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on March 6, 2016
Great reminder for physicians on common cognitive errors and how to avoid them as much as possible. The theme of trying to attach a diagnosis to a patient that doesn't quite fit, often based on their demographics or what is 'most likely' is reiterated throughout the book. Of course common conditions can present in uncommon ways, but the emphasis on trying to reach a diagnosis right away opens up the risk of missing something important - one example cited aortic dissection misdiagnosed as musculoskeletal pain and another a compression fracture that turned out to be cancer in a young boy. While these examples are extreme they are certainly not unheard of. Another was overreliance on clinical algorithms which resonated with me.

As a neurology resident we commonly evaluate patients with suspected stroke and grade the severity based on several exam findings which together make up the NIH stroke scale. This score helps determine whether to administer a clot busting drug called tpa, which can decrease the disability caused by a stroke but comes with a nontrivial risk of bleeding, both systemically and in the brain. While a high score indicates a severe stroke (or some other global process mimicking a stroke), a low score can be deceptive, as even a low score can indicate significant disability. For example, one patient working in a very cognitively demanding field had intact motor function and speech but was unable to accurately calculate even simple equations. His score was 1 (the highest score is 32). While some may argue that the patient had a low score, without treatment he would not have been able to continue his career- a large consequence for someone in their prime. The decision was made to give the patient the drug, and the next day his Mri indeed showed small strokes in a part of the brain important in solving calculations. He had no residual symptoms, and no untoward side effects from the drug. The idea of treating each patient as an individual is thus emphasized.

Another point made in the book was not to prematurely write a symptom off as being psychological. I once admitted a patient with acute onset of altered mentation and agitated behavior who had recently lost their family member. The family had reiterated that the loss was a month ago and that up until a few days prior to coming into the hospital the patient had been completely normal with the exception of some normal grief. She had gone to another hospital prior who felt that this may have been psychological, as the patient had imaging that turned out normal and labs which showed no drug ingestion. I admitted that while I had some ideas for what may be causing it, we would need further testing to confirm. An eeg showed a pattern consistent with encephalitis and the patient was found to have suspected autoimmune encephalitis, which presents with very bizarre neuropsychiatric symptoms (read the book Brain on Fire if interested). She responded beautifully to a course of treatment that dampened the immune system's abnormal response.

Of course there are the misses too- a time that I once thought a brain wave test on a child with autism and tics signified seizures, but in retrospect was artifact from repetitive hand movements the child was making.

Overall, I loved this book. While the information presented is going to be familiar to most physicians, it will make you think critically about your practice behaviors and how to improve upon them, as well as the limitations of medicine.
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on July 19, 2016
There are doctors that follow the tune that the Medical Industrial Complex plays, and there are ones who buck the trend. Dr. Groopman is one of the latter, thankfully.

In How Doctors Think, The New Yorker staff writer and Harvard professor of medicine & researcher Dr. Groopman offers a distinctive look into the structure of Big Medica in search for what exactly is the type of mindset Doctors employ when practicing their jobs.

Groopman does a compelling job throughout the book in making sure he relates the plights plaguing medicine from both sides of the coin, from the patients perspective, as well as from the perspective of a physician. This aids in the book not being one sided. It helps greatly that he’s also a Doctor with experience in this very field.

From medical, money, marketing, uncertainty, dogma, to various other components of medicine, Groopman attempts to turn over as many stones as possible in his search for what issues are the ones plaguing Doctors the most.

A notable point in the book that hit close to home, which many people will relate to is the emotional tension that can arise at times between patients and their doctors. Essentially, whether patients and doctors like each other. Groopman relates what Social Psychologist, Judy Hall discovered regarding emotional tension:

“..that those feelings are hardly secret on either side of the table. In studies of primary care physicians and surgeons, patients knew remarkably accurately how the doctor actually felt about them. Much of this, of course, comes from nonverbal behavior: the physician’s facial expressions, how he is seated, whether his gestures are warm and welcoming or formal and remote. “The doctor is supposed to be emotionally neutral and evenhanded with everybody,” Hall said, “and we know that’s not true.”[1]

What’s worse, is that Hall’s research indicated:

“…that the sickest patients are the least liked by doctors, and that very sick people sense this disaffection. Overall, doctors tend to like healthier people more.”[2] So much for quality health care.

Along with the above example, the author additionally notes many other examples of issues that arise due to a crisis in communication which can arrive in myriad ways.

In fact, one of these issues that Groopman relates is that:

“…on average, physicians interrupt patients within eighteen seconds of when they begin telling their story.”[3]

Another salient aspect of Big Medica that the author sunk his teeth into was the psychological aspect of medicine. Predictably, far too often doctors/western medicine view the patients psychological components as being apart from the body, rather than taking a much-needed holistic approach.

