Introduction
Anne Dodge had lost count of all the doctors she had seen over the past
fifteen years. She guessed it was close to thirty. Now, two days after
Christmas 2004, on a surprisingly mild morning, she was driving again into
Boston to see yet another physician. Her primary care doctor had opposed
the trip, arguing that Anne’s problems were so long-standing and so well
defined that this consultation would be useless. But her boyfriend had
stubbornly insisted. Anne told herself the visit would mollify her boyfriend and
she would be back home by midday.
Anne is in her thirties, with sandy brown hair and soft blue eyes.
She grew up in a small town in Massachusetts, one of four sisters. No one
had had an illness like hers. Around age twenty, she found that food did not
agree with her. After a meal, she would feel as if a hand were gripping her
stomach and twisting it. The nausea and pain were so intense that
occasionally she vomited. Her family doctor examined her and found nothing
wrong. He gave her antacids. But the symptoms continued. Anne lost her
appetite and had to force herself to eat; then she’d feel sick and quietly
retreat to the bathroom to regurgitate. Her general practitioner suspected
what was wrong, but to be sure he referred her to a psychiatrist, and the
diagnosis was made: anorexia nervosa with bulimia, a disorder marked by
vomiting and an aversion to food. If the condition was not corrected, she
could starve to death.
Over the years, Anne had seen many internists for her primary
care before settling on her current one, a woman whose practice was devoted
to patients with eating disorders. Anne was also evaluated by numerous
specialists: endocrinologists, orthopedists, hematologists, infectious disease
doctors, and, of course, psychologists and psychiatrists. She had been
treated with four different antidepressants and had undergone weekly talk
therapy. Nutritionists closely monitored her daily caloric intake.
But Anne’s health continued to deteriorate, and the past twelve
months had been the most miserable of her life. Her red blood cell count and
platelets had dropped to perilous levels. A bone marrow biopsy showed very
few developing cells. The two hematologists Anne had consulted attributed
the low blood counts to her nutritional deficiency. Anne also had severe
osteoporosis. One endocrinologist said her bones were like those of a
woman in her eighties, from a lack of vitamin D and calcium. An orthopedist
diagnosed a hairline fracture of the metatarsal bone of her foot. There were
also signs that her immune system was failing; she suffered a series of
infections, including meningitis. She was hospitalized four times in 2004 in a
mental health facility so she could try to gain weight under supervision.
To restore her system, her internist had told Anne to consume
three thousand calories a day, mostly in easily digested carbohydrates like
cereals and pasta. But the more Anne ate, the worse she felt. Not only was
she seized by intense nausea and the urge to vomit, but recently she had
severe intestinal cramps and diarrhea. Her doctor said she had developed
irritable bowel syndrome, a disorder associated with psychological stress. By
December, Anne’s weight dropped to eighty-two pounds. Although she said
she was forcing down close to three thousand calories, her internist and her
psychiatrist took the steady loss of weight as a sure sign that Anne was not
telling the truth.
That day Anne was seeing Dr. Myron Falchuk, a
gastroenterologist. Falchuk had already gotten her medical records, and her
internist had told him that Anne’s irritable bowel syndrome was yet another
manifestation of her deteriorating mental health. Falchuk heard in the doctor’s
recitation of the case the implicit message that his role was to examine
Anne’s abdomen, which had been poked and prodded many times by many
physicians, and to reassure her that irritable bowel syndrome, while
uncomfortable and annoying, should be treated as the internist had
recommended, with an appropriate diet and tranquilizers.
But that is exactly what Falchuk did not do. Instead, he began to
question, and listen, and observe, and then to think differently about Anne’s
case. And by doing so, he saved her life, because for fifteen years a key
aspect of her illness had been missed.
This book is about what goes on in a doctor’s mind as he or she treats a
patient. The idea for it came to me unexpectedly, on a September morning
three years ago while I was on rounds with a group of interns, residents, and
medical students. I was the attending physician on "general medicine,"
meaning that it was my responsibility to guide this team of trainees in its
care of patients with a wide variety of clinical problems, not just those in my
own specialties of blood diseases, cancer, and AIDS. There were patients on
our ward with pneumonia, diabetes, and other common ailments, but there
were also some with symptoms that did not readily suggest a diagnosis, or
with maladies for which there was a range of possible treatments, where no
one therapy was clearly superior to the others.
