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Friday, April 13th, 2007
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How Doctors Think

by Jerome Groopman

Heal Thyself

A review by David Brown

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 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.

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