Discussion
Medical decision-making has an additional level of complexity due to the expectations of the patient, and the considerations the physician must make in choosing a treatment that is not only effective, but also maximizes benefits while minimizing risks. Decision-making in medicine was historically based on intuition and the physician's personal experience, rather than on clinical evidence. However, the concept of evidence-based medicine, which has been encouraged since the early 1990s, changed the way decision-making was viewed, with the emphasis since then being on implementation of guidelines based on the highest levels of clinical evidence such as randomized clinical trials. Decision-making has moved too; from the traditional paternalistic model to a shared model with increasing emphasis on incorporation of the patient's views and wishes in the choice of treatment.
Physicians continue to use personal experience as part of their decision-making process and are subject to a wide range of influences, despite the recent emphasis on the use of EBM. The advocates of EBM might have expected the role of personal experience to have diminished. However, some degree of professional judgment is still to be expected and remains appropriate in the application of EBM, especially where strong evidence is lacking. This review leads one to question to what degree physicians are really using EBM in conjunction with their professional judgement.
Examples presented in this review suggest a disparity between prescribing practices and a lack of uniformity in decision-making between individual physicians and also, perhaps, between hospitals. Therefore, patients are still unlikely to receive equality of treatment.
In contrast to the evidence basis of management decisions within EBM, this review focuses on the wide variety of influences that the physician is subjected to, consciously or subconsciously, during the decision-making process. The integration by the physician of scientific evidence, the patient's personal circumstances and wishes, and other non-clinical influences comprises what has traditionally being described as the ‘Art of Medicine’. Physicians bring varying degrees of wisdom, experience, understanding and sensitivity to this process. It is important to understand the role of non-clinical influences in this process, because some of the non-clinical influences are positive and are appropriate in reaching the best decision for an individual patient. However, other non-clinical influences (e.g. the influence of race) may be entirely inappropriate and, if not recognized and discounted, may result in inappropriate and suboptimal decision-taking.
Physicians in training should be taught about the decision-making process and made aware of the range of positive and negative non-clinical influences to which they may be subjected. By understanding and becoming aware of these often subconscious influences, they may learn to make better decisions in the interests of their patients.
Conclusion
A lack of understanding of non-clinical influences by the physician while making management decisions could potentially lead to suboptimal individual patient care. Although physicians should always try to act in a rational, evidence-based and professional manner, they should also consider the unique circumstances of individual patients in their clinical practice and respect patients' values and beliefs. Treatment policies should promote management of all patients equally without differentiating between them because of gender, age, sexual orientation, religion or race, in order to ensure provision of the highest quality healthcare to all patients.
It is clear that one of the greatest challenges facing clinical medicine in the 21st century is the development of strategies that would acknowledge and integrate important non-clinical influences with evidence-based medicine without compromising the standard of overall healthcare. Physicians will not be able to practise true EBM unless non-clinical influences on decision taking are recognized, understood and openly taken into consideration during the clinical decision-making process.
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