Making Clinical Decisions

A typical family physician sees a patient every 15 minutes and addresses three separate problems during the visit (Beasley et al., 2004). Busy clinicians operating in such an environment must make snap decisions regarding patient care. Ethnographic studies of actual physician decision making in primary care offices indicate that physicians rely on “mindlines” to guide them (Gabbay and le May, 2004). Physicians develop these mindlines as a preconceived, conceptualized, and standardized approach to a particular clinical scenario. For example, for a child with fever and tonsillar exudates, one physician’s mindline may be to treat with penicillin, and another physician’s mindline may be to obtain a culture and treat if the results are positive for Streptococcus. The foundation of these mindlines is the tacit knowledge physicians acquire during their early training. For example, the best predictor of a clinician’s knowledge about hypertension treatment is his or her year of graduation from medical school (Evans et al., 1984). Subsequently, these mindlines are continuously refined by patient care experiences, interactions with colleagues, discussions with trusted experts, and to a lesser extent, focused reading. Mindlines allow the clinician a mechanism to cope with the demands of a busy office practice. If not continuously updated and refined, however, such mindlines can quickly become stale and outdated.

A significant lag often occurs between the publication of landmark clinical studies that change medical practice and their general adoption by the medical community. Often, an opinion leader or trusted expert must adopt the new clinical practice first before others in the medical community feel comfortable changing their own practices (Slawson et al., 1994). This supports the concept that interactions with colleagues and discussions with trusted experts are the primary influence in shaping physician mindlines. The challenge is for the physician to use the tools of evidence-based medicine to shape her or his own mindlines and become an opinion leader.

To make sound clinical decisions, the clinician must first check his or her mindline. If there are knowledge gaps in the mindline, it can be updated by asking a focused clinical question and using the techniques of evidence-based medicine. Next, the clinician discusses potential risks and benefits of treatment options with patients, determining their preferences. By integrating the medical evidence with patients’ preferences, a shared clinical decision is reached.

Focusing the Question

Key Points

Many studies have documented that important clinical questions arise during the day-to-day care of patients (Dee and Blazek, 1993). The number and types of questions depend on the clinical setting and the experience of the physician. The most common generic questions involve choosing which drugs to prescribe, determining the cause of a condition, and deciding what diagnostic study to order (Ely et al., 2000). Studies also show that answers are not sought for most questions that arise, but that physicians who seek answers are usually successful in finding them (Ely et al., 1999). Previous studies that documented little dependence on computerized resources for finding answers may reflect that the studies were conducted when computers were not extensively used in the course of routine patient care (Covell et al., 1985; Osheroff and Bankowitz, 1993).

After identifying a knowledge gap relevant to making a clinical decision, the next step is finding the information necessary to close the gap. To find the necessary information, an answerable question must be developed. There are two general types of clinical questions: background and foreground. Background questions are the “who, what, why, and how” questions usually answered in textbooks and asked by medical students; for example, What oral drugs are used in the treatment of diabetes? Foreground questions focus on the specifics surrounding care of a patient; for example, Which is more effective in reducing fasting blood sugar level in an obese patient with type 2 diabetes—metformin or glyburide? It is unlikely that a textbook could adequately answer this second question. Being able to identify the type of question helps direct the physician to the best source of information for answers.

Most of the questions that arise out of patient care can be categorized as foreground questions, because they are specific to a particular patient’s case. Although unlikely to be found in textbooks, the ability to answer these questions at the point of care is essential to providing the best care in a timely manner. A focused clinical question must be developed to find the information efficiently (Richardson et al., 1995). Unfortunately, this critical step is often overlooked, causing needless frustration when searching for answers among thousands of hits in a search engine. Sackett and colleagues (2000) propose that “educational prescriptions” be used to teach this important skill to physicians in training.

The four components of a focused clinical question are (1) the patient’s problem, (2) the intervention, (3) the comparison intervention, and (4) the outcome of interest. Patient-oriented outcomes are always better than disease-oriented outcomes because they are direct measures rather than secondary markers. For example, a study documenting that a new drug reduces total cholesterol by 20% (secondary marker) is important, but not as persuasive as a study documenting a decrease in cardiovascular death (direct measure).

