- The outcomes for large, heterogeneous samples are
involved, and interest in the individual case is min-
imal. Having a statistical formula to predict how
many of 50,000 soldiers will receive dishonor-
able discharges from the Army will be highly
useful to the Army, though less so for the
clinician who is dealing with Private Smith. - There is reason to be particularly concerned about
human judgmental error or bias. Fatigue, boredom,
bias, and a host of other human failings can be
responsible for clinical error. Often, such effects
are random and unpredictable. Formulas,
equations, and computers never become tired,
bored, or biased.
Much of the controversy over clinical versus
statistical methods has been heated. Each camp
seems to scorn the other. If a formula appears to
do better than intuition, clinicians become threat-
ened and react defensively. Similarly, some
researchers view all clinicians as nothing but
second-rate adding machines when it comes to
making predictions. Such reactions do little to
resolve anything but instead freeze both factions
into positions that prevent either from accepting
the strengths of the other.
The most useful position would seem to be one
that integrates the two approaches. The sensible clini-
cian will use every regression equation, objective test
score, or statistical method that shows promise of
working for a specific task. Such a clinician will fully
understand that clinical data gathering, hypothesis for-
mation, and even intuition will never be totally sup-
planted by a formula. By the same token, the clinician
can take comfort from the fact that even regression
equations must spring from somewhere. Just as some-
one must program a computer, so too must someone
decide which kinds of data should be quantified and
submitted for statistical analysis. Someone must ini-
tially select the tests and the test items. Although for-
mulas can be applied mechanically, their initial
development depends on the clinical psychologist.BOX10-3 Focus on Professional Issues: How Do Psychiatrists Make Clinical Decisions?Like clinical psychologists, psychiatrists engage in clinical
decision making. Furthermore, these decisions are often
based on data gathered from subjective self-reports of
the patient. A recent study (Bhugra, Easter, Mallaris, &
Gupta, 2011) sought to investigate the clinical decision-
making process of psychiatrists by conducting in-depth
interviews of 31 psychiatrists about their own ways of
obtaining, managing, and integrating patient data to
make clinical decisions. The researchers organized their
findings around several themes and stages in the clinical
decision-making process.
Information gathering: Psychiatrists relied heavily
on unstructured psychiatric interviews to gather data,
and they did not routinely use psychological or medical
tests.
Clinical intuition and experience: Psychiatrists
highlighted the importance of using clinical intuition and
hunches in evaluating symptoms and diagnoses of
patients but did cite the use ofevidence-based guidelines
when making decisions regarding medication and treat-
ment. Interestingly, novice psychiatrists were more likely
to rely on evidence-based guidelines than were more
experienced psychiatrists, who used more clinical intuition.Uncontrollable factors: Psychiatrists cited the
influence of many“uncontrollable”factors on their
decisions, including limited treatment options at the
facility, the availability of and costs of medications,
patient compliance, and the time available to make the
decision.
Multidisciplinary teams: Psychiatrists indicated
that the opinions of the multidisciplinary team (e.g.,
nurses, psychologists, social workers) frequently influ-
enced the ultimate clinical decision, especially in cases
of uncertainty or high risk.
The investigators concluded that these results
were broadly consistent with the dual-process theory
of decision making, which suggests two approaches
to clinical decision making depending on the famil-
iarity of the situation. When the clinical situation is
familiar, psychiatrists reported relying more on their
own clinical intuition. In contrast, when the clinical
situation was more unfamiliaroruncertain,psychia-
trists tended to rely more on an analytical approach
to decision making that involved evaluating the evi-
dence base for the decision and gathering additional
input.CLINICAL JUDGMENT 297