© 2019 Evgenia ZAITSEVA
2019 — № 2 (18)
Evgenia Aleksandrovna Zaitseva, Sociology MA, is an independent researcher working in Moscow.
Keywords: clinical decision-making, factors of decision-making, physician’s choice, methodology for physician’s choice research
Abstract. The article reviews the studies of clinical decision-making by biomedical physicians. The review covers normative and descriptive concepts of clinical decision-making from the 1970s up to the present time. Major tension points between various theoretical approaches are elicited, and the results of empirical studies in this field are systematized.
Decision-making process is the essence of clinical life – countless times a day the physician must make a choice regarding diagnostics or treatment of a patient. The purpose of this article is to present theoretical conceptualizations and empirical studies of medical choice and to reveal the main lines of tension in the observed field of research.
One of the basic tensions is between normative and descriptive decision theories. The first influential paradigm of decision-making studies was the expected utility hypothesis. Since the ethical imperative of the medical profession is the maximization of patient’s good, and doctors often act in a situation of diagnostic or therapeutic uncertainty, a look at clinical decisions through the prism of the expected utility hypothesis seems justified. This article examines threshold models that suggest predictions of clinical decisions in some simplified situations of choice. Early threshold models considered only clinical information regarding the probabilities of certain outcomes. The physician was conceptualized as an ideal patient’s agent that makes a choice based on a rational calculation of medical gains and losses.
The threshold approach and the expected utility hypothesis were heavily criticized. The main critical impulse came from the side of cognitive psychologists and decision-making researchers who found out that the behavior of a doctor, as well as any other person, often differs from the normative model prescriptions. An attempt to explain this gap spawned new theories – prospect theory developed by Daniel Kahneman and Amos Tversky, regret theory, dual process theory – that directly influenced the study of clinical choice. Authors of these theories tried to examine the nature of systematic irrationalities in human cognition from all possible sides and to incorporate them into a decision-making model. This article contains the main theses of listed theories and selected empirical researches of the clinical choice, most of which was based on vignettes – the method of hypothetical choices proposed in the earlier works of Kahneman and Tversky. We also briefly considered alternative research strategies that haven’t been widely used yet – Brunswick’s lens model and distributed decision-making model.
Empirical researches found, sometimes accidentally, multiple non-clinical factors that affect the provision of medical care and often impose restrictions on the medically ideal medical choice. A doctor and a patient themselves can become a source of non-medical influence since they are individuals with their personalities and preferences, cultural, psychological and cognitive characteristics. There can also be various “external” factors: situational, that is related to components of a specific meeting, as well as systematic, related to the medical institution or health system as a whole.
The second part of the article thus highlights and systemizes studies of non-clinical factors of influence a lot of which also used vignettes: textual, visual, or mixed. Qualitative research methods, such as interviews and focus groups with physicians, and quantitative analysis of national sociological surveys or statistics of selected health facilities. This article attempts to present the main conclusions from the above researches, elicit conflict lines of different influence factors and describe revealed strategies of their resolution in medical practice.
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