What is the Value I Bring as a Clinician?

What is the value that I bring as a clinician?

As clinicians, I think we do not ask ourselves this question enough and do not encourage our trainees to consider the question either. However, I think it is a good idea to keep this question in mind with all the demands and stressors that we encounter every day as clinicians. We can easily lose perspective on why we are valuable.

We apparently have some value because someone pays us a good salary, we carry a lot of responsibility, and we have a lot of training under our proverbial belts.

So what is the value that we bring into the patient encounter?

The most obvious effect is the medical knowledge. Clinicians graduate school with a lot of medical knowledge, and graduate residency with even more. However, medical knowledge changes as the field of medicine advances through research. What is cutting edge treatment today can be obsolete in 10 years or less.

Having the knowledge itself is only one part of our value. How we handle knowledge is arguably as important as the knowledge itself. In light of the field advancing, another skill clinicians learn is how to look for new knowledge. Our medical culture ingrains both formal and informal continuing education in most clinicians. This can range from going to a major conference to checking an old hospital algorithm for updates. From learning and evaluating the medical knowledge, clinicians become pretty good at differentiating legitimate medical knowledge from bogus medical knowledge. Finally we learn how to use the medical knowledge, how to apply it effectively in a real patient with all their complications and comorbidities.

Knowledge by itself is inert. Knowledge by itself is a tool lying unused on a shelf. A person must have certain skills to handle that tool properly. In the hands of someone that doesn’t know how to use it, the knowledge can be dangerous. Everyone with internet access can acquire medical knowledge. But it takes training and experience to find the knowledge efficiently, to know to question if the knowledge you find is legitimate, and to know how to apply it.

A patient may come to a clinician demanding a treatment that they read about online. Many clinicians have even had a patient tell them something to the effect of, “I don’t want to question your medical knowledge, but I think the treatment I read about on the internet would be better than what you recommend”. Typically this proverbial patient only comes with that bit of knowledge, not a greater context of how to properly handle medical knowledge. The patient may think the clinician’s only value is in the knowledge itself. The patient lacks the deeper understanding that, the ability to properly handle that knowledge is an equally powerful part of our value as clinicians.

So the next time someone tries to question what your value is as a clinician because they have found a bit of medical knowledge themselves or if for another reason you question what your value is as a clinician, remember that your value lies in not only your knowledge, but your ability to handle medical knowledge by reliably updating your knowledge, differentiating if the knowledge is legitimate, and knowing how to use the knowledge. These are important lessons for all clinicians to keep in mind regardless of their level of experience.

For those of you interested in learning more about the processes behind how we use medical knowledge in a clinical setting and a structure for teaching this to students and residents, please check out my book: A Guide to Clinical Decision Making

Pre-Test Probability: What Is It And Why Should I Care?

In the past colleagues would throw around terms like “pre-test” probability, and I would have a little discomfort. I had a general idea of what a pre-test probability was, but could not define it well. As I started to teach students and residents, I thought “The human mind doesn’t work like that, these statistical terms don’ t mean much to everyday clinical medicine”. I sense that many of my colleagues have the same sense that I did then.

In researching for my book, A Guide to Clinical Decision Making, I again ran into the pre-test probability. I discovered that it was both an applicable concept in clinical medicine, and that there was a better a way to explain the concept than I had been taught. 

I began teaching my students and residents that the pre-test probability was a powerful concept in making medical decisions. When explained well, a junior student can understand the concept and apply it. Although this is blog post is only meant to be a brief, easy-to-follow introduction, I think that for many students and their teachers the concept of pre-test probability will be less daunting and more concrete after reading this. 

You can define the pre-test probability simply by it’s name: the probability of disease in your mind before you know the test result. 

Taking this one step further, the post-test probability is the probability of the disease in your mind after you know the test result. 

Here’s the important concept:

A test result can change your estimate of the probability of disease.

That’s a powerful statement.

A real-life example is the current decision making guidelines for assessing a patient for a pulmonary embolism (PE). In this example, think of risk of disease before testing as the pre-test probability.

• A history and physical is sufficient to rule out a PE for the patients with the lowest risk, the lowest pre-test probability. The history and physical is a sufficient test to outweigh the chance of a PE (see my previous blog post: My History And Physical Are Tests Too!)
• A d-dimer is sufficient to rule out a PE for the patients with a slightly higher risk. We have to test a little bit more to outweigh the chance of a PE.
• An imaging study is sufficient to rule out a PE for the patients with moderate risk or higher. We have to do the most intensive testing to outweigh these higher risk patients.

Each testing modality carries a different amount of weight in the decision making process.

To rule out a disease the weight of the evidence against the disease must outweigh the risk of having the disease (the pre-test probability). 

For example, a negative d-dimer is not sufficient to rule out pulmonary embolism in a high risk patient. The negative d-dimer does not have the weight to outweigh the risk of a PE in a high risk patient. 

So generally, to rule out a disease: 

• For a low risk patient, you will need a low weight of evidence against the disease. 
• For a moderate risk patient, you will need a moderate weight of evidence against the disease.    
• For a high risk patient, you will need a high weight of evidence against the disease.

Remember, the risk of disease is your pre-test probability.

The topic of pre-test probabilities certainly goes far beyond this brief discussion, but hopefully you’ll be a bit more confident using the concept in clinical practice or teaching others to use it.

For further discussions on this topic and other topics in clinical decision making, please check out my book: A Guide to Clinical Decision Making