- STAFF PICKS
- GIFTS + GIFT CARDS
- SELL BOOKS
- FIND A STORE
Ships in 1 to 3 days
This title in other editions
How Doctors Thinkby Jerome Groopman
Anne Dodge had lost count of all the doctors she had seen over the past fifteen years. She guessed it was close to thirty. Now, two days after Christmas 2004, on a surprisingly mild morning, she was driving again into Boston to see yet another physician. Her primary care doctor had opposed the trip, arguing that Anne’s problems were so long-standing and so well defined that this consultation would be useless. But her boyfriend had stubbornly insisted. Anne told herself the visit would mollify her boyfriend and she would be back home by midday.
Anne is in her thirties, with sandy brown hair and soft blue eyes. She grew up in a small town in Massachusetts, one of four sisters. No one had had an illness like hers. Around age twenty, she found that food did not agree with her. After a meal, she would feel as if a hand were gripping her stomach and twisting it. The nausea and pain were so intense that occasionally she vomited. Her family doctor examined her and found nothing wrong. He gave her antacids. But the symptoms continued. Anne lost her appetite and had to force herself to eat; then she’d feel sick and quietly retreat to the bathroom to regurgitate. Her general practitioner suspected what was wrong, but to be sure he referred her to a psychiatrist, and the diagnosis was made: anorexia nervosa with bulimia, a disorder marked by vomiting and an aversion to food. If the condition was not corrected, she could starve to death.
Over the years, Anne had seen many internists for her primary care before settling on her current one, a woman whose practice was devoted to patients with eating disorders. Anne was also evaluated by numerous specialists: endocrinologists, orthopedists, hematologists, infectious disease doctors, and, of course, psychologists and psychiatrists. She had been treated with four different antidepressants and had undergone weekly talk therapy. Nutritionists closely monitored her daily caloric intake.
But Anne’s health continued to deteriorate, and the past twelve months had been the most miserable of her life. Her red blood cell count and platelets had dropped to perilous levels. A bone marrow biopsy showed very few developing cells. The two hematologists Anne had consulted attributed the low blood counts to her nutritional deficiency. Anne also had severe osteoporosis. One endocrinologist said her bones were like those of a woman in her eighties, from a lack of vitamin D and calcium. An orthopedist diagnosed a hairline fracture of the metatarsal bone of her foot. There were also signs that her immune system was failing; she suffered a series of infections, including meningitis. She was hospitalized four times in 2004 in a mental health facility so she could try to gain weight under supervision.
To restore her system, her internist had told Anne to consume three thousand calories a day, mostly in easily digested carbohydrates like cereals and pasta. But the more Anne ate, the worse she felt. Not only was she seized by intense nausea and the urge to vomit, but recently she had severe intestinal cramps and diarrhea. Her doctor said she had developed irritable bowel syndrome, a disorder associated with psychological stress. By December, Anne’s weight dropped to eighty-two pounds. Although she said she was forcing down close to three thousand calories, her internist and her psychiatrist took the steady loss of weight as a sure sign that Anne was not telling the truth.
That day Anne was seeing Dr. Myron Falchuk, a gastroenterologist. Falchuk had already gotten her medical records, and her internist had told him that Anne’s irritable bowel syndrome was yet another manifestation of her deteriorating mental health. Falchuk heard in the doctor’s recitation of the case the implicit message that his role was to examine Anne’s abdomen, which had been poked and prodded many times by many physicians, and to reassure her that irritable bowel syndrome, while uncomfortable and annoying, should be treated as the internist had recommended, with an appropriate diet and tranquilizers.
But that is exactly what Falchuk did not do. Instead, he began to question, and listen, and observe, and then to think differently about Anne’s case. And by doing so, he saved her life, because for fifteen years a key aspect of her illness had been missed. This book is about what goes on in a doctor’s mind as he or she treats a patient. The idea for it came to me unexpectedly, on a September morning three years ago while I was on rounds with a group of interns, residents, and medical students. I was the attending physician on “general medicine,” meaning that it was my responsibility to guide this team of trainees in its care of patients with a wide variety of clinical problems, not just those in my own specialties of blood diseases, cancer, and AIDS. There were patients on our ward with pneumonia, diabetes, and other common ailments, but there were also some with symptoms that did not readily suggest a diagnosis, or with maladies for which there was a range of possible treatments, where no one therapy was clearly superior to the others.
I like to conduct rounds in a traditional way. One member of the team first presents the salient aspects of the case and then we move as a group to the bedside, where we talk to the patient and examine him. The team then returns to the conference room to discuss the problem. I follow a Socratic method in the discussion, encouraging the students and residents to challenge each other, and challenge me, with their ideas. But at the end of rounds on that September morning I found myself feeling disturbed. I was concerned about the lack of give-and-take among the trainees, but even more I was disappointed with myself as their teacher. I concluded that these very bright and very affable medical students, interns, and residents all too often failed to question cogently or listen carefully or observe keenly. They were not thinking deeply about their patients’ problems. Something was profoundly wrong with the way they were learning to solve clinical puzzles and care for people.
