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Judgment Modes

A judgment is an opinion as to what was, is, or will be some decision-significant state of the world, for instance, a physician's conclusion that a patient has suffered a myocardial infarction. Judgment modes are qualitatively distinct means by which people arrive at their judgments. Contrast, say, a myocardial infarction diagnosis based solely on the physician's personal clinical experience with another derived from a validated formula applied to signs and symptoms on a checklist. This entry explains why judgment modes matter in medicine. It also describes major judgment modes that are especially useful to distinguish in medical practice. And, as appropriate, the entry further indicates specific practical implications of such distinctions.

Why Judgment Modes Matter

Judgments are important in medicine because their accuracy imposes a ceiling on the quality of the decisions they inform. That ceiling in turn sets bounds on the patient's well-being. A patient with severe chest muscle strain who is misdiagnosed as having had a myocardial infarction will be treated as a heart attack victim. This inappropriate treatment would be invasive and risky as well as needlessly expensive. Naturally, any physician or medical practice would like to minimize inaccurate judgments, be they diagnoses, prognoses, efficacy opinions, or any of the other myriad assessments that are required throughout every day in every clinic. Achieving that aim requires a deep understanding of precisely where those judgments originate. Such understanding makes it clearer how mistakes can occur and therefore what is sensible in efforts to prevent, correct, or compensate for them. If one actually misunderstands how particular medical judgments are achieved, then the resulting attempts to improve those assessments could easily backfire, making things worse. Assuming that judgments originate in procedures— that is, modes—that are fundamentally different from how they actually are generated is misunderstanding in the extreme.

A Judgment Mode Tree

Studies have shown that, as in most practical arenas, the judgments that support people's medical decisions can arise from sources as different from one another as apples and oranges, and hence the term judgment modes aptly describes those sources. Figure 1 shows a judgment mode tree. (The numbers on the nodes facilitate discussion.) This hierarchy is a taxonomy of major judgment modes, organized in a particular way. Specifically, there are reasons to expect the various modes to be invoked in roughly the order of a path from “northwest” to “southeast.” For a given judgment problem, modes to the left and top of the tree are likely to be attempted before ones to the right and the bottom. It is important to bear in mind, however, that in a single decision episode, several different modes, applied one after another, easily might contribute to the judgment ultimately rendered.

Figure 1 Judgment mode tree

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Individual versus Collective Modes

The first level of the tree distinguishes individual from collective modes. Individual modes (1) are those in which one person (e.g., the attending physician or, perhaps, a specialist whom the physician consults) provides the judgment in question. In contrast, in collective modes (2), the judgment is supplied by several individuals working collaboratively in some manner (e.g., three physicians conferring to reach consensus on an especially challenging diagnosis). Individual modes normally have priority over collective modes if for no other reason than that people often work alone, sometimes by necessity. In addition, collective judgment is generally slower and more expensive, materially and emotionally; it entails higher process costs, such as the time and goodwill used up working through disagreements (e.g., between two physicians with opposing opinions about the true cause of a patient's complaint).

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