Journal of General Internal Medicine, Nov 12, 2011
BACKGROUND: Routine assessments of pain using an intensity numeric rating scale (NRS) have improv... more BACKGROUND: Routine assessments of pain using an intensity numeric rating scale (NRS) have improved documentation, but have not improved clinical outcomes. This may be, in part, due to the failure of the NRS to adequately predict patients' preferences for additional treatment. OBJECTIVE: To examine whether patients' illness perceptions have a stronger association with patient treatment preferences than the pain intensity NRS. DESIGN: Single face-to-face interview. PARTICIPANTS: Outpatients with chronic, noncancer, musculoskeletal pain. MAIN MEASURES: Experience of pain was measured using 18 illness perception items. Factor analysis of these items found that five factors accounted for 67.1% of the variance; 38% of the variance was accounted for by a single factor labeled "pain impact." Generalized linear models were used to examine how NRS scores and physical function compare with pain impact in predicting preferences for highly effective/high-risk treatment. KEY RESULTS: Two hundred forty-nine subjects agreed to participate. Neither NRS nor functioning predicted patient preference (NRS: χ2=1.92, df=1, p= 0.16, physical functioning: χ2=2.48, df=1, p=0.11). In contrast, pain impact was significantly associated with the preference for a riskier/more effective treatment after adjusting for age, comorbidity, efficacy of current medications and numeracy (χ2=4.40, df=1, p=0.04). CONCLUSIONS: Tools that measure the impact of pain may be a more valuable screening instrument than the NRS. Further research is now needed to determine if measuring the impact of pain in clinical practice is more effective at triggering appropriate management than more restricted measures of pain such as the NRS.
Bulletin of the Association for the Advancement of Philosophy and Psychiatry, 2004
1st 2 paragraphs: Return to Reason (1), Stephen Toulmin’s latest book, represents what is perhaps... more 1st 2 paragraphs: Return to Reason (1), Stephen Toulmin’s latest book, represents what is perhaps the culmination of a career that has been dedicated to resurrecting practical reason from the throes of modernity. The book’s principal claim is that the unremitting quest for universal knowledge is part and parcel of a tradition that has thrown reason out of balance, and the resulting situation has become intolerable. In working out the implications of this claim, Toulmin gives a synoptic account of the rise and eventual (if not actual) fall of rationalism. The alternative he sketches gives us a glimpse into one possible version of the post-modern era.
Toulmin’s previous works speak extensively about medical and psychiatric practice, and Return to Reason is no exception. This proclivity alone makes his ideas worth examining, especially for those who are following or contributing to the rapidly evolving relationship between philosophy and psychiatry. My task in this review is to highlight some of the issues that Toulmin raises and draw out their historical context, give a brief surview of the book, and persuade the reader that the despite a few notable flaws, Return to Reason is a significant contribution to philosophy of science.
This presentation reports on the Applied Heidegger Conference held in 1989, and discusses the rel... more This presentation reports on the Applied Heidegger Conference held in 1989, and discusses the relevance of Heidegger's thinking to rhetorical theory and criticism. It discusses recent revelations regarding Heidegger's involvement with National Socialism, and indicates how his lecture, "The Question Concerning Technology" addresses the theme of our convention, communication and community.
Purpose: Tight control is a decision strategy widely advocated for the optimal treatment of patie... more Purpose: Tight control is a decision strategy widely advocated for the optimal treatment of patients with diabetes and rheumatoid arthritis (RA). Its purpose is to slow progression of illness by changing treatment when activity exceeds a minimum threshold. Despite considerable evidence that this strategy leads to improved outcomes, it has not been consistently adopted. We propose that patients' experience of illness complicates this decision strategy, and that recognizing how patient experience interacts with disease activity can enhance the implementation of tight control in clinical practice. The objective of this study was to identify experiential factors that combine with disease activity to influence actual treatment changes among RA patients. Methods: We conducted a prospective, repeated measures, study in which RA patients were interviewed at baseline, 2, 4, and 6 months. Disease activity was measured with a validated patient report outcome measure. Patient experience was...
