Medical decision making and medical education: challenges and opportunities

The Flexner Report highlighted the importance of teaching medical students to reason about uncertainty. The science of medical decision making seeks to explain how medical judgments and decisions ought ideally to be made, how they are actually made in practice, and how they can be improved, given the constraints of medical practice. The field considers both clinical decisions by or for individual patients and societal decisions designed to benefit the public. Despite the relevance of decision making to medical practice, it currently receives little formal attention in the U.S. medical school curriculum. This article suggests three roles for medical decision making in medical education. First, basic decision science would be a valuable prerequisite to medical training. Second, several decision-related competencies would be important outcomes of medical education; these include the physician's own decision skills, the ability to guide patients in shared decisions, and knowledge of health policy decisions at the societal level. Finally, decision making could serve as a unifying principle in the design of the medical curriculum, integrating other curricular content around the need to create physicians who are competent and caring decision makers.     

Identifying the Science and Technology Dimensions of Emerging Public Policy Issues through Horizon Scanning

Public policy requires public support, which in turn implies a need to enable the public not just to understand policy but also to be engaged in its development. Where complex science and technology issues are involved in policy making, this takes time, so it is important to identify emerging issues of this type and prepare engagement plans. In our horizon scanning exercise, we used a modified Delphi technique [1]. A wide group of people with interests in the science and policy interface (drawn from policy makers, policy adviser, practitioners, the private sector and academics) elicited a long list of emergent policy issues in which science and technology would feature strongly and which would also necessitate public engagement as policies are developed. This was then refined to a short list of top priorities for policy makers. Thirty issues were identified within broad areas of business and technology; energy and environment; government, politics and education; health, healthcare, population and aging; information, communication, infrastructure and transport; and public safety and national security.     

美国、加拿大环境和健康风险管理方法

对目前美国和加拿大多个部门使用的风险评价与风险管理方法进行了全面回顾和综合分析,论述各种不同方法的特征,深入探讨各种管理方法的基础、利弊、使用经验,辨识环境、人类健康和职业健康风险综合方法中应该包含的要素,阐述风险管理目标的确定方法,以期为中国的环境风险管理提供经验。     

The big ecological questions inhibiting effective environmental management in Australia

The need to improve environmental management in Australia is urgent because human health, well‐being and social stability all depend ultimately on maintenance of life‐supporting ecological processes. Ecological science can inform this effort, but when issues are socially and economically complex the inclination is to wait for science to provide answers before acting. Increasingly, managers and policy‐makers will be called on to use the present state of scientific knowledge to supply reasonable inferences for action based on imperfect knowledge. Hence, one challenge is to use existing ecological knowledge more effectively; a second is to tackle the critical unanswered ecological questions. This paper identifies areas of environmental management that are profoundly hindered by an inability of science to answer basic questions, in contrast to those areas where knowledge is not the major barrier to policy development and management. Of the 22 big questions identified herein, more than half are directly related to climate change. Several of the questions concern our limited understanding of the dynamics of marine systems. There is enough information already available to develop effective policy and management to address several significant ecological issues. We urge ecologists to make better use of existing knowledge in dialogue with policy‐makers and land managers. Because the challenges are enormous, ecologists will increasingly be engaging a wide range of other disciplines to help identify pathways towards a sustainable future.     

How can we improve information delivery to support conservation and restoration decisions?

Incorporating science into resource conservation and management is becoming increasingly important, but it is not yet clear how to provide information to decision makers most effectively. To evaluate sources of information used to support the management and conservation of California’s riparian bird habitat, we distributed a questionnaire to restoration practitioners and public and private land managers. We asked respondents to rate the importance and availability of different sources of information they use to inform their decisions. Synthetic reviews and peer-reviewed publications both received high importance and availability ratings. Web-based tools received low importance and availability ratings. One-on-one interactions between ecologists and decision makers received high importance ratings, similar to those of peer-reviewed publications and synthetic reviews, but their availability was rated lower than any other method of decision support. Our results suggest that the decision makers we surveyed are already using a wide variety of information, but that prioritizing one-on-one interactions between scientists and decision makers will enhance the delivery of all sources of information.     

