Medical Thinking: The Psychology of Medical Judgment and Decision Making PDF
Preview Medical Thinking: The Psychology of Medical Judgment and Decision Making
Contributions to Psychology and Medicine Contributions to Psychology and Medicine The Psychology of Childhood Illness Christine Eiser Psychological Aspects of Early Breast Cancer Colette Ray/Michael Baum Medical Thinking: The Psychology of Medical Judgment and Decision Making Steven Schwartz/Timothy Griffin Women With Cancer: Psychological Perspectives Barbara L. Andersen, editor The Somatizing Child: Diagnosis and Treatment of Conversion and Somatization Disorders Elsa G. Shapiro/Alvin A. Rosenfeld with Norman Cohen and Dorothy Levine Steven Schwartz Timothy Griffin Medical Thinking The Psychology of Medical Judgment and Decision Making With 28 Figures Springer-Verlag N ew York Berlin Heidelberg London Paris Tokyo Steven Schwartz Timothy Griffin Department of Psychology Department of Psychology University of Queensland University of Queensland St. Lucia, Queensland 4067 St. Lucia, Queensland 4067 Australia Australia Advisor J. Richard Eiser Department of Psychology University of Exeter Exeter EX4 40G England Library of Congress Cataloging in Publication Data Schwartz, Steven. Medical thinking. (Contributions to psychology and medicine) Bibliography: p. Includes indexes. 1. Medicine-Decision making-Evaluation. 2. Medical logic-Evaluation. 3. Cognition. I. Griffin, Timothy. II. Title. Ill. Series. [DNLM: 1. Decision Making. 2. Diagnosis. WB 141 S399m] R723.5.S38 1986 610'.68 86-6475 © 1986 by Springer-Verlag New York Inc. Softcover reprint of the hardcover 1s t edition 1986 All rights reserved. No part of this book may be translated or reproduced in any form without written permission from Springer-Verlag, 175 Fifth Avenue, New York, New York 10010, U.S.A. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Typeset by TC Systems, Shippensburg, Pennsylvania. Printed and bound by R.R. Donnelley & Sons, Harrisonburg, Virginia. 9 8 7 6 5 4 3 2 1 ISBN-13: 978-1-4612-9373-6 e-ISBN-13: 978-1-4612-9373-6 DOl: 10/1007-978-1-4612-9373-6 to our wives Carolyn and Helen Medicine is a science of uncertainty and an art of probability. Sir William Osler Who shall decide, when doctors disagree, And soundest casuists doubt, like you and me? Alexander Pope Preface Decision making is the physician's major activity. Every day, in doctors' offices throughout the world, patients describe their symptoms and com plaints while doctors perform examinations, order tests, and, on the basis of these data, decide what is wrong and what should be done. Although the process may appear routine-even to the physicians in volved-each step in the sequence requires skilled clinical judgment. Physicians must decide: which symptoms are important, whether any laboratory tests should be done, how the various items of clinical data should be combined, and, finally, which of several treatments (including doing nothing) is indicated. Although much of the information used in clinical decision making is objective, the physician's values (a belief that pain relief is more important than potential addiction to pain-killing drugs, for example) and subjectivity are as much a part of the clinical process as the objective findings of laboratory tests. In recent years, both physicians and psychologists have come to realize that patient management decisions are not only subjective but also prob abilistic (although this is not always acknowledged overtly). When doc tors argue that an operation is fairly safe because it has a mortality rate of only 1% , they are at least implicitly admitting that the outcome of their decision is based on probability. Understanding how doctors reach patient management decisions (and the role that subjective values play in clinical judgment) has been the subject of intensive psychological research over the past ten years. The present book contains a critical review of this research; its major focus is on the cognitive strategies doctors use to make everyday clinical judg ments. The book is intended to answer several related questions: Can the thought processes underlying medical judgment be understood? Is V1l1 Preface there anything special about how expert clinicians think that distin guishes them from less experienced doctors? Can medical judgment be improved through training? Can it be automated? We attempt to answer these questions by systematically describing and interpreting psychologi cal research concerned with medical judgment and decision making. Although applied decision making is the major focus of this book, the present volume is not meant to be a "how to do it" guide to decision making. The main goal of the book is to provide insight into the cogni tive operations underlying medical thinking. In other words, this is a book about cognitive psychology. The book has been written with several audiences in mind: as a text book for physicians with an interest in understanding and improving 'medical judgment, medical students, medical educators, and psycholo gists interested in cognitive psychology in general and in medical deci sion making in particular. We have attempted to keep the focus on problems and procedures; theories and mathematical tools are brought into the discussion only as they are needed to answer a clinically relevant question. Although we expect most readers to be familiar with basic psychological concepts and terminology, all new terms and concepts are explained as they arise and the details of the specific studies are given when necessary. Because the book is meant to appeal to a variety of readerships, no specific psychological or medical knowledge is assumed. The book consists of six chapters, The first chapter is introductory. It sets the stage for what follows by reviewing the major questions psychol ogists and others have raised about medical judgment and decision mak ing. The remaining chapters deal with research on several important topics in the psychology of medical decision making: how information is gathered and evaluated, how choices are made, learning to make better decisions, the nature of expertise, and the influence of social forces. While it is always dangerous to try to predict the future, in the final chapter, we make a conservative attempt to extrapolate from current work to future trends, pointing out research areas that seem likely to yield fruitful results. Because of the nature of their work, authors are generally indebted to many people for their support, advice, criticisms, and help. The first author's research has been generously supported by the Australian Re search Grants Scheme for many years. In addition, many people helped us prepare this book. We would like to acknowledge the helpful advice of Arthur Elstein, Jack Dowie, Paul Glasziou, and Dick Eiser. If faults and errors remain in the book, the responsibility is entirely ours-and may the judgment be not too heavy upon us. Steven Schwartz Timothy Griffin Contents Chapter 1 Medical Thinking: An Introduction Research in Medical Decision Making: Definitions, Theories, and Methods 4 Organization of this Book 17 Summary 24 Chapter 2 The Acquisition of Medical Data 26 The Quality of the Data Produced by Diagnostic Procedures 28 The Quality of the Data Recorded by Physician-Observers 35 The Development of Signal Detection Theory 41 Medical Applications of Signal Detection Theory 46 Summary 55 Chapter 3 Evaluating Medical Information 56 Probability Revision and Bounded Rationality 57 Judgment Heuristics and Biases 63 Information Integration 82 Summary 96 Chapter 4 Choosing Actions 97 Steps in Risky Decision Making 98 A Prescriptive Example 99 Structuring the Decision Task 106 Assessing the Probability of Outcomes 115 Utility Measurement 125 Comparing Costs and Benefits 147 Summary 156 x Contents Chapter 5 Learning, Feedback, and Decision Aids 158 Measuring Doctors' Performance 160 Training in Decision Making 166 The Nature of Medical Expertise 176 Learning from Experience 193 Automatic and Algorithmic Decision Making 198 Summary 214 Chapter 6 Interpersonal, Social, and Economic Factors in Medical Decision Making 216 Interpersonal and Social Factors in Patient Care 216 Economic Aspects of Medical Decisions 228 Toward the Future 232 Summary 234 References 236 Author Index 264 Subject Index 272
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