title: Physician styles of decision-making for a complex condition: Type 2 diabetes with co-morbid mental illness.
abstract: OBJECTIVE
  Variation in physician decisions may reflect personal styles of decision-making, as opposed to singular clinical actions and these styles may be applied differently depending on patient complexity. The objective of this study is to examine clusters of physician decision-making for type 2 diabetes, overall and in the presence of a mental health co-morbidity.
  
  
  METHODS
  This randomized balanced factorial experiment presented video vignettes of a "patient" with diagnosed, but uncontrolled type 2 diabetes. "Patients" were systematically varied by age, sex, race and co-morbidity (depression, schizophrenia with normal or bizarre affect, eczema as control). Two hundred and fifty-six primary care physicians, balanced by gender and experience level, completed a structured interview about clinical management.
  
  
  RESULTS
  Cluster analysis identified 3 styles of diabetes management. "Minimalists" (n=84) performed fewer exams or tests compared to "middle of the road" physicians (n=84). "Interventionists" (n=88) suggested more medications and referrals. A second cluster analysis, without control for co-morbidities, identified an additional cluster of "information seekers" (n=15) who requested more additional information and referrals. Physicians ranking schizophrenia higher than diabetes on their problem list were more likely "minimalists" and none were "interventionists" or "information seekers".
  
  
  CONCLUSIONS
  Variations in clinical management encompass multiple clinical actions and physicians subtly shift these decision-making styles depending on patient co-morbidities. Physicians' practice styles may help explain persistent differences in patient care. Training and continuing education efforts to encourage physicians to implement evidence-based clinical practice should account for general styles of decision-making and for how physicians process complicating comorbidities.
authors: Principal Research Scientist and Biostatistician, New England Research Institutes, Watertown, MA, USA.
authors: Felicia L
authors: FL
authors: Trachtenberg
authors: Mary K. Iacocca Visiting Interdisciplinary Faculty Fellow, Vascular Cell Biology, Joslin Diabetes Center & Visiting Assistant Professor of Medicine, Harvard Medical School, Boston, MA, USA.
authors: David M
authors: DM
authors: Pober
authors: Director, Clinical and Translational Science Institute, Boston, MA, USA.
authors: Lisa C
authors: LC
authors: Welch
authors: Senior Vice President; Co-director, Health Services and Disparities Research, New England Research Institutes, Watertown, MA, USA.
authors: John B
authors: JB
authors: McKinlay
keywords: Cluster analysis; co-morbidity; diabetes; patient complexity; person-centered healthcare; physician decision-making