Judgment - Discussion HINF Medical Methodologies Session 8

Objective To discuss two perspectives regarding judgment in medical decision making To discuss two perspectives regarding judgment in medical decision making

Reading Montgomery K (2006) Chapter 3: Clinical Judgment and The Interpretation of the Case in How Doctor’s Think: Clinical Judgment and Practice of Medicine, Oxford University Press, USA Montgomery K (2006) Chapter 3: Clinical Judgment and The Interpretation of the Case in How Doctor’s Think: Clinical Judgment and Practice of Medicine, Oxford University Press, USA Montgomery K (2006) Chapter 5: The Simplification of Clinical Cause in How Doctor’s Think: Clinical Judgment and Practice of Medicine, Oxford University Press, USA Montgomery K (2006) Chapter 5: The Simplification of Clinical Cause in How Doctor’s Think: Clinical Judgment and Practice of Medicine, Oxford University Press, USA Montgomery K (2006) Chapter 6: Clinical Judgment and Problem Particularizing in How Doctor’s Think: Clinical Judgment and Practice of Medicine, Oxford University Press, USA Montgomery K (2006) Chapter 6: Clinical Judgment and Problem Particularizing in How Doctor’s Think: Clinical Judgment and Practice of Medicine, Oxford University Press, USA Skaner Y, Strender L-E, Bring J (1998) How do GPs use clinical information in their judgments of heart failure? A clinical judgment analysis study, Scandinavian Journal of Primary Health Care; Vol:16, pp Skaner Y, Strender L-E, Bring J (1998) How do GPs use clinical information in their judgments of heart failure? A clinical judgment analysis study, Scandinavian Journal of Primary Health Care; Vol:16, pp Weed L, Weed LL (1999) Opening the black box of clinical judgment – an overview, BMJ, Vol: 319, pp.1279, November 1999 Weed L, Weed LL (1999) Opening the black box of clinical judgment – an overview, BMJ, Vol: 319, pp.1279, November 1999 Macnaughton RJ (1998) Evidence and clinical judgment, Journal of Evaluation in clinical practice, Vol: 4, No:2, pp Macnaughton RJ (1998) Evidence and clinical judgment, Journal of Evaluation in clinical practice, Vol: 4, No:2, pp

A Research How do GPs use clinical information in their judgments How great is the variation between the GPs’ diagnostic judgments? How great is the variation between the GPs’ diagnostic judgments? Which cues are most important for the diagnosis? Which cues are most important for the diagnosis? 45 case vignettes (five were duplicates) 45 case vignettes (five were duplicates) 27 GPs who are interested in continuing education 27 GPs who are interested in continuing education

A Research How do GPs use clinical information in their judgments Intercorrelations between cues were low; Intercorrelations between cues were low; Significant associations were found only between lung and heart x-rays and rales Significant associations were found only between lung and heart x-rays and rales Between heart x-ray and history of myocardial infarction Between heart x-ray and history of myocardial infarction Only 22 of 40 had ECHO results Only 22 of 40 had ECHO results Doctors were asked to assess the probability that the patient suffered from any degree of heart failure Doctors were asked to assess the probability that the patient suffered from any degree of heart failure

Findings There were big differences between the individual GP’s assessments for the case vignettes There were big differences between the individual GP’s assessments for the case vignettes In one case one GP rated 100% the other rated 6%. In one case one GP rated 100% the other rated 6%. Only five out of 45 ranged less than 50. Only five out of 45 ranged less than 50. The median rage was 66 The median rage was 66 The large ranges can not be explained by single doctors making extreme judgements The large ranges can not be explained by single doctors making extreme judgements Duplicated cases: 62% between 0 and 10, 25% between 11 and 20 and 13% more than 20. Duplicated cases: 62% between 0 and 10, 25% between 11 and 20 and 13% more than 20.

Conclusion of the Study Differences in judgment caused by; Differences in judgment caused by; Not by use of clinical information Not by use of clinical information Not by individual GPs making inconsistent probability assessments Not by individual GPs making inconsistent probability assessments By use of cues in each case By use of cues in each case

Evidence and Clinical Judgment Clinical judgment can not be reduced to algorithms or flowcharts Clinical judgment can not be reduced to algorithms or flowcharts In clinical situation judgment is irreplaceable and has its own identity In clinical situation judgment is irreplaceable and has its own identity Evidence based medicine is the observations of others for your patients and represent a generality of patients Evidence based medicine is the observations of others for your patients and represent a generality of patients Physicians must evaluate data or findings and judge whether or not they are directed at a hypothesis and how strongly or weakly. Physicians must evaluate data or findings and judge whether or not they are directed at a hypothesis and how strongly or weakly.

