Book Reviews 1121

to the ideal of the traditional gentleman-physician. Surgeons remained socially and professionally inferior, causing rivalry, as were physicians who practised midwifery, get Risse fails to explicate these conflicts.

Edinburgh medicine was in transition between 1770 and 1800. William Cullen’s Synopsis ;Vosologiue (1769) provided the accepted nosological model. Scottish medicine was empirical, based on careful history taking, clinical obser- vation and increasing skepticism about existing medical treatment. Research in Scottish medical institutions was hampered by financial constraints. Moreover, autopsies were seldom permitted by patients’ families. Finally. physi- cians held prejudice about the inferior social status of the surgeon. Body-snatching for anatomical instruction is ignored. Yet it was an agonizing reality for Scats up until the Burke and Hare murders of 1828 and the subsequent passage of the Anatomy Act.

Risse convincingly debunks the notion that Edinburgh’s Royal Infirmary was a “gateway to death” as generally argued by Michel Foucault and Thomas McKeown. Because of the enormous cultural and social differences between eighteenth-century Scotland and revolutionary France. further comparison is indivious.

The lack of a bibliography is a serious omission. More- over, R&se’s book raises more questions than it answers. What did doctors say in Annual Reports about the preva- lence of venereal disease in the institution? What were the specific conflicts between physicians and surgeons? It is clear that Edinburgh’s Royal Infirmary functioned primarily as a teaching hospital. In spite of impressive scholarship, Risse’s book seems unbalanced, requires better organization and lacks integration into the broader historical context.

Nevertheless. Risse has written an important study which probes into the state of the art of medicine and medical education in eighteenth-century Scotland. In spite of philan- thropic rhetoric and persuasive propaganda, the Royal Infirmary of Edinburgh did not provide significant medical service to the city’s poor. Risse underscores the basic inadequacy of the voluntary hospital movement that was to culminate in the Royal Commission of 1844 and the lengthy social debate on issues of health, poverty, pauperism and madness which would ultimately result in medical and legal reform in the mid-nineteenth century.

Department of History Bentley College Walrham. Mass., U.S.A.

MARGARET S. THOMP~~S

Doctors’ Decisions and the Cost of Medical Care, by JOHS M. EISEKBERG. Health Administration Press, Ann Arbor, Mich., 1986. 190 pp. No price given

Variation in physicians’ practice patterns is one major issue in health services research in the mid 1980s. Variation raises the possibility that not all medical practices are essential and provides a rationale for a reduction in certain medical services. Also, determination of the causes of this variation may lead to valuable insights into the underpinnings of medical decision making and ways to influence it. Although this area of research is not new, recent enthusiasm in and for this field is remarkable. This invigoration is fueled by the 1980s’ concern for cost containment. Interest in the topic is shared by health care policy makers, federal government budget balancers, industrial leaders (payers of insurance premiums), as well as by physicians themselves.

John Eisenberg has written a timely book which is an introduction to the research that attempts to elucidate the reasons doctors practice the way they do and make the decisions they do. He has divided his book into three parts: Understanding Variations in Physicians’ Practice Patterns, Changing Physicians’ Practice Patterns, and Directions for Research on Physician Utilization. Part one follows a well developed theme set out in Chap. 1: Practice variation exists

with evidence of overutilization. Medical decision making is a function of more influences than simply clinical data. Using language of the decision sciences, the physician’s response to a clinical problem is a “multiattribute utility problem”. The multiple attributes are expounded upon in the next three chapters: the physician’s own interests and desires, the patient’s benefit and the benefit to society at large.

He interprets the numerous studies from an objective and broadminded perspective, and is careful to explain the problems of drawing conclusions from studies without adequate controls (as a result of var$ng severity of disease or uncontrolled potential confounders). An example is the role of patient characteristics, why different patients are treated differently even when their medical problems are identical. He notes the difficulty of obtaining insight from demographic data without descriptors which impact on this issue, such as patients’ values, aversions to risk, or their likelihood of having disease.

His view of the issues seems, at times, more economic than medical. In delineating the physician’s role as the patient’s agent, he states that the physician will first seek to defend the patient’s economic well-being. “Second, clinical factors play a role in medical decision making. .“. This ordering would be more expected from an economist than a physician.

Part two, approaches toward changing physician practice patterns, provides an instructive framework in which to consider this issue. The six major ways of altering the established patterns (education, feedback, participation, ad- ministrative rules. incentives and penalties) are judged on past performance and viewed as even more potent in a cost-conscious medical era.

The third section outlines specific issues in physician utilization research which needs further development. These include challenges for research on methodological issues and on changing utilization.

For the most part, the book is written in non-technical language. References to decision theory or behavioral psy- chology are clearly explained. The writing is easily readable even though some sentences, at times, are circuitous.

