Mark V. Pezzo

Physicians’ Tacit and Stated Policies for Determining Patient Benefit and Referral to Cardiac Rehabilitation:

Background/Purpose. The benefits of prescribing cardiac rehabilitation (CR) for patients following heart surgery is well documented; however, physicians continue to underuse CR programs, and disparities in the referral of women are common. Previous research into the causes of these problems has relied on self-report methods, which presume that physicians have insight into their referral behavior and can describe it accurately. In contrast, the research presented here used clinical judgment analysis (CJA) to discover the tacit judgment and referral policies of individual physicians. The specific aims were to determine 1) what these policies were, 2) the degree of self-insight that individual physicians had into their own policies, 3) the amount of agreement among physicians, and 4) the extent to which judgments were related to attitudes toward CR. Methods. Thirty-six Canadian physicians made judgments and decisions regarding 32 hypothetical cardiac patients, each described on 5 characteristics (gender, age, type of cardiovascular procedure, presence/absence of musculoskeletal pain, and degree of motivation) and then completed the 19 items of the Attitude towards Cardiac Rehabilitation Referral scale. Results. Consistent with previous studies, there was wide variation among physicians in their tacit and stated judgment policies, and self-insight was modest. On the whole, physicians showed evidence of systematic gender bias as they judged women as less likely than men to benefit from CR. Insight data suggest that 1 in 3 physicians were unaware of their own bias. There was greater agreement among physicians in how they described their judgments (stated policies) than in how they actually made them (tacit policies). Correlations between attitude statements and CJA measures were modest. Conclusions. These findings offer some explanation for the slow progress of efforts to improve CR referrals and for gender disparities in referral rates.

Physician Evaluation after Medical Errors: Does Having a Computer Decision Aid Help or Hurt in Hindsight?

Objective. The authors examined whether physicians’ use of computerized decision aids affects patient satisfaction and/or blame for medical outcomes. Method. Experiment 1: Fiftynine undergraduates read about a doctor who made either a correct or incorrect diagnosis and either used a decision aid or did not. All rated the quality of the doctors decision and the likelihood of recommending the doctor. Those receiving a negative outcome also rated negligence and likelihood of suing. Experiment 2: One hundred sixty-six medical students and 154 undergraduates read negative-outcome scenarios in which a doctor either agreed with the aid, heeded the aid against his own opinion, defied the aid in favor of his own opinion, or did not use a decision aid. Subjects rated doctor fault and competence and the appropriateness of using decision aids in medicine. Medical students made judgments for themselves and for a layperson. Results. Experiment 1: Using a decision aid caused a positive outcome to be rated less positively and a negative outcome to be rated less negatively. Experiment 2: Agreeing with or heeding the aid was associated with reduced fault, whereas defying the aid was associated with roughly the same fault as not using one at all. Medical students were less harsh than undergraduates but accurately predicted undergraduates responses. Conclusion. Agreeing with or heeding a decision aid, but not defying it, may reduce liability after an error. However, using an aid may reduce favorability after a positive outcome.

The Transmitter-Persistence Effect: A Confounded Discovery?

In four studies, Boninger, Brock, Cook, Cruder, and Romer (1990) found that attitude change following exposure to a persuasive message persisted longer if recipients were expecting to have to transmit the message to someone else. The present experiment demonstrated that this effect obtains only if the people preparing to transmit, as was the case in the studies of Boninger et al., are denied the opportunity to do so. It is argued, then, that the findings of Boninger et al., may be attributable to a tendency toward thought perseveration triggered by the failure to complete the transmission task, rather than being a consequence of the preparation to transmit per se.