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I am excited to introduce you to this first edition of the SMDM News all-online format! Besides the pretty new design of our email cover page, you will see that we have arranged the newsletter into three sections:

1. In “Society Updates,” you will hear from people such as our esteemed President Kathy McDonald, committee representatives, and others, and you can find out about important deadlines or other highlighted news.
2. In “Commentary,” you can read fellow members’ stories, opinions, new methodological explorations, or other thought-provoking pieces.
3. In “Events and Opportunities” you can find out about job postings, volunteer opportunities, detailed meeting information, etc.

All content can be accessed right here with just a few clicks or scrolls of your mouse, taking you to either the newsletter-specific items (e.g., commentary pieces or the President’s letter) right here in this email, or to SMDM-general items (e.g., job postings or call for abstracts) on the SMDM website. And you can still always access older versions from the on-line archives.

We hope you enjoy both the new format as well as this issue’s contents. And as always, if you have feedback and/or want to get involved with the newsletter, please feel free to contact me (tbentley@pharllc.com) – I love hearing from fellow members!

Enjoy,

Tanya G. K. Bentley, PhD
SMDM Newsletter Editor-in-Chief

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Three things converged this past week (for me) that relate to SMDM directly or indirectly, and that fit into my attempt to alliterate in triplicate once again – college, careers and competition.
I had been planning to write about the new SMDM 2010-2015 Strategic Plan, but it is self-explanatory (available at http://smdm.org/draft_goals.shtml), and is really set in a bigger picture… which is what these three events reminded me of – our SMDM bigger picture, essentially our raison d’ệtre. So, even though this presidential column may seem like a digression, I hope you will engage in mulling over some of the questions that the recent events elicited for me, and for us. Feel free to email me (kathy.mcdonald@stanford.edu) with any of your thoughts in response.

College
First, I took my high school daughter on a trip to visit colleges in the Boston area, where we appreciated generous hosting by an SMDM friend and colleague (John Wong, last year’s Saenger Awardee for service to the Society). SMDM is a professional society that catalyzes life long friendships, in the midst of developing meaningful work and service collaborations. During the trip, it struck me that our society mirrors university life. My 4th child will leave for college in 2011, and if the admissions’ directors at the various universities we visited are correct, she will learn as much from her classmates as from her professors. They also spoke about teaching students to be global citizens prepared to serve the needs of the world. Similarly, SMDM has classroom opportunities in the form of short courses at annual meetings as well as peer exchanges through sharing research findings at the annual meeting and in our journal. We want to advance the science of decision making, and to have that advancement serve the needs of medical decision-makers. These are the questions I thus my fellow SMDM members:

• How can SMDM be more like a virtual college, supporting its students (e.g., members) to learn what they need from their SMDM affiliation?
• What should SMDM, as an organization, do to foster more educational interactions among members?
• How can our professional society help each of us as individuals serve those making medical decisions (e.g., patients, clinicians, policy-makers)?

Careers
The second event directly related to SMDM. I was interviewed by a Science magazine news correspondent working on an article about comparative effectiveness research (CER) as a career option. The journalist wanted to know what the difference was between clinical research and comparative effectiveness research, and what educational opportunities existed for PhD and MD students interested in learning to develop skills in CER. She wondered if there would be jobs outside of academia for these students.  I found her subject intriguing and it raises further questions for SMDM members:

• Isn’t the issue larger than comparative effectiveness research alone and more about the motivation for CER – the actual decisions that patients face?
• How do we prepare for a shifting research paradigm that focuses more on real medical decision-making and real choices? (I think we are the society best positioned to prepare future contributors!)
• What graduate level curriculum development is needed, and how can SMDM help?
• What is the right path for students?
• How should we think ahead to educational programs that support medicine of the future? What will that future look like?
• How will new developments in medicine change what SMDM might do to help advance the field of decision sciences in ways that support the decisional challenges we might anticipate? 

