ACADEMIA AND CLINIC

Sociologic Influences on Decision-Making by Clinicians JOHN M. EISENBERG, M.D.; Philadelphia, Pennsylvania

Recent articles on clinical decision-making have proposed sophisticated quantitative methods for improving the physician's clinical judgment. Actual clinical decisions, however, are influenced by interactions between the clinician, the patient, and the sociocultural milieu as well as by biomedical considerations. This paper explores these sociologic influences on the decision-making process. Four types of sociologic factors influence the clinician's judgment: the characteristics of the patient; the characteristics of the clinician; the clinician's interaction with his profession and the health care system; and the clinician's relationship with the patient. To illustrate sociologic influences on clinical decision-making, this paper presents observations from the literature of sociology, clinical psychology, psychiatry, and medicine. Further studies are needed to provide additional empirical information.

DECISION-MAKING by clinicians entails a complex interaction of various factors, including application of biomedical knowledge, rigorous problem-analysis, weighing of probabilities and usefulness of various outcomes, and acceptance of risk. Although clinical decisions are based on these scientific criteria, they are also influenced by interactions between clinician and patient and by sociocultural setting. This paper reviews the major contributions to our understanding of these sociologic influences on clinical decision-making. Because most of the literature on medical decisionmaking is founded on normative concepts, describing how decisions should be made rather than how they are made, authors often overlook the influence of the doctorpatient interaction and other sociocultural factors (1-7). The seminal works in medical decision-making, such as those by Feinstein (1), Schwartz and associates (3), and Lusted (5), only briefly mention sociocultural factors, concentrating instead on biomedical inputs to the decision-making process. Reflecting on the assumption that medical decision-making is based upon a scientific foundation, Waitzkin and Stoeckle (8), two internists writing in the psychiatric literature, have emphasized the importance of studying actual patterns of doctor-patient communication rather than normative patterns. They argue that normative descriptions are misleading because physicians should respond differently to different patients. The complexity of the decision-making process, however, renders its analysis difficult. Four characteristics of clinical thinking make it particularly difficult to characterize and quantify: It is usually quick; it handles an enormous amount of data; its style often differs for different physicians and different clinical problems; and it is • From the Section of General Medicine, Department of Medicine, and the National Health Care Management Center, Leonard Davis Institute of Health Economics, University of Pennsylvania; Philadelphia, Pennsylvania.

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mostly unconscious (9). Despite this, a number of observers and investigators have attempted to explain the sociologic influences on clinical decision-making. The Social Schema of Decision-Making

In 1935, Henderson (10) established himself as the first clinician to describe the doctor-patient relationship in terms of a sociologic interaction, although earlier physicians such as Osier had discussed the importance of nonbiomedical factors in medical care. Subsequently, Parsons (11) described the role of the sick patient as that of a person deviant from societal norms. Bloom (12) has also described the doctor-patient relationship as a social system and has noted that the doctor is influenced by his profession as well as by his own personality. In the process of applying objective medical science to a health problem, the physician interacts with the patient, who in turn is influenced by other forces, especially his family (12). A third sociologist, Freidson (13), has emphasized these sociologic influences by pointing out that diagnosis and treatment are not "biological acts common to mice, monkeys, and men" but are, instead, social acts peculiar to humans (13). Despite agreement among social scientists about the importance of sociocultural influences and the documented occurrence of what Stoeckle and Zola (14) have called "differential treatment," clinicians tend to deny the effect of nonbiomedical variables; most physicians contend there is no difference in the care they provide different types of patients (15). In one survey, for example, 80% of physicians claimed they gave the same amount of attention to all patients (16). Physicians often object to being asked questions relating to professional and social factors, especially religious affiliation and social class origin (17-19). This denial of social influences is not limited to medical clinicians. Potkay (20) found that even clinical psychologists believe personal history information is used only for orientation purposes and they down-grade its significance in decision-making, despite evidence that sociocultural variables do influence clinical psychologists significantly (20). The types of important sociocultural influences on medical decision-making may be summarized as the sociologic characteristics of the patient; the sociologic characteristics of the physician; the physician's interaction with his profession and the health care system; and the physician's interpersonal relationship with the patient. Characteristics of the Patient

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decisions made by health professionals. SOCIAL CLASS

Although there is evidence that British practitioners differ greatly in their ability to estimate the patient's social class (from 25% to 84% accuracy) (21), the bulk of the available literature implies a significant relation between social class and decisions regarding patient management. In the diagnosis of personality disorders, social class differences between patient and clinician have been shown to affect the diagnostic decision, social class bias causing lower-class patients to be diagnosed as aberrant more frequently than middle-class patients (22-25). In contrast, other investigators have found that in a simulated diagnostic process psychologists rate middle-class patients more harshly (26) and that these sociologic influences have more effect when the diagnostic situation is ambiguous (27). These conflicting results are difficult to evaluate with regard to physician decision-making because they deal primarily with psychologists rather than physicians and the severity of disease is not well controlled, an important factor since medical disease may, in fact, vary between social classes regardless of the artifacts of biased diagnosis. Social class influences therapeutic as well as diagnostic decisions in psychiatry according to numerous investigators, who have found that patients of lower social class are less often recommended for psychiatric therapy and that, when treated, are more often cared for by medical students. In addition, they are treated for a briefer duration and with less intensity, even when the presumed disease is the same (28-32). Lower social class patients receive less psychotherapy than middle- and upper-class patients and are more often treated with organic therapy, such as shock treatment or drugs (23). These studies, however, were inadequately controlled for case mix and severity of disease and do not convincingly show that patients with the same psychiatric clinical situation will be treated differently. When social class differences in treatment do occur for psychiatric patients, these differences cannot be attributed entirely to social class differences in patients' expectations regarding the choice of treatment (33); other sociologic factors must be sought. Studies of biomedical decision-making have drawn similar conclusions. In the controversial area of artificial organs, a complex mechanism exists by which middleclass values are applied to the establishment of "socialworth" criteria for acceptance into chronic hemodialysis programs, but there has been a recent shift toward a reluctance to reject anyone due to nonmedical criteria, a stance made possible by federal funding for dialysis (34). Although some authors (35, 36) have postulated that physicians more often refer upper- and middle-class patients to specialists, others (37, 38) have found that the poor are more often referred. In Sweden, social class is directly related to the incidence of appendectomies and tonsillectomies, with the higher classes undergoing more operations (9). Because the indications for these opera958

