Blog | Thursday, November 1, 2018

Some thoughts on clinical judgement


Thus far I have recorded eight podcasts for ”Annals on Call,” four of which have already been published. The term and concept of clinical judgement enters the conversations repeatedly. Each podcast has had a different guest, yet in most of these conversations I have heard clinical judgement invoked. What is clinical judgement? Do we just use the term when we want to stray from protocol or algorithm? I found this definition from “Clinical judgement & evidence-based medicine: time for reconciliation,” which appeared in the Indian Journal of Medical Research, which gets us part way to an understanding.
For purposes of description, it can be considered the sum total of all the cognitive processes involved in clinical decision making. It involves the appropriate application of knowledge and individual expertise to the problem at hand. It would appear that this view of clinical judgment does not conflict with the tenets of evidence-based medicine. But the problem arises (as we shall see later) because of the differing values attached to the different components of this cognitive process.

Perhaps some scenarios will help. An adolescent comes to the emergency department with a sore throat. They have a negative rapid strep test but a Centor score of 4. They “look sick”. They tell you that this is the worst sore throat they have ever had. They describe a rigor the previous night. Do you follow a guideline that says that you need not give antibiotics, or do you consider the likelihood of a bacterial infection other than group A strep?

A 54-year-old patient has type 2 diabetes. She originally had an HgbA1c of 9.3. A full dose of metformin has lowered it to 8.5. You want to add another medication. You then have a conversation with the patient to balance your understanding of the different options for a second oral drug with the costs of those medications.

A 52-year-old man comes in for a routine examination. He is worried because his father died of an MI at age 53. You draw labs, exam him and calculate his 10-year risk of atherosclerotic cardiovascular disease at 9%. Do you give him a statin prescription?

A 72-year-old man comes in for a routine examination. He exercises, has a BMI of 24, and no family history of atherosclerotic cardiovascular disease. The calculator gives his 10-year risk of 12%. Do you give him a statin prescription?

Clinical judgement, as I conceive it, involves taking the evidence and then applying it to an individual patient. It involves considering factors other than included in calculators or guidelines. Clinical judgement involves a patient rather than a population.

We will never place all considerations into calculators or protocols. We must consider side effects, costs (and not just monetary costs), potential benefits, worst case scenarios and multiple co-morbidities when working with an individual patient.

Much of medical training and our ongoing growth as physicians involves the honing of clinical judgement. We learn to focus on the patient's needs and situation (clinical, social, etc.). We develop instincts (type I reasoning) that a patient appears very sick or not that sick. Numbers are not always as valuable as an overall gestalt.

Excellent clinical judgement is a challenging goal, and possibly not measurable, yet most students, interns, residents and practicing physicians recognize it in their teachers or colleagues. This should be our personal goal, to achieve excellence in clinical judgement.

The bean counters may never understand this concept because there is not easy metric. They look for a simple solution to a complex problem.

H.L. Mencken famously wrote, “For every complex problem there is an answer that is clear, simple, and wrong.”

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.