0
June 3, 1988, Vol 259, No. 21 >
ARTICLE | June 3, 1988

Science, Ethics, and the Making of Clinical Decisions: Title and subTitle BreakImplications for Risk Factor Intervention FREE

Lachlan Forrow, MD; Steven A. Wartman, MD, PhD; Dan W. Brock, PhD
[+] Author Affiliations

Reprint requests to Division of General Internal Medicine, Rhode Island Hospital, Providence, RI 02902 (Dr Wartman).


JAMA. 1988;259(21):3161-3167. doi:10.1001/jama.1988.03720210051029
Text Size: A A A
Published online
Article
References

Recent improvements in the clinical care of individual patients are rooted in advances in two distinct fields of modern medicine: biomedical research and clinical ethics. In this article, we review the differing roles of these two disciplines in guiding decision making for individual patients. Particular attention is placed on decisions involving risk factor intervention, using the common problem of mild hypertension as an illustration. Both the importance and the limitations for decision making of some recently published clinical trials are reviewed. Differences in interpretation of these trials are a source of major disputes about the proper threshold for medical intervention. The ethical aspects of treatment decisions are then reviewed, with particular emphasis on the doctrine of informed consent and on the role of patient participation in treatment decisions. Finally, new directions for clinical research are suggested that may yield a more complete scientific basis for treatment decisions and that may aid in fulfilling the ethical ideals that underlie the physician-patient relationship.

(JAMA 1988;259:3161-3167)

REFERENCES

1 +
Cypress BK: Medication Therapy in Office Visits for Hypertension: National Ambulatory Medical Care Survey, 1980 . Hyattsville, Md, National Center for Health Statistics, 1982;.
2 +
The 1984 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure , publication 84-1088. Bethesda, Md, National Institutes of Health, 1984;.
3 +
Borhani NO:  Does early treatment benefit 'mild' hypertension? J Cardiovasc Med 1984;; (February) :145-150.
4 +
Borhani NO, Langford HG:  Treating mild hypertension. Ann Intern Med 1984;;100:312-313.
5 +
Breckinridge A:  Treating mild hypertension. Br Med J 1985;;291:89-90.
6 +
Chobanian AV:  Treatment of mild hypertension: The debate intensifies. J Cardiovasc Med 1983;; (August) :883-888.
7 +
Chobanian AV:  Antihypertensive therapy in evolution. N Engl J Med 1986;;314:1701-1702.
8 +
Freis ED:  Should mild hypertension be treated? N Engl J Med 1982;;307:305-309.
9 +
Gifford RW, Borhani N, Krishan I, et al:  The dilemma of 'mild' hypertension. JAMA 1983;;250: 3171-3173.
10 +
Hymon D, Kaplan NM:  Treatment of patients with mild hypertension. Hypertension 1985;;7:165-170.
11 +
Kaplan NM:  Initial treatment of adult patients with essential hypertension: II. Alternating monotherapy is the preferred treatment. Pharmacotherapy 1985;;5:195-200.
12 +
Kaplan NM:  Therapy for mild hypertension: Toward a more balanced view. JAMA 1983;;249: 365-367.
13 +
Kaplan NM:  Therapy of mild hypertension: An overview. Am J Cardiol 1984;;53:2A-8A.
14 +
Kaplan NM:  Mild hypertension: When and how to treat. Arch Intern Med 1983;;143:255-259.
15 +
Kopelman RI, Dzau VJ:  Trends in the therapy for mild hypertension: A word of caution. Arch Intern Med 1985;; 145:47-49.
16 +
Levy RI:  Hypertension control: A succeeding national effort. JAMA 1979;;241:2546.
17 +
McAlister NH:  Should we treat 'mild' hypertension? JAMA 1983;;249:379-382.
18 +
Moser M:  On the management of 'mild hypertension.' Arch Intern Med 1981;;141:1587-1588.
