Best,

Paul E. Alexander

Bengt,
I think commandments are used for all kinds of things that have no
religious context. They could be changed to anything like the 10 points of
diagnostic wisdom. 10 steps to accurate intervention,Ten ways to test it
right, 10 principles for diagnostic success etc….They were just a way for
the group to formulate a working template so we could give input.

Cultural sensitivity is important apparently a list like this was
considered somewhere else but they had strife about what to call it and
things fell apart. I am going to use this in my area of work and for a
public epidemiology project. I have no idea what I will call it when it is
done but it will take the basic principles and expand them with the
benefit of the group wisdom.

I guess someone could use them in a religious culture but what would you
diagnose?
Best
Amy

On 4/5/12 12:48 PM, "[log in to unmask]">[log in to unmask]" <[log in to unmask]">[log in to unmask]>
wrote:

>what are the 10 commandments in islam. Are they included in the Koran?
>// Bengt
>
>>----Ursprungligt meddelande----
>>Från: [log in to unmask]">[log in to unmask]
>>Datum: 2012-04-05 18:23
>>Till: <[log in to unmask]">[log in to unmask]>
>>Ärende: Re: The New Diagnostics: 10 Commandments
>>
>>This is a terrific list, thank you. What if each of us starting thinking
>>about how to apply them to a specific region of interest for guidelines?
>>Best,
>>Amy
>>
>>From:  Ash Paul <[log in to unmask]">[log in to unmask]>
>>Reply-To:  Ash Paul <[log in to unmask]">[log in to unmask]>
>>Date:  Thu, 5 Apr 2012 01:06:36 -0700 (PDT)
>>To:  Amy Price <[log in to unmask]">[log in to unmask]>,
>>"[log in to unmask]">[log in to unmask]"
>><[log in to unmask]">[log in to unmask]>
>>Subject:  Re: The New Diagnostics: 10 Commandments
>>
>>Dear Amy,
>>
>>Here's Michael's 10 Commandments for New Diagnostics:
>>
>>
>>Ten Commandments for testing ­ by Michael Power
>>Please do send your feedback to [log in to unmask]">[log in to unmask]
>><mailto:[log in to unmask]">[log in to unmask]> , cc. [log in to unmask]">[log in to unmask]
>><mailto:[log in to unmask]">[log in to unmask]> .
>>
>>
>>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 neighbour¹s 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 neighbour¹s, 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 patient¹s 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 and biases.
>>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 against thy patient.
>>Regards,
>>
>>Ash
>>
>>>   
>>> 
>>> 
>>>   
>>>   From: Amy Price <[log in to unmask]">[log in to unmask]>
>>>  To: [log in to unmask]">[log in to unmask]
>>>  Sent: Wednesday, 4 April 2012, 16:35
>>>  Subject: Re: The New Therapeutics: 10 Commandments
>>>   
>>> 
>>> Hi Does anyone have the latest version of the diagnostics we all
>contributed
>>> too? I want to add it to our EBHC student WIKI and for personal use
>>>in an
>>> upcoming class. I changed computers and it went missing in the
>>>transfer
>>>   Thanks
>>>
>>> Best
>>> Amy
>>>
>>> From:  Ash Paul <[log in to unmask]">[log in to unmask]>
>>> Reply-To:  Ash Paul <[log in to unmask]">[log in to unmask]>
>>> Date:  Sun, 25 Mar 2012 07:41:51 -0700
>>> To:  <[log in to unmask]">[log in to unmask]>
>>> Subject:  Re: The New Therapeutics: 10 Commandments
>>>
>>> 
>>>> Dear colleagues,
>>>> I seem to remember that this topic was discussed extensively in our
>>>>Group
>>>> some time back in the recent past.
