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Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors
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    The tension between "gestalt" and the checklist

    The tension between head, heart and checklist is strikingly exemplified by the clinical decision process involved in the diagnosis of pulmonary embolism(PE). Currently, this process is characterised by a proliferation of clinical decision rules which involve mind numbingly long lists of items, and their associated calculations, the latter intended to generate numerical scores(1)(2) which confer a semblance of scientific credibility to the process. By contrast, a school of thought has emerged which posits that clinical acumen, defined as unstructured clinical impression or "gestalt" is, at the very least, as reliable a sole reliance on clinical prediction rules for discriminating among patients who have a low, moderate, or high pretest probability of PE(1). Over time, gestalt, itself, appears progressively to confer increasing diagnostic accuracy, judging by the diagnostic performance of senior physicians(postgraduate year 4 plus) vs interns(postgraduate year 1) working in the emergency department of a large teaching hospital(3). Concurrently, we have seen the emergence of gestalt-based clinical decision strategies such as the PERC rule(4) and the YEARS algorithm(5). as an attempt to resolve the tension between underdiagnosis and overdiagnosis of PE.
    Clinical acumen, itself, performs best when it is informed, not only by the numerical score of years since obtaining one's medical qualification, but also by interaction(through the medium of case co...

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    Conflict of Interest:
    None declared.