Indianapolis Neurosurgical Group

Anatomy & Procedures | Spinal Conditions & Diseases | Understanding Your Back | Informed Patients

Making Informed Medical Decisions

Introduction
Decisions about medical care can be very difficult - and literally, matters of life and death. Feeling comfortable that a particular decision is the best decision for you (or for a person you love) depends a great deal on the process of understanding the choices. Knowing the steps in the medical decision process is often helpful in reaching a decision that "feels right." In this essay, we describe the 'basics' of making medical decisions and offer several suggestions that we hope will improve your confidence in the decision process.

The "Parts" of a Medical Decision
A remarkable amount of information is gathered (and created) in the medical decision process. Some information comes from the patient, some from the physician, and quite a bit is created new in the patient testing process. Medical information includes data about the following:

Past Medical History (including prior surgeries, previous illness, and personal health habits)
Current Health Status
- Medications
- Other current health conditions, such as chronic illness involving other organ systems
- Current physical condition, such as age, proper weight, nutrition, and other factors
- Cardiovascular fitness (physical "reserve" to withstand stress)
- Life expectancy
- Other measurements and attibutes of current health status
Personal Values
- Religious convictions that influence the care process
- Advance directives (including "Living Wills"), such as "Do Not Resuscitate" orders, and willingness to be an organ donor.
Medical Assessment
- Current History and Physical Examinations
- Laboratory Blood Testing, as needed
- Radiology (Imaging) Examinations, as needed
- Other Special Testing (Heart and Pulmonary Functions, etc, as needed)
- Specialty Physician Consultations, as needed
Medical Knowledge about the natural history of the Condition(s) being considered, including the fate of other patients with similar conditions and treatment options.

The "Sequence" of Medical Decisions
Although it may seem obvious, the medical decision process does not begin until the patient gives permission to begin. This means that the patient agrees that he or she has a medical condition (or change in health status) about which a decision (that is, a treatment) is desired.

Unfortunately, it is a not unusual to have a period of "denial" - when the patient (or another significant person in the patient's life) refuses to deal directly with the problem. (Occasionally, "denial" can result in delays which significantly interfere in the diagnostic and treatment process! Although the causes for denial can vary from person to person, it is often rooted in a fear of the unknown; once the person in denial decides that knowing more is probably better than knowing less, the process continues).

Step 1: Statement of the Presenting Complaint (or physical finding)
Step 2: Initial Medical Assessment (history, physical examination and pertinent special tests)
Step 3: Identification of Normal and Abnormal Findings (up to this point in the process)
Step 4: Creation of the Initial List of possible Medical Conditions (i.e. Differential Diagnoses)
Step 5: More testing, as needed, to narrow the list of possibilities and/or confirm the most likely condition. This may include invasive testing (like arteriograms, or tissue biopsies) or opinions from other medical specialists.
Step 6: Treatment Intervention (for example: medication, angioplasty, surgery)
Step 7: Collection of pertinent information to assess the effectiveness of the selected treatment.

Discussion
The sequence of the medical decision process repeats itself over and over until the presenting problem (abnormal condition) is resolved, or the patient dies (either from the condition undergoing treatment or for any other reason).

Early in the process, the decisions are focused on confirming the accuracy of the "working" diagnosis - a technical description of the problem. Once the diagnosis is certain (confirmed), the decision process narrows to the treatment options - although good physicians stay perpetually alert to any information that "doesn't fit the pattern."

The medical decision process is not perfect. Experts often disagree about the significance of particular findings, or may vary in their preference (experience) for specific treatment options. Expected and unexpected complications (and side effects) occur - nausea & vomiting from chemotherapy, or an allergy to a drug (which can be life threatening, by themselves).

Understanding the "Benefits versus the Risks" is a crucial step in the decision to make an intervention at all. "First of all, do no harm" is an expression that dates back to the Greeks (Hippocrates), and acknowleges that sometimes the treatment can become worse than the problem. Occasionally, the expression "Benefit vs Cost" is used nearly interchangeably with "Benefit vs Risk." Cost may be understood in broader terms than just dollars: the number of hours of nursing care, emotional suffering, disability from working, etc. In the decision process, each interventional option is considered with respect to its benefit versus risk/cost for this patient (when compared to similar patients in the past who selected different treatment options).

One difficulty in the medical decision process can be getting lost in statistics. Physicians have studied nearly everything about medical care, but not all researchers get the same results. Statistics are often used to try to "compare apples with apples." For example, suppose that you are told that the best drug for strep throat is penicillin -- which is 95% effective in your geographical area for the strain of Strep you have. You are also told that about 1 dose in 100,000 doses of penicillin is fatal, due to drug allergy, whether the recipient is known to be allergic or not (not a very common complication). But, if you are the one to whom that happens, you will still be 100% dead! At some point in nearly every medical decision, you "take your chances" and hope for the best. Obviously, everything is done to reduce the risk/cost, but the possibility of some risk is never completely eliminated.

The Time Factor
Some medical conditions, like abrupt unconsciousness or a serious heart attack, alter the medical decision process significantly. There is no longer the luxury of time to make a comprehensive decision that collects and considers all of the desired information. Rather a decision must be made on the spot, with the available information, hoping for the best. Under such conditions, many steps in the process described above may be left out due to the urgent effort to save the patient's life. (For example, brain damage occurs in 4 minutes when blood flow to the head is interrupted - in a cardiac arrest, therefore, asking questions is irrelevant, when cardiopulmonary resuscitation (CPR) is required.)

What YOU can do to be well-informed

Learn how the medical decision process works:
- Be certain you understand where you are in the process; early on, the decisions usually involve reaching the correct diagnosis; late in the process, decisions involved stopping or changing particular treatments.
- Making written notes is an excellent idea, especially if you have trouble remembering complicated material. Ask the physician or nurse to spell the key technical names
- Be sure you understand the possible complications, and how often they occur
- Ask what the cost will be, whether that is a factor in the decision or not
- Ask what you should be alert to notice as the process proceeds
- Be alert to the unexpected, and ask about what you don't understand. It may save your life.
Learn the functions of the normal and abnormal organs involved in the condition you are studying
Promote good health habits and a balanced life style
Learn about the condition (diagnosis) and its treatment from credible references
- Community library
- Internet - be careful to seek information at your level of comprehension (the Internet has everything) and beware of sites which are advertising specific products (they are not always honest and objective). Use your common sense, and whenever possible use website links recommended by respected health experts, such as those found on this website.
- Be cautious about testimonials and anecdotes - reported by friends, newspapers, and advertisers.
Ask for help !!
- Physical - stick to the prescribed treatment, once the decision has been made.
- Emotional - consider participating in a support group with others affected by this problem or seeking the support of trusted friends
- Spiritual - seeking help within your church, or research writers/speakers who have a spiritual message
Stay focused on what you CAN do, and don't dwell on what you CANNOT do.