Physician, choosing

Dominance is perhaps the most fundamental normative decision rule. Dominance is said to occur between two alternative actions A and Aj when A is at least as good as Aj for aU events E, tmd for at least one event E, Aj is preferred to Aj. For example, one investment might yield a better return than another regardless of whether the stock market goes up or down. Dominance can tilso be described for the case where the consequences are multidimensional. This occurs when for till events E, the kth consequence associated with action i (Cjj) and action j (Cj,), satisfies the relation Cj a Cj. for all kf and for at least one consequence > C, - For example, a physician choosing between alternative treatments has an easy decision if one treatment is both cheaper and more effective for all patients. 

The epidemiological studies that establish the basic validity of dose—toxic response relationships at low exposures also establish the validity of general causality of various adverse effects by lead. Equally important, such studies also establish the validity of a physician choosing to include lead-related effects when articulating a diagnosis of specific causality of some effect in a given patient. 

Surveys can help to define the components of disclosure that matter most to patients and their families (1) disclosure of all harmful errors, (2) an explanation as to why the error occurred, (3) how to minimize the error s effects, and (4) steps the physician and organization will take to prevent recurrences. Full disclosure of an error incorporates these components as weU as acknowledgement of responsibility and an apology by the physician. Many physicians choose their words carefully by failing to clearly explain the error or its effects on the patient s health. Circumstances surrounding an error can become complex. Physicians may not know how much information to disclose and how to explain the error to the patient. Recently developed guidelines should assist physicians with this process. Since 2001, the Joint Commission requires disclosure of unanticipated outcomes of care. In 2006, the National Quality Forum endorsed fuU disclosure of serious unanticipated outcomes as one of its 30 safe practices for healthcare. 

Some families and physicians may choose to use several brain protecting medications. We advise caution here. Medications, even over-the-counter herbs like ginkgo biloba, have side effects, and combining multiple medications (although sometimes necessary) increases the risk of delirium and other medical complications in these often-fragile patients. 

For infections frequently encountered outside hospitals, e.g. uncomplicated urinary tract infection in young women, surveillance of resistance data of the most likely pathogens Escherichia coli) allows physicians to prescribe empiric therapy without performing cultures in the individual patient. However, in severely ill hospitalised patients, it is necessary to take samples for culture before starting empiric therapy. Microscopy of the Gram stained smear can help fine-tune empiric therapy at an early stage. Whether the infection is community-acquired or hospital-acquired, and whether the patient has been exposed to previous antimicrobial therapy should also be taken into account when choosing empiric therapy. 

Beran, Mary Sue, Marianne Laouri, and Marika Suttorp. Brief Reports Medication Costs The Role Physicians Play with Their Senior Patients. Journal of the American Geriatrics Society 55, no. 1 (January 2007) 102— 107. How often do physicians discuss costs when choosing medications for senior patients A survey of 678 doctors found that they rarely discussed prices and, when they did, patients usually initiated the topic. The discussion typically results in recommending generic drugs and offering free samples. 

In the case of Ritalin, physicians also have a pragmatic reason for choosing the drug over more time-consuming treatments, such as individual or family therapy. In today s system of managed care, physicians can lose money if they spend too much time with particular patients or give referrals for specialists. In this situation, Ritalin seems to be the perfect solution, and because Ritalin has a quick effect on disruptive children, parents and teachers tend to agree. 

Pharmacies are continually looking for new and better ideas to differentiate themselves from other retail outlets and to offer additional health care services to their customers. The addition of in-store medical clinics allows customers to receive medical care that is quick, inexpensive, and convenient (Fig. 23-7). Staffed by nurse practitioners and physician assistants that have prescribing authority, patients can choose from a posted list of services provided, receive treatment, and be on their way in less time than at a medical clinic or emergency room. Patients who need OTC or prescription items can pick up these items right in the store. 

The use of standard dosage charts on nursing units in institutions and standard formulations in the pharmacy minimizes the possibility of error and makes calculations much easier. For example, in critical care units, physicians need to order only the amount of drug they want infused and list any titration parameters. No one has to perform any calculations because dosage charts can be readily available for choosing appropriate flow rates by patient weight (in kilograms) and dose ordered. 

Studies have shown that within the first month of treatment, roughly one third of patients will abandon medication treatment At the conclnsion of four months, approximately half of patients will do the same (Lin et ah, 1995). This is an nnfortnnate resnlt for a treatment that in most patients shonld last at least a year. There are many reasons patients choose to discontinne medication treatment in spite of their physicians advice to continne. The issne is complex and mnltifactorial (Table 3.9). 

The risk of switching into mania, once the patient has emerged from depression, continues to be a factor in treatment considerations. Physicians often choose to discontinue the antidepressant relatively soon after recovery and to continue treatment with the mood stabilizer alone, in order to diminish this risk. This approach is diametrically opposed to the strategies for unipolar depression, where antidepressant treatment must continue at least for 1 year and often longer. 

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