Ben and the list, Thanks for your comment Ben. I agree with you 100% and see no disservice to my comments. I think that we are saying the same thing and am glad that you amplified on the issue. There are too many instances when a test ought not be done since the result will not change pretest probability enough and we either will or won't treat regardless of the result. Thanks for sending on your example, Best wishes Dan **************************************************************************** Dan Mayer, MD Professor of Emergency Medicine Albany Medical College 47 New Scotland Ave. Albany, NY, 12208 Ph; 518-262-6180 FAX; 518-262-5029 E-mail; [log in to unmask] **************************************************************************** >>> "Djulbegovic, Benjamin" <[log in to unmask]> 12/30/2004 9:05:25 AM >>> Dan, sorry if I am doing some disservice to your thoughtful note on diagnostic testing issues that you and the rest of us think "are extremely important to the use of EBM in the ongoing practice of medicine." However, I want to comment on one aspect of your note. I agree with you that the reasons for ordering the test can help clarify should the test be ordered or not, and how it should be interpreted. As you said, " For the care of an individual patient, we look for the therapeutic or diagnostic benefits to the patient as a result of the clinician being more certain about the diagnoses (and that leading to a change in therapy or prognosis)." In these situations, ordering a diagnostic test can be actually linked directly to the evidence on benefits and harms of treatment that we may have in mind. For example, several years ago we "played" with integration of various evidence-based medicine therapeutic summary measures within the context of simple clinical decision analysis in order to find out that a diagnostic test should never be ordered if the harm of treatment is greater than or equal to its benefit (see http://www.medscape.com/viewarticle/403613). That is, our decision about using DIAGNOSTIC tests (at bedside) are ultimately linked to our knowledge about our TREATMENTS. So, perhaps indeed we can develop "A hierarchical outcomes approach to test assessment" as advocated in the reference you cited. best ben Benjamin Djulbegovic, MD,PhD Professor of Oncology and Medicine H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida Department of Interdisciplinary Oncology SRB #4, Floor 4, Rm #24031 (Rm# West 31) 12902 Magnolia Drive Tampa, FL 33612 Editor: Cancer Treatment Reviews (Evidence-based Oncology Section) http://www.harcourt-international.com/journals/ctrv/ e-mail:[log in to unmask] http://www.hsc.usf.edu/~bdjulbeg/ phone:(813)979-7202 fax:(813)979-3071 ###################################################################### This transmission may be confidential or protected from disclosure and is only for review and use by the intended recipient. Access by anyone else is unauthorized. Any unauthorized reader is hereby notified that any review, use, dissemination, disclosure or copying of this information, or any act or omission taken in reliance on it, is prohibited and may be unlawful. If you received this transmission in error, please notify the sender immediately. Thank you. ######################################################################