How Doctors Think

Features

• Cover Type: Paperback with 336 pages
• Published by: Mariner Books
• Edition: 1st Edition March 12, 2008
• Written in: English
• ISBN 10 Number: 0547053649
• ISBN 13 Number: 978-0547053646
• Book Dimensions: 8.2 x 5.5 x 0.7 inches
• Weighs: 8.8 ounces

From Publishers Weekly
Starred Review. SignatureReviewed by Perri KlassI wish I had read this book when I was in medical school, and I'm glad I've read it now. Most readers will knowJerome 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 lady 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)Klass is professor of journalism and pediatrics at NYU. Her most recent book is Every Mother Is a Daughter, with Sheila Solomon Klass.
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved. --This text refers to the Hardcover edition.

From The Washington Post
Reviewed 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 lady 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 lady "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 eighty 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 lady 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.

Copyright 2007, The Washington Post. All Rights Reserved. --This text refers to the Hardcover edition.

Reader Reviews
This review is from: How Doctors Think (Hardcover) This alarming statistic introduces Dr. Jerome Groopman's compelling analysis of how doctors think--and what this means for patients seeking diagnoses. Groopman is curious to discover how one doctor misses a diagnosis which another doctor gets. Interviewing specialists in different fields, he analyzes the ways they approach patients, how they gather information, how much they may credit or discredit the previous medical histories and diagnoses of these patients, how they deal with symptoms which may not fit a particular diagnosis, and how they arrive at a final diagnosis. Throughout, he considers the doctors' time constraints, the pressures on them to see a certain number of patients each day, the limitations on tests which are imposed by insurance companies or by hospitals themselves, and the many options for treating a single disease. He is sympathetic, both toward the patient and the physician, and, because he himself has had medical problems, he provides insights from his own experience to show how physicians (and patients) think. Case histories abound, beginning with the 82-pound woman, whose celiac disease was not diagnosed for fifteen years. Here Groopman analyzes the uses and misuses of clinical decision trees and algorithms used by many doctors and hospitals to assess probabilities and make decision-making more efficient. Sometimes, however, it is necessary for a doctor to depart from the algorithm and obey intuition. Recognizing when the physician is "winging it"--depending too much on intuition and too little on evidence--is a challenge for both patients and other physicians. Ultimately, Groopman focuses on language as the key to diagnosis, showing that when patients and physicians can communicate and truly share information, they have a better chance to come to correct diagnoses and appropriate treatments. The success of Groopman's book attests to the need for discussion of these issues, but I am not sure Groopman realizes the difficulty patients have in finding ideal doctors whose personalities, thinking, and communication styles are compatible with their own. Most of us are referred to specialists by our primary care physicians (some of whom we see only once a year and do not know well), and it is not possible to interview several specialists to find the one most compatible. We accept the appointment our primary care physician has set up for us, often with the specialist who has the earliest available appointment. Patients with urgent problems may have fewer choices than Groopman seems to think they have. Though we all search for the ideal, ultimately we must hope that our own diagnoses are not among the "problem fifteen percent." (4.5 stars) n Mary Whipple