Limits in
Yukalov, V I; Sornette, D
A rigorous general definition of quantum probability is given, which is valid not only for elementary events but also for composite events, for operationally testable measurements as well as for inconclusive measurements, and also for non-commuting observables in addition to commutative observables. Our proposed definition of quantum probability makes it possible to describe quantum measurements and quantum decision-making on the same common mathematical footing. Conditions are formulated for the case when quantum decision theory reduces to its classical counterpart and for the situation where the use of quantum decision theory is necessary.
Yukalov, V. I. Sornette, D.
The quantum decision theory introduced recently is formulated as a quantum theory of measurement. It describes prospect states represented by complex vectors of a Hilbert space over a prospect lattice. The prospect operators, acting in this space, form an involutive bijective algebra. A measure is defined for quantifying the entanglement produced by the action of prospect operators. This measure characterizes the level of complexity of prospects involved in decision making. An explicit expression is found for the maximal entanglement produced by the operators of multimode prospects.
Deco, Gustavo; Rolls, Edmund T.
Behavioral, neurophysiological, and theoretical studies are converging to a common theory of decision-making that assumes an underlying diffusion process which integrates both the accumulation of perceptual and cognitive evidence for making the decision and motor choice in one unifying neural network. In particular, neuronal activity in the ventral premotor cortex (VPC) is related to decision-making while trained monkeys compare two mechanical vibrations applied sequentially to the tip of a finger to report which of the two stimuli have the higher frequency (Romo et al. 2004, Neuron 41: 165). In particular, neurons were found whose response depended only on the difference between the two applied frequencies, the sign of that difference being the determining factor for correct task performance. We describe an integrate-and-fire attractor model with realistic synaptic dynamics including AMPA, NMDA and GABA synapses which can reproduce the decision-making related response selectivity of VPC neurons during the comparison period of the task. Populations of neurons for each decision in the biased competition attractor receive a bias input that depends on the firing rates of neurons in the VPC that code for the two vibrotactile frequencies. It was found that if the connectivity parameters of the network are tuned, using mean-field techniques, so that the network has two possible stable stationary final attractors respectively related to the two possible decisions, then the firing rate of the neurons in whichever attractor wins reflects the sign of the difference in the frequencies being compared but not the absolute frequencies. Thus Weber's law for frequency comparison is not encoded by the firing rate of the neurons in these attractors. An analysis of the nonstationary evolution of the dynamics of the network model shows that Weber's law is implemented in the probability of transition from the initial spontaneous firing state to one of the two possible attractor states
Fischer, Ute; Orasanu, Judith; Wich, Mike; Hart, Sandra G. (Technical Monitor)
In traditional laboratory studies of decision making, the experimenter structures the problem, defines the goal and specifies available information. In contrast, when people make decisions in non-laboratory environments characterized as complex, dynamic and consequential, they must first identify the problem and determine what information and responses are relevant. The present research was designed to investigate which situational aspects are important to experienced pilots making aviation decisions. Twenty-eight professional pilots were asked to sort descriptions of 22 aircraft incidents into piles involving similar types of major decisions. Preliminary analyses suggest four underlying variables: time pressure, risk level, available resources, and certainty of goal attainment.
For many years, economic development has mean industrial recruitment where business-at-any-cost was preached by a small elite, where civic discord replaced civic discussion, where families made more money but had less to spend, where residents learned to lock their doors, where communities changed from the unique to commonplace and a thousand towns looked alike. But now, scores of communities are saying no to old, worn-out approaches to development and embracing a new kind of development that respects the community and the environment. Created collaboratively by people from all walks of community life, this new approach is called sustainable community economic development. Though new, sustainable development is based on traditional values of stewardship and working together. Its principles are powerful in their simplicity. Its lessons enrich community decision making. This paper describes these principles and lessons. It introduces a community decision-making process that applies them and suggests the kinds of results you can expect from such a process in your town.
Zhang, Shaowu; Si, Aung; Pahl, Mario
Honeybees can easily be trained to perform different types of discrimination tasks under controlled laboratory conditions. This review describes a range of experiments carried out with free-flying forager honeybees under such conditions. The research done over the past 30 or so years suggests that cognitive abilities (learning and perception) in insects are more intricate and flexible than was originally imagined. It has become apparent that honeybees are capable of a variety of visually guided tasks, involving decision making under challenging situations: this includes simultaneously making use of different sensory modalities, such as vision and olfaction, and learning to use abstract concepts such as "sameness" and "difference." Many studies have shown that decision making in foraging honeybees is highly flexible. The trained animals learn how to solve a task, and do so with a high accuracy, but when they are presented with a new variation of the task, they apply the learnt rules from the earlier setup to the new situation, and solve the new task as well. Honeybees therefore not only feature a rich behavioral repertoire to choose from, but also make decisions most apt to the current situation. The experiments in this review give an insight into the environmental cues and cognitive resources that are probably highly significant for a forager bee that must continually make decisions regarding patches of resources to be exploited.
Valentini, Gabriele; Fernández-Oto, Cristian; Dorigo, Marco
The engineering of large-scale decentralised systems requires sound methodologies to guarantee the attainment of the desired macroscopic system-level behaviour given the microscopic individual-level implementation. While a general-purpose methodology is currently out of reach, specific solutions can be given to broad classes of problems by means of well-conceived design patterns. We propose a design pattern for collective decision making grounded on experimental/theoretical studies of the nest-site selection behaviour observed in honeybee swarms (Apis mellifera). The way in which honeybee swarms arrive at consensus is fairly well-understood at the macroscopic level. We provide formal guidelines for the microscopic implementation of collective decisions to quantitatively match the macroscopic predictions. We discuss implementation strategies based on both homogeneous and heterogeneous multiagent systems, and we provide means to deal with spatial and topological factors that have a bearing on the micro-macro link. Finally, we exploit the design pattern in two case studies that showcase the viability of the approach. Besides engineering, such a design pattern can prove useful for a deeper understanding of decision making in natural systems thanks to the inclusion of individual heterogeneities and spatial factors, which are often disregarded in theoretical modelling. PMID:26496359
Shad, Mujeeb U; Bidesi, Anup S; Chen, Li-Ann; Thomas, Binu P; Ernst, Monique; Rao, Uma
The study examined the relationship between risk-taking behavior during selection of monetary rewards and activations in the anterior cingulate cortex (ACC), orbitofrontal cortex (OFC) and medial prefrontal cortex (mPFC), brain regions that are associated with decision-making. Thirty-three adolescents with no personal or family history of any psychiatric illness were administered the Wheel of Fortune (WOF) task using a functional magnetic resonance imaging protocol. The WOF is a computerized two-choice, probabilistic monetary reward task. Selection of a reward, particularly a low-probability/high-magnitude reward choice, induced greater activations in dorsal ACC, ventrolateral OFC and mPFC than the control condition. Although similar findings have been reported by earlier studies, the results from this study were not impacted by reaction times and expected values and persisted even after controlling for sociodemographic factors. Post hoc analysis revealed greater activation of ACC and mPFC in response to selection of rewards of larger magnitude than those of smaller magnitude when the probability of reward was maintained constant. Adolescents with greater frequency of high-risk behavior (defined as low-probability/high-magnitude reward choice) had lower activation of ACC, OFC and mPFC than those who engaged in this behavior less frequently. These findings suggest individual differences in prefrontal cortical function with regards to decision-making process in adolescents.
Leshno, Moshe; Levy, Haim
Stochastic Dominance (SD) criteria are decision making tools which allow us to choose among various strategies with only partial information on the decision makers' preferences. The notion of Stochastic Dominance has been extensively employed and developed in the area of economics, finance, agriculture, statistics, marketing and operation research since the late 1960s. For example, it may tell us which of two medical treatments with uncertain outcomes is preferred in the absence of full information on the patients' preferences. This paper presents a short review of the SD paradigm and demonstrates how the SD criteria may be employed in medical decision making, using the case of small abdominal aortic aneurysms as an illustration. Thus, for instance by assuming risk aversion one can employ second-degree stochastic dominance to divide the set of all possible treatments into the efficient set, from which the decision makers should always choose, and the inefficient (inferior) set. By employing Prospect Stochastic Dominance (PSD) a similar division can be conducted corresponding to all S-shaped utility functions.
Keller, James M.; Yan, Bolin
The fuzzy integral has been shown to be an effective tool for the aggregation of evidence in decision making. Of primary importance in the development of a fuzzy integral pattern recognition algorithm is the choice (construction) of the measure which embodies the importance of subsets of sources of evidence. Sugeno fuzzy measures have received the most attention due to the recursive nature of the fabrication of the measure on nested sequences of subsets. Possibility measures exhibit an even simpler generation capability, but usually require that one of the sources of information possess complete credibility. In real applications, such normalization may not be possible, or even desirable. In this report, both the theory and a decision making algorithm for a variation of the fuzzy integral are presented. This integral is based on a possibility measure where it is not required that the measure of the universe be unity. A training algorithm for the possibility densities in a pattern recognition application is also presented with the results demonstrated on the shuttle-earth-space training and testing images.