Getting a head start: the importance of personal genetics education in high schools

With advances in sequencing technology, widespread and affordable genome sequencing will soon be a reality. However, studies suggest that "genetic literacy" of the general public is inadequate to prepare our society for this unprecedented access to our genetic information. As the current generation of high school students will come of age in an era when personal genetic information is increasingly utilized in health care, it is of vital importance to ensure these students understand the genetic concepts necessary to make informed medical decisions. These concepts include not only basic scientific knowledge, but also considerations of the ethical, legal, and social issues that will arise in the age of personal genomics. In this article, we review the current state of genetics education, highlight issues that we believe need to be addressed in a comprehensive genetics education curriculum, and describe our education efforts at the Harvard Medical School-based Personal Genetics Education Project.     

Challenges for Risk Assessors

At the early part of the 21st century, occupational safety and health risk assessors face a variety of challenges. In addition to technical issues, the challenges for risk assessors include: assessment of risks of mixtures/and synergistic effects; incorporation of biological information into risk assessments; development of different ways of presenting risk information to better inform policy makers and the public; better expressions of uncertainty and assumptions; and harmonization of assessments across agencies and countries. All of these challenges will occur against a background of unfolding understanding of human and other genomes. Risk assessors will be motivated and pressured to use genomic and related technologies, but ethical, social, and technical issues need to be addressed before widespread use.     

Using and communicating uncertainty for the effective control of invasive non-native species

Estimates of quantities needed to plan invasive species control, such as population size, are always uncertain; this is an issue that can become a problem when mishandled in ecological science and its communication. The complexities of incorporating uncertainty into sophisticated decision-support tools may be a barrier to their use by decision makers, leading to decisions being made without due regard to uncertainty and risking misplaced certainty of predicted outcomes. We summarise ways in which uncertainty has been incorporated into and used to advise decisions on the management of invasive non-native species and other problem species, and offer a simple conceptual model for accommodating and using uncertainty at the planning stage. We also demonstrate how frequently uncertainty has been misused and miscommunicated in the wildlife management literature. We contend that uncertainty in estimates of natural quantities must be acknowledged, can inform decisions and can be made to derive decisions, and should not be ignored if invasive species policy is to be delivered effectively. Uncertainty must be communicated thoroughly and correctly by scientists if decision makers are to understand its consequences for planning and resourcing control programmes.     

Advisory Committee on Dangerous Pathogens (ACDP) Seminar on Microbiological Risk Assessment, 28 January 1997

Microbiological risk assessment is an area of growing importance and significant potential, where the underlying science, software systems and databases are developing to the point of real and useful application. It is also an area where the developing science is posing as many questions as it is presenting answers. Key issues emerging from the day included: the need for more sophisticated management of uncertainty, which is much more relevant to microbiological risk analysis than to other applications; the need for global surveillance systems with better compatibility and appropriate peer review; considered assessment of the impact of new molecular-based diagnostic and screening techniques; the explosion of relevant information available, particularly on the Internet, which makes computer literacy essential both to professionals and 'laymen'; and the appearance of software systems which are either tailored for microbiological application or have the potential for this use. The closely associated issues of risk communication and perception also emerged as being vital to the effective application of microbiological risk management to public health issues. Overall, the majority of participants considered the event to have been valuable and stimulating and thought that it would lead to improvements in the use of microbiological risk assessment. The Advisory Committee on Dangerous Pathogens is committed to taking this topic forward and will be both taking up the messages from this seminar and encouraging development of suitable databases and software systems.     

Barriers to partnership working in public health: a qualitative study

Background

Public health provision in England is undergoing dramatic changes. Currently established partnerships are thus likely to be significantly disrupted by the radical reforms outlined in the Public Health White Paper. We therefore explored the process of partnership working in public health, in order to better understand the potential opportunities and threats associated with the proposed changes.

