by Dana Alden, PhD; The University of Hawai`i

Dear SMDM Newsletter Readers:

The Spring 2017 Edition of your SMDM Newsletter is a must read!  We begin with an expression of deep concern from President Angie Fagerlin with the unanimous support of the SMDM Board regarding the negative effects of the U.S. Presidential Order regarding travel from six countries on international health-related research.  I urge everyone to read Angie’s letter and think of ways our Society can work to minimize the impact of the Order, if upheld by the courts, on collaborative international research that is crucial to continued advances in health care and other scientific fields.  

Our Commentaries open with an interesting contribution from the SMDM Medical Informatics Interest Group leaders, David Chartash and Kaleb Michaud. Their article focuses on the complex challenge of using medical informatics to better understand and model patient/provider interactions.  In each issue, we will feature a Commentary from one of our SMDM IG’s.  As a result, we hope that Newsletter readers will gain a deeper understanding of what the Interest Groups are working on and discover new ways to work with others in our Society.    

Thereafter, Heather Gold tackles the growing problem of undocumented immigrants’ limited access (self- and/or structurally-imposed) to health care treatments that prevent or reduce the need for more expensive interventions down the road or, even worse, result in slow and painful deaths due to inadequate or inappropriate care in the early stages of a disease.  Heather points out ways that SMDM members can make a difference in this important area.   
Continuing our focus on pressing and relevant issues, Scott LaJoie offers a provocative overview of the controversy surrounding parents who delay or avoid vaccinating their children.  Do we, as advocates of patient empowerment in medical decision making, have a duty to respect and not criticize parents who fail to vaccinate their children?  This is a challenging question and Scott clearly describes the difficulty of determining the “right” position from multiple perspectives.

And, to top it off, Mark Liebow, provides us with his timely analysis of the rapidly changing U.S. health care environment as Congress considers repeal and replacement of the Affordable Care Act

As an international Society, we welcome Commentaries from our non-U.S. members who would like to discuss pressing issues such as these that are directly impacting their own region or country.  If you’re interested in submitting a 350 word or less Commentary, by all means, email me ( or our Deputy Editor, Ellen Engelhardt ( to discuss your ideas for a Commentary.  Guaranteed … we’ll make it easy and fun for you to share your important ideas with the Society!

Our regular features follow the Commentaries. These include: Member Updates and Announcements as well as our regular features covering position openings and your generous SMDM financial contributions.
Enjoy your Newsletter and, as always, don’t hesitate to let us know if there are additional topics you like to see addressed in an upcoming SMDM Newsletter.  

Aloha for now, 
Dana Alden, Editor 
by Angie Fagerlin , PhDChair of Population Health Sciences, Research Scientist, University of Utah, Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS)

The Value of Being an International Society

One of the things I most value about SMDM is that we are an international Society. Personally, my science has been improved by colleagues in the UK, Netherlands, Germany, and Australia. Our science and our collaborations are better because people with very different insights come together to share our methods, our results, and our unique perspectives. By being an international Society, we learn far more and advance our science considerably more than if any of us just belonged to a national Society for Medical Decision Making.   

SMDM values being an explicitly international Society, and a number of our initiatives have emphasized increasing collaboration and information sharing across country lines. In fact, one of our three strategic objectives is to grow our international membership and involvement in our Society. We are actively trying to increase the number of international members both overall and also in terms of board and committee representation.   

Unfortunately, a number of recent political events are challenging that core value that we hold. For example, our colleagues in the UK are concerned about losing the opportunity to collaborate with others in the EU. And of course, many Americans—and non-Americans— are very distressed about the travel ban(s) that President Trump has attempted to institute.  

Since the announcement of the travel ban, the Board of SMDM has talked extensively about how or if we should address this issue. I have to admit to personally being a little flummoxed given that I have not wanted to appear overly U.S.-oriented. For example, as shocked and dismayed the SMDM Board was about the Brexit vote, we did not issue a statement in response.  

However, the SMDM Board agreed it was appropriate to address the U.S. travel ban publicly. Our rationale was at least two-fold. First, our Society’s next North American meeting is in the U.S., and we are concerned about scientists being unable to attend due to their citizenship. Furthermore, we feel strongly that we should express our disgust with the idea that scientists (and others, too) would be forbidden to enter the U.S. due to their citizenship.

