Viewpoint Argues Clinical Responsibility Visibility Is Lost in Protocols

In a viewpoint published in the Journal of General Internal Medicine, Gus W. Krucke, MD, reflects on the evolving nature of clinical decision-making in modern healthcare. The article, titled “On Learning to Decide,” is a philosophical and professional examination of how medical training and practice have shifted. Krucke argues that contemporary systems, while designed to manage complexity, have subtly altered where decisions are made and who owns them. The central thesis is that the visibility of responsibility in clinical judgment has diminished, replaced by a reliance on established pathways and protocols that mediate the authority of individual reasoning.

The narrative begins with a personal account of Krucke’s interactions with Herbert L. Fred, MD, MACP, a physician known for his exacting standards in clinical reasoning. Fred’s teaching method was characterized by a rigorous, disciplined approach to differential diagnosis. During noon conferences, Fred would present cases in the usual manner, allowing residents to move forward with their initial assessments. However, Fred would then intervene to press for a more specific formulation of the clinical question. He insisted on filling the front rows of the auditorium, believing that physical distance diluted attention. This ritual underscored his belief that clinical thinking requires immediate, undivided engagement.

Fred’s approach to differential diagnosis was described as a structure rather than a list. It was layered, weighted, and continuously revised. Possibilities were neither dismissed too early nor allowed to linger without justification. Each potential diagnosis carried consequence and required ownership. Krucke notes that he has never seen a differential diagnosis constructed with such range and precision in any academic setting before or since. The distinguishing feature was not the breadth of the differential, but the commitment to fully understand the case before allowing it to resolve. This process left little room for error, as the answer, when it came, belonged to the reasoning that produced it.

A key element of Fred’s teaching was the insistence on identifying the precise clinical question. He would often bellow, “What is the clinical question?” pressing for a more specific formulation than the tentative answers provided by residents. This questioning was not a performance but a demonstration of thinking. The diagnosis would emerge not by declaration, but by convergence, as the only remaining explanation that had not been discarded by careful reasoning. Krucke emphasizes that this was not a philosophy in the abstract, but a practical aspect of medicine. It was an insistence on judgment, excellence, and accountability, where the decision belonged to the physician willing to carry it forward.

Krucke draws a parallel between Fred’s approach and the work of Gabriel Aisenberg, MD, FACP, another physician known for his commitment to clarity of thought. Aisenberg, trained abroad and later in infectious diseases in the United States, brought a broader clinical perspective to the same discipline of reasoning. Their exchanges reflected a shared commitment to thinking, deciding, and owning the outcome. Where Fred constructed the differential with exacting precision, Aisenberg often expanded its frame, incorporating context that extended beyond the immediate presentation. The result was a complementarity in teaching that reinforced the principle of responsibility.

The viewpoint then shifts to the implications of these historical teaching methods for contemporary clinical practice. Krucke argues that modern medicine is shaped by structures designed to manage complexity, including protocols, pathways, metrics, and committees. These systems serve important functions by allowing medicine to scale, standardize, and reduce unwarranted variation. They offer a shared language through which decisions can be justified. However, these structures also change where decisions appear to be made. Disagreement, once resolved through direct deliberation, is increasingly redirected into process. The question becomes not only what is most reasonable, but what is most consistent with established pathways.

This shift is described as subtle, presenting itself as alignment rather than loss. Over time, the center of gravity moves. The differential diagnosis is still constructed, but its implications are filtered through protocols. The reasoning is still performed, but its authority is mediated. The final decision may reflect sound judgment, but its ownership is less clearly held. Krucke argues that what is lost is not knowledge, but visibility—specifically, the visibility of responsibility. In modern healthcare, decisions tend to default to agreed-upon procedures, often grounded in empirical evidence and justified on that basis.

Krucke references the work of H. Tristram Engelhardt Jr. and others to support the argument that systems resolve disagreement differently than individuals. Where no shared moral authority exists, decisions default to procedures. While this has the advantage of clarity, it carries a risk. Evidence can inform what is likely to happen, but it cannot determine what ought to be done in every case. If judgment is not taught, not modeled, and not visibly owned, it cannot be reliably reproduced. The lesson from Fred’s noon conferences was not simply how to think through a case, but how to stand behind a decision once it was made.

The reasoning in Fred’s conferences was visible, and the uncertainty was acknowledged. However, the responsibility remained with the one who chose. Krucke notes that Fred never said this explicitly, but it was evident in his practice. The decision, once made, belonged to him. This stands in contrast to the current environment, where the physician often participates as one component within a larger mechanism that defines the range of acceptable outcomes in advance.

Subject of Research: The impact of clinical protocols on the visibility of physician judgment and responsibility

Article Title: On Learning to Decide

Article References: Krucke, G. W. (2026). On Learning to Decide. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10973-8

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10973-8

Keywords: clinical judgment, medical education, clinical protocols, differential diagnosis, physician responsibility, healthcare systems, medical reasoning, Journal of General Internal Medicine, Learning, Decide, scientific research