How Doctors Think
Jerome Groopman, M.D.
Boston: Houghton Mifflin Company, 2007, 307pp., $34.95.
Groopmanís book examines the complex thinking processes that enter into determining a patient-centered approach to a medical diagnosis. Some diagnoses are easy to procure while others take significant time and effort to achieve. Although clinical algorithms and statistics can be useful for a run-of-the-mill diagnosis and treatment, they quickly fall apart when a physician needs to think outside of the box because sometimes a patientís symptoms may be vague, multiple or confusing. In such cases, physicians are discouraged from thinking independently and creatively. Instead of expanding a physicianís thinking in complex diagnostic situations, such algorithms and statistics actually constrain it. Despite this, a movement is in place in medical practice to base all treatment decisions on strictly statistically proven data. This is quickly becoming a protocol in many hospitals.
The reliance on evidence-based medicine risks having the physician choose care solely by numbers. Physicians must remember that statistics usually embody averages but not individuals with a particular ailment. Errors in thinking can frequently occur when a
physician relies totally on statistics to make a diagnosis. There are ways that a physician can think so that (s)he can reduce the frequency and severity of clinical mistakes in judgment. The goal of the book is to show physicians how they usually think in order to determine how they can improve their thinking skills so that patient misdiagnoses
can be reduced.
Groopman argues for the importance of physician intuition in the diagnosis of an illness. Clinical intuition is a complex feeling that becomes refined through years of listening to patientís stories, examining thousands of patients and, most importantly, remembering when the physician was wrong in diagnosing a patient. Expertise is
acquired not only by sustained practice but also by receiving feedback from the patient so that the physician can understand the technical errors and misguided decisions which occurred. Sometimes a physician frames the patientís information wrongly by relying on useful shorthands. Physicians must not frame the diagnosis as given. A superior physician is sensitive to the patientís language and emotion while (s)he is disclosing his/her story of illness since language is the bedrock of clinical practice.
Sometimes a physicianís emotions may be skewed because of the emotionality that is inherent in a patientís medical situation. This can cause errors in judgment and can lead to serious misdiagnoses if a physician does not exercise extreme care. During these times, the physician must become aware of his/her thinking patterns and to recast
the information that the patient initially disclosed by asking the patient a few further questions about his/her symptoms. The questions that the physician chooses to ask and how (s)he asks them will shape the patientís answers and guide his/her thinking. When a physician offers a quick diagnosis without properly reflecting on the patientís unique medical situation, (s)he is prone to cognitive biases, such as anchoring and availability. Anchoring is a shortcut in thinking in which a physician does not consider multiple possibilities but quickly and firmly latches onto a single one, certain that he has thrown his anchor down just where (s)he needs to be. Availability is the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind. Because the physician is prone to these two cognitive errors, (s)he should pay close attention to how a patientís diagnosis is shaped and determined.
To provide quality care, the physician must strive to think broadly, making judicious decisions with limited data, neither overreacting nor being blasť about a patientís medical situation, and using words with precision and an appreciation of the patientís social context. In other words, quality of care requires that the physician should become the patientís gatekeeper by knowing where and when to guide him/her.
When a negative diagnosis has to be delivered, the patient should be guided, provided a balance, raise doubts, and highlight uncertainty (if necessary). In other words, the physician should think with the patient so that a mutual understanding between the patient and physician is achieved about the therapy, its rationale, and the specifics of the treatment.
In conclusion, Groopmanís approach is commonsensical and intuitive, highlighting the importance of forming a physician-patient partnership. Humane medical care cannot be achieved without ensuring that the physician communicate openly and honestly without biases. Groopmanís book delicately balances the theoretical and practical aspects of medical care in the new millennia, along with its complexities and difficulties. This book is recommended for general practitioners and specialists in all fields of medicine. The book may also be helpful for a lay person who is struggling to form a partnership with his/her physician. Medical care has grown in complexity over the past twenty five to thirty years due to technological advancements and the physicianís constant time constraints. After thirty years of practicing as a physician, Groopman
recognizes the benefits of treating the patient as a partner to improve his thinking, and to protect him from cognitive pitfalls. He has also learned to open his mind to understanding his patientís problems and emotional needs. There is no better way to care for those
who need to be cared for.
Irene S. Switankowsky, University of Wales, Lampeter