Better Doctors, Better Patients, Better Decisions

Better Doctors, Better Patients, Better Decisions: Envisioning Health Care 2020

Gerd Gigerenzer
J. A. Muir Gray
Copyright Date: 2011
Published by: MIT Press
Pages: 416
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  • Book Info
    Better Doctors, Better Patients, Better Decisions
    Book Description:

    Contrary to popular opinion, one of the main problems in providing uniformly excellent health care is not lack of money but lack of knowledge -- on the part of both doctors and patients. The studies in this book show that many doctors and most patients do not understand the available medical evidence. Both patients and doctors are "risk illiterate" -- frequently unable to tell the difference between actual risk and relative risk. Further, unwarranted disparity in treatment decisions is the rule rather than the exception in the United States and Europe. All of this contributes to much wasted spending in health care. The contributors to Better Doctors, Better Patients, Better Decisions investigate the roots of the problem, from the emphasis in medical research on technology and blockbuster drugs to the lack of education for both doctors and patients. They call for a new, more enlightened health care, with better medical education, journals that report study outcomes completely and transparently, and patients in control of their personal medical records, not afraid of statistics but able to use them to make informed decisions about their treatments.

    eISBN: 978-0-262-29895-7
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. The Ernst Strüngmann Forum
    (pp. vii-viii)
    Julia Lupp
  4. List of Contributors
    (pp. ix-xii)
  5. Health Literacy:: Is the Patient the Problem?

    • 1 Launching the Century of the Patient
      (pp. 3-28)
      Gerd Gigerenzer and J. A. Muir Gray

      Patients appear to be the problem in modern high-tech health care: they are uninformed, anxious, noncompliant folk with unhealthy lifestyles. They demand drugs advertised by celebrities on television, insist on unnecessary but expensive computer tomography (CT) and magnetic resonance imaging (MRI) scans, and may eventually turn into plaintiffs. Patients’ lack of health literacy and the resulting costs and harms have received much attention. Consider the following cases.

      Almost ten million U.S. women have had unnecessary Pap smears to screen for cervical cancer—unnecessary because, having already undergone complete hysterectomies, these women no longer had a cervix (Sirovich and Welch 2004)....

    • 2 When Misinformed Patients Try to Make Informed Health Decisions
      (pp. 29-44)
      Wolfgang Gaissmaier and Gerd Gigerenzer

      A recent press release advertised the results of an international randomized controlled trial on the benefits of using PSA tests for prostate cancer screening. It stated that PSA screening would reduce the risk of dying from prostate cancer by 20% (Wilde 2009). But what does that really mean? Just how big is 20%, and how many people does it equate to? It meant that out of every 1,410 men who regularly participated in prostate cancer screening, 1 less person died of prostate cancer than in an equally large group of men who did not participate (Schröder et al. 2009). What...

    • 3 Reducing Unwarranted Variation in Clinical Practice by Supporting Clinicians and Patients in Decision Making
      (pp. 45-52)
      Albert G. Mulley Jr. and John E. Wennberg

      In 1938, J. Allison Glover reported on the incidence of tonsillectomy among school children in England and Wales (Glover 1938). He meticulously documented peculiar increases and decreases in rates over the preceding 15 years as well as unexplained differences by age, gender, and social status. Most striking was a tenfold variation in tonsillectomy from one region to another. To explain these “strange bare facts of incidence,” Glover hypothesized that the conspicuous success of the operation in the occasional case had led to its adoption in many more doubtful cases, and he endorsed the earlier conclusion of a report from the...

    • 4 Do Patients Want Shared Decision Making and How Is This Measured?
      (pp. 53-58)
      Martin Härter and Daniela Simon

      Shared decision making has been advocated as an appropriate approach to involve patients in decision making. Since the late 1990s, when several publications on conceptual definitions of shared decision making emerged (Charles et al. 1997; Coulter 1997; Towle 1997), interest in this approach has steadily grown, especially for diseases for which more than one treatment option exists and the best choice depends on how a person values the benefits and harms of each option (O’Connor et al. 2009). Shared decision making is an approach where clinicians and patients communicate together using the best available evidence when faced with the task...

  6. Health Illiteracy:: Roots in Research

    • 5 Health Research Agendas and Funding
      (pp. 61-82)
      David E. Nelson

      There is increasing concern that the results from health research do not lend themselves to information that is practical and understandable by patients and other members of the public, clinicians, policy makers, and journalists. In other words, there is a gap between what health researchers study and communicate among themselves, and what lay audiences and clinicians want and need to know. Regardless of whether one looks at levels of funding for health literacy itself, or of funding for related topics such as health services research, health technology assessment, or dissemination and implementation, there are currently few resources being devoted to...

