What's involved in making a clinical decision?

Clinicians make decisions all the time, indeed it is inherent in being a ‘clinician’, but what are the factors that influence the decisions we make. Some came to mind (in no particular order)…

  1. Risk-benefit assessment (see below)
  2. What is morally right and perceived to be in the patient’s best interests?
  3. Compassion
  4. Wishes and values of the patient’s human family, his/her carers. And clearly it is unavoidable that at least some of the time financial considerations will be involved here.
  5. Resources and expertise available – are these a limitation? Can they be offered by transfer elsewhere?
  6. Mode of practice (see below)
  7. Time available to dedicate to clinical thinking and decision-making
Clinical decision-making

Clinical decision-making

Multiple factors are at play in clinical decision-making

More on risk-benefit assessment:

Although the mantra of ‘first do no harm’ is often bounded around, in reality this is impossible to guarantee. Every treatment or intervention we offer carries some risk of harm, variably large or small, and every so often one of our patients is going to suffer this harm. On the flip side, sometimes – although definitely not always! – not doing something carries a risk of even greater harm. In reality the best that we can do is to make a risk-benefit assessment at all times to try and do the best for our patient while avoiding unnecessary harm, causing the least harm possible, and simultaneously avoiding ‘for the sake of’ medicine. But note: don’t fall into the trap of over-estimating the benefits of some of what we can do while under-estimating the harms! When it comes to informing our risk-benefit assessments, clearly best quality evidence is ideal – although sadly all too often lacking in veterinary medicine now and for the foreseeable future – and individual experience and opinion also influential.

More on mode of practice:

To some extent the clinical decisions that we make, all other considerations taken as read, are influenced by our clinical attitude or philosophy. Some individuals seem inherently more aggressive than others who are more conservative, and some individuals change their positioning as time goes by, with greater experience/age/wisdom…! That said, the same individual at a specified point in time should have the ability to adapt their approach and philosophy to the individual patient.

Let’s use the scenario of a busy Out-of-Hours shift to illustrate the point. The patients that one sees during a shift will undoubtedly vary with respect to the seriousness of their condition, from patients whose prime reason for presentation is owner concern rather than patient suffering through to those in imminent danger of death. Clearly how one approaches patients therefore needs to be adapted dynamically all the time based on the individual patient in front of us, from more of a ‘cruise control’ comfortable perspective, embedded in a minimal intervention and harm ethos, to a maximally aggressive and efficient approach. Essentially it is necessary to flick a mental switch between these modes of practice based on the patient in front of us; we need to be able to flip modes between patients and moreover even during a single episode of care for the same patient.

Furthermore being maximally aggressive may be warranted to save a patient’s life, but when we consider the other factors alluded to above, is this appropriate for that individual patient, e.g. if an old dog with cancer carrying a grave prognosis also develops sepsis from aspiration pneumonia, while a maximally aggressive approach from the outset is indicated medically, is it in the patient’s best interests? What do the patient’s carers feel about what’s best to do?

A couple of final comments about mode of practice. The first is that being able to adopt a more conservative and reasonable mode when appropriate may potentially reduce over-testing/over-diagnosis, resource expenditure and patient harm (in all senses e.g. venepuncture is not benign!). The second point is that clearly our ability to flip between modes requires: a good grasp and understanding of what can be done and what the evidence is; gestalt (gut-feeling); and, availability of equipment and resources. It is hard to teach people to flip between modes but my personal experience is that clinicians become more comfortable with this the more experience they acquire; furthermore a more general observation is that sometimes this means that people with a tendency to perhaps overdo clinical treatments and interventions become a little more tempered – but I generalise.

I am sure I have overlooked some important aspects here. Do let me know…