How Doctors Think

I accidentally stumbled upon Jerome Groopman's book, and picked it up figuring it might be worth reading. As a science researcher who's considered attending medical school, Dr. Groopman's book was insightful in confronting the many problems affecting physicians and medical schools today. After several chapters of meaningful stories, I came to chapter 5, `A New Mother's Challenge". I wish I had skipped this chapter.

Groopman begins by explaining the story of a woman, Rachel, who adopts a baby from Vietnam. This child is found with a severe immunodeficiency of unknown causes. Throughout the chapter, Groopman explains how Rachel, (whom we later find he met in their local synagogue), falls back on God and her faith throughout her new baby's ordeal. We later find Rachel thanking God for saving her child's life on September 11, 2001.

Of course, this was the same day some of God's most faithful flew two planes into the World Trade Center in His name, killing thousands of innocent people. Yet amazingly as a clinician and scientist, Groopman seems to continue to preach faith at the end of the chapter, failing to recognize that what saved this baby's life is the rational human mind (even if it is fallible at times) . The research scientists who studied science for years to develop laboratory tests to diagnose the illness, the physicians and nurses who applied medical science knowledge in their care of the baby, and ironically the mother Rachel, all guided the doctors to the right diagnostic answer to save her baby's life. YET it is this unknowable metaphysical `God' who gets thanked time and again for her baby's survival?? Besides this unfortunate, and unnecessary, preaching that undermines the flow of the book, Dr. Groopman's tales are of great value in learning the difficult decisions and potential cognitive errors medical doctors can face everyday. It arms the lay reader with great insights into practical ways to discuss a loved one's health and one's own health with their physicians.

When Dr. Jerome Groopman began his medical internship at the Massachusetts General Hospital, he placed a high priority on facts. While in medical school he had tirelessly tried to "store an encyclopedia in [his] mind" as so that when faced with patients, he could "open the mental book and find the correct diagnosis and treatment." Thirty years later he saw students and residents relying on statistics, algorithms, "evidence-based" guidelines -- tools he feared would shackle their cognitive processes. How do doctors think, he wondered? How SHOULD they think?

This book is the product of his thoughtful consideration of those questions. He read the available research and spoke with many colleagues about their theory and experience, assembling cases to illustrate his findings. There are many ways a doctor can fall into errors of cognitive process. Representativeness error matches the patient against a prototype and fails to consider other possibilities: a fit, active man is probably not having a heart attack. Attribution error leads a doctor to categorize the patient negatively: the disheveled patient with edema and an enlarged liver is probably an alcoholic. Affective error prevents the doctor from looking beyond favorable indicators for a liked or admired patient. These and other errors are based in social assumptions and pattern recognition, and in the general rule that when you hear hoofbeats, you should think of horses, not zebras. In these days of managed medicine, there is bias toward a linear approach and "satisfaction of search" -- settling for the first answer that reasonably accommodates the available data.

The detailing of these and other cognitive errors and shortcuts actually forms a small part of How Doctors Think. Dr. Groopman goes on to discuss situations where errors of thinking are likely to occur: the reading of X-rays and CT scans, the impact of marketing on medical decision making, the roles of variability and uncertainty in treating babies with malformed hearts, the treatment of cancer. The patients and their stories are well integrated with Dr. Groopman's discussion of his subject: how to partner with the patient for the best possible outcome.

This is not a book of medical horror stories, nor of doctor-bashing; not even of managed care-bashing. It's a measured exploration of the doctor's role, with a final chapter offering advice to patients on questions they might ask their doctors. Required reading for all parties in the health care team. Yes, that means you!

Linda Bulger, 2008

Dr. Groopman really delves into how doctors come to certain conclusions about a patient's diagnosis. He reviews various case studies and interviews various doctors to clearly drive the message that doctors need to think differently and patients need to ask questions that will enable doctors to think differently. He also mentions some questions that patients can ask to get a doctor to channel his or her thinking elsewhere. I highly recommend both patients and doctors read this book.

This subject is very dear to my heart because I spent over four years being misdiagnosed until I found a doctor who discovered the problem. Once discovered, my insurance company refused to pay for an operation I needed because they felt I was new to this "diagnosing" doctor and he hadn't tried enough drugs to cure me even when many of the other doctors had prescribed the same or similar drugs in the past without any results. I had taken my case to the Independent Physicians Review Board (IPRO) which is at the state level and the last resort for HMO rulings to be overturned. They even ruled against the operation and said I needed to try more drugs. What was interesting was that the operation was also suppose to fix a structural defect in addition to everything else. Since when are structural defects cured by drugs? I called IPRO on this and got the response (after several weeks) that they didn't know that was a problem.

I hope Dr. Groopman writes a sequel to this book on how insurance companies perpetuate the suffering related to how doctors are thinking. In essence insurance companies are also "diagnosing" problems incorrectly without ever seeing the patient by disagreeing with a doctor's conclusion (via paperwork) and what the doctor's recommended treatment should be.

I recommend you take charge of your health care and learn the pitfalls doctors and patients fall into. What an excellent book in my opinion.

As an MD and ocxcasional patient, I think this book is a must for all of us. I gave it out as a present to my MD friends, to my private physician and to a cousin who is a very knowledgeable RN. This book is written with modesty, humor and empathy, things which some of us lack. I am not sure that all lay people will get the gist of it, but I recommend it highly.

When we're sick, we want to believe the doctor knows best. With authority and confidence, they assess our symptoms and assign a course of treatment, and we go along, perhaps anxiously but comforted by their wisdom just the same.

In "How Doctors Think," Jerome Groopman (himself an oncologist for decades) reveals how rarely doctors are totally sure of their diagnoses--and how when they are, it may be the biggest problem of all. Doctors, like all of us, are prone to thinking errors; for example, they may jump to the most obvious conclusion, or stop thinking when they find "the answer," or any number of other common pitfalls. But when doctors stop thinking, it can result in harm to the patient. Groopman's book explores how and why these mistakes happen, and the consequences they can have.

Luckily, it's not all bad news: far from trying to cast aspersions on the reliability of the medical profession, Groopman firmly believes that doctors can not only train themselves to avoid thinking errors, patients can help them by asking pointed questions during an exam or follow-up. (Groopman touches on such questions throughout, then summarizes them in a brief epilogue.)

Groopman is undoubtedly a doctor before he is a writer, but his style is good-natured, and a wealth of real-life examples makes his sometimes abstract subject matter engaging. "How Doctors Think" is a sometimes surprising, sometimes disturbing, but ultimately optimistic discussion of the ongoing art form that is modern medicine.

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