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?
Explore This IssueMay 2019
The second important element of clinical judgment is the dyad of critical thinking and interpretation. This dyad is informed by our knowledge, both fundamental and that which is pertinent to the individual patient through consideration of the evidence in the literature and how closely the evidence applies. The history and physical examination give rise to a differential diagnosis set, and from there we work with pertinent evidence to determine how to proceed with diagnostic testing. One can approach the critical thinking either pragmatically or open-mindedly, casting a narrow diagnostic net or a wide one. We are primarily biological scientists, so we can use the scientific method to follow the trail of evidence to the point of reasonable confidence in our interpretation in the context of population-based studies.
The third element of clinical judgment is decision-making. This is the culmination of acquisition of knowledge about the patient (history, physical examination, diagnostic studies, interpretation of the evidence, and critical thinking leading to a presumptive diagnosis) and the consideration of what recommendation(s) should be made to the patient for her/his consideration. The impact of clinical experience is quite important here, for the experienced otolaryngologist has an internal database of similar compilations of symptoms, signs, findings, and diagnoses that inform her/him what should be recommended to a given patient.
At times, the evidence-based recommendations will fit nicely with our working diagnosis, and the course of recommended action to the patient will be clear-cut. With other patients, some uncertainty in the diagnosis and management may be present—so how to deal with, or manage, uncertainty becomes our challenge. Some uncertainty is part and parcel of even the most refined scientific study, and when dealing with human illness, uncertainty may often play a role—uncertainty in how you should proceed in formulating a therapeutic recommendation, and uncertainty in how the patient will consider and respond to your recommendations. Herein lies the fourth element of clinical judgment—patient self-determination.
The primary ethical principle in patient care is often said to be “autonomy,” which is the right of patients to make their own decisions about their health care, in the context of unbiased explanation of the options and their basis by the clinician. In earlier times, where information technology was not prevalent, the physician held sway over the recommendations, for she/he had the information. Now, many patients are so much more prepared to make their own decisions, based on their own information, as well as what their otolaryngologist has explained to them. That doesn’t mean that the otolaryngologist has to compromise her/his professional integrity for a patient’s decision, but rather to accept a patient’s wishes after all information has been given and all professional recommendations have been discussed.
In most clinical encounters, physicians utilize some form of “shared decision-making” with patients that usually results in an acceptable therapeutic plan to both patient and physician. In shared decision-making, the physician explores the patient’s personal and health values, which can have a tremendous influence on what therapeutic plan will be acceptable to the patient. Other important factors may be religious and cultural preferences/influences, or constraints due to social, economic, or financial burdens. The otolaryngologist has an obligation to mitigate any “solvable” constraint, but also an obligation to understand and support the patient’s wishes, as long as they are professionally ethical. Gaining experience in dealing with patients, particularly in complex diseases and difficult therapies, can be helpful in developing a shared plan for the patient’s care.
In this clinical scenario, Mr. Jones is an older gentleman with the likely diagnosis of a progressive neurodegenerative disorder. Indeed, he does have a small tumor in the internal auditory canal, but his symptoms at this time are minimal from this tumor. You should discuss patient autonomy and clinical judgment with the resident, and point out that you could achieve a shared decision with the patient and his wife by accepting his decision to not have an intervention, and by offering to follow him closely for new signs or symptoms that may call for revisiting a potential intervention if indicated in the future. At this time, the patient appears to be competent to make his own healthcare decisions, and to cognitively understand the risks and benefits of observing a small acoustic tumor over time. Take the time to answer the patient’s and his wife’s questions to their satisfaction in the resident’s presence. Through appropriate and experienced clinical judgment, you will have followed an acceptable course of professionalism and ethics, supported the patient’s wishes, and shared an appropriate decision with the patient. You also may have impacted the resident’s understanding of clinical judgment.