Additionally, the institutional dogma that reigns down from the top is also touched upon in a few instances by the author. Open-mindedness is scoffed at, while conformity was expected.

Recounting an example of choosing between the availability of multiple medical options regarding a particular treatment, Groopman relates something noted by physician Jay Katz, who taught at Yale Law school at the time:

“In both [treatments]…we were educated for dogmatic certainty, for adopting one school of thought or the other, and for playing the game according to the venerable, but contradictory, rules that each institution sought to impose on staff, students and patients.”[4]

Another disturbing component that doctors acquiesce to that is covered by Groopman is how doctors far too often give into to corporate interests. This very issue has covered by other doctors such as Dr. Brogan, Dr. Breggin, Dr. Mercola and many others.

This book sheds much needed light into the inner workings of how doctors operate – how they think. While the author notes that a sizeable amount of the issues have a variety of roots at the outset, such as communication, what he conveys still leads to much concern within the Medical Industrial Complex.

In the end, individuals will need to become much more proactive/responsible in their health if they plan to breakaway from the conventional medical system that puts profits over people.


Sources & References:

[1] Dr. Jerome Groopman, M.D., How Doctors Think, pg. 19.
[2] Ibid., pg. 19
[3] Ibid., pg. 17
[4] Ibid., pg. 153

Kindest Regards,
Zy Marquiez
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on April 4, 2016
After suffering heart failure and a triple bypass at the age of 54, the recovery has been difficult. That was 5 years ago. What has been more difficult is communicating with my physicians. 10 months ago, I took my health into my own hands and changed my diet and supplementation. It has been an about face in my health. Blood and cardiac tests do not lie. I have kept what I am doing from my doctors in order not to second guess all my efforts in such a short time. This book helped me immensely in my last primary and cardiologist appointments in finally coming off most of my meds and replacing them with supplementation. Before reading this book I was met with raised eyebrows, but I am now able to tactfully communicate to my doctors that I am more than a "patient medical googler" and someone that has finally became responsible for my own health.
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on January 10, 2014
I have gone my whole life being afraid to talk straight to Doctors, and therefore never had much of success
getting the care to go in the direction that I needed it to go. I spent YEARS in a medical plan that served up to
me a new Med School Graduate every year as my GP. Each year I asked for help with my headaches and was
told that I didn't have a problem. I'd been hosed down with Agent Orange in Viet Nam, and had daily headaches
So I read Dr. Groopman's book and it taught me (an Engineer) how Doctors THINK. Now if you feel that you
just KNOW that Doctors have swelled heads, you never met a Design Engineer! We are the most egotistical
folks on the planet! But the book gave me the inside scoop on what I had been missing my whole life...a clear
understanding of what the DOCTOR is going through while He/She is interviewing you regarding your medical
history and complaints. It opened my eyes to the foolish mistakes I had been making all those years (decades).
I went to the next Doctor. Her name tag was so new it was hand-written. She explained to me that I didn't have
any allergies (like every year's Doctor had told me) and that I should just take a Decongestant. I told her if she
didn't send me to the Alergist, I would quit the plan. I FINALLY went to see an Allergist. They found some trouble,
and treated it immediately. Without this book, I would still be waiting to meet this year's new MD, with a headache.
It may sound corny, but this is a BREAKTHROUGH BOOK! You NEED it if you aren't getting the kind of results
from the Medical Profession that you want to get. It helps you CONNECT with your Physician, not just to bully him.
You really, truly need to understand how He/She thinks, and this is your KEY. BUY IT! BUY IT NOW!!! Hap
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on April 4, 2015
As a practicing Ob in a community setting, about 1 generation removed from Dr Groopman, I have to admit I was worried the book was going to be a condescending self aggrandizing tome. Nothing could be further from the truth. Bravo, sir. You have nailed down so many truths of this job, whether one practices at a university hospital or in the community.

Doctors make mistakes, most of the time not deliberately but frequently due to imperfect knowledge and cognitive errors. You can't be everyone's doctor, and some people who are "difficult" to you mesh well with another of your colleagues. And he is definitively right about the clock and the increasing paperwork burden turning us into bad listeners.

