A quantitative analysis demonstrating the superiority of positive findings over negative ones. Should be good post for fans of the JAMA's Users's Guides, our Symptom to Diagnosis and McGee's Evidence-Based Physical Diagnosis.
As a 64 year old practicing oncologist, my observation is that the concept of critical thinking is non existent among most young physicians. They practice based on self-inflicted algorithms that have no scientific or logical basis. Every conceivable test linked to a symptom is ordered hoping something sticks. They treat an EMR that shows labs and images, not patients. Their performance is measured in RVUs and a delusion of cost savings generated by decreased LOS, not appropriateness of care.
Very interesting piece! Though I must alert you that Bayesianism is, epistemologically, not a hypothetical-deductive model of inference and is much closely related to inductive logic -- it does make a big difference in philosophy of science and reasoning.
The best doctors I know are able to look at a patient and come up with a probable diagnosis which they then prove through testing. I understand the difficulty of teaching this to young doctors, but many times doctors these days are testing first and diagnosing based on what the test results tell them, with little physical exam. My best friend could feel your wrist and know that you were sick and what you are probably sick with. Doctors do not touch patients anymore. At least this is how patients see it. I realize the doctor must get through the EHR questions before they can deal with the patient, but I see one of the problems in our current medical system is the lack of emphasis on the actual physical exam
In many ways, teaching of probabilistic diagnosis in medical schools focuses on an opportunity to teach Bayes' rule, sensitivity, specificity, and likelihood ratios. For many diseases the pre-test probability of disease is more important than the test result, and estimation of pre-test probability is de-emphasized. Decision making would be improved by teaching the logistic regression model instead, where multiple continuous test results can be easily handled and the pre-test variables get all the emphasis they deserve. We need to move past oversimplified diagnostic impact summaries such as sens, spec, LR and think multivariably. And keep in mind that LRs, more useful than sens and spec, are still oversimplifications that have turned continuous test outputs into binary all-or-nothing variables.
Hence a coherent chief complaint is still more important in the note than a panoply of negative review of system check boxes, that nobody really asks anyway?
Nov 30, 2022·edited Nov 30, 2022Liked by Adam Cifu, MD
This is some excellent, interesting, and valuable work. I am stunned you couldn't find a home for it in the literature. Doubly stunned when I see the trivial nature of 80% of the material I see in the refereed literature.
As a 64 year old practicing oncologist, my observation is that the concept of critical thinking is non existent among most young physicians. They practice based on self-inflicted algorithms that have no scientific or logical basis. Every conceivable test linked to a symptom is ordered hoping something sticks. They treat an EMR that shows labs and images, not patients. Their performance is measured in RVUs and a delusion of cost savings generated by decreased LOS, not appropriateness of care.
Very interesting piece! Though I must alert you that Bayesianism is, epistemologically, not a hypothetical-deductive model of inference and is much closely related to inductive logic -- it does make a big difference in philosophy of science and reasoning.
The best doctors I know are able to look at a patient and come up with a probable diagnosis which they then prove through testing. I understand the difficulty of teaching this to young doctors, but many times doctors these days are testing first and diagnosing based on what the test results tell them, with little physical exam. My best friend could feel your wrist and know that you were sick and what you are probably sick with. Doctors do not touch patients anymore. At least this is how patients see it. I realize the doctor must get through the EHR questions before they can deal with the patient, but I see one of the problems in our current medical system is the lack of emphasis on the actual physical exam
In many ways, teaching of probabilistic diagnosis in medical schools focuses on an opportunity to teach Bayes' rule, sensitivity, specificity, and likelihood ratios. For many diseases the pre-test probability of disease is more important than the test result, and estimation of pre-test probability is de-emphasized. Decision making would be improved by teaching the logistic regression model instead, where multiple continuous test results can be easily handled and the pre-test variables get all the emphasis they deserve. We need to move past oversimplified diagnostic impact summaries such as sens, spec, LR and think multivariably. And keep in mind that LRs, more useful than sens and spec, are still oversimplifications that have turned continuous test outputs into binary all-or-nothing variables.
I hope medical schools incorporate sensible medicine into training!
Hence a coherent chief complaint is still more important in the note than a panoply of negative review of system check boxes, that nobody really asks anyway?
This is some excellent, interesting, and valuable work. I am stunned you couldn't find a home for it in the literature. Doubly stunned when I see the trivial nature of 80% of the material I see in the refereed literature.