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The “Art” of Clinical Decision-Making

Much nonsense has been written about the “art” of medicine. All too often, it amounts to a rationalization for doctors doing what they want to do instead of following the evidence. Medicine is not an art like painting. Neither is it a science like physics. It’s an applied science. Since patients are not all identical, it can be very tricky to decide how to apply the science to the individual.

The New England Journal of Medicine periodically runs a feature called “Clinical Decisions.” They present a case history, then they present 2 or 3 expert opinions on how to manage the case. They stress that none of the options can be considered either correct or incorrect. They allow readers to “vote” as well as to submit comments about why they voted that way. It is understood that the voting is only for interest and to stimulate discussion: it does not result in a consensus.

In April 2008 the topic was the management of carotid artery stenosis. The patient is a 67 year old man who has no symptoms but who is found to have a narrowing of 70-80% in one carotid artery and 20% in the other, putting him at increased risk for stroke. He has other risk factors for cardiovascular disease: hyperlipidemia, hypertension, and overweight. The 3 options are medical management, stent placement, and carotid endarterectomy.

In appendicitis, science gives us straightforward guidance: do an appendectomy. In this case, the decision is not so straightforward. Endarterectomy will reduce his risk of a stroke but the risk of the surgery itself may be as great as the risk of stroke; stenting may work as well as surgery and may be less traumatic, but so far it has only been tested in high-risk patients; medical treatment may not be quite as effective at preventing stroke but it may be more effective overall since it avoids surgical risks and might prevent a heart attack as well as a stroke. Three experts each give a cogent analysis, citing published evidence, and each recommends a different evidence-based option.

At the time I voted, 48% of respondents had voted for medical management, 19% for stenting, and 32% for endarterectomy. The numbers aren’t important, except to demonstrate that not all doctors are knife-happy. What’s really important is reading the 3 different expert opinions and the comments submitted and getting a sense of the complex decision-making that goes into the conscientious practice of science-based medicine. It provides a fascinating glimpse into how the medical mind works. Rather than give examples, I’d urge you to read through some of the comments yourself.

There is even more to think about than what appears in the medical journal. It can only address the patient as presented on paper in the case history. The real patient in the doctor’s office brings more baggage to the decision-making process. Allergies? Other factors that might increase the risk of surgery? A fear of surgery because his father died in the OR? An unwillingness to accept risks? A pathological fear of stroke that makes him WANT surgery no matter what? A history of poor compliance taking medications?

Then there are circumstantial considerations. Is there a surgeon in your area who is proficient and whose complication rate is low? What will the insurance company pay for? Is the patient even insured?

You can involve the patient in the decision-making process, but he may not understand all the implications, and the way you explain the options to him will influence his reaction. Sometimes when you explain too much, he may reject an option out of fear. And if you are too wishy-washy, you miss out on the potential placebo effect of a strong recommendation by a confident, hope-inspiring clinician.

We may hate to admit it, but every one of us has some degree of personal bias, whether we’re aware of it or not. There is no such thing as perfect objectivity. If there were, we would all make the same decision when given the same facts. We don’t. In the book I reviewed last week, On Being Certain, the author Robert Burton gives the example of a cancer patient getting the same exact story and the same 2 options from 2 oncologists, and then asking them what they would personally choose: one said he would personally opt for surgery and the other said he wouldn’t.

Every chemist gets the same product when he mixes two chemicals under standard conditions. Every physicist gets the same answer when he measures the speed of light. One critic of modern medicine told me medicine isn’t science, because if it were science, we would get the same diagnosis and treatment from every doctor. Of course it isn’t a pure science; it’s an applied science.

Medicine gets very messy at times, because we never have all the data we need and we are all subject to the foibles of human psychology. Often the best a doctor can do is look at the available data and then make an educated guess. Sometimes in an emergency he is forced into action before any test results are available. Even when we have good information, the crystal ball won’t tell us which patient will fail to respond to treatment or have a complication. Doctors agonize about some of their decisions and lose sleep over them; it’s a big responsibility to know your actions may have life-and-death consequences.

In the face of all this uncertainty, some patients turn to alternative medicine, not realizing that they’re exchanging something imperfect for something even more imperfect. Instead of making a reasonable choice between 3 evidence-based options, they may throw the baby out with the bath water and turn to a treatment based on belief, on inadequate evidence, or even based on total nonsense. To counteract that, we can do two things. We can try to help patients understand and accept a degree of uncertainty. And we can make the best possible use of the most reliable tool we have: the scientific method.

Posted in: General, Science and Medicine

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10 thoughts on “The “Art” of Clinical Decision-Making

  1. overshoot says:

    Science or art?

    We get the same discussion in engineering. Fortunately for us, we have a third option that’s gaining some mindshare: engineering is a “craft,” which is more scientific and systematic than an “art” but not quite a “science” since we (like medicine) apply our science in ways that leave a lot of room for individual expression [1]. We, however, have the advantage of producing “things,” which seems to be a requirement for “craftsmanship.”