As an international organization, The Society for Medical Decision Making strongly believes that science at its best depends on collaborations across a diverse group of scientists - based on diversity of life experiences, culture, and country of origin. This travel ban prevents the free flow of collaboration and learning that is critical to achieving our scientific goals, particularly our goal of improving the health of individuals and populations. As a Society, we value this diversity. We want to express our opposition to this, and any other, travel ban and our strongest support for our fellow scientists who are affected by this ban.  

The opinions stated in the following commentaries are solely those of the authors and do not reflect the opinions of the Society for Medical Decision Making.
Kaleb Michaud, PhD

Not Pictured:
David Chartash, PhD
Medical Informatics Challenged by Complexity of Clinical Encounter
by David Chartash, PhD and Kaleb Michaud, PhD

As the Medical Informatics Interest Group geared up for the 2017 SMDM Annual Meeting, we found ourselves pondering the nature of medical decision making and where informatics stands amidst the towering monoliths of decision science, epidemiology and cognitive science. Rather than serving as another basis by which medical decision making can be modeled, informatics serves as a grouping by which inter and multi-disciplinary research can be conducted with the sole purpose of integrating domains, fields and methods to achieve a common goal. Informatics in this vein, rather than being a conduit to insufficient approaches to computer science and engineering within the medical domain, offers us an approach to problem solving as an integrative science. (Bordogna, Fromm, and Ernst 1993, Journal of Engineering Education)

One such approach is to investigate patient-reported information and the narrative of the encounter with that information collected by quantifiable physiology, laboratory and imaging studies. The relative content of information between the history, physical exam, laboratory and imaging has sunk into the realm of clinical myth, yet assessing the value of this information is fraught with challenges, both analog and digital. (Bordage 1995, Canadian Medical Association Journal) To model the clinical encounter as it is written and read within the retrospective medical record, medical hermeneutics (Lock 1990, Theoretical Medicine) offers us a complex model of clinical information and its meaningful integration for diagnostic reasoning.

Specifically, by linking the disease objects to signs and symptoms through the phenomenology of the diagnosis, we can suggest that medical information and its collection exist outside the biomedical model of disease, and yet, are entwined with it. (Nessa 1996, Theoretical Medicine) The art of rapport with the patient, and the narrative which ensues and is written into the record, is therefore entwined with the acts of clinical judgement that serve to order laboratory tests and imaging studies. (Kay and Purves 1996, Methods of Information in Medicine)

A grand challenge, for both informatics and medical decision making, is investigating how to disentangle these components of the patient and encounter narrative, and to model this complex system of information as integrated facets of the medical decision making problem. We hope to further such discussion and others with interested members of the Medical Informatics IG and SMDM in general as you join us in Pittsburgh this October. 

Building Evidence to Protect the Most Vulnerable
by Heather Taffet Gold, PhD, SMDM Secretary-Treasurer; NYU School of Medicine, Department of Population Health

Recent changes to immigration enforcement policies in the United States have left many fearful of accessing healthcare due to their immigration status. This fear is exacerbated by the fact that most undocumented immigrants are potentially ineligible for life-saving healthcare services if they cannot pay out of pocket. The changes expose even further the problems in the U.S. healthcare system and the need for rational decision-making. As you readers know, other countries take a more systematic approach to inform healthcare policymaking and care prioritization, major areas of expertise for our Society for Medical Decision Making.

Patients in the U.S. who are both low-income and undocumented immigrants may be aware of their treatment choices and associated trade-offs, but without the means to purchase services, their options are limited. Safety-net hospitals often cover as much care as they can, some state programs provide emergency and/or prenatal care, and donations from pharmaceutical companies may help fill the gap. However, undocumented immigrants cannot get care through traditional Medicaid insurance (for low-income and disabled patients), which is funded jointly by the states and federal government. The insurance-coverage and access-to-care problems are ever present in other countries with universal health insurance, as well, because the safety net systems are weakened when nearly the entire population has coverage, yet the refugee and immigrant crisis across the globe continues to grow. This leaves major voids in care for chronic and acute conditions that arise for this vulnerable population, many of whom are long-term residents who have escaped terrible tragedy and threats to their livelihood.

