The book explains how to read, understand, and evaluate a medical journal article; make sense of statistics and risks; explore alternative and complementary therapies; research clinical trials; and make an ally of your healthcare provider.

It's no secret that, in this era of HMOs and seven-minute office visits, the quality of our healthcare is increasingly in our own hands. Making Informed Medical Decisions maps out a systematic approach for anyone facing a healthcare crisis, chronic illness, or serious medical decision. It's also a resource for healthcare providers and those who want to help a friend or relative get the best treatment. The book includes an extensive patient questionnaire that helps clarify your own healthcare goals, or understand how best to help a relative or friend who is ill.

Complementing Thomas's research skills are the patients-rights perspective of Oster, a medical writer and founder of the Breast Resource Center of Santa Barbara; and Dr. Joseff's expertise as a practicing internist and nephrologist.

Lucy Thomas's Story

Allen:

I'd like to begin by asking about the diagnosis that made your book so personally timely.

Thomas:

It was just a routine dental checkup. A couple of months back, I had noticed a red spot under my tongue way at the back that didn't go away. I asked my dentist and he said, "Oh, it's probably nothing, but let's do a biopsy." It turned out to be something. I got the results of the biopsy two days after we sent in the final revisions for the book.

Allen:

How did your having written this book affect what you did in response to the diagnosis?

Thomas:

I was greeted with a lot of alarm, but I knew that you don't have to do everything all at once. I didn't have a real diagnosis yet--I had something called atypical cells, which could have been benign, though as it turned out they were cancerous. But the surgeon was ready to throw me in the hospital and do a major biopsy. Doing that might have jeopardized further treatment, because up the road it would have been harder for the surgeon who eventually did the surgery to get clear margins. So I said, "First I want a consultation," because neither the dentist nor the oral surgeon really deals with what it turned out I had. Meanwhile, I did research. After I had the consultation with the oral surgeon, I went to an ear, nose, and throat surgeon to talk about treatment.

I was really grateful for the chapter on Patients' Rights, written by Nancy Oster. I used every bit of it for myself.

Allen:

Do you think the book nailed the subject?

Thomas:

Yes! The theoretical part was very helpful. So were the patients' stories. We interviewed people for the book who told us how valuable it was to their healing and treatment to talk to somebody who'd been through the same thing. As it became clear I would need major surgery, I asked the doctor for names of people who had the same surgery I would have.

One woman was especially helpful. I've never seen her face to face, but I talked to her on the phone and she kept saying, "Don't let yourself get down. Every day is a little bit better." If I'm having a bad day, I think "Well, tomorrow's going to be a little bit better and the next day better still," and she's been right about that. I was also prepared for what was going to happen to me. When the doctors replaced my jawbone with a bone from my leg, I couldn't take a regular shower for a long time. The doctor didn't have any idea how long. This same woman was real clear about it, and she gave me some tips on how to keep myself clean. Little stuff like that makes a big difference.

Allen:

Most of us tend to think that if you're diagnosed with a condition, you'll automatically be given the best therapy to overcome that condition. But the book--and your example--make it clear that there are many options. Can you give an example where treatment options require patients themselves to make difficult decisions about the course of their therapy?

Thomas:

There are so many. In my own situation, I could have had major surgery, which involves replacing a piece of my jaw with bone from my leg to make sure they got all of the cancer in that area, or they could have just taken tissue out and done a lot of radiation in my mouth. Well, I looked into the side effects of radiation and found it can be devastating. It can kill your saliva glands and your taste buds.

My doctors told me I might still have to have radiation if they couldn't get all the cancer, but they were pretty sure they could get it all with major surgery. In the end they did.

Evaluating Medical Information

Allen:

What do you tell non-medical people who want to read journal articles or research papers?

Thomas:

We tell them to be skeptical. Journals have the newest treatments and theories about an illness, but they are untested, and claims about a drug's effectiveness may be exaggerated. We want people to look closely at the numbers. If it's a clinical trial, how many people were involved? Ten, one-hundred, a thousand? Sometimes the article makes a fairly sensational claim, even though there are only five or ten people in the study. We tell them to compare what the article claims to, say, what's in the textbooks. Look at the numbers of people and how they were chosen and whether there were any financial interests supporting the study. Did a drug company pay for the research that supports this drug?

Allen:

There are a lot of medical terms in these papers. Is there a medical dictionary to help people understand?

Thomas:

We have medical dictionaries in the library, but there's also one on the Web in the free database called Medline Plus. Anybody who has Internet access can get to a medical dictionary.

Allen:

Your book is unusual in that it tackles statistics. For most of us, statistics can be very hard to grasp intuitively. How does the book help people evaluate statistics?

