Clinical algorithm; a powerful tool for facilitation of medical decision making

photo via PhotoMag

I was given a choice between doing physics or biology for my A levels. It was a no brainer at that time. Biology, it is. I have always wanted to do medicine and I had thought that biology was the path that would best prepare me for medical school.

Another reason was my contempt for physics. It was not because I could not deal with concept relating to energy, forces and etc. I believed I had a flair in choosing the right formulas and using them to solve exam questions. Getting decent grades in ‘O’ level physics was almost automatic for me; something that I could achieve with considerably less effort. But, what’s the fun in applying formulas to get the answers to problems that were hardly relevant to the life I was living? And so my contempt developed and it was directed not just towards physics but also towards related university courses such as mechanical engineering and other engineering courses – anything that involved using rigid impersonal formulas disinterest me.

This has definitely contributed to my preference for Biology and Medicine – a subject of study that (in my past opinion) requires more hard work, commitment, and a good understanding of concepts to be able to apply these to ‘real-life’ problems. Sometimes, imagination comes into play to create a three-dimensional construct which allowed me to understand the spatial relations.

Medicine is a field that boasts stories of great revered men i.e. stories of wise old consultants who appear in the nick of time to step in and help young greenhorn doctors solve difficult mystery-like diagnostic cases. The work of a doctor is always depicted as detective-like, fluid, genuine, mentally challenging, and typically head-scratching. It is widely acclaimed that no two patients are the same and therefore should not be seen that way. With such messages in my head, my younger self was convinced that algorithms and formulas have no place in Medicine.

"Surely it can’t be! How can an inflexible formula be applied to manage patients that are not consistent throughout the population?" I thought

Then, during one of my clinical placements, I was told of the importance of following the different guidelines for the various diseases seen. I was told that following guidelines is the wisest thing to do; it prevents us from doing anything seriously wrong or stupid and protects us from legal litigations. Lawsuits over medical negligence must be quite daunting, I thought. Even the walls of the ward were decorated with countless papers/posters illustrating guidelines for managing the different diseases. There are comprehensive A3-sized graphs detailing each step to managing different conditions.

Have a look at this simple guideline to managing hypertension via eMed

I was initially disheartened to know this. But, having done a substantial amount of reading and learning, I think I can now appreciate algorithms better; this new respect for algorithms arises from recently acquired understanding of the need for algorithms. Algorithms no longer give me the same kind of disgust or inferiority as it did back in high school. It was silly of me to think that way.

Consider APGAR score; a simple method of determining if a newborn requires immediate medical attention through the consideration of five variables, giving each of the variable a score and adding the total score. Consider FRAX score; an elaborate risk assessment tool that computes risk factors, churns out the 10-year osteoporotic fracture risk, and provides advice on management strategies. There are many other algorithms that supplement clinical expertise.

I have come to realise that algorithms and guidelines not only simplify complicated tasks but also provide efficient and more accurate way of reaching clinical decisions. Several algorithms are designed to elucidate prognosis, providing unbiased long term predictions of clinical outcomes. The ability to produce a number denoting the likelihood of future events is an extremely useful tool that provides the direction for clinical management. Besides, it is comforting to know that these algorithms are evidence-based and can be improved, where possible.

FRAX calculates risk of future fracture using a questionnaire involving 11 questions. Try it here 

On hindsight, my thoughts and prematurely conceived notions about the two subjects were silly. My impression of the world around me was oversimplified. My contempt at formulas, algorithms and anything that seemed rigid, impersonal, effortless and simple was not smart. My impression that algorithms leave nothing to the mind – to creativity or an eager mind that needs to churn information, analyse data and make an educated intuitive judgement – was not intelligent. Algorithms do have a place in Medicine. Not only should we welcome it, we should be developing it for the better.