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The following is a reproduction from this link.
Edition: September 2007 – Vol 15 Number 09
Author: Mark Thill
This book is titled How Doctors Think, but unfortunately, it won’t tell you how your physician customers think about med/surg products and equipment. However, it will tell you how doctors think about medical problems and the patients who have them. And it isn’t pretty. In fact, you might not want to know how doctors think, particularly if you’re the one with the medical problem.
This might be a book you’ll want to share on a very selective basis with your physician customers. That’s because the author, Jerome Groopman — himself a physician — works hard to shatter the myth of physician invincibility. Most doctors might not want the news to get out — that is, that they’re human, like the rest of us, and hence are subject to lapses in reasoning, to fear, to habitual thinking and to simple close-mindedness. But others do, and they’ll appreciate the insights this book contains.
What’s more, How Doctors Think makes a clear case for the potential power of a physician’s mind, instincts, curiosity and compassion, rather than blind adherence to best practices, algorithms and evidence-based medicine. And that’s something many doctors might want to hear. Repertoire readers might want to carefully read this book before using it as a conversation-opener with their customers.
The author, Jerome Groopman, M.D., is professor of medicine at Harvard Medical School and chief of experimental medicine at Beth Israel Deaconess Medical Center. He is also a researcher in cancer and AIDS, and author of several books as well as magazine articles. (He is a staff writer for The New Yorker.)
To be sure, it’s not easy being a doctor, says Groopman. Patients expect miracles; most fear signs of indecision. Doctors themselves are sometimes caught between clinical uncertainty and the need to take a clinical leap — and act.
What’s more, doctors — like the policymakers who try to regulate them — are caught in the age-old struggle between medicine as art and medicine as science. In Groopman’s words, medicine is an “uncertain science.” Most doctors know this, but are unwilling to admit it to themselves, let alone their patients.
One thing is for sure: Doctors are subject to mental and emotional lapses that can impede their medical judgment, and the consequences can be severe. Some of these lapses are of their own making; others are not.
In their haste to see patients and prescribe treatment, for example, doctors sometimes fail to take the time to truly listen to their patients for important clues about their medical problems, says Groopman. They can fall into ruts in their thinking and take shortcuts. Most of the time, they get it right — their initial diagnosis or treatment plan leads to a cure (or control of chronic disease). But sometimes they don’t … and patients suffer. In fact, if this book is about anything, it’s about how to be a better patient. In most cases, that means being more aggressive and attentive, insisting on a meaningful dialogue with your doctor, gauging his “emotional temperature,” and seeking help elsewhere if you’re not getting what you need.
Groopman is a good story-teller, a fact that improves the readability of this book. He begins with the story of Anne Dodge, a woman in her mid-30s who has been unable to hold down a meal since the age of 20. She has chased a cure for 15 years, visiting endocrinologists, orthopedists, hematologists, infectious disease specialists and psychiatrists. She has been told repeatedly that there was nothing physically wrong with her, and was treated for eating disorders — anorexia nervosa and bulimia. Her irritable bowel syndrome was diagnosed as further proof of her deteriorating mental health. Dodge visited dozens of doctors over the years, but none correctly diagnosed her. In fact — and this could be modern medicine’s greatest sin — each doctor tended to simply take at face value the diagnosis of the last one she saw. Over time, the prevailing diagnosis — that Dodge was suffering from emotional or mental illness — took on a life of its own. No doctor really saw her any more or took the time to listen to her story. In effect, they wrote her off.
To be sure, doctors aren’t the only professionals who fly on automatic pilot. Med/surg reps have, from time to time, been known to pull out the same products from their bags simply because they’re most familiar with them. And what rep hasn’t told his boss, co-workers or trainees that “This customer is a pain in the neck and not worth spending more than five minutes on”? For the rep, that can mean a lost sale or, worse, a lost customer. But for the doctor, it could mean needless suffering or worse on the part of his patients.
Anne Dodge’s case finally gets resolved, but not until a conscientious doctor closes the thick sheaf of past doctors’ notes and listens to her story — from start to finish, looking for the clues that might tell him what’s really going on. (Turns out she isn’t a nut after all, but that her illness does indeed have a physiological basis.)
