title: Clinical Recommendations in Medical Practice: A Proposed Framework to Reduce Bias and Improve the Quality of Medical Decisions.
abstract: Patients rely on, benefit from, and are strongly influenced by physicians' recommendations. In spite of the centrality and importance of physicians' recommendations to clinical care, there is only a scant literature describing the conceptual process of forming a clinical recommendation, and no discrete professional standards for making individual clinical recommendations. Evidence-based medicine and shared decision making together are intended to improve medical decision making, but there has been limited attention to how a recommendation is discretely formulated from either of those processes or how patients' preferences ought to be considered and how much weight they should hold. Moreover, physicians' bias has been reported to strongly influence how a recommendation is derived, thereby undermining the quality of healthcare decisions and patients' trust. To demonstrate a potential for improving the quality of decisions, this article proposes a conceptual framework for how physicians should reach a clinical recommendation and apply the process in practice. For preference-sensitive clinical decisions-that is, clinical decisions when patients' values and preferences are relevant-the process for reaching a recommendation should be transparent to patients and should be based solely on the medical evidence and patients' values and preferences. When patients' preferences for care do not prioritize health, physicians decide whether their recommendation will prioritize a welfare-enhancing versus an autonomy-enhancing approach. When there are gaps in understanding how physicians derive their clinical recommendations and how to further improve the quality of the decisions, the author calls for further empiric research.
authors.affiliation: New York University School of Medicine, 423 East 23rd St (10P6), New York, New York 10010 USA. david.alfandre@va.gov.
authors.forename: David
authors.initials: D
authors.lastname: Alfandre
mesh_terms: D000066491:Clinical Decision-Making / Q000941:ethics* / Q000379:methods; D003657:Decision Making / Q000941:ethics*; D019317:Evidence-Based Medicine; D006801:Humans; D015588:Observer Variation; D026684:Personal Autonomy; D010817:Physician-Patient Relations / Q000941:ethics*; D010818:Practice Patterns, Physicians' / Q000941:ethics / Q000592:standards / Q000639:trends; D011787:Quality of Health Care / Q000592:standards / Q000639:trends; D035502:Trust