    • 6 Reporting of Research: Are We in for Better Health Care by 2020?
      (pp. 83-102)
      Holger Schünemann, Davina Ghersi, Julia Kreis, Gerd Antes and Jean Bousquet

      Authors, editors and publishers all have ethical obligations with regard to the publication of the results of research. Authors have a duty to make publicly available the results of their research on human subjects and are accountable for the completeness and accuracy of their reports. They should adhere to accepted guidelines for ethical reporting. Negative and inconclusive as well as positive results should be published or otherwise made publicly available. Sources of funding, institutional affiliations and conflicts of interest should be declared in the publication. Reports of research not in accordance with the principles of this Declaration should not be...

    • 7 Medical Journals Can Be Less Biased
      (pp. 103-116)
      J. A. Muir Gray

      Over the last ten years, a revolution has occurred in how medical literature is perceived. Instrumental to this change, the Cochrane Collaboration has shifted the emphasis on quality, not just quantity, of medical literature. In the initial stages of the Cochrane Collaboration, people began to learn that when considering evidence about the effects of an intervention, the randomized controlled trial was the method of choice: it was the least likely to include errors due to bias and, if trials were well designed, least likely to include errors due to chance. In addition, Cochrane promoted the idea that a systematic review...

    • 8 What Is Needed for Better Health Care: Better Systems, Better Patients or Both?
      (pp. 117-134)
      Markus A. Feufel, Gerd Antes, Johann Steurer, Gerd Gigerenzer, J. A. Muir Gray, Marjukka Mäkelä, Albert G. Mulley Jr., David E. Nelson, Jay Schulkin, Holger Schünemann, John E. Wennberg and Claudia Wild

      Research has shown that the communication of scientific evidence is often incomplete and/or nontransparent, thus reducing its usability (Gigerenzer et al. 2007). This compromises health literacy (i.e., the ability to understand and use the current evidence base) of clinicians (Wegwarth and Gigerenzer, this volume), policy makers, as well as the general public (Gaissmaier and Gigerenzer, this volume). However, the issues that surround the problem of missing information and nontransparent communication constitute only one part of a larger, systemic health literacy problem. In this chapter, we review our group’s discussions of this problem and provide initial suggestions as to how it...

  7. Health Illiteracy:: Spread to the Public

    • 9 Statistical Illiteracy in Doctors
      (pp. 137-152)
      Odette Wegwarth and Gerd Gigerenzer

      In 1996, results of four randomized trials on mammography screening, which included approximately 280,000 women (Nyström et al. 1996), showed that out of every 1,000 women who participated in screening over ten years, 3 women died of breast cancer; for every 1,000 women who did not participate in screening over a 10-year period, 4 women died of breast cancer. Further analysis showed similar effects: breast cancer mortality was 4 out of every 1,000 women who attended mammography screening over a course of ten years, compared to 5 out of every 1,000 who did not (Nyström et al. 2002). In 2006,...

    • 10 Statistical Illiteracy in Journalism: Are Its Days Numbered?
      (pp. 153-168)
      Bruce Bower

      Journalists have been thrust into an uncertain world over the past decade. Like antelope crossing a dry stretch of savanna, herds of news gatherers nervously crane their necks and sniff the wind, checking to see who succumbs next to the pitiless lions of the Computer Age. Newspaper reporters, magazine writers, television news producers, and a gaggle of assorted media types just want to reach the next water hole in one piece.

      It is especially ironic that journalists trying to navigate through this hazardous habitat understand so little about statistical risks. Media reports routinely misrepresent and sensationalize the implications of health...

    • 11 Improving Health Care Journalism
      (pp. 169-190)
      Holger Wormer

      Medical and health care issues rank consistently at the top of all scientific topics covered by the international mass media. In an analysis of three leading German newspapers, research at my institute found that from 2003–2004 medical issues comprised 27.7% of all scientific articles reported; in 2006–2007, this figure rose to 28.9% (Elmer et al. 2008). After medical topics, environmental sciences (15.0%) ranked as the next most popular topic, followed by articles on biology (12.7%). If behavioral sciences are counted as medical topics, coverage climbs to 58% in U.S. papers (Clark and Illman 2006).

      The exact reasons for...

    • 12 Barriers to Health Information and Building Solutions
      (pp. 191-212)
      Talya Miron-Shatz, Ingrid Mühlhauser, Bruce Bower, Michael Diefenbach, Ben Goldacre, Richard S. W. Smith, David Spiegelhalter and Odette Wegwarth

      Health literacy is a broad, social concept. The Institute of Medicine (IOM 2004) defines it as “the degree to which individuals can obtain, process, and understand basic health information and services they need to make appropriate health decisions.” Statistical literacy can be interpreted as the ability to grasp the meaning of numbers, proportions, and probabilities. However, although statistical competency is important, it is not the essential component in health information. This was recognized by the World Health Organization, which included social competencies and skills into its definition of health literacy (WHO 2010): “Health literacy has been defined as the cognitive...