Competition on the World Stage
Finally, I watched the Winter Olympics. You probably did too. Snowboarding, speed skating, short track, figure skating, bobsledding, curling, ice hockey, biathlon, ski jump, alpine skiing, freestyle skiing, and cross country skiing. Athletic excellence everywhere, from all corners of the world, and hosted in Canada. Hence I ask you:

• Will our own Canadian event, the annual meeting later this year in Toronto, gain as much international exposure?
• Is our program committee, led by Ahmed Bayoumi and Murray Krahn, working hard to create a memorable experience? (Yes!)
• Will our athletes (presenters) perform to their utmost abilities, displaying new tricks and excellence beyond most mortals’ imaginations?
• Will we have a similar diversity of expertise, all showing up on snow and ice (posters and podium)?
• What sponsorship support will our games (annual meeting) garner?
• Where will we be in four years? (I can partially answer this question – Miami, Florida in 2014 for the North America based meeting, but the European meeting, and perhaps others, have yet to be scheduled.)
• How can we make sure that the torch of our traditions and the innovations of those with initiative within SMDM simultaneously co-exist and be supported?

On this last question, my digression ends. My hope is that the SMDM 2010-2015 Strategic Plan does help us maintain what’s working for SMDM, while providing general direction about where new ideas are needed to make SMDM ever more relevant to the needs of medical decision makers around the globe. So please do read through the plan, and think about ways you can help us reach our goals, together!

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One of SMDM's key strengths is its diversity of membership, which spans across disciplines as well as health care sectors.  Diversity within SMDM is not an accident – it is a key component in the Society's vision, mission, and goals.  A few years back, SMDM created an "Institutional Membership " to encourage more engagement from researchers working in private industry.  This program has been enormously successful, thanks in large part to Brian Rittenhouse from the Membership Committee. SMDM now has 12 Institutional Member companies, receiving as part of their membership other benefits such as individual SMDM memberships, scientific meeting registrations, and job postings.

In early March, the SMDM Board approved an exciting new (yet to be named) Institutional Membership category that will include one-day, on-site trainings in addition to the existing benefits. The genesis of this category came from institutional members’ feedback suggesting that they could benefit from bringing "back home" the types of trainings found in SMDM Short Courses. On-site training is not entirely new for the Society – e.g., SMDM members recently provided training for staff at the Food and Drug Administration – and it aligns well with the Society's vision and mission to “…improve health outcomes through the advancement of proactive systematic approaches to clinical decision making and policy-formation in health care by providing a scholarly forum that connects and educates researchers, providers, policy-makers, and the public.” It also provides training to clinicians and researchers who may not attend SMDM scientific meetings, helping to increase the degree and quality of MDM expertise in the field and possibly to encourage greater attendance at SMDM annual meetings.
Stay tuned for more details that will be available soon on the SMDM website !

Are you looking for ways to:

• Get more involved in SMDM?
• Interact with other SMDM members?
• Enhance your experience in the society (and improve your C.V.!)?

Consider volunteering! SMDM’s volunteer coordinator, Scott LaJoie, PhD (University of Louisville; lajoie@louisville.edu), has opportunities and openings with SMDM special interest groups, board groups, and the mentoring program. If you are already involved and want to recruit others, you can contact Scott and he will cross-reference his list of interested volunteers with your needs. Note that some positions, especially those related to the SMDM Board, require election or appointment; but keep in mind that involvement in interest groups or non-board activities can increase your chances for advancement in the Society!   

 


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SMDM members are doing many great things in the medical decision making world. What follows is just a sampling of some of your great contributions; and if you have something to share or contribute, please let me know for our next newsletter! (tbentley@ucla.edu)

• Kathy McDonald, Anirban Basu, Peter Neumann, and Milt Weinstein are quoted in this article in CTSciNet from the journal Science about the increasing opportunities and jobs in comparative effectiveness research.

• Mike Drummond, Peter Neumann, David Meltzer, Wilhelmine Miller, Robert Kaplan, Milton Weinstein, John Wong, Scott Grosse, William Lawrence, and Uwe Siebert:

