In this myth-shattering book, Dr. Jerome Groopman pinpoints the forces and thought processes behind the decisions doctors make. Groopman explores why doctors err and shows when and how they can avoid snap judgments, embrace uncertainty, communicate effectively and deploy other skills that can profoundly impact our health. Here's an excerpt from "How Doctors Think":
Introduction
Anne Dodge had lost count of all the doctors she had seen over the last 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 any illness like hers. Around age 20, 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 a severe aversion to food. If the condition is not corrected, people can starve to death.
Over the years, Anne had seen many internists for 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 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 scant numbers of developing cells. The two hematologists Anne 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 a bout of 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 3,000 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 desire 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 82 pounds. Although she said she was forcing down close to 3,000 calories, her internist and her psychiatrist took the steady loss of weight as a sure sign that Anne was not telling the truth.
Today Anne was seeing Dr. Myron Falchuk, a gastroenterologist. Falchuk had already received 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 the diagnosis she’d lived with for fifteen years was wrong.
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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 relatively common ailments like pneumonia and diabetes, but there were also some with symptoms that did not readily suggest a diagnosis, or with maladies for which there were a variety 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 to challenge me, with their ideas. But at the end of rounds on that September morning I found myself deeply disturbed. I was not only concerned about the content of the give-and-take among the trainees, but even more 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 my 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 deeper reflection, I saw that there also were deep 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 in 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 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.
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 strictly base all treatment decisions on statistically proven data. This so-called “evidence-based medicine” is rapidly becoming the canon in many hospitals. Treatments outside of 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. They 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 more questions: 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, confronted with a problem for which there is little or no precedent? (Here, algorithms are essentially irrelevant and statistical “evidence” 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 for 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 deeply intrigued by the questions, but confessed that they had never really thought about how they think. Then I searched the published 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 saw too 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 her true 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. While I hope physicians and other medical professionals will find it of interest, what follows in these pages is primarily for laymen. Why for laymen? Because doctors desperately need patients and their family 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.
Introduction continuedWe’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 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 communicating with the doctor, from telling him that he asked only half of the questions he should have, or that he overlooked an important symptom.
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 or her 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 only get 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 and threatening 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 constraints and 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 he is wrong. We also encounter the tension between his acknowledging uncertainty and yet having to take a clinical leap and act. One chapter reports on this in my own case; I sought help from five 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 health care 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.
In today’s world, 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 no new therapies, no progress. Several doctors, and a pharmaceutical executive, speak with great candor about the reach of drug marketing, and how patients can be alert to it.
Excerpted from "How Doctors Think" by Dr. Jerome Groopman. Copyright 2007 Jerome Groopman. Reprinted with permission of Houghton Mifflin. All rights reserved.