You hear this kind of criticism — that each new generation of young doctors is not as insightful or competent as its forebears — regularly among older physicians, often couched like this: “When I was in training thirty years ago, there was real rigor and we had to know our stuff. Nowadays, well . . .” These wistful, aging doctors speak as if some magic that had transformed them into consummate clinicians has disappeared. I suspect each older generation carries with it the notion that its time and place, seen through the distorting lens of nostalgia, were superior to those of today. Until recently, I confess, I shared that nostalgic sensibility. But on reflection I saw that there also were major flaws in my own medical training. What distinguished my learning from the learning of my young trainees was the nature of the deficiency, the type of flaw.
My generation was never explicitly taught how to think as clinicians. We learned medicine catch-as-catch-can. Trainees observed senior physicians the way apprentices observed master craftsmen in a medieval guild, and somehow the novices were supposed to assimilate their elders’ approach to diagnosis and treatment. Rarely did an attending physician actually explain the mental steps that led him to his decisions. Over the past few years, there has been a sharp reaction against this catch- as-catch-can approach. To establish a more organized structure, medical students and residents are being taught to follow preset algorithms and practice guidelines in the form of decision trees. This method is also being touted by certain administrators to senior staff in many hospitals in the United States and Europe. Insurance companies have found it particularly attractive in deciding whether to approve the use of certain diagnostic tests or treatments.
The trunk of the clinical decision tree is a patient’s major symptom or laboratory result, contained within a box. Arrows branch from the first box to other boxes. For example, a common symptom like “sore throat” would begin the algorithm, followed by a series of branches with “yes” or “no” questions about associated symptoms. Is there a fever or not? Are swollen lymph nodes associated with the sore throat? Have other family members suffered from this symptom? Similarly, a laboratory test like a throat culture for bacteria would appear farther down the trunk of the tree, with branches based on “yes” or “no” answers to the results of the culture. Ultimately, following the branches to the end should lead to the correct diagnosis and therapy.
Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment — distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctor needs to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact. In such cases — the kinds of cases where we most need a discerning doctor — algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they can constrain it.
Similarly, a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the canon in many hospitals. Treatments outside the statistically proven are considered taboo until a sufficient body of data can be generated from clinical trials. Of course, every doctor should consider research studies in choosing a therapy. But today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.
Statistics cannot substitute for the human being before you; statistics embody averages, not individuals. Numbers can only complement a physician’s personal experience with a drug or a procedure, as well as his knowledge of whether a “best” therapy from a clinical trial fits a patient’s particular needs and values.
Each morning as rounds began, I watched the students and residents eye their algorithms and then invoke statistics from recent studies. I concluded that the next generation of doctors was being conditioned to function like a well-programmed computer that operates within a strict binary framework. After several weeks of unease about the students’ and residents’ reliance on algorithms and evidence-based therapies alone, and my equally unsettling sense that I didn’t know how to broaden their perspective and show them otherwise, I asked myself a simple question: How should a doctor think?
This question, not surprisingly, spawned others: Do different doctors think differently? Are different forms of thinking more or less prevalent among the different specialties? In other words, do surgeons think differently from internists, who think differently from pediatricians? Is there one “best” way to think, or are there multiple, alternative styles that can reach a correct diagnosis and choose the most effective treatment? How does a doctor think when he is forced to improvise, when confronted with a problem for which there is little or no precedent? (Here algorithms are essentially irrelevant and statistical evidence is absent.) How does a doctor’s thinking differ during routine visits versus times of clinical crisis? Do a doctor’s emotions — his like or dislike of a particular patient, his attitudes about the social and psychological makeup of his patient’s life — color his thinking? Why do even the most accomplished physicians miss a key clue about a person’s true diagnosis, or detour far afield from the right remedy? In sum, when and why does thinking go right or go wrong in medicine?
I had no ready answers to these questions, despite having trained in a well-regarded medical school and residency program, and having practiced clinical medicine for some thirty years. So I began to ask my colleagues for answers.* Nearly all of the practicing physicians I queried were intrigued by the questions but confessed that they had never really thought about how they think. Then I searched the medical literature for studies of clinical thinking. I found a wealth of research that modeled “optimal” medical decision-making with complex mathematical formulas, but even the advocates of such formulas conceded that they rarely mirrored reality at the bedside or could be followed practically. I saw why I found it difficult to teach the trainees on rounds how to think. I also saw that I was not serving my own patients as well as I might. I felt that if I became more aware of my own way of thinking, particularly its pitfalls, I would be a better caregiver. I wasn’t one of the hematologists who evaluated Anne Dodge, but I could well have been, and I feared that I too could have failed to recognize what was missing in her diagnosis.