The Institute of Medicine's 1999 report on quality of health care (Kohn, Corrigan, & Donaldson, 1... more The Institute of Medicine's 1999 report on quality of health care (Kohn, Corrigan, & Donaldson, 1999) documents the prevalence of medical errors and their consequences. Based on the data from two states, adverse events occur in more than 3% of hospitalizations, with more than half resulting from preventable error. When these numbers are extrapolated to the more than 33.6 million admissions to hospitals in the United States during 1997, the disquieting conclusion is that at least 44,000 Americans die each year as a result of medical errors, making it the eighth leading cause of death in the United Sates. More Americans die in a given year as a result of medical errors than from motor vehicle accidents, breast cancer, or AIDS. Misadventures in Health Care, edited by Marilyn Sue Bogner and published in 2004 by Lawrence Erlbaum Associates, attempts to address the phenomenon of medical error in a distinctive and somewhat modest way. Rather than discerning the patterns and trends that emerge from broad-based epidemiological data or examining the effects of structural or organizational initiatives, the book presents a series of narratives that portray medical errors in the making. The book includes 11 accounts, one per chapter. Each deals with a separate issue or situation. Chapter 2 presents a blood transfusion scenario; surgical errors are the subject of chapters 4 through 8; chapter 10 discusses home care, and chapter 11 addresses aging. Each chapter, written by a different medical specialist, features a case vignette in which something goes awry. Sometimes, but not always, the discussion invokes data on prevalence and harm and includes an analysis of why errors were made and what might be done to prevent their recurrence. As with most compilations of readings, the quality fluctuates from one chapter to the next. The vignettes carry some chapters with their extensive accounts of events and procedures; in other chapters, vignettes serve mainly as vehicles for presenting viewpoints that are well documented in one instance and almost entirely anecdotal in another. Still, narratives comprise the bulk of the book, and readers who are interested in specific topics-for instance, anesthesia, trauma, or intensive care-may want to look at what the book has to offer. I have serious misgivings about this book taken as a whole, however, owing principally to how the editor has fulfilled her vision, as expressed in the final chapter: The editor decries the limited amount of information that can be gleaned from frequency and outcome reports, and she wants to give the reader a sense of reality that can be represented only by a narrative (see p. 201). Had the chapters been written by communication scholars or journalists,
As physicians are being trained to adapt their practices to the needs and experience of patients,... more As physicians are being trained to adapt their practices to the needs and experience of patients, initiatives to standardize care have been gaining momentum. The resulting conflict can be addressed through a practice-based learning and improvement (PBL) program that develops competency in using treatment guidelines as decision aids and incorporating patient-specific information into treatment recommendations. This article describes and tests a program that is consistent with the ACGME's multilevel competency-based approach, targets students at four levels of training, and features progressive learning objectives and assessments. The program was pilot-tested with 22 paid volunteer psychiatric residents and fellows. They were introduced to a schizophrenia treatment guideline and reviewed six case vignettes of varying complexity. PBL assessments were based on how treatment recommendations were influenced by clinical and patient-specific factors. The task permitted separate assessments of learning objectives all four training levels. Among the key findings at each level, most participants found the treatment guideline helpful in making treatment decisions. Recommendations were influenced by guideline-based assessment criteria and other clinical features. They were also influenced by patients' perceptions of their illness, patient-based progress assessments, and complications such as stressors and coping patterns. Recommendations were strongly influenced by incongruence between clinical facts and patient experience. Practical understanding of how patient experience joins with clinical knowledge can enhance the use of treatment guidelines as decision tools and enable clinicians to appreciate more fully how and why patients' perceptions of their illness should influence treatment recommendations. This PBL program can assist training facilities in preparing students to cope with contradictory demands to both standardize and adapt their practice. The program can be modified to accommodate various disorders and a range of clinical factors and patient-specific complications.
