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Judgment analysis in clinical nephrology.

M Pfister1, S Jakob, F J Frey

  • 1Department of Medicine, University of Bern, Bern, Switzerland.

American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation
|September 2, 1999
PubMed
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Nephrologists show significant inconsistency in diagnosing non-end-stage renal disease (ESRD) patients, with diagnoses changing frequently over time. This variability in diagnosis did not impact treatment or prognosis, questioning the utility of diagnostic consistency in clinical nephrology.

Area of Science:

  • Nephrology
  • Clinical judgment analysis
  • Medical decision-making

Background:

  • Improving nephrologists' clinical judgment is vital for patient care.
  • No established methodology exists for analyzing clinical judgment in nephrology.
  • Assessing intraphysician consistency is crucial for understanding diagnostic reliability.

Purpose of the Study:

  • To evaluate the consistency of clinical judgment among board-certified nephrologists.
  • To quantify intraphysician variability in diagnosing non-end-stage renal disease (ESRD) patients.
  • To determine the impact of diagnostic changes on prognosis, therapy, and follow-up strategies.

Main Methods:

  • A trial involving 24 board-certified nephrologists analyzing typical non-ESRD patient cases.

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  • Cases were presented twice to each nephrologist over six months, with participants unaware of the repeated presentation.
  • Analysis focused on interobserver variability in diagnosis, therapy, prognosis, and follow-up strategy, comparing results from initial and repeated assessments.

    • Main Results:

    • High intraobserver variability was observed, with significant percentages of changed diagnoses across different groups (A: 64%, B: 50%, C: 33%).
    • Diagnostic changes decreased with increased confidence in the initial diagnosis.
    • Knowledge of renal histology increased diagnostic confidence but did not significantly alter the frequency of diagnosis changes.

    Conclusions:

    • Individual diagnostic judgment in nephrology is inconsistent and highly influenced by subjective confidence.
    • Variability in diagnosis did not substantially affect judgments regarding prognosis, therapy, or follow-up strategy.
    • The utility of focusing solely on diagnostic consistency for clinical judgment analysis in nephrology warrants reconsideration.