Principles of diagnostic stewardship: A practical guide is out

1st in a series from the @SHEA_Epi task force
bit.ly/41wDRgC

Endorsed by @IDSAInfo @APIC @SIDPharm @SocietyHospMed

Diagnostic Stewardship is a exciting new concept, here are some highlights...

1/n Although Diagnostic Stewardship (DxSt) has been described BEFORE, and supported by @CDCgov
there are many details that needed to be addressed.
ja.ma/3SDdWjf
academic.oup.com/cid/article/74…

1/The hyperbolic, black/white, strawman COVID19 arguments are really getting me down. They feel like the broken part of America/ the world

Seems either partisan side must adhere or be canceled / threatened w/ violence.

The solution is some middle that adjusts to changing facts 2/ Recent tag by @drjohnm on a @VPrasadMDMPH comment that flu = covid19 in children emphasized this

Covid WAS worse than flu in 2020 because worldwide shutdown stopped flu

but Covid NO WORSE than USUAL flu year for kids

But flu and covid ARE BAD in some kids which is TRAGIC

As a vaccinated, liberal infectious disease doctor, who believes virtually all US adults should be vaccinated...

I'm bothered by people blaming the unvaccinated for the ongoing pandemic

There are a few reasons:

@sdbaral @VPrasadMDMPH 1) The unvaccinated are the biggest victims--99% of COVID deaths are unvaccinated

They put themselves at the most risk--much more than they harm me

We don't punish IVDU or prostitutes for the HIV epidemic although they spread an infectious agent

Do doctors understand how well treatments work?

We asked >500 clinicians in 8 US states

Chance that common treatments help an individual patient with
atrial fibrillation
hypertension
high cholesterol
osteoporosis

Open access: ja.ma/3A1u7N4 via @JAMANetwork

1/🧵 Recently we examined clinician understanding of probability in DIAGNOSIS

https://twitter.com/dr_dmorgan/status/1381667631099351040

The current question was similar but for TREATMENT

In the works, are numeracy, acceptance of uncertainty and other clinician personality factors associated with decisions?

2/🧵

How good are doctors at diagnosis?

This is the most relevant paper I have written. Not perfect but addresses a huge issue I think could change medicine if acknowledged
…it has changed how I think about diagnosis

ja.ma/3rQNtjv
@JAMAInternalMed
@drjohnm
1/n summary:
Clinicians widely overestimated chance of disease especially after testing

Cardiac ischemia after + ECG—EBM 2-11%, median answer 70%
UTI after + urine cx—EBM 0-8.3%, answer 80%
Breast CA after + mammo—EBM 3-9%, answer 50%
Pneumonia after + CXR EBM 46-65%, answer 95%

Like @BenMazer, I was bummed to have a op-ed during the riot

In it, I describe the reality that most medical treatments have very marginal effects.

A reality with big implications

d/w @VPrasadMDMPH @lowninstitute @AndrewFoy82 @drjohnm

washingtonpost.com/outlook/2021/0…
1/ 2/ If clinicians understood small chance of benefit with most Rx, I feel we would make very different decisions for most patients

Thanks @MikeMadden editor

By taking a medication daily we buy a lottery ticket with a payout often as low as 1% or 2%.

We set out to identify the sensitivity & specificity of common tests for #COVID19 along w/ @dan_diekema , @Anthony98947615 w/ @CDCgov support

A simple enough task, right?

I’ve seen tweets by @DrSidMukherjee @drjohnm @BenMazer @PaulSaxMD @BradSpellberg and others interested
1/n Looking for comments/criticism

What are we missing? No industry adverts please!

Important papers?
2/n

Catch yourself when you say “risks vs. benefits” because you aren’t making a fair comparison.

In @JAMA_current ja.ma/336Lj4Y
& podcast ja.ma/2FAGKI2

@eliowa @drjohnm @d_spiegel @zeynep @VPrasadMDMPH

Why we say it and what we think is better below... This building block of clinical decisions biases by framing uncertain harm vs. certain benefits and nudges towards treatment

Written with
@DKorenstein @ldscherer
(Over 2 years, i'm embarrassed to admit)