The role of experience in hypothesis verification phase of diagnosis

Elias Peter pheski69 at GMAIL.COM
Tue Jun 26 15:34:09 UTC 2018


A couple notes inline below…


On 2018.06.26, at 10:19 AM, Jain, Bimal P.,M.D. <BJAIN at PARTNERS.ORG> wrote:


> “... if a highly informative test result with likelihood ratio greater  than 10 is observed in a patient, then the definitive diagnosis of a disease in this patient is validated…”


In primary care, instances where there is “a” definable and definitive diagnosis and a highly informative test with a likelihood ration greater than 10 exists are the exception rather than the rule.  Discussion of these infrequent occurrences is interesting but of limited value to the majority of diagnostic processes in primary care.


> “...if we suspect hypothyroidism  in a patient with fatigue seen in office and find elevated TSH, the definitive diagnosis of hypothyroidism would be validated…”


True, but that would not necessarily mean that the hypothyroidism was the cause (or the only cause) of the fatigue in that patient. It could be true and partly related or unrelated.

In short, I am not disagreeing with the point(s) you make, just trying to make it clear where they do and don’t apply in primary care.

Peter



 
From: Elias Peter [mailto:pheski69 at GMAIL.COM <mailto:pheski69 at GMAIL.COM>] 
Sent: Wednesday, June 20, 2018 9:07 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] The role of experience in hypothesis verification phase of diagnosis
 
        External Email - Use Caution        

I have several comments to make.
 
First, I see Bayesian assessments as telling us how likely it would be for that evidence given a hypothesis, not how likely the hypothesis is given the evidence. A recent article offered a wonderful analogy I wish I had heard years ago: given a dog (test result) we can be pretty certain there are four legs (the evidence), but given four legs (the evidence) we need much more information to know if we are dealing with a dog, camel, or turtle.
 
Second, I think it is a mistake - or at least, too narrow a framing - to see diagnosis as an event rather than a process. This may reflect my 40 years in primary care, as I have noticed during my career that clinicians who work in settings like intensive care units or acute trauma centers have a very different process when caring for undiagnosed patients. In primary care (and in many specialties that deal mostly with chronic illness) it is often that one is best and most efficient making a diagnosis over time rather than during a single encounter. In this setting, it is unusual to be in the position of having a patient with a clinical snapshot (I don’t say picture, because it really IS a snapshot, obtained relatively quickly and in a limited context) and then having to make a diagnosis based on a test result. 
 
Third, at least in primary care, a very substantial number of diagnoses are made by a clinical picture over time (natural history). We don’t have a diagnostic ‘test’ for anxiety, depression, most of the causes of low back pain, most of the causes of headache, most of the causes of fatigue…   In these settings the process is something like this:
Are there any things I can’t miss, right now, in this visit, without putting the patient at immediate risk?
If so, what can I do to determine their presence or absence.
If not, how do I remember this list and refer back to it if the picture changes?
What are the most likely causes of what I am seeing and hearing?
Are there any likely causes of what I am seeing and hearing that I can easily and efficiently prove or disprove?
Have a conversation with the patient about the diagnostic possibilities, the degree of certainty and uncertainty.
Ascertain what part of the clinical picture the patient is most concerned about. (Some patients want a diagnosis and some want treatment and some want both, depending on the setting.)
Given that we have a collection of possibilities of varying severity and frequency and likelihood and we know what the patient’s preferences are (because we asked her and listened), what is a reasonable approach to managing the problem, including but not limited to:
Work on diagnosis, hold off on treatment?
Work on diagnosis, treat symptoms?
Treat symptoms and observe the course. (Here natural history is ‘the test’ we are using, but it doesn’t have a ‘result’ in the sense of Q waves or blood sugar or potassium.)
Not treat symptoms and observe the course.
Trial and error - treat something and see if it works.
 
Very few of my patients with back pain or headaches or fever have any ‘tests’ done. In primary care, depending on the patient context, fatigue may be best diagnosed by history and a brief exam - though there are settings where tests are clearly essential. I doubt that more than 2 patients a day needed a ’test’ in the sense that is being discussed in these threads. (My daily volume was 18-20 on a bad day, 16 on a good day.)
 
 
My point here is that framing the diagnostic process around how one interprets a test result considers a very limited piece of the diagnostic universe. It is important when it is germane - when I present to an ED poorly responsive and hypotensive, I want the test results to be properly and quickly evaluated. However, from my PCP, patient, and caregiver perspectives I think this is a tiny part of the diagnostic universe and not easily generalized across the broad landscape of medicine. I am much more interested in and concerned about ways to improve the diagnostic process in the 90% (or more) of circumstances where the results of ‘a test’ are unlikely to be definitive. Of course, that reflects my 40 years in the primary care front line where ambiguity is part of the air we breathe.
 
Peter
 
 
 
 
 
 
On 2018.06.20, at 12:46 PM, Jain, Bimal P.,M.D. <BJAIN at PARTNERS.ORG <mailto:BJAIN at PARTNERS.ORG>> wrote:
 
In this attached paper, I discuss that experience plays an important role in validating the verification of a diagnostic hypothesis by a test result. As our experience is gained from a heterogenous population of patients with varying prior probabilities, this validation is represented by a confidence and not by a Bayesian argument.
Please review and comment on this paper.
Thanks.
 
Bimal
 
Bimal P Jain MD
Northshore Medical Center
Lynn MA 01904.
 
 

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