    Alas, I don’t know of an equivalent to “craft” for services other than “profession,” which is certainly apt but includes too many other fields that have no science at all.

    [1] Never doubt it. I’ve seen some beautiful designs, even if the only people who appreciate the “art” are engineers. Likewise I’ve seen some very “pretty” surgery — and I know I’m missing most of the art.

  2. mckenzievmd says:

    Excellent summary of the problem faced in real clinical situations. As a vet, I often have even less reliable, good-quality evidence on which to base clinical decisions than most MDs, and generally a lot more severe financial limitations (though I also don’t have to deal with the lawyers as much :-). Clinical experience and intuition are unreliable compared with scientific evidence, but depending on the urgency of the clinical problem one has to balance the need to do something against the limitations on knowing the best thing to do. And, of course, doing nothing is sometimes the best option, but it’s the hardest to sell to the client. Fascinating and frustrating dilemma.

    I wonder how folks here feel about the question of “talent” or ability, which is part of the equation that makes medicine feel like an “art” at some level. A doctor can follow the evidence religiously and yet make terrible decisions due to failure to appreciate salient factors of the case. The evidence can never be a strict cookbook, except possibly for very simple and routine clinical entities. I do think some clinicians have a better ability to see what is important and what isn’t and to make a diagnosis or manage a complex case effectively than others, and slavish following of published guidelines is often a sign of a clinician with less native skill. How does one strike a balance between following the evidence and yet making full use of one’s own abilities, which may include attending to intuition or hunches even when they don’t initially fit a predetermined Dx or Tx algorithm?

  3. overshoot says:

    mckenzievmd:

    I wonder how folks here feel about the question of “talent” or ability, which is part of the equation that makes medicine feel like an “art” at some level.

    I suspect that the distinction becomes clearest in emergencies. I’ve seen good, solid, experienced emergency medics go all tunnel-vision in the crunch and I’ve seen others make amazingly good attention-selection choices.

    The old saw about draining a swamp and alligators would seem to apply in a crisis: there is, theoretically, a “correct” decision that you would make if you had enough information, but by the time you have enough information it’s too late to make any useful decision at all.

    The current practice is to go by a relatively rigid protocol to make sure that you don’t overlook key points. I suspect Harriet, as a pilot, is very familiar with that approach: have a response that you drill until its the next thing to a spinal reflex, then drill some more. I’d love to see her comments on flying relative to medical emergencies.

  4. Harriet Hall says:

    mackenzievmd,

    I don’t know if I would use the word “talent.” Maybe judgment or common sense. I had a classmate in med school who was brilliant on written tests but was useless at applying his knowledge to real patient situations. It never ceases to amaze me how some people with sky-high IQs are deficient in common sense.

  5. Harriet Hall says:

    Flying vs medical emergencies. Interesting thought.

    “Remain calm” applies to both.
    Keep priorities straight. On a flight test they try to distract you and get you to talk on the radio and you have to remember to fly the plane first and leave everything else to a lower priority. The radio callls can wait.
    Practicing for emergencies improves reaction time. That said, you need the common sense to know when not to slavishly follow a routine.
    Situational awareness is important to both.

    I once took a test that presented pilots with two equally reasonable options – neither option was “correct” but to pass the test you had to decide on one or the other and carry through. If you dawdled or changed your mind midstream, you crashed. I’d say that applies to medical emergencies too.

  6. Harriet said, “In the face of all this uncertainty, some patients turn to alternative medicine …. To counteract that, we can do two things. We can try to help patients understand and accept a degree of uncertainty. And we can make the best possible use of the most reliable tool we have: the scientific method.”

    There is another option. We can work to have laws changed so that alts are held to the same standards of truthfullness as those who practice scientific medicine. They should have to clearly state what they know, don’t know and suspect. In that case they will be reduced to saying, “Well there isn’t any objective evidence showing that it works and there aren’t any toxicology studies showing that it is safe, but I personally believe that it will cure you and not harm you. I mean the theory is just so delightful. It must be true, and the stuff is natural! The ancient Chinese have used it for 3 thousand years. No, I don’t have evidence of that either, but I really think they must have used it all that time and they must have consistently gotten great results! Heck, why would they continue to use it if they weren’t getting great results? That wouldn’t make sense.”

    Mckenzievmd, with vets a major consideration is experience at least in the rural area where I live. The clinic I go to has gone through over 10 vets in the last 10 years. They come out of school with very little experience and move on very quickly. A couple of years ago my dog’s leg went out from under her. I took her to the vet and found out that her weight had gone from 56# to 96# in maybe a year. Obviously, I should have noticed that. My only excuse is that she is a very “refined” Borzoi who has been described as two dimensional. X-rays showed no structural problems. I knew there was hypothyroidism in her line and checking the lit on the disease in humans found that it sometimes causes muscle problems. The young vets couldn’t believe that. I got them to check her thyroid levels which they found were exceedingly low. It’s a long story, and no I don’t know that her leg problem was caused by hypothyroidism. But it has never recurred since she got on the correct dose of soloxine. While they were trying to solve the problem, I got exasperated and requested the “old” vet, the one who had been practicing for over 10 years, but unfortunately, she has just retired to raise her children.

