Commentary: Breaking the Mold of Normative Clinical Decision Making: Is It Adaptive, Suboptimal, or Somewhere in Between?

Two articles in this issue, "Contextual decision making and the implementation of clinical guidelines" by Falzer and Garman, and " PERSPECTIVE: Uses and misuses of thresholds in diagnostic decision making" by Warner et al, take very different approaches to the issue of variation among physicians in diagnostic and therapeutic decision making. Falzer and Garman critically examine the well-known phenomenon of poor compliance with practice guidelines. They view this as a reflection of the mismatch between the guideline and the characteristics and needs of individual patients, and as a consequence of the adaptive judgment of the physician. They go on to show that, as the match between the individual patient and the hypothetical patient in the guideline increases, adherence with guidelines increases. Warner and colleagues take a more theoretical position on the larger issue of physician decision making, through the concept of "decision thresholds" originally advanced by Pauker and Kassirer, and attempt to model an example of clinical judgments through this conceptualization. The two articles represent an intriguing contrast on many levels, most fundamentally in that the first views any departure from normative behavior as goal oriented and adaptive and seeks to understand it; the second views it as suboptimal and seeks to minimize it.