"How Doctors Think"
(Reviewed by Mary Whipple APR 23, 2007)
"A 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…."
This alarming statistic introduces Dr. Jerome Groopman's compelling analysis of how doctors think—and what this means for patients seeking diagnoses. Groopman is a conscientious man and rigorous thinker, and he remembers and continues to ponder every misdiagnosis he's ever made—as, he says, do many other doctors. Curious about how one doctor misses a diagnosis which another doctor gets, he interviews many specialists in different fields, most of them prominent physicians in the Boston area, analyzing the ways they approach patients, how they gather information about these patients, 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 the particular diagnosis they want to make, and how they arrive at a final conclusion about what the patient's problem really is.
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 there may be for treating a single disease. He is sympathetic, both toward the patient and the physician, and, because he himself has had medical problems, he is able to use his own experience to add insight into the problem of how physicians (and patients) think.
Groopman opens with the case of a woman in her thirties who had been suffering for fifteen years with the inability to process food. Diagnosed with anorexia, bulimia, hypochondria, and/or irritable bowel syndrome, the patient weighed eight-two pounds, at this point, and suffered from osteoporosis, perilously low red blood cell count, low platelet count, low immune system (and had had meningitis), broken bones, and depression. Though she insisted that she was following her doctor's instructions to consume at least 3000 calories a day, she continued to lose weight, and her physicians no longer believed her assertions. Her new doctor ignored all this past history, asking the patient to describe her illness from the beginning. In listening to her and in "starting fresh," this doctor saved her life. She had celiac disease, an allergy to gluten in the pasta and breadstuffs she was required to eat as part of her 3000 calories a day. This possibility had never before been explored.
Stories like this abound here. Groopman analyzes the uses and misuses of clinical decision trees and algorithms, used by many doctors and hospitals to enable them to see probabilities and make decision-making more efficient in diagnosis. He recognizes that this Bayesian analysis can sometimes constrain physicians, making them think "inside the box," but this kind of evidence-based medicine can be very efficient. Patients, however, are complex human beings who think and feel, and sometimes it is necessary for a doctor to depart from the algorithm and obey intuition. Recognizing when the physician is "winging it," however, depending too much on intuition and too little on evidence, is a recognized challenge for both patients and other physicians. The "bravado" of the physician can also interfere with treatment, sometimes, as can the tendency for a doctor to look for and find a result which s/he then believes "satisfies the search."
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. Doctors and patients who have similar personalities tend to communicate and understand each other better, he says, and no patient should ever simply accept a diagnosis until the physician can explain effectively why it is the best or only explanation for his/her problem.
The success of Groopman's book attests to the need for discussion of these issues between doctors and patients, but I found this book unsettling. I am not sure to what extent Groopman realizes the difficulty patients have in finding ideal doctors who may be like them in personality, thinking, and communication styles. 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 very well), and we have no way of interviewing several specialists to find the one who suits us best. We take the appointment with the specialist our primary care physician has picked for us, or the one who has the earliest available appointment, even when that specialist turns out to be completely different from us in style and temperament--s/he is an expert, and we need an expert. With considerable waiting time to see specialists, the patient with an urgent problem may have fewer choices than Groopman seems to think s/he has in finding the ideal physician. We can all try, but ultimately, we must all hope that our own diagnosis is not among the problem 15%.
- Amazon readers rating: from 191 reviews
(back to top)
Bibliography: (with links to Amazon.com)
- The Measure of Our Days: A Spiritual Exploration of Illness (1997)
- Second Opinions: 8 Clinical Dramas Intuition Decision Making Front Lines (2000)
- The Anatomy of Hope: How People Prevail in the Face of Illness (2003)
- How Doctors Think (March 2007)
Movies from Books (sort of):
- Gideon's Crossing
(back to top)
- Official website for Dr. Jerome Groopman
- US News interview with Jerome Groopman
- An excerpt from The Anatomy of Hope
- The New York Times review of How Doctors Think with first chapter
- The New Yorker review of How Doctor Think
(back to top)
About the Author:
Dr. Jerome Groopman received his BA and MD fro Columbia College and did his internship and residency in internal medicine at Massachusetts General Hospital. He then did fellowships in hematology and oncology at the University of California and the Dana-Farber Cancer Institute a the Harvard Medical School in Boston, Massachusetts.
Much of Groopman's research is focused on the basic mechanisms of cancer and AIDS.
He teaches at the Harvard Medical School and is chief of experimental medicine at the 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.