As I look through my personal library of reference books, I notice that most of them have one unfortunate feature in common: nearly all are out of date. A 15-year-old diabetes text--all but useless. A 1990 issue of a prominent health journal devoted entirely to aging issues--germane in its time, but practically a museum piece today. A pocket medical dictionary from a few years ago contains almost none of the new terms I need defined. Keeping up with the introduction of worthy clinical interventions in the field of biomedical research is impossible enough; the idea of keeping pace with the thousands of new ideas, suggestions, and experiments bursting from the research centers of the world is unthinkable.
Komaroff, who is professor of medicine and senior physician at Brigham and Women's Hospital, says that he has often used such health guides to get a quick read on medical problems and procedures outside his specialty. But he found too often that the guides, though well-written, lacked the depth he desired. How was a certain test performed? What would a "false positive" result imply? In the Family Health Guide, therefore, Komaroff strove to provide those rich details, including sections on normal human anatomy and physiology, specialists' observations on controversies in their own fields, graphic representations of the risks and benefits of certain treatments, and the Internet component that will keep the book current.
"The website will not be an updated version of the book on-line," says Komaroff, "although there will be some interactive features that will make the website in some respects more accessible than the book. Rather, the site will contain a lot of stuff that ended up on the cutting-room floor, as it were, plus new information about diagnosis and treatment that lies somewhere in some researcher's computer as we speak. It will be everything that is not in the book already."
Hard to imagine something not already in the text of roughly a million words. Yet there is an enormous amount of information average citizens need to understand in order to weave their way through the bureaucratic headaches some call the American healthcare system. Twenty years ago, when a child broke out in small welts, Mother paid a quick visit to the family pediatrician. Today, the wait to be seen could be days, and the expense significant. Far better to have a pictorial guide that helps distinguish between chicken pox and a relatively harmless contact dermatitis that will recede in a few hours.
"We have straightforward graphics that are understandable on their own," says Henry H. Bernstein, associate professor of clinical pediatrics and associate chief of the division of pediatrics at Children's Hospital, who wrote much of his specialty's section. "This allows parents to make informed decisions about caring for their child. We also broke up the health and development section to separate kids two and under from older children. There's a tremendous difference, because kids under two are more likely to get infections, and they are growing so quickly. The most important thing is to put information in context so that parents won't be needlessly worked up."
About 10 percent of the book is devoted to a section that allows readers to interpret so-called "generalized symptoms," such as anxiety, depression, bleeding, fever, vomiting, and shortness of breath. Using a graphic decision tree, readers can look at their symptoms in the context of additional information and determine if they need immediate attention. In addition, more than a hundred pages of "symptom algorithms" graphically help readers decide whether their best option is an aspirin, a visit to the doctor's office, or an ambulance to the emergency room.
How do you address so many health information needs of the general public in one book? Perhaps it can't be done, but Komaroff felt that someone had to try.
"At the time Harvard Medical School entered the joint venture with Simon and Schuster," he recalls, "high on our list of priorities was a flagship book that would cover many topics in clinical medicine--for two reasons. There was widespread apprehension among patients about managed care, and doctors came under pressure to spend less time with patients. Coverage was shrinking, and people began spending more of their own money for medical care. Patients needed a reference to help them determine, as well as they could, the severity of their problems.
"At the same time, medicine has become far more complicated. There are so many treatment options for so many diseases, and with the reduced availability of physician consultation, we needed to give patients some common-sense information about how to decide. Balancing the benefits of doing something versus doing nothing is now an important issue that many doctors and patients need to consider. The debate over hormone replacement therapy [for menopausal women] is one example: are the increased risks of heart disease and cancer outweighed by the benefits to bone density and perhaps cognitive health? We felt that people didn't have a good sense of that balance, of the risks and benefits, and we wanted to portray it in a way that would be both accurate and engaging." [ Note: after publication, Dr. Komaroff noted that he had been incorrectly quoted. Considerable evidence indicates that hormone replacement therapy may lower the risk of heart disease in women, except perhaps in women who already have active heart disease. ]
Because the number and variety of drugs currently available in this country is extraordinary, the book's most useful section may be a drug-interaction chart, devised by associate editor Serena Koenig, an instructor in medicine at Brigham and Women's Hospital. It lists potentially serious consequences of 200 of the nation's most widely used pharmaceuticals. "Many people, for example, don't realize that if they're taking the blood-thinner Coumadin, they should avoid taking antibiotics, which enhance the drug's effects," says Koenig. "Even some doctors aren't aware of how dangerous this interaction can be, and people taking the drug should have their blood checked before they begin taking antibiotics of any kind."
Koenig, who was a teacher before entering medicine, believes that "better informed patients make more successful doctors." Patients always respond best when they are willing and enthusiastic participants in the treatment process, and the new health guide opens the door to that crucial measure of involvement. "I think this text is unique in that we have tried to give patients the information that will let them get the most out of health care," Koenig continues. "Patients have the right to know what's going on. It engages them in their healing process and, as a doctor, working in partnership with the patient feels to me more like what medicine ought to be ."