REVIEWED BY CHARLES H. KORTE, MD
Getting Doctors to Listen: Ethics and Outcomes Data in Context
Philip Boyle, ed.
Georgetown University Press, Washington, DC
1998, 248 pp., $45
"The nature of medical truth is not, and has never been, something about which all medical thinkers agree." This quotation from Getting Doctors to Listen: Ethics and Outcomes Data in Context serves as a nice summation of the book's purpose. In this compilation of articles edited by Phillip Boyle, a variety of writers examine, first, the current trend of implementation of outcomes data and practice guidelines and, second, the reluctance of many physicians to use these guidelines in their practices. The book looks at outcomes research and delves into the reasons behind physicians' opposition to and avoidance of the guidelines.
The book's contents are divided into three parts:
- An overview of the moral obstacles to utilizing outcomes data
- A look at outcomes data and how they are generated
- An examination of ethical issues — some resolvable, some intractable — in utilizing outcomes data
Each of the sections' authors examines the outcomes data employed in such technologies and therapies as hormone replacement therapy, ear tubes for otitis media, thrombolytic therapy, and autologous bone marrow transplantation for advanced breast cancer. The authors include practicing clinicians, ethicists, public health specialists, and academic teaching physicians.
The book is aimed primarily at the practicing physician, but it could also serve as a textbook for medical students and residents in a course on how to apply the art and science of medicine in daily practice. The book's second section, which serves as a primer on how outcomes data and clinical guidelines are generated, would be most instructive to the clinician. It was interesting to learn, for example, that some guidelines were based more on consensus than on "hard" clinical data. This section of the book also elucidates the biases often inherent in clinical guidelines.
A chapter titled "Guidance Glitches: Measurements, Money, and Malpractice" is the most readable and will probably appear, to the average doctor, the most germane to everyday practice. This chapter uses specific case examples to show how general guidelines cannot always be applied to individual patients. Extraneous factors such as the patient's social support, the pressures of capitated insurance plans, and the specter of malpractice suits can influence the implementation of any guideline. The chapter's final sentence — "Be modest; guidelines are just guidelines" — may be the most enlightened exhortation a clinician could receive.
The book's third section explores the ethical considerations of practice guidelines. For the practicing physician it will serve as a good review of the underlying assumptions and premises involved in making guidelines. According to bioethicists, some of these premises may present intractable problems in the application of guidelines — for example, physicians' tendency to rely on their own judgment rather than on rules, even when those rules are the result of outcomes research. The authors conclude by arguing that practicing physicians must be involved in formulating these guidelines if they are to feel some "ownership" of the process.
This book has instructive advice for the average practicing physician, but it may prove difficult for less motivated readers. On the other hand, some essays appear to be aimed at ethicists, using a vocabulary that will be foreign to the clinician. However, enough chapters are geared to specific clinical trials to hold the reader's interest. This book would be a good addition to the library of a physician manager, a health insurance physician reviewer, or any physician involved in trying to get other physicians to "listen" to clinical guidelines.
Charles H. Korte, MD
Medical Director
Mercy Mayo Family Practice, Residency Program
Des Moines