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August 11, 1993

Clinical Decision Making: Broadening the Responsibilities of Practitioners

Author Affiliations

Teterboro, NJ

JAMA. 1993;270(6):708-709. doi:10.1001/jama.1993.03510060054026

To the Editor.  —Dr Eddy's1 article on broadening the responsibilities of practitioners is a stimulating Socratic dialogue between himself and a nominal Kaiser Permanente radiologist, during which the radiologist bravely fights a losing battle trying to defend the use of expensive low osmolar contrast agents (LOCAs).Eddy defends the overall utility of severely limiting the use of LOCAs, even though—because of this decision—40 more patients each year will experience serious, but nonfatal, reactions to less expensive high osmolar contrast agents (HOCAs). This decision saves Kaiser Permanente of Southern California (KPSC) $3.5 million per year, money that will be used to screen more hard-to-reach women for cervical cancer. Eddy argues that such a transfer is of greater benefit to all members of the health maintenance organization.Eddy's conclusion is logically sound when based on the simple binary alternatives provided, but is incorrect if other alternatives are considered. His analysis, for