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Historically, decision -making during the management of disease was the domain and responsibility of the physician. Observation placed within a body of knowledge, derived from experience or didactically taught, was the framework for clinical decision –making. The artful application of knowledge, scientifically sustainable or not, constituted the identity of a profession where its members were given the social license to be the keepers of the knowledge they applied, as well as the evaluators of their own performance.
In the process of applying knowledge, the physician came to realize about the uncertainty of how various segments of knowledge interact. The management of this uncertainty has been associated with the “art” of applying incomplete and often untested knowledge toward the well-being of a patient. Hippocrates’s teaching, stated in Latin, summarizes the above reality of medicine as “Ars longa, vita brevis” (the task is huge, life is too short). Centuries later, Osler formulated the profession as “Medicine is a science of uncertainty and an art of probability…” (Brainy Quotes, 2012). It seems that medicine kept its identity almost intact over 20 centuries when dealing with the challenge of uncertainty. Yet, experimentation, also stated by Socrates, has acquired increasing importance as it can lead to a better understanding of how the segments of knowledge interact. In its most successful form, such experimentation can lead to evidence, or Evidence-based Medicine (EBM) (Bates, 2003; Guyatt, 2004; Strauss, 2005). Evidence in turn determines expectations both from providers and recipients of care, since the very nature of evidence is its replicability and hence predictability. The evolution of artfulness to application of predictable evidence did not however take the “art” of medicine away. Rather, it provided different and complementary dimensions to the evaluation of care provision: the “art” is readily appreciated by the recipient of care; and the evidence-based decision-making by those who evaluate the care scientifically.
As background, let us review the relevant Aphorism of Hippocrates (Wikipedia, 2012):
Ό βίος βραχύς,
ή δ έ τέχνη μακρή,
ό δ έ καιρ ό ς ό ξύς,
ή δ έ πεĩρα σφαλερή,
ή δ έ κρίσις χαλεπή.
The translation of this text into English is:
Life is short,
The art is long,
Opportunity fleeting,
Experiment fallible,
Judgment difficult.
The last statement uses the ancient Greek word Kairos (κρίσις), which means “opportune moment,” addressing the context and timing for the appropriate application of the knowledge. Kairos is different from Chronos, which deals with chronological timing (quantitative) – it defines a moment when an important decision is made (qualitative). Thus, judgment should best be seen as the culmination of the decision making within the context of the opportune moment.
The purpose of this chapter is to revisit the roots of clinical decision –making with a special emphasis on the management of uncertainty using information technology as the enabler for both responding in time to the “fleeting opportunity” and maximizing the appropriateness of the judgment within the “opportune moment.”