Clinical Decision Making

The reader leaving this discussion with a healthy appreciation of “just in time” versus “just in case” knowledge will have been well served. The objective is to shed light on the concepts, characteristics, tools, and process of clinical decisions. The cascade of the decision process is graphically depicted in Figure 1.

The change in the clinical decision process, even its mention in publications, has undergone meteoric growth in recent times, largely as a result of information technology and the creation of the Internet. From an obscure beginning envisioned as an indestructible defense communication system, the Internet has grown to the World Wide Web (WWW) with undefined borders. This revolutionary change may be rivaled only by the invention of descriptive language and Gutenberg's printing press. Like the press, the Internet has become the property of the people and, absent some catastrophic natural event, will not be turned back. A recent AMA survey found that almost half of physicians report the World Wide Web (WWW) has had a major impact on their practice of medicine. The Internet in medicine functions as a powerful resource, much as medical reference texts did 50 years ago. It is impossible to discuss clinical decision making today without considering the WWW impact.

Briefly, and for purposes of this article, a decision is “a position, an opinion, or a judgment reached after consideration” (American Heritage Dictionary). To a degree, by implication, decision signals closure and reduces uncertanity. Decisions are often driven by an individual's latest, or most disastrous, experience. Frailties sometimes overpower strengths, and errors usually decline as the knowledge base expands. Faulty or incomplete data carry a serious risk of failure, and until recently, a structured approach was uncommon. A search of Medline, which dates from 1960, using the phrase “medical decision” found only three references in the early 1960's: Two discussed court decisions, and a third reviewed contraceptives. Diabetes articles increased from 960 in 1965 to 10,416 in 2001; during the same time, articles on decision making increased to 21,847 or nearly 60 times the rate of increase in diabetes articles.

Anyone practicing for a few years can likely recall an experience with a patient in which the physician noted subtle changes unsupported by objective data and in which, nevertheless, additional testing confirmed a dangerous [Page 74]illness in an early stage. Justifiable pride can be taken in this metaphor of the indispensable human factor, because it will be a long time before a computer performs this diagnostic function. Yet computers do aid diagnostic decisions.

By the late 1980s several medicine-oriented programs entered the market, created for the personal digital assistant (PDA). Today, increased use of mobile devices foretells the replacement of pocket reference books. Reliable Web resources abound and Web sites formerly restricted to the academic medical centers, such as Medline, are now open to the world. Although a long way from Star Wars, this new system has the potential of ushering in the dawn of a new era in medical quality.