Of course, no one can expect a physician to be infallible. Medicine is, at its core, an uncertain science. Every doctor makes mistakes in diagnosis and treatment. But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better. This book was written with that goal in mind. It is primarily intended for laymen, though I believe physicians and other medical professionals will find it useful. Why for laymen? Because doctors desperately need patients and their families and friends to help them think. Without their help, physicians are denied key clues to what is really wrong. I learned this not as a doctor but when I was sick, when I was the patient.
We’ve all wondered why a doctor asked certain questions, or detoured into unexpected areas when gathering information about us. We have all asked ourselves exactly what brought him to propose a certain diagnosis and a particular treatment and to reject the alternatives. Although we may listen intently to what a doctor says and try to read his facial expressions, often we are left perplexed about what is really going on in his head. That ignorance inhibits us from successfully communicating with the doctor, from telling him all that he needs to hear to come to the correct diagnosis and advice on the best therapy.
In Anne Dodge’s case, after a myriad of tests and procedures, it was her words that led Falchuk to correctly diagnose her illness and save her life. While modern medicine is aided by a dazzling array of technologies, like high-resolution MRI scans and pinpoint DNA analysis, language is still the bedrock of clinical practice. We tell the doctor what is bothering us, what we feel is different, and then respond to his questions. This dialogue is our first clue to how our doctor thinks, so the book begins there, exploring what we learn about a physician’s mind from what he says and how he says it. But it is not only clinical logic that patients can extract from their dialogue with a doctor. They can also gauge his emotional temperature. Typically, it is the doctor who assesses our emotional state. But few of us realize how strongly a physician’s mood and temperament influence his medical judgment. We, of course, may get only glimpses of our doctor’s feelings, but even those brief moments can reveal a great deal about why he chose to pursue a possible diagnosis or offered a particular treatment.
After surveying the significance of a doctor’s words and feelings, the book follows the path that we take when we move through today’s medical system. If we have an urgent problem, we rush to the emergency room. There, doctors often do not have the benefit of knowing us, and must work with limited information about our medical history. I examine how doctors think under these conditions, how keen judgments and serious cognitive errors are made under the time pressures of the ER. If our clinical problem is not an emergency, then our path begins with our primary care physician — if a child, a pediatrician; if an adult, an internist. In today’s parlance, these primary care physicians are termed “gatekeepers,” because they open the portals to specialists. The narrative continues through these portals; at each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong. We also encounter the tension between his acknowledging uncertainty and the need to take a clinical leap and act. One chapter reports on this in my own case; I sought help from six renowned hand surgeons for an incapacitating problem and got four different opinions.
Much has been made of the power of intuition, and certainly initial impressions formed in a flash can be correct. But as we hear from a range of physicians, relying too heavily on intuition has its perils. Cogent medical judgments meld first impressions — gestalt — with deliberate analysis. This requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes. What can doctors and patients do to find time to think? I explore this in the pages that follow.
Today, medicine is not separate from money. How much does intense marketing by pharmaceutical companies actually influence either conscious or subliminal decision-making? Very few doctors, I believe, prostitute themselves for profit, but all of us are susceptible to the subtle and not so subtle efforts of the pharmaceutical industry to sculpt our thinking. That industry is a vital one; without it, there would be a paucity of new therapies, a slowing of progress. Several doctors and a pharmaceutical executive speak with great candor about the reach of drug marketing, about how natural aspects of aging are falsely made into diseases, and how patients can be alert to this.
Cancer, of course, is a feared disease that becomes more likely as we grow older. It will strike roughly one in two men and one in three women over the course of their lifetime. Recently there have been great clinical successes against types of cancers that were previously intractable, but many malignancies remain that can be, at best, only temporarily controlled. How an oncologist thinks through the value of complex and harsh treatments demands not only an understanding of science but also a sensibility about the soul — how much risk we are willing to take and how we want to live out our lives. Two cancer specialists reveal how they guide their patients’ choices and how their patients guide them toward the treatment that best suits each patient’s temperament and lifestyle.
At the end of this journey through the minds of doctors, we return to language. The epilogue offers words that patients, their families, and their friends can use to help a physician or surgeon think, and thereby better help themselves. Patients and their loved ones can be true partners with physicians when they know how doctors think, and why doctors sometimes fail to think. Using this knowledge, patients can offer a doctor the most vital information about themselves, to help steer him toward the correct diagnosis and offer the therapy they need. Patients and their loved ones can aid even the most seasoned physician avoid errors in thinking. To do so, they need answers to the questions that I asked myself, and for which I had no ready answers. Not long after Anne Dodge’s visit to Dr. Myron Falchuk, I met with him in his office at Boston’s Beth Israel Deaconess Medical Center. Falchuk is a compact man in his early sixties with a broad bald pate and lively eyes. His accent is hard to place, and his speech has an almost musical quality. He was born in rural Venezuela and grew up speaking Yiddish at home and Spanish in the streets of his village. As a young boy, he was sent to live with relatives in Brooklyn. There he quickly learned English. All this has made him particularly sensitive to language, its nuances and power. Falchuk left New York for Dartmouth College, and then attended Harvard Medical School; he trained at the Peter Bent Brigham Hospital in Boston, and for several years conducted research at the National Institutes of Health on diseases of the bowel. After nearly four decades, he has not lost his excitement about caring for patients. When he began to discuss Anne Dodge’s case, he sat up in his chair as if a jolt of electricity had passed through him.
