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\begin{document}

\title{Karl Popper 120th anniversary; Some reflections on the decision-making
process in medicine}



\author[1]{Elisha Krasin}%
\affil[1]{Tel Aviv Sourasky Medical Center}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\begin{abstract}
Rereading Popper's ``The Logic of scientific discovery'', at his 120th
anniversary, brings some thoughts regarding the diagnostic process and
decision making in medicine from the viewpoint of the classical
scientific method. In recent years physicians are increasingly becoming
technical experts who base their decision-making on uniform criteria,
guidelines and classifications but unfortunately have moved away from
understanding the basic concepts in the philosophy of science. This
raises an ethically and philosophically important issue; what does a
medical diagnosis mean? Is this an absolute or a relative truth? The
implications of this question are enormous in terms of prognosis and
treatment. Both patients and physicians should be educated about the
nature of the diagnostic process.%
\end{abstract}%



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\textbf{Karl Popper 120\textsuperscript{th} anniversary;}

\textbf{Some reflections on the decision-making process in medicine}

\emph{Running title:} Some reflections on the decision-making process in
medicine

Elisha Krasin MD

\emph{Division of Orthopedic Surgery, Tel Aviv Sourasky Medical Center,
affiliated with the Faculty of Medicine, Tel Aviv University,} \emph{Tel
Aviv, Israel.}

Correspondence: Elisha Krasin MD, https://orcid.org/0000-0001-7263-4422,

Email: ekrasin@outlook.co.il, Telephone: +972-3-6973484

\emph{Funding -- No funding was received for this paper.Conflicts of
interest/Competing interests -- The author declared no conflict of
interest.}

\emph{Ethics approval -- Not applicable.}

\emph{Consent to participate - Not applicable.}

\emph{}

\emph{Abstract:}

Rereading Popper's ''The Logic of scientific discovery'', at his
120\textsuperscript{th} anniversary, brings some thoughts regarding the
diagnostic process and decision making in medicine from the viewpoint of
the classical scientific method. In recent years physicians are
increasingly becoming technical experts who base their decision-making
on uniform criteria, guidelines and classifications but unfortunately
have moved away from understanding the basic concepts in the philosophy
of science. This raises an ethically and philosophically important
issue; what does a medical diagnosis mean? Is this an absolute or a
relative truth? The implications of this question are enormous in terms
of prognosis and treatment. Both patients and physicians should be
educated about the nature of the diagnostic process.

Keywords: diagnostic criteria\emph{;} diagnostic process; differential
diagnosis; intent-to-treat analysis; predictive values; scientific
method \emph{}

\emph{Main text:}

Inexperienced physicians tend to see diagnoses as absolute. It is more
prominent among surgeons. One who sees during an operation, a nerve root
that is compressed by a herniated disc or the collapse of the femoral
head due to avascular necrosis, would be convinced that he has a good
understanding of the pathophysiology of the disease and the causes that
brought the patient to his attention. Unfortunately the situation is not
always that clear. Rheumatic patients often spend weeks, months or even
years before getting a final diagnosis. Incomplete lupus erythematosus
(latent or ''non-criteria'' lupus) is a typical example. In oncology,
the pathologist is not always convinced about the precise type of the
tumor or even if the tumor is benign or malignant. Simple count of
mitoses, that is prone to subjectivity, \textsuperscript{1} sometimes is
the only method that determines if chemotherapy is necessary. The
purpose of this paper is to examine the diagnostic process from the
viewpoint of the classical scientific method, based on the work of Karl
Popper, and to shed some light on the meaning of making a diagnosis.

