Tag Archives: medical decision making

cancerBy H. Roger Segelken
Reprinted from Cornell Chronicle, March 25, 2015

The doctor says: “We offer two kinds of surgery for your cancer. Both procedures have 80 percent cure rates. After the first kind, 4 percent of patients have serious complications. In the second type, 20 percent simply die. No pressure to decide, but the sooner we start …”

Wishing you hadn’t slept through statistics class – trying to remember what went wrong with Uncle Joe’s surgery, and longing for the days when doctors knew best – you seek counsel in a decision-support tool, online or at the nearest cancer resource center.

“In fact, there are more than 40 tools to help people make informed decisions in cancer prevention, screening and treatment,” says Valerie F. Reyna, professor of human development in Cornell’s College of Human Ecology. “The more effective decision-support aids help with the numeracy problem – is a 10 percent chance riskier than one in a thousand? But not all tools help patients use their values, emotions and life experience to make decisions that affect their lives and their families’ future.”

Writing in the February-March 2015 special issue of American Psychologist, in an article titled “Decision Making and Cancer,” Reyna and her research colleagues want support tools to accommodate what they call “bottom-line gist options” that swirl though a patient’s mind – along with “verbatim” details about probable risk and whatever else the doctor said.

Gist is at the core of Fuzzy Trace Theory (which Reyna applied most recently to patients’ decisions to take antibiotics even though the misery is probably caused by viruses, not bacteria), and there’s nothing wrong with listening to one’s heart, Reyna says.

Reyna and her co-authors explain that “gist involves understanding meaning (insight in the gestalt sense) – integrating dimensions of information to distill its essence, not just processing fewer dimensions of information that are ‘good enough.’” Although people incorporate both verbatim details and gist in decision making, “they generally have a fuzzy processing (gist) preference” for information, the authors report.

The researchers offer this prescription for a Fuzzy Trace Theory-based cancer-decision tool: Ensure that patients understand the essential gist meaning of information; remind patients of an array of simple social and moral values that are important to them and that have relevance to the decision at hand; and assist patients in applying their values throughout the decision process.

“Every phase of the cancer continuum – from prevention, screening and diagnosis to treatment, survivorship and end of life – is fraught with challenges to our abilities to make informed decisions,” says Reyna. “People are not optimal decision makers. We struggle with complex information about benefits and risks, tradeoffs and uncertainties in cancer treatment.”

An impassionate computer could make optimal decisions on our behalf – disregarding the gist of what we think is best for us, Reyna adds. But the computer is too literal to make the best decisions for people, Reyna says: “Decision support should strive to capture the gist, the essential bottom line, of patients’ options.”

Reyna, director of the Human Neuroscience Institute in the College of Human Ecology, is the first author on the paper along with Wendy L. Nelson, National Cancer Institute; Paul K. Han, Maine Medical Center, Scarborough, Maine; and Michael P. Pignone, University of North Carolina at Chapel Hill.

Preparation of the American Psychologist report was supported, in part, by awards from the National Cancer Institute of the National Institutes of Health and the National Institute of Nursing Research.

By H. Roger Segelken
Reprinted from Cornell Chronicle, December 16, 2014

When the doctor says, “I could prescribe antibiotics for your sniffles, but it’s probably a virus – not bacterial,” do you decline? Many patients expect antibiotics, although overprescription is a major factor driving one of the biggest public health concerns today: antibiotic resistance.

Now researchers at Cornell, George Washington and Johns Hopkins universities have figured out why: “Patients choose antibiotics because there’s a chance [prescription medications] will make them better, and they perceive the risks of taking antibiotics as negligible,” says Cornell psychologist Valerie Reyna.

With her co-authors, the professor of human development has published new research with important implications for communicating about antibiotics: “Germs Are Germs, and Why Not Take a Risk? Patients’ Expectations for Prescribing Antibiotics in an Inner-City Emergency Department,” in the journal Medical Decision Making.

That’s encouraging news for health educators, Reyna says, noting: “Patients might expect doctors to prescribe antibiotics because patients confuse viruses and bacteria – and think antibiotics will be effective for either. Most educational campaigns attempt to educate patients about this misconception. However, we found fewer than half of patients in an urban ER agreeing with the message, ‘germs are germs.’”

Patients who understand the difference between viruses and bacteria – and take antibiotics anyway – are making a strategic risk assessment, Reyna says: “Our research suggests that antibiotic use boils down essentially to a choice between a negative status quo – sick for sure – versus taking antibiotics and maybe getting better. This risk strategy promotes antibiotic use, particularly when taking antibiotics is perceived as basically harmless.”

Fuzzy-trace theory

The Broniatowski-Klein-Reyna study is the first to apply “fuzzy-trace” theory to how people think about antibiotics. The theory predicts that patients make decisions based on the gist (or simple bottom line) of information.

As Reyna explains: “The goal is to make better decisions, getting antibiotics to patients who need them but not overusing them so the rest of the public is safe. Understanding how patients think is crucial because their expectations influence doctors’ decisions.”

