Chapter 003. Decision-Making in Clinical Medicine (Part 1)

Harrisons Internal Medicine Chapter 3. Decision-Making in Clinical MedicineDecision-Making in Clinical Medicine: Introduction To the medical student who requires 2 h to collect a patients history and perform a physical examination, and several additional hours to organize them into a coherent presentation, the experienced clinicians ability to reach a diagnosis and decide on a management plan in a fraction of the time seems extraordinary. While medical knowledge and experience play a significant role in the senior clinicians ability to arrive at a differential diagnosis and plan quickly, much of the processinvolves skill in clinical decision-making. The first goal...
Nội dung trích xuất từ tài liệu:
Chapter 003. Decision-Making in Clinical Medicine (Part 1) Chapter 003. Decision-Making in Clinical Medicine (Part 1) Harrisons Internal Medicine > Chapter 3. Decision-Making in ClinicalMedicine Decision-Making in Clinical Medicine: Introduction To the medical student who requires 2 h to collect a patients history andperform a physical examination, and several additional hours to organize them intoa coherent presentation, the experienced clinicians ability to reach a diagnosis anddecide on a management plan in a fraction of the time seems extraordinary. Whilemedical knowledge and experience play a significant role in the senior cliniciansability to arrive at a differential diagnosis and plan quickly, much of the processinvolves skill in clinical decision-making. The first goal of this chapter is toprovide an introduction to the study of clinical reasoning. Equally bewildering to the student are the proper use of diagnostic tests andthe integration of the results into the clinical assessment. The novice medicalpractitioner typically uses a shotgun approach to testing, hoping to hit a targetwithout knowing exactly what that target is. The expert, on the other hand, usuallyhas a specific target in mind and efficiently adjusts the testing strategy to it. Thesecond goal of this chapter is to review briefly some of the crucial basic statisticalconcepts that govern the proper interpretation and use of diagnostic tests.Quantitative tools available to assist in clinical decision-making will also bediscussed. Evidence-based medicine is the term used to describe the integration of thebest available research evidence with clinical judgment and experience in the careof patients. The third goal of this chapter is to provide a brief overview of some ofthe tools of evidence-based medicine. Clinical Decision-Making Clinical Reasoning The most important clinical actions are not procedures or prescriptions butthe judgments from which all other aspects of clinical medicine flow. In themodern era of large randomized trials and evidence-based medicine, it is easy tooverlook the importance of this elusive mental activity and focus instead on thealgorithmic practice guidelines constructed to improve care. One reason for thisapparent neglect is that much more research has been done on how doctors shouldmake decisions (e.g., using a Bayesian model, discussed below) than on how theyactually do. Thus, much of what we know about clinical reasoning comes fromempirical studies of nonmedical problem-solving behavior. Despite the great technological advances of medicine over the last century,uncertainty still plays a pivotal role in all aspects of medical decision-making. Wemay know that a patient does not have long to live, but we cannot be certain howlong. We may prescribe a potent new receptor blocker to reverse the course of apatients illness, but we cannot be certain that the therapy will achieve the desiredresult and that result alone. Uncertainty in medical outcomes creates the need forprobabilities and other mathematical/statistical tools to help guide decision-making. (These tools are reviewed later in the chapter.) Uncertainty is compounded by the information overload that characterizesmodern medicine. Todays experienced clinician needs close to 2 million pieces ofinformation to practice medicine. Doctors subscribe to an average of sevenjournals, representing over 2500 new articles each year. Computers offer theobvious solution both for management of information and for better quantitationand management of the daily uncertainties of medical care. While the technologyto computerize medical practice is available, many practical problems remain to besolved before patient information can be standardized and integrated with medicalevidence on a single electronic platform.