Uncertainty

Xavier Prida dr.xavier.prida at GMAIL.COM
Tue Jun 20 17:27:56 UTC 2017


All,
The stakes vs odds phenomenon is presumably resolved by a combination of
Bayesian knowledge of the complaint at hand (the pretest probability)-
guided by comparative effectiveness analysis of the risks/benefits/cost of
the test or cascade of tests.

The best example of the imperfection of this science is the cost and
resources delivered for E/M of chest pain in the ED. Even low probability
have event rates that to some systems and practioners(and perhaps patients)
find unacceptable which leads to overtesting.

Hence , the need for declaration to the patient of our uncertainties and
allow for shared decision making based on the specific patient's values and
preferences.

Xavier

On Tue, Jun 20, 2017 at 12:50 PM, Grubenhoff, Joe <
Joe.Grubenhoff at childrenscolorado.org> wrote:

> That STAKES vs ODDS argument drives a lot of health care costs and those
> extra tests that cost so much have a FP/FN rate that leads us down rabbit
> holes and may expose patients to unnecessary risks and harms in their own
> right. A more accurate assessment is that the STAKES matter more when
> something bad happens and the ODDS matter more when the pocket book is
> concerned. Being a physician and trying to balance that is a tricky task.
> Essentially we’re asked to have a crystal ball.
>
>
>
> We’ve had parents in our ER whose children have had significant blunt head
> trauma and have signs symptoms concerning for a serious intracranial injury
> so we order a head CT. When it comes back negative, they don’t want to pay
> the bill because it didn’t show anything so we should have somehow known
> not to get it.
>
>
>
> One failure of the health care system is that we have separated the
> discussion of risk and cost for our patients. Many want everything ruled
> out but balk at the cost.
>
>
>
> *[image: Sig1]*
>
>
> *Joe Grubenhoff, MD, MSCS| Associate Professor of Pediatrics  *Section of
> Emergency Medicine | University of Colorado
>
> Associate Medical Director - Clinical Effectiveness
>
> Children's Hospital Colorado
>
> 13123 East 16th Avenue, Box 251  |  Anschutz Medical Campus  |  Aurora, CO
> 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317
>
> joe.grubenhoff at childrenscolorado.org
>
>
> *Connect with **Children's Hospital Colorado*
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>
>
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>
> *                We are a caring community called to honor the sacred
> trust of our patients, families and each other through *
>
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>
> *…This is the moment.*
>
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>
> *From:* Phillip Benton [mailto:0000000697ec7b18-dmarc-request at LIST.
> IMPROVEDIAGNOSIS.ORG]
> *Sent:* Tuesday, June 20, 2017 9:52 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Uncertainty
>
>
>
> Rob & Xavier,
>
> The standard in patient/plaintiff's lawsuits is that when a physician is
> formulating a Diff Dx, the most dangerous Dx should be placed at the top
> and ruled out first. Stated simply, the STAKES matter far more than the
> ODDS.
> Phillip  Benton, MD, JD
> Adjunct Professor
> Emoty Law School
>
> Phillip Benton
> pgbentonmd at aol.com
>
>
> ------------------------------
>
> On Tuesday, June 20, 2017 robert bell <0000000296e45ec4-dmarc-
> request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:
>
> Xavier,
>
>
>
> I would think not in a very scientific way. But it should be, and
> explained to the patient.
>
>
>
> Doing a study with HCPs on their impression of the frequency of certain
> diseases/conditions in their practice and also in general practice would be
> interesting. The range I suspect would be eye opening.
>
>
>
> A similar study on the length to diagnosis of rarer conditions would also
> be enlightening.
>
>
>
> Should we not be able to get this information now from data bases?
>
>
>
> Rob Bell MD.
>
>
>
>
>
> On Jun 3, 2017, at 4:08 AM, Xavier Prida <dr.xavier.prida at GMAIL.COM>
> wrote:
>
>
>
> Is uncertainty allowed for in the expectations of diagnosis and management?
>
> Article;
>
> Assumptions of Quality Medicine- The Role of Uncertainty
>
> doi:10.1001/jamaoto.2017.0257
>
>
>
> ​Xavier​
>
>
>
> Xavier E. Prida MD FACC FSCAI
>
> Assistant Professor of Medicine
>
> Program Director Cardiology Fellowship Training
>
> USF Morsani College of Medicine
>
> Department of Cardiovascular Sciences
>
> 2 Tampa General Circle
>
> STC 5 th Floor
>
> Tampa, Fl 33606
>
> 813 259 0992 <(813)%20259-0992>(O)
>
>
>
>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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-- 
Xavier E. Prida MD FACC FSCAI
Assistant Professor of Medicine
Program Director Cardiology Fellowship Training
USF Morsani College of Medicine
Department of Cardiovascular Sciences
2 Tampa General Circle
STC 5 th Floor
Tampa, Fl 33606
813 259 0992(O)






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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