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Product Description
How Doctors Think is a window into the mind of the physician and an insightful examination of the all-important relationship between doctors and their patients. In this myth-shattering work, Jerome Groopman explores the forces and thought processes behind the decisions doctors make. He pinpints why doctors succeed and why they err. Most important, Groopman shows when and how doctors can — with our help — avoid snap judgments, embrace uncertainty, communicate effec… More >>
#1 by Mary Whipple on October 15th, 2010
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This alarming statistic introduces Dr. Jerome Groopman’s compelling analysis of how doctors think–and what this means for patients seeking diagnoses. Groopman is curious to discover how one doctor misses a diagnosis which another doctor gets. Interviewing specialists in different fields, he analyzes the ways they approach patients, how they gather information, how much they may credit or discredit the previous medical histories and diagnoses of these patients, how they deal with symptoms which may not fit a particular diagnosis, and how they arrive at a final diagnosis.
Throughout, he considers the doctors’ time constraints, the pressures on them to see a certain number of patients each day, the limitations on tests which are imposed by insurance companies or by hospitals themselves, and the many options for treating a single disease. He is sympathetic, both toward the patient and the physician, and, because he himself has had medical problems, he provides insights from his own experience to show how physicians (and patients) think.
Case histories abound, beginning with the 82-pound woman, whose celiac disease was not diagnosed for fifteen years. Here Groopman analyzes the uses and misuses of clinical decision trees and algorithms used by many doctors and hospitals to assess probabilities and make decision-making more efficient. Sometimes, however, it is necessary for a doctor to depart from the algorithm and obey intuition. Recognizing when the physician is “winging it”–depending too much on intuition and too little on evidence–is a challenge for both patients and other physicians. Ultimately, Groopman focuses on language as the key to diagnosis, showing that when patients and physicians can communicate and truly share information, they have a better chance to come to correct diagnoses and appropriate treatments.
The success of Groopman’s book attests to the need for discussion of these issues, but I am not sure Groopman realizes the difficulty patients have in finding ideal doctors whose personalities, thinking, and communication styles are compatible with their own. Most of us are referred to specialists by our primary care physicians (some of whom we see only once a year and do not know well), and it is not possible to interview several specialists to find the one most compatible. We accept the appointment our primary care physician has set up for us, often with the specialist who has the earliest available appointment. Patients with urgent problems may have fewer choices than Groopman seems to think they have. Though we all search for the ideal, ultimately we must hope that our own diagnoses are not among the “problem fifteen percent.” (4.5 stars) n Mary Whipple
Rating: 5 / 5
#2 by A Family Physician on October 16th, 2010
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Jerome Groopman’s “How Doctors Think” has been given generally favorable reviews in the lay press and many readers have echoed that praise. From this physician’s point of view, the book is a disappointment.
On the positive side, Dr. Groopman’s book is an attempt to bring to light some issues surrounding errors in medicine, a topic that is not discussed often enough in the medical and general literature. He discusses how physicians can make cognitive errors when they attempt distill an array of scattered bits of information in order to arrive at a conclusion to the question: what condition is this patient suffering from? He also tries to identify forces in the current American medical system that undermine a physician’s ability to think more broadly and deeply about a patient’s illness. His limited efforts in these areas can be a helpful starting point for patients, medical students, and physicians who are beginning to grapple with a simple fact: doctors are human, and they make mistakes.
On the negative side, Dr. Groopman offers little in the way of concrete suggestions for clinicians to fix the problems he identifies. He indicates the current system is driving physicians to see more patients in less time, but offers no realistic proposals for doctors or patients that would allow for a less hurried atmosphere. He makes a number of suggestions on how physicians can think more clearly: think outside the box, be wary of “going with your gut”, don’t judge a patient by her outward appearance, be prepared in your mind for the atypical patient, consider the possibility of more than one diagnosis, and other pearls of wisdom. While they are good recommendations, they fall far short of a concrete program for improving one’s diagnostic skills and thought processes. His only idea for improving medical training seems to be to push clinicians to ask themselves the above questions more often. If this was new, it would be worthy of all the praise that has been heaped on this book, but it honestly is not very new, and is simply a variation on the same ideas of how to better train clinicians that we have been working with since at least the 1970s. Given the current state of the American medical system, these old ideas clearly aren’t enough, and Dr. Groopman’s recommendations that we continue this strategy, only with more emphasis than before, leaves the reader desiring useful solutions feeling like he has been pushed out into the stream with only a toothpick for a paddle.
