Dr. Tait is the Department of Anesthesiology Endowed Professor of Clinical Research. Dr. Tait is a former long-standing member of the Institutional Review Board and a current member of the Medical School Admissions Executive Committee. In addition, Dr. Tait is the Chair of the Research Committee for the Society for Pediatric Anesthesia.
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Brian Zikmund-Fisher, Angela Fagerlin, Nicole Exe, and Knoll Larkin have been involved in the Visualizing Health Project, which has recently launched an online style guide for communicating health data. You can check it out at: www.vizhealth.org
The Visualizing Health project was a short and highly intense project funded by the Robert Wood Johnson Foundation designed to push the envelope both in considering visual designs for communicating health risk data and in developing iterative research approaches for testing them. The project involved a large team combining researchers and staff from both the University of Michigan's Center for Health Communications Research and the Center for Bioethics and Social Sciences in Medicine. The UM team then worked closely on a week by week basis with Thomas Goetz (former editor of Wired magazine) who envisioned the project, Tim Leong (graphic designer, author of Super Graphic), Andrea Ducas from the Robert Wood Johnson Foundation, and teams of graphic designers that Tim recruited.
They created 16 distinct visual data display tasks related to health risks, had teams of graphic designers develop display concepts, and iteratively tested these displays using multiple online survey methodologies. The resulting designs and data were then assembled in a project website that included all the images, plus commentary and additional features such as a design "wizard" to help guide users to visual displays that best fit their personal needs.
Also, see the Robert Wood Johnson Foundation Culture of health blog.
Click to decide between death and living with a colostomy. Which would you choose? Are you sure?
Given the choice, would you choose immediate death,or living with a colostomy (where part of your bowel is removed and you have bowel movements into a plastic pouch attached to your belly)?
- Immediate Death
Think about what it would be like if you were diagnosed with colon cancer. You are given the option of choosing between two surgical treatments.The first is a surgery that could result in serious complications and the second has no chance of complications but has a higher mortality rate.
|Possible outcome||Surgery 1
|Cure without complication||80%||80%|
|Cure with colostomy||1%|
|Cure with chronic diarrhea||1%|
|Cure with intermittent bowel obstruction||1%|
|Cure with wound infection||1%|
|No cure (death)||16%||20%|
If you had the type of colon cancer described above, which surgery do you think you would choose?
- Surgery 1
- Surgery 2
How do your answers compare?
Are you saying what you really mean?
CBDSM investigators Brian Zikmund-Fisher, Angela Fagerlin, Peter Ubel, teamed up with Jennifer Amsterlaw, to see if they could reduce the number of people choosing the surgery with the higher rate of death and therefore reducing the discrepancy. A large body of past research has shown that people are notoriously averse to uncertainty. The investigators had a hunch that uncertainty could account for some of the discrepancy. Surgery 1 has a greater number of ambiguous outcomes, perhaps causing people to be averse to it. In an effort to minimize this uncertainty, the investigators laid out a series of scenarios outlining different circumstances and presentations of the two surgeries. For example the research presented some of the participants with a reframing of the surgery information, such as:
|Possible outcome||Surgery 1
|Cured without complication||80%||80%|
|Cured, but with one of the following complications: colostomy, chronic diarrhea, intermittent bowl obstruction, or wound infection||4%|
|No cure (death)||16%||20%|
The investigators believed by grouping all of the complications together that people would be more apt to chose the surgery with the lower mortality rate, because seeing a single group of undesirable outcomes, versus a list, may decrease some of the ambiguity from previous research.
Although none of the manipulations significantly reduced the percentage of participants selecting Surgery 2, the versions that yielded the lowest preference for this surgery all grouped the risk of the four possible complications into a single category, as in the example shown above.
Why these findings are important
Over the past several decades there has been a push to give patients more information so they can make decisions that are consistent with their personal preferences. On the other hand there is a growing psychological literature revealing people's tendency to make choices that are in fact inconsistent with their own preferences; this is a dilemma. Because the present research suggests that the discrepancy between value and surgery choice is extremely resilient, much research still needs to be done in order to understand what underlies the discrepancy, with the goal of eliminating it.
The research reported in this decision of the month is currently in press. Please come back to this page in the near future for a link to the article.
Read the article:
Can avoidance of complications lead to biased healthcare decisions?
Amsterlaw J, Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Judgment and Decision Making 2006;1(1):64-75.
Are opinions on whether health care funding should be rationed dependent on an individual's perspective? Imagine that there are two regional health systems, each responsible for providing health care for one million people. The Director of each system has enough money to fund only one of two medical treatment programs. The health systems have the same limited budget and are the same in every way except for the treatment program that each Director decides to fund.