tions are not clearcut, it might be suggested that surgeons are more prone to operate on higher-class patients. Unfortunately, few of these studies were controlled for case mix or severity of disease, and it cannot be clearly shown that differences in therapy were due to differences in the sociologic situation. INCOME A N D E T H N I C B A C K G R O U N D

Although income and race are inextricably involved in the definition of social class, some investigators have chosen to study the independent influence of these variables on decision-making. It has been shown, for example, that psychotherapists resist treating low-income patients (39) and that the poor are treated longer for tuberculosis because the physician assumes they will be less responsible (40). Other authors have emphasized the effect of financial barriers to health care in modifying the physicians' decision-making process (37, 41). Again, potentially confounding variables such as clinical status or sociologic variables other than income are not adequately considered in these studies. Several authors have studied the influence of race on clinical decisions. In one study, whites were referred more often than blacks to other specialists by urban internists, but these data were not corrected for diseases seen in the two races (36). In a study of room assignment for patients admitted through the emergency room, Perkoff and Anderson (42) found that despite similar insurance coverage, black patients were assigned predominantly to ward classification while white patients were assigned predominantly to private status. The same held for Medicare and Medicaid patients. These assignments were usually made by clerks, who were themselves black, rather than by physicians. In addition, Perkoff and Anderson found that ward patients were regularly admitted less frequently than private patients, even when the complaints were the same. Although race and social status each might have exerted an influence, the ability to pay did not, since the same findings held when corrected for ability to pay. This study by Perkoff and Anderson is one of the few that takes into account clinical factors. In a brief research report supported by scanty data, Shaw (43) contends that there are unexplained differences in treatment procedures between blacks and whites in hospitals in the United States. Data are provided, however, by Egbert and Rothman (44), and they have reported that blacks are 2.2 to 4.3 times more likely than whites to be under the care of a surgeon in training rather than a fully trained surgeon. Their study was limited to gallbladder and inguinal hernia repair operations. Interestingly, the difference between the races disappeared when only patients being paid for by Medicaid were considered, so the difference may have been due at least in part to the payment mechanism or income level rather than race (44). Other investigators have found that black patients with tuberculosis are hospitalized longer and undergo more surgery than do white patients because of the physician's attitude that black patients lead a harder life outside the hospital and need a more certain cure (40). Ethnic origin of the patient may also affect the frequency

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with which psychiatric problems are diagnosed (45). OTHER V A R I A B L E S

Sociocultural variables other than class, income, and race have been purported to affect medical decision-making. The patient's sex, physical appearance, "social worth," and family influences have been studied. In an expository report, Lennane and Lennane (46) have stated that physicians diagnose and treat women on the basis of sexual prejudices. In another study (47) that did consider clinical factors, however, men were shown to be less likely than women to be referred to a psychiatric rehabilitation unit. The authors suggest it is more acceptable for women to assume such a dependent role. Duff and Hollingshead (38) have argued that the patient's physical appearance is a factor in diagnostic classification. There is evidence that overweight patients are judged by medical students to be more nervous, less competent, less likable, have a poorer prognosis, and be less well educated than normal-weight patients (48). Certain groups of patients such as alcoholics and those who have previously failed to follow medical advice are considered by physicians to be unworthy of the consideration and time given to a child or a wealthy businessman, an example of the use of "social worth" criteria that have been applied to dialysis patients (49). In her study of physicians' attitudes toward resuscitation, Crane (17-19) found that health professionals are more likely to perform heroic measures on those patients whom they perceive as contributing more to society. She describes the conflict for many clinicians between the humanitarian concern for the individual patient's welfare and the need to establish useful norms such as cost-benefit analysis in the allocation of scarce medical resources (19). Her conclusions, which can be criticized because they are based on simulated cases, support those of Sudnow (50), who found that the aged and those who are considered deviant, such as alcoholics and drug addicts, are not likely to receive even minimal attention that could prolong their lives. Similar biases against alcoholic patients have been demonstrated among nurses (51). Crane (19) also found physicians more willing to resuscitate patients whom they considered to be salvageable, especially if their damage was physical rather than mental. Other authors have shown that psychiatrists are more enthusiastic about treating "treatable" patients (52) and that attitudes about the patient's curability influence some clinicians (13). In a study of the decision to characterize patients as alcoholics, Wolf and colleagues (53) found a tendency for house officers to underestimate alcoholism in patients who were not derelicts. As in many studies of sociologic influences on clinical decisions, there was an obvious discrepancy between the house officer's actual diagnosis and his views expressed during an interview. The authors suggest that emotionally laden perceptions and attitudes are factors in clinical situations much more than are objective determinants of diagnostic behavior expressed on the abstract level. The effect of the patient's family has been shown to be important in physicians' decisions about resuscitation