>>>> The Ethical Nag Blog has now published this article:
>>>> http://ethicalnag.org/2012/03/06/the-new-therapeutics-10-commandments/
>>>> Regards,
>>>> Ash
>>>> 
>>>> The New Therapeutics: 10 Commandments
>>>> 
>>>> Posted on March 6, 2012
>>>>
>>>><http://ethicalnag.org/2012/03/06/the-new-therapeutics-10-commandments/
>>>>>   
>by
>>>> Carolyn Thomas <http://ethicalnag.org/author/czthomas/>
>>>> I like how the veteran health journalist Andrew Holtz  once explained
>>>>the
>>>> interesting concept of surrogate or intermediate endpoints for us
>>>>dull-
>witted
>>>> patients. He cites, for example, studies on patients with diabetes
>>>>that
>>>> included aggressive control of blood sugar, high blood pressure and
>>>> cholesterol in people considered to be at very high risk for heart
>attacks.
>>>> But oddly enough, this research showed that:
>>>> * strict management of blood sugar did not reduce heart attack deaths
>>>> * reduction in high blood pressure levels did not reduce heart attack
>deaths
>>>> * controlling high LDL cholesterol numbers with the use of statin
>>>>drugs
>did
>>>> not reduce heart attack deaths
>>>> Holtz explains that lab results may not actually be accurate
>>>>predictors
>of
>>>> mortality ­ they are merely intermediate or surrogate endpoints along
>>>>the
>>>> way.
>>>> And just because a drug improves lab test results doesn¹t mean it
>>>>saves
>lives
>>>> ­ despite the efforts of Big Pharma to convince drug prescribers
>otherwise.
>>>> Similarly, clinical trials have shown that the statin drug simvastatin
>>>> (Zocor) was effective in reducing cholesterol (the surrogate endpoint)
>>>> without showing directly that simvastatin prevents actual cardiac
>>>>events.
>>>> In fact, proof of Zocor¹s efficacy in reducing cardiovascular disease
>>>>was
>>>> finally only presented by Norwegian researchers five years after its
>original
>>>> introduction, and then only for secondary prevention in those already
>>>> diagnosed with heart disease.
>>>> To help doctors plow through the muck, Dr. John S. Yudkin, emeritus
>professor
>>>> of medicine at University College, London wrote the following 10
>Commandments
>>>> for his colleagues (but according to Dr. Richard Lehman of the British
>>>> Medical Journal*, Dr. Yudkin was dissuaded from publishing them more
>widely
>>>> due to American religious sensitivities).
>>>> Finally, with many thanks for this laymen¹s translation into plain
>English***
>>>> of Dr. Yudkin¹s work by Dr. Alice Dreger and Dr. Aron Sousa, here are:
>>>> The New Therapeutics: Ten Commandments
>>>> 1. Thou shalt treat according to the level of risk rather than level
>>>>of
>risk
>>>> factor.  ³In medicine, a risk factor is a trait that increases the
>likelihood
>>>> of having something really bad happen to you. For example, having a
>>>>high
>>>> level of triglycerides is a risk factor for having a heart attack.
>>>>(That
>>>> means that having high triglycerides increases the likelihood you
>>>>will
>suffer
>>>> a heart attack.) But you want your doctor to try to prevent what¹s
>>>>really
>bad
>>>> ­ the heart attack ­ not just treat your triglyceride level. Why?
>>>>Because
>>>> lowering your triglyceride level with some prescription drug won¹t
>actually
>>>> decrease your risk of a heart attack. Doctors need to treat what
>>>>really
>>>> matters to you, the patient, not what is merely measurable in you.²
>>>> 2. Thou shalt exercise caution when adding drugs to existing
>polypharmacy.