Over the last century there have not been significant changes in the anatomical location of obstruction. The age of presentation has increased along with age related co-morbidity. Management has consequently been challenging as risks keep on increasing with advanced age. Hence, clear decision making has become essential in its management. A selective review of the literature pertaining to common age related aetiologies, diagnosis methods leading to standard decision making and treatment of acute intestinal obstruction was done. The same is obtained from randomized controlled studies, meta-analysis and other related evidence based publications. Predicting the conservative or operative management of Bowel Obstruction (BO) is difficult. BO in young age, in unscarred abdomen and Large Bowel Obstruction (LBO) needs early surgery. Decision on surgery should be taken in paediatric patient by second day and preferably between 3-5 days of admission in adults. Higher American Society of Anaesthesiologists (ASA) grade correlates well with the mortalities. In this article, the timing of surgery, methods to avoid bowel resection and type of surgery in various causes are stressfully analysed and discussed. PMID:28050445
Dansereau, Donald F.; Knight, Danica K.; Flynn, Patrick M.
Human judgment and decision making (JDM) has substantial room for improvement, especially among adolescents. Increased technological and social complexity “ups the ante” for developing impactful JDM interventions and aids. Current explanatory advances in this field emphasize dual processing models that incorporate both experiential and analytic processing systems. According to these models, judgment and decisions based on the experiential system are rapid and stem from automatic reference to previously stored episodes. Those based on the analytic system are viewed as slower and consciously developed. These models also hypothesize that metacognitive (self-monitoring) activities embedded in the analytic system influence how and when the two systems are used. What is not included in these models is the development of an intersection between the two systems. Because such an intersection is strongly suggested by memory and educational research as the basis of wisdom/expertise, the present paper describes an Integrated Judgment and Decision-Making Model (IJDM) that incorporates this component. Wisdom/expertise is hypothesized to contain a collection of schematic structures that can emerge from the accumulation of similar episodes or repeated analytic practice. As will be argued, in comparisons to dual system models, the addition of this component provides a broader basis for selecting and designing interventions to improve adolescent JDM. Its development also has implications for generally enhancing cognitive interventions by adopting principles from athletic training to create automated, expert behaviors. PMID:24391350
Weitz, Joshua S; Mileyko, Yuriy; Joh, Richard I; Voit, Eberhard O
For many bacterial viruses, the choice of whether to kill host cells or enter a latent state depends on the multiplicity of coinfection. Here, we present a mathematical theory of how bacterial viruses can make collective decisions concerning the fate of infected cells. We base our theory on mechanistic models of gene regulatory dynamics. Unlike most previous work, we treat the copy number of viral genes as variable. Increasing the viral copy number increases the rate of transcription of viral mRNAs. When viral regulation of cell fate includes nonlinear feedback loops, very small changes in transcriptional rates can lead to dramatic changes in steady-state gene expression. Hence, we prove that deterministic decisions can be reached, e.g., lysis or latency, depending on the cellular multiplicity of infection within a broad class of gene regulatory models of viral decision-making. Comparisons of a parameterized version of the model with molecular studies of the decision structure in the temperate bacteriophage lambda are consistent with our conclusions. Because the model is general, it suggests that bacterial viruses can respond adaptively to changes in population dynamics, and that features of collective decision-making in viruses are evolvable life history traits.
Ito, Makoto; Doya, Kenji
Computational models of reinforcement learning have recently been applied to analysis of brain imaging and neural recording data to identity neural correlates of specific processes of decision making, such as valuation of action candidates and parameters of value learning. However, for such model-based analysis paradigms, selecting an appropriate model is crucial. In this study we analyze the process of choice learning in rats using stochastic rewards. We show that "Q-learning," which is a standard reinforcement learning algorithm, does not adequately reflect the features of choice behaviors. Thus, we propose a generalized reinforcement learning (GRL) algorithm that incorporates the negative reward effect of reward loss and forgetting of values of actions not chosen. Using the Bayesian estimation method for time-varying parameters, we demonstrated that the GRL algorithm can predict an animal's choice behaviors as efficiently as the best Markov model. The results suggest the usefulness of the GRL for the model-based analysis of neural processes involved in decision making.
Dansereau, Donald F; Knight, Danica K; Flynn, Patrick M
Human judgment and decision making (JDM) has substantial room for improvement, especially among adolescents. Increased technological and social complexity "ups the ante" for developing impactful JDM interventions and aids. Current explanatory advances in this field emphasize dual processing models that incorporate both experiential and analytic processing systems. According to these models, judgment and decisions based on the experiential system are rapid and stem from automatic reference to previously stored episodes. Those based on the analytic system are viewed as slower and consciously developed. These models also hypothesize that metacognitive (self-monitoring) activities embedded in the analytic system influence how and when the two systems are used. What is not included in these models is the development of an intersection between the two systems. Because such an intersection is strongly suggested by memory and educational research as the basis of wisdom/expertise, the present paper describes an Integrated Judgment and Decision-Making Model (IJDM) that incorporates this component. Wisdom/expertise is hypothesized to contain a collection of schematic structures that can emerge from the accumulation of similar episodes or repeated analytic practice. As will be argued, in comparisons to dual system models, the addition of this component provides a broader basis for selecting and designing interventions to improve adolescent JDM. Its development also has implications for generally enhancing cognitive interventions by adopting principles from athletic training to create automated, expert behaviors.
Bartelink, Cora; van Yperen, Tom A; ten Berge, Ingrid J
Assessment and decision-making in child maltreatment cases is difficult. Practitioners face many uncertainties and obstacles during their assessment and decision-making process. Research exhibits shortcomings in this decision-making process. The purpose of this literature review is to identify and discuss methods to overcome these shortcomings. We conducted a systematic review of the published literature on decision-making using PsychINFO and MEDLINE from 2000 through May 2014. We included reviews and quantitative research studies that investigated methods aimed at improving professional decision-making on child abuse and neglect in child welfare and child protection. Although many researchers have published articles on decision-making including ideas and theories to improve professional decision-making, empirical research on these improvements is scarce. Available studies have shown promising results. Structured decision-making has created a greater child-centred and holistic approach that takes the child's family and environment into account, which has made practitioners work more systematically and improved the analysis of complex situations. However, this approach has not improved inter-rater agreement on decisions made. Shared decision-making may improve the participation of parents and children and the quality of decisions by taking client treatment preferences into account in addition to scientific evidence and clinical experience. A number of interesting developments appear in recent research literature; however, child welfare and child protection must find additional inspiration from other areas, e.g., mental health services, because research on decision-making processes in child welfare and child protection is still rare.
Siegel, Marcelle A.
One of the most important challenges educators have is teaching students how to make decisions about complex issues. In this study, methods designed to enhance students' decision-making skills and attitudes were investigated. An issue-oriented science curriculum was partly replaced with activities designed by the experimenter. The first objective of the study was to examine the effects of an instructional method to increase students' use of relevant scientific evidence in their decisions. The second goal of the research was to test whether the instructional activities could promote students' beliefs that science is relevant to them, because attitudes have been shown to affect students' performance and persistence (Schommer, 1994). Third, the study was designed to determine whether the instructional activities would affect students' beliefs that their intelligence is not fixed but can grow; this question is based on Dweck and Leggett's (1988) definition of two orientations toward intelligence---entity theorists and incremental theorists (Dweck & Leggett, 1988; Dweck & Henderson, 1989). Two urban high-school classrooms participated in this study. Tenth graders examined scientific materials about current issues involving technology and society. Instructional materials on decision making were prepared for one class of students to enhance their regular issue-oriented course, Science and Sustainability. A computer program, called Convince Me (Schank, Ranney & Hoadley, 1996), provided scaffolding for making an evidence-based decision. The experimental group's activities also included pen-and-paper lessons on decision making and the effect of experience on the structure of the brain. The control class continued to engage in Science and Sustainability decision-making activities during the time the experimental class completed the treatment. The control group did not show significant improvement on decision-making tasks, and the experimental group showed marginally
Neonatal ventilation is an integral component of care delivered in the neonatal unit. The aim of any ventilation strategy is to support the neonate's respiratory system during compromise while limiting any long-term damage to the lungs. Understanding the principles behind neonatal ventilation is essential so that health professionals caring for sick neonates and families have the necessary knowledge to understand best practice. Given the range of existing ventilation modes and parameters available, these require explanation and clarification in the context of current evidence. Many factors can influence clinical decision making on both an individual level and within the wider perspective of neonatal care.
Evers, Colin W.
Explores implications for understanding educational decision making from a cognitive science perspective. Examines three models of mind providing the methodological framework for decision-making studies. The "absent mind" embodies the behaviorist research tradition. The "functionalist mind" underwrites traditional cognitivism…
Eskritt, Michelle; Doucette, Jesslyn; Robitaille, Lori
A number of theorists, as well as plain common sense, suggest that future-oriented thinking (FOT) should be involved in decision making; therefore, the development of FOT should be related to better quality decision making. FOT and quality of the decision making were measured in adolescents as well as adults in 2 different experiments. Though the results of the first experiment revealed an increase in quality of decision making across adolescence into adulthood, there was no relationship between FOT and decision making. In the second experiment, FOT predicted performance on a more deliberative decision-making task independent of age, but not performance on the Iowa Gambling Task (IGT). Performance on the IGT was instead related to emotion regulation. The study's findings suggest that FOT can be related to reflective decision making but not necessarily decision making that is more intuitive.
