Customer Reviews

The Decision Tree: Taking Control of Your Health in the New Era of Personalized Medicine

5 star:		(10)
4 star:		(13)
3 star:		(7)
2 star:		(0)
1 star:		(2)

 

 

As a physician with a public health background, I have a healthy amount of scepticism when 'the next great book' comes along and claims to change the way we live. However, while reading Goetz' book, it didn't take long for me to realize I was in for a wonderful surprise. Perhaps it is his background as an editor at Wired magazine that makes his writing so engaging. Combine that with a solid grounding in the public health arena and the result is impressive. Although written with the patient in mind, this book will serve as an invalubale tool for clinical practitioners and epidemiologists alike. It opens a window into the field of medicine that I found fascinating and highly educational. More importantly, it gives us a glimpse at the way the doctor-patient relationship will look in the future. And, whether we like it or not, as Goetz eloquently reminds us, we would be wise to take notice now.

When it comes to assessing the problems with our health care system and identifying ways to make it better, this book by Thomas Goetz is among the best I've ever read. Hopefully, it will be highly influential, especially considering that we live in an age when most of the "easy" medical problems have been solved and the hard ones remain (eg, cancer and many chronic conditions). Goetz proves to be an incisive analyst, a creative thinker, a balanced pragmatist, and a lucid writer.

The main idea presented in this book is that decision tools need to be developed which enable all available information to be rationally, systematically, and efficiently assembled and weighed in order to cost-effectively maximize individual and collective health outcomes. In other words, health care needs an engineering approach. This is really just common sense, yet our health care system unfortunately falls far short of this ideal, so we need books like this to help open people's eyes.

Here are some further key points from the book:

* Patients need to play an active role in their health care decisions, using physicians and other health care professionals largely as consultants, and collaborating with other patients in sharing information.

* Health care information (medical records, drug labels, etc.) needs to be presented in a sensible standardized format and made easily accessible online on a real-time basis.

* To account for biological heterogeneity among people, preventive measures and treatments need to be tailored to each individual. Thus, the information used to make decisions must include both statistical information drawn from populations as well as specific information particular to each individual (both phenotypic and genetic).

* Costs need to be controlled by emphasizing prevention of disease, lowering the cost for FDA drug approval, avoiding replacement of older/cheap drugs with newer/expensive drugs which aren't significantly better, avoiding use of expensive drugs which don't significantly improve outcomes (eg, many cancer drugs), using/avoiding screening based on relationship to outcomes, avoiding overuse of expensive medical technology, and linking physician payments at least partly to outcomes rather than extent of services.

The above ideas overlap considerably with ideas I arrived at myself after years of intense involvement with health care issues (especially related to cancer research and treatment). For example, see my detailed review of The War on Cancer: An anatomy of failure, A blueprint for the future by Guy Faguet.

This is a brilliant and important book, and I can't recommend it strongly enough.

`The Decision Tree` is easy to read (the author is an editor at Wired Magazine) and in terms of content there is nothing I really disagree with. My only problem is it seems heavy on vision and light on practical advice. The vision is great, but as another reviewer points out, we are not there yet. Do we really need an entire book on this subject, would a magazine article have sufficed? I think so. This is the sort of future zeitgeist weather vane that Wired Magazine is good at. It's exciting and makes you feel part of a cutting edge, but I don't think we are in an era of personalized medicine, it's changing so quickly, the practical content of this book will be outdated in a few years, it's ahead of its time. Still, there is good stuff here in particular if you've never considered the concept of personalized medicine and links to a few companies and websites that are leading the way. I did take away one important message and that is the idea of evidence-based health-care (or evidence-based anything) which clearly we need more of in this era of guru experts.

With a topic as dense as public health, THE DECISION TREE would have benefited from more rigorous editing and streamlining. It's just long and goes from anecdote to fact to observation to study to blah. I want to take control of my health but I felt like I needed a primer in public health before started this book. It was over my head. My other frustration with this book is that in some cases the expert advice or treatment that you need may be unknown or unavailable to you. Taking charge of your health implies that healthcare is something you direct, which implies a certain level of security and education.

Thomas Goetz catalogs the recent advances (and setbacks) in medicine & personal health, but also maps out the possibilities for how things could get better. He does this so convincingly that you can't believe it's not already taking root: clear labeling on drugs & food, passive tracking of our exercise routines, open access to our health data.

There are enough lessons for self-improvement in the book that I found myself comparing it to What to Expect When You're Expecting, but since Goetz focuses on the big picture (prevention, diagnosis, disease management) it is more like What to Expect When You're Expecting a Long Life.

