Toss-Ups and Close Calls

The term toss-up has different senses in the different contexts in which it is used. In a more technical sense, it is best understood in terms of the flip of a fair coin, where the chance of heads coming up is 50:50 and the chance of tails coming up is also 50:50. The term close call has more variation in the medical literature; for example, in the peer-reviewed scientific medical literature, a close call can be interpreted as a near miss in relation to patient safety—for example, during a surgical operation. Yet some individuals may interpret the term close call to reflect a decision to be made where the separation of a chance of a benefit accruing to a patient from one of two treatments being compared is, say, 48:52 and not strictly a 50:50 decision between the two treatments.

There are also other senses of the term toss-up. In some contexts, it can reflect an unpredictable situation of decision making—for example, in a population, as in an election or any process involving the counting of secret ballots, or in voting, such as on a medical, mental health, surgical, or other ward team. Or there are mixed cases, where, for example, it may not be clear in an individual's care what is the optimal treatment for the patient or which way a vote among medical team members with mixed opinions on what is the best strategy would go if a vote were taken.

In other contexts of speech in medicine, the term toss-up simply may be used in an even more general sense to refer to any unpredictable situation and the fact underlying the opinion that there is no systematic way to adequately determine what is optimal care in the patient at a particular time. Jerome Kassirer and Stephen Pauker point to this last sense of the term toss-up, where—after careful systematic assessment of the peer-reviewed scientific medical literature and the clinical experience of physicians—the evidence reviewed and assessed shows that there is no difference between treatments and the result is still the same. Thus, the treatments are considered a toss-up from the standpoint of the published peer-reviewed scientific medical literature and a toss-up from the standpoint of clinicians' opinions.

The contemporary published peer-reviewed scientific medical literature contains examples of decisions that are described as “a virtual toss-up” in the areas of screening, diagnostic, and treatment decisions.