  8. Health Care 2020

    • 13 How Can Better Evidence Be Delivered?
      (pp. 215-232)
      Norbert Donner-Banzhoff, Hilda Bastian, Angela Coulter, Glyn Elwyn, Günther Jonitz, David Klemperer and Wolf-Dieter Ludwig

      In evidence-based medicine, the term “bias” is usually used to refer to a systematic error in the design, conduct, or the analysis of a study. We will use the term in a broader sense to include manipulation of information, intentional or not. Bias can result during the production and dissemination of information as well as when it is received and interpreted.

      We realize that the delivery of “unbiased” evidence, in the strict sense, is not possible, for this notion implies an objective truth, deviations from which can be defined unequivocally. This assumption can neither be justified from a philosophical point...

    • 14 The Drug Facts Box: Making Informed Decisions about Prescription Drugs Possible
      (pp. 233-242)
      Lisa M. Schwartz and Steven Woloshin

      Direct-to-consumer prescription drug advertising exists only in the United States and New Zealand. In the United States, the first direct-to-consumer advertisement (an ad for the pneumonia vaccine) appeared inReader’s Digestin 1981. Today it is hard to find any American magazine or television show without finding drug ads.

      In theory, drug ads could raise consumer awareness about important diseases and educate the public about treatment choices. In practice, however, ads usually omit the most fundamental information that people need: how well the drug works (Bell et al. 2000; Frosch et al. 2007; Woloshin et al. 2001; Kallen et al....

    • 15 Reengineering Medical Education
      (pp. 243-264)
      David A. Davis

      Long before calls in the United States were made for health care reform, it was clear that a reengineering of health care and subsequent training of health professionals to match such was urgent. Among many reports that articulated the need for change in health care systems, the U.S. Institute of Medicine (IOM) identified the need to reengineer the way in which all health professionals were educated in its 2003 report: “Health Professions Education: A Bridge to Quality.” In summary, IOM called for training to deliver patient-centered care as members of an interdisciplinary team, a commitment to evidence-based practice, quality improvement...

    • 16 The Chasm between Evidence and Practice: Extent, Causes, and Remedies
      (pp. 265-280)
      Richard S. W. Smith

      We have huge amounts of evidence that many patients do not receive optimal care and that many people do not receive preventive interventions that could benefit them (IOM 2001). This has been the case for a very long time, and it is not clear whether this situation is better now than it was 25 years ago. We also have substantial evidence of dramatic variations in every aspect of health care (Wennberg and Cooper 1999). For example, fivefold variations in one year survival from cancer have been observed from different institutions in New York (Quam and Smith 2005) and a 50-fold...

    • 17 The Future of Diagnostics: From Optimizing to Satisficing
      (pp. 281-294)
      Henry Brighton

      In the United Kingdom, 81% of costs in patient services result from hospital expenditure (Dept. of Health 2005). One way to reduce these costs is to improve health care management of people at high risk of hospital admission. Among older people, certain subgroups are at a particularly high risk. If these high-risk individuals can be identified early, and their health care managed more effectively, preventive care could mean financial savings (Wagner et al. 2006). This holds for many problems in health care. Thus, the identification of predictive diagnostic instruments relating variables to outcomes is a necessary goal, and observations will...

    • 18 Direct-to-Consumer Advertising: Status Quo and Suggestions to Enhance the Delivery of Independent Medication Information
      (pp. 295-316)
      Wolf-Dieter Ludwig and Gisela Schott

      Pharmaceutical companies and providers of medical devices use DTCA to promote medications and medical devices to the public through many media forms—newspapers, magazines, billboards, television, radio, and the Internet (Wilkes et al. 2000). Additional forms (e.g., patient brochures and videos) are often made available in doctor’s offices or designed to be given to patients by medical professionals or patient groups.

      DTCA is just one example of the marketing and public relation efforts by drug companies to promote brand-name prescription drugs. More subtle forms of direct and indirect drug promotion, however, also take place, such as “disease awareness advertising” (i.e.,...

    • 19 How Will Health Care Professionals and Patients Work Together in 2020? A Manifesto for Change
      (pp. 317-338)
      Ralph Hertwig, Heather Buchan, David A. Davis, Wolfgang Gaissmaier, Martin Härter, Kai Kolpatzik, France Légaré, Norbert Schmacke and Holger Wormer

      Immediately after the election of Barack Obama and in the midst of the worst economic recession since the Great Depression, the President Elect’s newly designated chief of staff, Rahm Emanuel, pronounced what has since become known as the Emanuel Principle: “Rule one: Never allow a crisis to go to waste. They are opportunities to do big things” (Zeleny 2008). Stigler’s (1983) law of eponymy has it that a great idea is never named after the person who had it first. Corroborating this law, Emanuel’s observation echoed the advice of Niccolo Machiavelli inIl Principe:“Never waste the opportunities offered by...

  9. Abbreviations
    (pp. 339-342)
  10. Glossary
    (pp. 343-346)
  11. Bibliography
    (pp. 347-386)
  12. Subject Index
    (pp. 387-391)