Unlike the pregnancy bible I read 10 years ago (and more than once threw across the room), Goetz doesn't preach from a lofty whole-grain pulpit. He doesn't think we should ask people to do more, nor should we scold people for every mistake they have made, but rather we should give them tools to make better health choices.

You know how MDs are always asked for cocktail-party diagnoses? This book is for all the MPHs who stood nearby wishing that someone would ask them for on-the-spot health advice.

We've reached the point of critical mass when it comes to our collective health in the United States and that's why it is so important for people to stop trusting the conventional medicine of our day and take back control of their own health. While most doctors unfortunately pass out prescription medications as the ONLY option for treating chronic disease, the reality is there are natural dietary options for people wanting to get healthy that are rarely talked about outside of alternative medicine circles. That's what Thomas Goetz attempts to share in THE DECISION TREE--although there are a few flaws in his thinking about this, too. While railing against the current system of treating patients with drugs, part of his "decision tree" plan for patients is to look to pharmaceutical options. HUH?! What we know about most chronic illnesses is that simple changes in nutrition and lifestyle can go a long way in improving virtually any of these issues. That's the real decision that needs to be made...but it's not promoted as a primary method in this book. I love the idea of personalized medicine, but the drug promotion needs to go if we're ever gonna truly heal the health of Americans.

I found "The Decision Tree" to be an entertaining read, similar to what I expect to see in Wired magazine. However, what I was hoping for was a more cohesive argument for taking control of your own health using all avenues available to a patient today. I found that the author would tend to link various thoughts together by saying how important it is to use a Decision Tree instead of linking the thoughts via a solid argument or relevant research data. To me this was just showing that the book wasn't really complete, it reads like a collection of essays that you would expect to see in a blog. There certainly are the beginnings of a good argument far taking control of your own health, but "The Decision Tree" could have been so much better if the author had really polished the arguments he presents.

I have to say that before I review this book that I do appreciate the effort Thomas Goetz took to try and write a book about our health care system. I thought the information in this book was really great and uptodate! I really like the fact that he encourages people to take charge of their own health instead of letting doctors and other providers take charge of it instead. Nothing good has or will come from the medical field trying to do that. With that said...I am alittle confused with his book. I do like it, but it seems that Mr. Goetz needs to take to much information to point out the simple facts in his chapters. I am also left (after reading this book) alittle dazed about why exactly does he need to go through all the information that he did to explain his simple algorithm or the decision tree.

I am a obstetric provider now for at least ten years. His decision tree "maps" are little more than the same algorithms that I use to help ME make medical decisions about patient care. I like how he is trying to get people to use it, but is this enough to fill a book. My only point here is that...it really is nothing new to me, and I totally got lost in all the inforation he presented (great information by the way) along the way as he discussing "the decision tree".

I think what people really need is a type of health care advocate. I am very lucky that I have the knowlodge to help family members journey through the confusing health care system. People need others to help them steer through the medical profession. I am not sure that a decision tree is enough.


I think that Thomas Goetz's decision tree to work that more people in our country need make that decision about taking responsibility for their health. Some of my patients don't take personal responsibilty and DON"T want to take that personal responsibility for their own health. It is hard to motivate people to change their health habbits until there is a problem. We need to focus on this problem. Until we do the decision tree type of thinking won't be used by a large segment of the population, and probably the segment that probably needs to use it the most. I would have also liked him to put a chapter in his book on how doctors, clinics, and hospitals could help patients make use of the decision tree maps. How can the medical system embrace this type of map and help their patients use them. Is their anyway for us to enocourage it usage, and in doing so will our patients take more responsibility in their care.


One great thing about your book though Thomas Goetz. It does give me a resource to point patients in this direction. I hope it also starts a wave of thinking that maybe ones is responsible for their health. The last thing I did like about your book was the resources and web sites laced throgh out this book. Thanks!!!

I will be thinking about ways that maybe I can use the decision try in my practice. Maybe I can use it to explain certain options or decisions for my patients. I will let you know how it turns out.

How much you like this book will depend on what you were looking for when you picked it up. I had incorrectly believed from the summary and title that it would be a short dissertation on the current state of the art in managing your own health followed by a lot of practical suggestions and perhaps even forms or regimens to do just that. Instead, the whole first half of the book is a well-written, detailed, history and discussion of how we are moving into an age where individuals are able to monitor many of the factors that INFLUENCE their health and take pro-active measures to maximize their chance of maintaining a higher level of health for a longer time.

