MHPE 494 - Medical Decision Making

Course Syllabus and Notes

Arthur Elstein and Alan Schwartz

Course Faculty

Department of Medical Education

College of Medicine, University of Illinois at Chicago

Arthur Elstein, Professor, Department of Medical Education, College of Medicine, University of Illinois at Chicago, 808 S. Wood (M/C 591), Chicago, IL 60612-7309; Room 986-A; Tel: 312-996-5451; Fax: 312-413-2048; E-mail: aelstein@uic.edu

Alan Schwartz, Assistant Professor, Department of Medical Education, College of Medicine, University of Illinois at Chicago, 808 S. Wood (M/C 591), Chicago, IL 60612-7309; Room 976; Tel: 312-996-2070; Fax: 312-413-2048; E-mail: alansz@uic.edu

The goal of this one-week intensive course is to introduce students to the basics of medical decision making, including interpretation of diagnostic tests, assessment of patient preferences, integration of uncertainties and preferences, cost-effectiveness, clinical scoring rules, and ethical issues in medical decision making.

Course Objectives

1. Determine the statistical properties of diagnostic tests, appropriately select tests, and appropriately revise his/her estimate of the probability of a disease given a test result
2. Recognize the role of patient preferences in decision making, and understand how preferences can be measured and integrated into decisions along with probabilities
3. Read and interpret a decision analysis or cost-effectiveness analysis
4. Explain the basis of a clinical scoring rule and compare it to unaided clinical judgment
5. Discuss the ethical implications of decision analysis

Schedule and assignments:

Reading List

• Sackett, D. L. (1992). A primer on the precision and accuracy of the clinical examination. JAMA, 267(19): 2638-2644.
• Dawson, N. V., & Arkes, H. R. (1987). Systematic errors in medical decision making: Judgment limitations. J. of Gen. Int. Med., 2:183-187.

• Froberg, D. G., & Kane, R. L. (1989). Methodology for measuring health-state preferences -II: Scaling methods. J. Clin. Epi., 42(5): 459-471.
• Hodder, S. C., Edwards, M. J., Brickley, M. R., & Shepherd, J. P. (1997). Multiattribute utility assessment of outcomes of treatment for head and neck cancer. Br. J. Cancer, 75(6): 898-902.

• Rouse, D. J., & Owen, J. (1998). Decision analysis. Clinical Obstetrics and Gynecology, 41(2):282-295. Full text available on OVID.
• O'Meara, J. J., McNutt, R. A., Evans, A. T., Moore, S. W., & Downs, S. M. (1994). A decision analysis of streptokinase plus heparin as compared with heparin alone for deep-vein thrombosis. NEJM, 330(26):1864-1869. Full text available on OVID.
• Sonnenberg, F. A. & Beck, J. R. (1993). Markov Models in Medical Decision Making: A Practical Guide. Med. Dec. Making, 13: 322-338.

• Eddy, D. (1992). Cost-effectiveness analysis: A conversation with my father. JAMA, 267(12):1669-1675.
• Ebell, M. H. (1995). Using decision rules in primary care practice. Primary Care, 22(2): 319-340. Available here for registered students.
• Inouye J, Kristopatis R, Stone E, Pelter M, Sandhu M, Weingarten S. Physicians' changing attitudes toward guidelines. J Gen Intern Med 1998; 13:324-26. Full text available on OVID.

• Dowie, J. (1994). Decision analysis: the ethical approach to medical decision making. In: R. Gillon (Ed.) Principles of Health Care Ethics. Chichester: John Wiley, 412-434.
• Ubel P. A., Dekay, M. L., Baron, J., Asch, D. A. (1996). Cost-effectiveness analysis in a setting of budget constraints: Is it equitable? NEJM, 334: 1174-1177. Full text available on OVID.

Student Assessment:

Group exercises
	Diagnostic tests	5		_____
	Utility assessments	5		_____
	MAUT			5		_____
	Markov models		5		_____
	Case  			5		_____	(25) _____

Presentation/Participation				(50) _____

Letter to Dean   					(25) _____

			Total for 1-credit students:	     _____/100

Final paper (for 2-credit students)			(20) _____

			Total for 2-credit students:         _____/120

Grade:  A (85-100%) B (75-84) C (60-74) E (59 or less)

The Letter to Dean is a 2 page letter that you might send to the Head of your Department, Dean of your College, or similar person, discussing how well your institution supports good clinical decision making, and proposing suggestions to improve clinical decision making.