(38) and admission to a geriatric home (54). Twenty-nine percent of patients with psychiatric complaints seen in one emergency room were handled in accord with the family's desire but against the indications of the clinical data (52). Similarly, the family's attitude toward the treatment of the brain-damaged child is an important influence on the physician's decision to treat the child. If the family does not define such an infant or child as socially dead, he is more likely to be treated. In contrast, the adult patient's own attitude rather than the family's attitude affects the doctor's decision to treat or not to treat the terminally ill patient. However, the family's attitude may have an indirect influence on the treatment of unsalvageable adult patients (19). In addition to the effect of the family on the decision to resuscitate or admit a patient, families of patients have been shown to impose their expectations on doctors with regard to the prescription of drugs (55). Anderson and Sheatsley (56) have described several other nonbiomedical factors that influence the decision to admit a patient to the hospital, including home environment and the ability to afford hospital or outpatient costs. The same nonbiomedical influences seem to govern admission to British hospitals, as shown by a study in which 24% of bed-days on a British surgical ward could be accounted for by social or geriatric reasons, with 49% of patients aged 60 or older believing they could not cope with their home conditions. After the introduction of formal rounds and discharge planning by a medical social worker, the proportion of bed-days used because of social reasons was reduced to 16%, whereas clinical and administrative causes for delay were unchanged (57). A similar American study has shown that 21 % of hospital admissions occur because of sociologic reasons (58). Despite evidence that many patient characteristics influence clinical decision-making, most studies evaluate only one characteristic. Further investigation is needed to assess the multivariate sociocultural influences and study their relative importance. Physician's Personal Characteristics

In addition to patient characteristics, the physician's decision-making process is influenced by factors intrinsic to his own personality (8, 12, 15, 34, 59). Seldom, however, are objective data presented to support this contention. To understand the magnitude and type of influence that the physician's personality has on his decisions, more studies of his actual behavior must be conducted. Some of those that have been completed can be described here. It has been shown that physicians in different specialties differ in their tendency to implicate psychogenic causes for somatic complaints (45). For example, in a study of the management of patients with difficult problems that were undiagnosed but could have been psychogenic, internists tended to perform diagnostic procedures, while surgeons used placebos and general practitioners prescribed psychopharmacologic drugs (59). Similarly, specialty groups differ in their attitudes toward resuscitation, but current data do not distinguish how many of the Eisenberg

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characteristics of these specialty groups are due to the socializing forces of the profession and therefore to the physician's interaction with his colleagues and how many to the selection of that specialty by persons with certain personality traits. There were also differences in physician's attitudes toward resuscitation along religious lines (19). The personality of the physician may also determine, at least in part, his approach to medicine. Physicians have been characterized as being interventionist or oriented toward health maintenance (49). The interventionist seems more likely to be disease oriented, whereas the physician characterized by a tendency toward health maintenance is more likely to be patient oriented. Generally, the interventionist is inclined toward immediate action, whereas the health-maintenance-oriented physician is willing to observe the situation. A number of other personal characteristics of the physician that could potentially influence decision-making, such as age and education, have been carefully studied with regard to the use of laboratory tests and the prescription of drugs, but the effect of these personal characteristics on other aspects of decision-making has been inadequately evaluated. Younger physicians have been shown to prescribe drugs more appropriately but to order more laboratory tests and roentgenograms than older physicians (55, 60-65), even when diagnostic test use is controlled for case mix and severity of disease (66). Although most studies associating physician characteristics with the prescription of drugs and the ordering of diagnostic services have not been controlled for case mix and severity of disease, they have posited that better prescrib e s are better educated, more cosmopolitan, and more concerned with the psychological and qualitative aspects of medical care (55, 67) and that family physicians order more inapropriate drugs than do other physicians (67). While uncontrolled studies have suggested that internists order more laboratory tests and roentgenograms than do other physicians (61, 65), a study that did control for case mix and severity of disease showed that internists order about the same number of laboratory tests and roentgenograms as do family physicians but that both groups order more than do general practitioners (66). There is no agreement on the effect of board certification and location of practice with regard to the use of diagnostic services. Physician's Interaction with His Profession

In addition to the personal characteristics of the patient and clinician, medical decision-making may be influenced by the relation of the physician to his professional environment. Not only is the physician affected by formal and informal interaction with other professionals, but also by the setting in which he encounters the patient and the organization of the health care system. Freidson (13) describes two types of medical practice: the client-dependent and the colleague-dependent. A physician practicing in a client-dependent setting responds more readily to the desires of his patients. On the other hand, the colleague-dependent clinician responds to influence from his professional community. His perform960

