Medical Decision Making »

This is a clearly presented, step-by-step guide to understanding how, through the processes of decision analysis, a physician can reach valid, reasoned conclusions about medical treatment despite possibly imperfect information about the patient.

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Reviewer:Vincent F Carr, DO, MSA, FACC, FACP(Uniformed Services University of the Health Sciences)
Description:This seminal book, originally published in 1988, has been republished, but not revised, by a new publisher, the American College of Physicians. The author acknowledges that there have been some changes in medical decision making since the initial publication, but that does not detract from this reissue. In fact, reading through this book emphasizes the accuracy and validity of the initial work, despite the time that has passed.
Purpose:The stated goals were for physicians and students to use the principles of probabilistic reasoning and expected-value medical decision making in day-to-day practice. Today, more than ever, this is a necessary step in providing cost-effective and safe medical care.
Audience:The audience includes every practitioner at every level, from the resident in training to the experienced attending and all levels in between, including physician-extenders. The author is one of the most respected practitioners and editors in medical literature in America.
Features:The author describes the process of developing a differential diagnosis, moves through probability theory, lands directly in the heart of the decision-making process, and resurfaces in a discussion of cost-effectiveness in managing medical care. The journey is made exquisitely and entertainingly effective and educational with its accessible text and "typical" patient-physician conversations. The figures, examples, and tables are superb, illustrating the statistical points of discussion. The index is most appropriate, and because the book is dated, the references are appropriate for the original publication date. The author states his intention to update the book upon retirement and hopefully this will occur. At the end of each section there are summaries, problems, and definitions of new words encountered in the chapter.
Assessment:Despite being a republication, this remains a highly valuable and educational book, with the vast majority of the information relevant to medical decision making in the current era. It deserves a place in every practitioner's library.

Preface to the ACP Reprint     VII
Preface to the 1988 First Edition     IX
Introduction     1
How May I Be Thorough Yet Efficient When Considering the Possible Causes of My Patient's Problems?     1
How Do I Characterize the Information I Have Gathered during the Medical Interview and Physical Examination?     1
How Do I Interpret New Diagnostic Information?     5
How Do I Select the Appropriate Diagnostic Test?     6
How Do I Choose among Several Risky Treatment Alternatives?     6
Summary     7
Differential Diagnosis     9
Introduction     9
Learning from Observations of Skilled Clinicians     10
The Process of Differential Diagnosis     12
An Extended Example     22
Summary     25
References     26
Probability: Quantifying Uncertainty     27
Uncertainty and Probability in Medicine     27
Use of Persona! Experience to Estimate Probability     34
Use of Published Experience to Estimate Probability     52
Consideration of the Special Characteristics of the Patient When Estimating Probability     60
Summary     61
Problems     62
New Words in thisChapter     64
References     64
Understanding New Information: Bayes' Theorem     67
Introduction     67
Conditional Probability Defined     71
Bayes' Theorem     71
The Odds Ratio Form of Bayes' Theorem     75
Alternative Forms of Bayes' Theorem: The Tree and the 2 X 2 Table     80
Lessons to Be Learned from Bayes' Theorem     84
The Assumption of Bayes' Theorem     91
Interpreting a Sequence of Tests     93
Using Bayes' Theorem When Many Diseases Are Under Consideration     97
Summary     98
Problems     99
New Words in this Chapter     100
References     100
Measuring the Accuracy of Clinical Data     103
How Test Results Can Be Expressed as "Abnormal" and "Normal"     103
Measures of How Well a Test Discriminates between a Disease and All Other Conditions     106
How Test Performance Is Measured: A Hypothetical Case     113
Pitfalls of Predictive Value     115
Why Measures of Test Performance May Not Apply to Your Patient     116
Combining Data from Several Studies     128
Expressing Test Results as Continuous Variables      129
Summary     138
Problems     139
New Words in this Chapter     140
References     141
Derivation of the Method for Using the ROC Curve to Choose the Definition of an Abnormal Test Result     142
Expected Value Decision Making     147
Basic Concepts of Expected Value Decision Making     148
Decision Analysis: An Introductory Example     151
Summary     165
Problem     166
New Words in this Chapter     166
Measuring the Outcome of Care     167
Measuring the Patient's Preferences: Utility Assessment     168
Estimating the Expected Length of Life     182
Measuring How Well the Patient Is Able to Function     194
Satisfaction with One's State of Health     196
Using a Linear Scale to Express Strength of Preference     196
Summary     197
Problems     198
New Words in this Chapter     199
References     199
Axioms of Utility Theory     200
Decision Making When the Outcomes Have Several Dimensions     201
Assessing the Patient's Preferences for Outcomes with Several Dimensions     202
Measuring the Patient's Utility for a Period of Time in III Health: An Introduction     206
Assessing Preferences for the Length of Life     208
The Time Trade-Off Method     216
Measuring Preferences for Any Period of Time in III Health     220
Another Method for Adjusting Life Expectancy for the Quality of Life     225
Sources of Error in Utility Assessment     230
Last Words     232
Summary     232
New Words in this Chapter     233
Problems     233
References     236
Selection and Interpretation of Diagnostic Tests     239
Taking Action When the Consequences Are Uncertain: Principles and Definitions     239
Could a Diagnostic Test Change the Treatment of the Patient?     243
The Treatment Threshold Probability     246
The Decision to Obtain a Diagnostic Test     249
Setting the Treatment Threshold Probability     257
Taking Account of the Costs and Risks of the Test     270
A Clinical Case: Test Selection for Suspected Brain Tumor     274
Sensitivity Analysis     277
Choosing among Diagnostic Tests     280
Choosing the Best Combination of Diagnostic Tests     283
Summary     285
New Words in this Chapter      289
References     289
Bedside Decision Analysis     291
A Difficult Clinical Problem: Bleeding Esophageal Varices     291
Sensitivity Analysis     301
A Decision Problem in Which Three-Way Sensitivity Analysis Was Useful     309
Conclusions     314
References     315
Cost-Effectiveness Analysis and Cost-Benefit Analysis     317
The Physician's Conflicting Roles: Patient Advocate, Member of Society, and Entrepreneur     317
Cost-Effectiveness Analysis: A Method for Comparing Management Strategies     319
Cost-Benefit Analysis: A Method for Measuring the Net Benefit of Medical Policies     328
Measuring the Costs of Medical Care     331
Summary     333
New Words in this Chapter     334
Problem     334
References     335
Test Characteristics     337
Life Table     373
Glossary     379
Answers to Problems     383
Index     399