    Many years ago when I was being treated for breast cancer and was very tired myself, I noticed that one of my old cats was very ill. I took him to the vet who palpated him and said that his kidneys had atrophied. He thought he was in kidney failure. He said that he could do blood tests or we could treat the symptoms. He said that even if we did blood tests we still might wind up treating the symptoms. I opted to “treat the symptoms”. The disease, of course, was fatal. The vet left shortly thereafter. I believe he became a professor at the vet school at the U. of Penn.

  7. Mark Crislip says:

    The uncertainty in therapeutics is part of the ongoing problem of applying group data to the individual, discussed in an earlier post.

    And the problem of applying data from studies to patients who do not meet the profile of the study group.

    For my practice, the Art of medicine (I like the idea of craft) is not in choosing the right treatment. Thats usually a matter of looking it up. Its coming up with the right diagnosis. Half my consults are not “what to do” but “what do they have.” And watching for signs that the therapy is going wrong.

    It is also a matter of noticing the outliers in a case rather than collecting all the data that supports the diagnosis.

    I am especially aware as residents present cases or I do a history that I do not arrive at the potential diagnosis consciously, and my teaching is an after the fact rationalization of what is mostly processing below the level of active consciousness.

    The Art in medicine may occur as thinking about cases moves more and more over time from the conscious level of a third year medical student to the subconscious level of an experienced clinician. I recognize subtleties and important findings faster than newbies or the inexperienced (in my field, I probably wouldn’t recognize a heart attack if it bit me in the ass).

    Some people never make that transition or the transition is faulty.

    Most of the alt.med patients I see suffer from a misdiagnosis or, worse, no diagnosable illness for their symptoms. Most turn to alt.med because they get certainty of diagnosis first, then the quack treatment follows. People above all want to know what they have, good or bad, over not knowing.

    A ‘problem’ with science based medicine, is there is no science based diagnosis at the bedside. We still have to work with trying to synthesize uncertain incomplete and/or confusing histories, physicals and diagnostics.

    The quacks will always have the advantage in diagnosis and treatment and they are not limited by mere truth and reality and as a result find it easier to be certain.

    You know, I should expand this into a blog entry….

    Dibs:)

  8. mckenzievmd says:

    rjstan,

    I think experience is a two-edged sword. It helps one to see what matters in the clinical picture, and it helps in associating symptoms with diseases and drawing up mental differential diagnosis lists. But it also encourages one to take shortcuts, go with the gut, and stop looking things up or checking fcor new evidence since “I’ve seen this before” or “Well, the old treatment always worked fine for me.” There’s probably a balance point in most vets careers where they have enough experience to be good diagnosticians but they aren’t jaded and still keep a truly open mind. Of course, I’ve known vets who remained assiduous learners all of their careers and so had the best of both worlds, but it seems the exception, and I personally find those out of school between about 5 and 15 years the best bets for optimal clinical skills.

  9. Nick Barrowman says:

    Medicine is not an art like painting. Neither is it a science like physics. It’s an applied science.

    Though we tend to think of art as being what artists do, Merriam-Webster offers as their first definition (reflecting the earlier meaning of the word) “a skill acquired by experience, study, or observation”. So, in this sense, the practice of medicine certainly is an art.

    But medical science seeks to inform the practice of medicine.

    Some medical doctors are scientists, some are clinicians, and some are both. It sometimes seems that in the public mind, all doctors are both. I wonder if the white lab coat adds to the confusion?

    Since patients are not all identical, it can be very tricky to decide how to apply the science to the individual.

    Indeed. However, there is sometimes a scientific solution to this problem. It’s called an N-of-1 trial, and it works something like this. The patient receives a randomly-alternating order of treatments (e.g. with 2 competing treatments the sequence might be ABBAAB …). It may then be possible to identify a superior treatment for this particular patient. Interestingly, this blurs the line between clinical practice and scientific research.

    Every chemist gets the same product when he mixes two chemicals under standard conditions. Every physicist gets the same answer when he measures the speed of light. One critic of modern medicine told me medicine isn’t science, because if it were science, we would get the same diagnosis and treatment from every doctor. Of course it isn’t a pure science; it’s an applied science.

    The critic is referring to clinical practice rather than medical science. Diagnosis and treatment are not scientific activities (notwithstanding the N-of-1 trial), but the study of diagnosis and of treatment are.

    Clinical practice, like engineering, applies scientific knowledge. But someone has to generate that scientific knowledge.

    My point is that it’s useful to separate the practice of medicine from the science of medicine.

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