When your doctor gives you a choice between two different ways to treat a health problem, what factors influence your decision? Your age, your lifestyle, your activity level? What about how the doctor presents the question? As one of several Loeb researchers working to develop decision aids, Dr. Ian Graham is investigating the role that is played by the patient-physician interaction.

A decision aid is a health-care tool designed to help patients make good, informed decisions. A side benefit is the simultaneous improvement in the quality of the limited time that physicians and patients have to spend together. One decision aid, a kit called Making Choices, was developed by Loeb researchers Drs. Annette O'Conner and Peter Tugwell for post-menopausal women considering hormone replacement therapy. As part of the clinical trial of this aid, Dr. Graham is evaluating the kit from the physician's perspective, and determining how its use affects the patient-physician encounter. Half of the women in the trial receive the American College of Physicians pamphlet on hormone replacement thereapy, while the other half are given Making Choices. Through interviews with the women's physicians both before and after the pamphlet or decision aid is presented, and by audiotaping one patient consultation visit per physician, Dr. Graham will determine how the decision aid is used, and what the doctors think of it.

Dr. Graham is also surveying emergency room physicians to learn their attitudes toward such diagnostic innovations as the Ottawa Ankle Rules. Developed by Loeb researcher Dr. Ian Stiell, these guidelines help physicians rule out ankle fractures without resorting to unnecessary X rays, and are now in widespread use. Dr. Stiell recently devised a set of knee rules, and is currently working on similar guidelines for the use of CT scans on patients with minor head injuries, and for the use of cervical spinal X rays for trauma patients. Dr. Graham will gather data among physicians internationally about who uses the rules and why. By analyzing this data, he will learn things like how accurate such rules need to be before physicians will use them, what barriers there may be to their use, and what characteristics are common among those who are or are not using them--for example, whether older physicians might be less likely to be willing to use the rules.

Another survey Dr. Graham is conducting is part of the study directed by Loeb investigator Dr. Andreas Laupacis of six different technologies used to avoid the need for blood transfusion during surgery. Dr. Graham and his team have approached every hospital in Canada to learn which of several blood transfusion techniques they currently use, and how often. Once that information is gathered, follow-up interviews will be conducted with a small number of hospitals to determine what factors influence their choices, whether that might be cost, lack of demand, legal issues, or the degree of confidence in a given technique.

As a participant in the Ontario Cancer Treatment Practice Guidelines Initiative, which is engaged in developing oncology practice guidelines, Dr. Graham is a member of the research groups for lung and breast disease, and the Chairman of the Dissemination, Implementation, and Evaluation Group. Together, the members of the research groups review the literature focusing on one specific issue, for example, what the effectiveness is of a specific type of chemotherapy for patients with advanced lung cancer. After analyzing the published data, they write up a recommendation, and send it to practitioners for feedback. The responses are discussed, and the practice guideline is revised accordingly. Dr. Graham is currently working on the mechanism for disseminating these guidelines, as the first practice guideline has just been made ready for distribution. The guidelines will be posted on the internet (at http://www.cancercare.on.ca/).

About seventy practice guidelines are in various stages of completion, in the areas of lung, breast, gastro-intestinal, gynecological, and head or neck cancers. Because practitioners in other specialties, such as surgery or general medicine, make a significant number of cancer referrals, the guidelines will be an invaluable way to keep them apprised of up-to-the-minute developments in oncology. They will be available in two forms: a two-page version for those doctors who simply don't have the time to read more, and a longer version for those who want all the details. Dr. Graham is in the process of evaluating how best to provide these versions to pratitioners.