ance is likely to conform with the norms of other physicians rather than with the expectations of patients. Because of interpersonal influences in each type of practice, there may be a tendency for physicians to overdiagnose, that is, to pursue the diagnostic process despite the remote prospect of benefit to the patient. This tendency to overdiagnose has been described as the medical decision rule, implying that, in the eyes of most physicians, overdiagnosis is preferable to missing diagnoses (68). In the colleague-dependent practice this overdiagnosis may be due to peer pressure to leave no stone unturned, while in a client-dependent practice overdiagnosis may occur because of a patient's desire to have a name for his problem (13). In a classic study of colleague-dependent activities, Coleman and co-workers (69, 70) investigated the acceptance of a new drug in a medical community by studying filled prescriptions. They found that important interactions occurred through shared offices, informal relationships with other physicians, institutional ties, and contact with drug-company salesmen. Published literature on the drug was much less influential. Scientifically based studies of drug efficacy influenced only 14% of internists, the group found to be most influenced by the literature. A phenomenon of contagion was described whereby acceptance of the new drug increased along the lines of professional relationships and friendship. The greater the physician's involvement in the medical community, the greater the likelihood of early adoption of the new drug. It was concluded that acceptance of a new drug occurs as a community process among physicians and that interaction between physicians provides information about the new drug and legitimization of an innovation. Other investigators have found similar influences of the professional community on the adoption of new drugs by clinicians: Physicians practicing in groups tend to adopt new drugs more rapidly than do those in solo practice (71, 72). A number of other factors were also important in physicians' prescription of drugs: formal education, advertising, regulatory measures, demands from patients and society, and the doctor's own characteristics (55). Freidson (13) has asserted, based on mass-communications literature, that prestige and influence may be accorded journal authors. Such influence, however, when unsupported by everyday work settings or personal contact is likely to be slight. The influence of prestige has also been studied by Shortell (73) who showed that highstatus physicians have the most cohesive referral patterns and low-status physicians the lowest. The consultative relationship clearly plays an important role in the professional interaction among physicians, as does the informal discussion or meeting for lunch in the hospital cafeteria (74). Another potential source of influence on decisions made by physicians is that of nonphysician clinicians working with the physician. Although group dynamics of team-oriented health care is becoming better understood, the impact of nurse practitioners and paramedical personnel on physician decision-making has not been clarified (75).

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Another influence on decision-making by physicians is the pressure of one's peers, both formally and informally (12, 13). With regard to formal peer pressure, if Professional Standards Review Organizations (PSROs) become more widely accepted, this institutionalized influence may become important. The influence of informal peer pressure is felt most strongly when several physicians practice together, such as in group practice or among house officers. The interaction among house officers is often formalized in mortality conferences, residents' reports, and ward rounds. In comparing decision-making by surgical and medical house staff, Coser (76) found that it is difficult to distinguish between formal and informal influence. In a study of decision-making on hospital wards, she found that decision-making styles in internal medicine and surgery differed. In medicine there was a significant degree of delegation of responsibility and authority down formal hierarchical lines, from chief resident to assistant resident to intern to nurse. The medical house officers based their decisions, to a large extent, on consensus, with the chief resident or visiting physician presiding and leading the discussion. On surgical wards, decisions were made by the chief resident and orders were given to all members of the hierarchy. These styles of decision-making were well adapted to the nature of each specialty. In medicine, where problems of diagnosis and treatment are pondered and decisions often made by consensus, the time required for the delegation of decision-making is tolerable. In surgery, however, where decisions are often made with more rapidity and less reflection, the emphasis is on action and punctuality. Seeman and Evans (77) also found that medical services were low in stratification and surgical services high. Low stratification wards, in both medicine and surgery, were ranked higher with regard to teaching quality, used more consultations, and had fewer resignations from the nursing service. In a study of orthopedic surgery residents (78), it was found that junior residents were allowed little decisionmaking authority. They were expected to observe the decisions made by senior residents, who were themselves heavily influenced by the opinions of staff surgeons. In especially difficult or controversial cases, evaluation became both formalized and collective, especially with regard to pretreatment decisions. In contrast, decisionmaking on postoperative problems was more individualized and less subject to group processes (78). Other authors have found significant differences in decision-making among specialties, with surgical teams in the operating room often being highly structured (79). Part of this difference between the decision-making styles of different specialties may be due to differences in the personal characteristics of the individuals choosing those specialties, but no study has attempted to test this hypothesis. Alternatively, the different decision-making styles may be a function of the clinical problems with which the physicians are dealing, thus showing the importance of case mix in studies of sociocultural influences on clinical decision-making.

While Mumford (80) found that residents in a hospital closely affiliated with a medical school were less sensitive to their patients' wishes than were residents in a community hospital, Crane (19) found that residents in closely affiliated hospitals were more sensitive to the patient's wishes and less sensitive to socioeconomic and age characteristics. Crane also found residents in closely affiliated hospitals to be more active in treating patients than were their counterparts in other types of hospitals and speculates that there may be distinct subcultures within specialties that transmit different standards of performance (19). Although some authors have emphasized the effect of the professional community on the physician's style of decision-making, others have pointed to important structural and organizational factors that influence the practice. The National Health Service, for example, has altered the decisions of British physicians with regard to drug prescriptions and abortions (54), and reorganization of an outpatient clinic has been shown to influence physicians' decisions to treat and the quality of drug prescribing (45, 81). To ascertain the relative influence of the physician's personal characteristics and the work environment on physician performance, Rhee (82) undertook multivariate analysis of the practices of 454 physicians. He found that the physician's work environment has more influence on the quality of care than does the physician's formal training. The organizational influence is less strong for the more trained but stronger for the less-trained physician. The cost of care and the patient's ability to pay may also influence the doctor's therapeutic plan (41), as do the availability of hospital space and the physician's own schedule (56). Data also indicate that financial and organizational arrangements in pediatric practice influence clinical decisions when private fee-for-service practice is compared with prepaid practice (83). Mechanic (84) contends that prepaid groups encourage a more assemblyline type of practice that is less responsive to patients than the personalized pattern characteristic of fee-forservice practice. The influence of prepaid groups and the patient's insurance status on physician decision-making have been discussed in detail elsewhere (85, 86) and need not be reviewed here. The Doctor-Patient Relationship

