How Doctors Think

This book by Dr. Jerome Groopman, in my opinion, should be required reading of all medical students. Further since it is new (2007), I believe that all physicians whether they work directly with patients or interpreting diagnostic fims behind the scenes should read it, as well. Lastly, any potential or actual patient, which means everyone, should read it to understand the system they are being diagnosed and treated within, and the demands and limitations placed upon their well-meaning doctors. Physicians are not infallible. Some external constraints placed upon them derive from their administrative officers and, in turn, from the cost-efficiency efforts of HMO's. The time spent with each patient has been pared down and leads to more rigid and habituated diagnoses. Yet a proper and accurate diagnosis is critical since it is the engine that governs the treatment to follow. In addition to external constraints, the doctor's mind is all too often, by virtue of his or her training, locked into a template that leads to a stereotyping of the diagnostic process. As certain symptoms are relayed by the patient they are automatically made to fit an a priori template, hence, imposing closure on more creative and flexible thinkiong that may discern an unlikely or unexpected, but accurate diagnosis. Alternative, but potentially fruitful perspectives are overlooked if they fall outside the boundaries of the learned template. Dr. Groopman does not hesitate to acknowledge and emphasize that mood and temperament can influence the judgment of the diagnostician. The physician who is aware of this and is not defensive about it, is more likely to transcend the limitations imposed by the subjective thinking brought to the process. The book is written with sensitivity, insight, restraint, yet it is direct and to the point. Clinical vignettes are sprinkled throughout the book, adding clear illustrations, enhancing the author's meaning, and contributing a humane touch to every page. This work is a tour de force that will be compelling and illuminating to any reader. By Hugh Rosen, Philadelphia, PA, Autor of "Silent Battlefields: A Novel."

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

This is a well written and very informative book on how doctors arrive at a diagnostics. Groopman, a doctor, acknowledges that 20% of diagnostics are incorrect. He explains why this happens by interviewing various medical experts. These describe how they arrive at diagnostic decisions and how they have made errors during their career. From reading this book, you get that the main reason doctors make errors is time constraint. In our productivity driven health care system, doctors don't have the time to cogitate the potential diagnostic of patients' illnesses. Additionally, human physiology is incredibly complex. Each patient is unique and reacts differently to his environment, and treatment. Thus, medicine is a science of rules but with more exceptions than rules. Also as an offshoot of cost containments, doctors are discouraged to order more tests than is viewed as necessary by the health insurers. As a result, doctors make complex decisions with limited time and information. This combination of factors easily explains the 20% error rate. A doctors' thinking mode diverges much from his medical training. In medical school doctors are taught to crack complex disease diagnostics following deductive reasoning. They are given written data on a patient, and they arrive at a diagnostic within 20 to 30 minutes of thorough analytical deliberation. However, in the real world they typically arrive at a diagnostic within 30 seconds. They don't think at all in a slow deductive reasoning mode as they were trained. Instead, they think in an intuitive light speed pattern recognition mode that immediately zeroes in on two or three potential diagnostics. Within the 30 seconds, they narrowed it down to one. Their light speed pattern recognition thinking reflects two things: first, the chronic time pressure they work under (they don't have 30 minutes to deliberate); and second, how they gather information in the real world. The physical appearance, body language, communication style of the patient will give them a ton of qualitative information that they don't get when cracking a diagnostic in med school using just data. The author analyzes with his interviewees the different cognitive errors doctors make. A common one is the commission bias as doctors are prone to be decisive and action oriented. A surgeon will operate because that's what he does. Sometimes, doing nothing is the best policy (doing no harm). But, that's perceived as incompetent by both patients and doctors. Another prevalent error is "diagnostic momentum" where the very first diagnostic delivered by the primary care physician sends all following specialists taking care of the patient down the wrong path. Another interesting one is the "zebra retreat" where a doctor does not dare to investigate further a situation because his hypothesis represents a wild outlier (a zebra); Instead, the doctor falls back into another comfortable error "satisfaction of search" where the u

"Patients and their loved ones swim together with physicians in a sea of feelings. Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents". Jerome Groopman The Patient: as an undergrad in college in my nursing program, I was educated to understand that I always needed to listen to my patient, really listen. That philosophy has always served me well. Health care providers tend to be controlling, and when we, the patients, are given a diagnosis that shakes us to our core we need some control. As patients we need a physician and health care team that has the patient as the leader of the team. We listen to all of the recommendations and weigh the evidence as best we can. In the end we need to be able to trust our physicians and have a relationship that allows humor and sadness, questions and answers and honest give and take. It is a relationship like no other- it is sometimes life and death. Jerome Groopman has written a book for everyone. Everyone needs to be their own advocate for their healthcare. His ideas that the way physicians think result in the treatment and care for each and every one of us. "Every doctor makes mistakes in diagnosis and treatment," he writes. "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." He discusses the physicians who 'read' x-rays and CT's and MRI's, the radiologist. An exacting science is needed here. A radiologist with experience can pick up a disease process by the thickness of a rib. There is an accepted 'error' ratio in this science, and none of us want to be in that error ratio. There is a computer program to assist in diagnosis, but it is not perfect. We all want and need the experienced radiologist. When I entered the world of health care I learned that medicine is 50% rule out or question of. It remains in that corner. That is how we want our physicins to think-rule out #1,2,3 and come to a conclusion based on science, best practice and their ability to put it all together for us, the individual. He helps the layperson understand doctors' thinking with simple and accessible terms that suggest why it sometimes leads to undesired outcomes. As David Kessler in his reviews states "He introduces us to terms such as "diagnosis momentum" -- when a diagnosis becomes fixed in the mind of the physician despite incomplete evidence. Or "availability," which means the tendency to judge the likelihood of a medical event by the ease with which relevant examples come to mind. He takes phrases patients often hear, such as "we see this sometimes" and puts forth the idea that such generic comments deserve further questioning from the patients." Dr Groopman has written of fascinating case studies and the physicians who were part of them. The errors and the asute diagnoses are compiled in story after story. Physicians are open about the way and the analytical methods they us

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