Evidence-based medicine (EBM), one of the most important movements in health care, has been a lig... more Evidence-based medicine (EBM), one of the most important movements in health care, has been a lightning rod for controversy. Conflicts about the meaning and value of EBM are owing in part to lack of clarity about basic questions regarding its development, the importance of expertise and intuition, and the role of evidence in clinical decision making. These issues have persisted in part because of unclarity at the outset, but also because of how EBM evolved, why it was introduced when it was, and how it was modified following its introduction. This paper traces the evolution of EBM from clinical epidemiology (CE) and the internal dispute that precipitated the developers to establish EBM as a distinct approach to clinical practice. The paper proposes that health care industrialization also had a significant role in EBM's emergence and that industrialization influenced the decision to merge EBM with the method of normative decision making known as decision analysis (DA). The paper discusses the impact of this merger, in particular how it led to EBM's identification with managed care and has added momentum to the effort at forging a connection between a normative decision model and clinical judgement. This effort would turn clinical decision making into a conduit for bringing administrative rules and regulations into the consulting room and would result in expertise becoming a surplus skill. The paper closes by discussing a challenge yet unmet by EBM's advocates and critics-to chronicle the dangers that EBM in the framework of DA during the current era of industrialization poses to health and health care, and discover ways of unhinging the relationship between model and judgement.
Initiatives to improve the quality of healthcare delivery include the introduction of treatment g... more Initiatives to improve the quality of healthcare delivery include the introduction of treatment guidelines and the development of implementation science, which overcomes barriers in bringing evidence-based practices to routine clinical care. The implementation strategy is to identify impediments to guideline adherence, then develop means of changing behavior to increase conformance. Achievements to date have fallen short of the objectives, and the tactics oftentimes have provoked resistance. This response may illustrate the significance of the problem, but it may also indicate that the methods of implementation science tend to overstate the quality of evidence, ignore instances in which the appropriateness of a given practice cannot be clearly determined, and overlook the complexities of applying general knowledge to specific cases. This essay proposes that an inability to contextualize evidence is inherent to patient-oriented services research. The essay draws from discussions of d...
Treat‐to‐target (T2T) includes a target or goal, standard symptom assessment, and a treatment dec... more Treat‐to‐target (T2T) includes a target or goal, standard symptom assessment, and a treatment decision. In specialties that threat chronic pain, T2T is expected to be implemented collaboratively. The ability of patients to participate fully has been questioned, but these concerns have not been demonstrated empirically. The current study examined how patient self‐assessed symptom measures and illness beliefs affect their willingness to change their current treatment.
Social capital has played a prominent role in recent initiatives to improve mental health and enh... more Social capital has played a prominent role in recent initiatives to improve mental health and enhance the quality of services. However, efforts to substantiate a link between social capital and mental health have been daunted by equivocal findings and conceptual confusion. These consequences are in part due to having two prominent approaches that offer disparate and inconsistent accounts about what comprises social capital, how to increase it and how to use it to benefit mental health policy and practice. This paper lays the groundwork for a rapprochement.
The field of clinical decision making is polarized by two predominate views. One holds that treat... more The field of clinical decision making is polarized by two predominate views. One holds that treatment recommendations should conform with guidelines; the other emphasizes clinical expertise in reaching case-specific judgments. Previous work developed a test for a proposed alternative, that clinical judgment should systematically incorporate both general knowledge and patient-specific information. The test was derived from image theory's two phase-account of decision making and its "simple counting rule", which describes how possible courses of action are pre-screened for compatibility with standards and values. The current paper applies this rule to clinical forecasting, where practitioners indicate how likely a specific patient will respond favorably to a recommended treatment. Psychiatric trainees evaluated eight case vignettes that exhibited from 0 to 3 incompatible attributes. They made two forecasts, one based on a guideline recommendation, the other based on their own alternative. Both forecasts were predicted by equally-and unequally-weighted counting rules. Unequal weighting provided a better fit and exhibited a clearer rejection threshold, or point at which forecasts are not diminished by additional incompatibilities. The hypothesis that missing information is treated as an incompatibility was not confirmed. There was evidence that the rejection threshold was influenced by clinician preference. Results suggests that guidelines may have a de-biasing influence on clinical judgment. Subject to limitations pertaining to the subject sample and population, clinical paradigm, guideline, and study procedure, the data support the use of a compatibility test to describe how clinicians make patient-specific forecasts.
