Gerald B. Holzman

Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model

Decisions regarding estrogen replacement therapy were obtained from 50 physicians for 12 cases representing menopausal women with systematically varying levels of cancer risk, fracture risk, and symptom severity. Their decisions were compared with a decision analytic model for which each physician provided needed quantities--subjective probabilities, utilities of various outcomes, and weightings of the importance of the outcome categories. The majority of observed decisions were not to treat. By contrast, the decision analysis based on physician-provided estimates indicated that the optimal strategy was either to treat or a toss-up. Sensitivity analysis showed that these conclusions would hold over all possible utilities, over all plausible probabilities of cancer, and so long as symptom relief and fracture prevention were also considered as treatment objectives. The increased probability of early detection of cancer by regular follow-up was systematically incorporated into the decision analysis but apparently neglected in unaided clinical judgment, which follows the principle of minimizing the most important risk, regardless of its probability.

Practice trends in outpatient obstetrics and gynecology: findings of the Collaborative Ambulatory Research Network, 1995--2000.

Historically, obstetrics and gynecology has been a medical/surgical specialty focusing on women’s health and reproductive concerns during the childbearing years. Newer responsibilities—for example, in primary care, gerontology, and genetics—require Ob-Gyns to draw upon a base of medical knowledge that traditionally was not considered germane to their practices. Ob-Gyns are increasingly providing more primary care services to their patients; consequently, the field has expanded considerably. The Collaborative Ambulatory Research Network (CARN) was created in 1990 as a vehicle for investigating issues pertinent to women’s health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 1995 to 2000, covering a range of topics related to women’s health across the life cycle, including, but not limited to perinatal care. Topics include nutrition, infectious disease, hormone replacement therapy, psychosocial issues, and genetic testing in obstetric and gynecologic practice. Each study produced a picture of current practice patterns and knowledge of the physicians surveyed. Findings on knowledge, attitudes, and practices varied widely. Overall, Ob-Gyns were knowledgeable and consistent in more traditional areas of practice. Conversely, inconsistencies were observed in newer areas. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to define what the Collaborative Ambulatory Research Network (CARN) involves, describe how CARN obtains its data, and summarize some of the findings of CARN from the years 1995 to 2000.

Medical Decisions in Perspective: Applied Research in Cognitive Psychology

Medical decisions claim the attention ofthose outside the scientific and medical communities as well as of their members. The general pubUc has an abiding concern in the personal and economic consequences ofmedical decisions. Researchers are engaged in analyzing medical decisions and determining the information necessary for action under uncertainty and the impact of high technology on decision making. For these reasons, clinical decision making has become a major area for psychological investigation. The rapid growth of research in clinical decision making has led to interest in improved methods and frameworks for data analysis. The purpose of this paper is to describe and evaluate the primary theories and methods employed in contemporary psychological research on clinical decision making and to compare these approaches with two naturalistic methods of research in this field, chart audit and direct observation. The findings from this body of research wUl not be summarized here since several recent reviews are readUy avaUable [1-4]. Psychological research on medical decision making has generally been experimental or controlled research. Subjects respond to a carefully designed or selected medical problem, either a written or simulated case in an experimental setting. This design results in highly reproducible, reliable information but is subject to question about the relationship of these results to the real world. More naturaUstic studies, relying on patient charts or observation in clinical settings, are clearly related to die real world but may produce results that are so much a function of time and

Attitudes of Obstetricians and Gynecologists toward Hormone Replacement Therapy

Objective. To determine the attitudes of obstetricians and gynecologists toward hor mone replacement therapy (HRT), and the beliefs and intuitions that affected those attitudes. Design. A questionnaire was sent to 1,000 gynecologists in the United States; 328 replies were received. The questionnaire asked about effects of HRT, practices concerning HRT, and decisions in hypothetical scenarios. Results. The re spondents strongly favored HRT, and they were well informed about its effects on osteoporosis, cardiovascular disease, and breast cancer. They were aware of conflict ing findings concerning breast cancer. The strength of their recommendation of HRT was sensitive to patient differences in risk factors. The respondents also showed four biases hypothesized to cause resistance to HRT: omission bias (more concern about harmful acts than harmful omissions); proportionality bias (attention to relative risk rather than risk differences); naturalness bias (preference for the natural); and ambi guity (avoiding options with missing information). Proportion bias, naturalness bias, and (weakly) omission bias were related to less favorable attitudes toward HRT. Con clusion. Although specialists are highly favorable toward HRT in general, some neg ativity toward HRT may result from decision biases. Key words: hormone replacement; estrogen; decision making; biases. (Med Decis Making 1998;18:406-411)

