Leonard Zwelling

This is from the internet:

The word judgment, also spelled judgement, comes from the Old French word ‘jugement’ meaning ‘trial’ or ‘capacity for decision making’. It first appeared in Middle English sometime in the late 13th century as ‘juggement’ meaning ‘opinion’ or ‘penalty imposed by the court’.

Today, we usually refer to good judgment vs. bad judgment—good conclusions drawn from the evidence or wrong conclusions drawn from the evidence. Juries do it. Judges do it. Doctors do it.

Doctors often have to make judgments about a patient’s care and the doctor making the decision may or may not have sufficient evidence to be absolutely sure of what to do. That physician has to make a clinical judgment. What’s best for the patient? What’s the least harmful thing I can do? And all this may lead to a clinical judgment based on less than adequate evidence. That’s what doctoring is.

Throughout our medical training, we as physicians are taught to employ our best judgment about what to do. During our training we assess patients who are sick using standard tools—the history, the physical exam, laboratory data, and imaging. We come to a conclusion about what to do next diagnostically or therapeutically and we articulate that plan in front of our teachers—senior residents, fellows, or attending physicians who judge our judgment against what they would do with the same patient and patient data. Through this process of constant conclusion drawing, assessment by our seniors, and eventually channeling the best course for the patient and watching the results, we too develop clinical judgment. It is a time honored and effective process not likely to be improved upon by limiting training hours or the use of hospitalists or computer-based training.

Another part of clinical judgment is making sure the care delivery system actualizes the physician’s judgment and treatment plan. Reluctant administrative personnel or nursing staff may impair the implementation of the physician’s judgment. This can cause a patient harm. This can also cause a physician to get angry and be firm with the personnel caring for a patient to make sure that patient gets what is best for him or her. In other words, it is probably best to leave clinical matters to doctors.

I had a psychiatrist once. I asked her why she thought psychiatrists needed to be physicians. She said, “doctors bring people into this world and help people out of it. They can handle most of what happens in between.”

This brings me to two issues about which I am very concerned.

The first is the activity by many state legislatures to arbitrarily supplant a physician’s medical judgment about a women’s right or need for an abortion and the concomitant interference this poses for medical practice. Abortion is a fraught issue. People on both sides of the issue are passionate about their beliefs, BUT I know that many doctors are afraid to do what is clinically indicated in their best medical judgment when a pregnant patient in the doctor’s mind needs an abortion to save her life. My sources tell me that there has already been one death of a pregnant patient in Houston from sepsis following a spontaneous miscarriage when her doctors were afraid to perform a dilatation and curettage as this would be considered an abortion in Texas. The Texas State Legislature has no place in the operating room or in the practice of medicine beyond licensure. Leave the medical judgment to the doctors.

I also believe that the weaponization of professionalism that is going on at MD Anderson now is being applied with a heavy hand and is too often triggered by disgruntled staff wishing to punish a faculty member.

Being a doctor is hard. Being a doctor in a cancer center where many patients die and all may be in fear of the dreaded malignant diagnosis is especially hard. Doctors are trained to use their best judgment to help these patients as well. Let them. Keep the HR administrators and lawyers out of medical practice.

There are too many inexperienced people interfering with medical practice and it will be the patients who suffer the consequences. Leave abortion decisions to doctors and the implementation of treatment plans to them as well. The wrong people are legislating behavior and doing a poor job of it.

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