Adds David Broniatowski, assistant professor of engineering management and systems engineering at GWU, and the report’s first author: “We need to fight fire with fire. If patients think that antibiotics can’t hurt, we can’t just focus on telling them that they probably have a virus. We need to let them know that antibiotics can have some pretty bad side effects, and that they will definitely not help cure a viral infection.”

The third author is Dr. Eili Klein, assistant professor in the Department of Emergency Medicine at the Johns Hopkins University and a fellow at the Center for Disease Dynamics, Economics and Policy.

Reyna is the director of the Human Neuroscience Institute, co-director of the Cornell University Magnetic Resonance Imaging Facility, and a co-director of the Center for Behavioral Economics and Decision Research, all in the College of Human Ecology. She is a developer of “fuzzy-trace theory,” a model of the relation between mental representations and decision making that has been widely applied in law, medicine and public health.

The study was supported, in part, by funds from the National Institutes of Health and the U.S. Department of Homeland Security.

By Karene Booker
Reprinted from Cornell Chronicle, May 29, 2014

A screen shot from the BRCA Gist (Web-tutor) video tutorial that is designed to help explain the incidence of breast cancer in people with the BRCA mutations.

A screen shot from the BRCA Gist (Web-tutor) video tutorial that is designed to help explain the incidence of breast cancer in people with the BRCA mutations.

About one in eight American women will be diagnosed with breast cancer during her lifetime – more than 200,000 this year alone. A simple blood test can determine if a woman faces increased risk due to genetic mutations, yet decisions about whether to get the test and what to do about the results are far from simple – a fact exemplified by Angelina Jolie’s choice to undergo a double mastectomy last year upon learning she carried a harmful BRCA1 gene mutation.

To help women grappling with these decisions, Cornell psychologist Valerie Reyna and colleagues developed a computer-based system using artificial intelligence to mimic one-on-one human tutoring.

“To our knowledge, this is the first use of an Intelligent Tutoring System (ITS) in patients’ medical decision making,” said Reyna, professor of human development and director of the Human Neuroscience Institute in Cornell’s College of Human Ecology.

The breast cancer Web-tutor, called BRCA Gist (Breast Cancer Genetics Intelligent Semantic Tutoring), is more effective in helping women understand breast cancer risk and their options than traditional educational materials, reports a study published online May 14 in Medical Decision Making ahead of print.

BRCA Gist provides customized instruction on breast cancer and how it spreads, risk factors, genetic mutation testing and the consequences of testing using an animated talking avatar that engages women in “dialogue” about breast cancer and can even answer women’s questions.

The Web-tutor draws on well-vetted, publically available information and expert advice from physicians, “but the crucial added ingredient,” said Reyna, “is that it effectively conveys the bottom-line or gist of the information.” And that’s what people rely on to make medical decisions, not detailed facts, she said. The key to the Web-tutor’s success, she added, is its basis in fuzzy-trace theory, a model of memory and decision-making that she developed.

To test the Web-tutor’s effectiveness, the researchers conducted two randomized-control trials involving more than 400 women. The studies measured knowledge gains and decisions about genetic testing after completing the new Web-based tutorial, viewing the comparable information from the National Cancer Institute (NCI) website or completing an unrelated Web-based curriculum.

The team found that those who participated in the Web-tutor scored higher on knowledge of breast cancer, genetic testing and genetic risk than those using the NCI website, and both groups scored higher than the control group. In making judgments about genetic testing for those with no risk, the Web-tutor helped participants understand that most women do not have known genetic risks and are not good testing candidates, the authors say. Their results support the concept that a gist-based intervention powered by artificial intelligence can be an effective tool to aid patients’ medical decision-making, they concluded.

The study, “Efficacy of a Web-based Intelligent Tutoring System for Communicating Genetic Risk of Breast Cancer,” was supported by the National Cancer Institute and the National Institutes of Health. The co-authors are Christopher Wolfe, Colin Widmer, Elizabeth Cedillos, Christopher Fisher and Audrey Weill of Miami University of Ohio, and Cornell graduate student Priscila Brust-Renck.

Karene Booker is an extension support specialist in the Department of Human Development.

Related Links:
Valerie Reyna
The Paper

By Karene Booker
Reprinted from Cornell Chronicle, February 19, 2014

Pillemer

Pillemer

A low-cost, six-week program that teaches people how to manage pain and stay active has proven to reduce arthritis pain and disability, yet few of the nation’s 50 million adult arthritis sufferers have used it. By enhancing the program’s content and delivery with the help of community partners, Cornell researchers report that attendance improved dramatically, and participants were significantly more likely to stay in the modified program compared to the original, while experiencing the same physical and mental health improvements.

“Effective health programs may not reach people who need them due to factors such as culture, language, age or income, but changing programs to meet the needs of new target populations can make a dramatic difference,” said study co-author Karl Pillemer, professor of human development in Cornell’s College of Human Ecology.