“She was emaciated and looked haggard,” Falchuk told me. “Her face was creased with fatigue. And the way she sat in the waiting room — so still, her hands clasped together — I saw how timid she was.” From the first, Falchuk was reading Anne Dodge’s body language. Everything was a potential clue, telling him something about not only her physical condition but also her emotional state. This was a woman beaten down by her suffering. She would need to be drawn out, gently.
Medical students are taught that the evaluation of a patient should proceed in a discrete, linear way: you first take the patient’s history, then perform a physical examination, order tests, and analyze the results. Only after all the data are compiled should you formulate hypotheses about what might be wrong. These hypotheses should be winnowed by assigning statistical probabilities, based on existing databases, to each symptom, physical abnormality, and laboratory test; then you calculate the likely diagnosis. This is Bayesian analysis, a method of decision-making favored by those who construct algorithms and strictly adhere to evidence-based practice. But, in fact, few if any physicians work with this mathematical paradigm. The physical examination begins with the first visual impression in the waiting room, and with the tactile feedback gained by shaking a person’s hand. Hypotheses about the diagnosis come to a doctor’s mind even before a word of the medical history is spoken. And in cases like Anne’s, of course, the specialist had a diagnosis on the referral form from the internist, confirmed by the multitude of doctors’ notes in her records.
Falchuk ushered Anne Dodge into his office, his hand on her elbow, lightly guiding her to the chair that faces his desk. She looked at a stack of papers some six inches high. It was the dossier she had seen on the desks of her endocrinologists, hematologists, infectious disease physicians, psychiatrists, and nutritionists. For fifteen years she’d watched it grow from visit to visit.
But then Dr. Falchuk did something that caught Anne’s eye: he moved those records to the far side of his desk, withdrew a pen from the breast pocket of his white coat, and took a clean tablet of lined paper from his drawer. “Before we talk about why you are here today,” Falchuk said, “let’s go back to the beginning. Tell me about when you first didn’t feel good.”
For a moment, she was confused. Hadn’t the doctor spoken with her internist and looked at her records? “I have bulimia and anorexia nervosa,” she said softly. Her clasped hands tightened. “And now I have irritable bowel syndrome.”
Falchuk offered a gentle smile. “I want to hear your story, in your own words.”
Anne glanced at the clock on the wall, the steady sweep of the second hand ticking off precious time. Her internist had told her that Dr. Falchuk was a prominent specialist, that there was a long waiting list to see him. Her problem was hardly urgent, and she got an appointment in less than two months only because of a cancellation in his Christmas-week schedule. But she detected no hint of rush or impatience in the doctor. His calm made it seem as though he had all the time in the world.
So Anne began, as Dr. Falchuk requested, at the beginning, reciting the long and tortuous story of her initial symptoms, the many doctors she had seen, the tests she had undergone. As she spoke, Dr. Falchuk would nod or interject short phrases: “Uhhuh,” “I’m with you,” “Go on.”
Occasionally Anne found herself losing track of the sequence of events. It was as if Dr. Falchuk had given her permission to open the floodgates, and a torrent of painful memories poured forth. Now she was tumbling forward, swept along as she had been as a child on Cape Cod when a powerful wave caught her unawares. She couldn’t recall exactly when she had had the bone marrow biopsy for her anemia.
“Don’t worry about exactly when,” Falchuk said. For a long moment Anne sat mute, still searching for the date. “I’ll check it later in your records. Let’s talk about the past months. Specifically, what you have been doing to try to gain weight.”
This was easier for Anne; the doctor had thrown her a rope and was slowly tugging her to the shore of the present. As she spoke, Falchuk focused on the details of her diet. “Now, tell me again what happens after each meal,” he said.
Anne thought she had already explained this, that it all was detailed in her records. Surely her internist had told Dr. Falchuk about the diet she had been following. But she went on to say, “I try to get down as much cereal in the morning as possible, and then bread and pasta at lunch and dinner.” Cramps and diarrhea followed nearly every meal, Anne explained. She was taking anti-nausea medication that had greatly reduced the frequency of her vomiting but did not help the diarrhea. “Each day, I calculate how many calories I’m keeping in, just like the nutritionist taught me to do. And it’s close to three thousand.”
Dr. Falchuk paused. Anne Dodge saw his eyes drift away from hers. Then his focus returned, and he brought her into the examining room across the hall. The physical exam was unlike any she’d had before. She had been expecting him to concentrate on her abdomen, to poke and prod her liver and spleen, to have her take deep breaths, and to look for any areas of tenderness. Instead, he looked carefully at her skin and then at her palms. Falchuk intently inspected the creases in her hands, as though he were a fortuneteller reading her lifelines and future. Anne felt a bit perplexed but didn’t ask him why he was doing this. Nor did she question why he spent such a long while looking in her mouth with a flashlight, inspecting not only her tongue and palate but her gums and the glistening tissue behind her lips as well. He also spent a long time examining her nails, on both her hands and her feet. “Sometimes you can find clues in the skin or the lining of the mouth that point you to a diagnosis,” Falchuk explained at last.