Although access to comprehensive health insurance is non-existent for undocumented immigrants, select states provide support through programs often limited by class of service. That is, treatment options are not based on costs or effectiveness, but rather on categories of treatments classified as emergency care or prenatal care. For example, in the case of a patient presenting with cancer, chemotherapy is not considered “emergency care” for federal funding purposes, but safety-net hospitals can procure pharmaceutical donations, use state funds, or offer charity care. More concerning, however, is that patients who are undocumented immigrants are unable to gain access to non-drug regimens, such as stem cell transplant for leukemia, which often provides the best chance for durable remission (essentially a cure). They can only receive less effective chemotherapy through hospital/pharmaceutical charity care. Under the current approach, these patients may end up with a terribly painful and possibly drawn-out and expensive death in the same hospitals that cannot treat them optimally up front. In the case of prenatal care, because of the fear of accessing the healthcare system and hazard of being “found out”, pregnant women often forgo prenatal care, increasing the probability of complications and poor birth outcomes, and, as a result,  infants who are U.S. citizens with higher health risks. Neither of these health trajectories is rational or compassionate.

Undocumented immigrants continue to arrive, fueling the need for cost-effective care management. This requires high quality analyses that weigh the evidence and track health outcomes to make the case for or against coverage of comparative treatments (including not treating or delaying treatment) and facilitate informed healthcare decision making. Without objective studies, we risk allowing emotionally driven arguments to fuel detrimental changes in immigration and healthcare. In the current environment of fear and uncertainty, patients who are undocumented are going under cover, missing appointments, skipping treatments, and declining to give their true names/addresses to providers, all of which are likely to lead to worse health outcomes and cost inefficiencies. With expertise from members of the Society for Medical Decision Making and beyond, we can help inform the current irrational approach to caring for the most vulnerable in society. We can use our tools and knowledge to change policy and make noise about this tragic situation.

Note: The views expressed here are my own. I appreciate the thoughtful conversations and communications I had about this topic with Domna Antoniadis, Esq., Ahmed Bayoumi, MD, MSc, and Olga Kostopoulou, PhD, MSc, but they have no responsibility for the content of this commentary.

Selected sources for further reading:

The New England Journal of Medicine

ASCO Connection

NYC Human Resources Administration - Office of Citywide Health Insurance Access

Health Resources and Services Administration

Undocumented Patients

The Challenge of Vaccine Hesitancy and Shared Decision Making
by Scott LaJoie , PhD, MSPH

Vaccine hesitancy and refusal is a rising threat to the public’s health. Over the past decade, outbreaks of vaccine-preventable diseases, including measles, mumps, Hib, and pertussis, have occurred throughout North America. A systematic review in JAMA by Phadke et. al (2016) reported on 1,416 cases of measles between 2000 and 2015; 56.8% of cases had no history of vaccination and 70.6% of those with immunization status data had non-medical exemptions. College campuses, especially in the Midwest, are seeing hundreds of students with mumps. And, pertussis has become endemic in the US after falling drastically in the late 1970s. Parents are making the choice to delay or forgo childhood immunizations. As kids enter their teens and twenties, large numbers of them are rejecting the cancer-preventing HPV vaccine. Republican-controlled state houses are weakening non-medical exemption laws. 

Explaining these apparently irrational choices is not as simple as blaming Jenny McCarthy for popularizing the myth that vaccines cause autism.  Early in 2017, environmental lawyer Robert F. Kennedy Jr. and actor Robert De Niro offered $100,000 to anyone who could prove that vaccines are safe. The myth will not die, despite Andrew Wakefield admitting he fudged the data published in a 1997 Lancet article that linked autism to the MMR series. The decision to vaccinate is seen by some parents as a choice of uncertainty and they turn to social networks and social media for information. They assess the risk of vaccination as higher than the risk of diseases they have never seen. Increasing mistrust of the mainstream media, big pharmaceutical companies, and healthcare leads to doubting the data of vaccine safety. Psycho-emotional responses to the pressure to vaccinate can blunt the cognitive appraisal of information and health promotion efforts. 

