The document discusses the uncertainty inherent in medical diagnosis and treatment. It notes that diagnoses assign probabilities rather than certainties, and that tests have varying sensitivity and specificity levels. A key challenge is determining acceptable risk levels, such as how many missed diagnoses are tolerable. The document advocates considering pre-test probability, test accuracy metrics, and residual risk to determine appropriate diagnostic or discharge pathways. Overall, it emphasizes communicating risk to patients and balancing risk versus benefit in clinical decision making.
8. Truth table and calculations
Sensitivity=a/a+c
Specificity=d/d+b
9. H-FAB in AMI
Sensitivity 97%
Specificity 54%
HFABP
125
261
4
315
10. What answers do we really
get from a Truth table?
What does a +ve test
result really mean?
What does a -ve test result
mean?
HFABP
125
261
4
315
11. H-FAB testing for AMI
• A +ve test means they have
the diagnosis
• A +ve test means they
probably have the diagnosis
• A +ve test means they are
more likely to have the
diagnosis than before I did
the test
HFABP
125
261
4
315
12. Myth: Reality vs. research
•Researchers live in
the clouds
•Clinicians have their
feet on the ground
13. Probability
• Diagnosis often assigns a probability
• We will miss some people with disease
• We will mislabel (and treat) people without
disease
21. Which screening test?
• D-dimer rules out
• Wells score rules out
• PERC score rules out
• Wells and PERC rules out
• Wells + D-dimer rules out
• Other (e.g. dopplers, flip a coin, astrology etc)
24. Example - PERC rule
•
•
•
•
•
•
•
•
Age>49
Pulse>100
Pulse Ox<95%
Current haemoptysis
Oestrogen use
Previous venous thromboembolism
Recent surgery
Unilateral leg swelling
PERC Rule
sens = 97.4%
spec = 21.9%
37. Diagnosis missed
It gets worse
They don’t come
back
The treatment
does not work
Harm takes place
Diagnosis made
They get better
anyway
They do come
back
..but the diagnosis is
missed again!
The treatment
works
Significant harm
avoided
43. Patient confidence
Physician certainty
Patient concern
Physician discomfort
Uncertainty, responsibility and the evolution of the physician/patient relationship
Henry MS JMedEthics 2006;32:321-323
44. I don’t have a PE
You don’t have a PE
I might have a small risk
of PE
That patient might have
a PE and sue me
Uncertainty, responsibility and the evolution of the physician/patient relationship
Henry MS JMedEthics 2006;32:321-323
45. I don’t have a PE
You don’t have a PE
Is honesty is good for
doctor and patient?
Uncertainty, responsibility and the evolution of the physician/patient relationship
Henry MS JMedEthics 2006;32:321-323
46. Take away
• Do I make diagnoses or probabilities?
• Is some risk acceptable in my practice?
• How do I communicate risk to patients?
48. Risk vs Benefit
• Benefits to patients
• Access to therapy
• Knowledge
• Treatment benefit
• Cost
• Risks to patients
• Denied therapy
• Risk of therapy
• Risk of investigation
• Cost
Editor's Notes
General question as ice breaker
Common reasons likely to be labels, prognosis, therapy.
Ultimately because it is useful to know.
BUT
the key to a rational diagnostician is that it should be beneficial for the patient and not just the physician
55 year old man with 2 hour hx of chest pain. no risk factors. previously fit and well
Digivote slide
Answer is 90-95%
Howard Atwood Kelly (February 20, 1858 – January 12, 1943) was an American gynecologist. He was one of the "Big Four" founding professors at Johns Hopkins Hospital.[1] (The "Big Four" were William Osler, Professor of Medicine; William Stewart Halsted, Professor of Surgery; Howard A. Kelly, Professor of Gynecology; and William H. Welch, Professor of Pathology.) Kelly is credited with establishing gynecology as a true specialty.[2]
Harvey Williams Cushing, M.D. (April 8, 1869 - October 7, 1939), was an American neurosurgeon and a pioneer of brain surgery, and the first to describe Cushing's syndrome.[1] He is often called the "father of modern neurosurgery.
Thayer prof medicine at John Hoplins
Objective: Many Emergency Departments (EDs) utilise ‘triple marker’ testing with CK-MB, myoglobin and
troponin I (cTnI) to exclude acute myocardial infarction (AMI) within hours of presentation. We evaluated
the ability of 8 biomarkers to rapidly exclude AMI at the point of presentation and investigated whether
‘triple marker’ testing represents the optimal multimarker strategy.
Methods: We recruited patients who presented to the ED with suspected cardiac chest pain occurring
within 24 h. Blood was drawn at the time of presentation. Diagnostic value was assessed by calculating
the area under the ROC curve (AUC) and a multivariate model was constructed by logistic regression. The
primary outcome was a diagnosis of AMI, established by
≥12-h troponin testing in all patients.
