CLINICAL DECISION-MAKING IN A BIG RUSSIAN CITY: QUALITATIVE ANALYSIS

© 2018 Evgenya Zaitseva

2018 — №1 (15)


Снимок экрана 2018-10-15 в 14.55.32

Key words: medical choice, clinical decision-making, factors in clinical decisions, chronic patients

Abstract: The article is devoted to the problem of clinical decision-making in big Russian cities. It gives a detailed analysis of factors influencing a doctor who makes clinical decisions about diagnosis and treatment of chronic patients. The study is based on in-depth interviews of physicians from Samara and Moscow. The role and correlation of these factors are considered in a distinct manner for public and private health institutions, for outpatient and inpatient treatment.


The article is devoted to the problem of clinical decision-making in big Russian cities. It presents the results of a qualitative sociological research the purpose of which was to identify the spectrum of sociocultural factors that affect physicians during their clinical decisions regarding chronically ill patients. These factors were identified for two basic situations of clinical decisions – decisions made at the diagnostic stage and decisions made at the stage of prescribing treatment. The role and correlation of these factors are considered in a distinct manner for public and private health institutions, for outpatient and inpatient treatment.

The study is based on in-depth interviews with physicians from Samara and Moscow. A total of 25 physicians of different specialties was interviewed. Age of informants ranged from 26 to 63 years, their work experience – from 2 to 40 years.

The first part of the article highlights how physicians make early diagnosis through history-taking and physical examinations and how this stage correlates with subsequent instrumental diagnostics and laboratory testing. In the second partattention is paid to the most basic factors which influence all clinical decisions, both diagnostic and therapeutic. In the third and fourth parts, factors specific only for diagnostics and only for therapy are considered.

It was found out that the clinical decision-making is affected by many factors which often have the opposite effect. All factors can be divided into “internal” and “external”, or clinical and non-clinical. The main problem faced by physicians is to coordinate various external requirements with the ethical imperative of their profession – to be guided by the principle of maximum medical benefit for patients.

Understanding of maximum medicalbenefitoriginate in professional knowledge and experience. It may slightly vary from physician to physician, but in general, due to the process of continuing education and reliance on current clinical recommendations, they are fairly standardized. “Internal” factors also include credibility of particular laboratories, diagnosticians or drugs, arising from the physician’s knowledge and experience.

The “external” factors include above all various institutional requirements and restrictions: legislation that regulates health care, written and unwritten rules of particular medical facility, as well as its material capacities. In conditions of institutional limitations, a clinical decision oriented to the maximum patient’s benefit sometimes means a direct deviation from formal requirements. It is more typical of cases of severely ill patients, when risks of harming or even ‘losing’ them outweigh risks of negative consequences for a medical facility.

Often times a chance to make an “ethically correct” decision depends on establishing a relationship of trust between the doctor and the patient. A doctor can overcome external limitations without deviation from formal requirements if the patient has been categorized as an adequate and non-scandalous person. Then doctor explains to the patient what the most effective diagnosis and treatment strategies are, and why they are impossible if the doctor strictly follows formal standards or draws on resources available in his/her clinic/hospital.

In addition to institutional requirements, there is a number of “patient-related” factors: his/her financial status, past medical experience, opinions and beliefs concerning the proper way of diagnosis and treatment. Taking into account patient’s individuality, a doctor often has to adjust diagnostic and treatment plans which he/she considers optimal from a clinical perspective.

References

Burykin I.M., Aleeva G.N., Hafiz’yanova R.H. (2012) Metodologicheskie osnovy razrabotki ehffektivnoj sistemy vozmeshcheniya zatrat v gosudarstvennoj sisteme zdravoohraneniya [Methodological basis for the development of an effective cost recovery system in the public health system], Vestnik SPbGU [Bulletin of St. Petersburg State University], ser. 11, issue 2, p. 177–189.

Croskerry, P. (2013) From mindless to mindful practice – cognitive bias and clinical decision making, The New England Journal of Medicine,Vol. 368, p. 2445–2448.

Evans J.St.B.T. (2008) Dual processing accounts of reasoning, judgement and social cognition, Annual Review of Psychology,Vol. 59, p. 255–278.

