uncertainty in medical problem solving and decision making (Was: Dr R LONJON Confidence indicator !

[Gerard Freriks]

On Apr 27, 2005, at 8:19 AM, Arild Faxvaag wrote:

 We could say that physicians _infer_ diagnostic hypotheses based on
 - knowledge of the tentative underlying disease,
 - the patients subjective experiences
 - phenomena registered in the patients body

In any case it is a subjective statement and is  a professional  
opinion based on more (lab results, x-rays) or less (patient history)  
objective data.


 Phrases such as  cannot be exluded might be due to, probably,  
 definitely, beyond doubt  are statements of probability of the  
 inferrence being correct (and what to do next).

Inferrences expressed in the subjective statements documenting the  
treatment of the patient.


 Can one say that diagnoses belong to the class of statements  
 whereas the disease itself belong to the class of natural phenomena?

Disease is an abstraction of reality that for the moment, for the  
next decision is considered to represent the reality about the health  
of the patient.
Diagnosis is the professional but subjective opinion about a disease  
of a patient.

There is a continuum:
Real pathological, fysiologiscal phenomena in a patient.
Certain manifestations of these phenomena.
That are (or are not) experienecd by the patient of an other person.
The arrousal of distress, anxiety, etc, triggering a visit to a  
physisian.
What is said (or not) about the manifestations of the phenomena  
during the visit.
And how it is said.
How it is measured and documented.
What is understood  of what was said or measured about the  
manifestations of the phenomena.
How all this was mached to the state-of-the art knowledge, or  
interpreted in the context of a limited amount of available knowledge.
What was recorded about all these steps above.
How the same person (or others) interpret the recorded 'facts' at a  
later stage

So what do we record in an EHR?
And what do we interpret readingan EHR?
Then ...
What is certain?
And what is uncertain?
Certain or uncertain in what domain, in what line above, at what  
level of the whole described continuum?

In ?25% of the extremely wel researched patients in one University  
Hospital we not diagnosed correctly during their life time.
As could be concluded after an autopsy.
So what do we really know about disease and complaints?

What is certainty?
What is it refering to?

Do we understand this mine field well enough?



 The diagnosis establishes a relation between the subjective  
 experiences / phenomena and the disease that induces those symptoms  
 and findings.
 Example:
 Experiences and phenomena: Pain in the wrist joints, feeling of  
 joint stiffness, joint tenderness, joint swelling, elevated  
 sedimentation rate.
 Diagnostic inferrence:  Rheumatoid arthritis.
 Relation: Might be induced by/due to

 Can statements of probability be considered statements regarding  
 the strength of these relations??

This is what they are at best.


 Comments on this?

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Issue 1

[Dr LONJON Roger]

Hi all,
the exercise of medicine is an art.
This is not an exact science as the physics.
With the biology, the anatomo-pathology, the x'ray explorations and R.M.Imaging,
the physician gets information that are validated.
They are validated because there was physical signal registration that was
digital, pictures in RMI. These pictures, as blades of microscope, can be
reread, in the time by other physicians.
They have a statute of data validated by the physician and therefore publishable
in the file of cares of the sick.
The diagnosis makes by the physician is the result of a reasoning, from one
wholes of information that it to on his patient. One teaches it to students
future physicians.
The diagnosis is sometimes fast, but often it asks for a delay of several days
weeks or years!!  or never !!
Hypoth?seses, elaborate by the physician, are only some likely, probable
information.
 In France, there is an agreement to say that it is about  personal  Notes
that are not validated.and what are the property of the physician.
 They are not therefore publishable and especially no opposable in judicial
proc?s case.
 In short according to Shannon (theory of information), too much information, no
precise, mask the good information to take a decision.

  Distressed for my English!!

Dr R LONJON
 France

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