On Clinical Judgment

17

Category : Clinical articles, General, Medical Rants

Over the past year, I have thought extensively about the concept of quality health care. I have participated in research designed to measure one aspect of quality, i.e., adherence to known quality indicators.

    Examples of this version of quality include:

  • Foot exam in diabetes mellitus
  • Aspirin for patients with known CAD
  • Colon cancer screening in patients above age 50
  • ACE inhibitor (or ARB) in diabetes patients with proteinuria

To use a philosophical term, the above examples are necessary but not sufficient. Checking the boxes of the quality scorecard is useful, but does not define a high quality physician.

The competency that I worry about the most is clinical judgment. I fear that clinical judgment remains (and will remain) difficult to define and therefore even more difficult to measure.

Some commentors have suggested that competency measures are easy – just measure outcomes. Now this might work in subspecialties where one sees the same diagnosis repeatedly. This certainly would work for a cardiovascular surgeon who only does CABG procedures. This certainly would work for an interventional cardiologist.

But I am not concerned about subspecialists. I worry about specialists – general internists and family physicians. We live in a different world. We see undifferentiated patients, with undifferentiated complaints, and our job is to achieve differentiation. We live in a world of vague or common symptoms. We live in a world of causal comments that we must recognize as clues to follow.

At this risk of seeming self serving I will briefly present 3 patients in whom clinical judgment made a major difference. Now clearly I have picked patients for whom I made the right diagnosis. The point here is not the diagnosis, but rather the clinical judgment involved in getting to the answer – and the answer matters in all three cases.

#1

A 52 woman came to my office for investigation of abdominal pain. Her internist (my resident when I was an intern) asked me for a second opinion.

The patient had had severe (8/10) LUQ pain for 2 months. Extensive investigations including UGI, CT of the abdomen and colonoscopy had shown no abnormalities. Multiple laboratory tests had normal results.

She had a history of Type II Diabetes Mellitus for 15 years. On questioning, she said that she had a similar pain in the RUQ 3 years ago. At that time, testing showed no abnormalities, her doctor blamed depression and treated her with tricyclic antidepressants – with a slow resolution.

On examination, I noted that she had surface pain in a dermatomal pattern over the LUQ. She had no deep pain.

As I considered her problem, I considered the possibility of herpes zoster (shingles) with a rash. Then I wondered if diabetic neuropathy could present like this. I ordered nerve conduction tests and proved a diagnosis that I not previously known – Diabetic truncal radiculoneuropathy. For a good review of diabetic neuropathies – THE DIABETIC NEUROPATHIES: TYPES, DIAGNOSIS AND MANAGEMENT

The point! By carefully considering the patient’s complaint and physical exam – I avoided more expensive imaging studies. I made a correct (albeit rather unusual) diagnosis. This diagnosis led to appropriate treatment and the patient recovered over the next 3 months.

#2

A 57 yo executive secretary came to my office for spells. She described 7 episodes over the past 6 months – one a month until the previous month during which she had 2.

The spells caused great physical and emotional distress. She stated that she would feel ill and her pulse would go up to 150 (she recounted measuring her pulse precisely). The spells lasted approximately 15 minutes, after which she felt drained. She had had spells during the day, at work, at home and in the evening – no obvious inciting events.

After the 3rd episode she saw a cardiologist who ordered an echocardiogram and a stress test – both of which were normal – and told her that the spells were “in her head”. As she recounted the story, I could feel her frustration.

I ordered a loop monitor, which the patient wore for the next 2 months without any further spells (perhaps a therapeutic loop monitor). I was convinced that she had PSVT (paroxysmal supraventricular tachycardia), but I could not prove it.

So I told her that when her next episode occurred to immediately get to the ER and get an EKG. She lived in a very small town and was always within 5 minutes of the ER.

2 months later I received a faxed EKG confirming my suspicions. I referred her to an electrophysiologist who performed a radiofrequency ablation. Two years later she had no recurrences.

The point! The patient gave a clear history – virtually pathognomic for her eventual diagnosis. My job was to persist until we could confirm the diagnosis. However, many such patients have their symptoms dismissed as psychological.

#3

A 64 yo veteran was admitted to my service for chest pain. The housestaff presented his story on rounds, and reported that he was scheduled for a sestamibi stress test later that morning. They reported on his risk factors, and had prescribed all the correct medications.

