Make a decision already!

We all have our pet peeves in medicine. A big one for me is the rampant use of “consider” in clinical notes. Patient presents with chest pain? Consider a cardiac stress test. Patient has sepsis with unclear source? Consider additional imaging.

I imagine it’s a holdover from our training days. As an intern, you don’t really know whether to pursue a certain line of testing or treatment, so you list off items that sound reasonable without endorsing any particular action. That way, the attending knows you thought about the right things, but you spare yourself the embarrassment of a bad recommendation.

Once you’re out of training, however, this kind of hedging serves no purpose. “Considering” all of your interventions is non-committal and doesn’t help anyone understand your clinical reasoning. You considered it, so are you going to do it or not?

It’s a little more understandable when the action in question is outside your area of expertise, but if that’s the case, you should probably be taking other, more decisive action. As the primary team, for example, you might ponder switching your patient with persistent MRSA bacteremia from vancomycin to ceftaroline. However, if you aren’t comfortable making that call, the plan should probably read “consult Infectious Disease,” rather than “consider changing to ceftaroline.”

I find it even more exasperating when consultants play the “consider” card. Continuing with the MRSA bacteremia scenario, let’s say the primary team goes right for the ID consult. As the responding consultant, you perform a characteristically thorough history and physical. After careful contemplation of the findings, you outline a plan in which you “consider changing to daptomycin.” That’s great…except that the primary team is asking for your expert opinion on what they should or should not do. They probably already considered a lot of things, including a change in therapy, but they called you because they don’t feel equipped to make the right adjustments.

Clinicians may sometimes use “consider” when they believe something should be done, but they don’t feel comfortable making a firm recommendation outside their wheelhouse. If you’re worried about peripheral vascular disease in a diabetic foot infection, but you aren’t the vascular expert, you might “consider Vascular Surgery consult.” Maybe you aren’t sure that the patient really needs a formal Vascular Surgery evaluation, so you don’t want to go out on a limb and recommend it. There’s always a middle ground, though. Personally, I like to suggest actions in that situation – this at least makes it clearer that you think the consult should be pursued, even if you don’t have a high degree of confidence about it.

Another situation that may prompt us to “consider” our actions is when we suspect a patient will need an intervention in the near future, but they don’t need it right now. If you have an immunocompromised patient who hasn’t improved much after two days of broad-spectrum antibiotics, you might “consider adding antifungal coverage.” If you’re the ID consultant on the case, however, it’s preferable to offer a specific conditional – “if respiratory status has not improved by 10/25, will add antifungal coverage.” This leaves a lot less ambiguity about your intentions.

I think a lot of us are blissfully unaware of how our notes are perceived. Considering a plan item just floats an idea, hoping that someone else will take ownership of it and make a decision. Even if that’s not the desired message, I believe that’s how it comes across.

These days, it may feel like medical documentation is just checking a bunch of boxes for billing and insurance purposes, but let’s not forget the intended purpose. Clinical documents are meant to communicate our thought processes and outline courses of action that everyone reading the note can understand and follow. Spitballing tests and treatments does nothing to advance patient care. Somewhere in that sea of auto-generated EMR garbage, we need islands of discernment and decisive action. Despite the impression we may get from the never-ending clinical coding clarifications, there are still clinicians who read and appreciate quality notes. At least, now you know I’m reading yours.

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