- Director who funded Program A (moderate shortness of breath)
- Director who funded Program B (severe shortness of breath)
- Both choices were equally good
- strongly agree
- strongly disagree
- strongly agree
- strongly disagree
How do your answers compare?
Before we analyze your responses to the scenario, we'd like to offer some background information about this area of research.
In an environment of scarce health care resources, policy makers and leaders of health care organizations often must make difficult choices about funding treatment programs. Researchers find out how people value different health states by asking questions like the ones you've answered. This area of research is called "person tradeoff elicitation."
The problem is that many people refuse to give a comparison value, saying that both choices are equal ("equivalence refusal") or saying that millions of people would have to be cured of one condition to be equal to the other treatment choice ("off-scale refusal"). Sometimes these responses are appropriate, but many times these responses seem inappropriate. Furthermore, the frequency of these decision refusals depends on how the questions are asked.
What were the specific goals of this research study?
In an article published by Laura J. Damschroder, Todd R. Roberts, Brian J. Zikmund-Fisher, and Peter A. Ubel (Medical Decision Making, May/June 2007), the authors explored whether people would be more willing to make health care tradeoffs if they were somewhat removed from the decision making role. As part of their study, the researchers asked people to comment on choices made by others, in this case, the Directors of two identical regional health systems. For this study, the researchers anticipated that asking participants to judge someone else's decision would make it easier for the participants to compare the benefit of curing two conditions that have a clear difference in severity. The researchers thought that adopting a perspective of judging someone else's decision might lessen the participants' feeling about making "tragic choices" between groups of patients and hence result in fewer refusals to choose. The researchers also hypothesized that respondents taking a non-decision-maker perspective would be more detached and would feel less outraged about the idea of having to ration medical treatments. As we will explain below, the researchers were surprised to learn that their hypotheses were wrong!
What did this research study find?
Some people surveyed in this study were asked to decide for themselves which of two treatment programs for shortness of breath should be funded. Others, like you, were asked which health system Director made the better decision about treatment programs for shortness of breath. Significantly, the respondents who had the evaluator perspective had nearly two times higher odds of giving an equivalence refusal�that is, saying that the decisions were equal. Why did this evaluator perspective fail to decrease these decision refusals? One possibility is that respondents did not feel as engaged in the decision. It's also possible that respondents felt that they were judging the Directors who made the decision rather than the decision itself. Or maybe respondents didn't want to second-guess the decisions of people they perceived as experts. The researchers predicted that people who had to make the decision about treatment themselves would be more outraged about the idea of rationing health care treatments. This prediction was also wrong! 69% of all respondents agreed that rationing is sometimes necessary, and yet 66% of all respondents also felt outraged about the idea of having to ration. The percentages were nearly the same for those deciding directly and those evaluating the decision of Directors of health care systems.
What conclusions did the researchers draw?
The researchers in this study concluded that perspective definitely matters in making hard choices about allocation of health care resources. They attempted to increase people's willingness to make tradeoffs by changing their perspective from decision maker to evaluator of someone else's decision. These attempts backfired. Contrary to the researchers' predictions, people were dramatically more likely to give equivalence refusals when they were assigned to a non-decision-maker perspective. The researchers also concluded that the degree of emotion aroused by health care rationing also plays a role in people's willingness to make tradeoffs.
So, how does your response to the Directors' decision in the shortness-of-breath scenario compare with the responses of the people surveyed for this study?
If you responded that the choices of both Directors were equal, you were not alone! Overall, with this scenario and related ones, 32% of respondents in the published study refused to make the tradeoff. These were the equivalence refusals. In comparison, 21% of respondents in the study who were asked to decide themselves between two patient groups gave an equivalence refusal.
If you made a choice of Directors in the shortness-of-breath scenario, how does your numerical answer compare with the responses of people surveyed for this study?
In the study, 15% of respondents gave a number of one million or more as the point at which the Directors' decisions about the two treatment programs would be equal. These were the off-scale refusals. In comparison, 19% of respondents in the study who were asked to decide themselves about the two programs gave an off-scale refusal.
What about your level of outrage?
In the study, 69% of respondents agreed that rationing of health care treatment is sometimes necessary, but 66% also felt outraged about the idea of having to ration. These attitudes were the same whether the respondents were assigned an evaluator perspective (as you were) or a direct decision maker perspective.
Read the article:
Why people refuse to make tradeoffs in person tradeoff elicitations: A matter of perspective?
Damschroder LJ, Roberts TR, Zikmund-Fisher BJ, Ubel PA. Medical Decision Making 2007;27:266-288.