He also seemed to fix on the little loose stool that remained in her rectum. She told him she had had an early breakfast, and diarrhea before the car ride to Boston.
When the physical exam was over, he asked her to dress and return to his office. She felt tired. The energy she had mustered for the trip was waning. She steeled herself for yet another somber lecture on how she had to eat more, given her deteriorating condition.
“I’m not at all sure this is irritable bowel syndrome,” Dr. Falchuk said, “or that your weight loss is only due to bulimia and anorexia nervosa.”
She wasn’t sure she had heard him correctly. Falchuk seemed to recognize her confusion. “There may be something else going on that explains why you can’t restore your weight. I could be wrong, of course, but we need to be sure, given how frail you are and how much you are suffering.”
Anne felt even more confused and fought off the urge to cry. Now was not the time to break down. She needed to concentrate on what the doctor was saying. He proposed more blood tests, which were simple enough, but then suggested a procedure called an endoscopy. She listened carefully as Falchuk described how he would pass a fiberoptic instrument, essentially a flexible telescope, down her esophagus and then into her stomach and small intestine. If he saw something abnormal, he would take a biopsy. She was exhausted from endless evaluations. She’d been through so much, so many tests, so many procedures: the x-rays, the bone density assessment, the painful bone marrow biopsy for her low blood counts, and multiple spinal taps when she had meningitis. Despite his assurances that she would be sedated, she doubted whether the endoscopy was worth the trouble and discomfort. She recalled her internist’s reluctance to refer her to a gastroenterologist, and wondered whether the procedure was pointless, done for the sake of doing it, or, even worse, to make money.
Dodge was about to refuse, but then Falchuk repeated emphatically that something else might account for her condition. “Given how poorly you are doing, how much weight you’ve lost, what’s happened to your blood, your bones, and your immune system over the years, we need to be absolutely certain of everything that’s wrong. It may be that your body can’t digest the food you’re eating, that those three thousand calories are just passing through you, and that’s why you’re down to eighty-two pounds.”
When I met with Anne Dodge one month after her first appointment with Dr. Falchuk, she said that he’d given her the greatest Christmas present ever. She had gained nearly twelve pounds. The intense nausea, the urge to vomit, the cramps and diarrhea that followed breakfast, lunch, and dinner as she struggled to fill her stomach with cereal, bread, and pasta had all abated. The blood tests and the endoscopy showed that she had celiac disease. This is an autoimmune disorder, in essence an allergy to gluten, a primary component of many grains. Once believed to be rare, the malady, also called celiac sprue, is now recognized more frequently thanks to sophisticated diagnostic tests. Moreover, it has become clear that celiac disease is not only a childhood illness, as previously thought; symptoms may not begin until late adolescence or early adulthood, as Falchuk believed occurred in Anne Dodge’s case. Yes, she suffered from an eating disorder. But her body’s reaction to gluten resulted in irritation and distortion of the lining of her bowel, so nutrients were not absorbed. The more cereal and pasta she added to her diet, the more her digestive tract was damaged, and even fewer calories and essential vitamins passed into her system.
Anne Dodge told me she was both elated and a bit dazed. After fifteen years of struggling to get better, she had begun to lose hope. Now she had a new chance to restore her health. It would take time, she said, to rebuild not only her body but her mind. Maybe one day she would be, as she put it, “whole” again. Behind Myron Falchuk’s desk, a large framed photograph occupies much of the wall. A group of austerely dressed men pose, some holding derby hats, some with thick drooping mustaches like Teddy Roosevelt’s; the sepia tinge of the picture and the men’s appearance date it to the early 1900s. It seems out of phase with Falchuk’s outgoing demeanor and stylish clothes. But it is, he says, his touchstone.
“That photograph was taken in 1913, when they opened the Brigham Hospital,” Falchuk explained. “William Osler gave the first grand rounds.” A smile spread across his face. “It’s a copy. I didn’t steal the original when I was chief resident.” Osler was acutely sensitive to the power and importance of words, and his writings greatly influenced Falchuk. “Osler essentially said that if you listen to the patient, he is telling you the diagnosis,” Falchuk continued. “A lot of people look at a specialist like me as a technician. They come to you for a procedure. And there is no doubt that procedures are important, or that the specialized technology we have these days is vital in caring for a patient. But I believe that this technology also has taken us away from the patient’s story.” Falchuk paused. “And once you remove yourself from the patient’s story, you no longer are truly a doctor.”
