I used to think they didn’t but they do.
Clinical judgment is the application of individual experience to the variables of a patient’s medical presentation. It’s the hard worn skill of knowing what to do and how far to go in a particular situation. It’s having the confidence to do nothing. Clinical judgment is learned from seeing lots of sick people. Good clinical judgment is when the gifted capacity of reasoning intersects with experience. Some doctors have better judgment than others.
Aristotle called this phronesis – or practical judgment.
Patients have practical judgment. We often can tell when something’s amiss with our own body. Things feel different or look different. Taking action on these observations is how we exercise judgment as patients.
Parents of children with central venous lines, for example, can often identify the early signs of infection before fever has ever appeared. They know the subtleties of their child’s behavior. The same goes for children with epilepsy. People with diabetes increasingly have the latitude to apply judgment to the management of their disease. This tends to be quite defined, however, with fixed variables and limited options for intervention.
I’ve always known that patients have clinical judgment but I never recognized it as such. When I talk about ‘listening to a patient’ I am usually referring to the dialog about their strangest fears, questions, concerns and theories – I want to hear their introspection. This dialog reveals hidden agendas and clues that can be critical diagnostically or in the execution of treatment. I can’t prove it but I’m convinced it improves adherence.
The problem with the application of broader clinical judgment to our personal situations is that is that we aren’t always objective. Fear and denial dangerously influence our decision-making.
Take me, for example. My judgment with my own children is suspect. I function beautifully as a parent. But when it comes to the hard decision of when to draw the therapeutic line, I still think like a parent. My fear is likely to get in the way. With respect to ourselves or family members, acting solely on our own clinical judgment isn’t advisable in most cases.
But irrespective of how it’s exercised, patient judgment is ultimately important. It must be respected and factored into the decision-making that takes place between provider and patient.
I had never really thought about it before: Patient phronesis.