Portal de Periódicos da CAPES

Medical Decision Making

2002; Springer Nature (Netherlands); Linguagem: Inglês

10.1007/978-94-010-0462-6_9

2197-196X

Arthur S. Elstein, Alan Schwartz, Mathieu Nendaz,

Meta-analysis and systematic reviews

The expanding array of options for diagnosis and treatment have made choice a central issue in medical practice. Choices involve making decisions and many options are quite expensive. Practice variation has also been a troubling phenomenon and one approach to unraveling this puzzle has been to study why physicians make different decisions for what is ostensibly the same problem. Therefore decision making has become a central theme in medical education and clinical practice. Research into medical decision making may be divided into two distinct but related components normative/prescriptive on one side descriptive on the other. The normative component addresses how decisions should be made. It is concerned with a standard of idealized rationality. For modern decision theory, this standard is maximization of expected value, the strategy that maximizes the chances of achieving one's goals. Unfortunately, people do not always behave as they should, so normative and descriptive theories do not match entirely. In this respect, the field of clinical decision making resembles medical ethics: both aim to develop normative principles to guide behavior, but we are aware that people do not always behave in accordance with these principles. Descriptive research aims to answer the question, "How do physicians and patients make medical decisions?" Psychological principles are employed to explain the processes underlying observed decisions. The gaps between how decisions ought to be made and decision behavior are violations of normative principles and, consequently, errors (at least from the standpoint of these principles). In an attempt to close this gap, a variety of prescriptive decision supports have been developed, advising or suggesting what to do in specific clinical situations. This chapter first reviews the key concepts and principles that decision theory and decision analysis propose for structuring a problem and making a decision. We discuss Bayes' theorem a formal rule for updating opinion with imperfect information,and summarize the steps needed to structure a decision to insure that the action recommended maximizes expected value.Part 2 reviews behavioral decision theroy,the body of psychological principles that explain why clinicians and patiens do not always behave in accordance with normative principles.It discusses selected biases in probability estimation and valuing outcomes.Part 3 considers efforts to improve clinical decision making across the continuum of medical education.Theseinclude guidelines,algorrithms,and computer-based decision support.The review focuses especially on factors affecting the dissemination and acceptance of guidelines and otfer decision supports.