Thursday, January 3, 2008

How Doctors Think by Jerome Groopman - Book Review

Jerome Groopman, M.D. has written a book that provides a great service to anyone who ever had to visit a doctor. How Doctors Think (trade paperback edition out in March) helps readers to understand how our docs approach solving the problems of our health, but even more important, he suggests ways to help our physicians focus more thoughtfully. Perhaps the most frightening aspect of Groopman’s book is his willingness to open the door of doctor error and provide insights into what goes on inside a doc’s mind leading to those errors. He says that the majority of such errors lie in two kinds of problems. First, the cognitive errors doctors make in thinking through a complex series of factors to arrive at diagnosis and a treatment plan. Second, the effects on medical practice of the pressure from insurance companies, HMO’s, and government agencies to reduce costs by restricting practice. They force doctors to see more patients, to spend less time with each one through their reduction in payments, and reimburse expensive and spectacular surgeries at higher rates than they pay for the more mundane practice of nipping illness in the bud at the level of primary care.
Dr. Groopman teaches at Harvard Medical School where he holds a chair and is Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston. He specializes in hematology and oncology and writes regularly for The New Yorker magazine, where several of the chapters in this book first appeared. An extended biographical sketch appears here. He is the author of three previous general interest books as well as numerous professional papers.
In How Doctors Think Groopman identifies various ways that doctors’ diagnoses follow established patterns closing them off from engaging in original thinking and problem solving. He uses numerous case studies to support his assertions and to show how some doctors learn to force themselves outside stereotyped ways of thinking to find alternative solutions to problems viewed as intractable. The case studies feature engaging patients and doctors in real situations that actively involve the reader in the process of diagnosis and treatment. The result is a fascinating book whose narrative intrigues while its principles are clear not only to medical practicioners, but all decision makers.

Groopman champions the role and function of the primary care physician. He argues “the higher we go in the scale of specialist training, the less complex the medical problem becomes.” (98) Medical gatekeepers encounter patients who complain of symptoms that may have little or nothing to do with the underlying disease. They must work through a myriad of indicators to arrive at a preliminary diagnosis and refer to the appropriate specialist. This requires deep and thoughtful attention to physical as well as emotional components. He cites evidence that the typical doc listens to a patient for a mere eighteen seconds before beginning to talk. It has become increasingly fashionable for insurance companies and hospitals to develop templates and clinical algorithms leading to a narrowing of the doctor’s thinking process. Such formats often treat too few symptoms, deny useful or essential tests, and reduce the doctor’s ability to think deeply and seriously about solving the patient’s problem and often leading to a mistaken diagnosis. Groopman repeatedly emphasizes the importance of avoiding the stereotypical thinking that comes from the use of templates and clinical prototypes just because most patients fit into the typical diagnosis.
A number of bias enhancers function in a physician’s world, and it’s important to be aware of them. How the physicians feel about the patient, doctors’ discomfort with uncertainty, their tendency to piggyback on previous diagnoses, and their need to be right all affect the quality of their thinking. The pressure placed on them to see more patients and spend less time with each one makes their decision making even more difficult and precarious. Doctors’ efforts are further sabotaged by the pressure brought upon them by patients requesting drugs and treatments advertised in the media and sold to them by the drug companies, for whom Groopman reserves a special spot in hell for their pressure tactics while recognizing their importance in fighting disease and promoting research. Doctors are not immune from his criticism for their willingness to accept the largesse of the drug companies and equipment manufacturers.
Groopman continually returns to the “art” of diagnosis, focusing on doctors who go to special lengths not to allow their preconceptions or the previous judgments of others, keeping them from digging deeper to find a correct solution. He points out that medicine is often uncertain, but doctors are under pressure to present a specific differential diagnosis. Diagnosis may be made even more difficult because the new technology provides a plethora of detail. For instance, a CAT scan or an MRI may provide thousands of pictures for a radiologist to examine. Drug companies, he says, “create a clinical disorder by medicalizing normal changes and challenges in life.” (209-210) Thus, aging is seen as a condition subject to treatment rather than a part of the human life cycle.

Finally, the book’s most important chapter may be the last one “Epilogue: A Patient’s Questions” in which Groopman instructs readers on how to question their doctors in such a way as to encourage the practitioners to think through medical problems more thoroughly and in new ways. By suggesting non-threatening ways to ask open ended questions, Groopman seeks to help patients optimize their doctors' thinking and decision making without raising their defensiveness. Throughout this book, Groopman emphasizes the humanity of people in the medical profession. For good and ill, these are people subject to the strengths and weaknesses of all humans. When patients work with their physicians to help them be their best, they do themselves and the profession the greatest service. By writing this book, Jerome Groopman has contributed to such an enterprise.