How Doctors Think (Hardcover)

by Jerome Groopman (Author)
Key Phrases: how doctors think, lunate bones, fusion surgery, Pat Croskerry, Baby O'Connell, United States (more...)

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.
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

From The Washington Post
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 are still common."

"It is a matter," Groopman writes, "of juggling seemingly contradictory bits of data simultaneously in one's mind and then seeking other information to make a decision, one way or another. This juggling . . . marks the expert physician -- at the bedside or in a darkened radiology suite."

This need for self-awareness during the act of thinking and working extends to the physician's emotional state and personal beliefs. How a doctor feels about a patient can have a major effect on the care provided to people who are obese, poor, stupid, mentally ill, addicted, foreign, criminal, deviant or ill-smelling -- as well as to those who are rich, powerful, famous, personally familiar or smarter than the doctor.

Groopman doesn't go much into the sociology of medicine, which is unfortunate because it has quite a bit to do with laying the groundwork for the cognitive errors he describes. Many medical students and doctors are surprisingly incurious about human narrative, to which they have almost unparalleled access. Most have little exposure to unintelligent, inarticulate or life-weary people. Few have done manual labor or been in the position of taking orders rather than giving them (outside of medical training, that is). Many are poor listeners and like to hear themselves talk. If it is true, as one is taught in medical school, that 80 percent of diagnoses can be made purely on the medical history -- what the patient says before the physical exam or any tests are done -- these traits can be impediments to good care.

So what is Groopman's advice for ways to help doctors think better?

An entire chapter illustrates the first commandment of pediatrics: Always take seriously the mother's theory of what's happening, no matter how harebrained it sounds. Patients should feel free to voice what they suspect the doctor may be thinking. "With a disarming sense of humor, she communicated that she understood she fit a certain social stereotype, and that stereotype had caused her doctors to fail to fully consider her complaints," Groopman notes admiringly of a patient who admitted she was "a little crazy" but doubted that menopause was the cause of her severe headaches and crawling skin. (She turned out to have a tumor that floods the body with hormones.) Another doctor tells Groopman she was helped when her patient said, "Don't save me from an unpleasant test just because we're friends."

Simple questions can help refocus a physician's attention: "What's the worst thing this can be?" and "What body parts are near where I am having my symptom?" Before calling the pediatrician, parents should ask themselves "what it is that scares them the most about their child's condition." And everyone should be leery of lazy generalities: "No one -- no doctor, no patient -- should ever accept, as a first answer to a serious event, 'We see this sometimes.' "

For their part, doctors should be wary of diagnoses that appear instantly obvious. Groopman quotes one doctor who jumped to the conclusion that a woman had pneumonia when, in fact, she had an aspirin overdose, which can cause some of the same signs and symptoms. "I learned from this to always hold back, to make sure that even when I think I have the answer, to generate a short list of alternatives."

Groopman notes that having adequate time to think helps (but of course doesn't guarantee) good decision making. Much of medicine, however, is practiced with the consumer waiting for the product to be delivered, whether it's the proposed work-up, the diagnosis, the treatment options or the long-term prognosis. This expectation of instant knowledge and service is something few people would consider reasonable for tasks such as having a will drawn up or even getting a pair of skates sharpened. This is perhaps worth keeping in mind as doctors are increasingly asked to do more in shorter appointments for the same or less money.

When it comes to medical care, we Americans want everything -- limitless access to drugs, diagnostic studies, surgical procedures, experimental therapies. We might want to push the system to give us more of the most potent intervention in medicine -- a doctor with time to think and talk.

Copyright 2007, The Washington Post. All Rights Reserved.

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Product Details

• Hardcover: 320 pages
• Publisher: Houghton Mifflin Company; 1 edition (March 19, 2007)
• Language: English
• ISBN-10: 0618610030
• ISBN-13: 978-0618610037
• Product Dimensions: 9.1 x 6.1 x 1.1 inches
• Shipping Weight: 1.2 pounds (View shipping rates and policies)
• Average Customer Review: 4.4 out of 5 stars See all reviews (173 customer reviews)
• Amazon.com Sales Rank: #22,248 in Books (See Bestsellers in Books)

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Customer Reviews

Most Helpful Customer Reviews

112 of 122 people found the following review helpful:

5.0 out of 5 stars "As many as 15 percent of all diagnoses are inaccurate...a distressingly high rate of misdiagnosis." , March 24, 2007

By	Mary Whipple (New England) - See all my reviews (TOP 50 REVIEWER)    (COMMUNITY FORUM 04)

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

69 of 79 people found the following review helpful:

5.0 out of 5 stars The Patient: Leader of the Healthcare Team, March 31, 2007

By	prisrob "pris," (New EnglandUSA) - See all my reviews (TOP 500 REVIEWER)

"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 use in deliniating the final diagnosis. It is difficult to forget the misfortunes of some patients. We understand a little more completely the real-life drama that physicians face in their mistakes and when their diagnosis is right on.