19 +
Moser M:  Initial treatment of adult patients with essential hypertension: I. Why conventional stepped-care therapy of hypertension is still indicated. Pharmacotherapy 1985;;5:189-195.
20 +
Oliver MF:  Prevention of coronary heart disease: Propaganda, promises, problems, and prospects. Circulation 1986;;73:1-9.
21 +
Oslo Study Research Group:  MRFIT and the Oslo study. JAMA 1983;;249:893-894.
22 +
Paul O:  The Medical Research Council Trial. Hypertension 1986;;8:733-736.
23 +
Paul O:  The Multiple Risk Factor Intervention Trial: A retrospective. J Cardiovasc Med 1983;; (October) :1071-1081.
24 +
Pickering TG:  Treatment of mild hypertension and the reduction of cardiovascular mortality: The 'of' or 'by' dilemma. JAMA 1983;;249:399-400.
25 +
Ram CVS:  Should mild hypertension be treated? Ann Intern Med 1983;;99:403-405.
26 +
Ram CVS:  Treating mild hypertension: Response. Ann Intern Med 1984;;100:312-313.
27 +
Relman A:  Mild hypertension: No more benign neglect. N Engl J Med 1982;;302:293-294.
28 +
Rose G:  Strategy of prevention: Lessons from cardiovascular disease. Br Med J 1981;;282:1847-1851.
29 +
Wilburn RL:  Mild hypertension: Should all patients be treated? Postgrad Med 1984;;76:107-113.
30 +
Zanchetti A:  Treatment goals in hypertension. Am J Med Symp 1984;;76:1-3.
31 +
Zusman RM:  Alternatives to traditional antihypertensive therapy. Hypertension 1986;;8:837-842.
32 +
Brett AS:  Ethical issues in risk factor intervention. Am J Med 1984;;76:557-561.
33 +
WHO Cooperative Trial on Primary Prevention of Ischaemic Heart Disease With Clofibrate to Lower Serum Cholesterol:  Final mortality follow-up. Lancet 1984;;2:600-604.
34 +
University Group Diabetes Program:  A study of the effects of hypoglycemic agents on vascular complications in patients with adult-onset diabetes: I. Design, methods and baseline results; II. Mortality results. Diabetes 1970;;19( (suppl 2) ):747-830.
35 +
Multiple Risk Factor Intervention Trial Research Group:  Multiple Risk Factor Intervention Trial: Risk factor changes and mortality results. JAMA 1982;;248:1465-1477.
36 +
Hypertension Detection and Follow-up Pro- gram Cooperative Group:  The effect of treatment on mortality in 'mild' hypertension. N Engl J Med 1982;;307:976-980.
37 +
Report of the Management Committee:  The Australian Therapeutic Trial in Mild Hypertension. Lancet 1980;;1:261-267.
38 +
Veterans Administration Cooperative Study Group on Antihypertensive Agents:  Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA 1970;;213: 1143-1152.
39 +
Medical Research Council Working Party:  MRC trial of treatment of mild hypertension: Principal results. Br Med J 1985;;291:97-104.
40 +
Hypertension Detection and Follow-up Program Cooperative Group:  Implications of the Hypertension Detection and Follow-up Program. Prog Cardiovasc Dis 1986;;29( (suppl 1) ):3-10.
41 +
Cassell EJ:  The nature of suffering and the goals of medicine. N Engl J Med 1982;;306:639-645.
42 +
Horowitz M:  News of risk as a potential stressor. JAMA 1985;;253:1929.
43 +
Haynes RB, Sackett DL, Taylor DW, et al:  Increased absenteeism from work after detection and labeling of hypertensive patients. N Engl J Med 1978;;299:741-744.
44 +
 Report of Medical Research Council Working Party on mild to moderate hypertension. Lancet 1981;;2:539-543.
45 +
Gallup G Jr, Cotugno HE:  Preferences and practices of Americans and their physicians in antihypertensive therapy. Am J Med 1986;;81( (suppl 6C) ):20-24.