Nelson, Katherine E; Mahant, Sanjay
Shared decision-making is a process that helps frame conversations about value-sensitive decisions, such as introduction of assistive technology for children with neurologic impairment. In the shared decision-making model, the health care provider elicits family values relevant to the decision, provides applicable evidence in the context of those values, and collaborates with the family to identify the preferred option. This article outlines clinical, quality of life, and ethical considerations for shared decision-making discussions with families of children with neurologic impairment about gastrostomy tube and tracheostomy tube placement.
Marble, Julie Lynne; Medema, Heather Dawne; Hill, Susan Gardiner
Eight participants were asked to view a computer-based multimedia presentation on an environmental phenomenon. Participants were asked to play a role as a senior aide to a national legislator. In this role, they were told that the legislator had asked them to review a multimedia presentation regarding the hypoxic zone phenomenon in the Gulf of Mexico. Their task in assuming the role of a senior aide was to decide how important a problem this issue was to the United States as a whole, and the proportion of the legislator’s research budget that should be devoted to study of the problem. The presentation was divided into 7 segments, each containing some new information not contained in the previous segments. After viewing each segment, participants were asked to indicate how close they were to making a decision and how certain they were that their current opinion would be their final decision. After indicating their current state of decision-making, participants were interviewed regarding the factors affecting their decision-making. Of interest was the process by which participants moved toward a decision. This experiment revealed a number of possible directions for future research. There appeared to be two approaches to decision-making: Some decision-makers moved steadily toward a decision, and occasionally reversed decisions after viewing information, while others abruptly reached a decision after a certain time period spent reviewing the information. Although the difference in estimates of distance to decisions did not differ statistically for these two groups, that difference was reflected in the participants’ estimates of confidence that their current opinion would be their final decision. The interviews revealed that the primary difference between these two groups was in their trade-offs between willingness to spend time in information search and the acquisition of new information. Participants who were less confident about their final decision, tended to be
Obeidat, Rana; Khrais, Huthaifah I.
Objective: This study aims to determine the attitude of Jordanian physicians toward disclosure of cancer information, comfort and use of different decision-making approaches, and treatment decision making. Methods: A descriptive, comparative research design was used. A convenience sample of 86 Jordanian medical and radiation oncologists and surgeons practicing mainly in oncology was recruited. A modified version of a structured questionnaire was used for data collection. The questionnaire is a valid measure of physicians’ views of shared decision making. Results: Almost 91% of all physicians indicated that the doctor should tell the patient and let him/her decide if the family should know of an early-stage cancer diagnosis. Physicians provide abundant information about the extent of the disease, the side effects and benefits of the treatment, and details of the treatment procedures. They also provided less information on the effects of treatment on the sexuality, mood, and family of the patient. Almost 48% of the participating physicians reported using shared decision making as their usual approach for treatment decision making, and 67% reported that they were comfortable with this approach. The main setting of clinical activity was the only factor associated with physicians’ usual approach to medical decision making. Moreover, age, years of experience, and main setting of clinical activity were associated with physicians’ comfort level with the shared approach. Conclusions: Although Jordanian physicians appreciate patient autonomy, self-determination, and right to information, paternalistic decision making and underuse of the shared decision-making approach persist. Strategies that target both healthcare providers and patients must be employed to promote shared decision making in the Jordanian healthcare system. PMID:27981172
Wells, William A; Brooks, Alan
When a new health product becomes available, countries have a choice to adopt the product into their national health systems or to pursue an alternate strategy to address the public health problem. Here, we describe the role for product development partnerships (PDPs) in supporting this decision-making process. PDPs are focused on developing new products to respond to health problems prevalent in low and middle income settings. The impact of these products within public sector health systems can only be realized after a country policy process. PDPs may be the organizations most familiar with the evidence which assists decision making, and this generally translates into involvement in international policy development, but PDPs have limited reach into endemic countries. In a few individual countries, there may be more extensive involvement in tracking adoption activities and generating local evidence. This local PDP involvement begins with geographical prioritization based on disease burden, relationships established during clinical trials, PDP in-country resources, and other factors. Strategies adopted by PDPs to establish a presence in endemic countries vary from the opening of country offices to engagement of part-time consultants or with long-term or ad hoc committees. Once a PDP commits to support country decision making, the approaches vary, but include country consultations, regional meetings, formation of regional, product-specific committees, support of in-country advocates, development of decision-making frameworks, provision of technical assistance to aid therapeutic or diagnostic guideline revision, and conduct of stakeholder and Phase 4 studies. To reach large numbers of countries, the formation of partnerships, particularly with WHO, are essential. At this early stage, impact data are limited. But available evidence suggests PDPs can and do play an important catalytic role in their support of country decision making in a number of target countries.
Beck, Jeffrey M.; Ma, Wei Ji; Kiani, Roozbeh; Hanks, Tim; Churchland, Anne K.; Roitman, Jamie; Shadlen, Michael N.; Latham, Peter E.; Pouget, Alexandre
When making a decision, one must first accumulate evidence, often over time, and then select the appropriate action. Here, we present a neural model of decision making that can perform both evidence accumulation and action selection optimally. More specifically, we show that, given a Poisson-like distribution of spike counts, biological neural networks can accumulate evidence without loss of information through linear integration of neural activity, and can select the most likely action through attractor dynamics. This holds for arbitrary correlations, any tuning curves, continuous and discrete variables, and sensory evidence whose reliability varies over time. Our model predicts that the neurons in the lateral intraparietal cortex involved in evidence accumulation encode, on every trial, a probability distribution which predicts the animal’s performance. We present experimental evidence consistent with this prediction, and discuss other predictions applicable to more general settings. PMID:19109917
Postmes, T; Spears, R; Cihangir, S
Two studies investigated the impact of group norms for maintaining consensus versus norms for critical thought on group decisions in a modification of the biased sampling paradigm (G. Stasser & W. Titus, 1985). Both studies showed that critical norms improved the quality of decisions, whereas consensus norms did not. This effect appeared to be mediated by the perceived value of shared and unshared information: Consensus norm groups valued shared information more highly than critical groups did, and valence was a good predictor of decision outcome. In addition, the 2nd study showed that the group norm manipulation has no impact on individual decisions, consistent with the assumption that this is a group effect. Results suggest that the content of group norms is an important factor influencing the quality of group decision-making processes and that the content of group norms may be related to the group's proneness for groupthink.
Meshi, Dar; Biele, Guido; Korn, Christoph W.; Heekeren, Hauke R.
People often use expert advice when making decisions in our society, but how we are influenced by this advice has yet to be understood. To address this, using functional magnetic resonance imaging, we provided expert and novice advice to participants during an estimation task. Participants reported that they valued expert advice more than novice advice, and activity in the ventral striatum correlated with this valuation, even before decisions with the advice were made. When using advice, participants compared their initial opinion to their advisor’s opinion. This comparison, termed the “opinion difference”, influenced advice utilization and was represented in reward-sensitive brain regions. Finally, the left lateral orbitofrontal cortex integrated both the size of the opinion difference and the advisor’s level of expertise, and average activity in this area correlated with mean advice utilization across participants. Taken together, these findings provide neural evidence for how advice engenders behavioral change during the decision-making process. PMID:23185425
Warren, Jamie B; Wiggins, Nikki
Since the Institute of Medicine published Crossing the Quality Chasm in 2001, healthcare systems have become more focused on improving the quality of healthcare delivery. At Oregon Health & Science University and Doernbecher Children's Hospital, we recognize the need to take an interprofessional, team-based approach to improving the care we provide to our current and future patients. We describe here an ongoing quality improvement project in the Doernbecher Neonatal Intensive Care Unit (NICU), with specific attention to the factors we believe have contributed to the implementation and early success of the project. These factors include the history of quality improvement work in our NICU and in the field of neonatology, the "dyad leadership" structure under which we operate in our NICU, and our developing understanding of the concept of "team intelligence." These elements have led to the formation of a team that can practice shared decision making and work as one to realize a shared goal.
Mileti, D.; Sorensen, J.; Bogard, W.
The purpose was to describe the processes of evacuation decision-making, identify and document uncertainties in that process and discuss implications for federal assumption of liability for precautionary evacuations at nuclear facilities under the Price-Anderson Act. Four major categories of uncertainty are identified concerning the interpretation of hazard, communication problems, perceived impacts of evacuation decisions and exogenous influences. Over 40 historical accounts are reviewed and cases of these uncertainties are documented. The major findings are that all levels of government, including federal agencies experience uncertainties in some evacuation situations. Second, private sector organizations are subject to uncertainties at a variety of decision points. Third, uncertainties documented in the historical record have provided the grounds for liability although few legal actions have ensued. Finally it is concluded that if liability for evacuations is assumed by the federal government, the concept of a ''precautionary'' evacuation is not useful in establishing criteria for that assumption. 55 refs., 1 fig., 4 tabs.
