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Clinical Judgment Recently, we’ve spent a lot of time in our field talking about evidence-based medicine, as well as new technologies. I have written about these issues myself more than once. Clearly, the trend in podiatric medicine is to rely increasingly on the literature and high technology when treating our patients. Today I’d like to swing that pendulum the other way for just a moment. Recall that one major portion of EBM is the clinician’s experience and judgment. I’d like to present a short case study that exemplifies the importance of clinical judgment when treating patients. Recently, I was consulted on a hospital patient. He was a 44 year-old Hispanic male who’d been admitted 3 days prior for nausea, vomiting, and mental status changes — as a result of his type 2 diabetes mellitus and end-stage renal disease. He had undergone a transmetatarsal amputation in another state 3 months previously and was under wound care for a dehiscence of the incision, when he moved to Southern California. Due to his prolonged open lesion, I ordered radiographs to check for osteomyelitis and get a better appreciation for his original procedure (see the radiograph in Figure 1).
These radiographs were read by the radiologist as possible osteomyelitis of the 1st, 2nd, and 3rd metatarsals, and someone ordered an MRI. Of course, the MRI was read as possible osteomyelitis as well -- although when I sat down with the radiologist, she was less certain of the diagnosis. So far, the use of high technology was unable to solve this diagnostic problem. To add a little drama to the story, this patient had a prior transtibial amputation on the contralateral leg. As such, we needed a definitive diagnosis as possible — and I was loth to perform a more proximal amputation on this patient. In the mean time, I had been performing local wound care to the dehiscence site, and this is where my clinical judgment came into play. During the time everything above was occurring, I was watching his wound quickly healing. In my experience, wounds with underlying osteomyelitis either close with chronic recurrence or never actually close. So when I combined the radiograph (which looked more like postoperative bone growth rather than osteo), the equivocal MRI, and my clinical judgment, I concluded this patient did not have osteomyelitis.
Of course, that’s not the end of the story. What I didn’t relate before, is that the patient was awaiting a possible renal transplant with a family member as the donor. As a result, we needed a more definitive answer rather than relying on equivocal radiographs, MRI, and my clinical impression. And there’s only one true gold standard to diagnose osteomyelitis — biopsy. So…off we went to surgery. I performed a percutaneous bone biopsy, taking specimens for histopathology and microbiology. At the end of the story he turned out to have chronic inflammatory changes not consistent with osteomyelitis and negative culture results. At the end of the day, my clinical judgment was an integral and necessary part of the decision making process. It’s inappropriate to concede our experience and judgment to imperfect technology, advanced though it may be. Remember, evidence-based medicine must be a synthesis of the evidence as well as our clinical perspective and patient values. Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.
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