According to the study results published in JAMA Network Open, autonomic arousal among doctors can indicate how they deal with uncertainties when making therapeutic decisions and can be reduced with additional education.
This study was a randomized clinical trial (ClinicalTrials.gov Identifier: NCT03134794) that recruited neurologists (N = 34) to care for patients with multiple sclerosis (MS) in Canada. Study researchers randomly assigned physicians to receive traffic light systems (TLS) -based training (n = 20) or not (n = 14) and rated pupillary dilatation when making clinical decisions involving them during a simulation Clinical information was presented at 4 time points (T1-T4). The researchers defined therapeutic inertia (TI) as a lack of escalation in treatment despite signs of disease progression.
The TLS program aided decision-making by determining actions based on traffic light colors that encouraged clinicians to pause or continue. A thought-provoking action should be triggered in high risk scenarios. The opposite scenario was the green light, which indicated a low risk situation where the same strategy should be maintained.
The neurologists were on average 44.6 years old (standard deviation) [SD]11.6) years; 38.3 percent were women and 58.8 percent were MS specialists. Physicians had 12.5 (SD, 11.8) years of practical experience and rated an average of 23.1 (SD, 16) patients with MS per week.
Before the clinical simulation, the risk neutrality measures did not differ between the control and intervention groups (P = 0.14), nor did the mean pupillary dilatation at the start of the study (2.82 ± 0.35 mm versus 2.96 ± 0.99 mm; P = 0.57).
At baseline, 50 percent of participants had a TI for one or more clinical scenarios, and non-MS specialists were more likely to have a TI than specialists (11.5% versus 5.2%; P = 0.01).
For every SD of pupillary dilatation diameter during assessment, the probability of a TI at T1 increased by 51 percent (odds ratio) [OR] 1.51; 95% CI, 1.12-2.03); by 31 percent at T2 (OR 1.31; 95% CI, 1.08-1.59); and by 49 percent at T3 (OR 1.49; 95% CI, 1.13-1.97). At T4, the study researchers observed no relationship between pupil dilatation and TI (OR 1.07; 95% CI, 0.86-1.34).
The pupil size differed significantly between TLS and control groups during T2 (b, -0.46; 95% CI, -0.9 to -0.01; P = 0.049); T3 (b, -0.63; 95% CI, -1.04 to -0.22; P = 0.004); and T4 (b, -0.75; 95% CI, -1.12 to -0.37; P <0.001). These observations indicated that TLS training had a protective effect for doctors when decisions were made in the context of uncertainty.
Aside from the small sample sizes, this study may have been limited by the choice of pupillary dilatation, which was not a standard measure of autonomic arousal.
The study’s authors concluded that their “educational intervention can reduce autonomic arousal by reducing uncertainty, thereby enabling alternative behavioral strategies. In particular, the warning function of a red light can help to highlight the need to switch to a more effective active ingredient, while at the same time increasing the doctor’s confidence in the therapeutic decision. ”
Disclosure: Several authors have stated that they are part of the industry. For a full list of the authors’ claims, see the original article.
Saposnik G, Grueschow M, Oh J, he al. Influence of educational intervention on therapeutic indolence in neurologists with expertise in multiple sclerosis. a randomized clinical trial. JAMA Netw Open. 2020; 3 (12): e2022227. doi: 10.1001 / jamanetworkopen.2020.22227