Clinical decision instruments are all the rage, especially when incorporated into the electronic health record – why let the fallible clinician’s electrical Jello make life-or-death decisions when the untiring, unbiased digital concierge can be similarly equipped? Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
We spend a great deal of time deriving, validating, and comparing decision instruments – think HEART vs. TIMI vs. GRACE – but, as this article points out, very little time actually examining their performance compared to clinician judgment.
These authors reviewed all publications in Annals of Emergency Medicine concerned with the performance characteristics of a decision instrument. They identified 171 articles to this effect, 131 of which performed a prospective evaluation. Of these, the authors were able to find only 15 which actually bothered to compare the performance of the objective rule with unstructured physician assessment. With a little extra digging, these authors then identified 6 additional studies evaluating physician assessment in other journals relevant to their original 171.
Then, of these 21 articles, two favored the decision instrument: a 2003 assessment of the Canadian C-Spine Rule, and a 2002 neural network for chest pain. In the remainder, the comparison either favored clinician judgment or was a “toss up” in the sense the performance characteristics were similar and the winner depended on a value-weighting of sensitivity or specificity.
This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns. Neither should it be construed from these data that many common decision instruments are of lesser value than our current usage places in them, only that they have not yet been tested adequately. However, many of these simple models are simply that – and the complexity of many clinical questions will at least favor the more information-rich approach of practicing clinicians.
“Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and are Seldom Superior”