Hajjaj, F.M., Salek, M.S., Basra, M.K., Finlay, A.Y. (2010) Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice, Journal of the Royal Society of Medicine, Vol. 103 No.5, p. 178–187.

Kamenshchikova, A. (2017) Medico-economic standards in Russia: balancing legal requirements and patient’s needs. O. Zvonareva, E. Popova, K. Horstman (eds.), Health, technologies, and politics in post-soviet settings: navigating uncertainties, Palgrave Macmillan, p. 117–142.

Larinskij N.E., Abrosimov V.N. (2012) Istoriya fizikal’noj diagnostiki v biografiyah, portretah i faktah [The history of physical diagnosis in biographies, portraits and facts], Ryazan’.

Norman, G.R. and Eva, K.W. (2010) Diagnostic error and clinical reasoning, Medical Education, Vol. 44. No.1, p. 94–100.

Olejnikov, D. Zakonoproekt o klinicheskih rekomendaciyah – 2018. Novaya redakciya – novye perekosy[The draft law on clinical recommendations – 2018. New edition – new distortions]

Podlela S.A., Panov V.P., YAkimov O.S. (2006) Standartizaciya v sfere medicinskih uslug i medicinskogo strahovaniya [Standardization in the sphere of medical services and medical insurance], Voprosy ehkspertizy i kachestva medicinskoj pomoshchi [Issues of expertise and quality of medical care], № 5, p. 42–45.

Stanovich, K.E. and West, R.F. (2000) Individual differences in reasoning implications for the rationality debate, Behavioral and Brain Sciences, Vol. 23, p. 645–665.

Sklyar, T.M. (2010) Rol’ mediko-ehkonomicheskih standartov v finansirovanii medicinskih uchrezhdenij[The role of medico-economic standards in financing medical institutions], Voprosy ehkonomiki [Economic issues], № 8, p.132–143.

Van den Berge, K, Mamede, S. (2013) Cognitive diagnostic error in internal medicine, European Journal of Internal Medicine, Vol. 24. No.6, p. 525–529.

GOST R 1.4-93 «Gosudarstvennaya sistema standartizacii Rossijskoj Federacii. Standarty otraslej, standarty predpriyatij, standarty nauchno-tekhnicheskih, inzhenernyh obshchestv i drugih obshchestvennyh ob”edinenij. Obshchie polozheniya» [«State system of standardization of the Russian Federation. Industry standards, enterprise standards, standards of scientific and technical, engineering societies and other public associations. General provisions»] (http://docs.cntd.ru/document/1200006599) (25.06.2018).

Federal’nyj zakon ot 21.11.2011 g. № 323-FZ (red. ot 07.03.2018) «Ob osnovah ohrany zdorov’ya grazhdan v Rossijskoj Federacii» [Federal Law No. 323-FZ of November 21, 2011 (as amended on 07.03.2018) «On the fundamentals of protecting the health of citizens in the Russian Federation»]  (http://www.consultant.ru/document/cons_doc_LAW_292676/) (25.06.2018).

Federal’nyj zakon ot 29.11.2010 g. № 326-FZ (red. ot 28.12.2016) «Ob obyazatel’nom medicinskom strahovanii v Rossijskoj Federacii» (s izm. i dop., vstup. v silu s 09.01.2017) [Federal Law No. 326-FZ of November 29, 2010 (as amended on December 28, 2016) «On Compulsory Medical Insurance in the Russian Federation» (as amended and supplemented, effective as of January 9, 2017)] (http://www.consultant.ru/document/cons_doc_LAW_210053/) (25.06.2018).

Informacionnoe pis’mo Minzdravsocrazvitiya Rossii ot 24.11.2011 g. №14-3/10/2-11668 [Informational letter of the Ministry of Health and Social Development of Russia from November 24, 2011 №14-3 / 10 / 2-11668](http://www.consultant.ru/document/cons_doc_LAW_122384/) (25.06.2018).