I like to conduct rounds in a traditional way. One member of the
team first presents the salient aspects of the case and then we move as a
group to the bedside, where we talk to the patient and examine him. The
team then returns to the conference room to discuss the problem. I follow a
Socratic method in the discussion, encouraging the students and residents
to challenge each other, and challenge me, with their ideas. But at the end of
rounds on that September morning I found myself feeling disturbed. I was
concerned about the lack of give-and-take among the trainees, but even more
I was disappointed with myself as their teacher. I concluded that these very
bright and very affable medical students, interns, and residents all too often
failed to question cogently or listen carefully or observe keenly. They were
not thinking deeply about their patients’ problems. Something was profoundly
wrong with the way they were learning to solve clinical puzzles and care for
people.
You hear this kind of criticism – that each new generation of
young doctors is not as insightful or competent as its forebears – regularly
among older physicians, often couched like this: "When I was in training
thirty years ago, there was real rigor and we had to know our stuff.
Nowadays, well …" These wistful, aging doctors speak as if some magic
that had transformed them into consummate clinicians has disappeared. I
suspect each older generation carries with it the notion that its time and
place, seen through the distorting lens of nostalgia, were superior to those of
today. Until recently, I confess, I shared that nostalgic sensibility. But on
reflection I saw that there also were major flaws in my own medical training.
What distinguished my learning from the learning of my young trainees was
the nature of the deficiency, the type of flaw.
My generation was never explicitly taught how to think as
clinicians. We learned medicine catch-as-catch-can. Trainees observed
senior physicians the way apprentices observed master craftsmen in a
medieval guild, and somehow the novices were supposed to assimilate their
elders’ approach to diagnosis and treatment. Rarely did an attending
physician actually explain the mental steps that led him to his decisions.
Over the past few years, there has been a sharp reaction against this catch-
as-catch-can approach. To establish a more organized structure, medical
students and residents are being taught to follow preset algorithms and
practice guidelines in the form of decision trees. This method is also being
touted by certain administrators to senior staff in many hospitals in the
United States and Europe. Insurance companies have found it particularly
attractive in deciding whether to approve the use of certain diagnostic tests or
treatments.
The trunk of the clinical decision tree is a patient’s major
symptom or laboratory result, contained within a box. Arrows branch from the
first box to other boxes. For example, a common symptom like "sore throat"
would begin the algorithm, followed by a series of branches with "yes" or "no"
questions about associated symptoms. Is there a fever or not? Are swollen
lymph nodes associated with the sore throat? Have other family members
suffered from this symptom? Similarly, a laboratory test like a throat culture
for bacteria would appear farther down the trunk of the tree, with branches
based on "yes" or "no" answers to the results of the culture. Ultimately,
following the branches to the end should lead to the correct diagnosis and
therapy.
Clinical algorithms can be useful for run-of-the-mill diagnosis and
treatment – distinguishing strep throat from viral pharyngitis, for example.
But they quickly fall apart when a doctor needs to think outside their boxes,
when symptoms are vague, or multiple and confusing, or when test results
are inexact. In such cases – the kinds of cases where we most need a
discerning doctor – algorithms discourage physicians from thinking
independently and creatively. Instead of expanding a doctor’s thinking, they
can constrain it.
Similarly, a movement is afoot to base all treatment decisions
strictly on statistically proven data. This so-called evidence-based medicine
is rapidly becoming the canon in many hospitals. Treatments outside the
statistically proven are considered taboo until a sufficient body of data can be
generated from clinical trials. Of course, every doctor should consider
research studies in choosing a therapy. But today’s rigid reliance on
evidence-based medicine risks having the doctor choose care passively,
solely by the numbers.
Statistics cannot substitute for the human being before you;
statistics embody averages, not individuals. Numbers can only complement a
physician’s personal experience with a drug or a procedure, as well as his
knowledge of whether a "best" therapy from a clinical trial fits a patient’s
particular needs and values.
Each morning as rounds began, I watched the students and
residents eye their algorithms and then invoke statistics from recent studies.
I concluded that the next generation of doctors was being conditioned to
function like a well-programmed computer that operates within a strict binary
framework. After several weeks of unease about the students’ and residents’
reliance on algorithms and evidence-based therapies alone, and my equally
unsettling sense that I didn’t know how to broaden their perspective and show
them otherwise, I asked myself a simple question: How should a doctor
think?