Reluctance to follow treatment guidelines was illustrated previously by a study in this journal t... more Reluctance to follow treatment guidelines was illustrated previously by a study in this journal that found a 5% endorsement rate for a medication-switching algorithm for treatment-resistant schizophrenia. The study presented here attempted to account for this low rate by using clinical vignettes to manipulate key factors. Twenty-one psychiatric residents responded to 64 vignettes. Expected progress and patient adherence to treatment were systematically manipulated within the vignettes, because they were most responsible for clinician decisions. Endorsement was analyzed using a fully crossed 4 x 2 within-subjects design. When expected progress and patient adherence were factored in, mean endorsement ranged from 5% to 87%. Adding guideline variables (short-term progress assessment, current condition, and guideline step) expanded the endorsement range from 1% to 90%. The low endorsement rate found previously is explained principally by the patient's expected progress. The brief report concludes by discussing ways to promote implementation when expected progress is only moderate.
Pain practice : the official journal of World Institute of Pain, 2013
This study describes how pain practitioners can elicit the beliefs that are responsible for patie... more This study describes how pain practitioners can elicit the beliefs that are responsible for patients' judgments against considering a treatment change and activate collaborative decision making. Beliefs of 139 chronic pain patients who are in treatment but continue to experience significant pain were reduced to 7 items about the significance of pain on the patient's life. The items were aggregated into 4 decision models that predict which patients are actually considering a change in their current treatment. While only 34% of study participants were considering a treatment change overall, the percentage ranged from 20 to 70, depending on their ratings about current consequences of pain, emotional influence, and long-term impact. Generalized linear model analysis confirmed that a simple additive model of these 3 beliefs is the best predictor. Initial opposition to a treatment change is a conditional judgment and subject to change as specific beliefs become incompatible with p...
Overrepresentation of minorities and their disproportionate confinement in the U.S. justice syste... more Overrepresentation of minorities and their disproportionate confinement in the U.S. justice system are pernicious, unyielding problems. The authors used the Structured Assessment of Violence Risk in Youth to examine risk and protective factors of 757 juveniles admitted to detention centers. A chi-square analysis revealed that significantly more African American youth were rated low risk for violence compared to White counterparts. African American and Hispanic youth initiated violent behavior earlier and frequently lived in violent, disorganized neighborhoods. However, they had more prosocial involvement, stronger attachments and bonds, and more resilient personality traits. Ideas for targeted release and intervention with minority youth are described.
Journal of General Internal Medicine, Nov 12, 2011
BACKGROUND: Routine assessments of pain using an intensity numeric rating scale (NRS) have improv... more BACKGROUND: Routine assessments of pain using an intensity numeric rating scale (NRS) have improved documentation, but have not improved clinical outcomes. This may be, in part, due to the failure of the NRS to adequately predict patients' preferences for additional treatment. OBJECTIVE: To examine whether patients' illness perceptions have a stronger association with patient treatment preferences than the pain intensity NRS. DESIGN: Single face-to-face interview. PARTICIPANTS: Outpatients with chronic, noncancer, musculoskeletal pain. MAIN MEASURES: Experience of pain was measured using 18 illness perception items. Factor analysis of these items found that five factors accounted for 67.1% of the variance; 38% of the variance was accounted for by a single factor labeled "pain impact." Generalized linear models were used to examine how NRS scores and physical function compare with pain impact in predicting preferences for highly effective/high-risk treatment. KEY RESULTS: Two hundred forty-nine subjects agreed to participate. Neither NRS nor functioning predicted patient preference (NRS: χ2=1.92, df=1, p= 0.16, physical functioning: χ2=2.48, df=1, p=0.11). In contrast, pain impact was significantly associated with the preference for a riskier/more effective treatment after adjusting for age, comorbidity, efficacy of current medications and numeracy (χ2=4.40, df=1, p=0.04). CONCLUSIONS: Tools that measure the impact of pain may be a more valuable screening instrument than the NRS. Further research is now needed to determine if measuring the impact of pain in clinical practice is more effective at triggering appropriate management than more restricted measures of pain such as the NRS.
