Clinical Confidence

The Importance of Clinical Confidence

Doctors are losing confidence in their own clinical abilities as they are being deprioritised in the decision making process. It is an inevitable process as more technology becomes available to them. The possibility of delegating responsibility to the machines is becoming increasingly possible. The medico-legal environment ensures that every serious diagnosis and decision must be delegated to the hard evidence as a defence in court.

This contradicts the wisdom of always prioritising the global clinical picture over any individual technological result. If the result cannot be right given the overall picture, it is wrong. Something has gone wrong. The first thing to do is to retest the technology.

It is obvious when the heart monitor says that the patient you are talking to is flatlining. A lead has fallen off.

When the automated machine says the patient has no blood pressure, you measure it yourself the old-fashioned way. You do not believe or act on the hard evidence that the patient is half-dead with shock. It is inconsistent with the clinical situation.

A classic is that the blood looks more like saline. You seek out the idiot who took the sample from a vein upstream from the IV infusion.

The blood result proves the patient has a normal haemoglobin when you know they are bleeding and shocked. The implication of the result is exactly the opposite of the reassuring numbers. The blood loss is so acute and severe that the patient is not compensating.

Some of the pitfalls are well known. Most are obvious. However, this case should scare you into always trusting the clinical impression and clinical intuition....

It was of a diabetic admitted in coma. The clinical diagnosis was hyperglycaemic coma but the blood result came back at 3.0mmol/dl, hypoglycaemia. The patient was given glucogon to not effect. They were infused with glucose to no effect. The glucose was retested and came back at 45mmol/dl.

How could the machine have got it so wrong?

It did not. The error had happened in the printing of the result, not the measurement. With the infamous hindsight of the retrospectoscope, the decimal point between the 3 and the 0 was just a speck of dust in the photocopier.

How could the machine have got it so wrong?

It did not. The error had happened in the printing of the result, not the measurement. With the infamous hindsight of the retrospectoscope, the decimal point between the 3 and the 0 was just a speck of dust in the photocopier. The readout on the machine said 30.

The doctors trusted the result more than their clinical impression. Their original diagnosis had been hyperglycaemia and they had changed it because of the result. The machine's diagnosis was never consistent with the clinical picture. This was hot the adrenaline ridden, agitated coma of hypoglycaemia. The patient was hypoventilating rather than overbreathing. The clues were there. That should have been enough to reject the result as incompatible with the clinical evidence.

But in the modern clinical world, it is becoming increasingly difficult for a doctor to say 'I am right and the machine is wrong'. Reliance and dependency on technology is now cultural. Doctors almost never take responsibility for their own decisions without technological confirmation to back them up. They are not permitted to do so systematically even though the clinical decision of an experienced clinician is proven to be more reliable and precise than that of the technology.

Once upon a time, doctors had no technology to rely on. All that they had was their clinical skills and acumen with which they were making life and death decisions. They took absolute responsibility for their clinical decisions. The development of their clinical arts was of grave importance and they honed them as a matter of life and death.