Felicia L Trachtenberg1, David M Pober2, Lisa C Welch3, John B McKinlay4. 1. Principal Research Scientist and Biostatistician, New England Research Institutes, Watertown, MA, USA. 2. Mary K. Iacocca Visiting Interdisciplinary Faculty Fellow, Vascular Cell Biology, Joslin Diabetes Center & Visiting Assistant Professor of Medicine, Harvard Medical School, Boston, MA, USA. 3. Director, Clinical and Translational Science Institute, Boston, MA, USA. 4. Senior Vice President; Co-director, Health Services and Disparities Research, New England Research Institutes, Watertown, MA, USA.
Abstract
RATIONALE AIMS AND OBJECTIVES: Variation in physician decisions may reflect personal styles of decision-making, as opposed to singular clinical actions and these styles may be applied differently depending on patient complexity. The objective of this study is to examine clusters of physician decision-making for type 2 diabetes, overall and in the presence of a mental health co-morbidity. METHOD: This randomized balanced factorial experiment presented video vignettes of a "patient" with diagnosed, but uncontrolled type 2 diabetes. "Patients" were systematically varied by age, sex, race and co-morbidity (depression, schizophrenia with normal or bizarre affect, eczema as control). Two hundred and fifty-six primary care physicians, balanced by gender and experience level, completed a structured interview about clinical management. RESULTS: Cluster analysis identified 3 styles of diabetes management. "Minimalists" (n=84) performed fewer exams or tests compared to "middle of the road" physicians (n=84). "Interventionists" (n=88) suggested more medications and referrals. A second cluster analysis, without control for co-morbidities, identified an additional cluster of "information seekers" (n=15) who requested more additional information and referrals. Physicians ranking schizophrenia higher than diabetes on their problem list were more likely "minimalists" and none were "interventionists" or "information seekers". CONCLUSIONS: Variations in clinical management encompass multiple clinical actions and physicians subtly shift these decision-making styles depending on patient co-morbidities. Physicians' practice styles may help explain persistent differences in patient care. Training and continuing education efforts to encourage physicians to implement evidence-based clinical practice should account for general styles of decision-making and for how physicians process complicating comorbidities.
RATIONALE AIMS AND OBJECTIVES: Variation in physician decisions may reflect personal styles of decision-making, as opposed to singular clinical actions and these styles may be applied differently depending on patient complexity. The objective of this study is to examine clusters of physician decision-making for type 2 diabetes, overall and in the presence of a mental health co-morbidity. METHOD: This randomized balanced factorial experiment presented video vignettes of a "patient" with diagnosed, but uncontrolled type 2 diabetes. "Patients" were systematically varied by age, sex, race and co-morbidity (depression, schizophrenia with normal or bizarre affect, eczema as control). Two hundred and fifty-six primary care physicians, balanced by gender and experience level, completed a structured interview about clinical management. RESULTS: Cluster analysis identified 3 styles of diabetes management. "Minimalists" (n=84) performed fewer exams or tests compared to "middle of the road" physicians (n=84). "Interventionists" (n=88) suggested more medications and referrals. A second cluster analysis, without control for co-morbidities, identified an additional cluster of "information seekers" (n=15) who requested more additional information and referrals. Physicians ranking schizophrenia higher than diabetes on their problem list were more likely "minimalists" and none were "interventionists" or "information seekers". CONCLUSIONS: Variations in clinical management encompass multiple clinical actions and physicians subtly shift these decision-making styles depending on patient co-morbidities. Physicians' practice styles may help explain persistent differences in patient care. Training and continuing education efforts to encourage physicians to implement evidence-based clinical practice should account for general styles of decision-making and for how physicians process complicating comorbidities.
Authors: T R Konrad; E S Williams; M Linzer; J McMurray; D E Pathman; M Gerrity; M D Schwartz; W E Scheckler; J Van Kirk; E Rhodes; J Douglas Journal: Med Care Date: 1999-11 Impact factor: 2.983
Authors: E S Williams; T R Konrad; M Linzer; J McMurray; D E Pathman; M Gerrity; M D Schwartz; W E Scheckler; J Van Kirk; E Rhodes; J Douglas Journal: Med Care Date: 1999-11 Impact factor: 2.983
Authors: Johannes Siegrist; Rebecca Shackelton; Carol Link; Lisa Marceau; Olaf von dem Knesebeck; John McKinlay Journal: Soc Sci Med Date: 2010-04-28 Impact factor: 4.634