Clinical Judgment: Balancing Evidence-Based Medicine and Patient Self-Determination

Clinical Scenario: You are seeing a patient, Henry Jones, in your faculty clinic with a second-year otolaryngology resident. Mr. Jones is a 78-year-old gentleman who was referred by a neurology colleague for the evaluation of an incidental finding seen on an MR scan obtained during the course of a late-onset Alzheimer’s disease workup. The neurologist sent both the scan images and the neuro-radiologist’s report, which stated that, in addition to some early changes suggestive of neurodegeneration, there is a 3-mm presumed acoustic tumor in the right internal auditory canal.

The resident evaluated and examined the patient prior to presenting him to you, and you confirm the history, signs, symptoms, and examination findings with your own evaluation. Mr. Jones and his wife explain that he has had some hearing loss that has been present since his discharge from the military, where he completed 21 years as an aircraft mechanic. When pressed, he indicates that perhaps his hearing is worse in the right ear, but not substantially so. The tuning fork tests at 512 Hertz were normal. The neurological examination, including neuro-vestibular, facial, and oculomotor tests, was unremarkable. The patient states that he has had some occasional imbalance, but no falls and no vertigo. His neurology consultation was primarily for memory loss. You feel that he appears to be competent in his judgment. Before the patient is escorted to the audiometry suite, he emphatically states that he is not interested in any surgery or radiation at this time, which is what the neurologist had mentioned to him.

You and the resident return to discuss the findings with the patient, and review the MR scan, the audiogram, the history, and physical findings. An onsite audiogram demonstrates bilateral noise-induced hearing loss with a downward slope from 1000 Hertz, slightly worse in the right ear. When queried about what should be the recommended course of action for the patient, the resident excitedly tells you that, with a small tumor, either surgery or radiation therapy would be indicated. He further shows you printouts of several systematic reviews that support early intervention to lessen the effects of the mass on auditory and vestibular function. You remind him that the patient stated he did not want surgery or radiation treatments, but the resident makes his case for intervention—“We’re here to cure disease, aren’t we? And, we know much better than the patient what treatment is called for.” It is clearly time for a teaching moment.

How would you handle this moment?

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Discussion

The current state of patient care has been significantly influenced by the expansion of, and reliance on, evidence—acquired through outcome studies, systematic reviews, higher-level research, and other scientific work. There is no doubt of the importance of evidence-based medicine studies in clinical decision-making, but where now is the place for patient self-determination and the art of medical care? Past generations of physicians relied heavily on the history, physical examination, fundamental diagnostic tests, and subsequent discussions with patients about the physician’s diagnosis and recommended treatment. While technological advances have greatly enhanced physicians’ diagnostic capabilities, some feel that it may have been at the sacrifice of an extensive physical examination and patient-physician discussions. The profession now has become increasingly reliant upon algorithmic medicine, which outlines, to a significant degree of complexity, protocols and best practices, which are designed to reduce variance in patient care across the population and are based on available evidence acquired through scientific studies. The specialty of otolaryngology-head and neck surgery, along with every specialty through the efforts of groups of experts, reviews the available data for many diseases and disorders and develops practice guidelines which inform the otolaryngologist-head and neck surgeon in her/his clinical decision-making. How the individual otolaryngologist utilizes the recommendations, evidence, and data in the care of an individual patient is called “clinical judgment.”

What then, are the elements of clinical judgment that come to play in our care of patients? There are many synonyms for clinical judgment, and many authors have proposed various elements. This author believes that there are four major elements in clinical judgment that eventually lead to the therapeutic plan for a patient. These are:

• Knowledge;
• Critical thinking and interpretation;
• Patient self-determination; and
• Shared decision-making.

Impacting each element of clinical judgment is the acquisition of experience.

The first fundamental step is the acquisition of knowledge—the knowledge of anatomy, pathophysiology, metabolic pathways, evidence, pharmaco-therapeutics, surgical techniques and outcomes, and so much more—acquired over the long course of education, training, and practice. This author often tells medical students and residents that the acquisition of knowledge is an ethical responsibility to patients and fundamental to their care. It is driven by an ultimate obligation to patients to know as much as humanly possible about the diseases and disorders across our entire specialty. The patient expects us to know the information, or to seek the information as we develop a recommendation for their care. Knowledge in medicine is always changing; therefore, we must continue to learn new knowledge throughout our professional career—it is not trite to repeat the mantra “life-long learning.”

