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Analyzing How We Reach Clinical Decisions
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Huw Llewelyn and Anthony Hopkins; eds. 164 pages. London: Royal College of Physicians; 1993. £ 12.95.
Every day, the news reminds us that economics, politics, and medicine are linked in a set of thorny issues that engage public attention: the organization, politics, and financing of health care; the cost, efficacy, and appropriateness of medical interventions; the worry that the authority to make decisions is slipping into the hands of bureaucrats who do not know physicians or their patients; the public's anxiety that one catastrophic illness could wipe out a family's savings; and many others. These issues all involve judgments about the possible benefits of medical care, and decisions about whether these benefits are worth the cost. Thus, one perspective on these issues is provided by the emerging science of decision making.
Modern decision theory combines techniques and principles from economics, statistics, and psychology to study both how decisions are made and how they should be made. Since 1968, the field of medical decision making has grown steadily. Two systematic textbooks are available, and several other books discuss decision theory in the contexts of clinical epidemiology, biostatistics, medical informatics, and clinical reasoning.
This short monograph is the product of a workshop held at the Royal College of Physicians in London. To highlight the relevance of decision theory and its offspring to clinical practice, the book's 11 chapters, written by 13 authors, are organized around a single clinical case. These chapters survey the central topics and techniques of decision analysis (such as Bayes theorem, the evaluation of clinical evidence and tests, decision trees, and the combination of probabilities and preferences in evaluating alternative strategies), which are typically covered in books on medical decision making. Other more novel chapters touch on practice guidelines and computerized decision aids and present a detailed description of more informal clinical reasoning in the illustrative case. The authors also provide some new slants on topics neglected in existing textbooks: for example, the use of log-odds ratios to simplify combining a sequence of tests in a diagnostic workup.
This book will not replace existing texts; the presentation is too compressed for the novice, no sample problems are provided, and an index is not included. The title is misleading, too, for the text is about the way clinical decisions should be made rather than about the way they are made in daily practice. But the book has its virtues: It emphasizes the role of patients' preferences and wishes in decision making, criticizes practice guidelines for being inherently insensitive to these preferences, argues against complacency about the state of the clinical art, and relates principles systematically to a common clinical problem. Thus, it stresses the purposes of and need for decision analysis more than do other texts that emphasize techniques. This book is recommended for readers who want to know about the why of decision analysis rather than the how. It will also interest those already familiar with decision analysis who want to see a different approach. By insisting that patients' preferences be placed squarely at the center of the decision-making process, it raises some thorny questions to add to our thicket.
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