Anne Dodge’s story brings to light a sobering fact, says Groopman: Even as healthcare providers and policymakers focus on the human and financial toll of medical mistakes, they might be missing the boat on a much larger, but subtler and more intractable issue. “Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes,” he says. In one study of missed diagnoses, researchers found that mistakes were not caused by ignorance of clinical facts, but rather, by flaws in the thinking process, or what Groopman calls “cognitive traps.” And these traps have deep roots. Medical students are trained to make “differential diagnoses,” essentially, “trees” of potential diagnoses. “Does the patient exhibit X? If so, then X.” These diagnoses rest upon pattern recognition. Most times, they work in favor of the patient and the doctor. But not all patients fall neatly into one of the branches on that decision tree.
Another cognitive trap is the one that Anne Dodge fell victim to. According to Groopman, “Doctors frame patients all the time using shorthand: ‘I’m sending you a case of diabetes and renal failure,’ or ‘I have a drug addict here in the ER with fever and a cough from pneumonia’” Often a doctor chooses the correct frame, and all the clinical data fit neatly within it. “But a self-aware physician knows that accepting the frame can be a serious error,” he says.
Doctors — like all of us — can let their emotions get in the way of performing their best work. “Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment,” writes Groopman. “The doctor becomes increasingly convinced of the truth of his misjudgment, developing a psychological commitment to it. He becomes wedded to his distorted conclusion.”
Many times, patients are unaware or unwilling to accept the fact that their doctor doesn’t like them. If they do, they tend to blame themselves, saying “I’m not a good patient.” Beware, says Groopman. If your doctor is giving you negative vibes, get out — quickly. See someone else. Give yourself a chance, even if your doctor won’t. Conscientious doctors, of course, monitor their emotions and inquire about negative feelings they have toward a patient. Truly compassionate and self-aware ones may even refer a patient to another doctor who might be more open to him.
Conversely, a doctor might take a liking to a patient, and that emotion can cloud his judgment. The doctor might let the patient “off easy” and let him take a pass on painful but necessary tests — with severe and unintended consequences.
Pity the poor doctor. He is trapped between the need to shut off emotion and stick with the facts, and the need to acknowledge his emotions in order to truly hear and see the patient. And seeing and hearing are the doctor’s most important tools. The fact is, when they tell their story, patients are feeding the correct diagnosis to their doctor, if the doctor is willing to take the time and energy to listen.
Another cognitive trap is that of “availability.” Example: In the midst of a viral outbreak, the doctor mistakenly diagnoses a patient with viral pneumonia. It makes sense — after all, pneumonia is going around. But had he stopped to consider the evidence, he might see that the patient before him is displaying classic symptoms of aspirin toxicity. Take away the viral outbreak and it’s a relatively simple diagnosis. Groopman calls such lapses “cognitive cherry-picking,” or “confirming what you expect to find by selectively accepting, or ignoring information.”
Even radiologists looking at film or CT images can fall victim to lapses of cognition. Radiologists, like all doctors, are trained to read images quickly and make instantaneous observations. Often, these observations are correct. But radiologists misread X-rays 20 to 30 percent of the time, says Groopman. What’s more, haste leads to what he calls “search satisfaction,” that is, “a natural cognitive tendency to stop searching, and therefore stop thinking, when one makes a major finding.”
All of this isn’t to mention the cognitive traps that can be reinforced in part by heavy marketing by pharmaceutical and medical device vendors, says Groopman. “Drug companies … can drive doctors’ thinking about what constitutes a malady and how to remedy it,” he says. Normal biological processes, such as drops in testosterone levels among aging men, are “medicalized” by drug firms, leading to overmedication, he says. Given the power of suggestion (and of marketing), consumers want to believe that drugs will produce certain effects, even if studies show they won’t. And physicians often respond by prescribing them. “There is a powerful temptation felt by patients and doctors alike to have a simple answer to complicated problems,” he quotes one internist and endocrinologist as saying.
Indeed, medical device makers are not immune to overstatement, he says. “Spinal fusion may be the radical mastectomy of our time,” writes Groopman, pointing to the growing incidence of spinal fusion and comparing it to radical mastectomies for breast cancer in years past. The problem with spinal fusion is that there is little correlation between damaged or degenerated disks and low back pain, he says, adding that more than 80 percent of people with back pain will recover through more conservative treatment, such as anti-inflammatory medication. But caught up in marketing and media hype, doctors and patients are often powerless or unwilling to take any route but the most severe — surgery.
