Clinical Judgment: How to Do Less

 

It was around 11:00 AM when we were called to a local skilled nursing facility for a hip fracture. The patient was a 61-year-old male with mild mental retardation and several other issues, who’d fallen last night while walking to the bathroom. He was helped back to bed with moderate hip pain, and the staff physician stopped by to check him out. A portable X-ray was performed, which the physician interpreted as showing a proximal femur fracture as well as an associated pelvic fracture. This was communicated to us via a scrawled note and a cursory report.

The patient was found resting comfortably in bed, semi-Fowler’s and alert. He had no complaints at rest, although his pelvis and left femoral region were mildly tender and quite painful upon movement. No deformity was notable and there was no obvious instability. His vitals were stable and he was generally well-appearing, in no apparent distress. He denied bumping his head and had no pain or tenderness in the head or neck.

We gently insinuated a scoop stretcher underneath him, filled the nearby voids with towels and other linen, and bundled him into a snug, easily-movable package. Then we gave him the slow ride to his requested emergency department, a teaching hospital in town just a few minutes away.

We rolled into the ED and were lifting him into bed on the scoop when a young man entered the room, bescrubbed and serious-looking. I gave a brief report. As the words “pelvic fracture” left my lips, his mental alarms started visibly beeping and flashing, and he hurriedly asked, “What kind of pelvic fracture?”

“We don’t know. All we’ve got is the radiology note, which doesn’t say much.”

“Okay, but pelvic fractures can be a big deal. It could be … ” he sucked in air, “… open-book. There could be a lot of bleeding.”

I stared at him. “Well, sure. But he’s been stable since last night, and has a basically normal physical with no complaints at rest. He’s not exactly circling the drain.”

He didn’t seem to hear me as he briskly approached the patient and began poking him and asking questions. While we pulled our stretcher out of the room, he asked, “Does your neck hurt at all?”

Now that the patient had been stuck on a scoop stretcher for over twenty minutes, he thought for a moment and then shrugged. “Sure.” The doctor immediately ordered the placement of a cervical collar.

As we escaped, he was on the phone to the SNF, and the last thing I heard was him berating them with his urgent need to know exactly what type of pelvic calamity the patient had suffered.

 

What was the failure here? It was a failure of clinical judgment.

Clinical judgment is a phrase which means different things to different people, and often its meaning is so nebulous (much like “patient advocacy“) that it sounds good while saying nothing. But most would agree that it means something like this: the ability to combine textbook knowledge and personal experience, applying them intelligently to the current patient’s situation to yield an accurate sense of the possible diagnoses and the costs vs. benefits of possible treatments. In other words, it means knowing what the patient’s probably got and what to do about it, which is the heart of medicine anyway. So what’s all the fuss about?

In reality, when clinical judgment is mentioned, what’s often meant is something specific: the wisdom to know when something’s not wrong. Much of medicine is about planning for the worst, ruling out the badness, and looking for the unlikely-but-possible occult killer that nobody wants to miss. As a result, we often act as if nearly everybody is seriously ill, even when they probably aren’t.

On a practical level, most complaints — from chest pain to the itchy toe — could conceivably represent a disaster. Anything’s possible. So if we want to truly adopt perfectly mindless caution, we should be intubating every patient and admitting them directly to the ICU so that we’re ready when their skin melts off and their eyes turn backwards.

But we can’t do that, and we shouldn’t. So how do we know when to do a little less? Clinical judgment.

Clinical judgment is the acumen to assess a patient and say, “I think we’re okay here. Let’s hold off on that.” It’s what you develop when you have both the knowledge and experience to understand that a person is low-risk, and that certain tests or treatments are more likely to harm than to hurt them. That doesn’t mean that nothing will be done, or that more definitive rule-out tests will not occur, but it means you’re not freaking out in the meanwhile. It’s a triage thing.