Every act we perform in the course of evaluating a patient is knowledge acquisition—the history and physical examination is appreciated in the context of our knowledge of normal versus abnormal findings; our appreciation of various facial expressions and body language that can be interpreted in the light of the patient’s response to her/his health concerns; an understanding of side effects and adverse reactions of pharmaco-therapeutics—and we both consciously and unconsciously add these observations to our database of clinical medicine.

There is no doubt of the importance of evidence-based medicine studies in clinical decision-making, but where now is the place for patient self-determination and the art of medical care?

The second important element of clinical judgment is the dyad of critical thinking and interpretation. This dyad is informed by our knowledge, both fundamental and that which is pertinent to the individual patient through consideration of the evidence in the literature and how closely the evidence applies. The history and physical examination give rise to a differential diagnosis set, and from there we work with pertinent evidence to determine how to proceed with diagnostic testing. One can approach the critical thinking either pragmatically or open-mindedly, casting a narrow diagnostic net or a wide one. We are primarily biological scientists, so we can use the scientific method to follow the trail of evidence to the point of reasonable confidence in our interpretation in the context of population-based studies.

The third element of clinical judgment is decision-making. This is the culmination of acquisition of knowledge about the patient (history, physical examination, diagnostic studies, interpretation of the evidence, and critical thinking leading to a presumptive diagnosis) and the consideration of what recommendation(s) should be made to the patient for her/his consideration. The impact of clinical experience is quite important here, for the experienced otolaryngologist has an internal database of similar compilations of symptoms, signs, findings, and diagnoses that inform her/him what should be recommended to a given patient.

At times, the evidence-based recommendations will fit nicely with our working diagnosis, and the course of recommended action to the patient will be clear-cut. With other patients, some uncertainty in the diagnosis and management may be present—so how to deal with, or manage, uncertainty becomes our challenge. Some uncertainty is part and parcel of even the most refined scientific study, and when dealing with human illness, uncertainty may often play a role—uncertainty in how you should proceed in formulating a therapeutic recommendation, and uncertainty in how the patient will consider and respond to your recommendations. Herein lies the fourth element of clinical judgment—patient self-determination.

The primary ethical principle in patient care is often said to be “autonomy,” which is the right of patients to make their own decisions about their health care, in the context of unbiased explanation of the options and their basis by the clinician. In earlier times, where information technology was not prevalent, the physician held sway over the recommendations, for she/he had the information. Now, many patients are so much more prepared to make their own decisions, based on their own information, as well as what their otolaryngologist has explained to them. That doesn’t mean that the otolaryngologist has to compromise her/his professional integrity for a patient’s decision, but rather to accept a patient’s wishes after all information has been given and all professional recommendations have been discussed.

In most clinical encounters, physicians utilize some form of “shared decision-making” with patients that usually results in an acceptable therapeutic plan to both patient and physician. In shared decision-making, the physician explores the patient’s personal and health values, which can have a tremendous influence on what therapeutic plan will be acceptable to the patient. Other important factors may be religious and cultural preferences/influences, or constraints due to social, economic, or financial burdens. The otolaryngologist has an obligation to mitigate any “solvable” constraint, but also an obligation to understand and support the patient’s wishes, as long as they are professionally ethical. Gaining experience in dealing with patients, particularly in complex diseases and difficult therapies, can be helpful in developing a shared plan for the patient’s care.

In this clinical scenario, Mr. Jones is an older gentleman with the likely diagnosis of a progressive neurodegenerative disorder. Indeed, he does have a small tumor in the internal auditory canal, but his symptoms at this time are minimal from this tumor. You should discuss patient autonomy and clinical judgment with the resident, and point out that you could achieve a shared decision with the patient and his wife by accepting his decision to not have an intervention, and by offering to follow him closely for new signs or symptoms that may call for revisiting a potential intervention if indicated in the future. At this time, the patient appears to be competent to make his own healthcare decisions, and to cognitively understand the risks and benefits of observing a small acoustic tumor over time. Take the time to answer the patient’s and his wife’s questions to their satisfaction in the resident’s presence. Through appropriate and experienced clinical judgment, you will have followed an acceptable course of professionalism and ethics, supported the patient’s wishes, and shared an appropriate decision with the patient. You also may have impacted the resident’s understanding of clinical judgment.

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Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.