Discussion Board

Process of diagnosis in practice

  • 1.  Process of diagnosis in practice

    Posted 09-20-2021 12:20
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    In my ongoing efforts to understand the process of diagnosis in practice, I have expressed my latest thoughts about it in the attached paper. Most of these thoughts have been expressed in my previously posted papers; in this paper, I have aimed at expressing them in a more logical manner. The main points made in this paper are as follows:

    1. The goal in diagnosis in practice is to achieve high diagnostic accuracy to be able to treat and prognosticate a disease appropriately.
    2. The greatest challenge to achieving this goal, I believe, is wide variation in presentations and thus, of prior probabilities of a disease in different patients.
    3. Thus we require a highly reliable procedure to diagnose a disease accurately in patients with varying prior probabilities. The prescribed Bayesian method does not provide this procedure due to a prior probability being interpreted as a prior degree of belief for or against a disease in this method which may lead to a disease with atypical presentation (low prior probability) not being suspected or tested leading to a diagnostic error.
    4. The Bayesian method has been prescribed due to its coherence while the method employed for diagnosis in practice is driven by diagnostic accuracy. I cannot think of any theoretical or practical advantage of employing the Bayesian method for diagnosis as far as diagnostic accuracy is concerned. I could not find any published study or case report in which the Bayesian method has been employed for diagnosis in a real patient.
    5. The method employed in practice is the frequentist confidence method in which a suspected disease is formulated as a hypothesis without any prior probability attached to it so that it does not have any prior degree of belief for or against it. This hypothesis is inferred to be correct and a disease diagnosed in this method if a highly informative test result with likelihood ratio greater than 10 is observed due to the known performance of this test result in inferring the disease accurately in 85 percent or more patients.
    6. It is important to reach agreement about the method of diagnosis in practice, I believe, by performing experimental studies so that medical students can be taught the right method of diagnosis.
    Please let me know about any real patient in whom the Bayesian method was employed for diagnosis in a published study or in your personal experience. Thanks.
    Bimal

    Bimal Jain MD
    Mass General Brigham/Salem Hospital
    Salem MA 01970


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