STATISTICS IN MEDICINE, VOL. 9, 1223-1227 (1990)

BOOK REVIEWS Editor: Douglas G. Altman

FOLLIES AND FALLACIES IN MEDICINE. Petr Skrabanek and James McCormick, Tarragon Press, Glasgow, 1989. No. of pages: 170. Price: E7.95:

This book brings together in very readable form accounts of unintentional corruption of the truth from historic and recent times, and describes many snares still catching the unwary.

The first chapter deals with the placebo phe- nomenon, pointing out that, as faith in placebos is advantageous to both doctor and patient, critical enquiry may be perceived as subversive. Discus- sions usually concentrate ‘on the gullibility of patients but ignore the self-deception of physi- cians’, and this chapter should be compulsory reading for any clinicians or researchers who believe themselves to be immune!

Chapter 2 reviews and references numerous well-known and some less well-known fallacies. It also discusses some common practices which en- courage fallacious conclusions. For example, a trial with negative findings is less likely to be published than a similar trial with a positive out- come.

Chapter 3 takes a critical look at the process and effects of diagnosis and labelling, noting that a medical training, in which a missed diagnosis is a serious crime, encourages type I rather than type I1 errors. Medical readers may blush as memories are revived of listening to a patient’s heart having heard the consultant and others report a heart murmur, and being desperate to hear it too (‘the emperor’s clothes syndrome’ described by Gross). There is an interesting discussion of ‘non-diseases’, such as ‘normal variation syndrome’ (for example, short stature), and the possible harm done by informing an individual, who may previously have regarded himself as healthy, that he has slightly raised blood pressure. Now discredited are ‘drape- tomania’, a disease rampant in the last century, which gave Negro slaves an ‘irrestrainable pro- pensity to run away’, and some more recent ‘dia- gnoses’ thought to warrant brain surgery.

Chapter 4 will raise a few hackles! It highlights the lack of hard evidence for much dogma in preventive medicine, and asks if altering risk fac- tors for, for example, heart disease, in the popula-

0 1990 by John Wiley & Sons, Ltd.

tion is really worthwhile. The authors warn that, at a time when General Practitioners in the United Kingdom are being encouraged to undertake screening, the voice of caution is not being heard.

Chapter 5 takes a whirlwind tour through ‘al- ternative medicine’, and is even-handed in dis- missing everything. Chapter 6 briefly discusses issues of morality and medicine, and questions among other things the great pressure put upon those who persist in smoking. Chapter 7 is essen- tially an apology for being so negative about everything in the previous six chapters!

In a book covering so much ground, many examples are necessarily abbreviated, but the refer- ence section facilitates further reading. It is perhaps unfortunate that the reviewer happened to detect two papers which had been misquoted. The authors credit Hamblin’ (p. 32) with reporting a mistake by 1930s chemists which led the world to believe spinach to be a rich source of iron, but he actually wrote that in the 1930s German chemists discovered an error from the 1890s. The second misrepresentation (p. 127), probably due to brev- ity, refers to a study of ‘the objective efficacy of prayer’,’ saying that it ‘demonstrated no effect’. In fact the results were more complex than that, and it is possible that Skrabanek and McCormick have illustrated the ‘fallacy of covert bias’, strategy 6 (P. 54).

The authors, from the Department of Commun- ity Health, Trinity College, Dublin, admit that some say they suffer from ‘scepticaemia’, an un- usual condition in those who have passed through medical school. For medical students the question is too often ‘what do I have to say if I am asked this question in an exam’?’, so the authors seek to introduce their students to critical appraisal.

This is a delightfully irritating book. The au- thors would probably regard ‘irritating’ as a com- pliment, and it is intended as such, although it is also a sort of health warning to anyone who might prefer their equilibrium to remain undisturbed. How ‘delightful’ each reader finds it will depend to some extent upon how many cherished beliefs have been dismissed as fallacious. ‘Scepticism is the scalpel which frees accessible truth from the dead tissue of unfounded belief and wishful thinking’ (p. 144). I recommend that those who seek to

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pursue truth, using medical or statistical skills, or who attempt to teach others to do so, allow this book to challenge their thinking and practice.

PAMELA EVANS Department of Clinical Epidemiology

The London Hospital Medical College Turner Street

London El 2AD, U . K .

REFERENCES 1. Hamblin, T. J. ‘Fake!’ British Medical Journal,

2. Joyce, C. R. B. and Welldon, R. M. C. ‘The objective efficacy of prayer. A double-blind clinical trial’, Journal of Chronic Diseases, 18,

283, 1671-1674 (1981).

367-377 (1965).

RESEARCH METHODS IN CLINICAL ONCOLOGY. B. J. Leventhal and R. E. Wittes, Raven Press, New York, 1988. No. of pages: ix + 246. Price: $93.50

This book is aimed at clinicians carrying out clini- cal cancer trials or wishing to understand the principal issues involved in such investigations.

After a short introduction, two chapters deal with the measurement of disease, the definition and evaluation of response to treatment, and the assessment of toxicity and quality of life. There then follow three chapters dealing, respectively, with phase I, I1 and I11 trials. Statistical details are kept out of the main text, but appendices discuss in a simple way the concepts of type I and type I1 errors and power, the number of patients required in trials, and the method of balanced randomiz- ation. These chapters are inevitably very much orientated towards the evaluation of drug regimes, but many of the principles involved and recom- mendations made are equally applicable to trials of other types of treatment. The actual analysis of comparative trials is dealt with in a separate chap- ter where, again, the mathematics of the chi-square test, the construction of actuarial survival curves and the logrank test are illustrated by simple examples in appendices.

The special problems associated with trials of combination chemotherapy, combined modality therapy and the use of biological response modi- fiers are discussed in three further chapters, while

BIOPHARMACEUTICAL STATISTICS FOR DRUG DE- VELOPMENT. Karl E. Peace (ed), Marcel Dekker, New York, 1987. No of pages: xii +640. Price: $125.00 US and Canada; $150.00 other countries.

This book provides a great deal of inside in- formation about both statistics and drug develop- ment. It features a review of the field and provides excellent examples from applications that are not easily available in the statistical literature. For

the remainder of the book considers the more administrative aspects of trials, such as writing a protocol, monitoring reliability of the data, produ- cing a report and complying with ethical require- ments. The last-named includes a good exposition of the elements of informed consent as now layed down in the USA Code of Federal Regulations, and which, I suspect, still considerably exceed the requirements generally regarded as acceptable for trials in the U.K.

The authors have achieved their aims and pro- duced a very good introductory textbook for med- ical staff beginning their training in clinical onco- logy, and one which can also be usefully read by more experienced cancer clinicians. It has little to offer the statistician with wide experience of cancer clinical trials, but could be valuable reading for a statistician coming new into the field and needing to familiarize him or herself with the medical background of oncological investigations.

The book is well-produced, although not with- out some misprints and one or two minor errors. Unfortunately, the junior staff for whom it is mainly written may well consider its price puts it beyond their consideration for personal purchase.

JOHN HAYBITTLE MRC Cancer Trials Office

7 Green St. Cambridge CB2 3JU, U.K.

example, the account of optimization experiments in drug formulation provides insight and detail that will be very usable for many readers.

The book also contains a readable account of the pharmacology and chemistry necessary to understand this industry. Readable in this sense means that statisticians can read these descriptions and improve their knowledge of the disciplines practised by their collaborators. There are 14 chapters averaging 45 pages with a range from 20