Lee A. Resnick, MD, FAAFP
No other specialty requires more expertise in medical decision making than urgent care medicine. We specialize in the evaluation and management of the “undifferentiated patient,” with limited access to diagnostic and consultative resources.
Our scope of care is one of the broadest in medicine, requiring breadth of knowledge across disciplines. Our patients are almost entirely new to us, giving us limited clinical and personal insight into their presentations.
Finally, constraints on our time with the patient mandate an ability to quickly sift through relevant—and, often, irrele- vant—information in light of widely variable patient agendas, cultural differences, and education levels.
These challenges combine to require the most honed medical decision-making skills in all of medicine.
How can we perfect our craft? Of course, there is no one formula, but there are some basic ingredients:
Fund of Knowledge
Comprehensive understanding of the pathophysiology of disease forms the underpinnings of any evaluation.
History and Physical
Oh yeah, that little thing they taught me in med school.
Medical decision making begins with a systematic approach to the history and physical. It is, perhaps, the most obvious and underappreciated part of the evaluation. It is by far the most important tool we have in the evaluation of the undifferentiated patient.
I advise you to go back to your notes from med school and appreciate the importance of a complete and sound H & P. The vast majority of medical decisions can be made with a simple H & P, and the vast majority of errors can be avoided. A good H & P will guide appropriate utilization and will have a profound impact on patient trust and satisfaction.
Spending time here will save you time in the long run. Do not make productivity demands your excuse for not taking a systematic approach to the history and physical
Patient Agendas
If you do not understand what brought the patient in to seek care in the first place, you simply cannot make accurate medical decisions. Patient agendas color every encounter, and can derail an evaluation if not adequately assessed.
Judgments and Assumptions
I have discussed in previous columns how making judgments and assumptions about patients can lead to inaccurate decision making, so I will not elaborate here. Suffice to say that resisting the urge to judge your patients facilitates gaining their trust, which in turn enhances your ability to elicit the important in- formation necessary to ensure the best outcomes.
References
Referring to the medical literature through texts, online tools, and algorithms is a regular part of the decision-making process.
Diagnostics
Their importance has been overstated in the era of defensive medicine, but they still have an important place in decision making. (Notice, however, this is one of the last ingredients.)
Consultation
Relying on expert opinion, when appropriate, has always been central to the decision-making process.
Mix these ingredients together, throw them in the oven, and 15 minutes later, hopefully your cake will rise