Hormonal Replacement Therapy Analysis of Clinical Strategies Used by Residents

The authors investigated strategies employed by resident physicians to decide whether to prescribe hormonal replacement therapy (HRT) for menopausal women, a matter of contin uing clinical controversy. Verbal protocols were obtained from 21 residents in three specialties as they responded to 12 brief case descriptions. The cases incorporated three levels of cancer risk and two levels of osteoporosis risk in a 3 x 2 factorial design with two replications in each cell. Substantial variation in willingness to prescribe HRT was observed. By clustering subjects with relatively similar approaches to the problem, three treatment strategies were formulated that accounted for the decisions of 20 subjects. Each strategy is a simplified representation of the conflicting considerations in this clinical dilemma that facilitates rapid decision making. The differences between these representations and formal decision-analytic models help to explain why observed clinical decisions were inconsistent with expected utility maximization. Key words: hormonal replacement therapy; decision making; subjective prob ability estimates; regret; intuitive clinical reasoning. (Med Decis Making 1992;12:265-273)

Factors affecting laboratory utilization in clinical practice.

Recent work in decision analysis and cost-effectiveness suggests that there exists an optimum workup for a particular presenting problem, based on the prior likelihood of a specific diagnosis and the cost of missing a specific diagnosis. We have studied the relation between a specified optimum set of laboratory studies in patients presenting with the complaint of hirsutism and the laboratory studies ordered by a single practicing physician over a period of five years. Although a laboratory testing protocol had been developed by this physician, implying an optimal workup, signifi-

The absorption rate of blood from the peritoneal cavity by the fetus.

in the group of low socioeconomic patients were significantly more asphyxiated than were the infants of the higher class patients. The standard error of the difference between the means of maternal base excess is 1.08, and as the actual difference between the means was only 1.4, the latter was not significant. It could well be argued that the number of cases presented is far too small to afford definitive data. However, a striking variation, apparently related to the factor of poverty alone, in the status of the newborn has been demonstrated. Furthermore, the difference in the acid-base status between the two groups of mothers at the time of delivery was not significant. Of greater moment, the present report demonstrates the suggested method by which the importance of individual variations from obstetric normality may be gauged in respect to their influence upon the well-being of the child, and similarly, holds promise of its capacity for determining the efficiency of various therapeutic measures. The results of a pilot study of the influence of poor socio-economic status upon the condition of the newborn are presented. With the use of the concept of deriving baseline data from clinically acceptable ideal cases, it has been shown that a significant increase in the degree of neonatal asphyxia is associated with the factor of poor socioeconomic status, when the latter is present as a sole variant. The difference in the extent of neonatal asphyxia is not associated with a comparable difference in the acid-base status of the mothers. The absorption rate of blood from the peritoneal cavity by the fetus

Obstetrician-gynecologists' views on the health risks of obesity

OBJECTIVE To assess the knowledge and opinions of obstetrician-gynecologists concerning the health risks of obesity and the importance of weight management of patients to clinical practice. STUDY DESIGN A questionnaire survey covering physician and patient demography, disease risk related to obesity, relevance of weight management to patients health, and self-assessments of medical education and training was sent to the 418 American College of Obstetricians and Gynecologists (ACOG) fellows who constitute the Collaborative Ambulatory Research Network and to 700 ACOG fellows selected at random. RESULTS Five hundred twenty-five surveys were returned (47.0% response rate). Membership in the network was not a significant factor regarding responses; therefore, the data were pooled. Respondents estimated that 20.6 +/- 0.5% of their patients were obese and that a further 35.9 +/- 0.8% were overweight. The respondents were knowledgeable concerning health risks associated with obesity, and a majority considered obesity to be a major health concern that should be treated. Weight management was considered an important or very important part of practice by 81.5% of respondents. Almost half the respondents (45.5%) thought that the importance of weight management would increase. More than one of three responding physicians (36.4%) had prescribed weight loss medications in the previous year. Most responding physicians did not consider medical school or residency to be sources of information on these issues. CONCLUSION Obstetrician-gynecologists think that managing the weight of their patients is part of their clinical responsibilities but do not consider their training in medical school and residency on these topics to be adequate.