How a doctor thinks can first be discerned by how he speaks and how he listens. In addition to words spoken and heard, there is nonverbal communication, his attention to the body language of his patient as well as his own body language — his expressions, his posture, his gestures. Debra Roter, a professor of health policy and management at Johns Hopkins University, works as a team with Judith Hall, a professor of social psychology at Northeastern University. They are among the most productive and insightful researchers studying medical communication. They have analyzed thousands of videotapes and live interactions between doctors of many types — internists, gynecologists, surgeons — and patients, parsing phrases and physical movements. They also have assayed the data from other researchers. They have shown that how a doctor asks questions and how he responds to his patient’s emotions are both key to what they term “patient activation and engagement.” The idea, as Roter put it when we spoke, is “to wake someone up” so that the patient feels free, if not eager, to speak and participate in a dialogue. That freedom of patient speech is necessary if the doctor is to get clues about the medical enigma before him. If the patient is inhibited, or cut off prematurely, or constrained into one path of discussion, then the doctor may not be told something vital. Observers have noted that, on average, physicians interrupt patients within eighteen seconds of when they begin telling their story.
Let’s apply Roter’s and Hall’s insights to the case of Anne Dodge. Falchuk began their conversation with a general, open-ended question about when she first began to feel ill. “The way a doctor asks a question,” Roter said, “structures the patient’s answers.” Had Falchuk asked a specific, close- ended question — “What kind of abdominal pain do you have, is it sharp or dull?” — he would have implicitly revealed a preconception that Anne Dodge had irritable bowel syndrome. “If you know where you are going,” Roter said of doctors’ efforts to pin down a diagnosis, “then close-ended questions are the most efficient. But if you are unsure of the diagnosis, then a close-ended question serves you ill, because it immediately, perhaps irrevocably, moves you along the wrong track.” The great advantage of open-ended questioning is that it maximizes the opportunity for a doctor to hear new information.
“What does it take to succeed with open-ended questions?” Roter asked rhetorically. “The doctor has to make the patient feel that he is really interested in hearing what they have to say. And when a patient tells his story, the patient gives cues and clues to what the doctor may not be thinking about.”
The type of question a doctor asks is only half of a successful medical dialogue. “The physician should respond to the patient’s emotions,” Roter continued. Most patients are gripped by fear and anxiety; some also carry a sense of shame about their disease. But a doctor gives more than psychological relief by responding empathetically to a patient. “The patient does not want to appear stupid or waste the doctor’s time,” Roter said. “Even if the doctor asks the right questions, the patient may not be forthcoming because of his emotional state. The goal of a physician is to get to the story, and to do so he has to understand the patient’s emotions.”
Falchuk immediately discerned emotions in Anne that would inhibit her from telling her tale. He tried to put her at ease by responding sympathetically to her history. He did something else that Roter believes is essential in eliciting information: he turned her anxiety and reticence around and engaged her by indicating that he was listening actively, that he wanted to hear more. His simple interjections — “uh-huh, I’m with you, go on” — implied to Anne Dodge that what she was saying was important to him.
Judy Hall, the social psychologist, has focused further on the emotional dimension of the dialogue between doctor and patient: whether the doctor appears to like the patient and whether the patient likes the doctor. She discovered that those feelings are hardly secret on either side of the table. In studies of primary care physicians and surgeons, patients knew remarkably accurately how the doctor actually felt about them. Much of this, of course, comes from nonverbal behavior: the physician’s facial expressions, how he is seated, whether his gestures are warm and welcoming or formal and remote. “The doctor is supposed to be emotionally neutral and evenhanded with everybody,” Hall said, “and we know that’s not true.”
Her research on rapport between doctors and patients bears on Anne Dodge’s case. Hall discovered that the sickest patients are the least liked by doctors, and that very sick people sense this disaffection. Overall, doctors tend to like healthier people more. Why is this? “I am not a doctor- basher,” Hall said. “Some doctors are averse to the very ill, and the reasons for this are quite forgivable.” Many doctors have deep feelings of failure when dealing with diseases that resist even the best therapy; in such cases they become frustrated, because all their hard work seems in vain. So they stop trying. In fact, few physicians welcome patients like Anne Dodge warmly. Consider: fifteen years of anorexia nervosa and bulimia, a disorder with a social stigma, a malady that is often extremely difficult to remedy. Consider also how much time and attention Anne had been given over those fifteen years by so many caregivers, without a glimmer of improvement. And by December 2004, she was only getting worse.
Roter and Hall also studied the effect a doctor’s bedside manner has on successful diagnosis and treatment. “We tend to remember the extremes,” Hall said, “the genius surgeon with an autistic bedside manner, or the kindly GP who is not terribly competent. But the good stuff goes together — good doctoring generally requires both. Good doctoring is a total package.” This is because “most of what doctors do is talk,” Hall concluded, “and the communication piece is not separable from doing quality medicine. You need information to get at the diagnosis, and the best way to get that information is by establishing rapport with the patient. Competency is not separable from communication skills. It’s not a tradeoff.”