However, when I went to the bedside, I asked the patient what was bothering him, and he immediately complained of RUQ pain. He related a 2 month history of progressive RUQ abdominal pain. He denied a relation to eating. He admitted to a brief episode of chest pain the previous day, but minimized that pain compared to the RUQ pain. On exam he had a positive Murphy’s sign.

I ordered a RUQ ultrasound for that day, and assumed that he had gallbladder disease causing his abdominal pain (and probably his “chest pain”).

Later that day, radiology called to let me know that he had a liver mass – suggesting that he needed an abdominal CT. We had that test the next day – and they again called to tell me that he had a liver abscess. Now most clinicians joke that the national plant of radiology is the hedge, and yet these radiologists did not equivocate – they called it an abscess.

Liver abscesses are rare in the US. Over the next few days the patient developed a fever and an elevated white count. As this occured around Christmas (several years ago), we struggled to get the abscess drained. Surgery wanted interventional radiology (IR) to drain the abscess, and IR said that they could not drain the abscess because of location. We persisted and eventually got surgery to do an open drainage of a large staph abscess. The patient had a successful recovery.

The point! Rather than focusing on the initial complaint and reason for admission, I listened to the patient and proceeded in a linear fashion towards the correct diagnosis. Making that diagnosis may well have saved that patient’s life.

Now I have told you my successes. Like all physicians I have failures. My clinical judgment is good, but even the best make mistakes, because clinical judgment is difficult.

I submit that clinical judgment – making the correct diagnosis, ordering the correct tests or the correct antibiotics – is the key competency for generalist physicians We must note the clues, sorting through the false alarms to find those complaints which need evaluation.

Yet how does one measure this. Perhaps clinical judgment is like pornography. As Justice Potter Stewart once said “I shall not today attempt further to define the kinds of material [pornography] . . . but I know it when I see it.” And yet this seems unsatisfactory.

I do not believe that we assess clincial judgment well, because it requires so many skills and situations to truly demonstrated. Clinical judgment is nuanced. The best physicians note subtle details or inconsistencies to reach a good judgment. I believe this is a difficult process to evaluate.

And yet, I reassert that it is the most important process for physicians. As physicians we must make judgments daily, hourly and multiple times with each patient. These judgments matter, and thus we should emphasize clinical judgment in our training and our assessment.

As the quality movement grows, I fear that it could minimize our focus on judgment. If that is true, then we may harm health care rather than improve health care. Our quest for quality should not ignore other concerns in health care.

HL Mencken (although perhaps a despicable human being) has that wonderful quote –

For every complex problem, there is a solution that is simple, neat, and wrong.

Perhaps this applies to the quality movement.

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Comments (17)

Excellent point ! Good judgment takes time : time to develop it and time to exercise it. It can be also replaced easy by fear (of malpractice, for example) and mental fatigue (insurance rules and regulations, for example).
We have to nurture the art of/in medicine.

Thank you- for listening to the patient. I realize that this should not be an unusual happening, but all too often it seems like it is. These examples all show why it is of utmost importance that physicians should have the ability to make a judgement call when necessary and not always adhere to guidelines that are mandated by an insurance agent. You probably saved the liver patients life, and saves the herpes lady from years of pain. Good on you!

If everyone met a certain minimal standard then it would be better for public health than counterbalance effect of those with superior clinical judgement. Most doctors are just not as smart as you and giving them the enormous leeway the current system allows for is a waste of money and can be dangerous. What public health needs is a ways to raise the bar for everyone and P4P is a good start. Another place to look for improvement is better feedback mechanisms to continue to hone clinical judgement after doctors become attendings because for many doctors, self awareness is severely lacking.

For anyone who wants to further explore what “clinical judgment” really is, I would recommend Blink by Malcolm Gladwell. The continuous improvement of clinical judgment is a basic part of what being a physician is all about. It can’t be measured, and there will always be some who are better than others. I think that clinical judgment is what separates physicians from mid-level providers like PA’s and NP’s. While it may appear superficially that we do the same things, there is a big difference.

