LAUSR

For any decision in favor of performing an endoscopic procedure, its expected benefit should exceed its expected cost. Otherwise, one should not do the endoscopy. The choice between two options against, or in favor of, endoscopy is based on the underlying cost– benefit relationship. Occasionally, situations arise when, besides these two options, the endoscopist faces yet a third option of ‘‘willful ignorance.’’ Rather than focusing on the potential benefit of endoscopy, the physician (or the patient) may, a priori, decide to remain ignorant of any of its potential outcomes. For instance, an abdominal computer tomography (CT) scan in an asymptomatic 85-year-old man with serious comorbid conditions reveals the incidental findings of a pancreatic head mass. Instead of subjecting the patient to further testing with endoscopic ultrasound and fine needle aspiration (EUS with FNA) or endoscopic retrograde cholangio-pancreatography (ERCP), the patient and his family decide against any additional diagnostic workup. Such decisions are relatively simple if the procedure is risky with few, if any, beneficial consequences. The choice between competing options may become more complex and difficult to make if the procedural costs are less prohibitive and the diagnostic knowledge obtained through endoscopy comprises a mixture of beneficial, as well as harmful, aspects. The aim of the present article is to present an intuitive decision tool that would be applicable in clinical practice to resolve such diagnostic dilemmas without involving complex mathematical analysis.