On February 23-24, 2010, the NIH Office of Dietary Supplements with the support of NCCAM, NCI and NINR sponsored a workshop entitled "Economic Analysis of Nutrition Interventions: Methods, Research and Policy" in which SMDM members participated prominently and extensively. At the 2008 SMDM meeting, Mike Drummond said "From across the pond, if cost is the problem, how can cost not be part of the solution." America is facing a health crisis. Nationally, 2008 healthcare expenditures were estimated to be 17% of GDP, and these projected expenditures were largely associated with chronic disease. Medicare beneficiaries spent a median of 16% of their incomes on healthcare, and if current trends persist, a family earning $60,000 "gross wage base" will be spending more than 41% of wages on healthcare in 10 years time. Despite the rapid escalation of healthcare costs, research into healthcare economic solutions has not taken center stage. Nutrition is a foundation of preventive medicine in our healthcare system, and it is postulated that better health outcomes can be achieved for dollars spent by ensuring proper nutrition of the population. Health economic issues in the U.S. healthcare delivery have gained increased prominence with President Obama's expressed desire to "raise health care's quality and lower its costs." The National Institutes of Health Clinical and Translational Science Award Program has also recognized the importance of "enhancing the adoption of best practices in the community," including assessment of the costs and effectiveness of prevention and treatment strategies. The potential benefits of health economic analysis applied to health policy include: 1) identifying important factors affecting resource allocation in the setting of increasingly complex, uncertainty-laden medical detection and treatment advances; 2) specifying a basis for allocating resources among diseases and in prevention versus detection, versus treatment; 3) reminding decision-makers about the reality of limited resources; and 4) offering a rational approach to decision-making when resources are limited.

In view of the current interest in health economics and the potential societal benefit of incorporating health economics as a part of translational science, this workshop brought together U.S. and international academic and Federal and government researchers, policymakers and regulators to address the following key areas and questions specifically as applied to nutrition interventions: State of the Science: What are the health economic methods currently used to judge burden of illness, interventions or healthcare policies, and what new research methodologies are available (or are needed, i.e. what are critical knowledge or methodological gaps or barriers?) Research Applications: What are the current and planned evidence-based health economic research activities in nutrition at the Federal agencies, centers and institutes? Regulatory and Policy Maker Perspectives: Once these research goals have been met, how can they assist regulatory and policy makers with nutrition policy decision-making? The workshop had the following specific objectives: 1) Improve the methodological conduct of health economic research in nutrition; 2) Identify areas of congruence between health economic research aims and health policy and regulatory needs; and 3) Establish a health economic research agenda to foster the use of health economics in clinical and translational health science, ultimately to inform policy decision-making. Each objective constituted one-half day session focusing on methodology, research and policy. Research included that reported and done at the NIH, ODS, CDC, AHRQ and USDA. The clinical practice, regulartory and policy perspectives included the Government Accountability Office (GAO), Assistant Secretary for Planning and Evaluation (ASPE) of the Department of Health and Human Services, GRADE, NICE, German Agencies for Health Technology Assessment, Canadian Agencies for Drug and Health Technology Assessment, FDA and CMS. Details of the meeting are available at http://dietary-supplements.info.nih.gov/News/NutritionInterventionsWorkshop.aspx. SMDM speakers included Peter Neumann, Tufts Medical Center, David Meltzer, University of Chicago, Wilhelmine Miller, George Washington University, Robert Kaplan, University of California, Los Angeles, Milton Weinstein, Harvard School of Public Health, John Wong, Tufts Medical Center, Scott Grosse, Centers for Disease Control and Prevention, William Lawrence, Agency for Healthcare Research and Quality, and Uwe Siebert, UMIT - University for Health Sciences and Harvard School of Public Health.  This workshop showed how cost can and will be part of the conversation among methodologists, researchers, and policy makers.

• Jessie Juusola of Stanford University won a complimentary general session registration for the 2010 Annual Meeting.  This incentive was offered to encourage attendees from the 2009 Annual Meeting to complete the evaulation form.

• Tanya G.K. Bentley has moved from UCLA to a new position at a small, LA-based health policy consulting firm – Partnership for Health Analytic Research, LLC (PHAR, LLC) – where she will be helping to develop and implement a new decision-analytic research focus for the company. In this new capacity, she will continue and expand upon many of her prior research collaborations, especially those with fellow SMDM members, and maintain her RAND adjunct status. She also continues working part-time at UCLA throughout the spring to carry out her responsibilities analyzing health mandate bills for the CA state legislature.

