Kirwan J R, Currey H L, Brooks P M
Aust N Z J Med. 1985 Dec;15(6):738-44.
Most therapeutic decisions depend upon the clinical judgment of physicians assessing their patients. However the inherent and wide variation in such judgments is usually ignored. Rheumatoid arthritis typifies those diseases in which much information is available on which to base decisions, but little is known about how physicians combine the data to evaluate their patients' response to treatment. Thirty-four Australian rheumatologists recorded their assessments of the progress of 50 rheumatoid patients treated with 'second line' agents, based on data presented on previously validated written forms. Clinical judgment analysis, a form of multiple regression analysis, was then used to model the way physicians' judgments related to the available data. There were major differences of judgment in the assessments of response to therapy. This was so even when only 'clinically important' changes were identified. The variance in judgments which could be modelled by clinical judgment analysis ranged from 45% to 94%. Both individual inconsistency and differences in the underlying use of data contributed to disagreements between clinicians' assessments of identical cases. Identifying underlying differences in the way clinical data relate to clinicians' judgments is a step towards improving clinical consistency.
大多数治疗决策取决于医生对患者进行评估的临床判断。然而，这种判断中固有的巨大差异通常被忽视。类风湿性关节炎是这类疾病的典型代表，在这类疾病中，有大量信息可作为决策依据，但对于医生如何整合数据以评估患者对治疗的反应却知之甚少。34名澳大利亚风湿病学家根据先前经过验证的书面表格中呈现的数据，记录了他们对50名接受“二线”药物治疗的类风湿患者病情进展的评估。然后，使用临床判断分析（一种多元回归分析形式）来模拟医生的判断与现有数据之间的关系。在对治疗反应的评估中存在重大的判断差异。即使只识别出“具有临床重要性”的变化，情况也是如此。通过临床判断分析能够模拟的判断差异范围为45%至94%。个体的不一致性以及数据潜在使用方式的差异都导致了临床医生对相同病例评估之间的分歧。识别临床数据与临床医生判断之间潜在的差异是迈向提高临床一致性的一步。
