Jerome Groopman's "How Doctors Think" has been given generally favorable reviews in the lay press and many readers have echoed that praise. From this physician's point of view, the book is a disappointment.
On the positive side, Dr. Groopman's book is an attempt to bring to light some issues surrounding errors in medicine, a topic that is not discussed often enough in the medical and general literature. He discusses how physicians can make cognitive errors when they attempt distill an array of scattered bits of information in order to arrive at a conclusion to the question: what condition is this patient suffering from? He also tries to identify forces in the current American medical system that undermine a physician's ability to think more broadly and deeply about a patient's illness. His limited efforts in these areas can be a helpful starting point for patients, medical students, and physicians who are beginning to grapple with a simple fact: doctors are human, and they make mistakes.
On the negative side, Dr. Groopman offers little in the way of concrete suggestions for clinicians to fix the problems he identifies. He indicates the current system is driving physicians to see more patients in less time, but offers no realistic proposals for doctors or patients that would allow for a less hurried atmosphere. He makes a number of suggestions on how physicians can think more clearly: think outside the box, be wary of "going with your gut", don't judge a patient by her outward appearance, be prepared in your mind for the atypical patient, consider the possibility of more than one diagnosis, and other pearls of wisdom. While they are good recommendations, they fall far short of a concrete program for improving one's diagnostic skills and thought processes. His only idea for improving medical training seems to be to push clinicians to ask themselves the above questions more often. If this was new, it would be worthy of all the praise that has been heaped on this book, but it honestly is not very new, and is simply a variation on the same ideas of how to better train clinicians that we have been working with since at least the 1970s. Given the current state of the American medical system, these old ideas clearly aren't enough, and Dr. Groopman's recommendations that we continue this strategy, only with more emphasis than before, leaves the reader desiring useful solutions feeling like he has been pushed out into the stream with only a toothpick for a paddle.
Perhaps a physician's yearning for some answers from Dr. Groopman is asking too much. But even from a patient's point of view, given the harrowing stories that lead up to his epilogue, the few extra questions he suggests patients use to push the physician ("Is it possible I have more than one problem?") seem unimpressive. Given the severity of time constraints that Groopman very correctly describes, his dearth of suggestions for patients to assist their doctors and work as a team to make the most of their short time together makes this book of only limited value for the non-physician as well.
One of the great shames of the book is that, despite his clearly delineating the problems physicians face, Dr. Groopman rejects the modern tools that have been developed to aid physicians in diagnosis: evidence-based medicine, clinical algorithms, and practice guidelines. He glibly dismisses these tools again and again, arguing they "constrain" a doctor's thinking and fail "when symptoms are vague... or when test results are inexact." He goes at length to describe one oncology fellow using a particular hematology scoring system to make a poor choice of a treatment plan for a particular patient. Yet the text makes clear the fellow was applying the scoring system incorrectly. Dismissing diagnostic tools because some people misuse them is like telling someone a wrench is not a useful tool for anything because someone once used a wrench to hammer in a nail. Diagnostic tools and practice guidelines, when used in a measured way, can help physicians accurately diagnose many patients without subjecting them to a punishing series of unnecessary diagnostic procedures. Evidence-based medicine helps us determine what works and, perhaps even more importantly, what doesn't. Instead of a balanced discussion of the benefits and limitations of such diagnostic aids, he simply throws the baby out with the bath water.
The most insidious aspect of the book is the underlying suggestion that when a patient does not get a swift, accurate diagnosis of what ails them, it can always be traced back to some logical or other intellectual error on the part of the physician. The fact is some conditions will, for the foreseeable future, elude our best efforts to diagnose them. He brings up an example of a man with chest pain who was sent home from the ER, but then had a heart attack several hours later. In truth, we cannot differentiate all patients with cardiac chest pain from those without cardiac chest pain with 100% accuracy. This is never stated in the text, and only briefly mentioned in the chapter notes buried at the end of the book. Right now, somewhere in America, even with the best tests and the best diagnostician at the bedside, someone with chest pain will be sent home from the ER, only to have a heart attack a short time later. While Dr. Groopman goes on at length to humanize the patients he writes about, his overall argument dehumanizes physicians, holding them up to standards of accuracy that our current body of knowledge cannot support.
Even if it isn't providing many useful solutions, this book is at least raising some important questions. Take this book with a grain of salt (and perhaps even two tablets of aspirin). It is encouraging that we are openly discussing the subject of errors in medicine. It would be a great shame, though, if this book were the last word on the subject.