Bringing social structure back into clinical decision making.

Although research in the past twenty years has resulted in an increasingly sophisticated understanding of clinical decision making processes, the dominant approach in this area of inquiry remains limited. Most studies emphasize normative models of how decisions ought to be made, others attempt to describe physicians' thinking, but few take the social context of decision making systematically into account. Research models typically assume that physicians are autonomous professionals practicing in socially insular clinical settings--an approach that is consistent with classic formulations of the social structure of medical practice, but they ignore 30 years of sociological research on research on patient-physician relationships and major historical changes in the structure of medical practice. Eisenberg's still timely advice to students of clinical decision making--that they need to describe decision making in the context of 'sociologic influences' (including patient, physician and practice setting characteristics)--is expanded in the present discussion. Recent studies are reviewed, highlighting important dimensions of social structure impinging on physicians' decision making. Findings indicate that the process of clinical decision making is likely influenced by patients' age, gender, socioeconomic status, and race, physicians' professional training and experience, as well as by larger structural features of organized clinical settings. Our review of these studies on the social context of clinical decision making, however, reveals major methodological limitations including those inherently imposed by secondary data analysis, normative approaches, written case vignettes, small, non-random samples and the inadequate control of confounding influences. We present a feasible, alternative research strategy, built on a factorial experimental design. Illustrative findings indicate how complex social structural influence on clinical decision making may be disentangled in an unconfounded manner.