Sue Ieraci: Clinical nous

IN the US, it is often claimed that medical practice is hamstrung by the threat of litigation. In Australia, many of us feel the weight of regulation.

Neither the law nor the rules should stop us from exercising clinical judgement for the benefit of patients. But is it possible to negotiate the multiple — and often conflicting — influences on our behaviour while maintaining integrity, safety and sanity?

We are in an era of clinical governance practice that emphasises standardisation. The number of guidelines, policies, directives and performance indicators is mounting, along with an increasing tick-box mentality that assesses compliance.

Adherence to the guideline seems to have become the outcome — rather than better health for patients.

In this setting, what is the role of basic clinical assessment and decision making based on what we used to call clinical “nous”?

Well, reassuringly, it’s still there. It seems that the many rules that have been created to help standardise a clinical assessment and risk estimation, if applied wisely, can be almost as good as the advice of a sound clinician. If applied inappropriately however, decision rules and pathways can lead to inappropriate care.

For example, research in Annals of Emergency Medicine compared the use of a clinical scoring system with clinical judgement in the diagnosis of appendicitis. It found that unstructured clinical judgement performed better.

Another study in the same journal compared unstructured “clinician gestalt” with two validated scores for assessing the pretest probability for suspected pulmonary embolism. That research also found that clinician judgement performed better than decision rules for both low and high probability patients.

Clinician gestalt is not magic. Like other types of so-called intuition, clinical judgement is a subconscious appreciation of learned patterns or rules, based on both knowledge and experience.

What clinicians do better than any alternative is decide which patients should enter a particular diagnostic or therapeutic pathway. When decision rules lead to the inappropriate application of these pathways to a low-prevalence population of patients it can produce too many false-positive results. This causes harm.

The authors of a paper titled “Medical decisionmaking: let’s not forget the physician” hit the nail on the head. Just as new drugs need to be tested against existing therapy, clinical decision rules need to be tested against physician judgement without the tool.

As the authors say: “Risk-stratification tools do not eliminate subjectivity; they merely shift it from one domain (eg, does this patient need this test?) to another (eg, is this patient eligible for this decision rule?)”.

Clinical governance systems that pay lip-service to clinical judgement, but then punish individuals for not following specific steps, are sending mixed messages. We are fooling ourselves if we think that a decision rule can convert a novice into an expert.

The place for experience and judgement is at the beginning of any pathway.

Every guideline should start with: “Is this guideline appropriate for this patient? If unsure, consult a good clinician”.

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.