>>>> ³It¹s generally a bad idea to give a patient another drug when a
>>>>patient
>is
>>>> already on a drug. Doing so increases the risk of bad interactions
>between
>>>> the drugs. It also increases patient confusion, thereby again
>>>>increasing
>>>> risk. So adding one drug doesn¹t just introduce the risks named on the
>>>> pamphlet you get with that drug, because the body is a complex
>>>>machine,
>drug
>>>> interactions are poorly understood, and humans on lots of drugs make
>mistakes
>>>> in the use of those drugs.²
>>>> 3. Thou shalt consider benefits of drugs as proven only by hard
>>>>endpoint
>>>> studies. ³This is similar to the first commandment because it reminds
>>>>the
>>>> physician that what you really care about are ³hard endpoints² ­
>>>>things
>like
>>>> heart attacks and strokes, not things like levels of cholesterol and
>>>> triglycerides. A particular drug might make your lab results look
>>>>really
>>>> great, but it¹s not a good drug if it doesn¹t actually improve your
>>>>health
>in
>>>> the ways that matter (for example, reduction of risk of a major
>>>>disease,
>or
>>>> reduction of risk of death.) A drug might increase your bone density
>>>> <http://ethicalnag.org/2010/02/06/osteopenia/> , but if it doesn¹t
>>>>reduce
>>>> your risk of fracture, who cares that your bones are denser?²
>>>> 4. Thou shalt not bow down to surrogate endpoints
>>>> <http://ethicalnag.org/2010/06/25/health-world-cup/> , for these are
>>>>but
>>>> grave images.  ³Again, surrogate endpoints¹ are things like blood
>pressure
>>>> readings, as opposed to hard endpoints¹ like heart attacks and
>>>>strokes.
>It
>>>> doesn¹t actually matter what your blood pressure is if your blood
>pressure
>>>> doesn¹t hurt you. We use blood pressure readings as a surrogate for
>>>>what
>we
>>>> really care about. It¹s worth measuring, but we should not treat high
>blood
>>>> pressure with a drug unless that particular drug is shown to achieve
>>>>what
>we
>>>> really care about: reduction of risk of heart attacks and strokes.²
>>>> 5. Thou shalt not worship Treatment Targets, for these are but the
>creations
>>>> of Committees.   ³Sometimes consensus groups come up with treatment
>targets¹
>>>> that tell physicians what patients¹ lab numbers should look like. But
>>>> physicians need to take individual patients¹ bodies, lives, and needs
>into
>>>> account. An example: a consensus committee
>>>> <http://ethicalnag.org/2011/04/13/clinical-practice-guidelines/>
>>>>might
>issue
>>>> a treatment target for glucose (blood sugar) control. They might say
>everyone
>>>> should have low blood sugar. But imagine a patient who is an
>>>>80-year-old
>>>> woman who has been falling a lot. Lowering that woman¹s blood sugar
>>>>could
>>>> increase her risk of a big bone fracture from a fall. So she should
>>>>NOT
>be
>>>> treated glibly according to a Treatment Target that might be perfectly
>>>> reasonable for an otherwise healthy 30-year-old woman. Physicians and
>>>> patients should especially beware any consensus issued by a committee
>>>>of
>>>> people who have had financial ties to drug and device makers
>>>> <http://ethicalnag.org/2010/06/13/using-science-to-sell/> .²
>>>> 6. Thou shalt apply a pinch of salt to Relative Risk Reductions,
>regardless
>>>> of P values, for the population of their provenance may bear little
>>>> relationship to they daily clientele.  ³This is a complicated way of
>again
>>>> reminding physicians what should matter: actual reduction of risk of
>>>>the
>>>> things their own real patients really care about and are really
>>>>likely to
>>>> suffer from. Relative Risk Reduction is another way drug companies
>>>>often
>fool
>>>> physicians and patients into thinking a drug is better than it really
>>>>is.
>²
>>>> 7. Thou shalt honour the Numbers Needed to Treat, for therein rest
>>>>the
>clues
>>>> to patient-relevant information and to treatment costs.  ³The phrase
>numbers
>>>> needed to treat¹ refers to how many patients a doctor needs to treat
>>>>with
>a
>>>> particular intervention in order to have one patient¹s outcome
>>>>improve.
>This
>>>> concept acknowledges that not every intervention benefits every
>>>>patient.