• Gijs Hubben (Health Economist and Founder, BaseCase ) has just published a web-based decision tool on malaria treatment for developing nations, with the London School of Hygiene and Tropical Medicine. The tool can be used by decision makers in regions with malaria to determine if home treatment with antimalarials is cost-effective for their setting, or if it should be treated in health facilities. The base-line data comes from Uganda, and the tool uses a cost-effectiveness Markov model built in Excel to perform calculations for web users.

This tool is an example of how to make decision models accessible for a broader audience in the developing world, and can be found at: https://interactive.basecase.com/anon.py?HMM_Dashboard. Gijs focused his PhD research on finding ways to turn healthcare models into practical decision making tools for a broader audience.

• Tayla Miron-Shatz, PhD has written in Psychology Today about a recently published book (“The Pain Detective” by Dr. Hillel Finestone, MD) that highlights the mind-body connection. Her article is entitled “Boyfriends, heartaches, backaches? When your patients’ back hurts, ask about her love life” and can be found at: http://www.psychologytoday.com/blog/baffled-numbers/201002/boyfriends-heartaches-backaches.

• Benjamin Djulbegovic, MD, PhD wants to hear from you on the question he posed in the journal Medical Decision Making in 2009 about a fundamental issue in medical decision-making with important implications for health care reform: “Will Insistence on Practicing Medicine According to Expected Utility Theory Lead to an Increase in Diagnostic Testing?” He is interested in hearing comments from other SMDM members on this very important issue; please email comments to Benjamin and we will publish the commentary in the next issue of the newsletter.

• Jim Gudgeon recently coauthored a chapter in the book “Human Genome Epidemiology (2nd ed.): Building the evidence for using genetic information to improve health and prevent disease,” edited by Muin J. Khoury, Sara R. Bedrosian, Marta Gwinn, Julian P.T. Higgins, John P.A. Ioannidis, and Julian Little (2010). His chapter is called “Rapid Evaluation of genetic tests in the face of incomplete information” and can be found at: http://www.cdc.gov/genomics/resources/books/2010_HuGE/index.htm.

• Jerry Kassirer, one of the founding members of SMDM and one of the true 'fathers of the discipline and field' is one of 10 people from throughout the world nominated for the "BMJ Lifetime Achievement Award." Find out more on the British Medical Journal website.

• Ewout Steyerberg, Andrew Vickers, and Michael Kattan recently published a paper in Epidemiology (Jan 2010) covering the issue of performance assessment of clinical prediction models. The authors discuss several approaches and conclude
  that decision-analytic measures need to be used more often in assessing
  the quality of a prediction model.
  
• Valerie Reyna had a recent publication in Psychological Bulletin (November 2009) about numeracy in medical decision-making:

Americans are bombarded with information about their personal health care, from ads for medications to articles on the Internet and data from their doctors, notes Valerie Reyna, professor at Cornell University. Yet, she says, studies indicate that more than 93 million people across the United States do not have the numerical skills necessary to make well-informed decisions about their medical care. Reyna’s article reviews the research on so called "health numeracy," the ability to understand and use numerical information related to health behaviors and medical outcomes. This article can be accessed at: http://www.human.cornell.edu/che/HD/reyna/publications.cfm

• Junhua Yu has a forthcoming article in CNS Drugs entitled, "Cost-Effectiveness of Pharmacotherapy for the Prevention of Migraine: an Application of Markov Model."

Junhua expresses gratitude for Diana I. Brixner's work with her on this, and for Mark Roberts' and Ken Smith's cost effectiveness modeling seminar where she was able to present her ideas and receive guidance that was critical to the model development. Junhua celebrates this work as an example of a very successful collaboration between SMDM members in promoting and advancing cost-effectiveness modeling approach in outcomes research.

• Kevin Frick was recently promoted to Professor at the Johns Hopkins Bloomberg School of Public Health, which also just launched a one-year, interdepartmental MHS in health economics. They are currently accepting applications for Fall 2010, and interested applicants should contact John Bridges (jbridges@jhsph.edu) or Louis Niessen (lniessen@jhsph.edu) for more information.

