Search

Decision analysis is a tool that clinicians can use to choose an option that maximizes the overall net benefit to a patient. It is an explicit, quantitative, and systematic approach to decision making under conditions of uncertainty. In this article, we present two teaching tips aimed at helping clinical learners understand the use and relevance of decision analysis. The first tip demonstrates the structure of a decision tree. With this tree, a clinician may identify the optimal choice among complicated options by calculating probabilities of events and incorporating patient valuations of possible outcomes. The second tip demonstrates how to address uncertainty regarding the estimates used in a decision tree. We field tested the tips twice with interns and senior residents. Teacher preparatory time was approximately 90 minutes. The field test utilized a board and a calculator. Two handouts were prepared. Learners identified the importance of incorporating values into the decision-making process as well as the role of uncertainty. The educational objectives appeared to be reached. These teaching tips introduce clinical learners to decision analysis in a fashion aimed to illustrate principles of clinical reasoning and how patient values can be actively incorporated into complex decision making.

Background: Clinical prediction rules (CPR) are tools that clinicians can use to predict the most likely diagnosis, prognosis, or response to treatment in a patient based on individual characteristics. CPRs attempt to standardize, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. The teaching tips series is designed to give teachers advice and materials they can use to attain specific educational objectives., Educational Objectives: In this article, we present 3 teaching tips aimed at helping clinical learners use clinical prediction rules and to more accurately assess pretest probability in every day practice. The first tip is designed to demonstrate variability in physician estimation of pretest probability. The second tip demonstrates how the estimate of pretest probability influences the interpretation of diagnostic tests and patient management. The third tip exposes learners to various examples and different types of Clinical Prediction Rules (CPR) and how to apply them in practice. PILOT TESTING: We field tested all 3 tips with 16 learners, a mix of interns and senior residents. Teacher preparatory time was approximately 2 hours. The field test utilized a board and a data projector; 3 handouts were prepared. The tips were felt to be clear and the educational objectives reached. Potential teaching pitfalls were identified., Conclusion: Teaching with these tips will help physicians appreciate the importance of applying evidence to their every day decisions. In 2 or 3 short teaching sessions, clinicians can also become familiar with the use of CPRs in applying evidence consistently in everyday practice.

Objective: To determine if a simple educational intervention can increase resident physician literature search activity., Design: Randomized controlled trial., Setting: University hospital-based internal medicine training program., Patients/participants: Forty-eight medical residents rotating on the general internal medicine service., Interventions: One-hour didactic session, the use of well-built clinical question cards, and practical sessions in clinical question building., Measurements and Main Results: Objective data from the library information system that included the number of log-ons to medline, searching volume, abstracts viewed, full-text articles viewed, and time spent searching. Median search activity as measured per person per week (control vs intervention): number of log-ons to medline (2.1 vs 4.4, P <.001); total number of search sets (24.0 vs 74.2, P <.001); abstracts viewed (5.8 vs 17.7, P=.001); articles viewed (1.0 vs 2.6, P=.005); and hours spent searching (0.8 vs 2.4, P <.001)., Conclusions: A simple educational intervention can markedly increase resident searching activity.

Objective: To measure the impact of a teaching intervention and to compare process and outcomes of care for HIV-infected patients randomly assigned to a general medicine clinic (GMC) or an infectious disease clinic (IDC) for primary care., Design: Prospective, randomized, controlled trial., Setting: University hospital in Durham, NC., Patients: Two hundred fourteen consecutive HIV-infected patients presenting for primary care., Intervention: Physicians at the GMC received HIV-related training and evidence-based practice guidelines., Measurements: Utilization of services, health-related quality of life, preventive and screening measures, and antiretroviral use for one year., Results: At baseline GMC patients were more likely to be African American (85% vs 71%; P =.03) and had lower baseline CD4+ cell counts than IDC patients (262 +/- 269 vs 329 +/- 275; P =.05). A similar and high proportion of patients in both groups received appropriate preventive care services including Pneumocystis carinii pneumonia (PCP) prophylaxis, pneumococcal vaccination, and antiretroviral therapy. Screening for TB was more frequent in GMC (89% vs 68%; P =.001). In the year following randomization, GMC patients made more visits to the emergency department than IDC patients (1.6 +/- 3.0 vs 0.7 +/- 1.5; P =.05). Hospital use was higher for GMC patients with average length of stay 7.8 +/- 6.3 days compared to 5.7 +/- 3.8 days for IDC patients (P =.01). In analyses, which adjust for potential baseline imbalances, these differences remained., Conclusions: Targeted education in GMC achieved similar provision of primary care for GMC patients, yet use of health care services was higher for this group. The delivery of adequate primary care is necessary but not sufficient to produce changes in health care utilization.

Main Results: Compared with younger patients, patients aged 50 years or older were less likely to have acquired HIV via intravenous drug use or homosexual contact (p = .0001). Older patients were more likely to have comorbid diseases (12% vs 4%; p = .0001), had more frequent neurologic findings on admission (19% vs 9%; p = .0001), and scored higher on a PCP-specific severity-of-illness scale indicating more severe disease (p = .0001). Older patients had more intensive care unit admissions and intubations (p = .0001). Patients aged 50 years or older were less likely to have a diagnosis of HIV mentioned in their progress notes during the first 2 days of admission (75% vs 85%; p = .0001), less likely to receive PCP-specific therapy within the first 2 hospital days (58% vs 76%; p = .0001), and more likely to receive steroids (32% vs 22%; p = .0001). Older patients had a greater in-hospital mortality (32% vs 18%; p = .0001). However, in logistic regression analysis with mortality as the outcome, the effect of older age was diminished when adjustments were made for insurance status, severity of illness, comorbidity, timely PCP therapy, and inpatient use of steroids., Conclusions: Age differences in mortality for AIDS-related PCP may be explained by increased severity of presenting illness, underrecognition of HIV, and delay in initiation of PCP-specific therapy. Physicians may need to consider HIV-related infections for persons aged 50 years or older at risk of HIV infection.