Now, I have said that the text is well written, and it is. However, I'm going to give it up now that I'm half way through because it's still going into background data, long case studies and other information which is OK, but I'm already sold. Great. I'll go off and dump $399 into "23andme" and get some genetic testing done. Call me a left-brain kinda guy, but now I'm ready to enter the brave new world and this writer persists in continuing on with a dissertation in how we got here, where we are gong and how great it's going to be. I skipped ahead and looked, and this seems to continue for the rest of the book.

Now, if you are a policy and history wonk, you will enjoy reading the rest of this. I felt I got it about 60 pages in and was ready for some practical work, which doesn't seem to show up.

That said, it's still worth a look when you consider that the biggest issue we have in health care today and in the future is touched on in the discussion of obesity. The fact is, our health care system is broken not just because of greedy corporations, or the AMA or our bungling federal government. It's broken because we in America have decided that over 75% of our population can mistreat our bodies horribly through overeating, lack of exercise, smoking and other negative health practices, and still be owed insured health care. The author brings up these statistics sort of incidentally to the main topic, and he does not come to the same conclusion I did, but when you look at the statistics cited, it means we are trying to pay for the irresponsibility of a few hundred million folks in the form of health care after they've messed themselves up with very preventable ailments. For the price of Obama's health care initiative, we would be better off if we spent the money of free health club memberships and group or personal trainers.

Sorry for the rant. Enjoy the first half of the book.

Please see the update at the end of this review. I followed the book's suggestion re: genetic testing and learned some surprising and helpful things about myself.

Reading this book was a little like sitting in the classes of some of my favorite professors. The prose is engaging and often anecdotal, which is good, because the subject matter is so dry and dense that I really wanted to give up on this book a few times. I'm very glad that I stuck with it, because the book does describe a very useful method for gaining and using medical knowledge about oneself. At its most basic, a "decision tree" is a flow chart comprised of a logical series of questions and answers that starts with the information one has, and progresses through "if A is true, what do I do next?" hypothoses, potential diagnoses, treatments, etc. until one has developed a plan of action. Or inaction. Sometimes, the decision tree leads the patient to leave things be.

But the book, like my favorite professors, jumps from premise to anecdote to new premise, almost as if the author's brain is working too fast for his word processor.

And it's a bit rambly. It took somewhere between 50 and 60 pages to even point out that regular people can order their own DNA analyses (before I wrote this review today I checked online and found out it costs about $500, which is a lot, but which is also less than the price of a decent television), which is really what they need to do before they can design an effective decision tree (based on the concept that our health is the combined result of genetics and environmental factors. Once we know our genetic risks, we can make informed choices to avoid or ameliorate many, if not most, environmental triggers.)

Although the book addresses the fear surrounding the giving and the getting of this knowledge - the idea that patients will collapse, quit their jobs, become erratic in general if the news is bad - it neglects the financial incentive, in today's insurance climate, to avoid genetic testing if one wants to remain insurable.

In addition to arguing for genetic testing, Goetz argues against excessive use of other forms of screening, which can lead to wrong diagnoses and unnecessary (and dangerous, in some cases) treatment. He also details examples of decision trees that start with symptoms, or with decisions (like "quit smoking"), which maes the book a useful reference regardless of whether the reader wants to take Goetz' advice to get some genetic testing.

I would recommend this book to anyone who has recently received troubling news about his or her health or who is questioning whether to ask a doctor to run tests or who has a nagging feeling about some strange symptoms.

UPDATE:

I took the book's advice (and my own from the end of this review) and ordered genetic testing from Pathway Genomics (the least expensive alternative I could find). I have an autoimmune disorder (SLE), and when you have one of those, doctors tend to dump every little symptom you get into the autoimmune bucket, unless they find something else within the first or second try. It's frustrating for them, and for the patient as well, because autoimmune disorders mimic so many other diseases and conditions. They also complicate other diseases and conditions. So, when my heart rate spiked last year and stayed there, my doctors did some tests, decided the increase was due to damage to my nervous system (which is probably true), and said that it was benign absent any other cardiovascular risk factors, which, as far as they can tell, I don't have. My cholesterol and blood pressure are awesome. And because I'm sick and don't have a choice, I take extra care about diet and exercise.

I have a strapless heart rate monitor that I got right here on Amazon, and I watch it in case there's any further increase, because that would be really bad, but my doctors told me not to worry. Except, I couldn't really shake the feeling that maybe I was missing something. I had an incomplete family history, because my father's mother and uncle had both died suddenly and pretty young and nobody really followed up on it at the time. So, I took the test, waited six weeks, and learned that I'm at a significantly higher than average risk for myocardial infarction. Now, I know.

And I feel better, not worse. I feel sort of empowered.