46 +
Shulman NB, Martinez B, Brogan D, et al:  Financial cost as an obstacle to hypertension therapy. Am J Public Health 1986;;76:1105-1108.
47 +
Weinstein MC, Fineberg HV, Elstein AS, et al: Clinical Decision Analysis . Philadelphia, WB Saunders Co, 1980;.
48 +
Pauker SG, Kassirer JP:  Decision analysis. N Engl J Med 1987;;316:250-258.
49 +
Kassirer JP, Moskowitz AJ, Lau J, et al:  Decision analysis: A progress report. Ann Intern Med 1987;;106:275-291.
50 +
Ransohoff DF, Feinstein AR:  Is decision analysis useful in clinical medicine? Yale J Biol Med 1976;;49:165-168.
51 +
Weinstein MC, Stason WB: Hypertension: A Policy Perspective . Cambridge, Mass, Harvard University Press, 1976;.
52 +
McNeil BJ, Weichselbaum R, Pauker SG:  Fallacy of the five-year survival in lung cancer. N Engl J Med 1978;;299:1397-1401.
53 +
McNeil BJ, Weichselbaum R, Pauker SG:  Speech and survival: Tradeoffs between quality and quantity of life in laryngeal cancer. N Engl J Med 1981;;305:982-987.
54 +
KatzJ: The Silent World of Doctor and Patient . New York, Free Press, 1984;.
55 +
Faden RR, Beauchamp TL: A History and Theory of Informed Consent . New York, Oxford University Press Inc, 1986;.
56 +
President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research: Making Health Care Decisions . Government Printing Office, 1982;, vol 1.
57 +
Holmes MM, Rovner DR, Rothert ML, et al:  Women's and physicians' utilities for health outcomes in estrogen replacement therapy. J Gen Intern Med 1987;;2:178-182.
58 +
Kassirer JP, Pauker SG:  The toss-up. N Engl J Med 1981;;305:1467-1469.
59 +
Leonard CO, Chase GA, Childs B:  Genetic counseling: A consumer's view. N Engl J Med 1972;;287:433-439.
60 +
Lidz CW, Meisel A, Osterweis M, et al:  Barriers to informed consent. Ann Intern Med 1983;;99:539-543.
61 +
Eisenberg JM: Doctors' Decisions and the Cost of Medical Care . Ann Arbor, Mich, Health Administration Press Perspectives, 1986;.
62 +
Berwick DM, Fineberg HV, Weinstein MC:  When doctors meet numbers. Am J Med 1981;;71:991-998.
63 +
Casscells W, Schoenberger A, Graboys TB:  Interpretation by physicians of clinical laboratory results. N Engl J Med 1978;;299:999-1001.
64 +
Nightingale SD:  Risk preference and laboratory use. Med Decis Making 1987;;7:168-173.
65 +
Dawson NV, Arkes HR:  Systematic errors in medical decision making: Judgment limitations. J Gen Intern Med 1987;;2:183-187.
66 +
Greenfield S, Kaplan S, Ware JE Jr:  Expanding patient involvement in care: Effects on patient outcomes. Ann Intern Med 1985;;102:520-528.
67 +
Haber E:  Hypertension: Where do we go from here? Hypertension 1985;;7:311-312.
68 +
Guttmacher S, Teitelman M, Chapin G:  Ethics and preventive medicine: The case of borderline hypertension. Hastings Cent Rep 1981;;12:12-20.
69 +
James TN: Presidential address: Cardiology, technology, and common sense. Read before the Tenth World Congress of Cardiology, Washington, DC, Sept 15, 1986.
70 +
Feinstein AR:  An additional basic science for clinical medicine: I. The constraining fundamental paradigms; II. The limitations of randomized trials; III. The challenges of comparison and measurement; IV. The development of clinimetrics. Ann Intern Med 1983;;99:393-397, 544-550, 705-712, 843-848.