Perhaps a physician’s yearning for some answers from Dr. Groopman is asking too much. But even from a patient’s point of view, given the harrowing stories that lead up to his epilogue, the few extra questions he suggests patients use to push the physician (“Is it possible I have more than one problem?”) seem unimpressive. Given the severity of time constraints that Groopman very correctly describes, his dearth of suggestions for patients to assist their doctors and work as a team to make the most of their short time together makes this book of only limited value for the non-physician as well.
One of the great shames of the book is that, despite his clearly delineating the problems physicians face, Dr. Groopman rejects the modern tools that have been developed to aid physicians in diagnosis: evidence-based medicine, clinical algorithms, and practice guidelines. He glibly dismisses these tools again and again, arguing they “constrain” a doctor’s thinking and fail “when symptoms are vague… or when test results are inexact.” He goes at length to describe one oncology fellow using a particular hematology scoring system to make a poor choice of a treatment plan for a particular patient. Yet the text makes clear the fellow was applying the scoring system incorrectly. Dismissing diagnostic tools because some people misuse them is like telling someone a wrench is not a useful tool for anything because someone once used a wrench to hammer in a nail. Diagnostic tools and practice guidelines, when used in a measured way, can help physicians accurately diagnose many patients without subjecting them to a punishing series of unnecessary diagnostic procedures. Evidence-based medicine helps us determine what works and, perhaps even more importantly, what doesn’t. Instead of a balanced discussion of the benefits and limitations of such diagnostic aids, he simply throws the baby out with the bath water.
The most insidious aspect of the book is the underlying suggestion that when a patient does not get a swift, accurate diagnosis of what ails them, it can always be traced back to some logical or other intellectual error on the part of the physician. The fact is some conditions will, for the foreseeable future, elude our best efforts to diagnose them. He brings up an example of a man with chest pain who was sent home from the ER, but then had a heart attack several hours later. In truth, we cannot differentiate all patients with cardiac chest pain from those without cardiac chest pain with 100% accuracy. This is never stated in the text, and only briefly mentioned in the chapter notes buried at the end of the book. Right now, somewhere in America, even with the best tests and the best diagnostician at the bedside, someone with chest pain will be sent home from the ER, only to have a heart attack a short time later. While Dr. Groopman goes on at length to humanize the patients he writes about, his overall argument dehumanizes physicians, holding them up to standards of accuracy that our current body of knowledge cannot support.
Even if it isn’t providing many useful solutions, this book is at least raising some important questions. Take this book with a grain of salt (and perhaps even two tablets of aspirin). It is encouraging that we are openly discussing the subject of errors in medicine. It would be a great shame, though, if this book were the last word on the subject.
Rating: 2 / 5
#3 by prisrob on October 16th, 2010
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“Patients and their loved ones swim together with physicians in a sea of feelings. Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents”. Jerome Groopman
The Patient: as an undergrad in college in my nursing program, I was educated to understand that I always needed to listen to my patient, really listen. That philosophy has always served me well. Health care providers tend to be controlling, and when we, the patients, are given a diagnosis that shakes us to our core we need some control. As patients we need a physician and health care team that has the patient as the leader of the team. We listen to all of the recommendations and weigh the evidence as best we can. In the end we need to be able to trust our physicians and have a relationship that allows humor and sadness, questions and answers and honest give and take. It is a relationship like no other- it is sometimes life and death.
