Thursday, August 19, 2010

Decision making in our daily medical practice

In any action we take in our daily life we, consciously or not, consider the benefits and harms before deciding to do it. Although we do not make accurate calculations and construct decision trees, we make a rough judgment based on our knowledge and experience. This should certainly be the case when we take any decision concerning our patients. The benefits and harms differ in each individual situation and cannot be generalized. For example, you may put a man with paroxysmal atrial fibrillation who has a prolonged attack every several days or few weeks on long term anticoagulants but you do not do the same with a man who has a short attack every one or two years because you judge that the possible harm of the drug outweighs its benefit. Even if you have two patients with the same frequency and duration of attacks you may put one who is intelligent, educated and has a good laboratory within reach on long term anticoagulants and refrain from doing that to one who is not intelligent, not educated and has no reliable laboratory within reach. You may decide to give a hypotensive drug to a man who is obese, diabetic, heavy smoker, has high cholesterol and has a mild hypertension. In a different way you may be satisfied with an advice of change in diet and life style and follow up in the case of a man with the same level of blood pressure who is slim, not diabetic, non smoker and has normal cholesterol. The trade-off between the benefits of the drug and its side effects is different in the two situations. I can mention innumerable examples concerning various actions like asking for certain investigations, admitting patients to hospital, surgical operations and so on. The writers of medical books and journal articles can only give general guidelines on how best to behave in various situations. They cannot put themselves in your shoes in every possible situation you are likely to meet in your practice. These facts are even more important in the case of doctors practicing in developing countries and guided by books and journals written by people practicing in highly advanced institutions in developed countries.
Do we in our medical practice give enough thought and time for every decision and action we take with every individual patient in the same way we do with other actions we take during our normal daily life??

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