Falchuk conducts an inner monologue to guide his thinking. “She told me she was eating up to three thousand calories a day. Inside myself, I asked: Should I believe you? And if I do, then why aren’t you gaining weight?” That simple possibility had to be carried to its logical end: that she was actually trying, that she really was putting the cereal, bread, and pasta in her mouth, chewing, swallowing, struggling not to vomit, and still wasting away, her blood counts still falling, her bones still decomposing, her immune system still failing. “I have to give her the benefit of a doubt,” Falchuk told himself.
Keeping an open mind was reflected in Falchuk’s open-ended line of questioning. The more he observed Anne Dodge, and the more he listened, the more disquiet he felt. “It just seemed impossible to absolutely conclude it was all psychiatric,” he said. “Everyone had written her off as some neurotic case. But my intuition told me that the picture didn’t entirely fit. And once I felt that way, I began to wonder: What was missing?”
Clinical intuition is a complex sense that becomes refined over years and years of practice, of listening to literally thousands of patients’ stories, examining thousands of people, and most important, remembering when you were wrong. Falchuk had done research at the National Institutes of Health on patients with malabsorption, people who couldn’t extract vital nutrients and calories from the food they ate. This background was key to recognizing that Anne Dodge might be suffering not only from anorexia nervosa or bulimia but also from some form of malabsorption. He told me that Anne reminded him that he had been fooled in the past by a patient who was also losing weight rapidly. That woman carried the diagnosis of malabsorption. She said she ate heartily and had terrible cramps and diarrhea, and her many doctors believed her. After more than a month of evaluation, with numerous blood tests and an endoscopy, by chance Falchuk found a bottle of laxatives under her hospital bed that she had forgotten to hide. Nothing was wrong with her gastrointestinal tract. Something was tragically wrong with her psyche. Falchuk learned that both mind and body have to be considered, at times independently, at times through their connections.
Different doctors, as we will see in later chapters, achieve competency in remarkably similar ways, despite working in disparate fields. Primarily, they recognize and remember their mistakes and misjudgments, and incorporate those memories into their thinking. Studies show that expertise is largely acquired not only by sustained practice but by receiving feedback that helps you understand your technical errors and misguided decisions. During my training, I met a cardiologist who had a deserved reputation as one of the best in his field, not only a storehouse of knowledge but also a clinician with excellent judgment. He kept a log of all the mistakes he knew he had made over the decades, and at times revisited this compendium when trying to figure out a particularly difficult case. He was characterized by many of his colleagues as eccentric, an obsessive oddball. Only later did I realize his implicit message to us was to admit our mistakes to ourselves, then analyze them, and keep them accessible at all times if we wanted to be stellar clinicians. In Anne Dodge’s case, Falchuk immediately recalled how he had taken at face value the statements of the patient at NIH who was secretly using laxatives. The opposite situation, he knew, could also apply. In either setting, the case demanded continued thought and investigation.
When Falchuk told me that “the picture didn’t fit,” his words were more than mere metaphor. Donald Redelmeier, a physician at Sunnybrook Health Sciences Centre in Toronto, has a particular interest in physician cognition and its relation to diagnosis. He refers to a phenomenon called the “eyeball test,” the pivotal moment when a doctor identifies “something intangible yet unsettling in the patient’s presentation.” That instinct may, of course, be wrong. But it should not be ignored, because it can cause the physician to recognize that the information before him has been improperly “framed.”
Doctors frame patients all the time using shorthand: “I’m sending you a case of diabetes and renal failure,” or “I have a drug addict here in the ER with fever and a cough from pneumonia.” Often a doctor chooses the correct frame and all the clinical data fit neatly within it. But a self-aware physician knows that accepting the frame as given can be a serious error. Anne Dodge was fitted into the single frame of bulimia and anorexia nervosa from the age of twenty. It was easily understandable that each of her doctors received her case in 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. Except one. “It’s like DNA evidence at a crime,” Falchuk explained. “The patient was saying ‘I told you, I’m innocent.’” Here is the art of medicine, the sensitivity to language and emotion that makes for a superior clinician.
Falchuk almost rose from his chair when he showed me the pictures of Dodge’s distorted small intestine taken through the endoscope. “I was so excited about this,” he said. He had the sweet pleasure of the detective who cracks the mystery, a legitimate pride in identifying a culprit. But beyond intellectual excitement and satisfaction, he showed his joy in saving a life.
Intellect and intuition, careful attention to detail, active listening, and psychological insight all coalesced on that December day. It could have been otherwise. Anne Dodge, with her history of anorexia nervosa and bulimia, may then have developed irritable bowel syndrome. But Falchuk had asked himself, “What might I be missing in this case? And what would be the worst thing that could be missed?” What if he had not asked himself these questions? Then Anne Dodge, her boyfriend, or a family member could have asked them — perhaps many years earlier. Of course, a patient or a loved one is not a doctor. They lack a doctor’s training and experience. And many laymen feel inhibited about asking questions. But the questions are perfectly legitimate. Patients can learn to question and to think the way a doctor should. In the chapters and epilogue that follow, we will examine the kinds of errors in thinking that physicians can make, and the words that patients and their loved ones can offer to prevent these cognitive mistakes.
