Kieran Walsh: Clinical decision support—being worried is nothing to worry about

Many years ago I worked with a doctor who would disappear for a few moments at important decision points in clinical care. Sometimes this was during ward rounds and sometimes on call. He was an excellent doctor—the momentary absences never made a difference to the care of patients. Still I used to wonder where he was going. Eventually I found out. The hospital where I worked was run by nuns. The nuns were all-present and all-knowing and they put me right in the end. One of them told me that he doesn’t always know what to do and so he is going to look something up. But he doesn’t like to do it in front of everyone as he doesn’t want to look worried or lose face.

Clinical decision support tools are designed to help healthcare professionals when they are not sure what to do. But if healthcare professionals don’t like to admit that they are unsure, then there is a problem. The problem that users might have is that they are unwilling to show vulnerability in front of patients or colleagues—they are worried about looking foolish or uneducated. Some of them are worried about looking worried. Should they be?

The traditional view is that doctors who have to continually look things up might be seen as less knowledgeable than those who don’t. A study in 2007 by Arkes suggested that physicians who did not use diagnostic decision aids were viewed as having the highest diagnostic ability. (1) A subsequent study looked at why patients might look unfavourably at physicians who used these aids. (2) In this study patients once again rated more favourably those doctors who made diagnoses without help. However they also found that patients preferred doctors who sought help from an expert colleague to those who sought help from a computerised aid: the authors wondered whether the non-human aspect of the computerised decision aid was putting people off.

But these traditional views may be changing. There is emerging evidence that people understand that a doctor cannot know everything and that they don’t mind seeing a doctor looking things up. In a study of junior doctors, researchers found that, although some of the doctors were concerned about using clinical decision support tools in front of patients, the patients were not. (3) The patients said that they wanted their doctors to be well informed and to be able to get an online second opinion when they felt they needed it. However a critical point was that patients liked it when doctors told them that they were looking things up and why they were doing this: they wanted reassurance that doctors were not arranging their social life or engaging in other non work-related behaviours.

Developing an evidence base about the practice of evidence based medicine is not straightforward. A great deal depends on context. Few patients would rate a doctor who needed online guidance for every decision. Few would like their doctor to be continually staring at a computer screen throughout the consultation. But it would be different if the decision was complex or the stakes were high. Or if there was a need for the latest evidence on a new treatment or test. Or if the decision support was being actively used at the point of care for real life dilemmas.

We try to make evidence based decisions when developing our own clinical decision support tool—BMJ Best Practice. But what evidence should we rely on? One issue is the pace of change in technology and in our attitudes to technology. The pace is now so fast that we hesitate to believe a study that is only a few years old. In terms of mobile technology, 2007 is a long time ago. Smartphones have simply changed the way that we look at the world.

This might seem a long way from a hospital run by nuns. Or doctors who would only take furtive peeps at their Oxford Handbook. What would the nuns have made of online and offline clinical decision support at the point of care? The ones I knew would have said: don’t worry—look it up if you want to. Or better still let’s all get our heads together and look it up as a team.

Kieran Walsh is clinical director of BMJ Learning and BMJ Best Practice. He is responsible for the editorial quality of both products. He has worked in the past as a hospital doctor—specialising in care of the elderly medicine and neurology.

Competing interests: KW works for BMJ, which produces BMJ Best Practice—an evidence-based clinical decision support tool.


  1. Arkes HR, Shaffer VA, Medow MA. Patients derogate physicians who use a computer-assisted diagnostic aid. Med Decis Making. 2007;27(2):189–202.
  1. Shaffer VA, Probst CA, Merkle EC, Arkes HR, Medow MA. Why do patients derogate physicians who use a computer-based diagnostic support system? Med Decis Making. 2013 Jan;33(1):108–118.
  1. Patel R,Green W,Shahzad MWLarkin C. Use of Mobile Clinical Decision Support Software by Junior Doctors at a UK Teaching Hospital: Identification and Evaluation of Barriers to Engagement. JMIR Mhealth Uhealth. 2015 Aug 13;3(3):e80.