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Book reviews

Evidence-based medicine and the search for a science of clinical care. Jeanne Daly. University of California Press. ISBN 0-520-24316-1. £41.95, US$ 65.00. 275pp.
Evidence-based to value-based medicine. MM Brown, GC Brown, S Sharma. American Medical Association Press. ISBN 1-57947-625-2. £52.25. 339pp.
Sexual health and the menopause. Ed JM Tomlinson. Royal Society of Medicine Press. ISBN 1-85315-620-5. £12.95. pp80.


Evidence-based medicine and the search for a science of clinical care. Jeanne Daly. University of California Press. ISBN 0-520-24316-1. £41.95, US$ 65.00. 275pp.

We stand on the shoulders of others, and it is occasionally useful to meet and try to understand those whose shoulders we stand upon. Evidence-based medicine, or clinical epidemiology, or whatever you prefer to call it, did not spring fully into being overnight. Like all developments from pottery, writing, or cultivation of grain, it was a gradual development in which people learned what others had achieved, and improved upon it.

Jeanne Daly, herself no mean researcher and writer, has traced the stories and motivations of how EBM as we know it today has evolved, through interviews with many of the key contributors from the 1960s onwards. She gives us a series of their histories, and of their motivations and interactions. It is, like any such book, a personal account, but there is no harm in that.

Even when you know some of the players, and were around when some of the events and developments were occurring, you know only part of it. This book tells more. It is interesting to see coming though just how much the key players were, well, slightly maverick, in the good sense of somebody holding independent views, and refusing to conform to the accepted or orthodox thinking. Perhaps like most change, people had to think outside the box, and made sure that it wasn't just that the box was very small.

Difficulties had to be overcome. New thinking met with old certainties, and nobody likes some maverick coming along and suggesting some more detailed and insightful thinking about those certainties. Yesterday is just like today, and history isn't dead.

The cost is a bit steep for this to be light holiday reading, but borrow it, come to know just a little bit more, and who knows, be tempted to get out of the box yourself. This book should be read by anyone who wants to consider themseves expert on EBM, and those pontificating about it. The founders questioned, and kept on questioning. This is a lesson that needs eternally relearning.

Evidence-based to value-based medicine. MM Brown, GC Brown, S Sharma. American Medical Association Press. ISBN 1-57947-625-2. £52.25. 339pp.

Right at the end of this book, a final thought is that value-based medicine equals improved quality of care plus efficient use of healthcare resources. That seems fair enough, but actually this book is all about cost utility or cost effectiveness analysis, the resources expended for some improvement in life duration, or quality, or a combination, as in cost per QALY.

There's nothing wrong in that, and indeed, much right. Cost utility enables us to spend what resources we have in the most efficient way – or it would if budgets, politics, practice, and the difficulties in making change in large organisations did not intervene to complicate matters.

Getting a grip on cost utility is something that would benefit all of us, and this book helps. It details, for instance, a whole series of quality of life instruments, both general and specific. Looking at the actual measures used is rather interesting.

Figuring out discounting also clears a few cobwebs, and the table showing effects of discounting at different rates tells us that the time to reach half value is 70 years at 1%, 24 years at 3%, 15 years at 5%, but only eight years at 10%.

The problem, though, is that the book is more about economics than evidence, and what it says about evidence is uncritical. The format will irritate some, and the purely US perspective others. The problem is knowing who this book is for at this high price. It is too detailed and expensive for the general reader, but will be useful for those who want to get their brains firmly around cost utility.

Sexual health and the menopause. Ed JM Tomlinson. Royal Society of Medicine Press. ISBN 1-85315-620-5. £12.95. pp80.

Half of married women aged 66-71 are sexually active, almost a third of those aged over 78 years are sexually active, and the average frequency of sexual activity of people over 50 years in the USA is two to four times a month. Put that together with increasing divorce, more frequent or changing partners in older people, more older people, increasing rates of sexually transmitted infections in older people, and the need for a little book on sexual health in older people is obvious.

Though this book is headlined as being about the menopause, it is wider than that. It has 10 short and punchy chapters, including discussions on female and male sexual function and dysfunction. It includes good practical advice throughout, with one specifically on taking a sexual history.

The style is simple and the book is both readable and worth reading. Probably most useful in general practice, but not without value for us ordinary folk.

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