First10 EM - By Justin Morgenstern - February 2, 2023
This evidence review is the handout for the talk I gave at the Emergency Medicine Cases Summit entitled “Decision rules are ruining medicine”.
There is a common assumption that clinical decision rules must improve decision making and clinical care. This is based on the fact that clinical decision making (like all human decision making) is flawed, subject to many biases, and highly variable. However, this assumption is unproven, and probably not consistent with what we know about clinical decision rules.
Summary
Overall, the way they are currently used, I honestly think that medicine would be better off without any decision rules at all. But we don’t need to be that extreme. We shouldn’t throw the baby out with the bathwater.
Decision rules are like any diagnostic test. Decision rules are like a D-dimer in sheep’s clothing. The D-dimer is a horrible test when used indiscriminately, but can be very helpful when used thoughtfully. We have to think about our decision rules like D-dimers. We should use them, but we need to use them very carefully.
We need to be much more cautious in our application of decision rules. We need rules that are proven to provide patient oriented benefit. We need rules that are better than clinical judgement.
Ideally, rules should not be adopted until we see impact analyses in multiple settings proving patient oriented benefit, or at least cost or time savings. Rules without impact analyses should not be used as rules. If they are broadly validated, it is reasonable to consider risk predictions of the rules in clinical decision making, but without impact analyses these rules should not be used clinically, recommended in guidelines, nor used in courts or by governing bodies.
Decision rules are ruining medicine and we need to act now to solve this problem.