The fourth major sociocultural influence on decisionmaking by clinicians is the effect of the doctor-patient relationship, which is more heavily felt in those practices which Freidson (13) describes as client-dependent. As Henderson (10) wrote in 1935, a physician and a patient make up a social system. It is within the framework of this social interaction that medical decision-making occurs. Although physicians may claim to practice medicine with what may be called "detached concern" (87), unswayed in their clinical decisions by social, cultural, or economic considerations, Bloom and Wilson (88) point out that this view is a normative one, an ideal not necessarily achieved. Szasz and Hollender (89) have described three patterns Eisenberg

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of interaction between doctors and their patients in which the relationship is important: activity-passivity in which the physician controls the interaction and the patient is passive; guidance-cooperation in which the physician provides advice that the patient is expected to agree and comply with; and mutual participation in which the physician helps the patient to help himself. The role of this model in decision-making by physicians has been illustrated in research by Vertinsky and colleagues (90), who found that most patients do not want to take full responsibility for making their own medical decisions. Although patients may desire participation in the decision-making process, they do not want to make the decisions. This relationship seems to fit best the guidance-cooperation model (90). On the other hand, Waitzkin and Stoeckle (8) have written that physicians desire control over the doctor-patient relationship and that they tend to increase the patient's uncertainty to augment this control. Other authors have provided a more balanced view, showing that different patients and doctors will use different decision-making styles, often depending on the situation. Barber (91), for example, has described the traditional physician as using the model of the physician who is superordinate, whereas the more modern physician will share decision-making with the patient and family. Sorenson (92) has described two situations of uncertainty in which the decision-making process is likely to be shared by the physician with his patient: when a scientific development permits control or alleviation of an established and legitimate health problem that heretofore has been beyond medical control (such as organ transplantation); and when the development of a scientific advance permits increased control of a life or health situation previously not considered to be within the legitimate domain of medicine. Similarly, Fox (93) found that when a situation is exploratory or uncertain, mutual participation in decision-making seems to be more common. The specialty of the physician may predict his or her style of decision-sharing. Differences exist between surgeons and internists in sharing with other physicians the authority to make decisions (76), and various specialists differ in their willingness to share decision-making with the patient. Again physicians in internal medicine, along with those in pediatrics and psychiatry, more often encouraged patient participation, while surgeons and anesthesiologists were characterized by the physician taking an active role and the patient remaining passive (49). When the physician's and patient's personality, each of which have independent influences on decisions, clash during their interaction, personal conflict may influence the decision-making process. Freidson (13) has suggested that a clinician might refuse to treat a patient with whom he has a personal conflict, assuming that the patient can find care elsewhere, and psychiatrists have been shown to offer follow-up care more frequently to likable and treatable patients, those who are friendlier and more cooperative (52). Similarly, there are distinct differences in the way "good patients" and "problem patients" are treated in a general hospital (94). 962

A prominent clinician in the Veteran's Administration system (95) has described several types of patients commonly found to be undesirable to physicians: those who are aged, dirty, uneducated, very poor, and those of a minority race or religion; those who are undesirable because of their attitudes, including ungrateful and obnoxious patients; those who are undesirable on medical grounds because of characteristics of their medical problems, such as ordinary or untreatable illnesses and the absence of physical disease; those who are undesirable because of circumstances, such as arriving on the ward late at night or during an already busy day; and those who are undesirable because the physician considers them to be a distraction to preferred tasks, such as reading or laboratory research. Likewise, Groves (96) has characterized "hateful patients": the dependent dingers, the entitled demanders, the manipulative help-rejectors, and the self-destructive deniers. Most of the literature on the influence of the doctor-patient relationship on clinical decision-making is exploratory and expository and needs to be confirmed by empirical investigation. Conclusion

Although decision-making by clinicians has undergone increasing scrutiny recently, the emphasis has usually been on normative and quantitative clinical patterns of decision-making. This paper has reviewed the available literature on the ways in which sociocultural influences affect the decision-making process. These sociocultural influences may be due to characteristics of the patient, personal characteristics of the physician, the professional role of the physician, or the interaction between physician and patient. These factors may affect any type of clinical decision, including diagnostic and therapeutic, the decision to admit, and the decision to refer. Except for studies describing the activities of clinical psychologists, the available literature has assumed the clinician to be a physician. As nurses, nurse-practitioners, physician's-assistants, and other nonphysician clinicians assume more responsibility and authority regarding decision-making, the emphasis on the physician may become too limited. Taken as a whole, the literature offers considerable evidence that sociologic factors play a role in clinical decision-making. Few studies, however, have been sound enough methodologically to stand on their own. Few have controlled their findings for differences in case mix or the severity of disease. Often the data were not subjected to statistical analysis. Too frequently the author allowed the paper to become a polemic to grind his or her particular axe. Seldom were confounding variables taken into account, even sociologic variables other than the one under study. Many studies were not founded on actual clinical cases, but on simulated cases or questionnaires for which there was no evidence of validity or reliability. The preponderance of studies dealing with psychiatric decision-making leaves doubt on the relevance of the studies to the typical medical decision. Further, much of the literature in this field consists of

