The diagnostic process and Hamelin

From Wikipedia. Portrait in Hamelin. 1592

The history of the Pied Piper of Hamelin is well known. The king hired the services of a flautist to eliminate all the mice in the village, but when  the piper finished his work, he did not receive his payment, because the king had kept a mouse in a cage.

This story serves us as a imaginary representation about how much is enough in the diagnostic process. Should we always perform a bronchoscopy in a neoplasm of undetermined origin? Should we always do an upper endoscopy in all abdominal tumors? Should we ask for a  PET in the staging of a cancer? Should we perform a coronary angiography in every chest pain? Is CAT required in cases of sudden dyspnea to rule out pulmonary embolism?

These types of scenario can occur in the daily clinic and give rise to malpractice claims, especially if the clinical outcome is not favorable. In addition, the analysis of these situations is usually performed retrospectively, such as a photo taken at a time when the important clinical decisions had been taken. If we compare it with a river, the retrospective analysis would be the one we carried out at the mouth, where there is little of the swift and turbulent waters of its high course. And if the patient or family decides to start for legal actions, there can always be a hidden mouse, a therapeutic action not established as a standard or a procedure without a confirmed interpretation
What to do when a new therapeutic procedure seems to improve diagnostic accuracy but it needs time and money for its consolidation? A very recent example is a publication in “The Lancet” (1) , which compares multiparametric magnetic resonance imaging with ultrasound-guided transrectal biopsy. The resonance shows a sensitivity of 97% and helps avoid biopsies, reduce overdiagnosis and works better on the detection of high risk tumors, such as those located in the anterior area of ​​the prostate.
The doctor-patient-family relationship must be based on trust, with a high degree of information and communication, and the patient must perceive that  all necessary measures and tests will be performed for their best care, according to the current scientific knowledge. If this is not the case, we will always have the possibility to find a hidden mouse, broken the mutual trust between the patient and his or her doctor.

(1) Hashim U Ahmed*, Ahmed El-Shater Bosaily*, Louise C Brown*, Rhian Gabe, Richard Kaplan, Mahesh K Parmar, Yolanda Collaco-Moraes, Katie Ward, Richard G Hindley, Alex Freeman, Alex P Kirkham, Robert Oldroyd, Chris Parker, Mark Emberton, and the PROMIS study group† .The Lancet 2017;  389:815