From 1978 to 2009, Ed was head of the U-M Health System Legal Office. In 2009 he moved into the Medical School Department of ObGyn as an Associate Professor to work full-time on issues of sexual rights and reproductive justice. He has teaching appointments in the Medical School, the School of Public Health, the Law School, and LSA Women's Studies. He teaches courses on the legal and ethical aspects of medicine at the Medical School, the rules of human subjects research at the School of Public Health and reproductive justice in LSA and the Law School.. In 2011, Ed went to Ghana and helpe
Consider this scenario:
Alfred woke up at 4 am on Sunday morning with pain in his left foot. That place where his new running shoes had rubbed a raw spot earlier in the week was getting worse. By 9 am, the foot was red and swollen, with a large oozing sore, and Alfred decided to go to the Emergency Room at his local hospital.
Late on Sunday afternoon, Alfred returned home from the ER. He crutched his way into the house and collapsed on the sofa. His teenage son quizzed him.
How do your answers compare?
- Emergency care that was given
- Post-ER care needs
- Symptoms that would require a return to the ER
The Internet Survey Lab at the Center for Bioethics and Social Sciences in Medicine (CBSSM), led by Dr. Brian Zikmund-Fisher, facilitates the programming of complex experimental designs, using the graphical and interactive capabilities of the Internet. CBSSM has extensive experience in developing, programming and conducting survey research using Internet-based methodologies.
Why We Use the Internet
A key advantage of Internet surveys is that they can shape and direct a user's experience in response to computer generated randomization and/or respondents' own answers to questions earlier in the survey. Additionally, page and answer order can be truly randomized as appropriate to limit cognitive biases. The unique advantage of Internet surveys, however, is that many different types of stimuli can be randomized or varied; static visual images, movies, or sounds can all be used in addition to text. Furthermore, the nature of the browser interface enables user-directed interactivity, such as user-adjustable risk communication graphics, that provide unique opportunities for both knowledge communication and response assessment.
Using the Internet to conduct survey research is also very efficient: we can develop and test surveys in only a few months' time, and once a survey is ready, large scale data collection (e.g., 1500-3000 completed surveys) can be completed in only 2-3 weeks. Such surveys can also be cost effective, since while significant effort goes into development, creation, and testing of the survey, almost no personnel effort is required for data collection, entering, coding, or cleaning. In addition, oftentimes several small surveys can be combined into a single instrument, creating further efficiencies.
Sometimes, our studies use large, demographically diverse samples obtained through commercial survey research firms. This methodology allows us to tailor the population being surveyed on multiple demographic variables (e.g., sampling only women age 40-75 for a study about breast cancer treatments) and provides us with ample statistical power to conduct multi-factorial experimental tests. Other times, we use more inexpensive samples from Amazon Mechanical Turk (MTurk) for quick pilot testing or to enable rapid, iterative testing of designs. Regardless, the use of randomized designs ensures high internal validity for the research despite the use of an Internet-only sample.
CBSSM has had considerable success using this methodology, publishing multiple manuscripts in highly regarded peer-reviewed journals. Studies that have used this methodology have addressed a variety of topics, including:
- The use of pictographs to display risk (2008, 2008, 2014) including in comparison to other graphical formats (2008, 2010, 2010).
Note: to create your own pictographs, see www.iconarray.com.
- Misprediction of happiness between younger and older adults (2005)
- Elicitation of utility and willingness to pay (2007, 2007, 2008)
- Research ethics, e.g., participation of mentally vs. medically ill in research (2005)
- Risk communications that emphasize incremental risks instead of absolute risks (2008)
- Simplifying risk communications about adjuvant therapy options (2008).
- Effect of risk labels on prenatal screening decisions (2007).
- Time-insensitivity in people's understanding of survival curves (2005, 2007)
- Self-other discrepancies in medical decisions (2006, 2008)
- Sequential vs. all at once presentations of risk information (2011)
- Testing of animated or interactive risk graphics (2011, 2012, 2014)
- Optimal levels of precision in risk communications (2011, 2012)
- Framing of health promotion messages (2012)
- Exploration of role of narratives in decision making (2010)
- Values Clarification (2015)
- Intuition and Deliberation in Decision Making (2015)
For questions about our methods or inquiries about potential Internet survey research collaborations, please contact Brian Zikmund-Fisher at firstname.lastname@example.org.
Dr. Corriere’s research seeks to develop novel treatment approaches that incorporate patient-centered, cultural, and societal perspectives. His current work is focused on helping doctors understand what matters most to patients so that this information can be used to make shared treatment decisions based on their goals and values. Dr. Corriere also conducts research evaluating clinical treatment outcomes and imaging for arterial and venous disease. Dr.