Autonomic arousal among physicians may indicate how they handle uncertainty when making therapeutic decisions and may be reduced with additional education, according to study results published in JAMA Network Open.

This study was a randomized clinical trial ( Identifier: NCT03134794) that recruited neurologists (N=34) who provided care to patients with multiple sclerosis (MS) in Canada. Study researchers randomly assigned physicians to receive traffic light system (TLS)-based education (n=20) or not (n=14) and assessed pupil dilation when making clinical decisions during a simulation where they were presented with clinical information at 4 time points (T1-T4). The investigators defined therapeutic inertia (TI) as a lack of treatment escalation despite evidence of disease progression.

The TLS program supported decision making by establishing actions on the basis of the traffic light colors, which encouraged clinicians to stop or proceed. For high-risk scenarios, an action of stop to think should be triggered. The opposite scenario was the green light, which indicated a low-risk situation where the same strategy should be maintained.

The neurologists were a mean age of 44.6 (Standard Deviation [SD], 11.6) years; 38.3 percent were women and 58.8 percent were MS specialists. The physicians had 12.5 (SD, 11.8) years of experience in practice and assessed an average of 23.1 (SD, 16) patients with MS weekly.

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Before clinical simulation, risk-neutrality measures did not differ between the control and intervention groups (P =.14) nor did mean baseline pupil dilation (2.82±0.35 mm vs 2.96±0.99 mm, respectively; P =.57).

At baseline, 50 percent of participants had TI for 1 or more clinical scenario, and non-MS specialists were more likely to exhibit TI than specialists (11.5% vs 5.2%, respectively; P =.01).

For every SD of pupil dilation diameter during the assessment, the likelihood of TI increased by 51 percent at T1 (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, study researchers observed no relationship between pupil dilation and TI (OR 1.07; 95% CI, 0.86-1.34).

Pupil size differed significantly between TLS and control groups during T2 (b, -0.46; 95% CI, -0.9 to -0.01; P =.049); T3 (b, -0.63; 95% CI, -1.04 to -0.22; P =.004); and T4 (b, -0.75; 95% CI, -1.12 to -0.37; P <.001). These observations indicated the TLS educational training had a protective effect for physicians when making decisions in the context of uncertainty.

Beyond the small sample sizes, this study may have been limited by the choice to measure pupil dilation, which was not a standard measure for autonomic arousal.

The study authors concluded that their “educational intervention may reduce autonomic arousal by reducing uncertainty and thereby facilitating alternative behavioral strategies. Specifically, the warning function of a red traffic light may help emphasize the need for switching to a more effective agent and may concurrently boost the physician’s confidence in the therapeutic decision.” 

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of authors’ disclosures.


Saposnik G, Grueschow M, Oh J, er al. Effect of an educational intervention on therapeutic inertia in neurologists with expertise in multiple sclerosis. a randomized clinical trial. JAMA Netw Open. 2020;3(12):e2022227. doi:10.1001/jamanetworkopen.2020.22227