Couple these individual beliefs with the structural barriers to vaccination, such as lack of access, and vaccine hesitancy as well as refusal may not be so irrational, at least when considered from the patient’s perspective. Healthcare providers should engage in shared decision making with every parent or patient for whom vaccines are appropriate. Information about vaccine safety, presented in easily understood forms, needs to be provided at every opportunity -- even after a parent has consented to the vaccines. Some hesitant parents may acquiesce but leave the clinic and not return for follow up doses. Moreover, parents who are still uncertain about vaccinating their child may continue to seek information from unreliable sources to address the cognitive dissonance they feel. Lastly, as with all shared decisions, it is appropriate for a provider to emphasize evidence-based reasons for vaccination while avoiding direct declaration of the parent’s decision to delay or refuse the vaccine as irresponsible or ignorant. Doing so can destroy the provider-patient relationship and prevent future opportunities to change the decision maker’s mind. 

The Federal Budget May be a Severe Threat to MDM Research
by Mark Liebow, MD, MPH, Mayo Clinic

The Affordable Care Act (ACA) may have survived when the U.S. House of Representatives was unable to pass the American Health Care Act (AHCA) on March 24. However, the Trump budget for fiscal year 2018 has deep cuts for agencies that fund scientific research and those cuts may be more likely to pass at least in part.

The President has not yet sent Congress a proposed budget for the next fiscal year, though that often happens when administrations change. What we have is his “skinny budget”, somewhat of an executive summary, which proposes a $5.8 billion cut for the National Institutes of Health (NIH), almost 20% of its current budget. This would reduce the NIH funding to what it was in 2001 (not adjusted for inflation). A second proposal involves folding the Agency for Healthcare Research and Quality (AHRQ) into the NIH, though it isn’t clear whether this would bring the NIH any extra money. Other research agencies may be facing 10% cuts.

This is driven by the Trump administration’s desire to raise defense spending and reduce taxes, while lowering domestic spending in many areas. However, this is only a proposal. Agencies that fund research have many advocates and often have strong support in Congress, making it unlikely the proposed cuts will be enacted in full. Even so, the ultimate funding levels for the agencies are likely to be less, not more, than what they are receiving now.

Failure to repeal/replace the Affordable Care Act is good news for academic medical centers. Millions of people would have lost health insurance had the bill passed and medical centers would have been badly hurt financially as fewer people would be able to pay for their care. This would have limited the centers’ ability to provide internal funds for research or education. In addition, the Patient-Centered Outcome Research Institute (PCORI) would have lost its funding had the AHCA passed. Whether another attempt to repeal/replace the ACA will occur later this year is unclear. Even though this was a major Republican campaign priority, the problems the attempt ran into will make legislators nervous about trying again.

39th Annual North American Meeting Call for Abstracts and Short Courses Deadline: May 30, 2017
by Co-Chairs: Ken Smith, MD, MS, FACP and Janel Hanmer, MD, PhD

SMDM is now accepting abstracts for Oral and Poster Sessions and proposals for Short Courses to be presented at its 39th Annual North American Meeting. The deadline to submit proposals is Tuesday, May 30, 2017. All submissions will be reviewed and notifications sent out in early August 2017. Visit the Annual Meeting homepage for more information on submitting an abstract or short course.

This year's annual meeting will be held October 22 - October 25, 2017, at the Wyndham Grand Downtown, in Pittsburgh, PA. The theme of this year's meeting is Better Decisions Through Better Data Processes. Kathleen Sebelius, former US Secretary of Health and Human Services and an acknowledged expert in data use in governmental health policy, has been confirmed as our Keynote Speaker.  

Incremental gains in science are often made by standing on the shoulders of giants. Now that scientific advancement is increasingly dependent on complex data systems (the present-day giant), robust procedures are necessary to ensure that insights from data are not obscured from future scientists and real-time users. The Society for Medical Decision Making has a long history of developing methodologies which take advantage of complex data structures to enhance medical decision making and advance policy formation. The 2017 Annual Meeting will explore themes to ensure the credibility and usability of our Society’s efforts and to promote our vision of an integrated approach to health care decision making, through wise use and thoughtful communication of data.

