Abstract
To the Editor. —In closing his recent comments on diagnostic certainty, Dr Johnson1noted that the complex and often intuitive decision [of when to stop diagnostic investigation and start treatment] calls on broad clinical judgment beyond the scope of any rote diagnostic algorithm. Johnson is referring to the test-treatment threshold, and his statement ignores a large body of work that has been done in medical decision analysis over the last two decades. The decision to which Johnson refers depends on the perceived risks and benefits of treatment and of withholding treatment. This decision properly takes into account not only the virulence of the disease and the effectiveness of the treatment but also the understanding that diagnosis is imperfect, that one will end up treating some persons without the disease as well as withholding treatment from some who have the disease. One can, using decision analysis, express the possible outcomes
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