Methodology/Principal Findings

70 participants took part in an in-depth qualitative study involving 40 semi-structured interviews and three focus group discussions. Participants were senior and middle grade public health decision makers working in Primary Care Trusts, Local Authorities, Department of Health, academia, General Practice and Hospital Trusts and the third sector in England. Despite mature arrangements for partnership working in many areas, and much support for joint working in principle, many important barriers exist. These include cultural issues such as a lack of shared values and language, the inherent complexity of intersectoral collaboration for public health, and macro issues including political and resource constraints. There is particular uncertainty and anxiety about the future of joint working relating to the availability and distribution of scarce and diminishing financial resources. There is also the concern that existing effective collaborative networks may be completely disrupted as the proposed changes unfold. The extent to which the proposed reforms might mitigate or potentiate these issues remains unclear. However the threats currently remain more salient than opportunities.

Conclusions

The current re-organisation of public health offers real opportunity to address some of the barriers to partnership working identified in this study. However, significant threats exist. These include the breakup of established networks, and the risk of cost cutting on effective public health interventions.     

Process evaluation of appreciative inquiry to translate pain management evidence into pediatric nursing practice

Background

Current healthcare systems have extended the evidence-based medicine (EBM) approach to health policy and delivery decisions, such as access-to-care, healthcare funding and health program continuance, through attempts to integrate valid and reliable evidence into the decision making process. These policy decisions have major impacts on society and have high personal and financial costs associated with those decisions. Decision models such as these function under a shared assumption of rational choice and utility maximization in the decision-making process.

Discussion

We contend that health policy decision makers are generally unable to attain the basic goals of evidence-based decision making (EBDM) and evidence-based policy making (EBPM) because humans make decisions with their naturally limited, faulty, and biased decision-making processes. A cognitive information processing framework is presented to support this argument, and subtle cognitive processing mechanisms are introduced to support the focal thesis: health policy makers' decisions are influenced by the subjective manner in which they individually process decision-relevant information rather than on the objective merits of the evidence alone. As such, subsequent health policy decisions do not necessarily achieve the goals of evidence-based policy making, such as maximizing health outcomes for society based on valid and reliable research evidence.

Summary

In this era of increasing adoption of evidence-based healthcare models, the rational choice, utility maximizing assumptions in EBDM and EBPM, must be critically evaluated to ensure effective and high-quality health policy decisions. The cognitive information processing framework presented here will aid health policy decision makers by identifying how their decisions might be subtly influenced by non-rational factors. In this paper, we identify some of the biases and potential intervention points and provide some initial suggestions about how the EBDM/EBPM process can be improved.     

The use of research evidence in public health decision making processes: systematic review

Background

The use of research evidence to underpin public health policy is strongly promoted. However, its implementation has not been straightforward. The objectives of this systematic review were to synthesise empirical evidence on the use of research evidence by public health decision makers in settings with universal health care systems.

Methods

To locate eligible studies, 13 bibliographic databases were screened, organisational websites were scanned, key informants were contacted and bibliographies of included studies were scrutinised. Two reviewers independently assessed studies for inclusion, extracted data and assessed methodological quality. Data were synthesised as a narrative review.

Findings

18 studies were included: 15 qualitative studies, and three surveys. Their methodological quality was mixed. They were set in a range of country and decision making settings. Study participants included 1063 public health decision makers, 72 researchers, and 174 with overlapping roles. Decision making processes varied widely between settings, and were viewed differently by key players. A range of research evidence was accessed. However, there was no reliable evidence on the extent of its use. Its impact was often indirect, competing with other influences. Barriers to the use of research evidence included: decision makers'' perceptions of research evidence; the gulf between researchers and decision makers; the culture of decision making; competing influences on decision making; and practical constraints. Suggested (but largely untested) ways of overcoming these barriers included: research targeted at the needs of decision makers; research clearly highlighting key messages; and capacity building. There was little evidence on the role of research evidence in decision making to reduce inequalities.

