All the histopathologists in the study would have regarded themselves as
highly trained and professional.

Another study (again re-quoted in Bandolier) on melanocytic lesions showed
just how much variation in opinion can exist between 'experts'. (The
extremes were 11 non-malignant, 26 malignant from one expert and 11
malignant, 26 non-malignant from another).

Only through use of appropriate outcome measures do we have an objective
guide to the usefulness or otherwise of appended comments and only by
challenging ourselves can we hope to quantify the benefits or otherwise of
our wisdoms and dogmas. Harm, if it occurs, does not imply unprofessionalism
- it simply implies that we do not know all that we might about disease
processes. We can confidently predict that any comment that we make that is
beneficial is also, at times, harmful.

There are many such examples in our everday experience. Take maternal serum
screening. A comment is added that if the risk exceeds 1 in XXX
amniocentesis is advised/should be considered. Of those who choose to have
an amniocentesis a few, with normal foetuses, will suffer spontaneous
abortion as a result. This clearly is harm.

The best we can ever hope to do is to keep the benefit to harm ratio very
high!

Trevor Tickner

> -----Original Message-----
> From: Mohammad Al-Jubouri [SMTP:[log in to unmask]]
> Sent: 11 December 2001 14:38
> To:   TICKNER TREVOR (RM1) Norfolk and Norwich NHS Trust;
> [log in to unmask]
> Subject:      Re: a challenge for interpretative comments ....
>
> Appropriate comments, well constructed by an
> accredited biochemistry professional, on laboratory
> reports fulfill three important functions:
>
> 1. Provision of diagnosis/differential diagnoses,
> explaining a pathophysiological event, suggestion of
> further tests/follow-ups and prognostic information.
> All these have either no effect on outcome measures or
> postively influence them. I can not see how they can
> have a negative influence unless the comment is
> inappropriate and misleading.
>
> 2. Education of the requesters including junior
> doctors, nurse clinicians, GPs and even conslutants.
> Putting oucome measures aside, this function should
> not be under-estimated as real patients and their
> diagnostic results are the ultimate teacher for us
> all. Outcome measures is not relevant here but may be
> improved indirectly.
>
> 3. Laboratory reports are media of interaction with
> the requesting clinicians. They know us through our
> comments that add value to the numerical data. Sooner
> or later you become famous and a lot of people, that
> you haven't met, start ringing/writing letters asking
> for advice. Again outcome measures are irrelevant in
> this area but may improve indirectly.
>
> I know that all the aforementioned is common sense but
> do we need a study to prove it?
>
> Mohammad
>
> --- "TICKNER TREVOR (RM1) Norfolk and Norwich NHS
> Trust" <[log in to unmask]>
> wrote: > I do not agree that it is unfair to expect
> > interpretative comments to
> > influence outcomes.
> >
> > In histopathology comments clearly influence outcome
> > but not always in a
> > demonstrably positive manner. Many will recall the
> > 'Japanese' versus
> > 'Western' criteria studies for stomach neoplasia or
> > the melanocytic lesions
> > studies that were retold in Bandolier. The cancer
> > study showed that there
> > was agreement in only 18 of 35 cases - the
> > discrepant 17 all being
> > designated cancer by the Japanese criteria but not
> > by the Western. The
> > outcome measures would thereby be distorted. Cancer
> > would be commoner in
> > Japan but treatment would appear more successful.
> > Clearly we, too, could
> > influence outcomes were we so inclined by implying
> > that some dire
> > consequence will follow if our advice is not heeded.
> >
> > However, a comment is no different otherwise from
> > any other result and a 2x2
> > contingency table can be constructed for comment and
> > outcome positive,
> > comment positive and outcome negative, comment
> > negative and outcome positive
> > and comment and outcome negative. What one has to be
> > careful of is the
> > relationship between the comment and any piece of
> > data that is is the
> > precipitator of the comment for, obviously, the
> > outcome could be being
> > influenced less by the comment and more by the
> > primary data.
> >
> > Where we find that it is, indeed, the data that is
> > influential we should,
> > rather that worrying about our worth, be satisfied
> > that we, as a
> > professional group, have been able both to introduce
> > valuable data and to
> > inform others of its value.
> >
> > Trevor Tickner,
> > Norwich
> >
> >
> > > -----Original Message-----
> > > From: Mohammad Al-Jubouri
> > [SMTP:[log in to unmask]]
> > > Sent: 07 December 2001 14:36
> > > To:   [log in to unmask]
> > > Subject:      Re: a challenge for interpretative
> > comments ....
> > >
> > > It is unfair to expect interpretative comments on
> > a
> > > diagnostic aid to influence outcome measures. But
> > we
> > > all provide comments that sometimes provide a
> > timely
> > > diagnosis, explain a pathophysiological
> > abnomality,
> > > provide advice on treatment and further tests and
> > > give estimate of prognosis. This is the essence of
> > our
> > > specialty without which clinical cases will be
> > boring
> > > and bland. All our clinical colleagues value our
> > > contribution and keep asking our advice, this is a
> > > sufficient anecdotal evidence for me to continue
> > > practicing chemical pathology.
> > >
> > > regards
> > >
> > > Mohammad
> > >
> > >  --- Julian Barth <[log in to unmask]>
> > > wrote: > Dear All
> > > >
> > > > I do not think that any subject has hit as many
> > raw
> > > > nerves as this
> > > > issue of interpretative comments. I am currently
> > > > planning the
> > > > scientific programme for FOCUS 2003. Can I
> > challenge
> > > > any of you
> > > > to perform a prospective study of the utility of
> > the
> > > > addition of
> > > > interpretative comments with outcome measures?
> > > >
> > > > Yours hopefully
> > > > Julian
> > > >
> > > >
> > ___________________________________________________
> > > >
> > > > Julian H Barth
> > > > Department of Clinical Biochemistry & Immunology
> > > > Leeds Teaching Hospitals NHS Trust
> > > > Leeds General Infirmary
> > > > Leeds LS1 3EX
> > > > tel 0113-392-3416
> > > > fax 0113-392-5174
> > > >
> > ___________________________________________________
> > >
> > > =====
> > > Dr. M A Al-Jubouri
> > > Consultant Chemical Pathologist
> > >
> > >
> >
> ________________________________________________________________
> > > Nokia 5510 looks weird sounds great.
> > > Go to http://uk.promotions.yahoo.com/nokia/
> > discover and win it!
> > > The competition ends 16 th of December 2001.
> > >
> > >
> >
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> =====
> Dr. M A Al-Jubouri
> Consultant Chemical Pathologist
>
> __________________________________________________
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