Bulletin of the Association for the Advancement of Philosophy and Psychiatry, 2004
1st 2 paragraphs: Return to Reason (1), Stephen Toulmin’s latest book, represents what is perhaps... more 1st 2 paragraphs: Return to Reason (1), Stephen Toulmin’s latest book, represents what is perhaps the culmination of a career that has been dedicated to resurrecting practical reason from the throes of modernity. The book’s principal claim is that the unremitting quest for universal knowledge is part and parcel of a tradition that has thrown reason out of balance, and the resulting situation has become intolerable. In working out the implications of this claim, Toulmin gives a synoptic account of the rise and eventual (if not actual) fall of rationalism. The alternative he sketches gives us a glimpse into one possible version of the post-modern era.
Toulmin’s previous works speak extensively about medical and psychiatric practice, and Return to Reason is no exception. This proclivity alone makes his ideas worth examining, especially for those who are following or contributing to the rapidly evolving relationship between philosophy and psychiatry. My task in this review is to highlight some of the issues that Toulmin raises and draw out their historical context, give a brief surview of the book, and persuade the reader that the despite a few notable flaws, Return to Reason is a significant contribution to philosophy of science.
This presentation reports on the Applied Heidegger Conference held in 1989, and discusses the rel... more This presentation reports on the Applied Heidegger Conference held in 1989, and discusses the relevance of Heidegger's thinking to rhetorical theory and criticism. It discusses recent revelations regarding Heidegger's involvement with National Socialism, and indicates how his lecture, "The Question Concerning Technology" addresses the theme of our convention, communication and community.
Purpose: Tight control is a decision strategy widely advocated for the optimal treatment of patie... more Purpose: Tight control is a decision strategy widely advocated for the optimal treatment of patients with diabetes and rheumatoid arthritis (RA). Its purpose is to slow progression of illness by changing treatment when activity exceeds a minimum threshold. Despite considerable evidence that this strategy leads to improved outcomes, it has not been consistently adopted. We propose that patients' experience of illness complicates this decision strategy, and that recognizing how patient experience interacts with disease activity can enhance the implementation of tight control in clinical practice. The objective of this study was to identify experiential factors that combine with disease activity to influence actual treatment changes among RA patients. Methods: We conducted a prospective, repeated measures, study in which RA patients were interviewed at baseline, 2, 4, and 6 months. Disease activity was measured with a validated patient report outcome measure. Patient experience was...
