Physician Styles of Decision Making for a Complex Condition: Type 2 Diabetes with Comorbid Mental Illness

Abstract

Rationale, aims, and objectives: 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 comorbidity.

Method: 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 comorbidity (depression, schizophrenia with normal or bizarre affect, eczema as control).  256 primary care physicians, balanced by gender and experience level, completed a structured interview about clinical management. 

Results: Cluster analysis identified three 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 comorbidities, 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 comorbidities. 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.