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normative descriptions of how a physician should behave. Further investigation is needed into how the clinician does behave. Various methods of sociologic research could be used to provide the data for these studies—participant observation, record review, questionnaires, interviews, case studies, or direct recording of the interaction. Multivariate methods, which have been useful in psychology and marketing studies, may help to distinguish the many influences in clinical decision-making. Each method has its disadvantages, but each has the potential to contribute to an understanding of how sociocultural factors influence clincial decision-making (8, 97). A C K N O W L E D G M E N T S : The author thanks Renee C. Fox, Ph.D., Samuel P. Martin, M.D., and Debbie Kitz for their advice and assistance and Lorraine Kalman for her typing and patience. This study was supported in part by The Robert Wood Johnson Foundation Clinical Scholars Program, Princeton, New Jersey; the National Health Care Management Center at the Leonard Davis Institute of Health Economics at the University of Pennsylvania (which is supported by grant HS 02577, National Center for Health Services Research); and the Solomon Katz Chair in General Medicine at the University of Pennsylvania. The opinions and conclusions in this article are those of the author and do not necessarily represent those of The Robert Wood Johnson Foundation, the National Health Care Management Center, or the Leonard Davis Institute of Health Economics. • Requests for reprints should be addressed to John M. Eisenberg, M.D.; 3 Silverstein Pavilion, Hospital of the University of Pennsylvania, 3400 Spruce Street; Philadelphia, PA 19104. Received 20 September 1978; revision accepted 2 February 1979.

References 1. FEINSTEIN AR: Clinical Judgment. Baltimore, Williams and Wilkins, 1967 2. HENSCHKE UK, FLEHINGER BJ: Decision theory in cancer therapy. Cancer 20:1819-1826, 1967 3. S C H W A R T Z WB, G O R R Y G A , KASSIRER JP, ESSIG A: Decision analysis

and clinical judgment. Am J Med 55:459-472, 1973 4. LUSTED LB: Decision-making studies in patient management. N Engl J Med 284:416-424, 1971 5. LUSTED LB: Introduction to Medical Decision Making. Springfield, Illinois, Charles C Thomas, 1968 6. M C N E I L BJ, K E E L E R E, ADELSTEIN SJ: Primer on certain elements of medical decision making. N Engl J Med 293:211-215, 1975 7. PAUKER SG, KASSIRER JP: Therapeutic decision making: a cost-benefit analysis. N EnglJ Med 293:229-234, 1975 8. WAITZKIN H, STOECKLE JD: The communication of information about illness. Clinical, sociological, and methodological considerations. Adv Psychosom Med 8:180-215, 1972 9. A L L E N D E R E: Diagnostic process and rheumatic disease. Scand J Soc Med 1:97-108, 1973 10. HENDERSON LJ: Physician and patient as a social system. N EnglJ Med 212:819-823, 1935 11. PARSONS T: Social structure and the dynamic process, in The Social System. New York, Free Press, 1951, pp. 421-479 12. BLOOM SW: The Doctor and His Patient: A Sociological Interpretation. New York, Free Press, 1965 13. FREIDSON E: Illness as social deviance, in Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York, Dodd, Mead & Co., 1973, pp. 205-223 14. STOECKLE JD, ZOLA IK: After everyone can pay for medical care: some perspectives on future treatment and practice. Med Care 2:36-41, 1964 15. DRUCKER E: Hidden values and health care. Med Care 12:266-273, 1974 16. DAVIS MS: Attitudinal and behavioral aspects of the doctor-patient relationship as expressed and exhibited by medical students and their mentors. J Med Educ 43:337-343, 1968 17. C R A N E D: Physicians' attitudes toward the treatment of critically ill patients. BioScience 23:471-474, 1973 18. C R A N E D: Decisions to treat critically ill patients: a comparison of social versus medical considerations. Milbank Mem Fund Q 53(Winter):l33, 1975 19. C R A N E D: Controversy and the clinical mentality, in The Sanctity of Social Life: Physicians' Treatment of Critically 111 Patients. New York, Russell Sage Foundation, 1975, pp. 17-32 20. POTKAY CR: The role of personal history data in clinical judgment: a

selective focus. J Pers Assess 37:203-212, 1973 21. H U L L F M : Social class and the general practitioner. Practitioner 209:698-699, 1972 22. TRACHTMAN JP: Socio-economic class bias in Rorschach diagnosis: contributing psychosocial attributes of the clinician. / Pers Assess 35:229-240, 1971 23. HOLLINGSHEAD AB, R E D L I G H FC: Class and the prevalence of disorders, in Social Class and Mental Illness. New York, John Wiley and Sons, 1958, pp. 194-219 24. Di N A R D O P: Social class and diagnostic suggestion as variables in clinical judgment. / Consult Clin Psychol 43:363-368, 1975 25. L E E SD, T E N E R L I N MK: Social class, diagnosis and prognosis for psychotherapy. Psychother Theory Res Practice 7:181-185, 1970 26. KOSCHERAK S, MASLING J: Noblesse oblige effect: the interpretation of Rorschach responses as a function of ascribed social class. / Consult Clin Psychol 39:415-419, 1972 27. R O U T H DK, K I N G KM: Social class bias in clinical judgment. / Consult Clin Psychol 38:202-207, 1972 28. K U R T Z R M , W E E C H AA J R , D I Z E N H U Z IM: Decision-making as to

type of treatment in a child psychiatry clinic. Am J Orthopsychiatry 40:795-805, 1970 29. MYERS JK, SCHAEFFER L: Social stratification and psychiatric practice. A study of an outpatient clinic. Am Sociol Rev 19:307-310, 1954 30. S H A D E R RI, BINSTOCK WA, O H L Y JI, SCOTT D: Biasing factors in