The Institute of Medicine's 1999 report on quality of health care (Kohn, Corrigan, & Donaldson, 1... more The Institute of Medicine's 1999 report on quality of health care (Kohn, Corrigan, & Donaldson, 1999) documents the prevalence of medical errors and their consequences. Based on the data from two states, adverse events occur in more than 3% of hospitalizations, with more than half resulting from preventable error. When these numbers are extrapolated to the more than 33.6 million admissions to hospitals in the United States during 1997, the disquieting conclusion is that at least 44,000 Americans die each year as a result of medical errors, making it the eighth leading cause of death in the United Sates. More Americans die in a given year as a result of medical errors than from motor vehicle accidents, breast cancer, or AIDS. Misadventures in Health Care, edited by Marilyn Sue Bogner and published in 2004 by Lawrence Erlbaum Associates, attempts to address the phenomenon of medical error in a distinctive and somewhat modest way. Rather than discerning the patterns and trends that emerge from broad-based epidemiological data or examining the effects of structural or organizational initiatives, the book presents a series of narratives that portray medical errors in the making. The book includes 11 accounts, one per chapter. Each deals with a separate issue or situation. Chapter 2 presents a blood transfusion scenario; surgical errors are the subject of chapters 4 through 8; chapter 10 discusses home care, and chapter 11 addresses aging. Each chapter, written by a different medical specialist, features a case vignette in which something goes awry. Sometimes, but not always, the discussion invokes data on prevalence and harm and includes an analysis of why errors were made and what might be done to prevent their recurrence. As with most compilations of readings, the quality fluctuates from one chapter to the next. The vignettes carry some chapters with their extensive accounts of events and procedures; in other chapters, vignettes serve mainly as vehicles for presenting viewpoints that are well documented in one instance and almost entirely anecdotal in another. Still, narratives comprise the bulk of the book, and readers who are interested in specific topics-for instance, anesthesia, trauma, or intensive care-may want to look at what the book has to offer. I have serious misgivings about this book taken as a whole, however, owing principally to how the editor has fulfilled her vision, as expressed in the final chapter: The editor decries the limited amount of information that can be gleaned from frequency and outcome reports, and she wants to give the reader a sense of reality that can be represented only by a narrative (see p. 201). Had the chapters been written by communication scholars or journalists,
As physicians are being trained to adapt their practices to the needs and experience of patients,... more As physicians are being trained to adapt their practices to the needs and experience of patients, initiatives to standardize care have been gaining momentum. The resulting conflict can be addressed through a practice-based learning and improvement (PBL) program that develops competency in using treatment guidelines as decision aids and incorporating patient-specific information into treatment recommendations. This article describes and tests a program that is consistent with the ACGME's multilevel competency-based approach, targets students at four levels of training, and features progressive learning objectives and assessments. The program was pilot-tested with 22 paid volunteer psychiatric residents and fellows. They were introduced to a schizophrenia treatment guideline and reviewed six case vignettes of varying complexity. PBL assessments were based on how treatment recommendations were influenced by clinical and patient-specific factors. The task permitted separate assessments of learning objectives all four training levels. Among the key findings at each level, most participants found the treatment guideline helpful in making treatment decisions. Recommendations were influenced by guideline-based assessment criteria and other clinical features. They were also influenced by patients' perceptions of their illness, patient-based progress assessments, and complications such as stressors and coping patterns. Recommendations were strongly influenced by incongruence between clinical facts and patient experience. Practical understanding of how patient experience joins with clinical knowledge can enhance the use of treatment guidelines as decision tools and enable clinicians to appreciate more fully how and why patients' perceptions of their illness should influence treatment recommendations. This PBL program can assist training facilities in preparing students to cope with contradictory demands to both standardize and adapt their practice. The program can be modified to accommodate various disorders and a range of clinical factors and patient-specific complications.
Evidence-based medicine (EBM), one of the most important movements in health care, has been a lig... more Evidence-based medicine (EBM), one of the most important movements in health care, has been a lightning rod for controversy. Conflicts about the meaning and value of EBM are owing in part to lack of clarity about basic questions regarding its development, the importance of expertise and intuition, and the role of evidence in clinical decision making. These issues have persisted in part because of unclarity at the outset, but also because of how EBM evolved, why it was introduced when it was, and how it was modified following its introduction. This paper traces the evolution of EBM from clinical epidemiology (CE) and the internal dispute that precipitated the developers to establish EBM as a distinct approach to clinical practice. The paper proposes that health care industrialization also had a significant role in EBM's emergence and that industrialization influenced the decision to merge EBM with the method of normative decision making known as decision analysis (DA). The paper discusses the impact of this merger, in particular how it led to EBM's identification with managed care and has added momentum to the effort at forging a connection between a normative decision model and clinical judgement. This effort would turn clinical decision making into a conduit for bringing administrative rules and regulations into the consulting room and would result in expertise becoming a surplus skill. The paper closes by discussing a challenge yet unmet by EBM's advocates and critics-to chronicle the dangers that EBM in the framework of DA during the current era of industrialization poses to health and health care, and discover ways of unhinging the relationship between model and judgement.
