Tips4EyeDocs Daily – 12/21/2011 – No 7 – Clinical Decision Making + more


Last night, while I was driving home, I noticed a fork in the freeway. I, like other drivers, wondered which fork to take on this freeway. From afar, it appeared that both dorks had slow traffic. I was quite familiar with one fork because it was my common route between home and work. The other, although less known to me, appeared to be less crowded. I looked at my GPS computer and saw that both forks had slow traffic for several miles. I guessed and took the more familiar fork knowing that if I was caught in traffic I could tell more easily where I was. It was a guess, an intuition.

In optometry practice, we get decision all of the time. Some, like in clinic require split second decision and some don’t. I hearken back to my problem solving series ( and think of clinical decision making as one of irrational versus rational.

I believe there are times that you make a decision purely because you experience and intuition knows that a clinical course of management is the right one even though others might think otherwise. You know that it will work because you have done it before. Sometimes you cannot explain it.

On the other hand, it less acute clinical pictures, a deliberate rational decision requiring data collection and analysis may be needed, especially if support from the patient or other is needed, often relevant where the clinical entity has a less determinate path or when third party payers require supportive evidence.

This is one of the counterpoints to clinical guidelines or protocols. There are situations where a doctor’s intuition is better than any guideline and we must allow for that. However, in no way, should we approach clinical decision making in a cavalier fashion. The doctor must execute the intuitive decision far more artfully than a rational one.


  1. Dr. Kevin Pho’s of MedPage today and one of the most followed physicians in social media feels that physicians need to see and know the value of EMRs before a greater adoption can occur. He feels that physician end users have not felt that their input was heard in these EMRs and that it is even about age but being heard. Spotted on Twitter via @kevinmd: “Show doctors the value when it comes to social media and EMRs”
  1. One of the most important steps here is what you want your brand to look or act like. If this question is not adequately answered the following four will not help much. Spotted on Twitter via @AdzProz and @fbsmallbiz : “Five Easy Ways to Spread Your Brand Through Social Media | Fox Small Business Center” .


Choi J, Moon JW, Shin HJ. Chronic kidney disease, early age-related macular degeneration, and peripheral retinal drusen Ophthalmic Epidemiol. 2011 Dec;18(6):259-63.

Department of Family Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.

PURPOSE: To evaluate the association between chronic kidney disease (CKD) and early age-related macular degeneration (AMD) and peripheral retinal drusen in Korean adults 50 years and older.

METHODS: This study included 3008 participants aged 50-87 years. Early AMD was assessed from retinal photographs based on modified Wisconsin AMD grading system and peripheral retinal drusen were assessed with a standardized examination. We defined CKD as estimated glomerular filtration rate of 60mL/min/1.73m(2) and below according to the Modification of Diet in Renal Disease equation. Logistic regression was used to examine the association between early AMD, peripheral retinal drusen, and CKD.

RESULTS: There were 88 subjects with early AMD and 42 subjects with peripheral retinal drusen. After adjusting for age, gender, body mass index, smoking status, hypertension, and diabetes mellitus, a significant association was found between CKD and peripheral retinal drusen as well as early AMD. Subjects with CKD were more likely to have early AMD (OR, 1.68; 95% CI, 1.04-2.72) and peripheral retinal drusen (OR, 2.01; 95% CI, 1.02-3.99) than those without CKD.

CONCLUSIONS: CKD was associated with peripheral retinal drusen as well as early AMD in Korean adults 50 years and older.

About Richard Hom OD, MPA

Dr. Hom holds Doctor of Optometry and Masters in Public Administration degrees and practices family eye care and consults on public policy, health information technology and program evaluation.
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