Clinical Decision Rules

What are clinical decision rules? Clinical decision rules are tools that help with clinical decisions by organizing selected patient data. The purpose of these rules is to help clinicians make better, more efficient decisions. In many cases, they help assess the level of risk a patient has for a given disease. In other words, they are risk stratification tools. Risk stratification helps clinicians determine the extent of further workup and treatment the patient needs.

Examples of such tools at the time of this writing, include the NEXUS cervical spine criteria, HEART score and Well’s criteria for pulmonary embolism.

These can be useful tools. However, we must use them wisely.

How can we use these tools wisely? We can start by treating these rules as a guide that we can use to help us in our decision making. The rules are not the end all be all that overrules clinical judgement. They exist to make clinical judgement better by steering that judgement in the right direction.

The rules can be a starting point, a reference point from which a clinician can start making a clinical decision. Once you have that starting point you have a cognitive anchor from which you can venture out to find other important details with less chance of getting lost in the confusing picture the patient may initially give you. Once you have these additional details, you can individualize your assessment or treatment of the patient, because you will have the big picture.

These rules do not take every possible circumstance into consideration. Remember, these are just a starting point in decision making. They can give a framework upon which you can place the rest of the patient data. For example, a patient could have tachycardia and palpitations with no other symptoms, you could initially be considering a PE based on Well’s criteria, and will be more likely to keep an eye out for the subtle EKG changes that can come with a PE.

These tools can also defend your judgement. This is obvious when you are following the rules as written. But even when you go against the rule’s assessment, it gives you a reference point from which to make your defense. For example, you could write something like “patient has high HEART score, however, due to (insert strong evidence you have to the contrary here) acute coronary syndrome seems unlikely”.

Lastly they can be good educational tools. A junior clinician should have a structure with which to start assessing patients. Clinical decision rules that give a list of details to collect become a way to start learning about how a disease presents clinically. The problem comes when the learner believes the rule is all there is to know about assessing for that disease.

The next time you’re considering the utility of clinical decision rules, consider them as just another tool at your disposal. Like any other tool you might use to help you make clinical decisions, respect them for both their strengths and their weaknesses, and use them at their appropriate time. Use them wisely, meaning use them as guides, not as the absolute, last answer.

If you want to learn more about this topic or other, related topics in clinical decision making, check out my book: A Guide to Clinical Decision Making

How is Medicine an Art? AKA The Most Powerful Sentence a Teacher Told Me in Residency

What do we mean when we say medicine is part art? As clinicians, we say this a lot. Do we actually stop to think about what it means that medicine is an art?

In contrast, we can easily see how medicine is a science. We rely on evidence, on data. We have lots of data from research. Research can tell us a lot about what the effective therapies for a condition are, what optimal drug doses are, the optimal timeframe for surgical repair of an injury, etc.

Medicine as an art is more vague.

Let’s discuss what art is a bit first. We can think of art as an expression of the artist’s self. Each artist will express themselves differently in communicating the same idea. Consider if we asked several people to paint a picture of the same sunset. We’d give each painter the same set of paints and let them watch the same sunset. They’d all paint the same sunset, but somewhat differently. Each one would express their own version of the sunset, but they’d pretty much all be able to communicate the sunset.

So how does this apply to practicing medicine?

In much the same way as the hypothetical painters, clinicians use the same set of tools to arrive at their objectives… but sometimes in a different way. We may all have preferences, but in many situations there is more than one reasonable way to do the same thing.

The science is our tools. The art is how we use these tools. There can be more than one reasonable way to use the tools to meet the goal. However, the goal is still the same.

Another way to think of this is the most powerful sentence that one of my teachers used with me after I’d finished presenting a patient. He would say, “That’s reasonable”. What I realized he meant was that although his plan would have been different, my way also made sense… just like there is more than one way to paint the proverbial sunset.

A couple of simple examples will illustrate this.

We have a patient with gastroenteritis. It’s reasonable to start an IV, provide IV antiemetics, provide IV hydration, and discharge when the patient feels better. It is also reasonable to provide IM antiemetics, observe the patient, and discharge when they tolerate oral hydration. Both approaches have different merits and different drawbacks. However, both are reasonable ways to approach the same problem.

We have a patient with a vague abdominal pain. It’s reasonable to do a quick history and physical, get a CT scan, and discharge if the CT is negative. It’s also reasonable to do a thorough history and physical, specifically look for concerning findings, observe the patient, re-examine the patient for worsening exam, and discharge if there are no concerning findings. Again, both approaches have different merits and different drawbacks. However, both are reasonable ways to start approaching the same problem.

Every approach will have different pluses and minuses. Some ways will be longer, shorter, less painful, more painful, more expensive, less expensive, etc. In some situations, one approach may clearly be preferable to the others. However, in many situations more than one approach will be reasonable.

Different clinicians will have different preferences for the way they use their tools when there is more than one reasonable approach. Thus, we have many different “styles” of practice (of using our tools) and as long as they are reasonable, that’s ok.

If you’re interested in learning more about this topic and other processes behind making clinical decisions, check out my book: A Guide to Clinical Decision Making

Negotiating For Your First Job - Some Thoughts For a Senior Resident About to Graduate

Yes, you can negotiate your first job.

Negotiating sounds scary. For some docs, the word conjures images of sitting across a table form someone, arguing loudly about why you deserve what you’re asking for. For others, it’s evokes the icky feeling of haggling at a car dealership.

Even if you think you’re comfortable negotiating, you might think you have no leverage to negotiate.

Negotiating for that first job is straightforward. It should not be a scary, intimidating or hyper-confrontational experience. If it is, then maybe you’re negotiating for the wrong job. The conversation should be a polite conversation between professionals. Initiate the conversation by respectfully asking for what you want.

What might you want?

Weekends off, certain days off, certain nights off, etc.

At this point, you’re probably thinking that’s impossible. If you’re only asking for what you want, yes, it will be difficulty.

Here’s the concept you have to use: To get something you have to give something. Think of your request as an offer for a trade.

But what do you have to trade as a graduating senior resident? You most likely are a well-trained, adaptable, energetic, emergency doc. However, you probably do not have a special skill, do not have a unique knowledge base, are not the best doc who ever graced an emergency dept, etc. What you have to trade is your time.

Here’s a couple examples to flesh out these concepts:

You need weekends free. Offer to work weekday nights.

You want ¾ time with full time pay. Offer to work that ¾ time as only nights.

You want 2/3 time with benefits. Offer to work a disproportionate number of unpopular shifts (nights/weekends).

Many more variations exist, based on what you need and what your prospective employer can offer.

Your employer will have limits on what they are able to do for you. They may also not badly need what you have to offer (i.e. another night/weekend person). However, many times they’ll be able to adjust “the standard package” somewhat if you offer something in return for what you ask. Only getting part of what you asked for is a lot better than getting none of what you asked for.

After you’ve come to an arrangement both sides agree with, make sure the language of your contract reflects the changes both sides agreed to. Make sure the language of your contract has no ambiguity.

There are certainly many more points to negotiating than the basic concepts in this post. However, as a senior resident, you have more ability to negotiate than you may think.

About me: I’m an emergency physician currently practicing in New York City. I did not negotiate for my first job, but have negotiated some aspect of every full or part time job I’ve had after that. I’m also the author of The Handbook of Medical Charting and A Guide to Clinical Decision Making.