• Ambuj Kumar recently published a manuscript in the Journal of the National Cancer Institute (January 2009) comparing double versus single transplant in multiple myeloma.
  The article generated a great deal of controversy, as evidenced from the multiple letters published in response (July 2009), and the study results were also covered by the NCI, Reuters and Medscape. The work is now included in the Transfusion Evidence Library which can be freely accessed at: www.transfusionguidelines.org.uk For more information about the controversy itself, please refer to http://www.cancer.gov/clinicaltrials/results/tandem-transplant0209.

Pareto Level
(Contributions total $1,000 or more)
Joseph King (‘06, ‘07, ’08. ‘09)
Frank Sonnenberg (’06, “09)
Sankey Williams (‘08)
John Wong (‘06, ‘07, ’08, ‘09)

Edwards Level
(Contributions total $750 - $999)
Michael Barry (‘06, ‘07, ‘08, ‘09)
Dennis Fryback (‘05, ‘06, ‘07, ‘08, ‘09)
David Meltzer (‘07, ‘09)
Stephen Pauker (‘06, ‘09)
David Rovner & Margaret Holmes-Rovner (‘05, ‘06, ‘07, ‘08, ‘09)
Joel Tsevat (‘06, ‘09)

Tversky Level
(Contributions total $500 - $749)
Robert Beck (‘07)
Nananda Col (‘05, ‘06, ’07, ‘08, ‘09)
Arthur Elstein (‘06, ‘07, ‘08, ‘09)
Mark Helfand (‘05, ‘07)
Kate Christensen (‘09)
William Lawrence (‘06)
David Paltiel (‘07, ‘09)
Mark Roberts (‘08, ‘09)
Sankey Williams (‘06, ‘07)

von Neumann-Morgenstern Level
(Contributions total $250 - $499)
Ahmed Bayoumi (‘06, ‘09)
Scott Cantor & Lisa Stone (’07, ’08, ‘09)
Phaedra Corso (‘06, ‘07, ‘08)
Neal Dawson (‘05, ‘06, ‘07, ‘08, ‘09)
Mark Eckman (’06, “09)
Sara Knight (‘05, ‘06, ‘07, ‘08, ‘09)
Karen Kuntz (‘09)
Steven Kymes (‘05, ‘06, ‘07, ‘08, ‘09)
Jill Metcalf (‘07, ‘08, ‘09)
Bruce Schackman (‘06, ‘07, ‘08, ‘09)
Marilyn Schapira (‘07, ‘08, ‘09)
Seema Sonnad (‘06, ’07, ‘09)

Markov Level
(Contributions total $100 - $249)
Amber Barnato (‘05, ‘07, ‘08)
Cathy Bradley (‘07)
Scott Braithwaite (’09)
Dena Bravata (‘06, ‘09)
Randall Cebul (‘06, ‘08)
Elena Elkin (‘07)
Robert Hamm (‘06, ‘08)
Myriam Hunink (‘05, ‘06, ‘07, ‘08, ‘09)
Sun-Young Kim (‘07, ‘08, ‘09)
Miriam Kuppermann (‘06, ‘07, ‘08, ‘09)
Kathryn McDonald (‘07)
Richard Orr (‘05, ‘06)
Brian Rittenhouse (‘07)
Allison Rosen (‘07)
Alan Schwartz (‘07)
James Stahl (‘06, ‘09)
David Sugano (‘07, ‘09)
Joanne Sutherland (‘08, ‘09)
Heather Taffet Gold (‘08)
John Thornbury (‘05)
George Torrance (‘05)

Bayes Level
(Contributions total up to $100)
Denise Bijlenga (‘08)
Rowland Chang (‘06, ‘07)
Carmel Crock (‘09)
Ted Ganiats (‘05)
Lee Green (‘07, ‘09)
Amit Gupta (‘06)
David Howard (‘09)
David Katz (‘07, ’08)
Kerry Kilbridge (‘05, ‘07, ‘08)
Job Kievit (‘09)
Daniel Masica (‘08)
George Papadopoulos (‘08)
Lisa Prosser (‘08)
Michael Rothberg (‘09)
Gillian Sanders (‘07)
Jha Saurabh (‘09)
Ewout Steyerberg (‘06, ‘09)
Anne Stiggelbout (‘06)
Carol Stockman (‘05)
Danielle Timmermans (‘07)
Milton Weinstein (‘09)
Robert Werner (‘08)
Brian Zikmund-Fisher (‘08, ‘09)

*Donations received October 2005 – December 28, 2009



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The SMDM Education Committee is excited to offer our one-to-one mentoring program this year.  These one-to-one mentoring sessions at the Annual Meeting offer the opportunity for new meeting attendees, trainees, junior faculty, and others to meet and get advice from established members of the Society in an informal setting.  The purpose of the program is to provide mentoring about career trajectories and research topics as well as to establish new networks of colleagues.  Other potential discussion topics include navigating the annual meeting, discussion about presented research and advice and insight about professional development.