71 +
Croog SH, Levine S, Testa MA, et al:  The effects of antihypertensive therapy on the quality of life. N Engl J Med 1986;;314:1657-1664.
72 +
Thompson GE, Alderman MH, Wassertheil-Smoller S, et al:  High blood pressure diagnosis and treatment: Consensus recommendations versus actual practice. Am J Public Health 1981;;71:413-416.
73 +
Feinstein AR:  The 'chagrin factor' and qualitative decision analysis. Arch Intern Med 1985;:145: 1257-1259.
74 +
 Hypertension prevalence and the status of awareness, treatment, and control in the United States: Final report of the Subcommittee on Definition and Prevalence of the 1984 Joint National Committee. Hypertension 1985;;7:457-468.
75 +
Elstein AS, Holzman GB, Ravitch MM:  Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model. Am J Med 1986;;80:246-258.
76 +
Sackett DL:  A compliance practicum for the busy practitioner , in Haynes RB, Taylor DW, Sackett DL (eds): Compliance in Health Care . Baltimore, The Johns Hopkins University Press, 1979;, pp 286-294.
77 +
Conrad P:  The noncompliant patient in search of autonomy. Hastings Cent Rep 1987;;17:15-17.
78 +
Taylor WC, Pass TM, Shepard DS, et al:  Cholesterol reduction and life expectancy: A model incorporating multiple risk factors. Ann Intern Med 1987;;106:605-614.
79 +
Detsky AS:  Decision analysis: What's the prognosis? Ann Intern Med 1987;;106:321-322.
80 +
Brody DS:  The patient's role in clinical decision-making. Ann Intern Med 1980;;93:718-722.
81 +
Schulman BA:  Active patient orientation and outcomes in hypertensive treatment. Med Care 1979;;17:267-280.
82 +
Strull WM, Lo B, Charles G:  Do patients want to participate in medical decision making? JAMA 1984;;252:2990-2994.
83 +
Cassileth BR, Zupkis RV, Sutton-Smith K, et al:  Information and participation preferences among cancer patients. Ann Intern Med 1980;; 92:832-836.
84 +
Platt FW, McMath JC:  Clinical hypocompetence: The interview. Ann Intern Med 1979;;91:898-902.
85 +
Cassell EJ: Talking With Patients . Cambridge, Mass, MIT Press, 1985;.
86 +
Panel on the General Professional Education of the Physician and College Preparation for Medicine (GPEP): Physicians for the 21st Century . Washington, DC, Association of American Medical Colleges, 1984;.
87 +
American Board of Internal Medicine:  Evaluation of humanistic qualities in the internist. Ann Intern Med 1983;;99:720-724.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Cypress BK: Medication Therapy in Office Visits for Hypertension: National Ambulatory Medical Care Survey, 1980 . Hyattsville, Md, National Center for Health Statistics, 1982;.
2 +
The 1984 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure , publication 84-1088. Bethesda, Md, National Institutes of Health, 1984;.
3 +
Borhani NO:  Does early treatment benefit 'mild' hypertension? J Cardiovasc Med 1984;; (February) :145-150.
4 +
Borhani NO, Langford HG:  Treating mild hypertension. Ann Intern Med 1984;;100:312-313.
5 +
Breckinridge A:  Treating mild hypertension. Br Med J 1985;;291:89-90.
6 +
Chobanian AV:  Treatment of mild hypertension: The debate intensifies. J Cardiovasc Med 1983;; (August) :883-888.
7 +
Chobanian AV:  Antihypertensive therapy in evolution. N Engl J Med 1986;;314:1701-1702.
8 +
Freis ED:  Should mild hypertension be treated? N Engl J Med 1982;;307:305-309.
9 +
Gifford RW, Borhani N, Krishan I, et al:  The dilemma of 'mild' hypertension. JAMA 1983;;250: 3171-3173.
