How Doctors Think

A New Yorker staff writer, best-selling author, and professor at Harvard Medical School unravels the ultimate medical mystery: how doctors figure out the best treatments — or fail to do so.

On average, a physician will interrupt a patient describing her symptoms within twelve seconds. In that short time, many doctors decide on the likely diagnosis and best treatment. Often, decisions made this way are correct, but at crucial moments they can also be wrong — with catastrophic consequences. In this myth-shattering book, Jerome Groopman pinpoints the forces and thought processes behind the decisions doctors make. He explores why doctors err and shows when and how they can — with our help — avoid snap judgments, embrace uncertainty, communicate effectively, and deploy other skills that can have a profound impact on our health. This book is the first to describe in detail the warning signs of erroneous medical thinking, offering direct, intelligent questions patients can ask their doctors to help them get back on track.

Groopman draws on a wealth of research, extensive interviews with some of the country's best physicians, and his own experiences as a doctor and as a patient. He has learned many of the lessons in this book the hard way, from his own mistakes and from errors his doctors made in treating his own debilitating medical problems.

How Doctors Think reveals a profound new view of twenty-first-century medical practice, giving doctors and patients the vital information they need to make better judgments together.

"I wish I had read this book when I was in medical school, and I'm glad I've read it now. Most readers will know Jerome Groopman from his essays in the New Yorker, which take on a wide variety of complex medical conditions, evocatively communicating the tensions and emotions of both doctors and patients.But this book is something different: a sustained, incisive and sometimes agonized inquiry into the processes by which medical minds — brilliant, experienced, highly erudite medical minds — synthesize information and understand illness. How Doctors Think is mostly about how these doctors get it right, and about why they sometimes get it wrong: "[m]ost errors are mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don't realize." Attribution errors happen when a doctor's diagnostic cogitations are shaped by a particular stereotype. It can be negative: when five doctors fail to diagnose an endocrinologic tumor causing peculiar symptoms in "a persistently complaining, melodramatic menopausal woman who quite accurately describes herself as kooky." But positive feelings also get in the way; an emergency room doctor misses unstable angina in a forest ranger because "the ranger's physique and chiseled features reminded him of a young Clint Eastwood — all strong associations with health and vigor." Other errors occur when a patient is irreversibly classified with a particular syndrome: "diagnosis momentum, like a boulder rolling down a mountain, gains enough force to crush anything in its way." The patient stories are told with Groopman's customary attention to character and emotion. And there is great care and concern for the epistemology of medical knowledge, and a sense of life-and-death urgency in analyzing the well-intentioned thought processes of the highly trained. I have never read elsewhere this kind of discussion of the ambiguities besetting the superspecialized — the doctors on whom the rest of us depend: "Specialization in medicine confers a false sense of certainty." How Doctors Think helped me understand my own thought processes and my colleagues' — even as it left me chastened and dazzled by turns. Every reflective doctor will learn from this book — and every prospective patient will find thoughtful advice for communicating successfully in the medical setting and getting better care. Many of the physicians Dr. Groopman writes about are visionaries and heroes; their diagnostic and therapeutic triumphs are astounding. And these are the doctors who are, like the author, willing to anatomize their own serious errors. This passionate honesty gives the book an immediacy and an eloquence that will resonate with anyone interested in medicine, science or the cruel beauties of those human endeavors which engage mortal stakes. (Mar. 19)Signature Review by Perri Klass. Klass is professor of journalism and pediatrics at NYU. Her most recent book is Every Mother Is a Daughter, with Sheila Solomon Klass. Publishers Weekly (Starred Review) (Copyright © Reed Business Information)

"Why is it that 'How Doctors Think' is likely to find an audience while 'How Automotive Engineers Think' would be a tough sell, and 'How Bookkeepers Think' wouldn't have a prayer?

Part of the reason is that most of us believe, rightly or wrongly, that our lives might one day depend on the right decision by a doctor — a belief we share about few other occupations. Most, as well, have... Washington Post Book Review (read the entire Washington Post review) watched doctors work, an experience, whether good or bad, that tends to lend an oracular quality to what a doctor does. And then there's the drama and heroism that's supposed to be — and occasionally is — part of medicine.