One concern I have with current proposals for P4P is that they include things that are not completely up to the doctor – such some preventive measures like cancer screening (even if it is absolutely proven to save lives). It is fine to have suggesting/explaining/giving referrals for recommended tests on the list of requirements. But since the doctor cannot legally force patients to do anything, he shouldn’t be judged on the percentage of patients who actually do it. It is really not the doctor’s responsibility to call people and ask “I didn’t get the results of X why didn’t you do it?” – it is an extra work that doctors can do without and it may be unwelcome by some patients. If a patient simply forgot – it is his/her problem, if a patient made a conscious decision for whatever reason (religious, cultural, personal, etc.) it is also his/her choice.
Even if we forget that some tests have benefits as well as risks and different individuals have different feelings about the relative importance of each (or that the doctor should not be judged how well he can inflate the benefits or downplay the risks) some neighborhoods are bound to have higher percentage of patients who follow the recommendations. So doctors who practice in poorer neighborhoods will have no chance of achieving the same “percentage of patients that do such-and-such test” as those who work in more affluent ones. So I think whatever measurement there is shouldn’t depend on factors the doctors can’t and shouldn’t control (not as long as we have the laws of informed consent). I don’t believe any patient wouldn’t consider “power of persuasion” as a necessary quality of a good doctor.

In the first two cases discussed, why did the original doctors each make a single diagnosis, then when either all tests were negative, and appropriate treatments ineffective, they both resorted to either saying the patient suffered from depression, or that the patient’s problem was ‘all in her head’? Why didn’t the doctors go on to explore other possibilities? Is this the way that they were trained? Or are some other factors playing a role here?

renee

For a good look at how medicine treats women, please read “outrageous practices: the alarming truth about how medicine mistreats women” by leslie laurence and beth weinhouse. while you may not agree with many things in it, it is a very frank look at how too often women (and sometimes men) are not listened to by doctors, and how it impacts health. women are more than double the cance of men to have their complaints dismissed as psychosomatic. why is that? is it because most doctors “in charge” are men? who knows. you need to read and draw your own conclusions. why is it that women are dismissed all to often as not having a heart attack, because they display different symptoms than men? just a thought, and though i thought some of the stuff in the book was a bit militant, i still think that i have experienced enough bias as a woman and a mother to have me not be a part of the medical system unless i am forced to by fear of death. that may seem a strong statement, but it is heartfelt. i wonder how many other people feel the same way?

I think part of the problem is “trackbacks”. For instance, my best friend started having back pains at 14. In a specific location.
Her GP told her it was gas.
Still painful, her next doctor in her 20s told her it was PMS and when it persisted, despite “PMS treatment” put her on Prozac for two years.
When the pain continued, her referred her to a marriage counselor.
During this time, she visited the local emergency room several times and as soon as she shared her medical history (her doc’s diagnoses of PMS or the counseling) was given some pills (for pain) and sent home.
For eight years in her 20s every night she would come home from work and collapse on the floor because laying on a hard surface (and crying a lot) was the only way to relieve pain.
Finally one night she dragged herself once again to the emergency room.
An intern was diagnosing her with a panic attack when the attending came along, listened to her symptoms, and diagnosed gallstones.
When her gallbladder was removed the surgeon said he had never seen such a scarred gallbladder.
Now every single one of those previous diagnoses was wrong, but the doctors will never know because the GPs are not her doctors now and who knows where the emergency room docs are.
The point is that people who are misdiagnosed frequently just switch doctors when they get no satisfaction (since the one who can’t diagnose obviously isnt meeting their needs).
I think another problem is, obviously, the tendency to diagnose women with psycological problems. I think it has become a fall-back diagnosis for some docs but I also think it is probably because women are waaay more likely to go to or even admit to those problems in the first place.
That’s only anecdotal of course, I have no data.

wonderful post, great arguments and examples. i’ve not heard of diabetic truncal radiculoneuropathy, but it makes sense, and would indeed respond to TCA’s. The quality movement also favors those doctors who see easy, straightforward patients, compliant patients, resourceful patients, etc. we aren’t machines or sellers of a commodity, the business of medicine needs to back off a bit.

I’ve taken another look at Case #1, and something stood out to me in Dr. Centor’s report: “On examination, I noted that she had surface pain in a dermatomal pattern over the LUQ. She had no deep pain.”

I’m curious to know whether he asked the patient to point to where her pain was, and to ask her to describe what type of pain she had, or if she volunteered this information on her own. Whichever the case, Dr. Centor was astute enough to realize that her symptoms sounded like a nerve problem, and he was astute enough to send her for nerve conduction studies.

