donald stanley
University of New England, School of Health, Faculty Member
- Retired pathologistedit
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As medical care moves toward outpatient and managed care, FNA becomes an indispensable biopsy procedure that can replace many surgical biopsies. The reliability of the procedure is maximized by rapid assessment of the aspirates and the... more
As medical care moves toward outpatient and managed care, FNA becomes an indispensable biopsy procedure that can replace many surgical biopsies. The reliability of the procedure is maximized by rapid assessment of the aspirates and the team approach (the cytopathologist, radiologist, and clinician working closely together). Proper training and maintenance of competency are central to success. QA and QI programs are excellent means to monitor competency and improve performance. Aspirators who persistently produce a high rate of unsatisfactory aspirates (> 15%) should be identified and given remedial training. Clear, precise communication and rapid turn-around time for reporting are critical.
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Accuracy of diagnoses rendered using a live video telepathology network was assessed for permanent sections of surgical pathology specimens. To determine accuracy, telepathology diagnoses were compared with those obtained by directly... more
Accuracy of diagnoses rendered using a live video telepathology network was assessed for permanent sections of surgical pathology specimens. To determine accuracy, telepathology diagnoses were compared with those obtained by directly viewing the glass slide using a standard microscope. A total of 294 cases were read via both telepathology and glass slide by attending pathologists at a tertiary care medical center. Overall accuracy was defined as exact concordance between diagnoses. Clinically insignificant differences in diagnoses were excluded to determine clinically significant accuracy. For the 285 cases with complete data, the overall accuracy for telepathology was 0.912 (95% confidence interval [CI], 0.872-0.941), whereas the overall accuracy for glass slide readings was 0.968 (95% CI, 0.939-0.985). This difference is statistically significant (p = 0.009). When focusing on clinically significant discrepancies, where the difference in diagnosis might affect therapeutic decisions, the video accuracy was only slightly less than the glass slide accuracy (0.965 [95% CI, 0.934-0.982] vs. 0.982 [95% CI, 0.957-0.994], respectively), but this difference is not statistically significant (p = 0.302). Most of the cases with clinically significant differences involved lesions with inherently high interobserver variation. Certainty of diagnosis did not differ between video and glass slide readings (p = 0.911), but there was an association between certainty of diagnosis and diagnostic accuracy for video (p = 0.003 for clinically significant accuracies). Based on these findings, we recommend when using this telepathology system that only preliminary diagnoses should be given in the following situations: for diagnostic areas with known high interobserver variability; when the consultant has any degree of uncertainty about the presence or absence of the lesion in question; and when there is insufficient experience using telepathology as a diagnostic medium.
Research Interests: Medicine, Rural Health, Video microscopy, Humans, Female, and 14 moreVermont, American, Clinical Sciences, Medical Diagnosis, Concordance, Observer Variation, Reproducibility of Results, Diagnostic Accuracy, Leiomyosarcoma, Telepathology, Crohn Disease, Confidence Interval, Ileum, and Significant Difference
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We distinguish three aspects of medical diagnosis: generating new diagnostic hypotheses, selecting hypotheses for further pursuit, and evaluating their probability in light of the available evidence. Drawing on Peirce’s account of... more
We distinguish three aspects of medical diagnosis: generating new diagnostic hypotheses, selecting hypotheses for further pursuit, and evaluating their probability in light of the available evidence. Drawing on Peirce’s account of abduction, we argue that hypothesis generation is amenable to normative analysis: physicians need to make good decisions about when and how to generate new diagnostic hypothesis as well as when to stop. The intertwining relationship between the generation and selection of diagnostic hypotheses is illustrated through the analysis of a detailed clinical case study. This interaction is not adequately captured by the existing probabilistic, decision-theoretic models of the threshold approach to clinical decision-making. Instead, we propose to conceptualize medical diagnosis in terms of strategic reasoning.
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We aim to clarify the debate about the value of evidence-based medicine, or EBM. First, we note that EBM proponents have obscured the current debate by defining EBM in an overly broad, indeed almost vacuous, manner; we offer a clearer... more
We aim to clarify the debate about the value of evidence-based medicine, or EBM. First, we note that EBM proponents have obscured the current debate by defining EBM in an overly broad, indeed almost vacuous, manner; we offer a clearer account of EBM and its relation to the alternative approaches to medicine. Second, while EBM proponents commonly cite the philosophical work of Thomas Kuhn and claim that EBM is a Kuhnian ‘paradigm shift,’ we argue that such claims are seriously mistaken and unduly polarize the EBM debate. Third, we suggest that it is much more fruitful to understand the relationship between EBM and its alternatives in light of a different philosophical metaphor: W.V. Quine’s metaphor of the web of belief. Seen in this way, we argue that EBM is an approach to medical practice that is indeed importantly different from the alternatives.
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This article describes reasoning strategies used by clinicians in different diagnostic circumstances and how these modes of inquiry may allow further insight into the evaluation and treatment of patients. Specifically, it aims to make... more
This article describes reasoning strategies used by clinicians in different diagnostic circumstances and how these modes of inquiry may allow further insight into the evaluation and treatment of patients. Specifically, it aims to make explicit the implicit logical considerations that guide a variety of strategies in the diagnostic process, as exemplified in specific clinical cases. It focuses, in particular, in strategies that clinicians use to move from a large set of possible diagnoses initially suggested by abductive inferences - the process of hypothesis generation that creates a diagnostic space - to a narrower set or even to a single 'best' diagnosis, where the criteria to determine what is 'best' may differ according to different strategies. Experienced clinicians should have a diversified kit of strategies - for example, Bayesian probability or inference to a lovely explanation - to select from among previously generated hypotheses, rather than rely on any one approach every time.