10 +
Hymon D, Kaplan NM:  Treatment of patients with mild hypertension. Hypertension 1985;;7:165-170.
11 +
Kaplan NM:  Initial treatment of adult patients with essential hypertension: II. Alternating monotherapy is the preferred treatment. Pharmacotherapy 1985;;5:195-200.
12 +
Kaplan NM:  Therapy for mild hypertension: Toward a more balanced view. JAMA 1983;;249: 365-367.
13 +
Kaplan NM:  Therapy of mild hypertension: An overview. Am J Cardiol 1984;;53:2A-8A.
14 +
Kaplan NM:  Mild hypertension: When and how to treat. Arch Intern Med 1983;;143:255-259.
15 +
Kopelman RI, Dzau VJ:  Trends in the therapy for mild hypertension: A word of caution. Arch Intern Med 1985;; 145:47-49.
16 +
Levy RI:  Hypertension control: A succeeding national effort. JAMA 1979;;241:2546.
17 +
McAlister NH:  Should we treat 'mild' hypertension? JAMA 1983;;249:379-382.
18 +
Moser M:  On the management of 'mild hypertension.' Arch Intern Med 1981;;141:1587-1588.
19 +
Moser M:  Initial treatment of adult patients with essential hypertension: I. Why conventional stepped-care therapy of hypertension is still indicated. Pharmacotherapy 1985;;5:189-195.
20 +
Oliver MF:  Prevention of coronary heart disease: Propaganda, promises, problems, and prospects. Circulation 1986;;73:1-9.
21 +
Oslo Study Research Group:  MRFIT and the Oslo study. JAMA 1983;;249:893-894.
22 +
Paul O:  The Medical Research Council Trial. Hypertension 1986;;8:733-736.
23 +
Paul O:  The Multiple Risk Factor Intervention Trial: A retrospective. J Cardiovasc Med 1983;; (October) :1071-1081.
24 +
Pickering TG:  Treatment of mild hypertension and the reduction of cardiovascular mortality: The 'of' or 'by' dilemma. JAMA 1983;;249:399-400.
25 +
Ram CVS:  Should mild hypertension be treated? Ann Intern Med 1983;;99:403-405.
26 +
Ram CVS:  Treating mild hypertension: Response. Ann Intern Med 1984;;100:312-313.
27 +
Relman A:  Mild hypertension: No more benign neglect. N Engl J Med 1982;;302:293-294.
28 +
Rose G:  Strategy of prevention: Lessons from cardiovascular disease. Br Med J 1981;;282:1847-1851.
29 +
Wilburn RL:  Mild hypertension: Should all patients be treated? Postgrad Med 1984;;76:107-113.
30 +
Zanchetti A:  Treatment goals in hypertension. Am J Med Symp 1984;;76:1-3.
31 +
Zusman RM:  Alternatives to traditional antihypertensive therapy. Hypertension 1986;;8:837-842.
32 +
Brett AS:  Ethical issues in risk factor intervention. Am J Med 1984;;76:557-561.
33 +
WHO Cooperative Trial on Primary Prevention of Ischaemic Heart Disease With Clofibrate to Lower Serum Cholesterol:  Final mortality follow-up. Lancet 1984;;2:600-604.
34 +
University Group Diabetes Program:  A study of the effects of hypoglycemic agents on vascular complications in patients with adult-onset diabetes: I. Design, methods and baseline results; II. Mortality results. Diabetes 1970;;19( (suppl 2) ):747-830.
35 +
Multiple Risk Factor Intervention Trial Research Group:  Multiple Risk Factor Intervention Trial: Risk factor changes and mortality results. JAMA 1982;;248:1465-1477.
36 +
Hypertension Detection and Follow-up Pro- gram Cooperative Group:  The effect of treatment on mortality in 'mild' hypertension. N Engl J Med 1982;;307:976-980.