Be on the lookout for more announcements in the upcoming months! 

For more information or to participate, please contact:
Rosie Thein, MD, MPH, PhD rosie.thein@gmail.com
or
Natasha Stout, PhD natasha_stout@hms.harvard.edu.


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Long-term funding for comparative effectiveness research (CER) is tied up in the fight over health care reform, but the President’s administration has asked for $286 million in the fiscal year 2011 budget. The fight over breast cancer screening guidelines reveals how politically charged high-stakes medical decision-making can be. Both the House of Representatives and the Senate have passed health care reform bills that include substantial funding for CER, but they are different. When this column was written, neither House was willing to pass the other’s bill, though attempts to break the deadlock were ongoing. The bill appropriating money for the Department of Health and Human Services included $397 million for the Agency of Healthcare Research and Quality, $25 more than in fiscal year 2009. It is not clear how much new money will be available for CER. President Obama’s FY 2011 budget requests $611 million for the Agency for Healthcare Research and Quality, a $214 million (54%) increase over that appropriated in FY 2010; and $286 million is targeted for comparative effectiveness research. If that money is appropriated it would be by far the most ever available for CER from the Federal government.

When the U.S. Preventive Services Task Force (USPSTF) released its recommendations that routine screening mammography for women between 40 and 49 were no longer recommended, there was massive criticism from breast cancer advocacy groups and some medical specialty groups. These recommendations did not consider cost, as USPSTF decisions are made solely on the basis of effectiveness. However, the Task Force’s recommendation did consider the morbidity burden of screened women without cancer against the lower mortality rate of breast cancer in women this age, which was widely seen as an illegitimate methodology. While a few professional groups, notably the American College of Physicians, supported the USPSTF’s recommendation, the Secretary of the Department of Health and Human Services said the recommendations would not change federal policy. Since medical decision-making models almost always consider morbidity as well as mortality in assessing effectiveness, this is a challenge as to whether our work can be useful in policy-making. Policy-makers may fear using methodologically correct models if they face attacks from powerful advocacy groups, yet this issue must be directly addressed in our research in order to help ensure that decisions are being made based on the most complete information available.



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It is estimated that about 30% of health care is inappropriate or wasteful[1]. In a broader sense, there are two key reasons that are typically invoked to account for this less than desirable situation. The first is the lack of high quality evidence related to the effects of most health care interventions. The second relates to suboptimal decision-making.

All major theories of choice agree that rational decision-making requires the integration of benefits (gains) and harms (losses) associated with a particular decision. Yet these theories differ in their methods of integrating such benefits and harms for a given decision. The only theory that satisfies all axioms of rational decision-making (i.e., ordering management alternatives, dominance, continuity, transitivity, cancellation and invariance principle) is expected utility theory (EUT). Medical decision-making literature is dominated by the models based on EUT, but extensive research during the last three decades in psychology, economics, and philosophy show that normative theories that have relied on the mathematical axioms for integration of benefits and harms are often not adhered to by humans. Modern cognitive theories increasingly focus on so called dual-processing theory in which both intuition (system 1) and analytical, deliberative process (system 2) are important for balancing risks and benefits in decision-making process[2].

The question that we thus ask SMDM members is:

Would a suboptimal situation in health care improve if we acted according to EUT, or are we better off improving “predictably irrational” health professionals’ cognitive devices?

• The feasibility of developing techniques for improving communication between intuitive (system 1) and deliberative (system 2) cognitive systems.
• The techniques or methods that may be most suitable for medical decision-making? (e.g., we mentioned anticipation of regret as one of the suitable techniques, particularly in life-threatening situations such as decision-making in cancer; what other techniques/methods/approaches can the SMDM members suggest?)
• Whether or not we should forget about system 1 altogether, as the apparent deviations from rational decision-making can potentially be “saved” by improving our EUT models.