Karl Popper was born in Vienna in 1902 to a converted Jewish family.
After the annexation of Austria by the Nazis, he immigrated to New
Zealand and later to Britain. He wrote several books that had a profound
influence on the philosophy of science and medicine in the previous
century. In his 1959 book ''The Logic of scientific
discovery''\textsuperscript{2} Popper has thoroughly analyzed the
scientific method. He claims that after a tentative creation of a
hypothesis that is ''not justified in any way''; the hypothesis is
tested by the way of ''empirical applications of the conclusions that
can be derived from it''. A positive experiment is always temporary as
any future negative experiment can overthrow the theory. In the process
of medical diagnosis, when the patient presents with a symptom, the
physician makes a hypothetic list of diagnoses that can possibly explain
the symptom. The next stage would be to exclude or prove the diagnoses
by the means of history taking, physical examination and different
laboratory and imaging tests. In the same manner as Popper described, a
proof or a disproof of a diagnosis is in effect only until a new test
will change the conclusion. Reproducibility of an experiment is another
condition for the effect to be scientifically significant
\textsuperscript{2} and certainly is important in the diagnostic
process. Multiple repetitions of an experiment bring us closer to
exemplary proof, which is actually unreachable, as a single negative
experiment can disprove the theory. An experiment actually measures the
probability of a result and almost never the p-value in the medical
field would be zero. Even the most successful drug or procedure
sometimes fails, and patients in the control group can recover with
placebo treatment. Intent-to-treat analysis necessitates including
dropouts in the final statistic, thus decreasing the final effect of the
test, drug or the procedure that is under experiment.
\textsuperscript{3} Each medical laboratory test or imaging modality has
its own sensitivity, specificity and positive and negative predictive
values that are never absolute. So actually even at the end of the
diagnostic process we remain with a \emph{hypothesis that is proved both
temporarily and in a probabilistic manner} . Ilgen et
al\textsuperscript{4} indicate that skillful clinicians work comfortably
when uncertain and acquiring this ability to act in complex settings is
necessary for trainees.

Another subject that is a source of confusion and misunderstanding is
the common use of diagnostic criteria. They are very useful, especially
for the less experienced physician, but one should always keep in mind
that diagnostic criteria cannot be more accurate than the tests they are
based upon, prior to the clinical validation of the criteria for
diagnosis. For example, the diagnostic criteria for a prosthetic joint
infection rely on cultures, histology, elevation of acute phase
reactants and some other tests. Each of these tests has its own
sensitivity and specificity and the combination of tests does not create
100\% specific and sensitive method. Eventually validation of each set
of clinical criteria for diagnosis is based on a ``\emph{gold standard
test} '' that also has its sensitivity and specificity that never equals
one. Overdependence on diagnostic criteria will eventually lead to
misdiagnosis. For example, Li et al had found that the number of
patients diagnosed with a prosthetic joint infection in a group, grossly
varies depending on the diagnostic criteria that were
used.\textsuperscript{5}

In conclusion, the clinical data should be analyzed without prejudice.
Flexibility and readiness to re-evaluate the conclusions when new
information arrives is necessary. Criteria and classifications are
intended only to be an aid in diagnosis, not the absolute truth.
Understanding the intricacies of the diagnostic process is absolutely
necessary to provide proper care.

\emph{References:}

1. Balkenhol MCA, Tellez D, Vreuls W, et al. Deep learning assisted
mitotic counting for breast cancer. \emph{Lab Invest} .
2019;99(11):1596-1606. doi:10.1038/s41374-019-0275-0

2. Popper KR. \emph{The Logic of Scientific Discovery} . Repr. 2008
(twice). Routledge; 2008.

3. Brody T. Chapter 8 - Intent-to-Treat Analysis Versus Per Protocol
Analysis. In: Brody T, ed. \emph{Clinical Trials (Second Edition)} .
Academic Press; 2016:173-201. doi:10.1016/B978-0-12-804217-5.00008-4

4. Ilgen JS, Eva KW, de Bruin A, Cook DA, Regehr G. Comfort with
uncertainty: reframing our conceptions of how clinicians navigate
complex clinical situations. \emph{Adv Health Sci Educ Theory Pract} .
2019;24(4):797-809. doi:10.1007/s10459-018-9859-5

5. Li C, Renz N, Trampuz A, Ojeda-Thies C. Twenty common errors in the
diagnosis and treatment of periprosthetic joint infection. \emph{Int
Orthop} . 2020;44(1):3-14. doi:10.1007/s00264-019-04426-7

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