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The Rules of the Road

One of the things I’ve learned in Emergency Medicine is that if we don’t define ourselves then others will be more than willing to do it for us. The struggle to set the driving principles and priorities of our profession occurs in a thousand places; in a thousand different ways every day, and all of us are acutely aware how these struggles can impact the quality of our practice. That’s why it’s so disconcerting to see a trend within our speciality that potentially undermines us as clinicians.

In the current issue of Annals of Emergency Medicine, Dr. Schriger and Dr. Newman have teamed up to write about risk stratification tools.  Their motivation for the piece is in response to a concomitant publication about a potential biomarker for defining low risk head trauma, and the possibility that it could reduce the number of head CTs we order in these patients.  Here are the key points of their article.

  • There has been a huge proliferation in clinical decision tools that attempt to define low risk patients in the Emergency Department.
  • Many of these tools are poorly designed, and based on false assumptions about physician judgement, subjectivity, and why tests are ordered.
  • The overall benefit of these tools is questionable without a properly defined, clinically relevant method of evaluating them against physician evaluation alone.

The article is a call to reform our methodology but it’s also a plea to address some of our deeper assumptions before we run ourselves off a cliff with decision tool driven testing. The flawed assumption goes something like this:  clinical judgement is subjective and therefore imperfect.  The answer then is to find another more objective tool to save us from ourselves.

This strange desire to want simple answers for complex problems belies the fact that all tests are flawed, and that subjectivity is itself a tool that can be tested like any other.  It also ignores the fact that in the face of complexity sometimes there is no better tool than subjectivity.  It is a finely tuned  instrument developed over millions of years to absorb data and make quick and successful decisions in the face of rapidly changing information. Combine this with years of training and experience and it becomes a powerful foundation for most of what we call the practice of medicine.

Praising subjectivity is not a nostalgic plea for a return to the days when a doctor had only their experience and clinical exam skills to inform medical decision-making (these too are just imperfect tools) nor is it antithetical to the practice of best evidence. It’s simply a request not to “systematically discount”  doctors clinical ability in the name of progress, or burden us with expensive, cumbersome, or difficult to remember rules when clinical gestalt might work just as well – if not better.

Subjectivity, as Dr. Schriger and Dr. Newman elegantly point out, is inextricable from the process of medical decision making, and attempting to build an intellectual bypass around it with decision tools is a road to nowhere.


Medical decision-making: Let’s Not Forget the Physician, David L. Schriger, MD, MPH, David H. Newman, MD. From the University of California, Los Angeles, Los Angeles, CA (Schriger); and the Mt. Sinai School of Medicine, New York, NY (Newman).

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