Research Interests: Philosophy of Science, Pain, Philosophy of Medicine, Charles Sanders Peirce, Problem Solving, and 10 moreClinical Decision Making, Humans, Diagnosis, Skin Diseases, Public health systems and services research, Bayes Theorem, Logic of Inquiry, Practice Education/Clinical Evaluation, Lymphadenopathy, and Vertebral Artery Dissection
The term "evidence-based medicine" (or EBM) was introduced about ten years ago, and there has been considerable debate about the value of EBM. However, this debate has sometimes been obscured by a lack of conceptual clarity... more
The term "evidence-based medicine" (or EBM) was introduced about ten years ago, and there has been considerable debate about the value of EBM. However, this debate has sometimes been obscured by a lack of conceptual clarity concerning the nature and status of EBM. First, we note that EBM proponents have obscured the current debate by defining EBM in an overly broad, indeed almost vacuous, manner; we offer a clearer account of EBM and its relation to the alternative approaches to medicine. Second, while EBM proponents commonly cite the philosophical work of Thomas Kuhn and claim that EBM is a Kuhnian 'paradigm shift,' we argue that such claims are seriously mistaken and unduly polarize the EBM debate. Third, we suggest that it is much more fruitful to understand the relationship between EBM and its alternatives in light of a different philosophical metaphor: W.V. Quine's metaphor of the web of belief. Seen in this way, we argue that EBM is an approach to medical...
Research Interests: Medical Sociology, Evidence Based Medicine, History of Science, Treatment Outcome, Evidence, and 8 moreObservation, Library and Information Studies, Humans, Complementary Therapies, Social Values, Public health systems and services research, Randomized Controlled Trials as Topic, and attitude to health
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Slate is a metamorphic rock comprising silica, aluminum silicates, and small amounts of chlorite, hematite, magnetite, and various carbonates. In the United States slate is quarried in Virginia, Pennsylvania, New York, and Vermont.... more
Slate is a metamorphic rock comprising silica, aluminum silicates, and small amounts of chlorite, hematite, magnetite, and various carbonates. In the United States slate is quarried in Virginia, Pennsylvania, New York, and Vermont. Workers are exposed during mining and processing of the slate and in crushing mills that prepare gravel. We have conducted detailed mineralogic and pathologic studies on the lungs of 12 workers who developed a pneumoconiosis while employed in the quarries of west central Vermont and adjacent areas of New York. Perivascular and peribronchial lesions accompanied by interstitial fibrosis and macules were scattered diffusely in the lungs. The lesions were associated with a variable number of silicotic nodules. Scanning electron microscopy combined with energy-dispersive x-ray spectrometry demonstrated aluminum and silicon-containing particles with variable cationic constituents and silicon alone in a pattern typical of free crystalline quartz. By x-ray diffra...
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Establishing diagnoses is a crucial aspect of medical practice. However, this process has received comparatively little logical and pedagogical attention when compared to statistical methods for evaluating evidence. This article... more
Establishing diagnoses is a crucial aspect of medical practice. However, this process has received comparatively little logical and pedagogical attention when compared to statistical methods for evaluating evidence. This article investigates the logic of medical diagnosis in order to fill this void. It is organized in three parts: the first attempts to explain why more attention ought to be paid to diagnosis, at least as much as to evidence; the second calls attention to the method of diagnosis by abductive reasoning developed in the 19th century by Charles Sanders Peirce (1839-1914); and the third demonstrates the use and pervasiveness of abduction by any other name in clinical diagnosis. We examine six diagnostic strategies in common use that contain most, if not all, of Peirce's structure of inquiry in science.
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This guideline document was developed by the Standards of Practice Task Force of the Papanicolaou Society of Cytopathology, based on extensive literature reviews and the personal practical experience of task force members. The draft... more
This guideline document was developed by the Standards of Practice Task Force of the Papanicolaou Society of Cytopathology, based on extensive literature reviews and the personal practical experience of task force members. The draft guidelines were then subjected to expert review. The task force made revisions to the drafts based on the responses received from the consultant members, who are recognized experts in fine-needle aspiration biopsy.
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Jaakko Hintikka's move to the strategies of diagnosis are explored.
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Precision medicine entails the same future faced by bacterial antibiotic resistance.
Precision medicine is designed to understand the nature of disease. Disease is a natural kind: a homeostatic cluster of features that distinguish it from related diseases. Evolutionary changes in the body, dependent on both external and... more
Precision medicine is designed to understand the nature of disease. Disease is a natural kind: a homeostatic cluster of features that distinguish it from related diseases. Evolutionary changes in the body, dependent on both external and internal environment, allow diseases to escape natural controls i.e. the immune system. Tumor cells evolve to become refractory to chemotherapy e.g. loss of responsiveness to treatment with monoclonal antibodies (mAbs) such as rituximab is a serious complication during therapy of B-cell malignancies but the mechanisms responsible for it are not well understood.