The Default Position: Optimizing Pediatric Participation in Medical Decision Making

Inclusion of children in medical decision making, to the extent of their ability and interest in doing so, should be the default position, ensuring that children are routinely given a voice. However, optimizing the involvement of children in their health care decisions remains challenging for clinicians. Missing from the literature is a stepwise approach to assessing when and how a child should be included in medical decision making. We propose a systematic approach for doing so, and we apply this approach in a discussion of two challenging clinical cases. The approach is informed by a literature review, and is anchored by case studies of teenagers' refusal of clinical care, regulatory requirements for research assent, and the accepted approach to involving cognitively impaired adults in medical decisions.     

Parental Involvement in Children's Career Decision Making

This article presents findings of a survey of English, Swiss, and American parents regarding their involvement in their children's career decision-making process. A questionnaire was developed and a pilot survey was conducted. Although the results must be interpreted with caution, this study suggests that these parents exhibited some marked educational and career choice bias. Furthermore, these differences may reflect the nature of the educational systems of the countries represented. It seems that effective systems for career development and employment counseling result in parents who are confident in helping their children with career decision making.     

国外临床决策研究进展（上）

2004年～2010年国际医学决策学会年会,提出许多与临床相关的决策问题,其中包括健康经济学与成本效益分析,临床方法学研究进展,医患双方的临床决策选择,公共卫生服务研究和诊疗策略的关系,临床策略与治疗指南,高新技术与适宜技术等。本文就以上问题,尤其是临床决策研究热点,对国外临床决策研究进展进行总结、探讨和评价,为临床应...     

Characterization of Children's Decision Making: Sensitivity to Punishment Frequency,Not Task Complexity

On a gambling task that models real-life decision making, children between ages 7 and 12 perform like patients with bilateral lesions of the ventromedial prefrontal cortex (VMPFC), opting for choices that yield high immediate gains in spite of higher future losses (Crone &; Van der Molen, 2004 Crone, E. A. and Van der Molen, M. W. 2004. Developmental changes in decision-making: Performance on a gambling task previously shown to rely on ventromedial prefrontal cortex. Developmental Neuropsychology, 25(3): 251–279. [PUBMED][INFOTRIEVE][CROSSREF][Taylor &; Francis Online], [Web of Science ®] , [Google Scholar]). The current study set out to characterize developmental changes in decision making by varying task complexity and punishment frequency. Three age groups (7–9 years, 10–12 years, 13–15 years) performed two versions of a computerized variant of the original Iowa gambling task. Task complexity was manipulated by varying the number of choices participants could make. Punishment frequency was manipulated by varying the frequency of delayed punishment. Results showed a developmental increase in the sensitivity to future consequences, which was present only when the punishment was presented infrequently. These results could not be explained by differential sensitivity to task complexity, hypersensitivity to reward, or failure to switch response set after receiving punishment. There was a general pattern of boys outperforming girls by making more advantageous choices over the course of the task. In conclusion, 7–12-year-old children—like VMPFC patients—appear myopic about the future except when the potential for future punishment is high.     

重视临床决策,提高临床医学水平

当代临床医学的发展与提高,与基础医学的研究密切相关,与科学技术提供的诊疗装备密切相关.由于现代信息技术的发展迅速,科技情报传递速度很快,以及经济全球化提供的便利快速的物流网络,医学的任何新设备、新药物、新的诊疗方法问世后,很快就能传遍全世界.就我国而言,我国临床医学水平与一些国家的差距,主要不是装备的差距,不是新设备、新药物的差距,而是如何运用医学新技术、新设备、新药物的差距,实际上也就是临床研究思维和临床决策水平的差距.     

Combining Patient Utility with Health Status Assessment to Improve Medical Decision Making

Physicians often use health status assessment tools to evaluate a patient's condition, then apply established guidelines to determine the most medically effective treatment. Yet additional criteria, such as the appropriateness of the treatment given the particular patient's preferences and attitude toward risk, are also highly relevant to quality care. While such preferences could be addressed via patient utility functions, their use in actual practice is somewhat limited because elicitation is often considered too burdensome for patients, unreliable, or redundant given other measures. For a small group of real patients who have suffered a stroke, we measure both traditional health status and patient utility for the current state to determine whether limited, focused utility assessment is a practical means of obtaining additional and relevant patient information. We find that utility assessment is perceived as reasonable and useful by patients, even when quite ill, and that utilities and health status are not redundant. In fact, investigating apparent inconsistencies between patient utility and observed health status can alert the physician to patient concerns and criteria not captured by more traditional measures. We propose an approach to medical decision making that uses both measures to improve patient–physician communication.     

奖惩频率对3～5岁幼儿完成博弈任务的影响

通过对情感决策的常用研究工具——标准爱荷华博弈任务进行了得失总量不变而频率改变的修改,并使之适合于年幼的3～5岁儿童,可以比较幼儿在不同奖惩频率任务中的表现,从而考察奖惩频率对幼儿情感决策的影响。对120名3～5岁幼儿在四种不同类型的任务中的表现进行分析后,所得实验结果如下:(1)儿童对惩罚和奖励频率的变化比较敏感:正向博弈任务中,"有利纸牌不变,不利纸牌的惩罚总量不变,只增加不利纸牌的惩罚频率"可以使3～5岁儿童完成博弈任务的成绩有显著提高;逆向博弈任务中,"不利纸牌不变,有利纸牌的奖惩总量不变,而有利纸牌奖励频率的增加"能促使4～5岁幼儿更多更快地做出正确选择。(2)幼儿的情感决策能力在3～4岁时期发展迅速,而在4～5岁时仍然有较快发展。     

医疗决策的程序公正

由于社会满足不了所有的医疗需求,医疗决策问题变成了确定医疗的限度问题。由于社会对于限度决定很难获得共识,医疗决策要通过公正的程序获得。医疗决策不能由某个人或某个团体或权力机构做出,而应该通过民主协商来做出,否则,人们会质疑医疗决策的合法性。     

医疗决策的程序公正

由于社会满足不了所有的医疗需求,医疗决策问题变成了确定医疗的限度问题.由于社会对于限度决定很难获得共识,医疗决策要通过公正的程序获得.医疗决策不能由某个人或某个团体或权力机构做出,而应该通过民主协商来做出.否则,人们会质疑医疗决策的合法性.     

Spendthrifts and Tightwads in Childhood: Feelings about Spending Predict Children's Financial Decision Making

Adults differ in the extent to which they find spending money to be distressing; “tightwads” find spending money painful, and “spendthrifts” do not find spending painful enough. This affective dimension has been reliably measured in adults and predicts a variety of important financial behaviors and outcomes (e.g., saving behavior and credit scores). Although children's financial behavior has also received attention, feelings about spending have not been studied in children, as they have in adults. We measured the spendthrift–tightwad (ST–TW) construct in children for the first time, with a sample of 5‐ to 10‐year‐old children (N = 225). Children across the entire age range were able to reliably report on their affective responses to spending and saving, and children's ST–TW scores were related to parent reports of children's temperament and financial behavior. Further, children's ST–TW scores were predictive of whether they chose to save or spend money in the lab, even after controlling for age and how much they liked the offered items. Our novel findings—that children's feelings about spending and saving can be measured from an early age and relate to their behavior with money—are discussed with regard to theoretical and practical implications. Copyright © 2017 John Wiley & Sons, Ltd.