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Clinical decision-making: coping with uncertainty
  1. O M P Jolobe
  1. Department of Adult Medicine, Tameside General Hospital, Fountain Street, Ashton under Lyne OL6 9RW, UK

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    The uncertainty of clinical decision-making1 is compounded by the fact that, notwithstanding its value, an inherent flaw in the medical history is its instability, due to the fact that “patients' recollections of their past symptoms, illnesses, and episodes of care are often inconsistent from one inquiry to the next”.2 Rather than castigate the patient for being a “poor historian”, the authors proposed strategies to help clinicians recognise and overcome obstacles to good history taking.2 Clinical decision-making is also hampered by the absence of a clear survival advantage for conclusions based on higher levels of evidence.3 What the authors observed was that survival of conclusions did not differ between randomised and non-randomised studies in a selected field, namely, cirrhosis and hepatitis, even when comparison was restricted to therapeutic studies, and that, even after 1980, 25% of published randomised studies were of low methodological quality.3 In the event that these observations are applicable to the rest of medical practice, this would be indicative of a fundamental flaw in most clinical guidelines, especially those which do not specify the level of evidence on which they are based.

    Finally, there is the vast unchartered territory of what could be legitimately defined as evidence based ignorance, which has come into being because a lot of clinical research has restricted its focus to problems which are amenable to “quick fix” solutions. The unfortunate consequence is a “trade off”, which amounts to the acquisition of precise answers to the wrong questions instead of approximate answers to the right questions.