As we bang on about almost endlessly in Archi, we know that evidence is only part of a clinical decision. The story also includes the patient and their family, and sharing the decision is key to good medicine. There is the third leg on the tripod though – clinician expertise.

In the simple iterations of the Evidence Based Medicine formula we give examples of surgical skills or technical access to scans being examples of where the clinical expertise may influence decision.

Real life isn’t so simple. The same data may be read in multiple ways, and the clinical expertise may well be swayed by prior experience. If you were “Tally Ho!” for hypertonic saline in bronchiolitis, then read the SaBRE trial, you may be less tempted to follow the next recommendation from a systematic review (probiotic for diarrhoea, anyone?)

This evaluation feeds into the ways we talk about choices and options with families. We may be the keen types to offer low level laser therapy for mucositis, or the reluctant ones wanting to do another trial of STS for cisplatin chemotherapy. The “right” answer will emerge, but probably five years after we need to make it. Making the influences we own explicit is the best defence we can have against doing things daft.

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