Smart Health Choices: How to make informed health decisions
By J. Irwig, L. Irwig and M. Sweet. Allen & Unwin, 1999, AU $17.91(pb) , 226pp. ISSN 1‐86508‐146‐9. Web: http://allen‐unwin.com.au; E‐mail: frontdesk@allen-unwin.com.au
Patient involvement in health‐care decision‐making has gained prominence from two sources. The first is the patient empowerment movement. The second is health technology assessment. The first aims to involve patients in their diagnosis and treatment, the second to encourage consumers to accept only those treatments shown effective through rigorous research. Irwig and co‐workers draw on both traditions to produce a primer in evidence‐based decision‐making. As the title suggests, this is a decision‐making ‘How To’ book, primarily for patients. In the introduction, ‘This Book Could Save Your Life’, the authors suggest, that problems in the delivery of health‐care cause many deaths and injuries due to human errors and the failings of the health‐care system. In addition, commercial interests, such as pharmaceutical and medical technology companies promote the introduction of new practices before their risks and benefits have been carefully evaluated. The purpose of the book is to help consumers and practitioners develop the skills to assess health advice and make decisions that will improve the quality of care.
The book has five main parts. Part one describes, in lay terms, the rationale for evidence‐based medicine. It also identifies potentially misleading reporting styles found in the media. Part two is a consumer’s guide to picking a practitioner. It includes an algorithm for deciding whether to accept a recommended test or treatment. The five key questions are:
• What will happen if I do nothing?
• What are the intervention options?
• What are the benefits and harms of the intervention options?
• How do the benefits weigh up for me?
• Do I have enough information to make a choice?
Part three begins what is essentially a clinical epidemiology or critical appraisal course for consumers. This second half of the book may prove difficult reading for consumers. It covers study design (case study, case control, cohort, and randomized clinical trial) and sources of bias. Part four, called ‘evaluating the evidence’, differentiates efficacy and effectiveness and explains the epidemiological approach to causation. Part five comes back to the five questions in the context of a critical approach to evidence. The appendixes offer primers on sensitivity and specificity of diagnostic tests, decision thresholds, relative and absolute risks, and confidence intervals. There are five examples to use as tests of the new skills, as well as a concise list of good web sites and a glossary.
The great strength of Smart Health Choices is that it is a serious attempt to teach critical appraisal skills to consumers. This is a pioneering book, one of the first to offer tools to bring the public into dialog with their physicians and ultimately with policy makers about the evidence for treatments. It would be very interesting to have the book appear in physicians’ waiting rooms and surgeries for patients to read before seeing the doctor. The potential for this, however, may be limited by its somewhat pejorative tone when describing the sources of medical errors and bad outcomes. Attacking the system in an effort to stamp out corruption and waste is the forte of the consumer movement and frequently justified. However, the agenda of engaging physicians and patients in a partnership requires that both accept the inherent uncertainty in diagnostic tests and in treatments. Both parties must, however, reluctantly, give up the notion that medicine is perfect and that a cure is always possible if enough is done. It will be important, when introducing consumers to critical appraisal to point out that frequently no one is to blame for imperfect solutions. This requires a great deal of good will on all sides. Accessible texts, like this one, are engaging, and should start the conversation. The readers must use what they read to support a shared critical dialog.
The book should also be widely used by support groups, disease‐specific patient advocacy groups, and others. Advocacy groups will find that the approach demands a new role for them. Advocacy groups traditionally demand more treatment and more research directed at their diseases. This approach asks them to stop and reject some treatments that are not demonstrated to be effective. It also asks patients to consider if they are better off doing nothing than doing something risky for the sake of just doing something. In the long run, consumers and health‐care systems will save both lives and money if this approach comes into mainstream thinking. Accomplishing this major shift in approach to screening and treatment decisions will take a concerted approach from patients, policy‐makers and physicians. Smart Health Choices can help in that effort.
Edited by Mark Sculpher