As the book states, “the implications of research on physician behavior and the factors that influence medical decision making are increasingly pertinent as the constraints on the resources available for medical care become more apparent.” Docrors’ Decisions and the Cost of Medical Care is a fine introduction to this realm of health services research for both physician and non-physician. Not only does it establish a “state of the art” lor this rapidly expanding field, but, in appropriate academic fashion, it suggests areas fertile for future research.

General Medicine Unit Massachusetts General Hospital Boston, Mass., U.S. A.

JEFFREY H. SAMET

Traditional Medicine in Botswana: Traditional Healers, by FRANTS STAUGARD. Ipelegeng. Gaborone, Botswana, 1985. 276 pp. S10.00

This book, written by a medical doctor who worked in Botswana, provides a description of traditional healers in Botswana. The book places traditional and modern health care in their historical context in this southern African country, and considers the influence on health care and health seeking behaviors of two distinctively different cul- tures: the traditional tribal culture and the modem western civilization.

Two surveys, one of traditional healers and one of the utilization of health care, show that the traditional health care system still plays a very important role in the lives of people in both rural and urban communities. The social and religious roles of the various types of traditional healers and

1122 Book Revtews

their significance are discussed. Case studies of the sucker. faith healer, sangoma, herbalist, diviner and neoherbalist are used to complement the quantitative survey data by providing a holistic picture of the traditional healers’ practices. Classifications of traditional diseases and methods for their prevention and treatment are clearly described, as well as the role of magic and ‘witchcraft’. which are still prevalent in Tswana medicine.

The book also presents the major health problems of Botswana, from the perspective of modern medicine. These problems reflect the poverty, lack of nutritious iood. safe water and sanitation commonly found in developing coun- tries, especially among the rural uneducated groups. Even thou& modem health care services are avatlable to the majo%ty of the population in Botswana. data on health seeking behavior of the population indicate modem facilities are utilized to a high extent by the urban educated popu- lation who are attracted to modern care, while the under- privileged group is often rejected. A major thesis of the author is that the traditional healer in the local community is the “missing link” to the underprivileged majority of the population in rural areas.

Data on the utilization of the traditional sector for care indicate that a very high proportion of all visits to the traditional sector by both the rural and urban population were made in order to seek advice on health problems or for preventive reasons in the traditional sense of the word. Preventive services rendered by the traditional healer in- clude protection from ‘witchcraft’, bad luck. burglary, light- ning, and infertility among humans and cattle. In the modern sector more than 98% of all visits by adults were made for purely curative reasons. Communicable diseases, which might benefit from modern treatment, account for 20% of the cases of traditional healers. And psychosomatic diseases, which demand thorough understanding of per- sonal and sociocultural factors, are often treated in clinics or hospitals where the risk of ‘medicalization’ is high. This example serves to support the author’s conclusion regarding the benefits of cooperation between the two sectors.

The strengths of traditional medicine emphasized in the book include its sociocultural integration, holistic attitude. and preventive outlook. The author is critical of the curative orientation of modern medicine, an approach often neglect- ing complicated and time consuming preventive measures which require community participation. Even though pre- vention in the traditional concept is different from the

modern scienmic concept the idea of the caregiver being dominated by the aspiration to achieve effectrve prevention of disease and ill health rather than to treat an actual disease, is rightly pointed out as an area of traditional medicine from which the curatively biased modem medicine has much to learn.

Modem medicine is viewed as a mixed blessing. In addition to the curative orientation of modem medicine, the author notes the negative side effects of the institu- tionalization of birth and death. and the lack of progress in the human quality of care. Documentation on the negative aspects of traditional care are also provided through examples of four types of side effects and adverse reactions to traditional medicine,

The final chapter discusses alternative approaches of the modem sector to the traditional sector: confrontation, regulation. integration or cooperation. The author wisely advocates cooperation, characterized by mutual respect, open-mindedness and interest in learning and modifying ideas and practices, between two independent partners. The potential value in cooperation lies in reducing the ‘care failure’ (the number of people who want and need health care but are unable to obtain it in the modem sector) and also the ‘cure failure’ (the number of patients who obtain health care but not a cure for their disease). Strategies for cooperation at the central, regional and local level are proffered.

The author concludes that both sectors will be able to contribute toward the goal of health for all through cooper- ative efforts which preserve and utilize the specific values of both systems.

This book, the first of a trilogy on traditional medicine in Botswana and the following volumes on traditional mid- wives and on traditional medicinal plants, aim to provide a comprehensive description of Tswana traditional health care. Even though the first volume is based on data from Botswana, the insights and conclusions are useful for all health and health related professionals. Likewise, the strate- gies are applicable not only in Botswana but also in other developing countries.

Health Manpower SANDRA v~sD.4~ ANDERSON Development

World Health 0rgani:aiion Karhmandu, .Vepal