1. INTRODUCTION HINF 371 Medical Methodologies Session 1

2. Objective To understand the expectations of students and instructor To understand the expectations of students and instructor To review why medical decision making is important To review why medical decision making is important

3. Reading Eddy D (1990) The Challenge, JAMA No.263, pp. 287-290 Eddy D (1990) The Challenge, JAMA No.263, pp. 287-290

4. Healthcare Decision-Making Challenge In the past people believe that doctors know the best, not every patient could be cured but all were confident that whatever was done was the best possible In the past people believe that doctors know the best, not every patient could be cured but all were confident that whatever was done was the best possible Physicians were free, trusted and left alone to decide what was best for each patient Physicians were free, trusted and left alone to decide what was best for each patient

5. Then came the…. Tissue committees to make sure some physicians do the right thing (internal scrutiny) Tissue committees to make sure some physicians do the right thing (internal scrutiny) The practice guidelines The practice guidelines The pre-authorizations The pre-authorizations Second opinions Second opinions

6. Was it necessary Most decisions were correct, but some weren’t Most decisions were correct, but some weren’t Many decisions made by physicians appear to be arbitrary, highly variable Many decisions made by physicians appear to be arbitrary, highly variable Most cause benefits, some do no harm or benefit, but some may cause harm and costs Most cause benefits, some do no harm or benefit, but some may cause harm and costs Variation in decisions were caused by differences in physicians Variation in decisions were caused by differences in physicians Observations Observations Perceptions Perceptions Reasoning Reasoning Conclusions Conclusions And Practices And Practices Observers looking at the same thing disagree with each other and even with themselves Observers looking at the same thing disagree with each other and even with themselves

7. Was it necessary Perceptions regarding the benefits of alternate treatment options Perceptions regarding the benefits of alternate treatment options Even if perceptions are accurate, judgments and intuitions may not be Even if perceptions are accurate, judgments and intuitions may not be When there are this many variables in decision making, physicians facing the same problem may draw different conclusions When there are this many variables in decision making, physicians facing the same problem may draw different conclusions Variations from providers and variation from patients – possibly leaves things to chance Variations from providers and variation from patients – possibly leaves things to chance

8. Requirements for Accurate and Effective Decisions Evidence of accurate, interpretable, applicable to observations. Physicians use their experience as evidence but; Evidence of accurate, interpretable, applicable to observations. Physicians use their experience as evidence but; Observations are small Observations are small No controls No controls Patient’s and physician’s decisions about interventions are not random Patient’s and physician’s decisions about interventions are not random Follow-up is incomplete and usually short-term Follow-up is incomplete and usually short-term Memory is highly selective Memory is highly selective Ability to analyze all available evidence from people who trained to provide medical care is unrealistic and unfair Ability to analyze all available evidence from people who trained to provide medical care is unrealistic and unfair

9. Mechanisms (pre and second guessing physicians) Depend on questionable assumptions Depend on questionable assumptions Safety in number and accuracy in numbers Safety in number and accuracy in numbers Checking perceptions of one physician with another Checking perceptions of one physician with another Medical decisions are too subtle to make from a distance Medical decisions are too subtle to make from a distance If they have worked, they are If they have worked, they are Cumbersome Cumbersome Expensive Expensive Demoralizing for physicians and patients Demoralizing for physicians and patients Create an adversarial atmosphere that can harm patients Create an adversarial atmosphere that can harm patients There are no guarantees that recommendations are correct or the gains they make are worth the cost in time, money or hassle. There are no guarantees that recommendations are correct or the gains they make are worth the cost in time, money or hassle.

10. Recapping the Facts Medicine is not a fraud, decisions are not made randomly. They vary. Medicine is not a fraud, decisions are not made randomly. They vary. Physicians are faced with making decisions with about phenomenally complex problems, under very difficult circumstances with very little support, without knowing the results of their actions, Physicians are faced with making decisions with about phenomenally complex problems, under very difficult circumstances with very little support, without knowing the results of their actions, Most medical practices are effective. The question is which treatments work best and whether the costs and risks of more risky and expensive practices are matched by proposed benefits Most medical practices are effective. The question is which treatments work best and whether the costs and risks of more risky and expensive practices are matched by proposed benefits

11. Recapping the facts Problems described is no one’s fault. Problems described is no one’s fault. Physicians face one of the most difficult social and intellectual problems Physicians face one of the most difficult social and intellectual problems They need to deal with human biology and disease and medical technologies as well as many other factors. They need to deal with human biology and disease and medical technologies as well as many other factors. But we can do much better But we can do much better Clinical research is inefficient (dissected and selected questions, poor designs, poor coordination and communication) Clinical research is inefficient (dissected and selected questions, poor designs, poor coordination and communication) Ability to reason both collectively and individually is limited Ability to reason both collectively and individually is limited Current approach to analysing evidence, estimating the consequences of our actions, and determining the desirability of those outcomes is primitive Current approach to analysing evidence, estimating the consequences of our actions, and determining the desirability of those outcomes is primitive

12. Ideally… Decisions are made between patient and physician in consideration of patient’s needs Decisions are made between patient and physician in consideration of patient’s needs Physicians have solid information about the consequences of different choices Physicians have solid information about the consequences of different choices Physicians must be able to process information accurately Physicians must be able to process information accurately Quality concerns and cost containment mechanisms would not create one more factor to distort decisions Quality concerns and cost containment mechanisms would not create one more factor to distort decisions

13. Solution Not to undermine physician’s decision making but improve it by Not to undermine physician’s decision making but improve it by Providing information needed Providing information needed Institutionalization of skills to create this information Institutionalization of skills to create this information Developing processes to support decisions Developing processes to support decisions