Decision Science Roles in Medical Decision Making

Medical decisions are difficult for several reasons:

·         They involve multiple objectives, such as alleviating pain and suffering, quality of life, long term health impacts, cost, and so on.  

·         They involve numerous participants:  the patient, doctors, insurance companies, family, employers, and yes, even the government.  

·         More and more data (both good and not so good), is becoming available.  What information is more reliable and what treatments do the more reliable information support?

The question of who makes a medical decision is paramount.  Ideally, for most of us, it would be the patient, and ideally it would be a decision to select that alternative which best satisfies the patients objectives.  (A decreasing minority of people would like nothing to do making with the decision but just leave it up to the doctor).  Determining which alternative is ‘best’ is usually difficult because it requires a synthesis of tradeoffs among conflicting objectives, interpretation of opinions of more than one physician, and an understanding of the complex and often competing data and research results. 

Common practice today consists of a series of medical examinations, tests, and consultations, followed by a haphazard search for additional information.  The patient is often left weighing pros and cons that result from physician recommendations that are: conflicting, biased (naturally so since each understands their specialty best) , and constrained by cost/insurance considerations.  The patient must make a gut feeling choice after sleeping on an overload of information.  Moreover, the decision alternatives may be limited to a set of alternatives that have been pared down because of what some bureaucrat (does it matter if the bureaucrat works at an insurance company or the government?) has decided.

Newer techniques for helping patients decide are evolving.  These typically involve a more systematic way of gather information and presenting it to the patient (see “Weighty Choices, in Patients’ Hands”, Wall Street Journal, Aug 4, 2009 <http://online.wsj.com/article/SB10001424052970203674704574328570637446770.html>.  

However, even if the patient has the latest and best information, the decision is not likely to be one that best meets the patients objectives for at least two reasons.

First, and perhaps at the center of today’s debate on health care, is that patient  alternative choices need to be broadened by reducing restrictions imposed by insurance companies, government, and the ability to pay.  Vested interests are making it difficult to change from what is obviously a poorly functioning system where a patient is rarely even aware of the cost of alternative treatments, and  is sometimes even prevented from choosing  specific alternatives  which are deemed inappropriate by a third party.   Decision science has much too offer in this debate, but has contributed little thus far.

Second, in order for patients to make decisions that best meet their objectives, they must be able to synthesize data and information (much of which is very technical), physician opinions (sometimes from physicians in different fields, each only superciliously knowledgeable about fields outside their own), and most importantly, their own objectives (which are often conflicting).  

Medical decisions, are, by their very nature, subjective.  This is because the relative importance of the patients objectives differ from patient to patient.  But subjective doesn’t mean casual, sloppy, or inconsequential . Subjective simply means that the decision will differ from patient to patient.  There is, in fact, a single best choice for each patient.  Theoretically sound and practical techniques in the decision sciences, such as the Analytic Hierarchy Process,  have been shown to be able to help patients determine the alternative treatment best suited to their individual circumstances and objectives. (A Novel Computer Based Expert Decision-Making Model for Prostate Cancer Disease Management”, Journal of Urology 2005 Dec; 174(6) 2310-2318) http://linkinghub.elsevier.com/retrieve/pii/S0022534705009626.  Not only can such techniques help patients make decisions that best meet their objectives,  reassure patients that they are making the ‘best’ decision for them, are convincing to attending professionals and third parties who may be footing part or all of the bill, but the decisions can actually be less costly to the patient, insurance companies and the government alike.  The use of such techniques is likely to become widespread in the not to distant future.