37 +
Report of the Management Committee:  The Australian Therapeutic Trial in Mild Hypertension. Lancet 1980;;1:261-267.
38 +
Veterans Administration Cooperative Study Group on Antihypertensive Agents:  Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA 1970;;213: 1143-1152.
39 +
Medical Research Council Working Party:  MRC trial of treatment of mild hypertension: Principal results. Br Med J 1985;;291:97-104.
40 +
Hypertension Detection and Follow-up Program Cooperative Group:  Implications of the Hypertension Detection and Follow-up Program. Prog Cardiovasc Dis 1986;;29( (suppl 1) ):3-10.
41 +
Cassell EJ:  The nature of suffering and the goals of medicine. N Engl J Med 1982;;306:639-645.
42 +
Horowitz M:  News of risk as a potential stressor. JAMA 1985;;253:1929.
43 +
Haynes RB, Sackett DL, Taylor DW, et al:  Increased absenteeism from work after detection and labeling of hypertensive patients. N Engl J Med 1978;;299:741-744.
44 +
 Report of Medical Research Council Working Party on mild to moderate hypertension. Lancet 1981;;2:539-543.
45 +
Gallup G Jr, Cotugno HE:  Preferences and practices of Americans and their physicians in antihypertensive therapy. Am J Med 1986;;81( (suppl 6C) ):20-24.
46 +
Shulman NB, Martinez B, Brogan D, et al:  Financial cost as an obstacle to hypertension therapy. Am J Public Health 1986;;76:1105-1108.
47 +
Weinstein MC, Fineberg HV, Elstein AS, et al: Clinical Decision Analysis . Philadelphia, WB Saunders Co, 1980;.
48 +
Pauker SG, Kassirer JP:  Decision analysis. N Engl J Med 1987;;316:250-258.
49 +
Kassirer JP, Moskowitz AJ, Lau J, et al:  Decision analysis: A progress report. Ann Intern Med 1987;;106:275-291.
50 +
Ransohoff DF, Feinstein AR:  Is decision analysis useful in clinical medicine? Yale J Biol Med 1976;;49:165-168.
51 +
Weinstein MC, Stason WB: Hypertension: A Policy Perspective . Cambridge, Mass, Harvard University Press, 1976;.
52 +
McNeil BJ, Weichselbaum R, Pauker SG:  Fallacy of the five-year survival in lung cancer. N Engl J Med 1978;;299:1397-1401.
53 +
McNeil BJ, Weichselbaum R, Pauker SG:  Speech and survival: Tradeoffs between quality and quantity of life in laryngeal cancer. N Engl J Med 1981;;305:982-987.
54 +
KatzJ: The Silent World of Doctor and Patient . New York, Free Press, 1984;.
55 +
Faden RR, Beauchamp TL: A History and Theory of Informed Consent . New York, Oxford University Press Inc, 1986;.
56 +
President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research: Making Health Care Decisions . Government Printing Office, 1982;, vol 1.
57 +
Holmes MM, Rovner DR, Rothert ML, et al:  Women's and physicians' utilities for health outcomes in estrogen replacement therapy. J Gen Intern Med 1987;;2:178-182.
58 +
Kassirer JP, Pauker SG:  The toss-up. N Engl J Med 1981;;305:1467-1469.
59 +
Leonard CO, Chase GA, Childs B:  Genetic counseling: A consumer's view. N Engl J Med 1972;;287:433-439.
60 +
Lidz CW, Meisel A, Osterweis M, et al:  Barriers to informed consent. Ann Intern Med 1983;;99:539-543.
61 +
Eisenberg JM: Doctors' Decisions and the Cost of Medical Care . Ann Arbor, Mich, Health Administration Press Perspectives, 1986;.
62 +
Berwick DM, Fineberg HV, Weinstein MC:  When doctors meet numbers. Am J Med 1981;;71:991-998.
63 +
Casscells W, Schoenberger A, Graboys TB:  Interpretation by physicians of clinical laboratory results. N Engl J Med 1978;;299:999-1001.
