Clinical judgment is the application of individual experience to the variables of a patient’s medical presentation. It’s the hard-worn skill of knowing what to do and how far to go in a particular situation. It’s having the confidence to do nothing. Clinical judgment is learned from seeing lots of sick people. Good clinical judgment is when the gifted capacity of reasoning intersects with experience. Some doctors have better judgment than others.
Aristotle called this phronesis — or practical judgment.
Patients have practical judgment. We often can tell when something’s amiss with our own body. Things feel different or look different. Taking action on these observations is how we exercise judgment as patients.
Parents of children with central venous lines, for example, can often identify the early signs of infection before fever has ever appeared. They know the subtleties of their child’s behavior. The same goes for children with epilepsy. People with diabetes increasingly have the latitude to apply judgment to the management of their disease. This tends to be quite defined, however, with fixed variables and limited options for intervention. Read more »
*This blog post was originally published at 33 Charts*
I can’t say that I enjoy the patient encounter as much when it involves a translator. There’s just something about communicating through a third party that changes the experience. But there are some things you can do as a provider to bridge the language gap:
Look. Even thought the translator is doing the talking, look at the patient just as if you are asking the question yourself. There’s a tendency to let the translator act as a surrogate with respect to eye contact and visual feedback.
Smile. A smile doesn’t need translation. It conveys very clearly that have a sincere interest in making a connection.
Touch. I never leave the exam room without some type of sincere physical contact. A firm handshake or a hand on the shoulder go a long way in closing the language barrier.
Say something funny. Patients don’t expect jokes to come through a translator. And there’s nothing better than watching a silly, lighthearted remark make its way into another language. It’s powerful and fun.
It’s important to think about how we can recreate the elements of a one-on-one dialog. What do you do to make a connection beyond spoken language?
*This blog post was originally published at 33 Charts*
This video is an excellent testimony of what a truly engaged and knowledgable patient with diabetes looks and sounds like. Kudos to the Mayo Clinic for sharing this wonderful piece about shared decision making.
Pay particular attention to the fact that the patient in the video was treated for diabetes by her primary care physician for eight years before being referred to a clearly “patient-centered” endocrinologist. Also note her belief that a patient-centered approach to chronic disease management probably results in shorter, more productive visits in the long run.
*This blog post was originally published at Mind The Gap*
More Can Also Be Less: We Need A More Complete Public Discussion About Comparative Effectiveness Research
When the public turns its attention to medical effectiveness research, a discussion often follows about how this research might restrict access to new medical innovations. But this focus obscures the vital role that effectiveness research will play in evaluating current medical and surgical care.
I am now slogging through chemotherapy for stomach cancer, probably the result of high doses of radiation for Hodgkin lymphoma in the early 1970s, which was the standard treatment until long-term side effects (heart problems, additional cancers) emerged in the late 80s. So I am especially attuned to the need for research that tracks the short and long-term effectiveness — and dangers — of treatments.
Choosing a surgeon this September to remove my tumor shone a bright light for me on the need for research that evaluates current practices. Two of the three surgeons I consulted wanted to follow “standard treatment procedures” and leave a six-centimeter, cancer-free margin around my tumor. This would mean taking my whole stomach out, because of its anatomy and arterial supply.
The third surgeon began our consultation by stating that her aim would be to preserve as much of my stomach as possible because of the difference in quality of life between having even part of one’s stomach versus none. If at all possible, she wanted to spare me life without a stomach.
But what about the six-centimeter margin? “There isn’t really much evidence to support that standard,” she said. “This issue came up and was discussed at a national guidelines meeting earlier in the week. No one seemed to know where it came from. We have a gastric cancer registry at this hospital going back to the mid 1990s and we haven’t seen support for it there, either. A smaller margin is not associated with an increased risk of recurrence.” Read more »
#1 Doctor: Resolve to let patients speak without interruption and describe their symptoms. Patient: Resolve to focus on the problem I am seeing the doctor about and not come with a list of 10 complaints for a 15-minute office visit.
#2 Doctor: Resolve to keep a pleasant tone of voice when answering night and weekend phone calls from the answering service, patients, or nurses. Patient: Resolve to get my prescriptions filled during office hours, not forget my medications while traveling, and to use night and weekend phone calls for emergencies only.
#3 Doctor: Resolve to exercise a minimum of four times a week for better health. Patient: Ditto.
#4 Doctor: Resolve to train my staff and model excellent customer service for patients. Patient: Resolve to understand that getting an instant referral, prescription, note for jury duty, or letter to my insurance company from my doctor is not my God-given right and I will stop [complaining] if it doesn’t happen the day I request it. Read more »
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