Thanks everyone for the comments and suggestions
A fair amount of work is needed before the "10 commandments" are ready
to be carved in stone and published to the world.
The categories (headings) have sufficient scope and their ordering
needs only a slight adjustment to make them coherent.
The content however, is not always consistent with the headings.
And, the style could be simpler and sharper.
I am devoting a fair amount of displacement activity to producing
Draft 2, aspiring to approach Bradford Hill's clarity and concision.
Give me 25 more years, and I will have it in iambic pentameters.
Building the reference list is proving harder than expected. What it
needs is pointers to articles that would be good introductions to the
topics and not behind £$€walls. Any suggestions?
m
On 1/9/12, Fell Greg <[log in to unmask]> wrote:
> accept the need for a "full" version (with refs and all that)....guess
> it depends on intended audience and endpoint. I feel the slightly
> humerous biblified version might have more "reach" (on account of the
> humour factor)....but accept that "reach" and "influence" might be two
> slightly different things.
>
> I am not going to die in a ditch about either.
>
> The important thing is that the list sees the light of day outside this
> e group - published / blogged / other. I am intending on using it
> extensively locally.
>
> Do colleagues feel this is publishable.
>
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> gf
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> ________________________________
>
> From: Evidence based health (EBH) on behalf of Dawes, Martin
> Sent: Sun 08/01/2012 23:40
> To: [log in to unmask]
> Subject: Re: Ten commandments for testing
>
> These are really good. I would suggest that the challenge now is to word
> in it such a way as the prose is as complete ad enjoyable as Bradford
> Hills famous nine described in his talk: The Environment and Disease:
> Association or Causation?
>
> One imagines him spending time, without e-mail interruptions, creating
> each sentence carefully, each with its own subject, object and verb so
> that 45 years later it is actually a pleasure to read. However it
> probably took him 6 months to write.
>
> Sadly changing the font does not work.....but maybe Richard Lehmann can
> work some magic with a grammatical interpretation in the style of...
>
> Martin
>
>
>
> On 07-01-2012, at 7:40 PM, Michael Power wrote:
>
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>
> Greg, Kev, Anna, and Ash
>
>
>
> Many thanks for your very helpful suggestions and pointers. I have
> shamelessly plagiarised your (and George Lundberg's) ideas and reworked
> them.
>
>
>
> There is still room for improvement, so I would welcome suggestions. I
> am also copying this to Richard Lehman so he can pass it on to John
> Yudkin, as their comments would be much appreciated.
>
>
>
> Regards
>
>
>
> Michael
>
>
>
> ========================================================================
> ===
>
>
>
> Ten Commandments for testing
>
>
>
> Thou shalt obey the following ten Commandments for testing, whether it
> be for ruling in a diagnosis, ruling out a diagnosis, assessing risk or
> prognosis or response to treatment, or for monitoring for adverse
> effects and deteriorating status.
>
>
>
> Thou shalt understand testing in its broadest sense; it includes
> history, examination, laboratory tests, imaging investigations,
> diagnostic procedures, and therapeutic trials.
>
>
>
> When a commandment is impractical or impossible, thou shalt treat it as
> an aspiration and do thy best.
>
>
>
> For I am thy patient and client, whose interest thou shalt serve, and no
> other.
>
> 1. Evidence. Thou shalt not take the evidence in vain, but test
> according to the best estimates of prevalence, positive predictive
> value, and negative predictive value. If the predictive value of a test
> is less than about 50%, toss a coin - it will be cheaper and as useful.
>
> 2. Application of evidence. Thou shalt not overly rely on test
> results, but shalt apply your clinical judgement after clinically
> assessing your patient and critically appraising the evidence, taking
> into account its precision, risk of bias, and directness of
> applicability.
>
> 3. Cost-effectiveness. Thou shalt not covet thy neighbour's graven
> image technology (PET scanner, fMRI scanner, high resolution ultrasound
> scanner), nor his micro-array genetic tests, nor his direct to consumer
> testing business, nor his yacht, nor any thing that is thy neighbour's,
> but thou shalt practice cost-effective testing. If a cheaper test will
> be as useful, use it.
>
> 4. Patient-education. Thou shalt help thy patient understand that
> many diseases are gradual and progressive, analogue processes not
> digital events. Diagnostic thresholds and limits are chosen for
> convenience, but create artificial categories that may be misleading if
> they are misunderstood as boundaries between having and not having a
> disease, or having and not having a risk.
>
> 5. Joint decision-making. Thou shalt help thy patient understand
> the limitations of tests. Many conditions cannot be diagnosed or
> excluded by tests (for example dementia, wellness). Tests can be falsely
> positive or falsely negative or inconclusive. No test can give a precise
> prognosis for survival or other probability, and interpretation of
> prognostic tests should consider both the average (median or mean) and
> the distribution in the comparator population. Thou shalt remember that
> test results can in themselves be distressing or harmful. For these
> reasons, decisions about testing are best made jointly with thy patient.
>
> 6. Patient-centred care. Thou shalt not take thy patient's needs
> in vain, but before testing help them understand what the management
> options are for a positive, inconclusive, or negative result, and what
> support is available should the result be distressing. Honour the
> elderly patient, for although this is where the greatest levels of risk
> and temptation to test reside, so do the greatest needs for avoidance of
> useless and harmful testing.
>
> 7. Efficiency. Thou shalt not repeat a test when the result is
> already available or the result will not change (as with genetic tests
> or when the clinical indications have not changed). Thou shalt ensure
> that the results of tests you have ordered or performed are clearly
> recorded and available or communicated to any other physician caring for
> thy patient.
>
> 8. Ethics. Thou shalt not use testing as a defence against legal
> action, or as a placebo, or as a delaying tactic while nature takes its
> course, or to avoid confronting the limitations of curative medicine
> when care, support, or palliation is appropriate.
>
> 9. Education and engagement. Thou shalt help thy trainees and
> junior colleagues understand that they should investigate having
> considered the needs of their patients and the performance of the tests.
> The reason for testing should not be that it is routine, or policy, or
> what they imagine their consultant/attending expects.
>
> 10. Gnothi seauton. Thou shalt know thy cognitive limitations. Thou
> shalt try to avoid the fallacies of assuming that all abnormal results
> are important or that an abnormal result is sufficient to explain
> symptoms. Thou shalt consider the whole picture, and the differential
> diagnosis, and the possibility that tests bear false witness.
>
>
>
>
>
>
>
>
>
>
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