Evidence and Clinical Judgement Data becomes evidence if it relates to a hypothesis regarding a case Data becomes evidence if it relates to a hypothesis regarding a case This is not generalizable, the evidence is relevant to one and only one situation. This is not generalizable, the evidence is relevant to one and only one situation. The aim of research studies is to establish truths about clinical diagnosis and treatment which will be true for all common situations but the work of a practitioner is unique for each case The aim of research studies is to establish truths about clinical diagnosis and treatment which will be true for all common situations but the work of a practitioner is unique for each case

Evidence and Clinical Judgement EBM is precisely at the point of treatment that scientific evidence is relevant: clinician is not concerned with treatments in the abstract but concerned with treating specific patient and need to consider many factors EBM is precisely at the point of treatment that scientific evidence is relevant: clinician is not concerned with treatments in the abstract but concerned with treating specific patient and need to consider many factors Judgement in clinical setting requires practical wisdom (phronesis) Judgement in clinical setting requires practical wisdom (phronesis) These judgments have more to do with what is or is not appropriate for this patient, with this condition, and at this time. These judgments have more to do with what is or is not appropriate for this patient, with this condition, and at this time.

Evidence and Clinical Judgment Conclusion The correlative judgment is technical and is directed at generalized truth. It is often said that clinical treatment applies this scientific evidence to individual patients The correlative judgment is technical and is directed at generalized truth. It is often said that clinical treatment applies this scientific evidence to individual patients Evidence about what constitutes the best treatment for a given patient involves a wide range of imponderables, but especially a patient’s own (perhaps, irrational) perspective. Evidence about what constitutes the best treatment for a given patient involves a wide range of imponderables, but especially a patient’s own (perhaps, irrational) perspective. The correlative judgment in this case can be partly technical because it must tap into the belief system of the patient, and indeed, of the doctor. The correlative judgment in this case can be partly technical because it must tap into the belief system of the patient, and indeed, of the doctor.

Black box of clinical judgment Cognitive psychology has shown that the human mind normally functions by oversimplifying and filtering complex information Cognitive psychology has shown that the human mind normally functions by oversimplifying and filtering complex information The only barrier to an earlier diagnosis in a complex, unspecific case, was the doctor’s cognitive ability to couple the readily available findings on their patient with medical knowledge. The only barrier to an earlier diagnosis in a complex, unspecific case, was the doctor’s cognitive ability to couple the readily available findings on their patient with medical knowledge. Complex cases involve large volumes of patient data and multiple caregivers who must comprehend those data efficiently and coordinate actions over time Complex cases involve large volumes of patient data and multiple caregivers who must comprehend those data efficiently and coordinate actions over time Clinicians apply medical knowledge in the form of falliable, incomplete generalizations that often diverge from the realities of unique individual patients Clinicians apply medical knowledge in the form of falliable, incomplete generalizations that often diverge from the realities of unique individual patients Complex cases involve uncertain choices and difficult trade- offs that are inherently personal to patients Complex cases involve uncertain choices and difficult trade- offs that are inherently personal to patients

Black box of clinical judgment Patients need not be dependent on physicians for medical decision making, they are necessarily dependent on physicians and other caregivers and health care institutions execute decisions skilfully. Patients need not be dependent on physicians for medical decision making, they are necessarily dependent on physicians and other caregivers and health care institutions execute decisions skilfully. But these decisions are of variable and uncertain quality But these decisions are of variable and uncertain quality

Black box of clinical judgment Conclusions Medical records must be rigorously maintained in electronic form with a structure that permits rapid comprehension, reliable monitoring, and meaningful outcome studies. Medical records must be rigorously maintained in electronic form with a structure that permits rapid comprehension, reliable monitoring, and meaningful outcome studies. When uncertainty exists, patients themselves must become the primary decision makers and they should be able get sufficient information When uncertainty exists, patients themselves must become the primary decision makers and they should be able get sufficient information Individual caregivers should be awarded credentials periodically, not permanently, on the basis of demonstrated skills Individual caregivers should be awarded credentials periodically, not permanently, on the basis of demonstrated skills Healthcare institutions must put in place standards and systems designed to protect against error and enhance performance of individual caregiver Healthcare institutions must put in place standards and systems designed to protect against error and enhance performance of individual caregiver

What are your thoughts? Where do you stand in this discussion?