How Doctors Think
by Jerome Groopman
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
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
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."
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.
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?
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
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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