Conclusions

To more effectively implement research informed public health policy, action is required by decision makers and researchers to address the barriers identified in this systematic review. There is an urgent need for evidence to support the use of research evidence to inform public health decision making to reduce inequalities.     

Types of Integration in Risk Assessment and Management,And Why They Are Needed

Risk-based decision making requires that the decision makers and stakeholders are informed of all risks that are potentially significant and relevant to the decision. The International Programme on Chemical Safety of the World Health Organization has developed a framework for integrating the assessment of human health and ecological risks. However, other types of integration are needed to support particular environmental decisions. They are integration of exposure and effects, of multiple chemicals and other hazardous agents, of multiple routes of exposure, of multiple endpoints, multiple receptors, multiple spatial and temporal scales, a product's life cycle, management alternatives, and socioeconomics with risk assessment. Inclusion of all these factors in an integrated assessment could lead to paralysis by analysis. Therefore, it is important that assessors be cognizant of the decision process and that decision makers and those who will influence the decision (stakeholders) be involved in planning the assessment to ensure that the degree of integration is necessary and sufficient.     

Risk communication and decision tools for children's health protection

Scientific discovery linking the environment to beneficial and adverse health children's health outcomes is rapidly expanding, leading scientists and health professionals to call for timely action to prevent harm and secure benefits. A robust method to synthesize what is known about the environmental drivers of health is a foundational step to making the science actionable by individuals and decision‐makers. To meet this need, a methodology called the Navigation Guide was crafted by a collaboration of 22 clinical and environmental health scientists. The Navigation Guide proceeds from methods of research synthesis used in clinical settings but accounts for differences between environmental and clinical health sciences related to the evidence‐base and decision‐context. The methodology can be used to develop evidence profiles that provide simple, transparent summaries, such as practice guidelines or other evidence‐based recommendations for prevention. Establishing proof‐of‐concept of the method is underway. Development of the Navigation Guide is extremely timely as it coincides with growing recognition of the need for updated methods in risk assessment. The costs in 2008 to the US healthcare system for treatment of childhood illnesses linked to toxic environmental exposures is conservatively estimated to be over $76 billion, and it is anticipated that US healthcare policy decisions will increasingly rely on systematic reviews of the evidence. The Navigation Guide is poised to provide a methodological bridge to link healthcare decision‐making to efforts to reduce toxic environmental exposures. The institutionalization of the Navigation Guide would provide a concrete mechanism for linking science to action to protect children's health. Birth Defects Research (Part C) 99:45–49, 2013. © 2013 Wiley Periodicals, Inc.     

Ethical issues in animal cloning

The issue of human reproductive cloning has recently received a great deal attention in public discourse. Bioethicists, policy makers, and the media have been quick to identify the key ethical issues involved in human reproductive cloning and to argue, almost unanimously, for an international ban on such attempts. Meanwhile, scientists have proceeded with extensive research agendas in the cloning of animals. Despite this research, there has been little public discussion of the ethical issues raised by animal cloning projects. Polling data show that the public is decidedly against the cloning of animals. To understand the public's reaction and fill the void of reasoned debate about the issue, we need to review the possible objections to animal cloning and assess the merits of the anti-animal cloning stance. Some objections to animal cloning (e.g., the impact of cloning on the population of unwanted animals) can be easily addressed, while others (e.g., the health of cloned animals) require more serious attention by the public and policy makers.     

Developing core outcome sets for clinical trials: issues to consider

ABSTRACT: Selection of appropriate outcomes or domains is crucial when designing clinical trials to compare directly the effects of different interventions in ways that minimise bias. If the findings are to influence policy and practice then the chosen outcomes need to be relevant and important to key stakeholders including patients and the public, health care professionals and others making decisions about health care. There is a growing recognition that insufficient attention has been paid to the outcomes measured in clinical trials. These issues could be addressed through the development and use of an agreed standardised collection of outcomes, known as a core outcome set, which should be measured and reported, as a minimum, in all trials for a specific clinical area. Accumulating work in this area has identified the need for general guidance on the development of core outcome sets. Key issues to consider in the development of a core outcome set include its scope, the stakeholder groups to be involved, choice of consensus method and the achievement of a consensus.     

