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Brain Trust: Dr. Groopman On 'How Doctors Think'

Publication Date: 2007-03-31

Ohanian Comment: Because teachers are so inflicted by exhortations to be "more scientific," to "be more like doctors," it is always illustrative to look at how doctors work. It is of particular value when a doctor admits to error. I read Dr. Groopman's new book on a recent long plane ride (but I don't blame him for arriving home sicker than the proverbial dog). Groopman has provocative and disturbing things to say about how doctors think. For starters, 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; statistics embody average, not individuals. This is just for starters.

from The Wall Street Journal
March 31, 2007

It turns out that not all patients are equal in the eyes of their doctors. Physicians often judge us by our appearance and our medical history, and that can be a problem, according to Dr. Jerome Groopman. In his fourth book, "How Doctors Think," published by Houghton Mifflin, he explores how caregivers make diagnostic decisions.

Dr. Groopman is also a staff writer at the New Yorker magazine, where he has written extensively on medical issues. And yes, he's a working physician. He's chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston, and holds the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School. He has practiced for more than three decades.

What intrigued Dr. Groopman was the realization that most medical mistakes don't involve lab errors or poorly informed doctors, but rather errant diagnosis. Physicians use mental checklists while trying to decipher symptoms described by their patients, but they must also rely on their own observations. The many factors that affect those observations serve as the starting point for this work. Dr. Groopman, 55 years old, was interviewed by telephone by The Wall Street Journal's Jeffrey A. Trachtenberg.

The Wall Street Journal Online: You stress the importance of listening, yet many doctors have to work fast in order to stay profitable. What chance do those patients have if they require a sophisticated diagnosis?

Dr. Jerome Groopman: We're all working with tremendous time pressure. And this is one of the greatest problems. It's a set-up for thinking errors and misdiagnosis. If the problem is complex and the symptoms aren't getting better, either the visit needs to be extended, which is often difficult because it backs up the waiting room, or a second appointment should be scheduled in a short period. This way you can extend the conversation and get to the bottom of what's wrong.

WSJ.com: You explain that doctors are more influenced by physical appearance than many of us thought. What can patients do to avoid being stereotyped by their doctors?

Dr. Groopman: This is a huge issue because stereotypes are the basis of attribution errors. We begin to attribute all of your symptoms or complaints to the stereotype. One patient knew she was anxious and that she could be stereotyped. So she told her fifth doctor that she was kooky and high strung, but that she knew something was different. She was feeling explosions in her body. It turned out she had a tumor producing adrenalin. So she'd get a burst that felt like an explosion.

Another example: how many old people are told that their legs are weak because of their age? That's a stereotype. A family member in his 80s, retired, said his legs were weak and that he felt wobbly. For two years he was told it was old age. This filtered down to me. I said it's not an answer. It turned out that he had myositis, which is a very common inflammation of muscle. It's completely curable, but it had been missed for two years because of an attribution error.

WSJ.com: Early on, you discuss a woman who was diagnosed as anorexic and appeared to have psychiatric issues. The doctor who saved her ignored that judgment and looked for a physical cause. In a collaborative business, how often do doctors think independently?

Dr. Groopman: In the same way that when we function as individual doctors we make thinking errors, we make collective cognitive errors when we work as teams. It's almost as though the thinking error is infectious. There's a term for it: diagnosis momentum. The first doctor, often somebody in authority, sets it in motion. Then everyone falls in line. A contributing member of the team will challenge received wisdom. That's the kind of doctor you want.

WSJ.com: As you were working on this book, did you feel as though you were lifting a veil that hangs between doctors and their patients?

Dr. Groopman: Absolutely. This is clearly the most revelatory book I've written. I began with making myself vulnerable by recounting the worst thinking errors I've made. I remembered the mistakes, but I didn't know why they occurred. It was only when I began to do the research for this book that I was able to put them into context.

WSJ.com: In your book you cite how difficult it was for several doctors to discover that ligament damage was the cause of ongoing pain in your right hand. Later, the doctor who performed the corrective surgery counseled you to keep in mind that you likely wouldn't have full mobility in the future, saying, "Just be careful. There are limits." Is this something a patient wants to hear? Won't it prompt a search for a more optimistic physician?

Dr. Groopman: That's why I included it. There is a balance of ego and confidence versus realism in a doctor. You want a surgeon who is confident and thinking and experienced and won't panic, and that's how a lot of surgeons are built. On the other hand, be careful of over promising.

WSJ.com: You cite a couple who look for a new pediatrician after their kid's doctor called and apologized for having "injected saline and forgotten to mix in the vaccine." In that case, the doctor confessed to having made a mistake. But if that doesn't happen, how can a patient judge when it's time to look for a new doctor?

Dr. Groopman: Language is the first clue to how a doctor thinks. A doctor who can explain to you in clear language, that makes sense regarding what he or she is thinking, is the kind of doctor you want.

WSJ.com: How can patients help their doctors make the correct diagnosis?

Dr. Groopman: First, you should try to tell as best you can the whole story. Sometimes the key clue comes at the end of the story. No one knows what the key clue is.

Second, having been a patient and having cared for thousands of patients, often patients are fearful and inhibited for different reasons. Sometimes you are scared and your mind goes blank so you don't report what is worrying you the most. Sometimes you are superstitious; my parents thought if you didn't say the word cancer it didn't happen. That was very common. You have to tell the doctor everything and be in a comfortable situation where the doctor prompts you do that. It requires a doctor who listens carefully and without being judgmental. Some people may have a sexual history or psychiatric history crucial to unraveling a clinical puzzle.

WSJ.com: How can patients tell the difference between doctors who lack an inquiring mind and doctors who are simply harried?

Dr. Groopman: Sometimes when I'm harried I'll say to the patient, I have six more people to see this afternoon and have a patient in the ER. I don't mean to cut you short, but let's see you again next Tuesday. This approach compares to a doctor who cuts you off after 18 seconds. The better approach is the doctor who says I need more time to figure this out. That's a harried doctor who wants to get it right.

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