Initiatives to improve the quality of healthcare delivery include the introduction of treatment g... more Initiatives to improve the quality of healthcare delivery include the introduction of treatment guidelines and the development of implementation science, which overcomes barriers in bringing evidence-based practices to routine clinical care. The implementation strategy is to identify impediments to guideline adherence, then develop means of changing behavior to increase conformance. Achievements to date have fallen short of the objectives, and the tactics oftentimes have provoked resistance. This response may illustrate the significance of the problem, but it may also indicate that the methods of implementation science tend to overstate the quality of evidence, ignore instances in which the appropriateness of a given practice cannot be clearly determined, and overlook the complexities of applying general knowledge to specific cases. This essay proposes that an inability to contextualize evidence is inherent to patient-oriented services research. The essay draws from discussions of d...
Treat‐to‐target (T2T) includes a target or goal, standard symptom assessment, and a treatment dec... more Treat‐to‐target (T2T) includes a target or goal, standard symptom assessment, and a treatment decision. In specialties that threat chronic pain, T2T is expected to be implemented collaboratively. The ability of patients to participate fully has been questioned, but these concerns have not been demonstrated empirically. The current study examined how patient self‐assessed symptom measures and illness beliefs affect their willingness to change their current treatment.
Social capital has played a prominent role in recent initiatives to improve mental health and enh... more Social capital has played a prominent role in recent initiatives to improve mental health and enhance the quality of services. However, efforts to substantiate a link between social capital and mental health have been daunted by equivocal findings and conceptual confusion. These consequences are in part due to having two prominent approaches that offer disparate and inconsistent accounts about what comprises social capital, how to increase it and how to use it to benefit mental health policy and practice. This paper lays the groundwork for a rapprochement.
The field of clinical decision making is polarized by two predominate views. One holds that treat... more The field of clinical decision making is polarized by two predominate views. One holds that treatment recommendations should conform with guidelines; the other emphasizes clinical expertise in reaching case-specific judgments. Previous work developed a test for a proposed alternative, that clinical judgment should systematically incorporate both general knowledge and patient-specific information. The test was derived from image theory's two phase-account of decision making and its "simple counting rule", which describes how possible courses of action are pre-screened for compatibility with standards and values. The current paper applies this rule to clinical forecasting, where practitioners indicate how likely a specific patient will respond favorably to a recommended treatment. Psychiatric trainees evaluated eight case vignettes that exhibited from 0 to 3 incompatible attributes. They made two forecasts, one based on a guideline recommendation, the other based on their own alternative. Both forecasts were predicted by equally-and unequally-weighted counting rules. Unequal weighting provided a better fit and exhibited a clearer rejection threshold, or point at which forecasts are not diminished by additional incompatibilities. The hypothesis that missing information is treated as an incompatibility was not confirmed. There was evidence that the rejection threshold was influenced by clinician preference. Results suggests that guidelines may have a de-biasing influence on clinical judgment. Subject to limitations pertaining to the subject sample and population, clinical paradigm, guideline, and study procedure, the data support the use of a compatibility test to describe how clinicians make patient-specific forecasts.
