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?


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.

© BlurryMe / shutterstock.com

© BlurryMe / shutterstock.com

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.


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.

Hospitalists as Test Subjects

  1. Knowledge: The knowledge of anatomy, pathophysiology, metabolic pathways, evidence, pharmaco-therapeutics, surgical techniques and outcomes, and so much more acquired over the course of education, training, and practice.
  2. Critical Thinking and Interpretation: Physician 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.
  3. Decision-Making: The culmination of acquisition of knowledge about the patient and the consideration of what recommendation(s) should be made to the patient for her/his consideration.
  4. Patient Self-Determination: Acceptance of a patient’s wishes after all information has been given and all professional recommendations have been discussed.

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Otolaryngologists Discuss Keys to Treating Top Athletes

For James Kearney, MD, an interaction with professional athletes began as it does for most people: with passion, but from a distance. In 1974, the Philadelphia Flyers, his hometown hockey team, won the Stanley Cup, sparking city-wide euphoria.

“One of my enduring childhood memories was going out in front of my house when the Flyers won the Stanley Cup … and cars were beeping, people were jubilant,” Dr. Kearney said. “It was the first championship in Philadelphia in a long, long time, and the entire city had rallied behind the Flyers, who are a gritty bunch of players that Philadelphia could really identify with. From then on, I was a hockey fan.”

Now, Dr. Kearney, chairman of otorhinolaryngology at Pennsylvania Hospital of the University of Pennsylvania Health System, treats members of the Flyers team for otolaryngology conditions. As a physician, his interaction with the world-class athletes is much different than the connection he had with them when he was young. In the exam room, he’s no longer at a distance. He’s close up.

When it comes to being a fan, though, Dr. Kearney stays relatively dispassionate. A friendly remark about a recent game might be OK, but autograph seeking is not. Otolaryngologists who treat professional athletes say that, while they are aware of the stakes that are involved, a crucial part of the job is treating professional athletes as they would other people—as patients first.

They also emphasize availability and, when necessary, discretion. “You can’t let the celebrity aspect of it overwhelm your willingness to take care of this individual as a human being who needed your help as a physician and not as somebody who is a public figure,” said Dr. Kearney, who also provided care for the Philadelphia Eagles football team for two decades until 2018. “You need to treat them as real human beings.”

Medical Conditions

© Wikipedia/Keith Allison

Pro athletes frequently need custom-made protective masks so that they can continue to play while facial injuries heal.
© Wikipedia/Keith Allison

In terms of the care provided, there is a lot of overlap between professional athletes and other patients, otolaryngologists say. While a hockey or basketball player might be more likely than an average patient to come in with a laceration or a facial bone fracture, otolaryngologists typically see conditions that are run-of-the-mill—from sinus infections to chronic tonsillitis to earwax build-up.

“Most of the injuries or problems I see in these patients are not something that is an injury or a condition unique to a professional athlete,” said Christopher Larsen, MD, associate professor of general otolaryngology at the University of Kansas, who provides care for the Kansas City Royals baseball team and Kansas City Chiefs football team. “It’s more common conditions that every human being gets; it just so happens that it’s occurring in a professional athlete.” For these conditions, athletes receive the same treatment as most other patients would, otolaryngologists say.

Dr. Larsen said he screens baseball players for oral cancer, provides antihistamines for allergies, chooses topical steroid spray or surgery for swollen turbinates, and performs routine sinus, nasal, and throat surgeries on players who fail maximal medical management.

Many football players, and some baseball players, struggle with snoring and obstructive sleep apnea (OSA), which interrupts sleep and can have a big effect on focus and performance, he said. But in his experience, professional athletes struggle just as much with adherence to and tolerance of continuous positive airway pressure (CPAP) for OSA as other patients do.

During spring training, some players on the Royals team develop nosebleeds because they are unaccustomed to the dryness of the Arizona desert air, he said.

Pro athletes frequently need custom-made protective masks so that they can continue to play while facial injuries heal, and at Detroit’s Henry Ford Health System, some of their faces are pre-scanned so that the 3D printing process for the masks can be started right away, said Lamont Jones, MD, MBA, vice chair of otolaryngology, head and neck surgery at the Henry Ford, who treats members of the Detroit Pistons basketball team, Detroit Lions football team, and Detroit Tigers baseball team.

