Dear Ben,
> As we
> argued elsewhere (and on this discussion group as well) , EBM therapeutic
> (and diagnostic) summary measures cannot alone be used in medical decision
> making (MDM), but require integration within a normative framework of
> decision analysis (DA).
I agree that the numbers themselves don't lead to decisions - they
have to be judged by the clinician and the patient in an individual
context. However, I have problems when you say that they "require
integration" with decision analysis. One problem is that I feel
uncomfortable with the theory on which it is based ie I don't accept
rational choice theory as the be all and end all. I therefore can't
accept decision analysis as gold standard JUST because it's explicit,
logical etc etc.
I also don't make decisions in either my everyday or professional
life by creating a decision tree, calculating probabilities for each
branch and then assigning utilities to each outcome either on a 0-100
scale or by standard gamble (I've never tried administering them but
when I try to do them myself, I have enormous difficulty getting my
head round them). Changing the way I make or negotiate clinical
decisions would require considerable effort and there is likely to be
an associated time cost.
Before doing this, I would want some kind of empirical evidence
that DA is better than me trying to tell the patient the gist of the
probabilities and trying to guage what their values are by 'normal'
consultation methods (talk, leaflets, time to think, agreeing to
defer the subject for six months, agreeing that they try alternatives
first etc). This comes back to my original question as to how you
might judge which decision making method is 'better'. It sounds like
either there isn't a simple answer to this, or that there isn't
research evidence directly addressing the issue.
Bruce
Bruce Guthrie,
MRC Training Fellow in Health Services Research,
Department of General Practice,
University of Edinburgh,
20 West Richmond Street,
Edinburgh EH8 9DX
Tel 0131 650 9237
e-mail [log in to unmask]
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