I bought a copy for my grandfather who recently retired from medicine at 84. I know he enjoyed it.
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on October 3, 2012
Dr. Groopman begins his book with a story of a very sick patient who went from doctor to doctor for fifteen years, and continued to get worse. Finally, she found a doctor who was able to accurately diagnose her illness, suggest appropriate treatment, and save her life. The difference? The way he listened. He calmly put aside her file and said to the patient: "I want to hear your story in your own words." This doctor is concerned that technology has taken doctors away from the patient's story, and you can't be a doctor without the patient's story. Groopman notes that "on average, physicians interrupt patients within eighteen seconds of when they begin telling their story." He says that how a doctor asks a question structures the patient's answers. Generally, an open-ended question is better because it is more likely to give the doctor new information. He also notes that patients are very sensitive to whether the doctor likes them. The tendency is that doctors like sicker patients less. Groopman is saying that it is important for doctor and patient to be aware of these dynamics. Throughout his book he encourages doctor and patient alike to think and ask questions of one another. A patient, for instance, can ask why, ask what else it might be, ask if there is anything that doesn't fit, ask what's the worst case scenario, can retell their story, can tell what they are most worried about, tell what they discovered in their internet research, can say "I still don't feel good." All these can improve a doctor's thinking.

Each chapter of Groopman's book has a personal example that reads like a detective story which he uses to make a point. In the chapter, "Gatekeepers," he tells how doctors are expected to see a patient every 15 minutes thereby missing essentials and reducing medical care to a commodity. In a chapter about a baby undergoing heart surgery, the point is made that "experts" must acknowledge their uncertainties if they are to be successful. In a chapter about a brain surgery, the point is that inaction is sometimes better than action.

The major points of Groopman's book are that, as a physician, his major partner is the patient, that it is always important to improve his thinking, that to do so he must open his mind, and the patient helps him to do that by asking questions.
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on December 15, 2016
Wonderful book, even for a seasoned psychiatrist like myself. It's a good idea every now and then to question our assumptions, and this book is a wonderful journey into how we use information in a world of uncertainty. I am recommending it to all my colleagues, especially those who train young physicians. The author also gives the lay public the right words to use when speaking to physicians in order to me most effective.
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TOP 1000 REVIEWERVINE VOICEon January 22, 2012
An eye-opening view into the decisions doctors make based on information from the patient as well as influences from tests, statistics and how they were trained.

We would all like to think that when we tell the doctor something is wrong, that we are uniquely listened to, but the reality is, the doctor has many influences, sometimes the least of which being your story as you tell it.
They will consider:
* Your previous doctor's diagnoses
* Various lab results
* Urgency of your situation
* Urgency of all the other patients they are treating that day
* The time your insurance company gives them to consider your care
* Their previous training

Since they are human, they are also influenced by:
* Whether they find you believable or not
* Whether they like you or not
* How challenging your case seems. Doctors don't like to fail.

Not surprisingly, doctors will tend to lean toward previous opinions even if they are wrong. They also wonder if the patient is being compliant with the doctors recommended regimen of care. This can greatly influence whether they determine if the regimen is the right one for the patient. In fact, they might opt to continue a treatment that is cleary not working, assuming the patient is not being compliant.

They also tend to:
* Assume there is only one thing wrong with you, though your symptoms might in fact be caused by more than ailment.
* Assume due to statistics, that you have the more common ailments rather than something more exotic
* May opt not to order painful or uncomfortable tests for people they like.

For the most part, doctors treat patients in a very linear fashion. If you come in with complaints associated with your lower abdomen, they are going to look at your lower abdomen. But, a human being is a system. Issues in one area can cause problems in another and seem quite unrelated. It takes a dedicated doctor, to detach from previous diagnoses and look at the entire person, to try to determine what is wrong. It sometimes when it comes to reading tests, X-rays and all the data available, becomes a question of what does not look right, rather than what fits the diagnoses.

There is also the case of considering the patients overall health and wishes when considering aggressive treatment versus palliative care in a disease that is sure to end in death. One person may wish to pull out the stops to live another 6 months, while another would rather have 2 months in little pain. Hard choices but doctors must allow the patient to guide this course, or be sensitive enough to a patient, to recognize this.

Finally there is the part that money plays in the marketing of various drugs by drug companies. Doctors are deluged with information on many medicines. Some are medicines looking for a disease and patients will come to doctors asking for medicines by name, as they feel this treatment is what they need. It is hard to determine the right course of action, under this influence.

In summary, this book covers so many situations and touches on the mistakes doctors can make. If you have been well treated by your doctor over the years, all these items noted above worked in your favor. However if you have issues that remain unresolved this book can help you understand the factors your doctor maybe dealing with. It can help you ask the right questions, or realize it is time to move on. Remember you are a partner in your own care and must advocate and educate yourself to do this in the best way possible.
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on September 10, 2013
This book is a bit longer than it really needed to be, but it does provide good insight into how doctors are accustomed to approaching things, for better or worse. People do things a certain way because it seems to work for them most of the time, but the flip side is that there may be times when it doesn't. In addition to noting how and why doctors are taught or encouraged to approach diagnosing and treating people, there are a series of case examples, and one example is the long-running thread that it returns to repeatedly throughout the book, ultimately showing how "the usual" approach almost killed a patient until a different doctor entered the picture and set things right.