Results: 705 included patients underwent venepuncture a median of 3.5 h after symptom onset. Heart
fatty acid binding protein (H-FABP) had an AUC of 0.86 (95% CI 0.82–0.90), which was significantly higher
than any other biomarker including cTnI. While no single biomarker could enable exclusion of AMI,
multivariate analysis identified cTnI and H-FABP as the optimal biomarker combination. Combined with
clinical risk stratification, this strategy had a sensitivity of 96.9%, specificity of 54.7%, PPV 32.4% and NPV
98.8%.
Conclusions: We have derived an algorithm that would enable AMI to be immediately excluded in 315
(44.7%) patients at the cost of missing 6 AMIs per 1000 patients treated. While the risk is likely to be
unacceptable for clinical implementation, we have highlighted an area for future development using
serial testing and increasingly sensitive assays.
Digivote
LR +ve 2.138
LR -ve 0.057
+ve test is not a diagnosis
They still probably don’t have a diagnosis.
Pretest probability was 129/705 = 18.3%
After testing probability is = 33.2%
So as a clinician we have no idea whether our patient has the right diagnosis or not. We just know that they probably do or they probably don’t.
Even with tests that have a high sensitivity.
Probability
So if we accept that we have a probability issue then we have a problem of risk.
Digivote
D-dimer sensitivity 90%
Wells score misses 3.4%
PERC score rules out 2.6%
Wells and PERC rules out 1% (but you only rule out a small number)
Wells + D-dimer rules out 2% (rules out about 50%)
Other (e.g. dopplers, flip a coin, astrology etc)
chest pain tests.
Digivote
1666 ?PE patients in 13 US and NZ EDs
Gestalt plus PERC gives the following
PERC Rule
sens = 97.4%
spec = 21.9%
Designed with acceptable miss rate of 2%
Even in this study PEs were missed.
^ Kline, JA; Courtney, DM; Kabrhel, C; Moore, CL; Smithline, HA; Plewa, MC; Richman, PB; O'Neil, BJ et al (2008). "Prospective multicenter evaluation of the pulmonary embolism rule-out criteria". Journal of Thrombosis and Haemostasis 6 (5): 772–780. doi:10.1111/j.1538-7836.2008.02944.x. PMID 18318689.
J Thromb Haemost. 2008 May;6(5):772-80. Epub 2008 Mar 3.
Prospective multicenter evaluation of the pulmonary embolism rule-out criteria.
Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O'Neil BJ, Nordenholz K.
Source
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC 28323-2861, USA. jkli[email_address].org
Abstract
BACKGROUND:
Over-investigation of low-risk patients with suspected pulmonary embolism (PE) represents a growing problem. The combination of gestalt estimate of low suspicion for PE, together with the PE rule-out criteria [PERC(-): age < 50 years, pulse < 100 beats min(-1), SaO(2) >or= 95%, no hemoptysis, no estrogen use, no surgery/trauma requiring hospitalization within 4 weeks, no prior venous thromboembolism (VTE), and no unilateral leg swelling], may reduce speculative testing for PE. We hypothesized that low suspicion and PERC(-) would predict a post-test probability of VTE(+) or death below 2.0%.
METHODS:
We enrolled outpatients with suspected PE in 13 emergency departments. Clinicians completed a 72-field, web-based data form at the time of test order. Low suspicion required a gestalt pretest probability estimate of <15%. The main outcome was the composite of image-proven VTE(+) or death from any cause within 45 days.
RESULTS:
We enrolled 8138 patients, 85% of whom had a chief complaint of either dyspnea or chest pain. Clinicians reported a low suspicion for PE, together with PERC(-), in 1666 patients (20%). At initial testing and within 45 days, 561 patients (6.9%, 95% confidence interval 6.5-7.6) were VTE(+), and 56 others died. Among the low suspicion and PERC(-) patients, 15 were VTE(+) and one other patient died, yielding a false-negative rate of 16/1666 (1.0%, 0.6-1.6%). As a diagnostic test, low suspicion and PERC(-) had a sensitivity of 97.4% (95.8-98.5%) and a specificity of 21.9% (21.0-22.9%).
CONCLUSIONS:
The combination of gestalt estimate of low suspicion for PE and PERC(-) reduces the probability of VTE to below 2% in about 20% of outpatients with suspected PE.
Digivote
6.9 % pre test probability of PE.
Kline study multicentre
8138 patients gestalt plus PERC
3500
Digivote slide
No guarantee that failure to diagnose = harm
No guarantee that diagnosis = success.
Sequence has to be completefor harm to occur
IN appendicitis. Miss diagnosis, not come back early, not get recognised, not get to theatre, not respond to treatment, not survive.
Sequence has to be complete for harm to occur
IN appendicitis. Miss diagnosis, not come back early, not get recognised, not get to theatre, not respond to treatment, not survive.