García-Retamero, Rocío; Takezawa, Masanori; Gigerenzer, Gerd
In daily life, people frequently make inferences about current and future states of the world. Most of these inferences are not made individually, but by exchanging information about which strategies could be used with other people. In an experiment, we analyzed whether exchanging information socially increased the probability of selecting the most adaptive strategy. In our experiment, take-the-best (TTB; Gigerenzer & Goldstein, 1996), a simple heuristic that employs one-reason decision making, achieved the highest payoff. Results showed that the fit of TTB increased substantially across trial blocks when participants were allowed to exchange information with other group members. In contrast, when participants made inferences individually, they did not select the most adaptive strategy even after seven trial blocks. Overall, our results support the hypothesis that group communication increases the likelihood that participants select the most adaptive strategy for making inferences.
Gettings, M. E.
Combining information of disparate types from multiple data or model sources is a fundamental task in decision making theory. Procedures for combining and utilizing quantitative data with uncertainties are well-developed in several approaches, but methods for including qualitative and semi-quantitative data are much less so. Possibility theory offers an approach to treating all three data types in an objective and repeatable way. In decision making, biases are frequently present in several forms, including those arising from data quality, data spatial and temporal distribution, and the analyst's knowledge and beliefs as to which data or models are most important. The latter bias is particularly evident in the case of qualitative data and there are numerous examples of analysts feeling that a qualitative dataset is more relevant than a quantified one. Possibility theory and fuzzy logic now provide fairly general rules for quantifying qualitative and semi-quantitative data in ways that are repeatable and minimally biased. Once a set of quantified data and/or model layers is obtained, there are several methods of combining them to obtain insight useful in decision making. These include: various combinations of layers using formal fuzzy logic (for example, layer A and (layer B or layer C) but not layer D); connecting the layers with varying influence links in a Fuzzy Cognitive Map; and using the set of layers for the universe of discourse for agent based model simulations. One example of logical combinations that have proven useful is the definition of possible habitat for valley fever fungus (Coccidioides sp.) using variables such as soil type, altitude, aspect, moisture and temperature. A second example is the delineation of the lithology and possible mineralization of several areas beneath basin fill in southern Arizona. A Fuzzy Cognitive Map example is the impacts of development and operation of a hypothetical mine in an area adjacent to a city. In this model
Dezfuli, Homayoon; Stamatelatos, Michael; Maggio, Gaspare; Everett, Christopher; Youngblood, Robert; Rutledge, Peter; Benjamin, Allan; Williams, Rodney; Smith, Curtis; Guarro, Sergio
This handbook provides guidance for conducting risk-informed decision making in the context of NASA risk management (RM), with a focus on the types of direction-setting key decisions that are characteristic of the NASA program and project life cycles, and which produce derived requirements in accordance with existing systems engineering practices that flow down through the NASA organizational hierarchy. The guidance in this handbook is not meant to be prescriptive. Instead, it is meant to be general enough, and contain a sufficient diversity of examples, to enable the reader to adapt the methods as needed to the particular decision problems that he or she faces. The handbook highlights major issues to consider when making decisions in the presence of potentially significant uncertainty, so that the user is better able to recognize and avoid pitfalls that might otherwise be experienced.
Purcell, Braden A.; Heitz, Richard P.; Cohen, Jeremiah Y.; Schall, Jeffrey D.; Logan, Gordon D.; Palmeri, Thomas J.
Stochastic accumulator models account for response time in perceptual decision-making tasks by assuming that perceptual evidence accumulates to a threshold. The present investigation mapped the firing rate of frontal eye field (FEF) visual neurons onto perceptual evidence and the firing rate of FEF movement neurons onto evidence accumulation to test alternative models of how evidence is combined in the accumulation process. The models were evaluated on their ability to predict both response time distributions and movement neuron activity observed in monkeys performing a visual search task. Models that assume gating of perceptual evidence to the accumulating units provide the best account of both behavioral and neural data. These results identify discrete stages of processing with anatomically distinct neural populations and rule out several alternative architectures. The results also illustrate the use of neurophysiological data as a model selection tool and establish a novel framework to bridge computational and neural levels of explanation. PMID:20822291
Sörensen, Silvia; Mak, Wingyun; Pinquart, Martin
The need to plan for future health care and residential adjustments increases with age, growing frailty, and restrictions in coverage of long-term care and will continue to grow with population aging. Older adults’ lack of financial preparation for health care costs, insufficient knowledge about available options, and inadequate communication about care-related values has become an increasing public health challenge. This chapter describes a model of Preparation for Future Care (PFC), which encompasses different levels and domains of planning. Research about the extent to which planning is helpful in navigating care transitions is reviewed, and barriers and facilitators of planning including individual, familial, cultural, and national long-term care policy factors are discussed. Planning in the context of dementia and practical approaches that can be taken to enhance PFC is addressed, as well as recommendations for future research in the area of planning and decision making in the context of care transitions. PMID:26207079
... 36 Parks, Forests, and Public Property 3 2012-07-01 2012-07-01 false Corporation decision making... CORPORATION ENVIRONMENTAL QUALITY § 907.14 Corporation decision making procedures. To ensure that at major decision making points all relevant environmental concerns are considered by the Decision Maker,...
... 36 Parks, Forests, and Public Property 3 2014-07-01 2014-07-01 false Corporation decision making... CORPORATION ENVIRONMENTAL QUALITY § 907.14 Corporation decision making procedures. To ensure that at major decision making points all relevant environmental concerns are considered by the Decision Maker,...
... 36 Parks, Forests, and Public Property 3 2013-07-01 2012-07-01 true Corporation decision making... CORPORATION ENVIRONMENTAL QUALITY § 907.14 Corporation decision making procedures. To ensure that at major decision making points all relevant environmental concerns are considered by the Decision Maker,...
... 36 Parks, Forests, and Public Property 3 2011-07-01 2011-07-01 false Corporation decision making... CORPORATION ENVIRONMENTAL QUALITY § 907.14 Corporation decision making procedures. To ensure that at major decision making points all relevant environmental concerns are considered by the Decision Maker,...
Schildkamp, Kim, Ed.; Lai, Mei Kuin, Ed.; Earl, Lorna, Ed.
In a context where schools are held more and more accountable for the education they provide, data-based decision making has become increasingly important. This book brings together scholars from several countries to examine data-based decision making. Data-based decision making in this book refers to making decisions based on a broad range of…
Mau, Wei-Cheng J.
This study investigated cultural dimensions of career decision-making difficulties using the Career Decision-Making Difficulties Questionnaire. Career decision-making difficulties were compared among White, African, Hispanic, and Asian American high school and university students at U.S. schools. Results indicated Asian American students perceived…
Chen, Yiwei; Wang, Jiaxi; Kirk, Robert M.; Pethtel, Olivia L.; Kiefner, Allison E.
The primary purposes of the present study were to examine age differences in adaptive decision making and to evaluate the role of numeracy in mediating the relationship between age and adaptive decision making. Adaptive decision making was assessed by the Cups task (Levin, Weller, Pederson, & Harshman, 2007). Forty-six younger (18 to 24 years…
Kampmann, Jennifer A.
Within the scope of leadership and management, decision making greatly defines the role of university administrator, in particular, the university department head and his/her ability to be a reflective practitioner in the realm of decision making. Decision making is one characteristic of university department head work which warrants close…
Bright, Leslie Shay
The purpose of this study was to describe and determine the prevalence of decision-making characteristics of recreational backcountry groups when making a decision of where to travel and ride in avalanche terrain from the perspective of individuals. Decision-making characteristics encompassed communication, decision-making processes, leadership,…
... 36 Parks, Forests, and Public Property 3 2010-07-01 2010-07-01 false Corporation decision making... CORPORATION ENVIRONMENTAL QUALITY § 907.14 Corporation decision making procedures. To ensure that at major... Corporation's decision making process to ensure adequate consideration of environmental factors. (b)...
Kelly, Rosemary R.; Hatcher, Tim
This study explored differences between career decision-making self-efficacy (CDMSE) and career barriers of students enrolled in applied technology programs compared to those enrolled in college transfer. Participants in the ex post facto cross-sectional survey included 787 students at a community college. The following research questions were…
Vetter, Donald P.; And Others
This unit on economic decision-making is the fourth of five units in a ninth grade social studies course (see SO 010 891). Major objectives are to help students (1) explain how dissent and protest may be used as effective means of change and to consider the consequences of such actions; (2) examine the judicial branch of government in order to…
Broman, D.; Gangopadhyay, S.; Simes, J.
Climate assessments have become an accepted and commonly used component of long term water management and planning. There is substantial variation in the methods used in these assessments; however, managers and decision-makers have come to value their utility to identify future system limitations, and to evaluate future alternatives to ensure satisfactory system performance. A new set of decision-making frameworks have been proposed, including robust decision making (RDM), and decision scaling, that directly address the deep uncertainties found in both future climate, and non-climatic factors. Promising results have been obtained using these new frameworks, offering a more comprehensive understanding of future conditions leading to failures, and identification of measures to address these failures. Data and resource constraints have limited the use of these frameworks within the Bureau of Reclamation. We present here a modified framework that captures the strengths of previously proposed methods while using a suite of analysis tool that allow for a 'rapid climate assessment' to be performed. A scalable approach has been taken where more complex tools can be used if project resources allow. This 'rapid assessment' is demonstrated through two case studies on the Santa Ana and Colorado Rivers where previous climate assessments have been completed. Planning-level measures are used to compare how decision making is affected when using this new decision making framework.
