An outcomes model of medical decision making

In the traditional fix-it model of medical decision making, the identified problem is typically characterized by a diagnosis that indicates a deviation from normalcy. When a medical problem is multifaceted and the available interventions are only partially effective, a broader vision of the health care endeavor is needed. What matters to the patient, and what should matter to the practitioner, is the patient's future possibilities. More specifically, what is important is the character of the alternative futures that the patient could have and choosing among them so as to achieve the best future possible, with the ranking of outcomes determined by the patient's preferences. This paper describes the fix-it model, presents and defends the outcomes-based model, and demonstrates that the latter is useful in developing normative conceptions of informed consent and decision making and in establishing a basis for societal involvement in the decision making process. Finally, several shortcomings of the model will be acknowledged.     

KNOWING WHEN TO SAY WHEN: A SIMPLE ASSESSMENT OF ALCOHOL IMPAIRMENT

The use of writing samples as indices of alcohol impairment was explored. Students at a campus fraternity party wrote a sentence and their signatures before and after consuming alcohol (in beer and mixed drinks). Later, undergraduate and graduate students attempted to discriminate between pre- and postparty handwriting samples. The average percentage of correct discriminations of entrance and exit writing samples was 83.7% for sentences and 67.5% for signatures, and the percentage of correct discriminations increased directly with the blood alcohol concentration of the partier who gave the writing sample. When a partier's blood alcohol concentration reached 0.15, all of the judges accurately discriminated 90% or more of the sentences, and 25 of the 28 judges correctly discriminated at least 80% of the signatures. All of the judges correctly discriminated at least 90% of the 18 sentences written by partiers with a blood alcohol concentration of 0.12 or more. Implications of these findings for reducing the risk of driving while intoxicated are discussed, as well as directions for follow-up research.     

Development of a drinking self-efficacy questionnaire

Self-efficacy has been postulated as a construct of central importance in the acquisition, maintenance, and treatment of addictive behavior. To date research has largely examined the role of outcome expectancies but literature on the relationship of self-efficacy and drinking is still unclear. This paper describes the development and psychometric properties of a Drinking Self-Efficacy Questionnaire (DSEQ). In Study I, 251 students were used to test the factor structure of the DSEQ. Factor analysis of the DSEQ showed three clear factors accounting for 60% of the common variance. These factors can be summarized as self-efficacy in situations characterized by social pressure, opportunistic drinking, and emotional relief. Study II used 138 people from a general community sample and discriminant analyses showed that the DSEQ has good discriminant validity. The findings suggest that the DSEQ has potential for use in research examining the role of drinking self-efficacy in problem drinkers.This paper was partly supported by grants from the NH&MRC to Dr. Oei.     

Stimulus Presentation Ratios And The Outcomes For Correct Responses In Signal-detection Procedures

Three pigeons were trained to discriminate between two line orientations (S₁ and S₂). A left-key peck was correct when S₁ was presented, and a right key-peck was correct when S₂ was presented. In all procedures, correct responses were occasionally reinforced with food paired with the presentation of the magazine light. Incorrect responses produced a blackout. Six detection procedures were used. In the first, the signal presentation ratio was varied across conditions and the reinforcer ratio was allowed to covary. In the second, the signal presentation ratio was held constant at 1:1 and the reinforcer ratio varied across conditions. In the third, the signal presentation ratio was varied across conditions and the reinforcer ratio was held constant at 1:1. In these three procedures, correct responses that were not scheduled for reinforcement were followed by blackout. The remaining three procedures repeated those described above with one procedural change: Nonreinforced but correct trials were followed by the presentation of the magazine light. Birds showed systematic preferences for the key associated with the stimulus presented or reinforced most often. There was no change in the birds' performance over changes in the feedback for nonreinforced but correct responses.     