Reluctance to follow treatment guidelines was illustrated previously by a study in this journal t... more Reluctance to follow treatment guidelines was illustrated previously by a study in this journal that found a 5% endorsement rate for a medication-switching algorithm for treatment-resistant schizophrenia. The study presented here attempted to account for this low rate by using clinical vignettes to manipulate key factors. Twenty-one psychiatric residents responded to 64 vignettes. Expected progress and patient adherence to treatment were systematically manipulated within the vignettes, because they were most responsible for clinician decisions. Endorsement was analyzed using a fully crossed 4 x 2 within-subjects design. When expected progress and patient adherence were factored in, mean endorsement ranged from 5% to 87%. Adding guideline variables (short-term progress assessment, current condition, and guideline step) expanded the endorsement range from 1% to 90%. The low endorsement rate found previously is explained principally by the patient's expected progress. The brief report concludes by discussing ways to promote implementation when expected progress is only moderate.
Pain practice : the official journal of World Institute of Pain, 2013
This study describes how pain practitioners can elicit the beliefs that are responsible for patie... more This study describes how pain practitioners can elicit the beliefs that are responsible for patients' judgments against considering a treatment change and activate collaborative decision making. Beliefs of 139 chronic pain patients who are in treatment but continue to experience significant pain were reduced to 7 items about the significance of pain on the patient's life. The items were aggregated into 4 decision models that predict which patients are actually considering a change in their current treatment. While only 34% of study participants were considering a treatment change overall, the percentage ranged from 20 to 70, depending on their ratings about current consequences of pain, emotional influence, and long-term impact. Generalized linear model analysis confirmed that a simple additive model of these 3 beliefs is the best predictor. Initial opposition to a treatment change is a conditional judgment and subject to change as specific beliefs become incompatible with p...
Overrepresentation of minorities and their disproportionate confinement in the U.S. justice syste... more Overrepresentation of minorities and their disproportionate confinement in the U.S. justice system are pernicious, unyielding problems. The authors used the Structured Assessment of Violence Risk in Youth to examine risk and protective factors of 757 juveniles admitted to detention centers. A chi-square analysis revealed that significantly more African American youth were rated low risk for violence compared to White counterparts. African American and Hispanic youth initiated violent behavior earlier and frequently lived in violent, disorganized neighborhoods. However, they had more prosocial involvement, stronger attachments and bonds, and more resilient personality traits. Ideas for targeted release and intervention with minority youth are described.
Presentation at the International Symposium on the Philosophy and Ethics of Psychiatry, 2002
1st paragraph: Most practitioners and researchers in psychiatry and the related disciplines are s... more 1st paragraph: Most practitioners and researchers in psychiatry and the related disciplines are striving to understand how people feel, think and experience. Some may be satisfied with the lexicon of signs and symptoms, but most of us would concur with Strauss and Estroff (1989), who say that an inability to assist our understanding of subjective experience is a major failing of descriptive psychiatry. A number of efforts have been made to overcome this limitation, with many focusing on the concept of self. Almost inevitably, self is characterized as a polysemous concept, with a host of distinctions following close behind. The question before us is whether we need a special vocabulary to fully explore the concept of self, or whether ordinary language will suffice.
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Papers by Paul Falzer
Toulmin’s previous works speak extensively about medical and psychiatric practice, and Return to Reason is no exception. This proclivity alone makes his ideas worth examining, especially for those who are following or contributing to the rapidly evolving relationship between philosophy and psychiatry. My task in this review is to highlight some of the issues that Toulmin raises and draw out their historical context, give a brief surview of the book, and persuade the reader that the despite a few notable flaws, Return to Reason is a significant contribution to philosophy of science.
Toulmin’s previous works speak extensively about medical and psychiatric practice, and Return to Reason is no exception. This proclivity alone makes his ideas worth examining, especially for those who are following or contributing to the rapidly evolving relationship between philosophy and psychiatry. My task in this review is to highlight some of the issues that Toulmin raises and draw out their historical context, give a brief surview of the book, and persuade the reader that the despite a few notable flaws, Return to Reason is a significant contribution to philosophy of science.