I wonder if this patient’s first physician was as careful in getting a good description of her symptoms, before he ordered up any tests.

The comment about P4P including things not under the doctor’s control hit home with me. I will think long and hard before I get another mammogram, no matter what my GP recommends. Last one they saw nodules and referred me for biopsy. Biopsy found nothing. HOWEVER, as a result of a biopsy site infection I suffered thru over a month of draining dressings, antibiotics, messy topical preparations and 3 kinds of tape (after developing rashes from the 1st 2). If I had refused or failed to follow up with the biopsy no harm would have been done. But a P4P program would penalize my GP for my so-called non-compliance.

Great points. As a Radiologist, I am always aware of our national tree. I am also aware of how poor clinical exam skills/diagnosis has become with the continued advancements in imaging. Kudos to you for listening to your patients!

The above comment about “clinical judgment” being the quality that separates NPs/PAs from physicians is unwarranted. Clinical judgment is the quality that separates experienced, reflective clinicians from inexperienced “kneejerk” clinicians. Clinical judgment is not awarded with the degree but is something gained incrementally by seeing patient after patient and learning from those outcomes.

Pat’s nailed it. Judgment comes from experience, thinking of variables that rookies don’t think of because they simply haven’t seen enough unusual cases. Taking the time to use it, though, is another matter, and may be why otherwise smart docs miss a lot.

Well summarised, Dr DB. I’d like to add that the cases exemplify something I stress with students – “If you don’t ask, you don’t know. If you don’t look, you don’t find”.

I think the litigious medical climate nowadays stresses excluding the serious without subsequently enough focus on actually rectifying the problem. Spinal problems, in general, are the classic missed diagnosis, in my opinion, for “nonpsecific” anterior abdominal or chest pain. For example, had a classic T4 syndrome presenting as distressed chest pain yesterday.

Clinical judgement is one thing which differentiates physicians from technicians. As much as we like to think we know, there is much that we don’t, and to assume psychological dysfunction by exclusion of our area of subspecialty focus…well, to me it reeks of narcissistic arrogance.

Medicine is art built upon science, and each aspect is nothing without the other.

“Now every single one of those previous diagnoses was wrong, but the doctors will never know because the GPs are not her doctors now and who knows where the emergency room docs are.”

I am reminded of MY good friend who did something I only dreamed of doing. She was extremely young when she had her first. (I was over twenty). When she was in the hospital this year for her last baby, with pregnancy complications, she was visited by a pediatrician she had seen with her first child, who had some breathing issues, and was FINALLY diagnosed with asthma. This particular pediatrician had treated her like a brainless twit, and an overwhelmed young mother. I had the very same experience with him when my daughter had pneumonia. Anyways, fourteen years later, and without him realizing who she was, he breezed into her room to say he had been assigned to her case. She tore a strip off of him. She told him she had her own doctor, and even if she didn’t she would never allow him in the room with her child because of how he had treated her previously. He sputtered and stammered as she went on her rampage, and was quite defensive, but did leave when she ordered him out of her room.

Now, was that the best thing to do? Maybe not. But fourteen years before he had blown her off in a way that not only questioned her fitness as a parent, but cost her child precious time. He prejudged her based on age. As the head of pediatrics in the hospital he works at, he should have had his bias examined by somebody who could do something. But who is going to believe a teenage mother over a renowned specialist?

I would like to add that not only did I feel dismissed by this doctor, but two years later while waiting for my doctor I looked through my records. In it this doctor had written a letter to my family physician saying that I was an “inexperienced, over anxious young mother”, and my child was fine. Not long after the date of that letter, my daughter was admitted to the hospital for four days for pneumonia.

Bias could have killed my child and my friend’s son. Thankfully we just kept going back to whoever would truly listen to us.

I am sufferring from RUQ Abdomen pain without any diagnosis. Have lost over 20Kgs in 8 months. All routine gastro tests comes normal. Finally read somewhere about herpes and tried Amitripline. Now iam taking 50mg amitripline at bedtime daily. My pain has definetely subsided to a greater extent but i still continue to have severe episodes once in 15 days(prviously once in 4 – 5 days). Still confused if herpes is the cause. I have no rash eruptions but had chicken pox in childhood. Kindly help me.

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