Put another way, imagine the patient who you’re placing in spinal immobilization, or providing with supplemental oxygen, or to whom you’re securing a splint. They ask, “Look, I don’t much like this; do I really need it?” Well, I don’t know, rockstar — does he? If you’re simply acting on algorithms, reflexively doing x because you found y, then you really don’t know. How important is that oxygen? To answer that, you’d need to truly understand the benefits versus the potential harms, which means having a strong grasp of the mechanism of action, familiarity with the relevant literature (including the pertinent odds ratios, NNT and so forth), prior experience with similar patients, et cetera… only with that kind of knowledge do you really understand what’s happening. In essence, the patient is asking for the informed element of informed consent, something he’s entitled to, and you can’t provide it if you don’t have it yourself.

But when you do develop that depth and breadth of knowledge, you gain a special ability. It’s the ability to do less. When you truly understand what you’re dealing with, and more importantly, what you’re not dealing with, you can titrate medicine to what’s actually needed and stop there. Along with the knowledge comes the confidence, because you don’t merely know, you know that you know; in other words, you don’t need to take precautionary steps merely because you’re worried there might be considerations you don’t understand.

When it comes to withholding anything, even the kitchen sink, you might ask, “isn’t there risk here?” And strictly speaking, there is risk. But you can set that bar wherever you want. The important thing to grasp is that “doing everything for everyone” is not the “safe” approach; overtriage and overtreatment are not benign. All those things you’re doing have a cost. They may cause real harm. Even at best, they cost time and money, and subject the patient to unnecessary discomfort and inconvenience. We’d like to minimize all that whenever possible.

So, we return to the gentleman with the pelvic fracture. Strictly speaking, fracture of the pelvis has the potential to be life-threatening; certain types of unstable fracture can cause massive bleeding, along with damage to nervous, urinary, and other structures. So a textbook response to “pelvic fracture?” might be to treat it as a high-risk trauma.

But a patient with an unstable, severely hemorrhaging open-book pelvic fracture probably wouldn’t look like that. It would be evident; it would cause a number of apparent effects, such as pain and distress, shock signs, altered vitals, deformity or palpable instability. Except in bizarre cases or in patients who are clinically difficult to evaluate, big problems create big changes. While it’s true that we don’t know exactly what the X-ray showed, so one could theoretically argue for any conceivable pathology, there’s no question that the patient appeared stable, had remained unchanged for many hours, and had apparently been judged low-acuity after evaluation and imaging by his own doctor. In other words, let’s take it easy.

The question of spinal immobilization is another example. Strictly speaking, could we rule out the possibility of a cervical spine fracture? Well, no. Not without CT and MRI and even then who knows. But the fall was many hours ago, the patient was freely mobile and turning his head throughout that period, had no peripheral neurological deficits, denied striking his head or loss of consciousness, and quite frankly, had no pain until he spent twenty minutes with his head against a metal board.

It’s not often that you find a doctor more concerned about C-spine than an EMT. How did it happen here?

Despite the fact that we delivered the patient to a major tertiary center, it was nevertheless a teaching hospital, and the new interns had just hit the wards. While this particular clinician was undoubtedly smart and well-educated, at this stage he had about two weeks of experience behind him, and that is not conducive to providing judicious (rather than applied-by-spatula) care. He had neither the experience to know when to take it easy, nor the confidence in that experience to stand by such a decision.

We don’t want to take this concept to its extreme, which would involve doing very little for most of our patients. In the end, this is still emergency medicine, and emergency care will always involve screening for the deadly needle in the benign haystack. There’s also danger in simply becoming lazy and burned-out, and using Procrustean application of cynical “street smarts” to justify never bothering with anything. The real goal is to do the right things for the right reasons, no more, no less. And to get to that point, you have to put in some time.

Comments

  1. Just got canned from a BLS company for patient advocacy, SNF dump to make room. Called them on it, after the RN admitted it to me. The administrator called my VP, w/ 3 SNF’s on there account we lost our jobs today. This industry is so dirty.

