Schuur and colleagues in JAMA Internal Medicine listed five low value services in the emergency department (ED). Although compilation was not solicited by the American College of Emergency Physicians as part of the Choosing Wisely program, it has its ethos. The list was developed by a technical expert panel after multiple iterations. The list is not only wise but derived from sound methodology. Most importantly, the recommendations are ...

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Would you tell me, please, which way I ought to go from here? That depends a good deal on where you want to get to. I don't much care where – Then it doesn't matter which way you go. - Lewis Carroll In the new world, payers will increasingly ask before reimbursing medical imaging: why did you bother finding out? This is why we must pay attention to clinical trials. An instructive case is in the ...

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An advantage astrologers have over genetic testing is that the prediction of astrologers are personally verifiable. An astrologer once emphatically stated that I had no chance of a career in international cricket or Bollywood. So far both claims have turned out to be remarkably accurate. How does one personally verify a “12.5%” increased chance of lung cancer, the sort of number the vendor for genetic testing 23andMe produces? If one develops ...

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The interpretation of results of a policy study lies in the political inclination of the beholder. If one likes the results they are “ground breaking.” If they are not in line with our world view there are “nuances” of hypothesis testing that detractors have overlooked, it’s too “premature” to draw conclusions and “further research” is needed. Statisticians, like lawyers, can be recruited to argue any point of view to meaningless insignificance. This ...

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When you get frustrated with my interpreting a chest x-ray as “atelectasis at the right lung base, pneumonia can't be excluded,” trust me, I don’t enjoy it. But when you ask me to rule out pneumonia you leave me no choice but to tell you that pneumonia can’t be ruled out. To rule out a disease a test must have a sensitivity of 100%, meaning there should be no false negatives. ...

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Recently, I spoke with a primary care physician (PCP) about a young runner who had a syncopal episode. Because of the increasing awareness of sudden cardiac death in athletes, she had an electrocardiogram and an echocardiogram to look for structural abnormalities of the heart. The PCP was inclined to dismiss the syncope as an isolated episode. However, the echocardiogram, otherwise normal, equivocated: “possible hypertrabeculation of the left ventricular apex, consider cardiac ...

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You know that old joke. What's a radiologist's favorite plant? The hedge. Radiologists are famous for equivocating, or hedging. "Pneumonia can't be excluded, clinically correlate," or "probably a nutrient canal but a fracture can't be excluded with absolute certainty, correlate with point tenderness." Disclaiming is satisfying neither for the radiologist nor the referring physician. It confuses rather than clarifies. So one wonders why legislators have decided to codify this singularly unclinical practice ...

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