Jerome Groopman, a physician at Harvard Medical School who is also a writer for the New Yorker, does not debunk the notion of medical 'exceptionalism.' His book contains all kinds of smart, often selfless, occasionally heroic doctors making good decisions and sometimes saving lives. But it is far from a narcissistic paean to his profession. It is an effort to dissect the anatomy of correct diagnosis, successful treatment and humane care — and also of diagnostic error, misguided therapy and thoughtless bedside manner. His task is to offer practical advice to both patients and physicians. He succeeds at both.

Groopman catalogues the many species of clinical errors, a whole taxonomy of misperceptions and wrong conclusions illustrated with real examples offered as representative types. All are fascinating, a few are chilling.

Into the latter category falls the case of a woman who for 15 years suffered from chronic diarrhea, vomiting and eventually anemia, osteoporosis and severe weight loss. Doctors said she had anorexia, bulimia and irritable bowel syndrome — a proliferation of diagnoses that should have been a hint they were wrong. After initially resisting, she had come to accept this explanation of her problem, dutifully taking antidepressants and forcing down 3,000 calories of largely indigestible food each day. By the time she consulted one of Groopman's colleagues at Beth Israel Deaconness Hospital in Boston, she weighed 82 pounds. He diagnosed celiac disease, an allergy to the protein gluten found in many grains. The disease denudes the inner surface of the small intestine, reducing its ability to absorb nutrients; it explained all her symptoms.

The woman 'was fitted into the single frame of bulimia and anorexia nervosa from the age of twenty,' writes Groopman. 'It was easily understandable that each of her doctors received her case within that one frame. All the data fit neatly within its borders. There was no apparent reason to redraw her clinical portrait, to look at it from another angle.

Many of the mistakes Groopman describes are variants of this one. They come from the physician's inability to keep his or her mind open, a reluctance to abandon initial impressions or received wisdom, and a willingness to ignore (often unconsciously) contradictory evidence. At the same time, the facts of biology rightly steer physicians away from endlessly pursuing improbable diagnoses — a truth captured in such medical-school aphorisms as: 'When you hear hoofbeats, don't immediately think of zebras' and 'Don't forget that common things are still common.'

'It is a matter,' Groopman writes, 'of juggling seemingly contradictory bits of data simultaneously in one's mind and then seeking other information to make a decision, one way or another. This juggling ... marks the expert physician — at the bedside or in a darkened radiology suite.'

This need for self-awareness during the act of thinking and working extends to the physician's emotional state and personal beliefs. How a doctor feels about a patient can have a major effect on the care provided to people who are obese, poor, stupid, mentally ill, addicted, foreign, criminal, deviant or ill-smelling — as well as to those who are rich, powerful, famous, personally familiar or smarter than the doctor.

Groopman doesn't go much into the sociology of medicine, which is unfortunate because it has quite a bit to do with laying the groundwork for the cognitive errors he describes. Many medical students and doctors are surprisingly incurious about human narrative, to which they have almost unparalleled access. Most have little exposure to unintelligent, inarticulate or life-weary people. Few have done manual labor or been in the position of taking orders rather than giving them (outside of medical training, that is). Many are poor listeners and like to hear themselves talk. If it is true, as one is taught in medical school, that 80 percent of diagnoses can be made purely on the medical history — what the patient says before the physical exam or any tests are done — these traits can be impediments to good care.

So what is Groopman's advice for ways to help doctors think better?

An entire chapter illustrates the first commandment of pediatrics: Always take seriously the mother's theory of what's happening, no matter how harebrained it sounds. Patients should feel free to voice what they suspect the doctor may be thinking. 'With a disarming sense of humor, she communicated that she understood she fit a certain social stereotype, and that stereotype had caused her doctors to fail to fully consider her complaints,' Groopman notes admiringly of a patient who admitted she was 'a little crazy' but doubted that menopause was the cause of her severe headaches and crawling skin. (She turned out to have a tumor that floods the body with hormones.) Another doctor tells Groopman she was helped when her patient said, 'Don't save me from an unpleasant test just because we're friends.'

