From the Editors’ Desk: Decisions, Decisions
Mitchell D. Feldman, MD, MPhil
1
and Richard L. Kravitz, MD, MSPH
2
1
Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, USA;
2
University of California, Davis,
Sacramento, CA, USA.
J Gen Intern Med 26(4):353
DOI: 10.1007/s11606-011-1649-1
© The Author(s) 2011. This article is published with open access at
Springerlink.com
I
n his book, How Doctors Think, Jerome Groopman argues
that medicine is an “uncertain science,” and as such,
medical decision-making often relies as much on intuition
and experience as it does on evidence. In fact, Groopman
cautions against the over-reliance on evidence-based decision-
making, arguing that it must be balanced with the physician’s
own personal experience with the patient or the treatment. He
contends that doctors “desperately need patients and their
families and friends to help them think,” and without this help,
doctors are unlikely to make the correct diagnosis or give the
most useful advice.
In this issue of JGIM, several articles examine the art and
science of clinical decision-making. One way that doctors can
use evidence to inform decision-making is by applying
probability theory (or Bayes’ theorem) to clinical decisions.
While not eliminating uncertainty, it can, as suggested by Sox
et al., “reduce uncertainty about uncertainty.”
In this issue, Agoritsas et al. investigate the extent to which
practicing doctors in Geneva, Switzerland, use disease preva-
lence when interpreting a positive test result. Prevalence
matters, of course, in determining the post-test probability of
disease (think HIV testing in a nunnery), but the study by
Agoritsas et al. found that most physicians were unable to
apply this concept when presented with a simple clinical
scenario. This may lead to both unnecessary testing and
diagnostic errors.
Few clinical decisions are as important as the determination
of code status in a hospitalized patient. Anderson et al. examine
audiotape code status discussions between attending hospitalist
physicians and medical patients to better understand how these
decisions are made. They found that despite the growing focus
on this issue over the past decade, code status still is not
discussed with many seriously ill patients, and when it is, the
discussions are often incomplete. As Hauer and colleagues
highlight in their research, part of the problem may reside in our
not knowing how to adequately assess medical students’
competence in shared decision-making. Key clinical decisions
such as code status rely on shared decision-making between
the doctor and patient. We must improve our ability to teach
and assess this core skill in future physicians.
Meanwhile, clinical investigators (including many JGIM
readers) are engaged in a different sort of decision-making:
where to submit the results of completed research. At JGIM,
we’re concerned about demands on authors’ time and have
taken steps to ease the submission process. Instructions for
authors (http://www.jgimed.org/) are brief and (we hope)
unambiguous. In contrast to many other journals, authors are
requested to submit their manuscripts as a single Word
document, inclusive of figures and tables. There is no cumber-
some data entry process. And, on initial submission, we will
accept references in any numbered format—no need to spend
additional time finding the right EndNote reference style.
Another way we save authors’ time is by promptly returning
manuscripts thought unlikely to weather the editorial process.
JGIM currently returns approximately 40% of original research
submissions without external peer review. We do not do so lightly.
In most cases, a co-Editor and/or Associate Editor and at least
one other member of the editorial team review each manuscript.
The most common reason for “reject without review” is lack of fit
with the journal’s scope, although we sometimes reject for lack of
topicality, overlap with other recently published content, or major
problems with clarity. We believe that prompt rejection gives
authors an opportunity to submit their work to a more suitable
venue without wasting their time.
Despite efforts at process improvement here and at other
journals, the road from study completion to publication is often
slow and precarious. One reason is that authors whose work is
not accepted at one journal have to start the process all over again
at the next. We are pleased to announce a new partnership
between JGIM and the Annals of Internal Medicine that eliminates
some of the redundancies. The Annals
and JGIM have negotiated
an arrangement such that authors who submit manuscripts to
Annals can request at the time of submission that Annals send
the manuscript directly to JGIM if after external review Annals
decides not to publish it. This will greatly decrease the hassle
factor for authors in resubmitting to JGIM after review at Annals
and will allow JGIMto streamline our decision-making process for
the submission. We are excited about this new venture and
welcome your comments on this and other ways we can make
JGIM more responsive to your needs.
Open Access: This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
Corresponding Author: Mitchell D. Feldman, MD, MPhil; Division of
General Internal Medicine, University of California, San Francisco,
400 Parnassus Avenue, San Francisco, CA 94143-0320, USA
(e-mail: Mitchell.Feldman@UCSF.edu).
Published online February 17, 2011
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