    • Sorry to hear it Heath. Honestly, the industry as a whole has issues, but that is clearly an organization that you do NOT want to work for. In the short run, that sucks, but in the long run, you’ll be much better off.

      As for the article above, it is well written and insightful as always. Clinical JUDGEMENT is something that should be advanced with continuing medical education, but begun in in initial training programs.

      • I agree. While this sort of thing is ugly for everyone, Heath, in most cases people seem to be able to use it as an opportunity to step up, as long as you don’t just take the first rebound job that’s available.

        The trouble with clinical judgment in this job is that the training model is generally not built to facilitate it. Rather than introducing a broad foundation of “hows and whys” (i.e. A&P, pathophysiology, therapeutic mechanisms, evidence-based principles, etc.), it’s taught in generalized algorithms, and the only way to manage that is to always teach to err on the side of caution. Everyone gets the non-rebreather, the backboard, etc. Resolving that isn’t a quick fix, it goes to the heart of how we learned and basically involves retraining.

        • The difference between you and the doc, as wierd as it seems, is that in the emergency situation you took the time to thoroughly evaluate the pt. on paper and in person, while in the hospital, the FNG doc was focused on “catching” something that you didn’t!

          That’s what inexperience does; looks for the flaws in others to feel better about themselves. Wherever there’s a hierarchy in medicine, you’ll find this. So the Doc wanted to feel smarter than the medic!

          Bottom line, though, was the patient compromised by the Doc’s actions? Not on the surface while you were there, it seems. Otherwise, would you have stepped in? At what point would you have?

          Whereas you were with the patient and took the time to make a clinical judgment based on your experience (and first and foremost your observations of what the pt. was REALLY going through), the Doctor, hobbled by technology at his fingertips and lawyers lurking in the hallway, won’t take the time to see for himself but will wait until every little test has been done, racking up bills and discomfort for the patient.

          Makes you a little appreciative of the freedom there is in the field, doesn’t it?

          • Yes, I don’t think he was a trained killer. But he heard those keywords and didn’t want to be asked later why he didn’t do “x” in the case of “y.” Someone with more knowledge and experience could articulate the reason he didn’t, because he understands not all x is the same, but that comes in time.

            The extent to which the patient suffers from this sort of thing is obviously less than the opposite scenario (not providing a needed therapy), which is why we so often err on the side of caution. But it’s still harmful — for instance, the patient had to suffer through an unneeded C-collar. My biggest peeve is when the inability to prioritize care (i.e. x is important, y is not, so we’ll do x first) leads to unsorted “laundry lists” of interventions, and you end up delaying compressions to place a tube, or delaying transport to board someone, etc.

            I do appreciate the independence of prehospital care! Of course, if someone dislikes what you did enough, you’ll just get fired; there’s not really much middle ground. Can’t win ‘em all…

  2. Simple fact:
    The reason why we over treat in the ED is because of litigation risk. End of story. It has nothing to do with clinical acumen or judgement. The only thing that will ever change that is tort reform.
    Then there’s that theoretical risk, which you touched upon: the one-in-a-million patient with the significant injury that you wrote off. Again, I’m not losing my license, income, and throwing my life away because you think the collar is uncomfortable. I also don’t have X-ray vision. Like I said during our podcast interview, I’ve taken care of an uninjured sky diver and a fall from standing who died. Hate to use such a wastebasket cliche, but protocols exist for a reason. Like I also said in the podcast, it simply shouldn’t be happening that EMS delivers a patient without a collar and the ER places the collar. Sure, they’ve been fine for the past day, but our job is to prevent any further harm at minimum. Again, I’ve taken care of many patients who arrived with no collar and ended up having significant injury.

    • Thanks Jeff. I’m working on a more comprehensive look at the evidence and risk behind spinal immobilization, so that may be a topic for another day! The general point, I think, is just that more experienced clinicians (whether the new EMT, house staff, or the head of the department and full professor who teaches this stuff) usually feel like they have room to treat more judiciously than the newer folks, and it’s not because they’re looking at different patients.

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