But the Pittsburgh meeting need not be all work and no play. With its museums, restaurants, tech hub activities, and other cultural and not-so-cultural attractions, Pittsburgh has ranked among the best places to travel to in the USA. Save the date and join us in Pittsburgh!
Maria A. Lopez-Olivo Completes SMDM's Core Course Curriculum in Medical Decision Making
Congratulations to Maria A. Lopez-Olivo, MD, PhD, for completing the Core Course Curriculum in Medical Decision Making. Maria completed the curriculum at the 16th Biennial European Conference in London, UK in June 2016. 

The SMDM Curriculum is an initiative of the Society with the goal of having a set of introductory level Core Courses in foundational aspects of medical decision making. This effort serves the core mission of the Society to educate its members in key content areas. Core Courses are offered at SMDM meetings in North America, Europe and Asia.
Learn more  about SMDM’s Core Course Curriculum and to view descriptions of the four Core Courses.
Best Short Course at the 2016 Annual Meeting
by Elisabeth Fenwick, PhD, MSc and David Whitehurst, PhD, MSc
2016 Annual Meeting Short Course Co-Chairs

This year, we offered 20 short courses and had 265 registrants (ranging from 4 to 25 per course) at the 2016 SMDM Annual Meeting. The course that received the highest rating from its attendees was INTRODUCTION TO COST-EFFECTIVENESS ANALYSIS. This beginner level, half-day course is one of the SMDM four Core Short Courses. The course introduces participants new to the field of cost-effectiveness analysis to the important concepts for “smart shopping” for healthcare. It provides participants with the background and confidence to ask the Who, Why, When, Where, What and How questions of SMDM conference presenters and to better understand the responses conveyed irrespective of language (plain, math, graph and jargon).  

Congratulations to  Jeff Hoch, PhD  – a very worthy winner!  
What Are You Working On? 
Connect and collaborate with your fellow members on their latest projects:
Elizabeth W. Patton , MD, MPhil, MSc, Boston Medical Center, Boston University School of Medicine ( 

