Shamy Michel C F, Pugliese Michael, Meisel Karl, Rodriguez Rosendo, Kim Anthony S, Stahnisch Frank W, Smith Eric E
From the Department of Medicine (M.C.F.S., R.R.) and Division of Neurology (M.C.F.S.), and School of Public Health, Preventive Medicine and Epidemiology (M.C.F.S., M.P.), University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (M.C.F.S., R.R.); Department of Neurology, University of California San Francisco (K.M., A.S.K.); and Department of History (F.W.S.), Department of Community Health Sciences (F.W.S., E.E.S.), and Department of Clinical Neurosciences (E.E.S.), University of Calgary, Alberta, Canada.
Stroke. 2016 Aug;47(8):2051-7. doi: 10.1161/STROKEAHA.116.013344. Epub 2016 Jun 30.
Understanding physician decision making is increasingly recognized as an important topic of study, especially in stroke care. We sought to characterize the process of acute stroke decision making among neurologists in the United States and Canada from clinical and epistemological perspectives.
Using a factorial design online survey, respondents were presented with clinical data to mimic an acute stroke encounter. The history, examination, computed tomographic (CT) scan, CT angiogram, and CT perfusion were presented in sequence, and respondents rated their diagnostic confidence and likelihood of treatment with tissue-type plasminogen activator after each element. Patient age, race, sex, and CT perfusion imaging results were randomized, whereas the rest of the clinical presentation was held constant.
We collected 715 responses, of which 473 (66%) were complete. Diagnostic certainty and likelihood of treatment with tissue-type plasminogen activator rose incrementally as additional clinical data were provided. Diagnostic certainty and treatment likelihood were strongly influenced by the clinical history and the CT scan. Other factors such as physicians' personal beliefs or biases were not influential. Respondents' accuracy in interpreting CT angiographic and CT perfusion images was variable and generally low.
Diagnostic certainty and likelihood of treatment with tissue-type plasminogen activator increase with additional clinical data, with the history being the most important factor for diagnostic and treatment decisions. Respondents had difficulty in interpreting the results of CT perfusion scans although they had little impact on treatment decisions. We did not identify treatment bias based on patient age, race, or sex.
理解医生的决策过程日益被视为一个重要的研究课题，尤其是在中风治疗方面。我们试图从临床和认识论的角度描述美国和加拿大神经科医生急性中风决策的过程。
采用析因设计在线调查，向受访者呈现临床数据以模拟急性中风诊疗过程。依次展示病史、体格检查、计算机断层扫描（CT）、CT血管造影和CT灌注成像，受访者在看到每个项目后对其诊断信心以及使用组织型纤溶酶原激活剂治疗的可能性进行评分。患者的年龄、种族、性别和CT灌注成像结果是随机的，而其余临床表现保持不变。
我们收集了715份回复，其中473份（66%）完整。随着更多临床数据的提供，诊断确定性和使用组织型纤溶酶原激活剂治疗的可能性逐渐增加。诊断确定性和治疗可能性受临床病史和CT扫描的强烈影响。医生的个人信念或偏见等其他因素没有影响。受访者解读CT血管造影和CT灌注图像的准确性参差不齐，总体较低。
随着更多临床数据的提供，诊断确定性和使用组织型纤溶酶原激活剂治疗的可能性增加，病史是诊断和治疗决策的最重要因素。尽管CT灌注扫描结果对治疗决策影响不大，但受访者在解读其结果方面存在困难。我们未发现基于患者年龄、种族或性别的治疗偏见。