The dangers of haste
Pediatrics offers plenty of opportunities for lapses in judgment, says Groopman. That’s because most kids are, fundamentally, pretty healthy. After awhile, the pediatrician can shrug off just about anything. That’s why the diligent doctor must prepare himself mentally before each patient visit, in order to guard against being lulled into complacency. Add the dilemma of low reimbursement — which drives doctors to try to see more patients in shorter periods of time — and one can see how the likelihood of cognitive errors increases.
Haste can also impede doctor/patient communication about the most basic things, such as how to properly take prescribed medication. Even worse, a physician in a hurry can discourage patients from communicating their deepest fears about what’s truly bothering them. That’s because patients often push from their minds the concern that is most frightening to them. “[T]he pediatrician should budget time to allow the concern to come to the surface, drawn out through a dialogue,” says Groopman.
Thoughtful dialogue doesn’t exactly square with one of modern medicine’s sexiest ideas, namely, that algorithms or critical pathways can help doctors improve the quality of care. Says Groopman, “Lists are useful, and like algorithms, can make care more efficient in certain circumstances, yet they also pose the same risks, that the doctor will not ask the kinds of open-ended questions” that they should. Electronic medical records, while useful for many things, might end up being a crutch for the doctor to hide behind, making it easy for him to avoid asking open-ended questions, he adds.
Quality measures pose the same dilemma. On one hand, they promote good, complete medicine. On the other hand, they can cause the doctor to totally miss the boat. “Currently, the bean counters are generating metrics to judge a physician’s ‘quality,’ but many of these are trivial, simply scorecards to ensure that the blood sugar was measured and a flu shot given,” says Groopman. “‘Quality’ in primary care means much more. It means thinking broadly, because any and every problem of human biology can present itself; it means making judicious decisions with limited data about children and adults, neither overreacting nor being blasé; it means wielding one’s words with precision and with a profound appreciation of the social context of the patients.”
The wisdom of uncertainty
The reason some doctors might not take to Groopman’s book is because it is, in the end, a plea for humility on their part. One cardiologist tells him, “What we know is based on only a modest level of understanding. If you carry that truth around with you, you are instantaneously ready to challenge what you think you know the minute you see anything that suggests it might not be right.” One doctor he knows — and admires — keeps a list of all the mistakes he has ever made, and refers to it now and again to remind him, and to learn anew from them.
For many doctors, the enemy is uncertainty. Not only are they unwilling to accept their own uncertainty about a case, but they’re unwilling to share that with their patients. But to Groopman, such doctors are missing an opportunity to get better. “Does acknowledging uncertainty undermine a patient’s sense of hope and confidence in his physician and the proposed therapy?” he asks. “Paradoxically, taking uncertainty into account can enhance a physician’s therapeutic effectiveness, because it demonstrates his honesty, his willingness to be more engaged with his patients, his commitment to the reality of the situation rather than resorting to evasion, half-truth and even lies. And it makes it easier for the doctor to change course if the first strategy fails, to keep trying. Uncertainty sometimes is essential for success.”
To be sure, patients don’t always like indecision. It makes them nervous. And physicians often err on the side of action rather than inaction, despite the fact —and sometimes because of the fact — that they’re not quite sure what to do. But Groopman recalls a mentor saying to him, “Don’t just do something, stand there,” when the author was unsure of a diagnosis. In other words, sometimes inaction is the best course.
Of course, inaction shouldn’t be confused with paralysis. Sometimes, faced with a patient who is not responding to treatment, the doctor may lapse into what Groopman calls “anchoring.” Unsure of a course of treatment, he throws down his anchor and refuses to budge from a certain (and ineffective) course of action. For heaven’s sake, as a patient, be worried — be very worried — if your doctor says something like, “We see this sometimes.” That means he has no clue about what’s going on, and has thrown the matter of your health and well-being to chance, God, or whoever else will take responsibility for it.
Groopman does not set out to damn those in his profession, nor does he appear to set himself apart from “the masses.” Rather, he makes a case for intelligent, compassionate healthcare. “As years pass, physicians derive gratification not only from the challenge of solving difficult cases, but also from trying to decipher the character of their patients.” That we as patients should be so lucky to come across such doctors.