Pressure to Perform

With players being paid millions of dollars to perform on the field, otolaryngologists acknowledge there can be at least implicit pressure to get players back on the field quickly, although not nearly as much as orthopedic surgeons face in treating injuries such as, say, Achilles tendon tears or knee injuries. But they say they have to stay mindful of their obligation to the health of the person in front of them.

“As physicians, the key to remember is the patient is your first priority and then, as long as you remember that, you do what’s best for the patient and counsel them appropriately,” Dr. Larsen said. “Should they choose to do something outside of your guidelines or your recommendation, it’s only going to potentially be fraught with complications or problems…. What I know for a fact working with the Kansas City Royals is that it’s a team approach. The athletic trainers, physical therapists, physicians, and surgeons really work together as a team, and there’s constant communication, because at the end of the day, the investment is in the player and their future. Bringing them back too soon, or rushing them back to the field, is not always going to be in their best long-term interest.”

Sometimes, there can be conflicts of interest for a physician. “Somebody else is paying [the athletes] a lot of money to perform, and every time they are injured, they are not performing,” Dr. Kearney said. “And that is an issue for the team; it can be a competitive issue, it can be a financial issue. So there can be some conflicts of interest that come in particularly for physicians who are being
compensated by the team…. There can be a conflict in that they are being paid by the team that wants the athlete back on the field, but your obligation to the athlete is to provide what is best for them.”

While most otolaryngologists downplay the pressures they feel taking care of these athletes, they say there is a certain amount of pressure performing surgery on a player. “You treat every patient the same, and to say differently I don’t think is right,” Dr. Larsen said. “The flip side to that is, sure, you’re a little extra amped up that morning.”

Dr. Jones said surgeries are the most difficult scenarios he faces when treating pro athletes or celebrities. “In general, we want good outcomes, and sometimes if you have a high-profile player, it’s not that you would do anything differently, but the potential for, let’s say, good or bad publicity just magnifies itself,” he said. “In the era of social media, it’s easy for a routine or non-routine outcome to really be publicized.”

Privacy

The goal of a good outcome remains the same regardless of the public profile of the patient, but physicians say their centers do take steps to shield players from unwanted attention. Henry Ford  employs a concierge who coordinates care among physicians, the player, and the team, Dr. Jones said. Sometimes, he said, players are able to enter at a different location than the general public. Sometimes, he goes to see them rather than having them come to the medical center. “It depends on the person,” Dr. Jones said. “Some players are escorted; they may come in through a back entrance. For some of the players, I’ve actually gone to the sports arenas to evaluate them.”

Dr. Kearney said professional athletes coming to see him are typically not forced to stay in the main waiting area. “They are susceptible to their illnesses becoming public spectacle,” he said. “So if they’re coming into your office to be seen, if you keep them waiting out in your waiting area, it can be awkward for the athlete. People will wind up coming up to them, asking [them] to sign autographs or asking questions about why they’re seeing the doctor, things that people would not normally do to another patient. … I have always tried to go out of my way to help to preserve these athletes’ privacy.”

Professionalism and Availability

With time, otolaryngologists said it gets easier to regard the dynamic with a pro athlete as a typical physician–patient relationship, without worrying that inclinations as a fan will get in the way. Any references to their performance, they say, should be only for the purpose of rapport, much as they might converse with any other patient.

After a seven-foot-tall basketball player had a nasal bone fracture, Dr. Jones kidded him that he might have avoided the injury if only he had stood up tall and hadn’t had to bend down all that distance to pick the basketball up off the court. And, after a high draft pick in football had an unfavorable outing in his Eagles debut and got booed on his home field, Dr. Kearney good-naturedly told him, “Welcome to Philly.”

In the end, though, it’s professionalism that should guide the way, they say.

An indispensable ingredient in taking care of pro athletes is being available when they need care, they say. Usually, they can treat the player when needed. But if not, they find someone who can. “The nice thing about being in a large group practice is that we have redundancy,” said Dr. Jones at Henry Ford. “So, if for some reason I’m not available, there’s usually somebody available who can address the issue.”

“When I was in medical school, an otolaryngologist told me the three keys to success are availability, affability, and ability—in that order,” Dr. Larsen said. “And at the end of the day, even before I was associated with the Royals or any professional sports players, I would try to always be available for my patients and try to see as many people as I possibly could in a day while taking good care of them. And I think applying that philosophy … goes a long way with patients.”


Thomas Collins is a freelance medical writer based in Florida.

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