Rational Diagnosis and Treatment

Now in its fourth edition, Rational Diagnosis and Treatment: Evidence-Based Clinical Decision-Making is a unique book to look at evidence-based medicine and the difficulty of applying evidence from group studies to individual patients.The book analyses the successive stages of the decision process and deals with topics such as the examination of the patient, the reliability of clinical data, the logic of diagnosis, the fallacies of uncontrolled therapeutic experience and the need for randomised clinical trials and meta-analyses. It is the main theme of the book that, whenever possible, clinical decisions must be based on the evidence from clinical research, but the authors also explain the pitfalls of such research and the problems involved in applying evidence from groups of patients to the individual patient.For this new edition, the sections on placebo and meta-analysis and on alternative medicine have been thoroughly updated, and there is more focus on insufficient reporting of harms of interventions. The sections on different research designs describe advantages and limitations, and the increased medicalisation and the effects of cancer screening on health people are noted. A section on academic freedom when clinicians collaborate with industry and ghost authors is added.This essential reference work integrates the science and statistical approach of evidence-based medicine with the art and humanism of medical practice; distinguishing between data, sets of data, knowledge and wisdom, and their application. Such an intellectually challenging book is ideal for both medical students and doctors who require theoretical and practical clinical skills to help ensure that they apply theory in practice.

Peter C. Gøtzsche, D. MSc. Director, Specialist in internal medicine, Director of the Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark.

Preface	p. ix
Introduction	p. xi
The Foundation of Clinical Decisions	p. 1
The clinical decision process	p. 2
Clinical data	p. 4
Scales of measurement	p. 7
Taking the history	p. 9
The physical examination	p. 11
Paraclinical findings	p. 12
Global assessments	p. 14
Reliability and Relevance of Clinical Data	p. 17
Clinical data on an interval scale	p. 19
Clinical data on an ordinal scale	p. 22
Clinical data on a binary scale	p. 22
Descriptive paraclinical findings	p. 22
Descriptive physical signs	p. 26
The statistical concept of normality	p. 27
The concept of disease	p. 30
Interpretation and relevance	p. 33
Indicators	p. 35
The Disease Classification	p. 37
The historical perspective	p. 38
The seventeenth and eighteenth centuries	p. 38
The nineteenth and twentieth centuries	p. 40
The theoretical perspective	p. 42
The mechanical model of disease	p. 42
Molecular biology	p. 43
Disease and the environment	p. 44
The practical perspective	p. 46
Name of disease	p. 46
Definition	p. 47
Causes of disease (aetiology and pathogenesis)	p. 52
The clinical picture	p. 56
Diagnosis and treatment	p. 59
Diagnosis	p. 61
The diagnostic universe	p. 62
Diagnosis of diseases with an accessible defining criterion	p. 65
The direct method for assessing the accuracy of test results	p. 65
The indirect method for assessing the accuracy of test results	p. 68
Terminological confusion	p. 72
Quantitative data	p. 74
Diagnosis of disease with a concealed defining criterion	p. 77
Syndrome diagnosis	p. 80
Three patients	p. 84
Diagnosis in practice	p. 85
Frequential and subjective probabilities	p. 85
Diagnostic strategy	p. 87
Uncontrolled Experience	p. 91
Uncontrolled experience in a pre-scientific era	p. 92
The numerical method	p. 94
The era of laboratory research	p. 96
The spontaneous course of the disease	p. 98
Regression towards the mean	p. 99
Run of luck	p. 101
Bias	p. 103
The placebo effect	p. 104
The need for controlled experience	p. 108
Alternative edicine: pseudoscientific thinking	p. 109
The Randomized Clinical Trial	p. 115
Selection of patients	p. 116
Randomization	p. 117
Choice of treatment in the control group	p. 119
Principles of blinding	p. 120
Cross-over trials	p. 122
Measures of benefits and harms	p. 123
Stopping rules	p. 126
Assessment of the results	p. 127
Statistical analysis	p. 129
Hypothesis testing	p. 129
Estimation	p. 133
Other statistical measures of effect	p. 135
Subgroup analyses	p. 136
Systematic reviews	p. 136
From trials to practice	p. 142
Evidence-based medicine and commercial pressures	p. 145
Medicine and the Humanities	p. 149
The four components of clinical reasoning	p. 149
The empathic-hermeneutic component	p. 151
The ethical component	p. 153
Three kinds of norms	p. 154
The foundation of health care ethics	p. 155
The structure of ethical reasoning	p. 157
Assessment of the facts of the case	p. 159
Consequential considerations	p. 159
Deontological considerations	p. 160
The ethical decision	p. 161
Quality of life	p. 162
Autonomy and paternalism	p. 164
Clinical examples	p. 166
Clinical research ethics	p. 174
Critical Reading of Medical Journals	p. 179
Logical analysis of medical papers	p. 179
Assets and limitations of cohort studies	p. 182
Assets and limitations of case-control studies	p. 183
Other designs	p. 186
Descriptive statistics	p. 187
Estimation	p. 190
Testing hypotheses	p. 192
Pseudohypothetico-deductive logic	p. 193
Wrong sampling unit	p. 193
Sample size calculations	p. 195
Interpretation of P-values	p. 196
Statistical tests	p. 199
Examples	p. 200
Correlation analysis	p. 202
Life table analysis	p. 207
References	p. 211
Index	p. 225
Table of Contents provided by Ingram. All Rights Reserved.

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Rational Diagnosis and Treatment Evidence-Based Clinical Decision-Making

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