McKinlay John B, Lin Ting, Freund Karen, Moskowitz Mark
New England Research Institutes, 9 Galen St., Watertown, MA, USA.
J Health Soc Behav. 2002 Mar;43(1):92-106.
This experiment was designed to determine: (1) whether patient attributes (specifically a patient's age, gender, race, and socioeconomic status) independently influence clinical decision-making; and (2) whether physician characteristics alone (such as their gender, age, race, and medical specialty), or in combination with patient attributes, influence medical decision-making.
An experiment was conducted in which 16 (= 2(4)) videotapes portraying patient-physician encounters for two medical conditions (polymyalgia rheumatica (PMR) and depression) were randomly assigned to physicians for viewing. Each video presented a combination of four patient attributes (65 years or 80 years of age; male or female; black or white; blue or white collar occupation). Steps were taken to enhance external validity. One hundred twenty-eight eligible physicians were sampled from the northeastern United States, with numbers balanced across 16 (= 2(4)) strata generated from the following characteristics (male or female; < 15 or > or = 15 years since graduation; black or white; internists or family practitioners). The outcomes studied were: 1) the most likely diagnosis; 2) level of certainty adhering to that diagnosis; and 3) the number of tests that would be ordered.
Patient attributes (namely age, race, gender, and socioeconomic status) had no influence on the three outcomes studied (the most likely diagnosis, the level of certainty, and test ordering behavior). This was consistent across the two medical conditions portrayed (PMR and depression). In contrast, characteristics of physicians (namely their medical specialty, race, and age) interactively influenced medical decision-making.
Epidemiologically important patient attributes (which Bayesian decision theorists hold should be influential) had no effect on medical decision-making for the two conditions, while clinically extraneous physician characteristics (which should not be influential) had a statistically significant effect. The validity of idealized theoretical approaches to medical decision making and the usefulness of further observational approaches are discussed.
本实验旨在确定：（1）患者属性（具体为患者的年龄、性别、种族和社会经济地位）是否独立影响临床决策；以及（2）仅医生特征（如他们的性别、年龄、种族和医学专业），或与患者属性相结合，是否会影响医疗决策。
进行了一项实验，将16部（=2(4)）描绘两种医疗状况（风湿性多肌痛（PMR）和抑郁症）患者与医生诊疗过程的录像带随机分配给医生观看。每个视频呈现了四种患者属性的组合（65岁或80岁；男性或女性；黑人或白人；蓝领或白领职业）。采取了措施以提高外部效度。从美国东北部抽取了128名符合条件的医生，根据以下特征（男性或女性；毕业少于15年或大于或等于15年；黑人或白人；内科医生或家庭医生）在16个（=2(4)）层次中进行数量平衡抽样。研究的结果包括：1）最可能的诊断；2）对该诊断的确信程度；以及3）将开出的检查项目数量。
患者属性（即年龄、种族、性别和社会经济地位）对所研究的三个结果（最可能的诊断、确信程度和检查开具行为）没有影响。这在描绘的两种医疗状况（PMR和抑郁症）中都是一致的。相比之下，医生特征（即他们的医学专业、种族和年龄）交互影响医疗决策。
从流行病学角度看重要的患者属性（贝叶斯决策理论家认为应该有影响）对这两种状况的医疗决策没有影响，而临床上无关的医生特征（不应有影响）却有统计学上的显著影响。讨论了理想化的医疗决策理论方法的有效性以及进一步观察方法的实用性。
