Medical decision making should never become formulaic. While I use, and have developed, clinical prediction rules, we must always remember that they are merely diagnostic or prognostic tests. Tests provide us some information, but we should always use them in the context of the patient in front of us.

Community acquired pneumonia-Pneumonia severity index falls short

…These AJM authors reviewed 3065 admissions in Edmonton with a diagnosis of CAP over a 2 year period. 586 (19.1%) were classified as “low risk” using the PSI. Was the hospitalization of ” low risk” patients a shameless, thoughtless waste of precious medical resources? Apparently not. Almost half ( 48.4%) were sick enough to be in the hospital for more than five days.19% suffered one or more complications and 31% were still unable to ear or drink to maintain hydration by the fifth hospital day. Clearly the admitting physician’s clinical judgment appropriately overruled the PSI score. Fine’s classification system keys to mortality rate.Those in risk classes I to III have a < 1 % mortality rate.The authors point out that the PSI does not work if the patient has COPD or pulmonary fibrosis or HIV infection or immuno suppression, etc. etc. and there are important prognostic factors not captured by the Fine index including nausea,shortness of breath and diarrhea . Their final sentence is: ” It is clear that low-risk patients are a heterogenous group and that a low risk for mortality is not the only factor to be considered in admission decisions”.Fortunately for a significant number of patients with CAP, the admitting physicians used what seems to often elude guidelines and algorithms namely clinical judgement…

Retired doc makes a most important point. Physician excellence is manifested by excellent clinical judgement. I know of no quality score which measures clinical judgement.

In taking with some faculty colleagues yesterday, I opined that the biggest difference between 1st and 3rd year residents was in their clinical judgement. That is what we teach during residency. All the faculty agreed enthusiastically.

Clinical judgment cannot be taught quickly. One must see many patients who do well, and many who do less well, to learn the difference. One learns clinical judgement over time.

The wise physician interprets all data in the context of the patient history and examination. This includes lab tests, imaging studies, biopsies and prediction rules.

I will rant more on clinical judgment in the near future. This is the essence of excellence. The mystery is how we might measure it.