I am an obstetrician-gynecologist and new member of SMDM (my first meeting was last year in Vancouver). My colleague Kate White ( and I are both OBGYNs at Boston Medical Center, the largest safety net hospital in New England. Many of our patients have low health literacy and low numeracy, and a significant minority do not speak English, or have only very limited English. We are part of a growing community in reproductive health interested in shared decision making. Reproductive health as a field is a natural fit with SDM given that so many of the things we counsel patients about (miscarriage management, contraceptive choice, prenatal genetic screening, trial of labor after cesarean to name just a few) are preference sensitive. Our current work involves grant proposal submissions to explore the relationship between patient contraceptive decisions and the influence of their social networks on those decisions using mixed methods including qualitative interviews, surveys and social network analysis. We are also interested in understanding the interaction between patient and physician/provider mental models in contraceptive decision making. Additionally we are exploring the current ARHQ RFP for developing and testing measures of the process of SDM. We would be very interested to both hear from others with relevant expertise and to offer our clinical reproductive health perspective to other SMDM members with similar interests.
Latest News From Your Fellow Members
The book "Listening for What Matters: Avoiding Contextual Errors in Health Care", by SMDM members Saul Weiner, MD and Alan Schwartz, PhD received the 2017 PROSE Award for Excellence in the Biological & Health Sciences, recognizing the best book published in the area in 2016. It also received the PROSE subject category award in Nursing & Allied Health. The PROSE Awards are given annually by the Professional and Scholarly Publishing Division of the American Association of Publishers. Weiner and Schwartz's company, the Institute for Practice and Provider Performance Improvement, in collaboration with the American College of Physicians, received a grant from the Robert Wood Johnson Foundation to conduct a study of the impact of using unannounced standardized patients, one of the methods described in the book, to evaluate and improve the cost-effectiveness of primary care for practices and a payer.
Longtime SMDM member Rob Hamm, PhD is attending a meeting of the Brunswik Society in conjunction with the Psychonomic Society and Judgement in Decision Making Society meetings in Vancouver this coming November. The Society is meeting to commemorate the 100th birthday of the late Ken Hammond who led development of the lens model equation and effectively encouraged its application. Rob notes that there will "most likely be medical content (particularly if you submit an abstract)." He also provided the following background regarding the Brunswik Lens Model: "In situations of diagnostic uncertainty (where the clinical findings are not definitive proof of disease), one way to analyze clinicians’ diagnostic or judgmental accuracy is to compare a model of how much weight the clinician places on the various findings (cues) to the cues’ actual relevance for the diagnosis. The Brunswik Lens Model is an approach to analyzing judgmental accuracy, using the lens model equation which decomposes the accuracy of a set of judgments into that which is due to shared models (i.e., where our model of the clinician’s judgment based on the cues matches our model of the way the cues predict the state of the world) and that which is not modeled (whether that be due to luck, or due to the clinician using cues that the researcher has not measured). Over the years there has often been a Brunswik Lens modelling short course offered at SMDM meetings." Rob would like to encourage those with an interest to attend the meeting. 
Cara McDermott, PharmD, PhD, University of Washington School of Medicine, is part of the AcademyHealth 2017 New Investigator cohort. She received a New Investigator Small Grant Award for her project, "Care Coordination and Low-Value Care at End-of-Life Among Patients with Advanced Cancer." Additional information (
C. Ralph Buncher, MS, ScD, University of Cincinnati, has just retired from the University of Cincinnati Department of Environmental Health after 46 years. He is now Professor Emeritus of Biostatistics and Epidemiology. (
Chris A. Jones, PhD, launched a rewards chatbot that provides free prizes to improve healthy activities and reduce premiums. (
Geri Lynn Baumblatt, MA, Emmi, published a chapter in the recently published textbook: Transformative Healthcare Practice through Patient Engagement (IGI Global). Additional information (
Fernando Gutierrez, BA, Healthcare Ethics Consultant, has developed a radio series, "The Patient Advocate Show", a program which helps to educate healthcare surrogates and their significant others make informed medical decisions. Guest include bioethicist, other patient advocates, clinicians, hospital and nursing home administrators, etc. who share insights into medical protocol. The series can be viewed on or on local Tampa-area radio on 1340 AM or 106.1 FM. (
Michael Kattan, PhD, Professor of Medicine, Epidemiology and Biostatistics, Cleveland Clinic, won the 2016 Sones Innovation Award at the Cleveland Clinic. Additional information  (
Olga Kostopoulou, MSc, PhD, Imperial College London and Brendan Delaney, MD, Imperial College London, published the evaluation of a Decision Support System (DSS) for diagnosis in primary care, which they developed during 2010-2015 with EU funding. The evaluation was conducted in a high-fidelity simulation, where family physicians consulted with standardised patients (actors). The researchers found a significant improvement in diagnostic accuracy with the use of the DSS, without significant increase in the number of investigations ordered or time taken. They also found a large and significant increase in the number of clinical data coded into the electronic health record, as a result of using the DSS. The physicians thought that the DSS was useful and usable. “Patient" satisfaction was the same for consultations with and without the DSS. View the full text here. The research was covered in The Times. (
Olga Kostopoulou, MSc, PhD, Imperial College London, and colleagues recently published an article in Health Psychology. It reports experimental evidence  of the influence of antibiotics requests on family physicians’ prescribing decisions. This influence has long been reported in physician surveys and interviews. Importantly, the researchers also found that although requests for antibiotics increased the likelihood of prescribing decisions, they did not increase physicians’ perceived probability of a bacterial infection. This is in contrast to other studies reporting that people adjust their probability estimates to be consonant with their decisions.

View the press release by the American Psychological Association
Here are the most recent job opportunities since our last newsletter. SMDM members can stay current on the newest opportunities in the Resources Section of SMDM Connect.
SMDM extends its heartfelt appreciation to its members for their charitable contributions!

The SMDM Lifetime Contributors list acknowledges donations, and in-kind donations, received Oct. 2005 - March 31, 2017.
Editor in Chief
Dana Alden, PhD
The University of Hawai`i

Deputy Editor
Ellen G. Engelhardt, MA
VU University Medical Center, Amsterdam