A Guide To Clinical Decision Making

Traditional clinical teaching tells us to treat the patient, not the number.  At face value, you could interpret this old teaching as “only treat if there are symptoms”. When applying this teaching, we should include some nuance, namely see how the number fits into the big picture . Good examples include abnormalities in asymptomatic patients that may not be causing a problem right now, but have consequences in the future. Such abnormalities could include:   Elevated Hemoglobin A1c   Decreased g lomerular filtration rate   Elevated blood pressure In an asymptomatic patient, these types of measures are analogous to someone walking towards a cliff’s edge. They are not falling yet. However, the closer they get to the edge the more at risk they are of falling. When you take the big picture into account, you understand “the number” in the context of the overall, clinical situation. So what is this big picture then? The big picture includes information from ...

You’ve ordered a slew of tests for your patient. You hope that one of them comes back positive, giving you guidance for the next step in the patient's care. However, your tests all come back negative, leaving you wondering what to do next. This is a common scenario whether you work inpatient, outpatient, or a combination of both. Most of the time, it’s easy to know what to do if the tests are positive. It’s much harder to decide what to do if the tests are negative. We cannot discuss every single scenario, but it’s important to bring up the following concept: When you order a test, consider what you will do if the result is negative. Do this and you find yourself one step ahead in many clinical scenarios. Ask yourself questions like: ·          Should I expand my differential diagnosis? o    If so, what other diagnoses should I check for? o    If not, am I sure that I have enough information to pro...

Most American, medical students come out of medical school having passed 2 USMLE’s, accumulated well over 3,000 hours of clinical experience, evaluated hundreds of patients, and assisted with scores of procedures. They then enter residency where they are treated as if they know nothing.  Most of these students slog through medical school rotations and later residency, picking up pearls along the way. With these pearls , they stitch together what will eventually become their way of practicing. They do this under the watchful eyes of attending physicians who often bemoan of how the younger generation does not get “it”. No one ever defines what “it” is. Few of these attending physicians remember that their own teachers also said the exact same thing about them.  I will not pretend to know all aspects and permutations of “it”. However, sometimes “it” is the lack of a framework with which to understand the information and experiences that the student is thrown into. ...

  A nurse walks up to a physician, “The lab just called for the asthmatic in bed 14, the lactic acid is 6. I’m going to start the sepsis protocol”. “No need,” says the physician, “continue the albuterol”. “But the lactic acid is high. We have to follow the protocol.” “The patient has a lactic acidosis because she’s hypoxic from her asthma.” “That may be so, but we have to follow the protocol, it’s hospital policy.” ********** When interpreting the lab test or any new information, we need to put that new information into the bigger context of our patient. Sounds obvious, but it’s easy to fall into the trap of a knee-jerk reaction to do what we have always done (our custom) or what the hospital policy is. Custom and policy usually give decent results and create consistency. Most of the time, the custom and policy are good enough to get the job done. However, from time to time they give us the wrong result. When we get the wrong result, we lik...

What is critical thinking and how does it apply to these 3 scenarios? A nurse walks over to communicate a minor, patient inquiry to a physician who is sitting, brow wrinkled, focused, deep in thought, and contemplating the next step in another patient’s care. The nurse interrupts his train of thought, because “protocol says I have to inform the physician when the patient makes these kinds of requests”. An intern orders hepatic function tests on every patient with abdominal pain regardless of the pain’s exact location, because “that’s how we do it here .” An experienced physician orders a chest x-ray for every admission even if the patient’s symptoms do not include the chest, because “that’s the way I was trained and that’s the way I’ve practiced it for years.” ********* We all fall into old, familiar patterns. Most of the time these patterns serve us well. However, following our familiar patterns is occasionally dysfunctional or wasteful, like in the examples above....

  A 3 rd year medical student walks into a patient’s room. His short, the pockets of his well-starched white coat overflow with pieces of paper, small handbooks, his stethoscope, a reflex hammer, a pen light, and 3 pens. He fidgets a little as he asks the patient questions. His questions are staccato and rapid-fire. He has a long list of the questions he wants to ask to make his history complete. Every few seconds, he looks down at the list of questions in his hand. After about 15 minutes he walks out to present the case to his attending. His presentation is a mishmash of facts the patient has given him and a laundry list of physical exam findings. He lists 6 tests that the patient needs.   He stops, slightly winded from reciting all of his findings, looking up to his attending. His attending asks what he thinks is going on with the patient. Caught off guard, he stammers an answer, then a second, and then a third. The attending gets up to see the patient. She stri...

  Real cases inspired the following story. I changed some of the details for patients’ privacy. I saw a young lady complaining of palpitations early one morning in the ER. The palpitations started gradually, an hour or two before presentation.  She denied chest pain, SOB, leg swelling, recent travel, oral contraceptives, and recent surgery.  She was tachycardic, but otherwise had a normal cardiac exam, normal pulmonary exam, clear speech, and   normal gait.  Her EKG showed sinus tachycardia with a rate of 103 bpm, normal intervals, no ST segment deviation, and normal T waves.  I did Wells score for pulmonary embolism, and then talked to the patient and her boyfriend about my plan for testing.  As I talked to them further, she revealed that earlier this morning she drank several, high-caffeine energy drinks to stay awake after coming back from a nightclub at about 4 AM. About half an hour after the energy drinks she began ...

What are clinical decision rules?  Clinical decision rules are tools that help with clinical decisions by organizing selected patient data. The purpose of these rules is to help clinicians make better, more efficient decisions. In many cases, they help assess the level of risk a patient has for a given disease. In other words, they are risk stratification tools. Risk stratification helps clinicians determine the extent of further workup and treatment the patient needs. Examples of such tools at the time of this writing, include the NEXUS cervical spine criteria, HEART score and Well’s criteria for pulmonary embolism. These can be useful tools. However, we must use them wisely . How can we use these tools wisely? We can start by treating these rules as a guide that we can use to help us in our decision making. The rules are not the end all be all that overrules clinical judgement. They exist to make clinical judgement better by steering that judgement in t...

What do we mean when we say medicine is part art? As clinicians, we say this a lot. Do we actually stop to think about what it means that medicine is an art? In contrast, we can easily see how medicine is a science. We rely on evidence, on data. We have lots of data from research. Research can tell us a lot about what the effective therapies for a condition are, what optimal drug doses are, the optimal timeframe for surgical repair of an injury, etc. Medicine as an art is more vague. Let’s discuss what art is a bit first. We can think of art as an expression of the artist’s self. Each artist will express themselves differently in communicating the same idea. Consider if we asked several people to paint a picture of the same sunset. We’d give each painter the same set of paints and let them watch the same sunset. They’d all paint the same sunset, but somewhat differently . Each one would express their own version of the sunset, but they’d pretty much all be able ...