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WHY DECISION ANALYSIS?

Why should we use Clinical Decision Analysis (CDA)?  We should use it for the same reason that we should wear a seat belt, have a smoke detector, advice syrup of Ipecac for parents with young children, or tell parent to quit smoking. In other words CDA allows the clinician to advice their patient the “best bet” or the best outcome given a certain condition. In the end, CDA keeps the interest of the patient always in the frontal lobes of a clinician.

Although CDA has not yet been studied in a controlled trial showing positive outcome, by intuition, it would seem that a decision based on some form of step by step thinking is better that random decisions without any conscious methodology which is used  commonly used by majority of physicians.

Unlike the “standard” clinical decisions or the random decision, the discussion on CDA starts with treatment consideration like harm and improvement, followed by testing and diagnosis with its likelihood ratio and pre-test estimation. The reason for thinking of treatment first, then testing or diagnosis, is that decisions about tests can be properly made after the risks and benefits of a treatment has been critically dissected. Knowing and understanding the risk and benefits, harm and improvement, the clinician and patient can discuss if a test is worthwhile doing.

The function of decision analysis, unlike scientific experiment that shows natural truth, is to help a decision maker choose the best option among many alternatives of treatment. Decision analysis does not reduce the uncertainty about the true nature of our patient’s illness, but rather it makes our choice more rational in light of uncertainty. In the long run, if we apply decision analysis in most of our complicated patients, our probability of making a grave error is lesser compared to the method of “intuitive” thinking which is most commonly done by majority of students, residents, and many experienced attending physicians.

Tomorrow, 6 August, Why Have A Differential Diagnosis?

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Leo Leonidas, MD, FAAP

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