The study, which was published in February in the Musculoskeletal Journal of the Hospital for Special Surgery (Vol. 10:1), focuses on the Arthritis Self-Management Program, also known as the Arthritis Self-Help Course.

Reed

Reed

“To our knowledge, this is the first controlled study to directly compare the effects of an adapted chronic disease self-management program with the original,” said co-author Dr. M. Carrington Reid, associate professor in geriatrics at Weill Cornell Medical College. He added that rigorously evaluating modified programs such as this one to ensure they still deliver the expected benefits is rare, but critical.

To modify the underutilized program, Reid, Pillemer and his colleagues collaborated with a team of staff from local agencies and senior centers, older adults and program instructors. The team incorporated nearly 40 enhancements suggested by program participants and instructors, such as adding in-class exercise practice and individual action plans to make use of local health programs, expanding information on healthy eating and weight management, and simplifying reading materials.

The adapted and original versions were tested with 201 older adults, with baseline data collected at the beginning, at program completion and 18 weeks later. While both groups experienced equivalent relief in pain, stiffness and perceived disability, attendance in the adapted program improved by 46 percent, and participants were 26 percent more likely to stay in the modified program than in the original.

That means that the modified program could have significantly more reach and impact, the authors say. Their findings not only underscore the value of involving local stakeholders in tailoring interventions to specific populations, but also the importance of conducting controlled experiments to quantify the results, they say. Furthermore, they add, their findings highlight the potential of relatively simple programs to help build self-efficacy for arthritis management and improve quality of life.

The study, “Measuring the Value of Program Adaptation: A Comparative Effectiveness Study of the Standard and a Culturally Adapted Version of the Arthritis Self-Help Program,” was also co-authored by graduate student Emily Chen and senior research associate Charles Henderson of Cornell, and Samantha Parker of Tulane University School of Medicine. It was supported in part by the National Institute of Nursing Research and the National Institute on Aging.

Karene Booker is an extension support specialist in the Department of Human Development.

Related Information:

 

       
By Karene Booker

Reyna

Despite the success of vaccines in preventing a long list of diseases, why is opposition to vaccination gaining hold? Decision-making expert Valerie Reyna contends that it’s because anti-vaccination messages tell a compelling story compared with official sources, and they meet people’s need to understand rare adverse outcomes.

A Google search of “vaccine,” for example, produces links to government and science-based vaccine websites on the same screen as official-sounding anti-vaccination links.

Given the success of vaccines in preventing a long list of diseases, why is opposition to vaccination gaining hold? Decision-making expert Valerie Reyna contends that it's because anti-vaccination messages tell a compelling story compared to official sources, and they meet people's need to understand rare adverse outcomes.

"In the era of Web 2.0, the contagion of ideas, transmitted rapidly through social media, is as concerning as the contagion of diseases because of their power to reduce vaccination rates, leaving populations vulnerable to preventable death and disability," said Reyna, professor of human development in the College of Human Ecology and a co-director of the Center for Behavioral Economics and Decision Research.

This spring, the Centers for Disease Control reported that the United States is experiencing the highest number of measles cases in more than a decade. According to the alert, measles was declared eliminated in the United States in 2000 due to a high vaccination rate. This could change should vaccination rates decline.

Reyna presented her model of vaccine decisions at the University of Erfurt, Germany, in May to an international meeting of scientists examining the implications of the Internet and social media such as Twitter on public health messages about vaccination.

Being informed about vaccines involves more than having the facts. According Reyna's research, people primarily rely on the meaning or "gist" of a situation rather than details to make judgments and decisions.

"Gist is simple, but not simple-minded," Reyna said. "It involves connecting the dots -- building on background knowledge, life experience and values. When people lack background knowledge, they tend to rely on anecdotes, personal experience and the little information that is widely available."

Since most people don't understand how vaccines work, the Internet, which facilitates users across the globe to sharing personal experiences and ideas about health care, fills the vacuum.

According to Reyna, anti-vaccination messages are expected when people don't understand how vaccination works and when adverse events that are difficult to explain appear to be connected. Autism, for example, is diagnosed in children during the same time period that children receive a battery of vaccinations. Despite research to the contrary, anti-vaccination messages have claimed vaccines are to blame. Official sites, on the other hand, tend not to provide a convincing narrative story line that helps people connect the dots.

Under these circumstances, how do people approach the decision to vaccinate? In Reyna's model, the decision to get a flu shot, for example, could be a seen as a decision between feeling OK (by not getting the vaccine) or taking a chance on not feeling OK (due to a vaccine side effect). Without better information, many people would choose not to get a vaccine.

"Public health messages need to be designed so that the correct 'gist' pops out," Reyna said, "because the drive to extract meaning, combined with widespread lack of background knowledge about how vaccination works, is fertile ground for misleading explanations to take root."

The conference was supported by grants from the German Science Foundation, the European Center of Disease Prevention and Control, the University of Erfurt and other sources.

Karene Booker is extension support specialist in the Department of Human Development.

Related Links:
College of Human Ecology
Department of Human Development
Valerie Reyna