We aim to clarify the debate about the value of evidence-based medicine, or EBM. First, we note t... 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.
What is precision medicine? No standard definition is found. Sometimes described as High Definiti... more What is precision medicine? No standard definition is found. Sometimes described as High Definition Medicine which is: “the dynamic assessment , management, and understanding of an individual’s health measured at (or near) its most basic units.” The impetus for this venture was advanced and stimulated by biogenetics, the study of how genes and their products affect health but also contribute to disease or resistance to cure. Medicine is an epistemology: a way of knowing, perceiving, remembering, finding out, proving, inferring, wondering, reflecting, a conceptual knowing relying upon observations fitted to disease concepts.
Nineteenth-century American philosopher Charles Sanders Peirce offered a picture of the scientifi... more Nineteenth-century American philosopher Charles Sanders Peirce offered a picture of the scientific method that can be fruitfully applied to the practice of medical diagnosis. Physicians can use this framework to become more self-consciously aware of what they are doing when they diagnose medical conditions, and they can also learn more about the potential pitfalls of communication between physicians and their patients.
Morphologic diagnosis of inflammatory skin lesions is traditionally performed with punch biopsies... more Morphologic diagnosis of inflammatory skin lesions is traditionally performed with punch biopsies or incisional biopsies. Skin nodules are excised for both curative and diagnostic purposes. Fine-needle aspiration cytology (FNAC) of skin nodules offers the possibility of avoiding surgical biopsy and provides rapid diagnosis, making it a valuable examination tool in cases of metastatic depositions in the skin and subcutaneous tissue.
Clinical diagnostic medicine is an experimental science based on observation, hypothesis making, ... more Clinical diagnostic medicine is an experimental science based on observation, hypothesis making, and testing. It is an use dynamic process that involves observation and summary, diagnostic conjectures, testing, review, observation and summary, new or revised conjectures, i.e. it is an iterative process. It can then be said that diagnostic hypotheses are also 'observation-laden'. My aim is to enlarge on the strategies of medical diagnosis as these are meshed in training and clinical experience—that is, to describe the patterns of reasoning used by experienced clinicians under different diagnostic circumstances and how these patterns of inquiry allow further insight into the evaluation and treatment of patients. I do not aim to present a theory and illustrate it with examples; I wish rather am to let a realistic example, similar to actual clinical scenarios, direct the exposition. To this end, I introduce an account of medical diagnosis—briefly comparing and contrasting it to other accounts—in order to focus on discussing the process of diagnosis through a detailed clinical case.
Slate is a metamorphic rock comprising silica, aluminum silicates, and small amounts of chlorite,... 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...
Background: The term "evidence-based medicine" (or EBM) was introduced about ten years ago, and t... more Background: 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.
Abstract: This article describes reasoning strategies used by clinicians in different diagnostic ... more Abstract: 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 may have a diversified kit of strategies—to select from among previously generated hypotheses.
Journal of Evaluation in Clinical Practice, DOI: 10.1111/jep.12417, Jul 23, 2015
This article describes reasoning strategies used by clinicians in different diagnostic circumstan... 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—e.g. Bayesian probability or inference to a lovely explanation—to select from among previously generated hypotheses, rather than rely on any one approach every time.
Perspectives in Biology and Medicine, 56(2), 300-315., 2013
Establishing diagnoses is a crucial aspect of medical practice. However, this process has receive... 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.
We aim to clarify the debate about the value of evidence-based medicine, or EBM. First, we note t... 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.
What is precision medicine? No standard definition is found. Sometimes described as High Definiti... more What is precision medicine? No standard definition is found. Sometimes described as High Definition Medicine which is: “the dynamic assessment , management, and understanding of an individual’s health measured at (or near) its most basic units.” The impetus for this venture was advanced and stimulated by biogenetics, the study of how genes and their products affect health but also contribute to disease or resistance to cure. Medicine is an epistemology: a way of knowing, perceiving, remembering, finding out, proving, inferring, wondering, reflecting, a conceptual knowing relying upon observations fitted to disease concepts.
Nineteenth-century American philosopher Charles Sanders Peirce offered a picture of the scientifi... more Nineteenth-century American philosopher Charles Sanders Peirce offered a picture of the scientific method that can be fruitfully applied to the practice of medical diagnosis. Physicians can use this framework to become more self-consciously aware of what they are doing when they diagnose medical conditions, and they can also learn more about the potential pitfalls of communication between physicians and their patients.
Morphologic diagnosis of inflammatory skin lesions is traditionally performed with punch biopsies... more Morphologic diagnosis of inflammatory skin lesions is traditionally performed with punch biopsies or incisional biopsies. Skin nodules are excised for both curative and diagnostic purposes. Fine-needle aspiration cytology (FNAC) of skin nodules offers the possibility of avoiding surgical biopsy and provides rapid diagnosis, making it a valuable examination tool in cases of metastatic depositions in the skin and subcutaneous tissue.
