How Doctors Think (Hardcover)

by Jerome Groopman (Author)

Editorial Reviews

From Publishers Weekly
Starred Review. SignatureReviewed by Perri KlassI wish I had read this book when I was in medical school, and I'm glad I've read it now. Most readers will knowJerome Groopman from his essays in the New Yorker, which take on a wide variety of complex medical conditions, evocatively communicating the tensions and emotions of both doctors and patients.But this book is something different: a sustained, incisive and sometimes agonized inquiry into the processes by which medical minds—brilliant, experienced, highly erudite medical minds—synthesize information and understand illness. How Doctors Think is mostly about how these doctors get it right, and about why they sometimes get it wrong: "[m]ost errors are mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don't realize." Attribution errors happen when a doctor's diagnostic cogitations are shaped by a particular stereotype. It can be negative: when five doctors fail to diagnose an endocrinologic tumor causing peculiar symptoms in "a persistently complaining, melodramatic menopausal woman who quite accurately describes herself as kooky." But positive feelings also get in the way; an emergency room doctor misses unstable angina in a forest ranger because "the ranger's physique and chiseled features reminded him of a young Clint Eastwood—all strong associations with health and vigor." Other errors occur when a patient is irreversibly classified with a particular syndrome: "diagnosis momentum, like a boulder rolling down a mountain, gains enough force to crush anything in its way." The patient stories are told with Groopman's customary attention to character and emotion. And there is great care and concern for the epistemology of medical knowledge, and a sense of life-and-death urgency in analyzing the well-intentioned thought processes of the highly trained. I have never read elsewhere this kind of discussion of the ambiguities besetting the superspecialized—the doctors on whom the rest of us depend: "Specialization in medicine confers a false sense of certainty." How Doctors Think helped me understand my own thought processes and my colleagues'—even as it left me chastened and dazzled by turns. Every reflective doctor will learn from this book—and every prospective patient will find thoughtful advice for communicating successfully in the medical setting and getting better care.Many of the physicians Dr. Groopman writes about are visionaries and heroes; their diagnostic and therapeutic triumphs are astounding. And these are the doctors who are, like the author, willing to anatomize their own serious errors. This passionate honesty gives the book an immediacy and an eloquence that will resonate with anyone interested in medicine, science or the cruel beauties of those human endeavors which engage mortal stakes. (Mar. 19)Klass is professor of journalism and pediatrics at NYU. Her most recent book is Every Mother Is a Daughter, with Sheila Solomon Klass.
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From The Washington Post's Book World/washingtonpost.com
Reviewed by David Brown

Why is it that How Doctors Think is likely to find an audience while How Automotive Engineers Think would be a tough sell, and How Bookkeepers Think wouldn't have a prayer?

Part of the reason is that most of us believe, rightly or wrongly, that our lives might one day depend on the right decision by a doctor -- a belief we share about few other occupations. Most, as well, have watched doctors work, an experience, whether good or bad, that tends to lend an oracular quality to what a doctor does. And then there's the drama and heroism that's supposed to be -- and occasionally is -- part of medicine.

Jerome Groopman, a physician at Harvard Medical School who is also a writer for the New Yorker, does not debunk the notion of medical "exceptionalism." His book contains all kinds of smart, often selfless, occasionally heroic doctors making good decisions and sometimes saving lives. But it is far from a narcissistic paean to his profession. It is an effort to dissect the anatomy of correct diagnosis, successful treatment and humane care -- and also of diagnostic error, misguided therapy and thoughtless bedside manner. His task is to offer practical advice to both patients and physicians. He succeeds at both.

Groopman catalogues the many species of clinical errors, a whole taxonomy of misperceptions and wrong conclusions illustrated with real examples offered as representative types. All are fascinating, a few are chilling.

Into the latter category falls the case of a woman who for 15 years suffered from chronic diarrhea, vomiting and eventually anemia, osteoporosis and severe weight loss. Doctors said she had anorexia, bulimia and irritable bowel syndrome -- a proliferation of diagnoses that should have been a hint they were wrong. After initially resisting, she had come to accept this explanation of her problem, dutifully taking antidepressants and forcing down 3,000 calories of largely indigestible food each day. By the time she consulted one of Groopman's colleagues at Beth Israel Deaconness Hospital in Boston, she weighed 82 pounds. He diagnosed celiac disease, an allergy to the protein gluten found in many grains. The disease denudes the inner surface of the small intestine, reducing its ability to absorb nutrients; it explained all her symptoms.

The woman "was fitted into the single frame of bulimia and anorexia nervosa from the age of twenty," writes Groopman. "It was easily understandable that each of her doctors received her case within that one frame. All the data fit neatly within its borders. There was no apparent reason to redraw her clinical portrait, to look at it from another angle.

Many of the mistakes Groopman describes are variants of this one. They come from the physician's inability to keep his or her mind open, a reluctance to abandon initial impressions or received wisdom, and a willingness to ignore (often unconsciously) contradictory evidence. At the same time, the facts of biology rightly steer physicians away from endlessly pursuing improbable diagnoses -- a truth captured in such medical-school aphorisms as: "When you hear hoofbeats, don't immediately think of zebras" and "Don't forget that common things