diagnosis and disposition. Compr Psychiatry 10:81-89, 1969 31. BRILL NQ, STORROW HA: Social class and psychiatric treatment. Arch Gen Psychiatry 3:340-344, 1960 32. B R O W N JS, KOSTERLITZ N: Selection and treatment of psychiatric outpatients. Determined by their personal and social characteristics. Arch Gen Psychiatry 11:425-438, 1964 33. F R A N K A, EISENTHAL S, LAZARE A: Are there social class differences in patients' treatment conceptions? Arch Gen Psychiatry 35:61-69, 1978 34. F o x RC, SWAZEY JP: Patient selection and the right to die, in The Courage to Fail: A Social View of Organ Transplants and Dialysis. Chicago, University of Chicago Press, 1974, pp. 240-279 35. SUCHMAN EA: Stages of illness and medical care. J Health Soc Behav 6:114-128, 1965 36. PENSCHASKY R, F O X D: Frequency of referral and patient characteristics in group practice. Med Care 8:368-385, 1970 37. M I L L E R MH: Who receives optimal care? J Health Soc Behav 14:176182, 1973 38. D U F F RS, HOLLINGSHEAD AB: Sickness and Society. New York, Harper and Row, 1968 39. LORION RP: Patient and therapist variables in the treatment of low-income patients. Psychol Bull 81:344-354, 1974 40. R O T H J A: Treatment of the sick, in Poverty and Health: A Sociological Analysis, edited by KOSA J, ANTOMOVSKY A, ZOLA IK. Cambridge, Massachusetts, Harvard University Press, 1969, pp. 214-243 41. BRIAN EW, GIBBENS SF: California's Medi-Cal copayment experiment. Med Care 12(suppl): 1-303, 1974 42. PERKOFF GT, ANDERSON M: Relationship between demographic characteristics, patient's chief complaint, and medical care destination in an emergency room. Med Care 8:309-323, 1970 43. S H A W CT: A detailed examination of treatment procedures of whites and blacks in hospitals. Soc Sci Med 5:251-256, 1971 44. EGBERT LD, R O T H M A N IL: Relation between the race and economic status of patients and who performs their surgery. N Engl J Med 297:9091, 1977 45. ZOLA IK: Problems of communication, diagnosis, and patient care: the interplay of patient, physician and clinic organization. / Med Educ 38:829-838, 1963 46. L E N N A N E KJ, L E N N A N E RJ: Alleged psychogenic disorders in women—a possible manifestation of sexual prejudice. N Engl J Med 288:288292, 1973 47.

K E S K I N E R A, Z A L C M A N MJ, R U P P E R T EH: Advantages of being fe-

male in psychiatric rehabilitation. Arch 1973

Gen Psychiatry

28:689-692,

48. B A L D I G O J, BREYTSPRAAK LM, C O H E N - C O N G E R J, W H A T L E Y JL,

49.

50. 51. 52.

M O O R E J: Impression formation in the patient interview: a training experiment with first year medical students, in Proceedings of the Fourteenth Annual Conference on Research in Medical Education. Washington, D.C., Association of American Colleges, November 1975, pp. 206211 H A N E Y CA: Psychosocial factors involved in medical decision making, in Medical Behavioral Science, edited by M I L L O N T. Philadelphia, W. B. Saunders, 1975, pp. 420-432 S U D N O W D: Passing On. Englewoods Cliffs, New Jersey, Prentice-Hall, 1967 CORNISH R D , M I L L E R MV: Attitudes of registered nurses toward the alcoholic. / Psychiatr Nurs 14(12):19-22, 1976 TISCHLER GL: Decision-making process in the emergency room. Arch Gen Psychiatry 14:69-78, 1966 Eisenberg

• Clinical Decision-Making

Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19547/ by a University of California San Diego User on 04/28/2017

963

53. W O L F I, C H A F E T Z ME, B L A N E HT, H I L L MJ: Social factors in the

diagnosis of alcoholism. II. Attitudes of physicians. Q J Stud Alcohol 26:72-79, 1965 54. G I L L DG, HOROBIN GW: Doctors, patients and the state: relationships and decision-making. Sociol Rev 20:505-520, 1972 55. H E M M I N K I E: Review of literature on the factors affecting drug prescribing. Soc Sci Med 9:111-115, 1975 56. ANDERSON OW, SHEATSLEY PB: Hospital Use: A Survey of Patient and Physician Decisions. University of Chicago Research Series, No. 24. Chicago, Center for Health Administration Research Series, 1967 57. B A T E S T, M E N Z I E S K, B E H R A, R E N D A L L M: The place of early social

assessment in the management of surgical patients. Postgrad Med J 52:61-65, 1976 58. M U S H L I N A, A P P E L F: Extra-medical factors in the decision to hospitalize medical patients. Am J Public Health 66:170-172, 1976 59. CAREY K, K O G A N WS: Exploration of factors influencing physicians' decisions to refer patients for mental health services. Med Care 9:55-66, 1971 60. P I N E A U L T R: The effect of medical training factors on physician utilization behavior. Med Care 15:51-67, 1977

76. COSER RL: Authority and decision making in a hospital: a comparative analysis. Am Sociol Rev 23:56-64, 1958 77. SEEMAN M, EVANS JW: Stratification and hospital care. II. The objective criteria of performance. Am Sociol Rev 26:193-204, 1961 78. K N A F L K, B U R K E T T G: Professional socialization in a surgical specialty: acquiring medical judgment. Soc Sci Med 9:397-404, 1975 79. WILSON RN: Teamwork in the operating room, in Medical Care Readings in the Sociology of Medical Institutions, edited by SCOTT WR, VOLKANT EH. New York, John Wiley and Sons, 1966, pp. 354-367 80. M U M F O R D E: Patient and physician, in Interns: From Students to Physicians. Cambridge, Massachusetts, Harvard University Press, 1970, pp. 184-213 81. POZEN MW, G L O G E R H: The impact on house officers of educational and administrative interventions in an outpatient department. Soc Sci Med 10:491-495, 1976 82. R H E E S-O: Relative importance of physicians' personal and situational characteristics for the quality of patient care. J Health Soc Behav 18:1015, 1977 83. EISENBERG J, M A C K I E A, K A H N L, P E R K O F F G T : Patterns of pediatric

61. F R E E B O R N D K , B A E R D, G R E E N L I C K MR, B A I L E Y JW: Determinants

of medical care utilization: physicians' use of laboratory services. Am J Public Health 62:846-853, 1972

84.