Rodriquez, Luis F.; Drysdale, Alan E.; Jones, Harry; Levri, Julie A.
The Advanced Life Support (ALS) Metric is the predominant tool for predicting the cost of ALS systems. Metric goals for the ALS Program are daunting, requiring a threefold increase in the ALS Metric by 2010. Confounding the problem, the rate new ALS technologies reach the maturity required for consideration in the ALS Metric and the rate at which new configurations are developed is slow, limiting the search space and potentially giving the perspective of a ALS technology, the ALS Metric may remain elusive. This paper is a sequel to a paper published in the proceedings of the 2003 ICES conference entitled, "Managing to the metric: an approach to optimizing life support costs." The conclusions of that paper state that the largest contributors to the ALS Metric should be targeted by ALS researchers and management for maximum metric reductions. Certainly, these areas potentially offer large potential benefits to future ALS missions; however, the ALS Metric is not the only decision-making tool available to the community. To facilitate decision-making within the ALS community a combination of metrics should be utilized, such as the Equivalent System Mass (ESM)-based ALS metric, but also those available through techniques such as life cycle costing and faithful consideration of the sensitivity of the assumed models and data. Often a lack of data is cited as the reason why these techniques are not considered for utilization. An existing database development effort within the ALS community, known as OPIS, may provide the opportunity to collect the necessary information to enable the proposed systems analyses. A review of these additional analysis techniques is provided, focusing on the data necessary to enable these. The discussion is concluded by proposing how the data may be utilized by analysts in the future.
Wang, Zheng; Busemeyer, Jerome R
Many decision making tasks in life involve a categorization process, but the effects of categorization on subsequent decision making has rarely been studied. This issue was explored in three experiments (N=721), in which participants were shown a face stimulus on each trial and performed variations of categorization-decision tasks. On C-D trials, they categorized the stimulus and then made an action decision; on X-D trials, they were told the category and then made an action decision; on D-alone trials, they only made an action decision. An interference effect emerged in some of the conditions, such that the probability of an action on the D-alone trials (i.e., when there was no explicit categorization before the decision) differed from the total probability of the same action on the C-D or X-D trials (i.e., when there was explicit categorization before the decision). Interference effects are important because they indicate a violation of the classical law of total probability, which is assumed by many cognitive models. Across all three experiments, a complex pattern of interference effects systematically occurred for different types of stimuli and for different types of categorization-decision tasks. These interference effects present a challenge for traditional cognitive models, such as Markov and signal detection models, but a quantum cognition model, called the belief-action entanglement (BAE) model, predicted that these results could occur. The BAE model employs the quantum principles of superposition and entanglement to explain the psychological mechanisms underlying the puzzling interference effects. The model can be applied to many important and practical categorization-decision situations in life.
Terra. Aqua. Cloudsat. Landsat. NASA runs and partners in many missions dedicated to monitoring the Earth, and the tools used in these missions continuously return data on everything from shifts in temperature to cloud formation to pollution levels over highways. The data are of great scientific value, but they also provide information that can play a critical role in decision making during times of crisis. Real-time developments in weather, wind, ocean currents, and numerous other conditions can have a significant impact on the way disasters, both natural and human-caused, unfold. "NASA has long recognized the need to make its data from real-time sources compatible and accessible for the purposes of decision making," says Michael Goodman, who was Disasters Program manager at NASA Headquarters from 2009-2012. "There are practical applications of NASA Earth science data, and we d like to accelerate the use of those applications." One of the main obstacles standing in the way of eminently practical data is the fact that the data from different missions are collected, formatted, and stored in different ways. Combining data sets in a way that makes them useful for decision makers has proven to be a difficult task. And while the need for a collaborative platform is widely recognized, very few have successfully made it work. Dave Jones, founder and CEO of StormCenter Communications Inc., which consults with decision makers to prepare for emergencies, says that "when I talk to public authorities, they say, If I had a nickel for every time someone told me they had a common operating platform, I d be rich. But one thing we ve seen over the years is that no one has been able to give end users the ability to ingest NASA data sets and merge them with their own."
Schatten, Heather T.; Armey, Michael F.; Andover, Margaret S.
Research suggests that individuals with a history of non-suicidal self-injury (NSSI) do not have difficulty generating alternatives to social problems but choose more negative solutions, suggesting a deficit in decision-making. However, studies report no significant differences in risky decision-making on a performance-based task among individuals with and without NSSI histories. A limitation of these studies is that decision-making was only assessed at baseline. As individuals with a history of NSSI typically self-injure when experiencing negative emotions, decision-making ability may become impaired specifically in the presence of these emotions. The aim of the current study was to investigate decision-making ability among individuals with and without NSSI histories both at baseline and following a distressing social exclusion task. We compared individuals with (n = 48) and without (n = 72) NSSI histories on the Iowa Gambling Task, a behavioral measure of risky decision-making, before and after exclusion or inclusion on the Cyberball task. Results indicated no significant group differences in performance regardless of condition. When participants were grouped by racial/ethnic minority status, results indicated that non-Hispanic White individuals with a history of NSSI exhibited deterioration in risky decision-making ability following social exclusion. Potential explanations for these findings and clinical implications are discussed. PMID:26260569
Schiebener, Johannes; Schulte, Frank Paul; Hofmann, Jens; Brand, Matthias
In neuropsychological decision-making research, several different tasks are used to measure decision-making competences in patients and healthy study participants. Unfortunately, the existing tasks are often inflexible for modification, use different scenarios, and include several gambling cues. Therefore, comparisons between participants' performances in different tasks are difficult. We developed the Truck Dispatcher Framework (TDF), in which different decision-making tasks can be designed within one unitary, flexible, and real-world-oriented story line. To test the story line, TDF analogues of three standard decision-making tasks (Game of Dice Task, Probability-Associated Gambling task, Iowa Gambling Task) were developed. In three studies with brain-healthy participants, the behavior in standard decision-making tasks and the TDF analogues of those tasks were compared. Similar behaviors indicate that the TDF tasks measure decision making appropriately. Thus, the TDF is recommended for experimental and clinical research because it allows for examining decision-making competences in tasks with different demands that take place within one unitary story line.
Thomas, A.; Huff, A. K.; Gomori, S. G.; Sadoff, N.
In order to enhance the capacity for air quality modeling and improve air quality monitoring and management in the SERVIR Mesoamerica region, members of SERVIR's Applied Sciences Team (AST) are developing national numerical air quality models for El Salvador and Costa Rica. We are working with stakeholders from the El Salvador Ministry of the Environment and Natural Resources (MARN); National University of Costa Rica (UNA); the Costa Rica Ministry of the Environment, Energy, and Telecommunications (MINAET); and Costa Rica National Meteorological Institute (IMN), who are leaders in air quality monitoring and management in the Mesoamerica region. Focusing initially on these institutions will build sustainability in regional modeling activities by developing air quality modeling capability that can be shared with other countries in Mesoamerica. The air quality models are based on the Community Multi-scale Air Quality (CMAQ) model and incorporate meteorological inputs from the Weather Research and Forecasting (WRF) model, as well as national emissions inventories from El Salvador and Costa Rica. The models are being optimized for urban air quality, which is a priority of decision-makers in Mesoamerica. Once experimental versions of the modeling systems are complete, they will be transitioned to servers run by stakeholders in El Salvador and Costa Rica. The numerical air quality models will provide decision support for stakeholders to identify 1) high-priority areas for expanding national ambient air monitoring networks, 2) needed revisions to national air quality regulations, and 3) gaps in national emissions inventories. This project illustrates SERVIR's goal of the transition of science to support decision-making through capacity building in Mesoamerica, and it aligns with the Group on Earth Observations' health societal benefit theme. This presentation will describe technical aspects of the development of the models and outline key steps in our successful
Hudson, Darren; Singh, Gurmeet
The major task of physicians is decision making. This is often done in time pressured situations. The traditional theory of decision making does not reflect this reality and naturalistic decision making is a more appropriate model. The first step is to make sense of the patient or the problem and the Data-Frame Theory of Klein seems to be the best model. This model has significant implications in the way we view clinical information systems, communication and medical education.