Simple questions can help refocus a physician's attention: 'What's the worst thing this can be?' and 'What body parts are near where I am having my symptom?' Before calling the pediatrician, parents should ask themselves 'what it is that scares them the most about their child's condition.' And everyone should be leery of lazy generalities: 'No one — no doctor, no patient — should ever accept, as a first answer to a serious event, "We see this sometimes."'

For their part, doctors should be wary of diagnoses that appear instantly obvious. Groopman quotes one doctor who jumped to the conclusion that a woman had pneumonia when, in fact, she had an aspirin overdose, which can cause some of the same signs and symptoms. 'I learned from this to always hold back, to make sure that even when I think I have the answer, to generate a short list of alternatives.'

Groopman notes that having adequate time to think helps (but of course doesn't guarantee) good decision making. Much of medicine, however, is practiced with the consumer waiting for the product to be delivered, whether it's the proposed work-up, the diagnosis, the treatment options or the long-term prognosis. This expectation of instant knowledge and service is something few people would consider reasonable for tasks such as having a will drawn up or even getting a pair of skates sharpened. This is perhaps worth keeping in mind as doctors are increasingly asked to do more in shorter appointments for the same or less money.

When it comes to medical care, we Americans want everything — limitless access to drugs, diagnostic studies, surgical procedures, experimental therapies. We might want to push the system to give us more of the most potent intervention in medicine — a doctor with time to think and talk.

David Brown, a physician, is a science reporter at The Washington Post.

" Reviewed by Barry SchwartzDonna BrazileDavid Brown, Washington Post Book World (Copyright 2006 Washington Post Book World Service/Washington Post Writers Group)
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"Dr. Jerome Groopman is bringing out his most essential book yet, How Doctors Think." Boston Phoenix

"A highly pleasurable must-read." Kirkus Reviews, (Starred Review)

"A book to restore faith in an often-resented profession, well enough written to warrant its quarter-million first printing." Booklist

"A cogent analysis of all the wrong ways his fellow practitioners are trained to approach the patients they treat." Elle

"A sage, humane prescription for medical practitioners and the people who depend of them." O, The Oprah Magazine

"Splendid and courageous...Groopman lifts the veil on the most taboo topic...the pervasive nature of misdiagnosis." Ron Chernow, author of Alexander Hamilton

"Groopman has written a unique, important and wonderful book....You’ll never look at your own doctor in the same way again." Steven D. Levitt and Stephen J. Dubner, authors of Freakonomics

A New Yorker staff writer, bestselling author, and professor at Harvard Medical School unravels the mystery of how doctors figure out the best treatments — or fail to do so. This book describes the warning signs of flawed medical thinking and offers intelligent questions patients can ask.

The renowned Harvard Medical School physician and New Yorker writer Jerome Groopman presents an entirely new way of understanding medicine and medical care to give patients and their families insight into why some doctors succeed in thinking through problems and why some doctors fail. Dr. Groopman reveals the most common mistakes in doctors' thinking and tells patients how to engage in dialogue to help their doctors prevent misdiagnoses in treatment....It's a book for everyone who's ever been a patient. Even other doctors can't wait to read it.

Jerome Groopman, M.D., holds the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School and is chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston. He has published more than 150 scientific articles. He is also a staff writer at the New Yorker and has written editorials on policy issues for the New Republic, the Washington Post, and the New York Times.

Introduction 1
1. Flesh-and-Blood Decision-Making 27
2. Lessons from the Heart 41
3. Spinning Plates 59
4. Gatekeepers 77
5. A New Mother's Challenge 101
6. The Uncertainty of the Expert 132
7. Surgery and Satisfaction 156
8. The Eye of the Beholder 177
9. Marketing, Money, and Medical Decisions 203
10. In Service of the Soul 234
Epilogue: A Patient's Questions 260

Acknowledgments 271
Notes 274
Index 292