Doctors and economists often hold very different views about health care problems. Consequently, it is hardly surprising if their solutions to these problems are very different. The doctor on the ward and in the clinic comes face to face with the individual patient and feels responsible for treating h i d e r in the best possible way, whatever the price. The fact of constrained resources is ignored. On the other hand, economists understand neither the ethos of health nor the ethics of medicine. the economist feels more responsible at the social level, particularly in respect to society's resources. This is perhaps an exaggerated view of the two stances; but, since the starting point of the two disciplines is so different, the debate is often on the basis of images rather than realities.
Hence, what makes this book especially interesting is that the author has a background in both medicine and economics; and is therefore able to combine these two perspectives in ways that help doctors to understand and recognize many of the problems outlined and to have their interest stimulated.
The book ends up with a question which might well have been posed at the start: why should we care about doctors' decisions and the costs of medical care? The answer lies in the central role of the physicians in allocating resources in health care; the importance of 'ensuring that limited resources are used efficiently'.
Medical decision-making is relatively new as a research area, though interest has grown apace during the last 15 years. However, as the author indicates, the area remains something of a black box with relatively few windows to look through. It is emphasized that, if we want to explain the variations in the use of health care services and wish to treat the sometimes inappropriate behaviour of the medical profession, further investigations are necessary.
Hence, perhaps, the book is in three parts: (1) understanding variations in physicians' practice patterns; (2) changing physicians' practice patterns; and, (3) indicating future directions for research on physicians' utilization patterns.
Part One discusses the results of research on regional variations. It is now widely accepted that geographically variations exist in almost all elements of medical practice. Yet the causes of these variations are not fully understood. Hypotheses that 'supply induces demand' and 'supply breeds demand' are discussed in detail. Thereafter, the author examines the role of the physician as the self-fulfilling practitioner, the patient's agent and the guarantor of social good. An important issue here is the potential conflict between the doctor's role as the agent of the individual patient and as the agent of society. For our 'doctor-economist' author the solution to this key issue is quite clear: 'political and social decisions about the allocation of society's resources will be made, and it is the doctors' responsibility to have an active role in their making, just as it is their responsibility to use the available resources as effectively as possible at the clinical level'. It is worth noting the stress placed on the question of responsibility; that is, the fact that the author suggests that these roles of the doctor also include elements of duty.
In Part Two, Eisenberg examines the medical decision process through investigating ways of changing doctors' behaviour. The six most commonly applied methods through which attempts have been made to change physicians' practice patterns are discussed: education, feedback, participation, administrative changes, incentives, and penalties. This section includes a brief introduction to behaviour modification and to management theory. As in the rest of the book, this is debated against the background of good, applied case studies. Related methodological problems are discussed in a readable, lucid way. This part should inspire the reader to go deeper into these matters.
The last Part of the book seeks to summarize the possibilities for future research on