© 2018 Evgenya Zaitseva
2018 — №1 (15)
Key words: medical choice, clinical decision-making, factors in clinical decisions, chronic patients
Abstract: The article is devoted to the problem of clinical decision-making in big Russian cities. It gives a detailed analysis of factors influencing a doctor who makes clinical decisions about diagnosis and treatment of chronic patients. The study is based on in-depth interviews of physicians from Samara and Moscow. The role and correlation of these factors are considered in a distinct manner for public and private health institutions, for outpatient and inpatient treatment.
The article is devoted to the problem of clinical decision-making in big Russian cities. It presents the results of a qualitative sociological research the purpose of which was to identify the spectrum of sociocultural factors that affect physicians during their clinical decisions regarding chronically ill patients. These factors were identified for two basic situations of clinical decisions – decisions made at the diagnostic stage and decisions made at the stage of prescribing treatment. The role and correlation of these factors are considered in a distinct manner for public and private health institutions, for outpatient and inpatient treatment.
The study is based on in-depth interviews with physicians from Samara and Moscow. A total of 25 physicians of different specialties was interviewed. Age of informants ranged from 26 to 63 years, their work experience – from 2 to 40 years.
The first part of the article highlights how physicians make early diagnosis through history-taking and physical examinations and how this stage correlates with subsequent instrumental diagnostics and laboratory testing. In the second partattention is paid to the most basic factors which influence all clinical decisions, both diagnostic and therapeutic. In the third and fourth parts, factors specific only for diagnostics and only for therapy are considered.
It was found out that the clinical decision-making is affected by many factors which often have the opposite effect. All factors can be divided into “internal” and “external”, or clinical and non-clinical. The main problem faced by physicians is to coordinate various external requirements with the ethical imperative of their profession – to be guided by the principle of maximum medical benefit for patients.
Understanding of maximum medicalbenefitoriginate in professional knowledge and experience. It may slightly vary from physician to physician, but in general, due to the process of continuing education and reliance on current clinical recommendations, they are fairly standardized. “Internal” factors also include credibility of particular laboratories, diagnosticians or drugs, arising from the physician’s knowledge and experience.
The “external” factors include above all various institutional requirements and restrictions: legislation that regulates health care, written and unwritten rules of particular medical facility, as well as its material capacities. In conditions of institutional limitations, a clinical decision oriented to the maximum patient’s benefit sometimes means a direct deviation from formal requirements. It is more typical of cases of severely ill patients, when risks of harming or even ‘losing’ them outweigh risks of negative consequences for a medical facility.
Often times a chance to make an “ethically correct” decision depends on establishing a relationship of trust between the doctor and the patient. A doctor can overcome external limitations without deviation from formal requirements if the patient has been categorized as an adequate and non-scandalous person. Then doctor explains to the patient what the most effective diagnosis and treatment strategies are, and why they are impossible if the doctor strictly follows formal standards or draws on resources available in his/her clinic/hospital.
In addition to institutional requirements, there is a number of “patient-related” factors: his/her financial status, past medical experience, opinions and beliefs concerning the proper way of diagnosis and treatment. Taking into account patient’s individuality, a doctor often has to adjust diagnostic and treatment plans which he/she considers optimal from a clinical perspective.
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