64 +
Nightingale SD:  Risk preference and laboratory use. Med Decis Making 1987;;7:168-173.
65 +
Dawson NV, Arkes HR:  Systematic errors in medical decision making: Judgment limitations. J Gen Intern Med 1987;;2:183-187.
66 +
Greenfield S, Kaplan S, Ware JE Jr:  Expanding patient involvement in care: Effects on patient outcomes. Ann Intern Med 1985;;102:520-528.
67 +
Haber E:  Hypertension: Where do we go from here? Hypertension 1985;;7:311-312.
68 +
Guttmacher S, Teitelman M, Chapin G:  Ethics and preventive medicine: The case of borderline hypertension. Hastings Cent Rep 1981;;12:12-20.
69 +
James TN: Presidential address: Cardiology, technology, and common sense. Read before the Tenth World Congress of Cardiology, Washington, DC, Sept 15, 1986.
70 +
Feinstein AR:  An additional basic science for clinical medicine: I. The constraining fundamental paradigms; II. The limitations of randomized trials; III. The challenges of comparison and measurement; IV. The development of clinimetrics. Ann Intern Med 1983;;99:393-397, 544-550, 705-712, 843-848.
71 +
Croog SH, Levine S, Testa MA, et al:  The effects of antihypertensive therapy on the quality of life. N Engl J Med 1986;;314:1657-1664.
72 +
Thompson GE, Alderman MH, Wassertheil-Smoller S, et al:  High blood pressure diagnosis and treatment: Consensus recommendations versus actual practice. Am J Public Health 1981;;71:413-416.
73 +
Feinstein AR:  The 'chagrin factor' and qualitative decision analysis. Arch Intern Med 1985;:145: 1257-1259.
74 +
 Hypertension prevalence and the status of awareness, treatment, and control in the United States: Final report of the Subcommittee on Definition and Prevalence of the 1984 Joint National Committee. Hypertension 1985;;7:457-468.
75 +
Elstein AS, Holzman GB, Ravitch MM:  Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model. Am J Med 1986;;80:246-258.
76 +
Sackett DL:  A compliance practicum for the busy practitioner , in Haynes RB, Taylor DW, Sackett DL (eds): Compliance in Health Care . Baltimore, The Johns Hopkins University Press, 1979;, pp 286-294.
77 +
Conrad P:  The noncompliant patient in search of autonomy. Hastings Cent Rep 1987;;17:15-17.
78 +
Taylor WC, Pass TM, Shepard DS, et al:  Cholesterol reduction and life expectancy: A model incorporating multiple risk factors. Ann Intern Med 1987;;106:605-614.
79 +
Detsky AS:  Decision analysis: What's the prognosis? Ann Intern Med 1987;;106:321-322.
80 +
Brody DS:  The patient's role in clinical decision-making. Ann Intern Med 1980;;93:718-722.
81 +
Schulman BA:  Active patient orientation and outcomes in hypertensive treatment. Med Care 1979;;17:267-280.
82 +
Strull WM, Lo B, Charles G:  Do patients want to participate in medical decision making? JAMA 1984;;252:2990-2994.
83 +
Cassileth BR, Zupkis RV, Sutton-Smith K, et al:  Information and participation preferences among cancer patients. Ann Intern Med 1980;; 92:832-836.
84 +
Platt FW, McMath JC:  Clinical hypocompetence: The interview. Ann Intern Med 1979;;91:898-902.
85 +
Cassell EJ: Talking With Patients . Cambridge, Mass, MIT Press, 1985;.
86 +
Panel on the General Professional Education of the Physician and College Preparation for Medicine (GPEP): Physicians for the 21st Century . Washington, DC, Association of American Medical Colleges, 1984;.
87 +
American Board of Internal Medicine:  Evaluation of humanistic qualities in the internist. Ann Intern Med 1983;;99:720-724.

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