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Disease, Diagnosis and Decisions
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Graham W. Bradley. 182 pages. New York: John Wiley and Sons; 1993. $29.95.
Medical students react strongly when first exposed to real patients. They are often baffled by the ease with which more experienced clinicians render humane, effective judgments about complicated questions of patient care; their teachers make it look so easy! If there were an ESPN television network of medicine, medical students might ask the same question as the chubby basketball wannabe: "How do they DO that?" This feeling sometimes persists well into residency, mainly because faculty members often cannot explain, demystify, or humanize the application of their decision-making skills.
Fortunately, analyses of clinical decision making have appeared and have made inroads into the mainstream of the medical literature. These include texts on decision analysis, regular features in respected journals concerning clinical problem solving, and useful, often algorithmic treatises that are disease- or symptom-based. None, however, has the scope or the wide applicability of this small text by Graham Bradley.
Bradley's avowed purpose in writing this book was to define the nature of uncertainty in medicine, to reassure the reader that uncertainty has always been part of a physician's work, and to show that, for the good of the patient, uncertainty must be explored and thereby minimized. Bradley begins with sections about the historical and philosophic underpinnings of medicine, reminding us that even when we are most scientific, uncertainty is at the core of what we do. These instructive, entertaining essays are followed by succinct, well-referenced chapters concerning diagnostic reasoning, test characteristics, decision analysis, and computer-aided decision making. A final section addresses the limitations of statistics and the care that must be taken before new information can be applied to practice.
The writing is clear throughout and reflects the practical experience of an expert, caring, generalist clinician. I found it surprising, however, that as a British physician, Bradley was underwhelmed by the information provided by the physical examination and the autopsy. Missing were comments about the psychology of individual and group decision making, particularly as it applies to the roles of primary and consultant physicians. But this would have added little to this compact, excellent book, which is chock full of important information for all students of medicine. For faculty, this book would serve nicely as a basic text in an introduction to clinical medicine course.
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