62. STOLLEY P D , B E C K E R M H , LASAGNA L, M C E V I L L A J D , S L O A N E LM:

63.

64. 65. 66. 67.

68. 69. 70. 71.

The relationship between physician characteristics and prescribing appropriateness. Med Care 10:17-28, 1972 ROSE H, ABEL-SMITH B: Doctors, Patients and Pathology. Occasional Papers on Social Administration, No. 49. London, G. Bell and Sons, 1972 L A V E JR, L E I N H A R D T S: The cost and length of a hospital stay. Inquiry 13:327-343, 1976 C H I L D S AW, H U N T E R D: Non-medical factors influencing use of diagnostic x-ray by physicians. Med Care 10:323-335, 1972 NICKLIN D, EISENBERG JM: Utilization of diagnostic services by physicians in community practice (abstract). Clin Res 26:336A, 1978 R A Y WA, FEDERSPIEL C F , SCHAFFNER W: Prescribing of chloramphenicol in ambulatory practice. An epidemiologic study among Tennessee Medicaid recipients. Ann Intern Med 84:266-270, 1976 SCHEFF TJ: Being Mentally 111: A Sociological Theory. Chicago, Aldine Publishing Co., 1966 COLEMAN JC, KATZ E, MENZEL H: Medical Innovation: A Diffusion Study. Indianapolis, Bobbs-Merrill Co., 1966 COLEMAN J, M E N Z E L H, K A T Z E: Social processes in physicians' adoption of a new drug. / Chronic Dis 9:1-19, 1959 WILLIAMSON PM: The adoption of new drugs by doctors practising in group and solo practice. Soc Sci Med 9:233-236, 1975

85. 86. 87. 88.

89.

90. VERTINSKY IB, T H O M P S O N WA, U Y E N O D: Measuring consumer de-

91. 92. 93.

72. B E C K E R M H , STOLLEY P D , LASAGNA L, M C E V I L L A J D , S L O A N E LM:

Differential education concerning therapeutics and resultant physician prescribing patterns. J Med Educ 47:118-127, 1972 73. SHORTELL S: Patterns of referral among internists in private practice: a social exchange model. J Health Soc Behav 14:335-348, 1973 74. FREIDSON E: Doctoring Together: A Study of Professional Social Control. New York, Elsevier-North Holland, 1976 75. N A G I SZ: Team work in health care in the U.S.: A sociological perspective. Milbank Mem Fund Q 53(Winter):75-91, 1975

9 6 4

practice by the same physicians in a prepaid and a fee-for-service setting. Clin Pediatr (Phila) 13:352-359, 1974 MECHANIC D: The organization of medical practice and practice orientations among physicians in prepaid and nonprepaid primary care settings. Med Care 13:189-204, 1975 L U F T HS: How do health-maintenance organizations achieve their "savings"? Rhetoric and evidence. N Engl J Med 298:1336-1343, 1978 DONABEDIAN A: Use of service, in Benefits in Medical Care Programs. Cambridge, Massachusetts, Harvard University Press, 1976, pp. 64-71 L I E F HI, F o x RC: The medical student's training for detached concern, in The Psychological Basis of Medical Practice, edited by LIEF HI, LIEF VF, L I E F NL. New York, Harper and Row, 1963, pp. 12-35 BLOOM SW, WILSON RN: Patient-practitioner relationships, in Handbook of Medical Sociology, edited by F R E E M A N HE, L E V I N E S, R E E D ER LG. Englewood Cliffs, New Jersey, Prentice-Hall, 1972, pp. 315-339 SZASZ TS, H O L L E N D E R MH: A contribution to the philosophy of medicine. The basic models of the doctor-patient relationship. Arch Intern Med 97:585-592, 1956

94. 95. 96. 97.

sire for participation in clinical decision making. Health Serv Res 9:121134, 1974 BARBER B: Compassion in medicine: toward new definitions and new institutions. N Engl J Med 295:939-943, 1976 SORENSON JR: Biomedical innovation, uncertainty, and doctor-patient interaction. J Health Soc Behav 15:366-374, 1974 F o x RC: Training for uncertainty, in The Student-Physician: Introductory Studies in the Sociology of Medical Education, edited by MERTON RK, R E A D E R G, K E N D A L L P. Cambridge, Massachusetts, Harvard University Press, 1957, pp. 207-241 LORBER J: Good patients and problem patients: conformity and deviance in a general hospital. J Health Soc Behav 16:213-225, 1975 PAPPER S: The undesirable patient. / Chronic Dis 22:777-779, 1970 G R O V E S JE: Taking care of the hateful patient. N Engl J Med 298:883887, 1978 PHILLIPS DL: Knowledge from What: Theories and Methods in Social Research. Chicago, Rand McNally, 1971

June 1979 • Annals of Internal Medicine • Volume 90 • Number 6

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