Anyone considering a career in medicine should read this, but anyone who may ever, possibly become sick or see a doctor (meaning, everyone) should be aware that doctors can get on a wrong track or make assumptions or mistakes, and a person needs to be their own advocate and press for different approaches if the existing one isn't working. Can't expect miracles nor flawless, error-free care, but never hurts to question and re-assess things.

This author has written many books, all seem highly rated, but this is the only one from him that I've read so far. We have some doctors in our family and more coming, and we are all patients at one point or another, so it's an interesting and helpful book. It is a bit longish and at times a bit redundant, but not oppressively so. The subject is compelling and the author is highly knowledgeable in the profession.
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on May 7, 2011
I picked up How Doctors Think by Jerome Groopman, MD as a fluke. Having accumulated more books than I can read, they gather dust on shelves or in boxes in my basement. But, around the holidays, I found myself with a gift card from Barnes & Noble, and I wandered its aisles, looking for something to grab me. It was there I spotted Dr. Groopman's book.

I work in health care, in finance and have since 1988. This book a look at how physicians are trained, and how their training as well as their experience impacts the way physicians think, and diagnose their patients. Dr. Groopman put it this way. "This book is about what goes on in a doctor's mind as he or she treats a patient."(p3) The book is about cognitive errors physicians make and how patients can contribute to their physician's successful diagnosis and treatment. The author, a practicing oncologist posits comments on how healthcare economics undermines the chances of avoiding the mental errors that lead to incorrect diagnoses. (People like me get labeled "bean counter" with great aplomb. [pp90, 100, 127])

Jerome Groopman chronicles how patients access physicians, through hospital emergency rooms, primary care doctors, surgical specialists, and radiologists. During this discourse, he labels a number of thinking models, common to physicians and the intellectual errors that are linked to those models. Additionally, he spends a significant amount of time discussing how the modern practice of medicine exacerbates the conditions that may lead to misdiagnosis.

Dr. Groopman repeatedly dicusses a cognitive model for diagnosing patients followed by a criticism of the model's weakness, demonstrated by a misdiagnosed patient. He criticizes the evolution of quality programs and "evidence-based medicine" programs in hospitals across the country. "Physicians should caution themselves to be not so ready to match a patient's symptoms and clinical findings against their mental templates or clinical prototypes. This is not easy. In medical school, and later during residency training, the emphasis is on learning the typical picture of a certain disorder...'Common things are common'...'When you hear hoof beats, think about horses, not zebras...Powerful forces in modern medicine discourage hunting for [zebras]." (pp126, 127)

He criticizes of the economic organization of medicine, today.

"...deliberate analysis...requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes...Today, medicine is not separate from money. How much does intense marketing by pharmaceutical companies actually influence either conscious or subliminal decision-making? Very few doctors, I believe, prostitute themselves for profit, but all of us are susceptible to the subtle and not so subtle efforts of the pharmaceutical industry to sculpt our thinking." (p178)

This book is not a "page-turner." Dr. Groopman's examples are interesting, though they make me as a non-clinician frustrated. His attacks on evidence-based medicine can feel like an attack on those that want to reduce medical uncertainty, and their motives. His description and sometimes praise for a model of diagnosis, usually to be followed by the parallel pitfalls of that model can leave me feeling in despair. The first time I tried to read it, it was over a month long period and I had only gotten half way through the book. It just didn't compel me. When I began rereading it, I pushed through and got it completed in about one and a half weeks, skipping several days.

Dr. Groopman talks about how doctors know what they know, and discusses the general environmental characteristics that lead to intellectual errors in medicine. I have seen similar forces influencing the business and industry of health care. In seminars and webinars, I see ideology, groupthink, magical thinking, fashionable nomenclature and platitudes being used as substitutes for real strategic thought and planning, then becoming conventional wisdom. Many times the tools we all learned in business school are being ignored rather than to challenge the trendy idea being proffered. It is as if business strategy has more in common with finger painting than business science.

This book was worth reading! This book reminds me that these problems, paradigm lock, unwillingness to challenge authority, blindness to extraneous data are pervasive. I need to listen more, respectfully question, learn from my own errors in thinking. I have drawn value from How Doctors Think. I just had to work to get at that value.
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