Thomas:

This is Nancy's specialty, but there are some very good explanations of some of the concepts that aren't always made clear in, say, a journal article. Sometimes papers don't explain what kind of risk they're talking about. For example, one in 100,000 people would normally get some condition and if you give a certain drug to all 100,000 only one in 50,000 would get it. They could say, "This drug decreases your risks of getting the disease by 50 percent," and people think, "Great, let's all take this drug." Well, one in 50,000 is still pretty low risk. Why would you take a drug every day to go from one in 100,000 to one in 50,000? The statistics chapter helps you understand how those numbers are derived.

I remember a hormone study that showed one drug to be detrimental. My staff and I had that study torn up in about five minutes because the number of people who had a bad reaction was small, and they all lived in the same town in Sweden. They could have all been related, you know? And when you looked at the numbers of people in the study and the number of side effects, it was minuscule. We laughed about it, because for all we know, it could have been the water they drank! We decided it wasn't really a good study, although it got a lot of press because it was about hormones.

Allen:

So much information is now available because of the Internet. Perhaps there's too much for people to digest. How does the book help people sort through all that information and make sense of it?

Thomas:

We tried to readers the most reliable Web sites--such as the National Library of Medicine, the National Institutes of Health, and the National Cancer Institute. And we gave them some guidelines for what to look for in a Web site. Because the Internet is so new, people think if they found it on the Web, it must be true. We give them warning signs to look for: If it cures more than one or two diseases, if they ask you for money, or if ingredients are secret. Other red flags include testimonials, because that typically doesn't happen; a "doctor" who's not an M.D.; or an offer to let you help sell their product. The basic rule is, if it seems too good to be true, it probably is.

Allen:

In what other ways does your book help people look for information?

Thomas:

We advise people to look at all aspects of the treatment and ask questions. Find ways to get your questions answered in the very short time you have with any doctor.

Allen:

I've certainly experienced that! You're in the office with your doctor and she's looking at her watch.

Thomas:

Or say you have a diagnosis that managed care prefers to treat in a particular way, and it's not the best way. One woman was in a real managed-care nightmare. She had a thoracic outlet syndrome--a pinched nerve--because of a car accident. They told her they were going to take out a rib! It's the most extreme treatment for what she had, but it's fast and cheap. The recommended treatment is six months of physical therapy to release the pressure on the nerve, and that usually works; if it doesn't work, then they might look at surgery. But the HMO was trying to save money by taking out a rib. This woman was nearly hysterical because they wouldn't consider anything else. When she found out what the recommended treatment was, she fought to get it.

Allen:

Did she succeed?

Thomas:

She did. But she needed to be armed with information, because the only other thing her HMO offered was to send her to a psychiatrist because she seemed so upset!

Allen:

Patient empowerment represents a clear shift in the doctor-patient relationship. How well are most doctors coping with patients who come armed with all these study results and technical questions about different options?

Thomas:

Some of them don't want to deal with it. But I think if you meet them halfway, most of them do really well, providing you don't bring them a telephone book's worth of stuff and say, "Would you go over this and tell me what you think?" If you read everything you find and sift out the five or six really big questions, then, if the doctor says, "Oh, don't worry about that," you can say, "What about this study that says I should worry?" They really appreciate it if patients focus in on specifics.

Non-Medical Support is Important Too

Allen:

This book covers some aspects of illness that are not strictly medical, such as social and spiritual support. Has this kind of support been shown to make a difference medically?

Thomas:

Definitely. Probably the best study to support it is by David Spiegel, M.D., at Stanford University, on a support group for women who had metastatic breast cancer. In other words, they had a terminal illness. But compared to another group that didn't have a support group, these women lived 18 months longer.

Allen:

That's impressive.

Thomas:

Support can help in so many ways. Concerning my condition, people warned me that I should look out for depression that might set in because the healing is so slow. My doctor even gave me some pills to take if I start to get depressed. But she said, "Don't take these unless you really get down." And I haven't, but then I have a good support network. People look in on me. I seem to get a get-well card every day, or a get-well phone call from a nurse who tells me she misses me and then fills me in on all the gossip at work.

More and more research comes up with the same answer, that your spiritual and emotional health impact your physical health. In the healing community there's a difference between healing and being cured. Sometimes you can't be cured, but you can be emotionally and spiritually healed. Some people can be cured but not healed; their scars go away but they still have an illness mentality.

Allen:

Is there anything that you'd like to add in closing?

Thomas:

The medical system can be very frustrating, especially right now with all the changes in healthcare. Knowing how to get information can ease the way so much and help you to be your own advocate. We felt we had the knowledge to help people learn to find this information on their own, and we thought it was really important to share this knowledge. We wanted to give people a head start, so that if you get a diagnosis or even if you're just worried about something, you don't need to feel alone and, so to speak, unarmed. This book was a labor of love for all three of us.