This question, not surprisingly, spawned others: Do different
doctors think differently? Are different forms of thinking more or less
prevalent among the different specialties? In other words, do surgeons think differently
from internists, who think differently from pediatricians? Is there one "best"
way to think, or are there multiple, alternative styles that can reach a correct
diagnosis and choose the most effective treatment? How does a doctor think
when he is forced to improvise, when confronted with a problem for which
there is little or no precedent? (Here algorithms are essentially irrelevant and
statistical evidence is absent.) How does a doctor’s thinking differ during
routine visits versus times of clinical crisis? Do a doctor’s emotions – his
like or dislike of a particular patient, his attitudes about the social and
psychological makeup of his patient’s life – color his thinking? Why do even
the most accomplished physicians miss a key clue about a person’s true
diagnosis, or detour far afield from the right remedy? In sum, when and why
does thinking go right or go wrong in medicine?
I had no ready answers to these questions, despite having trained
in a well-regarded medical school and residency program, and having
practiced clinical medicine for some thirty years. So I began to ask my
colleagues for answers. Nearly all of the practicing physicians I queried were
intrigued by the questions but confessed that they had never really thought
about how they think. Then I searched the medical literature for studies of
clinical thinking. I found a wealth of research that modeled "optimal" medical
decision-making with complex mathematical formulas, but even the
advocates of such formulas conceded that they rarely mirrored reality at the
bedside or could be followed practically. I saw why I found it difficult to
teach the trainees on rounds how to think. I also saw that I was not serving my own
patients as well as I might. I felt that if I became more aware of my own way
of thinking, particularly its pitfalls, I would be a better caregiver. I wasn’t
one of the hematologists who evaluated Anne Dodge, but I could well have been,
and I feared that I too could have failed to recognize what was missing in her
diagnosis.
Of course, no one can expect a physician to be infallible.
Medicine is, at its core, an uncertain science. Every doctor makes mistakes
in diagnosis and treatment. But the frequency of those mistakes, and their
severity, can be reduced by understanding how a doctor thinks and how he or
she can think better. This book was written with that goal in mind. It is
primarily intended for laymen, though I believe physicians and other medical
professionals will find it useful. Why for laymen? Because doctors
desperately need patients and their families and friends to help them think.
Without their help, physicians are denied key clues to what is really wrong. I
learned this not as a doctor but when I was sick, when I was the patient.
We’ve all wondered why a doctor asked certain questions, or
detoured into unexpected areas when gathering information about us. We
have all asked ourselves exactly what brought him to propose a certain
diagnosis and a particular treatment and to reject the alternatives. Although
we may listen intently to what a doctor says and try to read his facial
expressions, often we are left perplexed about what is really going on in his
head. That ignorance inhibits us from successfully communicating with the
doctor, from telling him all that he needs to hear to come to the correct
diagnosis and advice on the best therapy.
In Anne Dodge’s case, after a myriad of tests and procedures, it
was her words that led Falchuk to correctly diagnose her illness and save her
life. While modern medicine is aided by a dazzling array of technologies, like
high-resolution MRI scans and pinpoint DNA analysis, language is still the
bedrock of clinical practice. We tell the doctor what is bothering us, what we
feel is different, and then respond to his questions. This dialogue is our first
clue to how our doctor thinks, so the book begins there, exploring what we
learn about a physician’s mind from what he says and how he says it. But it
is not only clinical logic that patients can extract from their dialogue with a
doctor. They can also gauge his emotional temperature. Typically, it is the
doctor who assesses our emotional state. But few of us realize how strongly
a physician’s mood and temperament influence his medical judgment. We, of
course, may get only glimpses of our doctor’s feelings, but even those brief
moments can reveal a great deal about why he chose to pursue a possible
diagnosis or offered a particular treatment.
After surveying the significance of a doctor’s words and feelings,
the book follows the path that we take when we move through today’s
medical system. If we have an urgent problem, we rush to the emergency
room. There, doctors often do not have the benefit of knowing us, and must
work with limited information about our medical history. I examine how
doctors think under these conditions, how keen judgments and serious
cognitive errors are made under the time pressures of the ER. If our clinical
problem is not an emergency, then our path begins with our primary care
physician – if a child, a pediatrician; if an adult, an internist. In today’s
parlance, these primary care physicians are termed "gatekeepers," because
they open the portals to specialists. The narrative continues through these
portals; at each step along the way, we see how essential it is for even the
most astute doctor to doubt his thinking, to repeatedly factor into his
analysis the possibility that he is wrong. We also encounter the tension
between his acknowledging uncertainty and the need to take a clinical leap
and act. One chapter reports on this in my own case; I sought help from six
renowned hand surgeons for an incapacitating problem and got four different
opinions.
(Continues…)
Excerpted from How Doctors Think
by Jerome Groopman
Copyright © 2007 by Jerome Groopman.
Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Houghton Mifflin Company
Copyright © 2007
Jerome Groopman
All right reserved.
ISBN: 978-0-618-61003-7
