John C. Peirce, MD, MA, MS
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Peirce JC. Talking about Treatment. Ann Intern Med. 2000;132:93-94. doi: 10.7326/0003-4819-132-1-200001040-00019
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Published: Ann Intern Med. 2000;132(1):93-94.
TO THE EDITOR:
Steiner (1) has captured the difficulties in translating population-based studies into a language that informs patient's decisions. Goodman (2) adds a historical perspective that contrasts the deterministic with the probabilistic model, noting “ … that in the individual patient … the concept of probability … is ambiguous and elusive, no matter how we choose to communicate it.” This description fits the properties of complex systems wherein events often are surprising and are revealed only through nonlinear dynamics (3). It is not surprising, then, that epidemiologic biostatistics, which is the basis of most if not all of our experimental studies and is rooted in general linear models, explains only a limited proportion of the variability. This is analogous to saying that tornadoes are much more likely in Oklahoma City than in Albuquerque, 550 miles to the west, yet this probabilistic approach will fall short of being able to predict if, when, and where a 4-F tornado will touch down in the Oklahoma City area. Goldberger (4) argues that “fractal variability”—found in complex systems—is a sign of health, and that people who lose this variability in the physiologic measures showing a highly predictable periodicity are those with disease. Steiner attempts to get at the complexity of individual human beings through subgroup analyses, but human beings are far too complex to allow for such a priori analyses. Holland (5) demonstrates the impossibility of such an approach in his discussion of a hypothetical board game, far less complex than human beings, that has 10 possible approaches for every move. At the end of 10 moves, there are 1010 or 10 000 000 000 possibilities.
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