GHESKIO CENTERS in Port-au-Prince, Haiti was the first institution in the world dedicated to the fight against HIV/AIDS. GHESKIO has provided continuous medical care in Haiti since 1982, never once shutting its doors or charging fees. Since the January 12th, 2010 earthquake hit Haiti, GHESKIO has been providing humanitarian assistance and emergency care to those affected by the disaster and continues to provide life-saving medications to people with HIV/AIDS. A recent article published in the New England Journal of Medicine by GHESKIO collaborators describes the situation in Port-au-Prince: http://content.nejm.org/cgi/content/full/NEJMp1001015?query=TOC.

You may donate to GHESKIO at http://med.cornell.edu/haiti. Weill Cornell Medical College (WCMC), which has partnered with GHESKIO for 30 years, will receive your donation and ensure that 100% of all funds will go to GHESKIO under the leadership of Dr. Jean William Pape. WCMC is a 501(c)(3) organization so your donation is tax deductible. SMDM Trustee Bruce Schackman, Associate Professor of Public Health at Weill Cornell Medical College, has been a part of the GHESKIO program for the past several years.



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In confronting medical decisions, do patients have a set of innate preferences that inform their choices or do they construct preferences in response to available options? This was the question that we addressed in the first installment of Decision Matters. In this column, we extend this theme further by exploring how feelings invoked by a particular choice can influence the decision making process. As always, we turn to behavioral decision theory for illumination. Behavioral decision theory posits that individuals process information through dual mechanisms: the first is an instinctive process that rapidly evaluates information based on an emotional response while the second is a deliberative, rational and analytical process.

Instinctual, emotional responses tend to label choices as either good or bad based on the feelings of hope or dread, and can exert a powerful influence on decision processing. In the words of psychologist Seymour Epstien, “If the activated feelings are pleasant, they motivate actions and thoughts anticipated to reproduce the feelings. If the feelings are unpleasant, they motivate actions and thoughts anticipated to avoid the feelings”.  Rapid emotional judgments can also be made based on the potential gains and losses involved with any potential loss carrying a greater emotional weight. Such subjective responses can influence how patients perceive the relative risks and benefits of a particular treatment option or can lead to biases in processing medical information. For example, studies have shown that if a particular treatment outcome invokes a clear, emotionally charged imagery, then variation in probability of the event carries very little weight. In other words, the ‘possibility’ of a certain event has a stronger effect than can be inferred from a mere probability evaluation, and as a result smaller probabilities can carry a disproportionate weight. This paradox explains the reactions of parents when safety of toys is concerned (witness the headline, “Robotic hamsters might give kids cancer,” regarding safety concerns about the must-have toy during the last holiday season) or the evaluation of car safety following a recall announcement (“Toyota resale values falling amid recall expansion”).

Evaluating options based on subjective feelings invoked by the choices also explains greater risk perceptions when statistically equivalent risks are represented in the form of relative frequencies instead of probabilities; representation in the form of relative frequencies (as in 5 out of every 1000 patients) are often reported to carry greater emotional weight. Experiential processing based on emotions also fails when health outcomes being evaluated are remote in time or when benefits accrue slowly over time (risk of smoking, benefits of exercise, etc). Advancing patient-centered care and implementing shared decision making paradigm requires an understanding of the role that prior experiences and feelings may play in informing patient choices; this will help us develop choice architectures that protect patient interests and improve their health outcomes.



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Are you interested in sharing your knowledge? In contributing to the SMDM Newsletter? We would like to hear from you on the important topic of defining the attributes involved in probabilistic sensitivity analyses (PSA) – either by writing a brief article, sending in a few points of interest, or co-authoring an article with your favorite MDM-methods-junkie! PSA is central to modern decision analysis and the core of PSA is defining the attributes of variables, including their distributions.  However, this seems to be as much art as science.  We request a volunteer(s) to author a review of this important topic...to help 'lift the veil' for your fellow SMDM members! Contact Jim Gudgeon to contribute or for more information: Jim.Gudgeon@imail.org



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