Clinical Problem Solving

Gregory M. Garrison, Denise M. Dupras, Stephen P. Merry, and Alan J. Smith

Chapter contents

Making Clinical Decisions


Incorporating Patient Preferences


Focusing the Question




Finding the Evidence


• Taking care of patients requires clinical decision-making skills.

• Most physicians rely on "mindlines" formed by previous knowledge and experience.

• A lag exists between the publication of new evidence and its incorporation into clinical practice.

• Clinicians should use evidence-based medicine techniques to update their mindlines.

During a 15-minute follow-up visit for her diabetes, Mrs. Smith, a 78-year-old white patient who has a history of well-controlled type 2 diabetes mellitus, hypertension, asthma, and mild dependent edema, requests a refill of her hormone replacement therapy (HRT). Glancing at her chart, you note that she has been taking 0.625 mg daily of conjugated estrogen (Premarin) since a hysterectomy for excessive bleeding at age 53. She is also taking 1000 mg of metformin twice daily, 20 mg of lisinopril daily, 25 mg of hydrochlorothiazide daily, and fluticasone plus albuterol (Advair; 250/50 ^.g twice daily) and using an albuterol metered-dose inhaler as needed. Before reaching for your pen, you wonder if HRT is the right choice for Mrs. Smith.

Anyone engaged in primary care faces scenarios such as this on a daily basis. Such a seemingly simple request requires that clinicians rapidly assess the current medical evidence as it applies to the particular patient, communicate the risks and benefits using language the patient understands, and recommend a course of action based on the patient's preferences. This is a daunting task, but most clinicians do it without a second thought. By analyzing how clinical decisions are made, physicians can better understand how to integrate evidence-based medicine and patient preferences to improve the efficacy and efficiency of clinical practice.

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