Colakkadioglu, Oguzhan; Celik, D. Billur
Problem Statement: Decision making is a critical cognitive process in every area of human life. In this process, the individuals play an active role and obtain outputs with their functional use of decision-making skills. Therefore, the decision-making process can affect the course of life, life satisfaction, and the social relations of an…
Elton, Amanda; Smith, Christopher T; Parrish, Michael H; Boettiger, Charlotte A
Excessively choosing immediate over larger future rewards, or delay discounting (DD), associates with multiple clinical conditions. Individual differences in DD likely depend on variations in the activation of and functional interactions between networks, representing possible endophenotypes for associated disorders, including alcohol use disorders (AUDs). Numerous fMRI studies have probed the neural bases of DD, but investigations of large-scale networks remain scant. We addressed this gap by testing whether activation within large-scale networks during Now/Later decision-making predicts individual differences in DD. To do so, we scanned 95 social drinkers (18-40 years old; 50 women) using fMRI during hypothetical choices between small monetary amounts available "today" or larger amounts available later. We identified neural networks engaged during Now/Later choice using independent component analysis and tested the relationship between component activation and degree of DD. The activity of two components during Now/Later choice correlated with individual DD rates: A temporal lobe network positively correlated with DD, whereas a frontoparietal-striatal network negatively correlated with DD. Activation differences between these networks predicted individual differences in DD, and their negative correlation during Now/Later choice suggests functional competition. A generalized psychophysiological interactions analysis confirmed a decrease in their functional connectivity during decision-making. The functional connectivity of these two networks negatively correlates with alcohol-related harm, potentially implicating these networks in AUDs. These findings provide novel insight into the neural underpinnings of individual differences in impulsive decision-making with potential implications for addiction and related disorders in which impulsivity is a defining feature.
Lenert, Leslie; Dunlea, Robert; Del Fio, Guilherme; KellyHall, Leslie
Shared Decision Making (SDM) is an approach to medical care based on collaboration between provider and patient with both sharing in medical decisions. When patients’ values and preferences are incorporated in decision-making, then care is more appropriate, ethically sound, and often lower in cost. However, SDM is difficult to implement in routine practice because of the time required for SDM methods, the lack of integration of SDM approaches into electronic health records systems (EHRs), and absence of explanatory mechanisms for providers on the results of patients’ use of decision aids. This paper discusses potential solutions including the concept of a “Personalize Button” for EHRs. Leveraging a four-phased clinical model for SDM, this article describes how computer decision support (CDS) technologies integrated into EHRs can help insure that healthcare is delivered in a way that is respectful of those preferences. The architecture described herein, called CDS for SDM, is built upon recognized standards that are currently integrated into certification requirements for EHRs as part of Meaningful Use regulations. While additional work is needed on modeling of preferences and on techniques for rapid communication models of preferences to clinicians, unless EHRs are re-designed to support SDM around and during clinical encounters, they are likely to continue to be an unintended barrier to SDM. With appropriate development, EHRs could be a powerful tool to promote SDM by reminding providers of situations for SDM and monitoring on going care to insure treatments are consistent with patients’ preferences. PMID:25224366
Dickinson, H D
A practical theory of argumentation is outlined and applied to a hypothetical clinical scenario to elucidate the use of research evidence in individual treatment decisions. The primary role of research evidence is to establish warrants as opposed to warrant using. Warrants are defined as the rules, principles or interpretive rationales used to justify an inference from observed data to conclusion, or clinical claim. Clarity on the appropriate use of research evidence in clinical decision-making can help resolve current debates over the nature and consequences of evidence-based medicine. The theory of argumentation has potential to inform both the design of decision support tools and to provide criteria for assessing decisional performance.
Fracture Diaphyseal Femur in a Case of Ipsilateral Excision Arthroplasty of Hip: Report of Two Cases with Description of an Unusual Injury Pattern, Mechanism, and Clinical Decision-making in Management
Shah, Kunal; Ubale, Tushar; Abdul, Rahematullah; Kasodekar, Vaibhav; Assudani, Ashish; Makwana, Kiran
Introduction: Although fracture diaphyseal femur is commonly seen in orthopedic practice, its association with ipsilateral resection arthroplasty of hip/pseudarthrosis of neck is rare. The technique of excision arthroplasty has undergone modification with emphasis on preserving as much bone as possible. However, it is not always possible to preserve bone while removing the earlier prosthesis and cement. This often leads to extensive proximal bone loss. Associated ipsilateral fracture femur presents a unique scenario. Till date, only one case report is published highlighting its surgical management. Case Report: We report two cases of diaphyseal fracture femur associated with resection arthroplasty of hip at subtrochanteric level with greater trochanter as a separate fragment (Case 1) and other with pseudarthrosis of the neck of femur with intact greater trochanter (Case 2). The first case was operated with surface fixation, whereas the second was operated with closed antegrade intramedullary nail. Conclusion: Decision-making and formulating treatment plan includes taking various factors into account such as level of resection arthroplasty of hip/pseudarthrosis of neck, status of greater trochanter (intact or separate fragment), osteoporosis, and post-operative ambulation and rehabilitation. In this report, we highlight the unusual occurrence, probable mechanism of injury, risk factors for fracture, and decision-making in the surgical management of such a condition. PMID:28164068
Liu, Zhengrong; Sheng, Grant; Wang, Lei
Public participation is an integral part of legislation or decision making processes. Traditionally, public participation took place through face-to-face encounters such as public meetings and other fora. However, some important factors limiting the efficiency and effectiveness of this mode of public participation include: geographic separation of participants, scheduling and financial constraints in attending meetings, and limited duration of meetings. These led to the awareness that public participation requires new methods in order to achieve a better democratic decision making. On the other hand, GIS has in the past been accused of being an elitist technology, giving more power to those people already possessing it and depriving those, namely the general public, who more often lack such direct forms of information access. Public participation GIS (PPGIS) is emerging as a distinct subset of two previously separate activities: technology-based spatial analysis and participatory democracy. The paper considers both traditional methods and Internet-based technologies of public participation and argues that new Internet-based technologies have the potential to widen participation by using online spatial decision support systems. GIS and the Internet can be used together to provide the general public with a powerful mechanism for becoming more involved in decision problems. Provision of full access to spatial and non-spatial data, along with the appropriate tools with which to use it, may greatly empower the general public. PPGIS focuses on engaging the public to participate and become involved in a particular subject of interest. It empowers GIS users from all walks of life and enabling them to use the technology purposefully to capture their local knowledge and advance their goals. In the project of public participatory Ontario nuclear waste siting, we focused on developing an Internet based PPGIS prototype to help the public to participate online from inception to
Garvelink, Mirjam M; Ngangue, Patrice A G; Adekpedjou, Rheda; Diouf, Ndeye T; Goh, Larissa; Blair, Louisa; Légaré, France
We conducted a mixed-methods knowledge synthesis to assess the effectiveness of interventions to improve caregivers' involvement in decision making with seniors, and to describe caregivers' experiences of decision making in the absence of interventions. We analyzed forty-nine qualitative, fourteen quantitative, and three mixed-methods studies. The qualitative studies indicated that caregivers had unmet needs for information, discussions of values and needs, and decision support, which led to negative sentiments after decision making. Our results indicate that there have been insufficient quantitative evaluations of interventions to involve caregivers in decision making with seniors and that the evaluations that do exist found few clinically significant effects. Elements of usual care that received positive evaluations were the availability of a decision coach and a supportive decision-making environment. Additional rigorously evaluated interventions are needed to help caregivers be more involved in decision making with seniors.
Ronningstam, Elsa; Baskin-Sommers, Arielle R.
Linking psychoanalytic studies with neuroscience has proven increasingly productive for identifying and understanding personality functioning. This article focuses on pathological narcissism and narcissistic personality disorder (NPD), with the aim of exploring two clinically relevant aspects of narcissistic functioning also recognized in psychoanalysis: fear and decision-making. Evidence from neuroscientific studies of related conditions, such as psychopathy, suggests links between affective and cognitive functioning that can influence the sense of self-agency and narcissistic self-regulation. Attention can play a crucial role in moderating fear and self-regulatory deficits, and the interaction between experience and emotion can be central for decision-making. In this review we will explore fear as a motivating factor in narcissistic personality functioning, and the impact fear may have on decision-making in people with pathological narcissism and NPD. Understanding the processes and neurological underpinnings of fear and decision-making can potentially influence both the diagnosis and treatment of NPD. PMID:24174893
Ronningstam, Elsa; Baskin-Sommers, Arielle R
Linking psychoanalytic studies with neuroscience has proven increasingly productive for identifying and understanding personality functioning. This article focuses on pathological narcissism and narcissistic personality disorder (NPD), with the aim of exploring two clinically relevant aspects of narcissistic functioning also recognized in psychoanalysis: fear and decision-making. Evidence from neuroscientific studies of related conditions, such as psychopathy, suggests links between affective and cognitive functioning that can influence the sense of self-agency and narcissistic self-regulation. Attention can play a crucial role in moderating fear and self-regulatory deficits, and the interaction between experience and emotion can be central for decision-making. In this review we will explore fear as a motivating factor in narcissistic personality functioning, and the impact fear may have on decision-making in people with pathological narcissism and NPD. Understanding the processes and neurological underpinnings of fear and decision-making can potentially influence both the diagnosis and treatment of NPD.
