JRSM о некоторых аспектах EBM

[FRSM]

J R Soc Med 2010;103:178-187 Review

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice
FM Hajjaj1 MS Salek2 MKA Basra1 AY Finlay1
1 Department of Dermatology and Wound Healing, School of Medicine, Cardiff University UK
2 Centre for Socioeconomic Research, School of Pharmacy, Cardiff University UK


SUMMARY

This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.

What is clinical decision-making?

The process of clinical decision-making is the essence of everyday clinical practice. This process involves an interaction of application of clinical and biomedical knowledge, problem-solving, weighing of probabilities and various outcomes, and balancing risk-benefit. A key task is to balance personal experience and prevalent knowledge.1 Evidence-based medicine protocols provide a pathway to physicians which allows them to make sound therapeutic decisions with an element of confidence rather than being based purely on personal experience. Clinical decision-making is the process of making an informed judgment about the treatment necessary for our patients.2 This process is complex involving several important steps in which patient involvement is essential:3–6

Recognition and clarification of the problem;

Identification of potential solutions;

Discussing the options and uncertainties;

Providing tailor-made information;

Checking understanding and reactions;

Checking patient's preferences;

Exploring the patient's view;

Agreeing with the patient about a course of action;

Implementing the chosen course of action;

Arranging follow-up with the patient;

Evaluation of the outcome.

What do we mean by non-clinical influences?

Although most clinical decisions are based on ‘traditional’ clinical criteria, they are also influenced by a wide range of non-clinical factors, for example, the patient's socioeconomic circumstances. Some influences fall in a grey area between ‘clinical’ and ‘non-clinical’, e.g. patient adherence. Patient adherence may be a ‘clinical’ influence, but if it is associated with, for instance, frequent absence from follow-up appointments, it could be considered ‘non-clinical’. Patient age could be considered to be a clinical rather than non-clinical influence because it is associated with physical ability and other co-morbidities. However, the patient's age may also be a non-clinical influence7 because of associated non-clinical aspects, such as transportation problems in the elderly, making follow-up appointments more difficult.

It is, therefore, not possible to categorize all influences on clinical decisions into either ‘clinical’ or ‘non-clinical’, as overlap areas exist. We use the ‘artificial’ descriptor of ‘non-clinical influences on clinical decision-making’ in order to focus thinking on this broader aspect of clinical medicine.

There are many ‘non-clinical’ factors7–9 that may influence clinical decision-making


Table 1. Examples of non-clinical influences on clinical decision-making
Patient-related factors
Patient's socioeconomic status
Patient's race
Patient's age, gender and other personal characteristics
Patient's adherence to treatment or inappropriate behaviour that may influence adherence (e.g. chaotic life style, frequent non-attendance for follow-up appointments)
Patient's wishes and preferences
Patient's attitude and behaviour
Patient's concerns and worries (medical and non-medical concerns)
Others: Influences of patient's family members and friends, faith, culture and quality of life
Physician-related factors
Physician's personal characteristics, age, gender, culture, faith and race
Physician's time constraints and work overload in the clinic
Physician's professional interaction; e.g. relationship with colleagues, hospital staff and with pharmaceutical industry
Practice-related factors
Type of practice (e.g. private vs public)
Size of practice, practice organization, geographical location, and availability of health resources
Management policies/implication of treatment cost