# More Statistics and Medicine

I wrote last on the intersection of these two disciplines back in March 2011 (Medical Malpractice). What has prompted me to return to the subject is some medical tests that I was offered recently. If the reader will forgive me, I won’t go into the medical details – and indeed have also obfuscated some of the figures I was quoted – but neither are that relevant to the point that I wanted to make. This point relates to how statistics are sometimes presented in medical situations and – more pertinently – the disconnect between how these may be interpreted by the man or woman in the street, as opposed to what is actually going on.

Rather than tie myself in knots, let’s assume that the test is for a horrible disease called PJT Syndrome [1]. Let’s further assume that I am told that the test on offer has an accuracy of 80% [2]. This in and of itself is a potentially confusing figure. Does the test fail to detect the presence of PJT Syndrome 20% of the time, or does it instead erroneously detect PJT Syndrome, when the patient is actually perfectly healthy, 20% of the time? In this case, after an enquiry, I was told that a negative result was a negative result, but that a positive one did not always mean that the subject suffered from PJT Syndrome; so the issue is confined to false positives, not false negatives. This definition of 80% accuracy is at least a little clearer.

So what is a reasonable person to deduce from the 80% figure? Probably that if they test positive, that there is an 80% certainty that they have PJT Syndrome. I think that my visceral reaction would probably be along those lines. However, such a conclusion can be incorrect, particularly where the incidence of PJT Syndrome is low in a population. I’ll try to explain why.

If we know that PJT Syndrome occurs in 1 in every 100 people on average, what does this mean for the relevance of our test results? Let’s take a graphical look at a wholly representative population of exactly 100 people. The PJT Syndrome sufferer appears in red at the bottom right.

Now what is the result of the 80% accuracy of our test, remembering that this means that 20% of people taking it will be falsely diagnosed as having PJT Syndrome? Well 20% of 100 is – applying a complex algorithm – approximately 20 people. Let’s flag these up on our population schematic in grey.

So 20 people have the wrong diagnosis. One is correctly identified as having PJT Syndrome and 79 are correctly identified as not having PJT Syndrome; so a total of 80 have the right diagnosis.

What does this mean for those 21 people who have been unfortunate enough to test positive for PJT Syndrome (the one person coloured red and the 20 coloured grey)? Well only one of them actually has the malady. So, if I test positive, my chances of actually having PJT Syndrome are not 80% as we originally thought, but instead 1 in 21 or 4.76%. So my risk is still low having tested positive. It is higher than the risk in the general population, which is 1 in 100, or 1%, but not much more so.

The problem arises if having a condition is rare (here 1 in 100) and the accuracy of a test is low (here it is wrong for 20% of people taking it). If you consider that the condition that I was being offered a test for actually has an incidence of around 1 in 20,000 people, then with an 80% accurate test we would get the following:

1. In a population of 20,000 one 1 person has the condition
2. In the same population a test with our 80% accuracy means that 20% of people will test positive for it when they are perfectly healthy, this amounts to 4,000 people
3. So in total, 4,001 people will test positive, 1 correctly, 4,000 erroneously
4. Which means that a positive test tells me my odds of having the condition being tested for are 1 in 4,001, or 0.025%; still a pretty unlikely event

Low accuracy tests and rare conditions are a very bad combination. As well as causing people unnecessary distress, the real problem is where the diagnosis leads potential suffers to take actions (e.g. undergoing further diagnosis, which could be invasive, or even embarking on a course of treatment) which may themselves have the potential to cause injury to the patient.

I am not of course suggesting that people ignore medical advice, but Doctors are experts in medicine and not statistics. When deciding what course of action to take in a situation similar to one I recently experienced, taking the time to more accurately assess risks and benefits is extremely important. Humans are well known to overestimate some risks (and underestimate others), there are circumstances when crunching the numbers and seeing what they tell you is not only a good idea, it can help to safeguard your health.

For what it’s worth, I opted out of these particular tests.

Notes

 [1] A terrible condition which renders sufferers unable to express any thought in under 1,000 words. [2] Not the actual figure quoted, but close to it.