Medical Decisions in Perspective: Applied Research in Cognitive Psychology

MEDICAL DECISIONS IN PERSPECTIVE: APPUED RESEARCH IN COGNITIVE PSYCHOLOGY ARTHUR S. ELSTEIN* MARGARET M. HOLMES* MICHAEL M. RAVITCH* DAVID R. ROVNERA GERALD B. HOLZMAN,% and MARILYN L. ROTHERT* Medical decisions claim the attention ofthose outside the scientific and medical communities as well as oftheir 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 aboutthe relationship ofthese 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 Work supported in part by die National Library of Medicine grant LM-03396 and Biomedical Research Support grant SO7RR05656-13 to Michigan State University. "Office of Medical Education Research and Development, Michigan State University, East Lansing, Michigan 48824. tDepartment of Medicine, Michigan State University, East Lansing, Michigan 48824. ^Department of Obstetrics and Gynecology and Reproductive Biology, Michigan State University, East Lansing, Michigan 48824.© 1983 by The University of Chicago. All rights reserved. 0031-5982/83/2603-0343$01.00 486 J Arthur S. Ebtein, Margaret Af. Holmes, et al. * Medical Decisions in Perspective setting that questions of generalizability arise once again. This paper wiU discuss the advantages and limitations of experimental versus naturalistic design as well as the research questions that are characteristic ofthree major psychological theories. Cognitive Theories in Clinical Research The major cognitive theories employed in research on clinical reasoning are information-processing psychology, social judgment theory, and decision theory. The information-processing view of clinical reasoning aims to characterize the reasoning processes by recording and analyzing the steps and thoughts of clinicians as they attempt to solve clinical problems. The goal is to describe the ongoing processes in terms of basic psychological elements and principles. Socialjudgment theory, on the other hand, deals statistically with correlations between original cues and final outcome. The thought processes are regarded as a black box, and linear correlations are used to depict the degree to which each cue enters into the final judgment. Decision analysis approaches the solution of clinical problems from the standpoint of risky choice under uncertainty. The decision problem is carefully structured and bounded. The approach requires one to be explicit and quantitative. It assumes that, given a choice, the physician will act rationally to maximize the best outcome for the most patients. Each approach provides an analytic perspective which suggests questions to be asked and the kind of data best suited to answer these questions . In general, both information processing and social judgment theory rely on descriptive data. These studies aim to identify the organization of factual knowledge and inference rules required for effective clinical judgment [5, 6] or to analyze the determinants of decisions in situations where competent decision makers differ in their recommendations for the diagnostic workup or management of a particular condition [7, 8]. Studies in the information-processing tradition have analyzed expert performance on problems where consensus can be obtained in order to specify the points to be emphasized in instructional materials and the knowledge base or practical skills students should acquire [9, 10]. These studies assume that better understanding of the thought processes...