Kieran Walsh: Too much medicine—practical tools that could help

Doctors are constantly being told that they overdiagnose and overtreat their patients. They are told that they overdiagnose and overtreat a range of conditionsbut one simple example is the overdiagnosis of bacterial upper respiratory tract infections. We urge doctors not to overmedicalise and not to overprescribe antibiotics. But then when a diagnosis is missed or a patient develops complications from an untreated infection, doctors are the first to be blamed. Is it any wonder that they feel they are in a no-win situation?

Until now most of our efforts to help doctors have focused on education to help them get their diagnosis and management strategies just rightwithout under or overdoing it. Clinical decision support aims largely to do the same thing. But Islam et al have suggested an interesting new direction in their study that seeks to understand complex clinical reasoning in infectious diseases—with the aim of improving clinical decision support design. [1]

In their study, they interviewed ten infectious disease specialists to find out how they made complex decisions. The authors then considered how future clinical decision support resources might be able to help these specialists. A number of themes emerged from the interviews. The specialists used several strategies to help them make difficult decisions. One example is anticipatory thinkingwhere clinicians think through the medium and long-term implications of various decisions that they might take. In the case of infectious diseases, anticipatory thinking might lead clinicians to decide that on balance the patient is better off not being prescribed antibiotics and so a “watch and wait” strategy is chosen. 

How could clinical decision support help with this? Well, the clinicians often found these decisions difficult as they felt they were taking a risk. They felt anxious and under pressure and sometimes this influenced their decisions. So maybe if the clinical decision support included ongoing monitoring of the patient with reminders when needed on reviewing the decision, the doctors might feel more reassured and so more confident in their clinical decision to go for watchful waiting (and not to dive in with antibiotics). This is just one examplebut there are lots of others: documentation tools that promote shared decision making between patients and doctors and other team members would likely take the burden of a decision from a single set of shoulders; better visual displays in clinical decision support could match the mental model of the clinician and help them to make safe decisions at the point of care while they are in the middle of their workflow. 

BMJ Best Practice is the clinical decision support tool of the BMJ. We have been thinking about these issues for some timeone example is better visual display. We have worked to improve the online version of the site and also the appwhich is used a lot at the point of care. But we are keen to do more and, like the authors of this paper, to listen to the needs of our users. If you have any ideas of what we could do better, we would be delighted to hear from you.

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 Best Practice – a clinical decision support tool.


[1] Islam R, Weir CR, Jones M, Del Fiol G, Samore MH. Understanding complex clinical reasoning in infectious diseases for improving clinical decision support design. BMC Med Inform Decis Mak. 2015 Nov 30;15:101.