How Doctors Think [Hardcover]

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.

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

Most doctors are highly educated, hard working people. They may sometimes get a bit tetchy because they overwhelmed by the demands made on them, but most of the time they do their best. Yet in our blame culture there are places in America where you can't get a specialist to treat you: they have all been driven out of business by lawyers representing unhappy clients. The question of why this has come to pass has occupied the minds of the American medical profession for three decades.

For more than a decade, Groopman's trenchant analyses have always been illuminating, and he has a rare gift for communicating them.

This is one of the best books that he has written, about one of the issues that may lead to medical errors: simply not thinking well. It is a very real factor. We all - and not just doctors - jump to conclusions; believe what others tell us and trust the authority of "experts." Clinicians bring a bundle of pre-conceived ideas to the table every time that they see a patient. If that have just seen someone with gastric reflux, they are more likely to think that the next patient with similar symptoms has the same thing, and miss his heart disease. And woe betides the person who has become the "authority" on a particular illness: everyone coming through his or her door will have some weird variant of the disease. As Abraham Maslow once said, "If the only tool you have is a hammer, you tend to see every problem as a nail." To that we have to add that not all sets of symptoms fall neatly into a diagnostic box. That uncertainty can cause doctors and their patients to come unglued. Sometimes when doctors disagree it is based not on facts, but on different interpretations of this uncertainty.

On this one topic the book is very good as far as it goes, thought I do think that the analysis is incomplete.

I have taught medical students and doctors on five continents, and this book does not address some of the very marked geographic differences in medical practice. While I think that the book is terrific, let me point out some of the ways in which it is "Americano-centric."

The first point is that the evidence base in medicine is like an inverted pyramid: a huge amount of practice is still based on a fairly small amount of empirical data. As a result doctors often do not know want they do not know. They may have been shown how to do a procedure without being told that there is no evidence that it works. As an example, few surgical procedures have ever been subjected to a formal clinical trial. Although medical schools are trying to turn out medical scientists, many do not have the time or the inclination to be scientific in their offices. In day-to-day practice doctors often use fairly basic and sometimes flawed reasoning. A good example would be hormone replacement therapy. It seemed a thoroughly good idea. What could be better than re-establishing hormonal balance? In practice it may have caused a great many problems. Medicine is littered with examples of things that seemed like a good idea but were not. Therapeutic blood letting contributed to the death of George Washington, and the only psychiatrist ever to win a Nobel Prize in Medicine got his award for taking people with cerebral syphilis and infecting them with malaria. The structure of American medicine does not support the person who questions: consensus guidelines and "standards of care" make questioning, innovation and freedom very difficult. A strange irony in a country founded on all three.

The second major factor in the United States - far more than the rest of the world - is the practice of defensive medicine: doctors have to do a great many procedures to try and protect themselves against litigation. This is having a grievous effect not only on costs, but also on the ways in which doctors and patients can interact.

Third is the problem of demand for and entitlement to healthcare. We do not have enough money for anything: but what is enough if the demand for healthcare continues to grow as we expect? And if people are being told that it is their right to live to be a hundred in the body of a twenty year-old? Much of the money is directed in questionable directions. There are some quite well known statistics: twelve billion dollars a year spent on cosmetic surgery, at a time when almost 40 million people have no health insurance. There are some horrendous problems with socialized medicine, but most European countries have at least started the debate about what can be offered. Should someone aged 100 have a heart transplant? Everyone has his or her own view about that one, but it is a debate that we need to have in the United States.

Fourth is the impact of money on the directions chosen by medical students and doctors starting their careers. Most freshly minted doctors in the United States have spent a fortune on their education, so they are drawn to specialties in which they can make the most money to pay back their loans. In family medicine and psychiatry, even the best programs are having trouble filling their residency training programs. Many young doctors are interested in these fields, but they could die of old age before they pay off their loans.

Fifth is the problem of information. It is hard for most busy doctors in the United States to keep up to date on the latest research, and many are rusty on the mechanics of how to interpret data. So much of their information comes from pharmaceutical companies. Many of the most influential studies have been conducted by pharmaceutical companies, simply because they have the resources. But there have been times when data has therefore appeared suspect. Industry is not evil, but companies certainly hope that their studies will turn out a certain way, and the outcome of any study depends on the questions asked and the way in which the data is analyzed. And like any collection of people, it is easy to fall into a kind of groupthink. There are countless examples of highly intelligent individuals who all missed the wood for the leaves. "Our product is the best there's ever been, and we are all quite sure that the stories about side effects are just a bit of "noise" created by our competitors." That topic alone could provide much grist for Dr. Groopman's mill.

Another related problem is that many scientists are now also setting up companies to try and profit from the discoveries that they have made in academia. Most are working from the highest motives, but sometimes there are worries about impartiality. So once again, the unsuspecting physician may add data to the diagnostic mix without knowing its provenance. There have recently been a number of high profile examples of that.

It could well be that Groopman will cover all of these points and more in his next book, and I can, of course, be accused of criticizing him for not writing the book that "I" wanted!

This is a book that should be read by every doctor and patient in America.

It is also good to know that there are other ways of thinking about some of the problems before us.

Very highly recommended.