Zeiss, Ragna; van Egmond, Stans
This article studies the roles three science-based models play in Dutch policy and decision making processes. Key is the interaction between model construction and environment. Their political and scientific environments form contexts that shape the roles of models in policy decision making. Attention is paid to three aspects of the wider context of the models: a) the history of the construction process; b) (changes in) the political and scientific environments; and c) the use in policy processes over longer periods of time. Models are more successfully used when they are constructed in a stable political and scientific environment. Stability and certainty within a scientific field seems to be a key predictor for the usefulness of models for policy making. The economic model is more disputed than the ecology-based model and the model that has its theoretical foundation in physics and chemistry. The roles models play in policy processes are too complex to be considered as straightforward technocratic powers.
N'Guyen, Steve; Moulin-Frier, Clément; Droulez, Jacques
We propose a new approach for solving a class of discrete decision making problems under uncertainty with positive cost. This issue concerns multiple and diverse fields such as engineering, economics, artificial intelligence, cognitive science and many others. Basically, an agent has to choose a single or series of actions from a set of options, without knowing for sure their consequences. Schematically, two main approaches have been followed: either the agent learns which option is the correct one to choose in a given situation by trial and error, or the agent already has some knowledge on the possible consequences of his decisions; this knowledge being generally expressed as a conditional probability distribution. In the latter case, several optimal or suboptimal methods have been proposed to exploit this uncertain knowledge in various contexts. In this work, we propose following a different approach, based on the geometric intuition of distance. More precisely, we define a goal independent quasimetric structure on the state space, taking into account both cost function and transition probability. We then compare precision and computation time with classical approaches. PMID:24376697
Bain, Gregory Ian; McGuire, Duncan Thomas
Limited wrist fusions are effective surgical procedures for providing pain relief while preserving motion of the wrist in patients with localized arthritis of the carpus. In deciding which motion-preserving procedure to perform, the etiology of the arthritis, which joints are involved, and which are spared should be determined. The main principle is to fuse the involved joints and to allow motion through the uninvolved joints. In this article, we discuss the various traumatic and nontraumatic conditions causing arthritis of the wrist and the treatment options for those conditions. Common indications for limited wrist fusions include scapholunate advanced collapse and scaphoid nonunion advanced collapse. Options for treating these conditions include three- and four-corner fusions as well as a proximal row carpectomy. This paper discusses which procedures are the most appropriate as well as the outcomes of these procedures. If the basic principles of limited wrist fusions are adhered to, a good outcome can be obtained. The authors' surgical technique and decision-making processes are discussed. PMID:24179713
Salek, M. Mehdi; Guasto, Jeffrey S.; Stocker, Roman
Swimming cells are often guided by chemical gradients (``chemotaxis'') to search for nutrients, hosts, and mates, and to avoid predators and noxious substances. It remains unclear, however, how variable the chemotactic abilities of cells are among cells of one species, and whether there are better ``decision makers'' within a population. Inspired by studies in macro-organism ecology, we fabricated a microfluidic ``T-maze'' in which marine bacteria are subjected to a chemical attractant gradient at each of a series of consecutive T-junctions. We used video microscopy to capture the motion of thousands of bacteria as they migrate up or down the gradient at each subsequent junction. This approach provides detailed statistics at both the single-cell and population levels, while simultaneously sorting the cells by chemotactic ability. Using a range of bacteria, we demonstrate how the microfluidic T-maze allows us to sort the better decision-making cells in the population, opening the door for improved efficiency of a range of microbial processes in nature and industry.
The study investigated the relationship of nature of science (NOS) instruction and students' decision-making (DM) related to a controversial socioscientific issue about genetically modified food. Participants were ninth-grade students in four intact sections (two regulars and two honors) in a public high school in the Midwest. All four groups were taught by their regular science teacher. The treatment comprised a four-week unit about genetic engineering. Two groups (one regular and one honors), referred to as comparison groups, received instruction in genetic engineering and how to formulate arguments and make decisions related to this controversial issue. The other two groups (one regular and one honors), referred to as treatment groups, received instruction in genetic engineering and how to apply NOS aspects as they formulate arguments and make decisions in relation to this controversial issue. Chi-square analyses showed significant differences between the comparison and the treatment groups in relation to the understandings of four NOS aspects. There were no differences in their decisions, but there were differences in their DM factors in the context of the controversial socioscientific issue about genetically modified food. These results are discussed in light of the relationship between students' understandings of NOS and their DM related to controversial socioscientific issues.
Mason, Keith J.
This research surveys twenty large companies and their travellers to identify and evaluate the effects of pressures on the business travel market in the future. The influence of the following areas on the decision making process are addressed: (1) Corporate travel policies and increasing professionalism in corporate purchasing; (2) The development of global strategic airline alliances; (3) The emergence of low cost airlines on short haul markets; and (4) The development of internet based booking tools and travel agency IT. The survey shows differences in views between travel managers, and travellers with regard to corporate travel policies. While travel managers see policy rules, travellers interpret these as guidelines, indicating travel managers will need to take further actions to exercise true control of travel budgets. The data shows that companies are more likely to prescribe a class of airline ticket, than the choice of airline itself. Corporate hierarchical bias in travel policies is still common both for short and particularly long haul flying. Other findings show that while travel managers believe that their companies are likely to sign global deals with strategic airline groups within a five year period in a bid to consolidating spending, they also believe that nearly a third of short haul flying will be taken with low cost carriers, indicating further penetration in this business travel market by these carriers. The paper also provides other predictions about the business travel market, based on the survey findings.
This paper is a reflection on the representation of nurses and their practice at a global level. In considering the International Council of Nurses (ICN) conference in Malta (2011), it is clear that certain assumptions have been made about nurses and their practice which assume that globalization is under way for the whole of the profession and that the assumptions can be applied equally around the world. These assumptions appear in many ways to be implicit rather than explicit. The implicitness of the assumptions is examined against the particular decision-making processes adopted by the ICN. An attempt is then made to identify another base for the ongoing global work of the ICN. This involves the exploration of taboo (that which is forbidden because it is either holy or unclean) as a way of examining why nursing is not properly valued, despite years of international representation. The paper concludes with some thoughts on how such a new approach interfaces with the possibilities held out by new information technologies.
I contrast Robert Veatch's recent liberal vision of medical decision-making with a more rationalist liberal model. According to Veatch, physicians are biased in their determination of what is in their patient's overall interests in favour of their medical interests. Because of the extent of this bias, we should abandon the practice of physicians offering what they guess to be the best treatment option. Patients should buddy up with physicians who share the same values -- 'deep value pairing'. The goal of choice is maximal promotion of patient values. I argue that if subjectivism about value and valuing is true, this move is plausible. However, if objectivism about value is true -- that there really are states which are good for people regardless of whether they desire to be in them -- then we should accept a more rationalist liberal alternative. According to this alternative, what is required to decide which course is best is rational dialogue between physicians and patients, both about the patient's circumstances and her values, and not the seeking out of people, physicians or others, who share the same values. Rational discussion requires that physicians be reasonable and empathic. I describe one possible account of a reasonable physician.
van der Meer, Matthijs; Kurth-Nelson, Zeb; Redish, A. David
Decisions result from an interaction between multiple functional systems acting in parallel to process information in very different ways, each with strengths and weaknesses. In this review, the authors address three action-selection components of decision-making: The Pavlovian system releases an action from a limited repertoire of potential actions, such as approaching learned stimuli. Like the Pavlovian system, the habit system is computationally fast but, unlike the Pavlovian system permits arbitrary stimulus-action pairings. These associations are a “forward” mechanism; when a situation is recognized, the action is released. In contrast, the deliberative system is flexible but takes time to process. The deliberative system uses knowledge of the causal structure of the world to search into the future, planning actions to maximize expected rewards. Deliberation depends on the ability to imagine future possibilities, including novel situations, and it allows decisions to be taken without having previously experienced the options. Various anatomical structures have been identified that carry out the information processing of each of these systems: hippocampus constitutes a map of the world that can be used for searching/imagining the future; dorsal striatal neurons represent situation-action associations; and ventral striatum maintains value representations for all three systems. Each system presents vulnerabilities to pathologies that can manifest as psychiatric disorders. Understanding these systems and their relation to neuroanatomy opens up a deeper way to treat the structural problems underlying various disorders. PMID:22492194
Bhattacharya, K.; Vicsek, Tamás
Most of us must have been fascinated by the eye-catching displays of collectively moving animals. Schools of fish can move in a rather orderly fashion and then change direction amazingly abruptly. There are a large number of further examples both from the living and the non-living world for phenomena during which the many interacting, permanently moving units seem to arrive at a common behavioural pattern taking place in a short time. As a paradigm of this type of phenomena we consider the problem of how birds arrive at a decision resulting in their synchronized landing. We introduce a simple model to interpret this process. Collective motion prior to landing is modelled using a simple self-propelled particle (SPP) system with a new kind of boundary condition, while the tendency and the sudden propagation of the intention of landing are introduced through rules analogous to the random field Ising model in an external field. We show that our approach is capable of capturing the most relevant features of collective decision making in a system of units with variance of individual intentions and being under an increasing level of pressure to switch states. We find that as a function of the few parameters of our model the collective switching from the flying to the landing state is indeed much sharper than the distribution of individual landing intentions. The transition is accompanied by a number of interesting features discussed in this paper.
