From Doody's Book Reviews,
Reviewer: Vincent F Carr, DO, MSA, FACC, FACP (Uniformed Services University of the Health Sciences)
This book is dedicated to explaining the risks of illness or therapeutic interventions and the associated benefits of interventions. The world of medicine and the words of informed consent or declining medical or surgical intervention are often difficult for laypersons. This book gives clinicians a superb way to explain the risks and benefits in a visual representation that is very easy for a nonmedical audience to understand.
Clinicians of all levels can use this book to understand risks and benefits and then to employ the models to help patients understand the concepts. The authors begin by exploring the necessity of having patients share in the decision-making process and some of the concepts for bridging the gap between the medical thought process and how laypersons digest medical information. In the early chapters, the authors introduce the concept of decision aids as a way to communicate medical information, particularly a decision aid for the benefit/risk characterization theatre (BRCT). This simple visual construct is a highly useful and easy-to-understand way to present the benefits and risks to patients. After developing the concept, the authors demonstrate, with numerous examples, how the BRCT is used, how it looks to patients, and how the benefits and risks are clearly depicted.
This is a uniquely exceptional book on communication between patients and medical personnel. The decision aid is extraordinarily easy to use. This is an outstanding book for every academic and teaching institution.
From Tom FInucane, MD, Professor of Medicine, Johns Hopkins Hospital
“Doctor” comes from classical Latin “teacher, adviser”. (It is also related, more distantly, to “decent”.) In modern medicine the role of teacher has reassumed prominence in the work of doctors. The idealized paradigm now is shared decision-making; doctors provide real, accurate information (teach), help patients articulate goals, and advise on strategies to achieve these goals. The patient decides.
As is often the case with paradigms, reality is a bit sloppier than this. The shenanigans of Big Pharma and the device makers and the lurking threat of litigation are in the exam room when doctor and patient talk. The doctor’s desire to get paid may intrude. The vagaries of human decision-making are there too. Osler said that the main thing that distinguishes man from the animals is the desire to take medication. The contemporary yearning for risk-free existence dovetails with the ancient, widespread and deeply held desire not to be dead. In the exam room, the balance tilts strongly towards doing something. Overtreatment is ascendant.
How does good doctoring create meaningful shared decision-making and limit overtreatment? You will see in the pages of this book. Andy Lazris is a seasoned, thoughtful clinician who has obviously spent a lot of time thinking about how to teach his patients. He is also an unbiased, careful reader of the medical literature. Erik Rifkin is an environmental scientist with decades of experience teaching individuals and organizations about risk evaluation with respect to environmental threats. Together they have written Interpreting Health Risks and Benefits, in which they provide the essential ingredients to help patients make sensible decisions in a world that will always be risky.
The book considers several high-stakes decisions that are likely to be familiar to readers. Should I get a mammogram? A blood test for prostate cancer? Should I take a statin? An aspirin? What about antibiotics for sinusitis? Blood thinners to prevent stroke in atrial fibrillation? And many other treatment decisions that doctors and patients are making every day. For each, precise, referenced data about the benefits and risks associated with the intervention are presented. This is one of the strong points of the book.
A second strong point is the Benefit Risk Characterization Theater. The authors spend some time demonstrating how presenting data as relative risk reduction is routinely misleading; the vaunted 50% reduction in stroke among people with atrial fibrillation who take Coumadin blood thinner compared to aspirin turns out to be a reduction of not quite one disabling stroke per year. BRCT graphic is the ideal way to grasp this idea more firmly. Their unique visual approach also makes clear just what it means to say, for example, that spiral CT scanning 1000 patients for lung cancer saves 3 lives in 5 years, but with a lot of unnecessary and harmful treatment in the group that was screened.
In summary, this book considers several common and important situations where faulty decision-making makes overtreatment a serious risk. Clear, fair, referenced, and useful information is provided. And a powerful intuitive technique is introduced which allows patient and doctor to talk as equals as they work together in the exam room. The authors emphasize that some patients who have been fully educated will still accept high risks of harm for a small chance of avoiding premature death. But as this book is accepted and its ideas and technique are extended, I feel sure that net harm to patients will be curtailed. And what is more, the integrity of the decision-making process will be improved.
From Nortin M Hadler MD MACP MACR FACOEM
Emeritus Professor of Medicine, University of North Carolina
Shared decision making, informed medical decision making, and evidence based medicine are all clarion calls for a patient-physician dialogue that will enlighten health care in the 21st Century. But calling for such and engaging in such are not the same. Both patients and doctors must first learn how to communicate at a level that makes the patient the captain of the ship, the doctor the navigator. Interpreting Health Benefits offers such a language.
From Stephen Schimpff, MD
Author of the Crisis in Primary Care, Former CEO of Univeristy of Maryland Health Systems
Patients and doctors need to be a team in making important health care decisions. Good decision making requires solid, appropriate information but all too often it is either not available or presented in a format that is not of great value. Well grounded decision making is critical because every action has not only the hoped for outcome but also the risk of an adverse outcome. No medicine is devoid of side effects. A diagnostic test may produce a false positive or a false negative. A procedure may or may not cure. For example, choosing statins may lower cholesterol but may also cause muscle damage. A decision to have a mammogram may lead to a suspicion of cancer leading to a biopsy which turns out to be negative – a false positive. Choosing to have a stress test that turns out negative may lead to a sigh of relief and yet the patient dies of a heart attack the next week. A false negative.
Erik Rifkin, PhD and Andy Lazris, MD address these in Interpreting Health Benefits and Risks– A Practical Guide to Facilitate Doctor-Patient Communication. For each of twenty commonly encountered decision points they offer well informed information. Should I get a mammogram at my age? How likely is a stress test to clarify if I have coronary artery disease? What are the risks/benefits of taking a statin? Do I need an annual examination with my primary care physician, and if so what should it include? If I have atrial fibrillation should I take a blood thinner?
To each of these and sixteen others they give a concise overview of the data available, pointing out where it is strong or weak. They also include a patient vignette from Dr. Lazris’ internal medicine practice, thus giving each decision issue a compelling connection to real life situations. They then add a third and critical layer, a visual representation that adds clarity to the complex issues.
The visual is called Benefit Risk Characterization Theater (BRCT). It uses the floor plan for a thousand seat theater. Each seat represents a person. So for example, if a person smokes regularly, the question might be what is the risk of death at 25 years of doing so? The theater shows a thousand seats with 198 of them blackened out. This of course means that compared to 1,000 non-smokers, this group of smokers will experience 198 extra deaths compared to the other group. Seeing the blackened seats is a strong statement of risk – more compelling than just indicating a percentage. As the authors state, “the graphic should do the math for the patient.”
Implicit throughout the book is the understanding that great controversy exists within the medical community about the risks and benefits of many screening tests, diagnostic procedures and therapeutic approaches. The BRCT allows the patient to become a co-equal with the doctor regarding the data and thus a real contributor to the decision making process.
For the purpose of shared decision making, the combination of factual data, a patient’s story and especially the visual BRCT allows patient and doctor to approach the question at hand with substantial assurance that whatever decision is made, it was done so in the context of real knowledge.
I have only one criticism of the book and it is leveled squarely at the publisher (Springer), not the authors. It is a paperback priced at $89.99, apparently assuming it will be of interest to a limited number of academics. In fact, it should be in the consultation room of every primary care physician and available to all patients who want to participate in their health care decision making. My recommendation: It is too expense for the average person to buy so ask your library to get some copies and then avail yourself. You may be surprised at what you learn. You will certainly be better equipped to talk with your doctor.