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A Black Day for Clinical Judgment

L Reinecke   (5 December 1999)

Re: A Black Day for Clinical Judgment

Robert R Weaver   (24 March 2000)

A Black Day for Clinical Judgment 5 December 1999
L Reinecke, radiation oncologist Rand Clinic, Johannesburg, South Africa Send response to journal: Re: A Black Day for Clinical Judgment	It would be a black day indeed if Weed & Weed's words were to be accepted concerning the human mind and its functions with special regard for those who have been in medical practice for several years and who've spent up to 16 years in training (including the Bachelor's and Master's degrees) in one or other branch of Medicine (1) Even sadder would be the position of the patient who anxiously walks into a consulting room if there was no need for intimate and confidential contact between patient and physician. The numerous times that diagnoses were made through a combination of visual, aural and sensory functions of the brain (seeing, hearing and smelling). Not to mention the number of times a diagnosis is made after a telephone conversation, or, a chance remark made in passing. The intuition which develops in a physician after many years in practice who knows their patient's life-style and habits and which would enable a diagnosis to be made with unusual symptoms is to be totally discounted according to Weed & Weed. (1) We (the creators of the computer), must now believe that the computer is able to function as our master. Our brain is "inferior" to this instrument of technology.(1) We are told to "worship and serve the creature more than the creator"(2). Caring is our business, love is our method and science is our tool - how can a computer do that? A statement made by Michael S. Brown (3) would appropriately summarise the position. "A physician's job is to diagnose and treat disease. Here, the most precious attributes are knowledge, skill and the ability to act decisively. The physician must know all that can be known about the human body, how each cell works, how cells work together to produce organs, and how organs work together to produce a human being. Physicians must know how diseases disrupt this organisation, but they need more than knowledge. They need skills. Physicians must develope their senses so that they can size up a patient with their hands, eyes, and noses, and most importantly, their ears. Physicians must also be ready to act. There isn't time to look things up in books. Sick patients need action now, and when doctors see 50 patients a day, they must be able to recognize diseases quickly and intervene decisively. This task can be accomplished only if physicians have precise knowledge and buoyant self-confidence. Physicians must trust the information they gather with their own senses and they must be ready to act" (3) References: 1. Weed LL & Weed L. Opening the black box of Clinical Judgement eBMJ 1999;319 (7220) 1279 Data Supplement - Complete Version. 2. Romans 1:25 (King James Version) 3. Great Issues for Medicine in the Twenty-first Century. Eds. Dana Cook Grossman & Heinz Valtin. "The Making of a Physician-Scientist 2000" Brown MS. Ann NY Acad Sci 1999:882;247-256.
Re: A Black Day for Clinical Judgment 24 March 2000
Robert R Weaver, Associate Professor, Sociology Youngstown State University Send response to journal: Re: Re: A Black Day for Clinical Judgment	As a medical sociologists who has examined the role computers have played, and not played, in health care, I remain intrigued by physicians' opposition to the use of the knowledge coupling approach to decision support. As a patient with a keen interest in receiving the best possible care, however, I am more disturbed by this opposition. Physicians readily embrace and widely use all sorts of technological aids to enhance their diagnostic abilities. Indeed, it would be considered malpractice if my physician failed to use her stethoscope, the MRI, laboratory tests or other aids available for diagnosing my condition. Physicians take no offense at using such devices and show no fear that their judgments and intuitions will become subservient to them. Why should computer systems such as knowledge couplers be treated differently? True, physicians undergo lengthy training, but it seems obvious that physicians cannot "know all that can be known about the human body", never mind apply this knowledge routinely and reliably. Just as other technologies enable our senses to see, hear, and feel things that would otherwise remain inaccessible, computers enable us to reliably organize and process knowledge and information relevant to patients that we would otherwise forget, overlook or, more likely, never had access to. Having observed the routine deployment of knowledge coupling in a primary care practice, I see no evidence that they detract from the "intimate contact" between providers and patients. On the contrary, by "opening the black box" of clinical judgment knowledge coupling enables patients and providers to more openly discuss the a range of health care options, rather than the more limited set the provider might recall and share with the patient. This enhances rather than detracts from the human relationship. Moreover, it would be a profound misunderstanding of the knowledge coupling approach to think that the tools undermine clinical intuition and judgment. Rather, the tools merely bring more relevant knowledge to bear on the judgments humans render and the decisions humans make. In so doing, patients can have confidence that the best available knowledge is being applied to their particular case. As a patient I believe this only enhances the "care" that physicians are called upon to deliver.