Jerome Groopman has written a book for everyone. Everyone needs to be their own advocate for their healthcare. His ideas that the way physicians think result in the treatment and care for each and every one of us. “Every doctor makes mistakes in diagnosis and treatment,” he writes. “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.” He discusses the physicians who ‘read’ x-rays and CT’s and MRI’s, the radiologist. An exacting science is needed here. A radiologist with experience can pick up a disease process by the thickness of a rib. There is an accepted ‘error’ ratio in this science, and none of us want to be in that error ratio. There is a computer program to assist in diagnosis, but it is not perfect. We all want and need the experienced radiologist. When I entered the world of health care I learned that medicine is 50% rule out or question of. It remains in that corner. That is how we want our physicins to think-rule out #1,2,3 and come to a conclusion based on science, best practice and their ability to put it all together for us, the individual.
He helps the layperson understand doctors’ thinking with simple and accessible terms that suggest why it sometimes leads to undesired outcomes. As David Kessler in his reviews states “He introduces us to terms such as “diagnosis momentum” — when a diagnosis becomes fixed in the mind of the physician despite incomplete evidence. Or “availability,” which means the tendency to judge the likelihood of a medical event by the ease with which relevant examples come to mind. He takes phrases patients often hear, such as “we see this sometimes” and puts forth the idea that such generic comments deserve further questioning from the patients.”
Dr Groopman has written of fascinating case studies and the physicians who were part of them. The errors and the asute diagnoses are compiled in story after story. Physicians are open about the way and the analytical methods they use in deliniating the final diagnosis. It is difficult to forget the misfortunes of some patients. We understand a little more completely the real-life drama that physicians face in their mistakes and when their diagnosis is right on.
We learn about Bayesian Perspective thinking. “We all like to know how reliable and how risky certain situations are, and our increasing reliance on technology has led to the need for more precise assessments than ever before. Such precision has resulted in efforts both to sharpen the notions of risk and reliability, and to quantify them. Quantification is required for normative decision-making, especially decisions pertaining to our safety and well being. Increasingly in recent years Bayesian methods have become key to such quantifications.” says Dr Groopman. The thought processes of physicians is an insight few of us have thought about. We should all be prepared for our next encounter.
It was refreshing to learn of Dr Groopman’s frustrations with his medical care, and the four different opinions he received about his right hand. He carefully delineates how each physician came to their conclusion, and this is the type of thinking we need to engage in. We all have our stories of healthcare, and this book will give us more insight into the ‘whys and wherefores’ of our physicians’ thought processes.
“Dr. Groopman gives a brief mention of how modern evidence-based medicine competes with the art of using your intuition. He touches on how drug and insurance companies pressure doctors as he explores their influence via big drug company sales representatives. I would have liked him to have written more about the influence of insurance companies, an area barely touched on, and about finances. This might have given readers a more complete picture of the intersection of medicine and finances.” David Kessler
Most of us will be left with more respect for the art of medicine, and the careful consideration Groopman’s doctors give to their patients. “How Doctors Think” is a book every patient needs to read. We, the patients have much more power than we know, and we can change the shape of the physician/patient relationship. We need to come to the doctor’s office prepared to ask the right questions so that our physician’s thought processes will be beneficial to both of us.
Highly Recommended. prisrob 4-01-07
The Anatomy of Hope: How People Prevail in the Face of Illness
The Measure of Our Days: A Spiritual Exploration of Illness
Rating: 5 / 5
#4 by R. Albin on October 16th, 2010
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This book is essentially a collection of Groopman’s New Yorker pieces. While most of these essays focus on diagnostic error, some of the essays and parts of a majority discuss topics such as physician-patient relations and the impact of financial incentives on practice. The recurrant theme is what Groopman refers to as cognitive errors in diagnosis. Groopman provides a series of well written vignettes that illustrate a number of pitfalls in diagnosis. Groopman is highlighting a significant problem and one that deserves public discussion.
This is not, however, a systematic discussion of these issues. For example, what types of the cognitive errors described by Groopman are the most common? What factors predispose physicians to these errors? Are some specialties more prone to different kinds of errors? Groopman doesn’t provide any information that might be useful either for physicians and patients in reducing the frequency of such errors.
While Groopman may not have seen his task as necessitating recommendations to improve the present situation, the lack of serious discussion about improving diagnosis is a serious defect. All Groopman has to offer are nostrums about the requirement to listen to patients and that patients should forward in engaging their physicians with questions.