Students taking the 2-credit version of the course must turn in a paper of no more than 5 pages (double-spaced) reviewing two decision analyses, cost-effectiveness analyses, etc., from their fields, and discussing how these might be useful in informing clinical decision making. The paper is due by October 1, with no exceptions. These students will receive an incomplete for their summer grade, which will be converted to a real grade once the paper is received and graded.

Resources and References

Medicine

John Clarke's Workshop on Surgical Decision Making is an excellent interactive tutorial on the web at http://www.auhs.edu/cgi-bin/tutorial/tutorial.cgi.

The Evidence-Based Medicine Toolbox at the Center for Evidence-Based Medicine at Oxford has a bunch of web-based explanations of diagnostic testing concepts, along with examples from the literature at http://cebm.jr2.ox.ac.uk/docs/toolbox.html.

• Bergus, G. R. & Cantor, S. B. (Eds.) (1995). Primary Care: Medical Decision Making. Philadelphia: Saunders.
• Bogner, M. S. (Ed.) (1994). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum.
• Dowie, J. & Elstein, A. (1991). Professional Judgment: A reader in clinical decision making. Cambridge: Cambridge University Press.
• Eddy, D. M. (1996). Clinical Decision Making: From theory to practice. Sudbury, MA: Jones and Bartlett.
• Kassirer, J. P, & Kopelman, R. I. (1991). Learning Clinical Reasoning. Philadelphia: Williams & Wilkins.
• Llewelyn, H. & Hopkins, A. (1993). Analysing How We Reach Clinical Decisions. London: Royal College of Physicians of London.
• Panzer, R. J., Black, E. R., & Griner, P. F. (Eds.) Diagnostic Strategies for Common Medical Problems. Philadelphia: American College of Physicians.
• Rigelman, R. K. (1995). The Measure of Medicine: Benefits, Harms, and Costs. Cambridge, MA: Blackwell Science.
• Sox, H. C., Blatt, M.A., Higgins, M. C., & Marton, K. I. (1988). Medical Decision Making. Boston: Butterworths.
• Sackett, D. L., Haynes, R. B., & Tugwell, P. (1991). Clinical Epidemiology: A basic science for clinical medicine, 2nd Ed. Boston: Little, Brown.
• Weinstein, M. C. & Fineberg, H. V. (1980). Clinical Decision Analysis. Philadelphia: Saunders.

Psychology

• Arkes, H. R. & Hammond, K. R. (1986). Judgment and Decision Making: An interdisciplinary reader. New York: Cambridge University Press.
• Baron, J. (1994). Thinking and Deciding, 2nd Ed. New York: Cambridge University Press.
• Edwards, W. (1992). Utility Theories: Measurements and applications. Boston: Kluwer.
• Hogarth, R. (1987). Judgment and Choice: The psychology of decision making, 2nd Ed. New York: John Wiley and Sons.
• Johnson-Laird, P.N. & Shafir, E. (1993). Reasoning and Decision Making. Cambridge, MA: Blackwell.
• Kahneman, D., Slovic, P., & Tversky, A. (1988). Judgment Under Uncertainty: Heuristics and biases. New York: Cambridge University Press.
• Payne, J.W., Bettman, J.R., & Johnson, E. J. (1993). The Adaptive Decision Maker. New York: Cambridge University Press.
• Plous, S. (1993). The Psychology of Judgment and Decision Making. New York: McGraw-Hill Inc.
• Poulton, E. C. (1994). Behavioral Decision Theory: A New Approach. New York: Cambridge University Press.
• Yates, J. F. (1990). Judgment and Decision Making. New Jersey: Prentice Hall.

Business and Public Policy

• Bazerman, M. H. (1990). Judgment in Managerial Decision Making, 2nd Ed. New York: John Wiley and Sons.
• Keeney, R. L. and Raiffa, H. (1993). Decisions with Multiple Objectives: Preferences and Value Tradeoffs. New York: Cambridge University Press.
• Kleindorfer, P. R., Kunreuther, H. C., and Schoemaker, P. J. H. (1993). Decision Sciences: An Integrative Perspective. New York: Cambridge University Press.
• Morgan, M. G. and Henrion, M. (1992). Uncertainty: A Guide to Dealing with Uncertainty in Quantitative Risk and Policy Analysis. New York: Cambridge University Press.
• Russo, J. E. and Schoemaker, P. J. H. (1989). Decision Traps: The Ten Barriers to Brilliant Decision-Making and How to Overcome Them. New York: Simon & Schuster.