Jerome P. Kassirer

The physician's estimate of the probability that a patient has a particular disease is a principal factor in the determination of whether to withhold treatment, obtain more data by testing, or treat without subjecting the patient to the risks of further diagnostic tests. Using the concepts of decision analysis, we have derived expressions for two threshold probabilities involved in this choice: a "testing" threshold and a "test-treatment" threshold. Values can be assigned to these thresholds from data on the reliability and potential risks of the diagnostic test and the benefits and risks of a specific treatment. Treatment should be withheld if the probability of disease is smaller than the testing threshold, and treatment should be given without further testing if the probability of disease is greater than the test-treatment threshold. The test should be performed (with treatment depending on the test outcome) only if the probability of disease is between the two thresholds. The method exposes important principles of decision making and helps the clinician develop a rational, quantitative approach to the use of diagnostic tests.

Conflicts of interest between physicians' commitment to patient care and the desire of pharmaceutical companies and their representatives to sell their products pose challenges to the principles of medical professionalism. These conflicts occur when physicians have motives or are in situations for which reasonable observers could conclude that the moral requirements of the physician's roles are or will be compromised. Although physician groups, the manufacturers, and the federal government have instituted self-regulation of marketing, research in the psychology and social science of gift receipt and giving indicates that current controls will not satisfactorily protect the interests of patients. More stringent regulation is necessary, including the elimination or modification of common practices related to small gifts, pharmaceutical samples, continuing medical education, funds for physician travel, speakers bureaus, ghostwriting, and consulting and research contracts. We propose a policy under which academic medical centers would take the lead in eliminating the conflicts of interest that still characterize the relationship between physicians and the health care industry.

What is there about alternative medicine that sets it apart from ordinary medicine? The term refers to a remarkably heterogeneous group of theories and practices — as disparate as homeopathy, therapeutic touch, imagery, and herbal medicine. What unites them? Eisenberg et al. defined alternative medicine (now often called complementary medicine) as “medical interventions not taught widely at U.S. medical schools or generally available at U.S. hospitals.”1 That is not a very satisfactory definition, especially since many alternative remedies have recently found their way into the medical mainstream. Medical schools teach alternative medicine, hospitals and health maintenance organizations offer it,2 and . . .

To help the physician decide whether or not to treat a patient who may or may not have a disease, a method has been developed for calculating a therapeutic threshold. If the probability of disease in a given patient exceeds the threshold, the preferable course of action is to treat; if the probability is below the threshold, the preferable course of action is to withhold treatment. This method is applicable in many medical and surgical settings in which some diagnostic uncertainty exists after all appropriate studies have been carried out. The technic not only exposes some of the basic principles of therapeutic decision making in the face of diagnostic uncertainty but also forms a convenient framework for analyzing the impact of "soft" clinical data on the decision-making process.

EXCELLENT clinical judgment requires optimal decision making. Many of the decisions that physicians make in their practices involve little uncertainty and little risk: these rote or routine choices need no special contemplation because they are "tried and true" practices. But for each routine problem there are several for which no easy solution is at hand. To deal with these, the tough problems, a physician can search for a properly designed, double-blind controlled study that examined patients of the same age, sex, and race and with the same conditions in the same stage; use an algorithm developed for such patients; use . . .