


BOOK REVIEW 

Year : 2014  Volume
: 140
 Issue : 3  Page : 445446 

Medical decision making
KR Sundaram
Department of Biostatistics Amrita Institute of Medical Sciences & Research Centre (AIMS) Ponekkara P.O., Kochi 682 041, India
Date of Web Publication  1Nov2014 
Correspondence Address: K R Sundaram Department of Biostatistics Amrita Institute of Medical Sciences & Research Centre (AIMS) Ponekkara P.O., Kochi 682 041 India
Source of Support: None, Conflict of Interest: None  Check 
How to cite this article: Sundaram K R. Medical decision making. Indian J Med Res 2014;140:4456 
2 ^{nd} ed., H.C. Sox, M.C. Higgins, D.K. Owens (WileyBlackwell, UK) 2013. 364 pages. Price: not mentioned
ISBN 9780470658666
Books in the area of Medical Decision Making are very few and in that context, this book is a welcome edition. The first edition of this book was published in 1988 and the second edition published after a gap of 25 years. The authors have presented previously discussed chapters but with updated information, such as chapters 1 through 5, 9 and 11 have been updated in this second edition. They have updated the examples and added new developments, especially likelihood ratios, metaanalysis, cost benefit analysis and validity parameters in diagnostic analysis. Utility assessment, Markov models and mathematical modes of life expectancy are some of the new topics that have also been added. Harold Sox concluded the preface by adding that the applicants should have the cultural understanding of decision modelling and should be able to tradeoff methods to assess patient's utilities for a health state.
The authors have delineated the different principles and methods and how the applications are spelt out keeping in mind the requirements of academicians, students and researchers. This book has 11 chapters and 347 pages. Each chapter is given with different sections. Most of the chapters have a summary, a set of problems and a bibliography at the end. The first chapter gives an introduction to the concepts of probability, characterization of information obtained from the patients and their problems, choosing appropriate methods of diagnosis and treatment modality. This information put together can help physicians in decision making. The introduction of this chapter could have been given with more clarity with examples.
Chapter 2 deals with the concept of differential diagnosis which is the process of considering the possible causes of the patient's symptoms and physical findings. This is done on a logical basis and depends on the experience of the clinicians. The concept of generating appropriate diagnostic hypothesis is discussed in this chapter. Only a broad idea on hypothesis generation with respect to patient's history and symptoms can be obtained from this chapter. The contents are not statistically oriented.
Chapters 3, 4 and 5 are statistically oriented and form the critical foundation of this book. The basis of clinical decision making i.e., probability of measuring uncertainty and its applications in decision making are explained clearly. In chapter 4, the extension of probability in solving Bayes theorem has been explained with examples. The concept of odds ratio and its application has also been explained in this chapter. The definitions of validity parameters such as sensitivity and specificity in clinical diagnosis have been explained with clear examples which can be understood by clinicians without having any foundation in the theory of probability. Graphs on sensitivity analysis have been explained at different combinations of true positives. In chapter 5, measuring the accuracy of diagnostic information and predictive values of positives and negatives and the application of ROC (Receiver Operating Characteristic) curve for finding an appropriate cutoff value of the measurable diagnostic variable are explained with examples. Chapters 3, 4 and 5 are the primary chapters leading to the medical decision making. One reservation is the linking of the chapters 4 and 5. It is opined that one chapter on all the validity parameters would have been sufficient to explain the relevant concepts, reasonably well. Another reservation is that to what extent a clinician will be able to understand the mathematical part of the different formulae given in these chapters.
In chapter 6, details of decision making procedures have been explained in terms of sensitivity analysis and the corresponding decision trees, with examples. In chapter 7, Markov models and transition probabilities have been explained in terms of diagrams and graphs. The diagrams showing the probabilities of different likelihood of transition over a period could have been made in simpler ways. In their present form these appear a bit clumsy and may pose problems in clearly understanding the contents in the diagrams. Chapters 8 and 9 present advanced aspects of decision making in terms of utility analysis and diagnostic analysis. Both these chapters explain the concepts of these aspects in terms of theoretical support.
Chapter 10 deals with cost effectiveness and cost benefit analyses which are very important in decision making analysis in medicine. The distinction between these two methods has been explained clearly with examples. The clinician has a responsibility which is an ethical obligation to make the decision making costeffective in the background of limited resources. Only principles of these methods have been explained in this chapter. A couple of worked out examples could have made these applications more clear. The last chapter gives some advanced methods, with respect to modelling approaches with variations in patient's information on symptoms, laboratory findings and other relevant tests.
At the end of most of the chapters, problems are given for testing whether the readers have understood the concepts and methods given in each chapter. However, the possible answers have not been given for these problems. It would have been possible for the readers to check whether their explanations and answers for the problems are correct or not if the answers for the problems were given at the end of the book. The index is fairly exhaustive and adequate.
In short, this book is certainly recommended to the medical post graduate students and faculty and the statisticians. This would help the faculty and statisticians in their teaching and research and the students can develop an interest in this important area. As indicated previously mathematical portions would be appreciated mainly by the statisticians and as far as the clinicians are concerned they will certainly get to know the principles of decision making rules and develop an aptitude and interest in its appropriate applications. Those who are engaged in research in medical decision making with respect to different clinical conditions and problems will certainly benefit from this book.