Clinical diagnostic medicine is an experimental science based on observation, hypothesis making, ... more Clinical diagnostic medicine is an experimental science based on observation, hypothesis making, and testing. It is an use dynamic process that involves observation and summary, diagnostic conjectures, testing, review, observation and summary, new or revised conjectures, i.e. it is an iterative process. It can then be said that diagnostic hypotheses are also 'observation-laden'. My aim is to enlarge on the strategies of medical diagnosis as these are meshed in training and clinical experience—that is, to describe the patterns of reasoning used by experienced clinicians under different diagnostic circumstances and how these patterns of inquiry allow further insight into the evaluation and treatment of patients. I do not aim to present a theory and illustrate it with examples; I wish rather am to let a realistic example, similar to actual clinical scenarios, direct the exposition. To this end, I introduce an account of medical diagnosis—briefly comparing and contrasting it to other accounts—in order to focus on discussing the process of diagnosis through a detailed clinical case.
Slate is a metamorphic rock comprising silica, aluminum silicates, and small amounts of chlorite,... 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...
Background: The term "evidence-based medicine" (or EBM) was introduced about ten years ago, and t... more Background: 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.
Abstract: This article describes reasoning strategies used by clinicians in different diagnostic ... more Abstract: 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 may have a diversified kit of strategies—to select from among previously generated hypotheses.
Journal of Evaluation in Clinical Practice, DOI: 10.1111/jep.12417, Jul 23, 2015
This article describes reasoning strategies used by clinicians in different diagnostic circumstan... 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—e.g. Bayesian probability or inference to a lovely explanation—to select from among previously generated hypotheses, rather than rely on any one approach every time.
Perspectives in Biology and Medicine, 56(2), 300-315., 2013
Establishing diagnoses is a crucial aspect of medical practice. However, this process has receive... 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.
Disease is a natural kind; this implies that diseases are categories having modal implications: N... more Disease is a natural kind; this implies that diseases are categories having modal implications: Nature fixes natural kinds as sortals. Sortals is a predicate name for disease to tell us what kind of category it is and implies conditions for those kinds to be similar. Diseases evolve, transmute, providing precision medicine treatment is not feasible because medical evidence is based on general tenets applicable to all patients with a disease. Diseases are not stable entities but evolve under treatment to resist treatments, the modal nature is altered by treatment e.g. MRSA, Influenza, cancers. Tuberculosis, the origin in the middle east is at least 9000 years old 1 and common resistant mutations are numerous, Thr(ACA), Asn(AAC), Ile(ATC), Thr(ACT), Gly(GGC) inhA promoter-15T and evade drug therapy. Malaria has defied cure based on the point mutations and gene amplifications e.g.crt, dhps, dhfr, mdr1, and kelch13. 2 EBV sequesters in B cells and silently reproduces only to remain viable. Herpes hides in neural ganglia for many years until opportunity arises. Our taxonomy of disease is based on observations that, given signs and symptoms, diseases reflect the relationship between the disease, its resistance to interventions, natural and therapeutic, and the patient; each patient manifests symptoms and signs that mimic, but do not match exactly those in others with the same disease. Disease is a natural kind: a homeostatic cluster of features that distinguish it from related diseases. "We carve nature at its joints." accordingly. This notion of natural kinds is one among many diseases. Leukemia requires a predicate, a sortal predicate if you will, thus ALL, AML, CLL, B-cell lymphomas are categories of the disease, yet antigenic markers (sortal predicates) distinguish among these diseases allowing targeted therapy, e.g. based on cytogenetics and therapeutically on molecular markers KIT,
Visual training is paramount to medical diagnosis: pattern recognition most efficient;other metho... more Visual training is paramount to medical diagnosis: pattern recognition most efficient;other methods involve probability
When we examine a biopsy specimen under the microscope, how do we make a diagnosis? Does our mind... more When we examine a biopsy specimen under the microscope, how do we make a diagnosis? Does our mind works like a well-programmed digital computer, activating circuits which turn switches to the yes or to the no position? Are we using our diagnostic skill like a bucket, sweeping up the facts in swoops, gathering as many morsels as we dare to, hoping the filled bucket will reveal the truth? Do we move from firm observations to general conclusions? To a diagnosis? All of these rhetorical questions rest on premises which have been debated by philosophers, especially logicians, since the 17 th century. John Stuart Mill and Francis Bacon, the fathers of modern inductive logic, taught us to move from the particular to the general, from observation to conclusion, from information gathering to truths. This inductive method of arriving at a conclusion relies on systematic classification and tedious collections. It is idealized in the sense that numbers must prove something, i.e., can 10 mitoses per high-power field mean malignancy where is three or five do not? The soundness of inductive proof has long been debated and even today there are schools of thought that deny the epistemological
Peircean abduction: how to strategize; examples from medical diagnoses to illustrate how to use ... more Peircean abduction: how to strategize; examples from medical diagnoses to illustrate how to use in diagnosis.
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Papers by Donald Stanley