Thursday, May 17, 2007

How Doctors Think

by Jerome Groopman. (Houghton Mifflin)

A jolt of insight accompanied a book review that I read this morning in the New York Times online edition.
The book was recommended by one of the members of the COPD-International forum -
it will be well worth the read.
The author, Jerome Groopman is professor of medicine at Harvard University and a staff writer for The New Yorker magazine.
His book is about what goes on in a doctor's mind while he is treating a patient - “a window into the medical mind,” revealing “why doctors fail to question their assumptions, why their thinking is sometimes closed or skewed, why they overlook the gaps in their knowledge.”

He goes on to explain:
"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."

"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. "

He is led to ask the 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?"

Reading the review and the first chapter of the book provided in another preview gave me new insight into the workings of the collective "medical mind" along with new thinking to consider when I next approach my own doctor for care.

"How Doctors Think" is available on and other online booksellers, in addition to local bookstores and the public library.
I'd say it comes close to being a must read for those of us who live with chronic disease.