A four-step approach to clinical decision making

Clinical decision making is a complex process that is part art and part science. Although there is no one correct method, it can be helpful to think about your approach so you can refine it as needed to improve patient care.

Author Donald (Raj) R. Woolever, MD, offers the following four-step approach, essentially a modified scientific method:

1. Determine your probabilities. Based on the patient’s symptoms, history, etc., what is the likelihood of a particular diagnosis? For example, if a patient presents with a fever, productive cough, and decreased appetite, your initial hypothesis might be pneumonia, bronchitis, or an upper respiratory infection.

2. Gather data by further evaluating the patient. This usually requires additional history, vital signs, and a physical exam, which will help you confirm or reject your hypothesis.

3. Update your probabilities based on the data you’ve gathered. This includes the pre-test probability of any test you may want to order. Then, carefully collect and interpret additional data from diagnostic tests. The most probable diagnosis should begin to emerge at the top of your differential diagnosis list.

4. Consider an intervention to see whether it crosses your treatment threshold. The larger the therapeutic benefit is relative to the potential harm, the lower the threshold. If you don't have enough information to convince yourself to cross the threshold, consider other options, which may include gathering additional data or watchful waiting.

Adapted from "The Art and Science of Clinical Decision Making."

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