Practical Decision Methods for Watershed Management

Why are formal statistical methods for risk-based decision-making so seldom used in the practice of watershed management? I contend that complex formal methods, while internally consistent, are often inappropriate to real world decision-making. The primary purpose of risk analysis is to support risk management, and decision methods need to be effective not just in evaluating risk, but also in communicating risk among stakeholders and decision makers. Useful methods must be not only correct, but also readily communicable. Many formal risk-based decision methods have real obstacles to practical application in one of the following areas: (1) many important components of risk that matter to stakeholders are difficult to express in quantitative terms, and any method which turns “fuzzy” information and subjective opinion into hard numbers is prone to be regarded with suspicion; (2) methods which are not understandable and convincing to decision makers have little practical value; (3) a complex formal analysis will be seen as misguided or irrelevant if it does not represent the full spectrum of management goals. This paper compares the process of watershed management with the process of ecological risk assessment, highlighting similarities and key differences. A practical decision method which balances quantitative rigor with ability to communicate to and forge consensus among stakeholders is then outlined with reference to a successful case study.     

Getting ready for malaria elimination: a check list of critical issues to consider

In recent years, a renewed interest in malaria elimination and eradication has emerged and seems to be rooting in the minds of the scientific community, public health specialists, funding bodies, policy makers and politicians. Malaria eradication will certainly benefit from improved and innovative tools; notwithstanding novel knowledge in fields ranging from basic science to mathematical modelling and health systems research. However, the elimination of malaria also encompasses a broad range of essential aspects that countries and other actors need to consider when thinking of embarking on such an adventure, including the implementation of innovative strategies, the ability to incorporate the most up-to-date evidence into policy, the integration of malaria into the broader health agenda, the strengthening of surveillance and health systems, capacity building, funding, advocacy and, very importantly, research. While in some cases this enthusiasm is clearly justified, some countries are still a long way from realistically advancing towards elimination. This paper attempts to provide guidance on all the necessary issues that should be considered when initiating a malaria elimination program.     

A systematic methodology for selecting decontamination strategies following a biocontamination event

Decontamination and recovery of a facility or outdoor area after a wide-area biological incident involving a highly persistent agent (eg, Bacillus anthracis spores) is a complex process that requires extensive information and significant resources, which are likely to be limited, particularly if multiple facilities or areas are affected. This article proposes a systematic methodology for evaluating information to select the decontamination or alternative treatments that optimize use of resources if decontamination is required for the facility or area. The methodology covers a wide range of approaches, including volumetric and surface decontamination, monitored natural attenuation, and seal and abandon strategies. A proposed trade-off analysis can help decision makers understand the relative appropriateness, efficacy, and labor, skill, and cost requirements of the various decontamination methods for the particular facility or area needing treatment--whether alone or as part of a larger decontamination effort. Because the state of decontamination knowledge and technology continues to evolve rapidly, the methodology presented here is designed to accommodate new strategies and materials and changing information.     

AN INQUIRY INTO THE PRINCIPLES OF NEEDS‐BASED ALLOCATION OF HEALTH CARE

The concept of need is often proposed as providing an additional or alternative criterion to cost‐effectiveness in making allocation decisions in health care. If it is to be of practical value it must be sufficiently precisely characterized to be useful to decision makers. This will require both an account of how degree of need for an intervention is to be determined and a prioritization rule that clarifies how degree of need and the cost of the intervention interact in determining the relative priority of the intervention. Three common features of health care interventions must be accommodated in a comprehensive theory of need: the probabilistic nature of prognosis (with and without the intervention); the time course of effects; and the fact that the most effective treatments often combine more than one intervention. These common features are problematic for the concept of need. We outline various approaches to prioritization on the basis of need and argue that some approaches are more promising than others.