Making Clinical Decisions

A typical family physician sees a patient every 15 minutes and addresses three separate problems during the visit (Bea-sley 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 "mind-lines" 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 If not continuously updated and refined, however, such mindlines can quickly become stale and outdated.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.

You recall learning in medical school that HRT reduced the risk of cardiovascular disease and osteoporosis. Because your patient, Mrs. Smith, is clearly at risk for both, you have always refilled her conjugated estrogen (Premarin) since first seeing her 25 years ago. When a bone density scan 4 years ago showed no evidence of osteopenia, you congratulated yourself for all those years of prescribing HRT. However, a colleague recently presented a paper at an educational conference and, based on the results of the Women's Health Initiative (WHI) study, recommended that all women be taken off estrogen replacement therapy. The estrogen was originally started because of concerns about osteoporosis, but now you wonder whether Mrs. Smith should continue it.

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