Finding the Evidence

Key Points

Having identified a focused question, the astute clinician is ready to find the information needed to answer it. The usefulness of medical information can be modeled in the following equation (Slawson et al, 1994):

As the formula shows, busy clinicians should concentrate their efforts on easily obtained, valid evidence that is highly relevant (i.e., patient-oriented evidence). Such a strategy focuses attention on useful information and makes wise use of limited time and resources.

As shown in Figure 10-1, the work required to find useful medical information is inversely proportional to its quantity. At the bottom of the pyramid is original research. Although plentiful, much of it represents “medical chatter” among researchers (Slawson et al., 1994). Researchers are intimately familiar with published data in their narrow field of study and are able to place the article in its proper context. A busy clinician reading a single article in a relatively unfamiliar field is akin to overhearing a snippet of conversation at a dinner party. It may be dangerous to base decisions on such snippets without knowledge of the larger context. Checking the relevance and validity of such studies requires knowledge of statistical methods and study design. It is too time-consuming to be useful for answering clinical questions that arise during a patient visit.

Figure 10-1 Evidence pyramid.

At the next level of the pyramid are systematic reviews and meta-analyses. These types of studies focus on a single topic and attempt to draw conclusions from the volume of previously reported data. Although an improvement, the clinician still must explore the methodology used to select and analyze the data to ensure relevance to the clinical question. Often, these types of reviews focus on disease-oriented outcomes rather than patient-oriented outcomes, potentially making them less relevant. Disease-oriented outcomes, such as an increase in bone mineral density, may be a secondary marker for fracture risk, but they are inherently less relevant to the patient.

At the peak of the pyramid are patient-oriented evidence that matters (POEM) reviews (Table 10-1). Clinicians must decide if the POEM is relevant to their clinical question, but the amount of work required is greatly reduced. POEMs offer the most useful type of information for answering clinical questions that arise during patient visits. Unfortunately, a POEM does not exist for every clinical question. In these cases the clinician must step down the pyramid until relevant information is found.

Table 10-1 POEM^∗ Sources

∗ Patient-oriented evidence that matters.

The medical evidence often tells conflicting stories, as with HRT. This is particularly problematic at the original research or bottom level of the evidence pyramid. Differences in methodology, study populations, statistical power, and bias often explain the different conclusions and result in medical chatter. Putting such articles in their proper context is difficult at best for the practicing clinician. Moving up the evidence pyramid helps alleviate conflicting evidence, yielding results that are more reliable.

Often, minimal or no reliable medical evidence is available to answer a clinical question. In these cases, practicing clinicians must rely on their clinical experience and background medical knowledge—their mindlines.

Haynes (2001) defined another pyramid that is relevant to answering clinical questions. This is the pyramid of services for finding the best evidence. It is depicted as the third dimension of the evidence pyramid (Figure 10-1). At the bottom of the pyramid are tools to find the original studies. The National Library of Medicine maintains a database of more than 15 million articles, called MEDLINE. Various engines are available to search MEDLINE and other databases for articles that may be used to answer clinical questions. For example, PubMed (www.pubmed.gov) provides tools to help clinicians search for meta-analyses and systematic reviews through the use of limits and clinical queries (Ebbert et al., 2003; Haynes and Wilczynski, 2005; Sood et al., 2004).

As in Mrs. Smith’s case, there may not be a single study that addresses the specific question posed. In looking for the best evidence to inform clinical decision making, it is important to determine the standard of care for the patient’s condition. Clinical guidelines, which are typically updated every 2 years, may be a useful resource. An excellent clearinghouse for clinical guidelines is sponsored by the Agency for Healthcare Research and Quality (AHRQ, www.guidelines.gov), although the listed guidelines are neither reviewed nor endorsed by AHRQ. Clinicians must critique the guidelines for validity and relevance in their own setting. This resource is higher up the services pyramid and reflects some interpretation and synthesis of original research and clinical practice.

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