In Anne Dodge’s case, it was Falchuk who asked simple but ultimately life-saving questions, and to answer them he needed to go further. And Anne Dodge needed to agree to go further, to submit to more blood tests and an invasive procedure. For her to assent, she had to trust not only Falchuk’s skill but also his sincerity and motivations. This is the other dimension of Roter’s and Hall’s studies: how language, spoken and unspoken, can give information essential to a correct diagnosis, and persuade a patient to comply with a doctor’s advice. “Compliance” can have a negative connotation, smacking of paternalism, casting patients as passive players who do what the all-powerful physician tells them. But according to Roter’s and Hall’s research, without trust and a sense of mutual liking, Anne Dodge probably would have deflected Falchuk’s suggestions of more blood tests and an endoscopy. She would have been “noncompliant,” in pejorative clinical parlance. And she would still be struggling to persuade her doctors that she was eating three thousand calories a day while wasting away.
My admiration for Myron Falchuk increased when we went on from Anne Dodge’s case to discuss not his clinical triumphs but his errors. Again, every doctor is fallible. No doctor is right all the time. Every physician, even the most brilliant, makes a misdiagnosis or chooses the wrong therapy. This is not a matter of “medical mistakes.” Medical mistakes have been written about extensively in the lay press and analyzed in a report from the Institute of Medicine of the National Academy of Sciences. They involve prescribing the wrong dose of a drug or looking at an x-ray of a patient backward. Misdiagnosis is different. It is a window into the medical mind. It reveals why doctors fail to question their assumptions, why their thinking is sometimes closed or skewed, why they overlook the gaps in their knowledge. Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes. In one study of misdiagnoses that caused serious harm to patients, some 80 percent could be accounted for by a cascade of cognitive errors, like the one in Anne Dodge’s case, putting her into a narrow frame and ignoring information that contradicted a fixed notion.
Another study of one hundred incorrect diagnoses found that inadequate medical knowledge was the reason for error in only four instances. The doctors didn’t stumble because of their ignorance of clinical facts; rather, they missed diagnoses because they fell into cognitive traps. Such errors produce a distressingly high rate of misdiagnosis. As many as 15 percent of all diagnoses are inaccurate, according to a 1995 report in which doctors assessed written descriptions of patients’ symptoms and examined actors simulating patients with various diseases. These findings match classical research, based on autopsies, which shows that 10 percent to 15 percent of all diagnoses are wrong.
I can recall every misdiagnosis I’ve made during my thirty-year career. The first occurred when I was a resident in internal medicine at the Massachusetts General Hospital; Roter’s and Hall’s research explains it. One of my patients was a middle-aged woman with seemingly endless complaints whose voice sounded to me like a nail scratching a blackboard. One day she had a new complaint, discomfort in her upper chest. I tried to pin down what caused the discomfort — eating, exercise, coughing — to no avail. Then I ordered routine tests, including a chest x-ray and a cardiogram. Both were normal. In desperation, I prescribed antacids. But her complaint persisted, and I became deaf to it. In essence, I couldn’t think in a different way. Several weeks later, I was stat paged to the emergency room. My patient had a dissecting aortic aneurysm, a life-threatening tear of the large artery that carries blood from the heart to the rest of the body. She died. Although an aortic dissection is often fatal even when discovered, I have never forgiven myself for failing to diagnose it. There was a chance she could have been saved.
Roter’s and Hall’s work on liking and disliking illuminates in part what happened in the clinic three decades ago. I wish I had been taught, and had gained the self-awareness, to realize how emotion can blur a doctor’s ability to listen and think. Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment. The doctor becomes increasingly convinced of the truth of his misjudgment, developing a psychological commitment to it. He becomes wedded to his distorted conclusion. His strong negative feelings about the patient make it harder for him to abandon that conclusion and reframe the clinical picture differently.
This skewing of physicians’ thinking leads to poor care. What is remarkable is not merely the consequences of a doctor’s negative emotions. Despite research showing that most patients pick up on the physician’s negativity, few of them understand its effect on their medical care and rarely change doctors because of it. Rather, they often blame themselves for complaining and taxing the doctor’s patience. Instead, patients should politely but freely broach the issue with their doctor. “I sense that we may not be communicating well,” a patient can say. This signals the physician that there is a problem in compatibility. The problem may be resolvable with candor by a patient who wants to sustain the relationship. But when I asked other physicians what they would do if they, as patients, perceived a negative attitude from their doctor, each one flatly said he or she would find another doctor.
* I quickly realized that trying to assess how psychiatrists think was beyond my abilities. Therapy of mental illness is a huge field unto itself that encompasses various schools of thought and theories of mind. For that reason, I do not delve into psychiatry in this book. Copyright © 2007 by Jerome Groopman.
What Our Readers Are Saying
Average customer rating based on 2 comments:
Other books you might like
Health and Self-Help » Health and Medicine » Consumer Guides