Okazanie vysokotekhnologichnoj medicinskoj pomoshchi v ramkah bazovoj programmy obyazatel’nogo medicinskogo strahovaniya [Provision of high-tech medical assistance in the framework of the basic program of compulsory medical insurance], sajt Federal’nogo fonda obyazatel’nogo medicinskogo strahovaniya [the site of the Federal Compulsory Medical Insurance Fund] (http://www.ffoms.ru/system-oms/about-fund/modernizatsiya-sistemy-oms/okazanie-vysokotekhnologichnoy-meditsinskoy-pomoshchi-v-ramkakh-bazovoy-programmy-oms/) (25.06.2018).

Pis’mo Minzdrava Rossii № 11-7/10/2-8080, FFOMS № 13572/26-2/i ot 21.11.2017 (s izmeneniyami ot 12 marta 2018 goda) «O metodicheskih rekomendaciyah po sposobam oplaty medicinskoj pomoshchi za schet sredstv obyazatel’nogo medicinskogo strahovaniya» [Letter of the Ministry of Health of the Russian Federation No. 11-7/10 /2-8080, Federal Compulsory Medical Insurance Fund № 13572/26-2/i dated November 21, 2017 (as amended on March 12, 2018) «On methodological recommendations on how to pay for medical care from the compulsory medical insurance»](http://www.consultant.ru/document/cons_doc_LAW_283654/) (25.06.2018).

Prikaz Minzdravsocrazvitiya Rossii ot 05.05.2012 № 502n (red. ot 02.12.2013) «Ob utverzhdenii poryadka sozdaniya i deyatel’nosti vrachebnoj komissii medicinskoj organizacii» (Zaregistrirovano v Minyuste Rossii 09.06.2012 N 24516) [Order of the Ministry of Health and Social Development of Russia from 05.05.2012 No. 502n (as amended on 02.12.2013) “On approval of the procedure for the establishment and activity of a medical commission of a medical organization” (Registered in the Ministry of Justice of Russia on 09.06.2012 N 24516)] (http://www.consultant.ru/document/cons_doc_LAW_131200/) (25.06.2018).

Prikaz Ministerstva zdravoohraneniya RF ot 23.01.15 g. №12n «Ob utverzhdenii administrativnogo reglamenta Federal’noj sluzhby po nadzoru v sfere zdravoohraneniya po ispolneniyu gosudarstvennoj funkcii po osushchestvleniyu gosudarstvennogo kontrolya kachestva i bezopasnosti medicinskoj deyatel’nosti putem provedeniya proverok primeneniya osushchestvlyayushchimi medicinskuyu deyatel’nost’ organizaciyami i individual’nymi predprinimatelyami poryadkov okazaniya medicinskoj pomoshchi i standartov medicinskoj pomoshchi» [Order of the Ministry of Health of the Russian Federation of 23.01.15 No. 12n «On the approval of the administrative regulations of the Federal Service for Supervision in the Health Care for the execution of the state function for the implementation of state control of the quality and safety of medical activities by conducting inspections of the procedures for rendering medical services by organizations and individual entrepreneurs medical care and standards of medical care»] (http://www.consultant.ru/document/cons_doc_LAW_175898/) (25.06.2018).

Proekt Federal’nogo zakona № 449180-7 «O vnesenii izmenenij v Federal’nyj zakon «Ob osnovah ohrany zdorov’ya grazhdan v Rossijskoj Federacii» po voprosam klinicheskih rekomendacij» (red., prinyataya GD FS RF v I chtenii 07.06.2018) [The draft Federal Law No. 449180-7 «On Amendments to the Federal Law «On the fundamentals of protecting the health of citizens in the Russian Federation» on the Issues of Clinical Recommendations» (Ed., Adopted by the State Duma of the Russian Federation in 1st reading on June 7, 2018)] (http://www.consultant.ru/cons/cgi/online.cgi?req=doc&base=PRJ&n=172809#07213744674646274) (25.06.2018).

V Rossii izmenyaetsya poryadok finansirovaniya vysokotekhnologichnoj medpomoshchi [The procedure for financing high-tech medical care is changing in Russia], sajt Informacionnogo agentstva TASS [the website of the TASS Information Agency]. 01.01.2017. (http://tass.ru/obschestvo/3918702) (25.06.2018).

Leave a Reply

Your email address will not be published. Required fields are marked *