Effect of Favorable Employment Change on Alcohol Abuse: One- and Five-Year Follow-Ups in the National Longitudinal Survey of Youth

Job loss has been linked to adverse outcomes such as alcohol abuse, but improved employment, usually assumed to be beneficial, has seldom been evaluated and may not help with addictive disorders. Using the National Longitudinal Survey of Youth, young adults who were unemployed or underemployed (low income or involuntary part-time) in 1984 were followed up in 1985 and 1989. Controlling for 1984 alcohol abuse, there were no effects of positive employment change on 1985 symptoms, but there were significant restorative effects on 1985 binge drinking among those who were heavy drinkers in 1984. There also appeared to be an indirect link of favorable 1984–1985 employment change to heavy drinking in 1989 via 1989 employment status. Because the effects of underemployment partially resembled those of unemployment, the discussion cautions against the conventional wisdom of promoting any work, including underemployment, as curative for the ills of unemployment.     

The effects of alcohol consumption and expectancies in an experimental date rape analogue

This study examined the impact of perceived token resistance and the psychological and pharmacological effects of alcohol consumption on men's discrimination of when a female wants her partner to stop his sexual advances. In a 2 (alcohol vs. no alcohol) × 2 (expectancy vs. no expectancy) × 2 (perceived token resistance vs. no resistance) randomized factorial design, male college students were exposed to an audiotape of a date rape. Before listening, participants were told that on the previous date the woman did not resist sexual contact or that she initially objected to the contact but the man was able to obtain the level of intimacy he desired. Relative to participants assigned to the no-alcohol expectancy or no-alcohol consumption group, participants in the alcohol expectancy and alcohol consumption groups took significantly longer to determine that the man should refrain from attempting further sexual contact. The implications of the findings are discussed.This investigation was carried out by the first author under the supervision of the second author in partial fulfillment of the requirements for the degree of Doctor of Philosophy.     

Alcohol First Use and Attitudes Among Young Children

We describe the attitudes and first use of alcohol by children, grades 3-6, who participated in the Bogalusa Heart Study, 1993-94. Questionnaire data reflected that more than one-third of the children had experimented with alcohol at the time of the study. The dominant environmental factor in experimentation was family modeling, and the dominant personal factor was curiosity, regardless of race, gender, or grade. Most children believed that alcohol use can lead to accidents, that drinking has negative social consequences, and that alcohol use hurts only if done to excess. Indications are that young children generally have negative attitudes regarding alcohol use, and that public and family alcohol education efforts need to be more specific about deleterious effects of even low levels of alcohol use in the young.     

Exposure to negative emotional cues and alcohol cue reactivity with alcoholics: a preliminary investigation

Fifty-one male and female inpatient alcoholics received cue exposure treatment involving in vivo exposure to alcohol cues and imaginal exposure to individualized high-risk drinking situations involving negative emotional cues. At post-test, self-report measures of urge to drink alcohol and negative emotional states were obtained during an alcohol cue reactivity assessment. Contrary to our hypothesis, greater exposure to negative emotional cues during treatment was associated with greater urge and negative emotional responses at post-test. In addition, greater duration of exposure to negative emotional cues predicted greater attention to alcohol-related stimuli and thoughts about drinking during the post-test. Implications for future research in this area include extending the duration of exposure to negative emotional cues in order to establish the optimal exposure durations within which a majority of individuals achieve clinically significant reductions in their urge to drink alcohol.     

I. V. Zavadskii and the beginnings of behavioral pharmacology: an historical note and translation.

I. V. Zavadskii, who worked in Pavlov's laboratory between 1907 and 1909, performed a study that has many of the characteristics of modern behavioral pharmacology. He studied the effects of alcohol, morphine, cocaine and caffeine on the conditioned salivary reflex. A translation of his paper and some brief comments on his life are presented.     

Test-retest reliability of retrospective self-reports in three populations of alcohol abusers

The reliability of alcohol abusers' retrospective self-reports was evaluated using a time-line follow-back interview technique. Independent groups of male subjects were interviewed in three different treatment settings (outpatient,n=12; inpatient,n=12; residential,n=12) on two separate occasions to assess the test-retest reliability of their self-reports of daily drinking and related events occurring 1 year prior to treatment. Correlational and scatterplot analyses generally showed a high correlation and low discrepancy between the two sets of interview responses for all groups. However, since some population differences were found in the reliability of reports for some variables, further research is needed to delineate the conditions under which reliable and valid retrospective self-reports can be obtained from different populations of alcohol abusers.This research was supported, in part, by Grant No. AA07072 from the National Institute on Alcohol Abuse and Alcoholism to Vanderbilt University.