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Decision Aids Rarely Beat Clinical Judgment

March 27, 2017

Short Attention Span Summary

Do you ever feel buried in protocols?  Clinical decision rules are helpful, don’t get me wrong.  I use them every day, from PERC to PECARN.  Can we just enter patients’ signs and symptoms into a computer and Robo-Doc will diagnose and treat?  Hardly.  Annals of EM searched from 1998 to present and found that of studies that were evaluating some type of clinical decision instrument, only 15% compared them to unaided physician judgment.  And those that did rarely found the decision rule was better than a thinking doc at the bedside.  My take is to use clinical decision rules as tools to inform your thinking about testing, treatment, diagnosis, or disposition.  But never, ever check your brain at the door and blindly follow them.  And if you’re conducting new research, don’t forget to compare your shiny new rule to plain old physician judgment.  What good is a clinical decision rule if we can already make the decision at the bedside without it?

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Use all the clinical decision rules at your disposal and the tools to compare, recall, and apply them to practice.  But your judgment at the bedside is still the final and best decision rule.


Ann Emerg Med. 2017 Feb 23. pii: S0196-0644(16)31520-7. doi: 10.1016/j.annemergmed.2016.12.004. [Epub ahead of print]

Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and are Seldom Superior.

Schriger DL1, Elder JW2, Cooper RJ3.

Author information:

1Department of Emergency Medicine, University of California, Los Angeles, CA. Electronic address: schriger@ucla.edu.

2Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, CT.

3Department of Emergency Medicine, University of California, Los Angeles, CA.



We determine how often studies that evaluate the performance of an aid for decision making, be it a simple laboratory or imaging test or a complex multielement decision instrument, compare the aid’s performance to independent, unaided physician judgment.


This was a cross-sectional survey of all Original Research and Brief Research Report articles in Annals of Emergency Medicine from 1998 to 2015. We included all articles that evaluated the performance of an aid for decision making in assisting a physician with a decision about testing, treatment, diagnosis, or disposition. Two authors independently characterized the intent and purpose of each aid for decision making, determined whether each study had a comparison to unaided physician judgment within the article or in a separate article, and recorded the result of that comparison.


One hundred seventy-one (8.3%) of 2,060 research articles studied the performance characteristics of an aid for decision making, 48 of which were formal clinical decision instruments. Forty of the 171 studies retrospectively analyzed existing databases and therefore could not assess physician judgment. Investigators compared the aid for decision making to physician judgment in 11% (15/131) of the prospective studies, including 15% (6/41) of studies that evaluated a formal clinical decision instrument. For 9 articles that had no comparison to physician judgment, we found 6 unique external publications that compared that aid to physician clinical judgment. The decision aid was superior to clinical judgment in 2 of the 21 studies that contained a comparison.


Physician judgment is infrequently assessed when the performance of an aid for decision making is evaluated, and, when reported, the decision aid seldom outperformed physician judgment.

Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 28238497 [PubMed – as supplied by publisher]

What are your thoughts?