Clinical Judgment: Balancing Evidence-Based Medicine and Patient Self-Determination

by G. Richard Holt, MD, MSE, MPH, MABE, D Bioethics •

How would you handle this moment?

Discussion

The current state of patient care has been significantly influenced by the expansion of, and reliance on, evidence—acquired through outcome studies, systematic reviews, higher-level research, and other scientific work. There is no doubt of the importance of evidence-based medicine studies in clinical decision-making, but where now is the place for patient self-determination and the art of medical care? Past generations of physicians relied heavily on the history, physical examination, fundamental diagnostic tests, and subsequent discussions with patients about the physician’s diagnosis and recommended treatment. While technological advances have greatly enhanced physicians’ diagnostic capabilities, some feel that it may have been at the sacrifice of an extensive physical examination and patient-physician discussions. The profession now has become increasingly reliant upon algorithmic medicine, which outlines, to a significant degree of complexity, protocols and best practices, which are designed to reduce variance in patient care across the population and are based on available evidence acquired through scientific studies. The specialty of otolaryngology-head and neck surgery, along with every specialty through the efforts of groups of experts, reviews the available data for many diseases and disorders and develops practice guidelines which inform the otolaryngologist-head and neck surgeon in her/his clinical decision-making. How the individual otolaryngologist utilizes the recommendations, evidence, and data in the care of an individual patient is called “clinical judgment.”

What then, are the elements of clinical judgment that come to play in our care of patients? There are many synonyms for clinical judgment, and many authors have proposed various elements. This author believes that there are four major elements in clinical judgment that eventually lead to the therapeutic plan for a patient. These are:

  • Knowledge;
  • Critical thinking and interpretation;
  • Patient self-determination; and
  • Shared decision-making.

Impacting each element of clinical judgment is the acquisition of experience.

The first fundamental step is the acquisition of knowledge—the knowledge of anatomy, pathophysiology, metabolic pathways, evidence, pharmaco-therapeutics, surgical techniques and outcomes, and so much more—acquired over the long course of education, training, and practice. This author often tells medical students and residents that the acquisition of knowledge is an ethical responsibility to patients and fundamental to their care. It is driven by an ultimate obligation to patients to know as much as humanly possible about the diseases and disorders across our entire specialty. The patient expects us to know the information, or to seek the information as we develop a recommendation for their care. Knowledge in medicine is always changing; therefore, we must continue to learn new knowledge throughout our professional career—it is not trite to repeat the mantra “life-long learning.”

Every act we perform in the course of evaluating a patient is knowledge acquisition—the history and physical examination is appreciated in the context of our knowledge of normal versus abnormal findings; our appreciation of various facial expressions and body language that can be interpreted in the light of the patient’s response to her/his health concerns; an understanding of side effects and adverse reactions of pharmaco-therapeutics—and we both consciously and unconsciously add these observations to our database of clinical medicine.