>In
>>>> fact, there¹s a number needed to harm¹ for each drug, too, but you
>>>>don¹t
>>>> often hear about either stat from your doctor. Yet for many medical
>>>> interventions, you have to treat a relatively large number of people
>>>>to
>>>> benefit just one, but you¹re introducing ALL of them to the risks of
>>>>that
>>>> intervention. You might think from pharmaceutical ads that a drug for
>>>> heartburn will lower your risk of esophageal cancer. But the truth is
>that
>>>> probably dozens if not hundreds of people will have to take the drug
>before
>>>> just ONE of those people has cancer prevented by the drug, while ALL
>>>>of
>you
>>>> on the drug will bear all of the risks of the drug. Note that this
>>>> commandment also refers to treatment cost, an idea that is supposed
>>>>to
>offend
>>>> us. But the truth is that it would be better if we thought rationally
>about
>>>> how much money it makes sense to prevent, say, one death from cancer.
>>>>If
>we
>>>> keep ignoring that calculation, we¹ll kill a lot more people than we
>>>>save.
>²
>>>> 8. Thou shalt not see detailmen (drug reps
>>>> <http://ethicalnag.org/2010/05/28/fewer-physicians-see-reps/> ), nor
>>>>covet
>an
>>>> Educational Symposium in a luxury setting.   ³These days, detailmen
>>>>are
>>>> actually often women ­ perky, young, blonde women chosen because they
>still
>>>> carry their cheerleader looks from high school. They are the
>representatives
>>>> from drug and device makers who come to seduce your doctor into using
>their
>>>> products on your body, so that profit can ensue. Drug and device
>>>>makers
>also
>>>> like to whisk your doctor off to educational symposia¹ where they
>>>>are
>wined,
>>>> dined, and sold the idea of using more of the companies¹ products.
>>>>Profit
>is
>>>> the only endpoint these companies really care about, so they will
>>>>take
>all
>>>> the risks they need to in order to achieve that endpoint, including
>treating
>>>> your life as an acceptable risk. If you are at your doctor¹s office
>>>>and
>you
>>>> see detailmen or their paraphernalia (pens, mugs, posters, videos,
>>>>etc.
>>>> produced by these companies), you can assume your body is being used
>>>>as
>an
>>>> endpoint by a corporation that doesn¹t care what really happens to
>>>>you.
>So
>>>> ask yourself: how much does your doctor really care about you?²
>>>> 9. Thou shalt share decisions on treatment options with the patient
>>>>in
>the
>>>> light of estimates of the individual¹s likely risks and benefits.
>>>>³Your
>>>> doctor needs to talk to you about what YOU are trying to achieve with
>your
>>>> medical care. Then she or he needs to discuss with you the reasons and
>>>> evidence for the options being offered to you. She or he really
>>>>should be
>>>> educating you about all the things we¹ve covered so far: risk factor
>versus
>>>> risk, surrogate endpoints, unknown drug interactions, etc.  You can
>>>>start
>>>> this conversation
>>>> <http://myheartsisters.org/2012/02/21/six-rules-doctors-appointment/>
>>>> by
>>>> telling your doctor about what exactly you¹re trying to achieve in a
>given
>>>> office visit. For example, you might say in a yearly exam, I would
>rather
>>>> live a healthy life than a longer life, so I¹m only interested in
>>>>tests,
>>>> procedures, and interventions that are likely to give me good health,
>>>>not
>>>> those that will necessarily keep me alive longer but make me feel
>unhealthy
>>>> during those years.¹ Or at a sick visit, you might say, I didn¹t
>>>>come for
>a
>>>> prescription. I came to try to figure out why I feel sick, and what I
>>>>can
>>>> expect in terms of healing. I only want a prescription if I really
>>>>need
>one
>>>> to get better. I would rather suffer the symptoms of this thing than
>>>>take
>the
>>>> risk of a drug that¹s just going to treat the symptoms and increase
>>>>my
>risk
>>>> of side effects.¹ ³
>>>> 10. Honour the elderly patient, for although this is where the
>>>>greatest
>>>> levels of risk reside, so do the greatest hazards of many treatments.
>>>> 
>³This
>>>> one is self-explanatory, but too often ignored.²
>>>> 
>>>>
>>>>
>>>> 
>>>> 
>>>> 
>>>   
>>>
>>>
>>> 
>>> 
>>> 
>>   
>>
>>
>>
>
>
>