Oud, Bastiaan; Krajbich, Ian; Miller, Kevin; Cheong, Jin Hyun; Botvinick, Matthew; Fehr, Ernst
Time is an extremely valuable resource but little is known about the efficiency of time allocation in decision-making. Empirical evidence suggests that in many ecologically relevant situations, decision difficulty and the relative reward from making a correct choice, compared to an incorrect one, are inversely linked, implying that it is optimal to use relatively less time for difficult choice problems. This applies, in particular, to value-based choices, in which the relative reward from choosing the higher valued item shrinks as the values of the other options get closer to the best option and are thus more difficult to discriminate. Here, we experimentally show that people behave sub-optimally in such contexts. They do not respond to incentives that favour the allocation of time to choice problems in which the relative reward for choosing the best option is high; instead they spend too much time on problems in which the reward difference between the options is low. We demonstrate this by showing that it is possible to improve subjects' time allocation with a simple intervention that cuts them off when their decisions take too long. Thus, we provide a novel form of evidence that organisms systematically spend their valuable time in an inefficient way, and simultaneously offer a potential solution to the problem. PMID:26763695
Pushkarskaya, Helen; Smithson, Michael; Joseph, Jane E; Corbly, Christine; Levy, Ifat
HIGHLIGHTS We use a simple gambles design in an fMRI study to compare two conditions: ambiguity and conflict.Participants were more conflict averse than ambiguity averse.Ambiguity aversion did not correlate with conflict aversion.Activation in the medial prefrontal cortex correlated with ambiguity level and ambiguity aversion.Activation in the ventral striatum correlated with conflict level and conflict aversion. Studies of decision making under uncertainty generally focus on imprecise information about outcome probabilities ("ambiguity"). It is not clear, however, whether conflicting information about outcome probabilities affects decision making in the same manner as ambiguity does. Here we combine functional magnetic resonance imaging (fMRI) and a simple gamble design to study this question. In this design the levels of ambiguity and conflict are parametrically varied, and ambiguity and conflict gambles are matched on expected value. Behaviorally, participants avoided conflict more than ambiguity, and attitudes toward ambiguity and conflict did not correlate across participants. Neurally, regional brain activation was differentially modulated by ambiguity level and aversion to ambiguity and by conflict level and aversion to conflict. Activation in the medial prefrontal cortex was correlated with the level of ambiguity and with ambiguity aversion, whereas activation in the ventral striatum was correlated with the level of conflict and with conflict aversion. These novel results indicate that decision makers process imprecise and conflicting information differently, a finding that has important implications for basic and clinical research.
Pushkarskaya, Helen; Smithson, Michael; Joseph, Jane E.; Corbly, Christine; Levy, Ifat
HIGHLIGHTS We use a simple gambles design in an fMRI study to compare two conditions: ambiguity and conflict.Participants were more conflict averse than ambiguity averse.Ambiguity aversion did not correlate with conflict aversion.Activation in the medial prefrontal cortex correlated with ambiguity level and ambiguity aversion.Activation in the ventral striatum correlated with conflict level and conflict aversion. Studies of decision making under uncertainty generally focus on imprecise information about outcome probabilities (“ambiguity”). It is not clear, however, whether conflicting information about outcome probabilities affects decision making in the same manner as ambiguity does. Here we combine functional magnetic resonance imaging (fMRI) and a simple gamble design to study this question. In this design the levels of ambiguity and conflict are parametrically varied, and ambiguity and conflict gambles are matched on expected value. Behaviorally, participants avoided conflict more than ambiguity, and attitudes toward ambiguity and conflict did not correlate across participants. Neurally, regional brain activation was differentially modulated by ambiguity level and aversion to ambiguity and by conflict level and aversion to conflict. Activation in the medial prefrontal cortex was correlated with the level of ambiguity and with ambiguity aversion, whereas activation in the ventral striatum was correlated with the level of conflict and with conflict aversion. These novel results indicate that decision makers process imprecise and conflicting information differently, a finding that has important implications for basic and clinical research. PMID:26640434
Anagnostou, Theodore; Remzi, Mesut; Lykourinas, Michael; Djavan, Bob
The authors are presenting a thorough introduction in Artificial Neural Networks (ANNs) and their contribution to modern Urologic Oncology. The article covers a description of Artificial Neural Network methodology and points out the differences of Artificial Intelligence to traditional statistic models in terms of serving patients and clinicians, in a different way than current statistical analysis. Since Artificial Intelligence is not yet fully understood by many practicing clinicians, the authors have reviewed a careful selection of articles in order to explore the clinical benefit of Artificial Intelligence applications in modern Urology questions and decision-making. The data are from real patients and reflect attempts to achieve more accurate diagnosis and prognosis, especially in prostate cancer that stands as a good example of difficult decision-making in everyday practice. Experience from current use of Artificial Intelligence is also being discussed, and the authors address future developments as well as potential problems such as medical record quality, precautions in using ANNs or resistance to system use, in an attempt to point out future demands and the need for common standards. The authors conclude that both methods should continue to be used in a complementary manner. ANNs still do not prove always better as to replace standard statistical analysis as the method of choice in interpreting medical data.
Hotaling, Jared M; Cohen, Andrew L; Shiffrin, Richard M; Busemeyer, Jerome R
In cognitive science there is a seeming paradox: On the one hand, studies of human judgment and decision making have repeatedly shown that people systematically violate optimal behavior when integrating information from multiple sources. On the other hand, optimal models, often Bayesian, have been successful at accounting for information integration in fields such as categorization, memory, and perception. This apparent conflict could be due, in part, to different materials and designs that lead to differences in the nature of processing. Stimuli that require controlled integration of information, such as the quantitative or linguistic information (commonly found in judgment studies), may lead to suboptimal performance. In contrast, perceptual stimuli may lend themselves to automatic processing, resulting in integration that is closer to optimal. We tested this hypothesis with an experiment in which participants categorized faces based on resemblance to a family patriarch. The amount of evidence contained in the top and bottom halves of each test face was independently manipulated. These data allow us to investigate a canonical example of sub-optimal information integration from the judgment and decision making literature, the dilution effect. Splitting the top and bottom halves of a face, a manipulation meant to encourage controlled integration of information, produced farther from optimal behavior and larger dilution effects. The Multi-component Information Accumulation model, a hybrid optimal/averaging model of information integration, successfully accounts for key accuracy, response time, and dilution effects.
Ernst, J; Holze, S; Sonnefeld, C; Götze, H; Schwarz, R
The changes in the relationship between doctors and patients and the transfer of shared decision making into medical treatment has often been discussed. The role and the perspective of the patients are primarily described. The aim of our study is to examine the attitudes of physicians regarding the shared decision making concept, based on 15 interviews with clinical doctors. Our findings show that most doctors know the content of the concept and mostly agree with it. Practical barriers for the realisation of shared decision making are often stressed. The meaning of the concept of shared decision making for the physicians is in some respects different from the meaning of this concept for the patients. It is important to examine this concept more particularly with standardised instruments. It will be necessary to explore not only the role of patients and physicians in the medical decision making process but also the position of other relevant persons like the relatives of the patients or the nursing staff.
Abreu, Mirhelen Mendes de; Battisti, Raphael; Martins, Rachel Samhan; Baumgratz, Thiago Dias; Cuziol, Mirella
There is no SDM in clinical practice in Brazil. The first steps have been taken towards research and tool development recently. Likewise, our society is starting to get involved with decision making in health care. This paper aims to offer an overview of the Brazilian health system history, its values, and its influence on SDM. The participative social control concept is introduced as a result of the movement against the dictatorship era. In addition, the influence of social changes on the Medical Ethical Code is delineated. SDM state of the art in Brazil is also discussed and the challenges to implement it on clinical practice are described. Regardless the challenges, it is possible to make a positive assessment of SDM in Brazil.
Grabbe, Shon R.; Sridhar, Banavar; Mukherjee, Avijit
A generalized approach is proposed to support integrated traffic flow management decision making studies at both the U.S. national and regional levels. It can consider tradeoffs between alternative optimization and heuristic based models, strategic versus tactical flight controls, and system versus fleet preferences. Preliminary testing was accomplished by implementing thirteen unique traffic flow management models, which included all of the key components of the system and conducting 85, six-hour fast-time simulation experiments. These experiments considered variations in the strategic planning look-ahead times, the replanning intervals, and the types of traffic flow management control strategies. Initial testing indicates that longer strategic planning look-ahead times and re-planning intervals result in steadily decreasing levels of sector congestion for a fixed delay level. This applies when accurate estimates of the air traffic demand, airport capacities and airspace capacities are available. In general, the distribution of the delays amongst the users was found to be most equitable when scheduling flights using a heuristic scheduling algorithm, such as ration-by-distance. On the other hand, equity was the worst when using scheduling algorithms that took into account the number of seats aboard each flight. Though the scheduling algorithms were effective at alleviating sector congestion, the tactical rerouting algorithm was the primary control for avoiding en route weather hazards. Finally, the modeled levels of sector congestion, the number of weather incursions, and the total system delays, were found to be in fair agreement with the values that were operationally observed on both good and bad weather days.