Purpose: Evidence of effectiveness can potentially influence the clinical choices made by physicians and the value of health care delivered, yet few studies have sought to examine the types of evidence physicians draw upon as they make decisions in real time. This pilot study examines physicians' self-reported basis for their clinical decisions.
Method: Ten pediatric cardiologists recorded every clinically significant decision made during procedures, test interpretation, or delivery of inpatient and outpatient care during five full days and five half days of care delivery. The physician indicated the basis for each decision by selecting from 10 pre-determined categories, ranging from ‘arbitrary and anecdotal’, to evidence from published studies, to ‘parental preference’ and ‘avoiding a lawsuit’. The physicians could cite a published study only if it was specifically recalled. However, decisions reported to be based on ‘guidelines’ were classified post-hoc according to the evidence upon which the guideline recommendations were based.
Result: During the 7.5 days, 1188 decisions (158/day) were made. Almost 80% of decisions were deemed, by the physicians, to have no basis in any prior published data and fewer than 3% of decisions were based on a study specific to the question at hand. More than one-third were attributed to experience or personal anecdote, the most common basis for a decision. Senior physicians were more likely than residents to attribute a decision to specific experience or anecdote (41% vs. 26%), and less likely, to “taught to do it” (9% vs 29%).
Conclusion: This pilot study found that a group of pediatric cardiologists were unable to cite a published evidence source for most of their real-time clinical decision making, including those that consumed significant medical resources. Yet despite the lack of formal evidence base, there has been tremendous progress in the field of pediatric cardiology in the past 2 decades, suggesting that information about effectiveness is obtained and transmitted through an alternative process. Novel approaches to building an evidence base produced from real-time clinical decisions may be critical to comparative effectiveness research.