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Doctors as a knowledge and intelligence building group: pragmatic principles underlying decision-making processes
  1. Francisco Borrell-Carrió1,
  2. Anna Estany2,
  3. Frederic W Platt3,
  4. Vicente MoralesHidalgo4
  1. 1Department of Family Medicine, School of Medicine (UB), Catalonian Health Institute (ICS), University of Barcelona, Barcelona, Spain
  2. 2Philosophy Department (UAB), Autonomous University of Barcelona, Barcelona, Spain
  3. 3Department of Internal Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
  4. 4Department of Pediatria, Catalonian Health Institute (ICS), Vilafrancadel Penedés, Spain

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Pragmatism, as a philosophical option, is concerned with end results and argues that “all our thought-distinctions, however subtle, demand a possible difference of practice.”1 Physicians calculate daily the best plan of action for each patient, following some pragmatic rules: only taking into account different strategies when they lead to different results, the personal effort and moral risks are considered, and if of equal outcome and cost, the strategy that best preserves clinical safety and moral values. The purpose of this study is not to clarify the content of philosophical pragmatism, but to observe how it is applied in clinical decisions and what difficulties arise. We propose a paediatric case to illustrate this process: Dr Seel has just been visited by a 3 year old boy affected by earache. Dr Seel thinks the boy has otitis, because the eardrum was bulging and slightly red, and Dr Seel is aware of current evidence-based recommendations2 which suggest that it is often not necessary to treat otitis with antibiotics. However the mother requests such treatment: “A few months ago he also had ear pain and non steroidal anti-inflammatory medicine didn’t work.” Dr Seel reconsiders her decisions, recalling the eardrum appearance, and prescribing antibiotics as a safer option.

We can distinguish several aspects in this vignette:

  1. Calculation of efficiency: What must I do to achieve a diagnosis or therapeutic goal, and how time-consuming would it be? For this calculation, the doctor has four sources of information: (1) her own experience; (2) evidence-based clinical guidelines; (3) deliberation with colleagues or her team3 and (4) any assistance available from laboratory or radiology studies. The result of this process is an action plan.4 Pragmatic calculus integrates all four elements, being physicians—in general—unable to specify the assigned weight to each one. The result of …

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