We learn about Bayesian Perspective thinking. "We all like to know how reliable and how risky certain situations are, and our increasing reliance on technology has led to the need for more precise assessments than ever before. Such precision has resulted in efforts both to sharpen the notions of risk and reliability, and to quantify them. Quantification is required for normative decision-making, especially decisions pertaining to our safety and well being. Increasingly in recent years Bayesian methods have become key to such quantifications." says Dr Groopman. The thought processes of physicians is an insight few of us have thought about. We should all be prepared for our next encounter.

It was refreshing to learn of Dr Groopman's frustrations with his medical care, and the four different opinions he received about his right hand. He carefully delineates how each physician came to their conclusion, and this is the type of thinking we need to engage in. We all have our stories of healthcare, and this book will give us more insight into the 'whys and wherefores' of our physicians' thought processes.

"Dr. Groopman gives a brief mention of how modern evidence-based medicine competes with the art of using your intuition. He touches on how drug and insurance companies pressure doctors as he explores their influence via big drug company sales representatives. I would have liked him to have written more about the influence of insurance companies, an area barely touched on, and about finances. This might have given readers a more complete picture of the intersection of medicine and finances." David Kessler

Most of us will be left with more respect for the art of medicine, and the careful consideration Groopman's doctors give to their patients. "How Doctors Think" is a book every patient needs to read. We, the patients have much more power than we know, and we can change the shape of the physician/patient relationship. We need to come to the doctor's office prepared to ask the right questions so that our physician's thought processes will be beneficial to both of us.
Highly Recommended. prisrob 4-01-07

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22 of 23 people found the following review helpful:

5.0 out of 5 stars Excelllent investigation inside the minds of doctors, May 15, 2007

By	Gaetan Lion - See all my reviews (TOP 500 REVIEWER)    (REAL NAME)

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 unrevised diagnostic fits pretty well allowing him to move forward even though it is the wrong one. The "availability error" is what is most available in a doctor's mind based on recent experience and association with a similar case. It plays into the doctor's pattern recognition mode. The author mentions many other interesting ones that are common to other professional fields.

In chapter 8, the author indicates that technology is not so helpful. The diagnostic error rates associated with the interpretation of X rays, EKGs, MRIs, mammograms, biopsies under microscope are far higher than what one expects. Two radiologists or pathologists often reach different conclusions. Sometimes even the same ones can arrive at different conclusions at different times (after reinterpreting their earlier findings).

In chapter 9, the author investigates economic incentives that distort the judgment of doctors. This includes Big Pharma relentless marketing of prescription drugs through persistent marketing reps. This also entails Big Pharma's effort to medicalize what is the normal process of aging. The author mentions the concept of Andropause (male menopause) that has no scientific bearing; but, doctors have aggressively treated this condition with testosterone supplements. These are useless. Economic incentives also lead surgeons to conduct operations way too often that provide no benefit to the patients. The author mentions spinal fusion and radical mastectomy among the surgeries that are way overdone in the U.S. Spinal fusion does not work better than not operating to eliminate low back pain. Oddly enough, insurers are responsible for excess surgeries as they offer higher reimbursement rates for invasive surgeries than for alternative therapies. The author also mentions the occasional nefarious networking between lawyers, radiologists, and surgeons creating a cycle of referrals, aggressive X ray diagnostics, and resulting unnecessary spinal fusion operation surgeries. Everybody makes money, and the patient believes his back problem was well taken care off.

Thus, diagnostic errors are a function of four factors: 1) the time and cost pressure associated with today's medical environment, 2) the complexity of human physiology, 3) the cognitive errors that the human brain makes across any profession, and 4) distorted economic incentives generated by Big Pharma, insurers, lawyers, and doctors themselves.

To prevent diagnostic errors ask the right type of open-ended questions suggests the author. These include: What else could it be? Is there anything that does not fit the current diagnostic? Is it possible I have more than one problem? These questions will force the doctor's thinking to slowdown his pattern recognition reflex and allow for more deliberation about a condition. These questions will also fight most of the mentioned cognitive errors that are all associated with expediting a diagnostic so as to move on to the next patient.

If you want to further understand medical errors due to economic incentives I recommend another book "What Doctors Don't Tell You" by Lynne McTaggart. Another excellent book on a similar subject is "The Last Well Person" by Nortin Hadler.