Even more disappointing is Groopman’s attitude towards the most serious effort to rectify this kind of problem, the evidence-based medicine movement. For example, Groopman makes several dismissive remarks about the introduction of Bayesian reasoning in diagnosis and management. This is misunderstanding of the role of Bayesian analysis. Despite what Groopman writes, there is nothing novel about Bayesian reasoning in medicine. Bayesian reasoning is actually implicit in a great deal of traditional diagnostic thinking. Formal Bayesian analysis is an effort, like much evidence based medicine, to make implicit assumptions explicit and then subject them to critical analysis. The evidence based evidence movement is an effort to make physicians self-critical about what they do on a day to day basis. This is precisely what Groopman claims is needed in clinical practice but he seems intent on disparaging the only viable path to obtaining the result he thinks is needed.
The only alternative is to retreat to some form of traditional authoritarianism.
Rating: 2 / 5
#5 by Gaetan Lion on October 16th, 2010
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This is a well written and very informative book on how doctors arrive at a diagnostics. Groopman, a doctor, acknowledges that 20% of diagnostics are incorrect. He explains why this happens by interviewing various medical experts. These describe how they arrive at diagnostic decisions and how they have made errors during their career.
From reading this book, you get that the main reason doctors make errors is time constraint. In our productivity driven health care system, doctors don’t have the time to cogitate the potential diagnostic of patients’ illnesses. Additionally, human physiology is incredibly complex. Each patient is unique and reacts differently to his environment, and treatment. Thus, medicine is a science of rules but with more exceptions than rules. Also as an offshoot of cost containments, doctors are discouraged to order more tests than is viewed as necessary by the health insurers. As a result, doctors make complex decisions with limited time and information. This combination of factors easily explains the 20% error rate.
A doctors’ thinking mode diverges much from his medical training. In medical school doctors are taught to crack complex disease diagnostics following deductive reasoning. They are given written data on a patient, and they arrive at a diagnostic within 20 to 30 minutes of thorough analytical deliberation. However, in the real world they typically arrive at a diagnostic within 30 seconds. They don’t think at all in a slow deductive reasoning mode as they were trained. Instead, they think in an intuitive light speed pattern recognition mode that immediately zeroes in on two or three potential diagnostics. Within the 30 seconds, they narrowed it down to one. Their light speed pattern recognition thinking reflects two things: first, the chronic time pressure they work under (they don’t have 30 minutes to deliberate); and second, how they gather information in the real world. The physical appearance, body language, communication style of the patient will give them a ton of qualitative information that they don’t get when cracking a diagnostic in med school using just data.
The author analyzes with his interviewees the different cognitive errors doctors make. A common one is the commission bias as doctors are prone to be decisive and action oriented. A surgeon will operate because that’s what he does. Sometimes, doing nothing is the best policy (doing no harm). But, that’s perceived as incompetent by both patients and doctors. Another prevalent error is “diagnostic momentum” where the very first diagnostic delivered by the primary care physician sends all following specialists taking care of the patient down the wrong path. Another interesting one is the “zebra retreat” where a doctor does not dare to investigate further a situation because his hypothesis represents a wild outlier (a zebra); Instead, the doctor falls back into another comfortable error “satisfaction of search” where the unrevised diagnostic fits pretty well allowing him to move forward even though it is the wrong one. The “availability error” is what is most available in a doctor’s mind based on recent experience and association with a similar case. It plays into the doctor’s pattern recognition mode. The author mentions many other interesting ones that are common to other professional fields.
In chapter 8, the author indicates that technology is not so helpful. The diagnostic error rates associated with the interpretation of X rays, EKGs, MRIs, mammograms, biopsies under microscope are far higher than what one expects. Two radiologists or pathologists often reach different conclusions. Sometimes even the same ones can arrive at different conclusions at different times (after reinterpreting their earlier findings).
In chapter 9, the author investigates economic incentives that distort the judgment of doctors. This includes Big Pharma relentless marketing of prescription drugs through persistent marketing reps. This also entails Big Pharma’s effort to medicalize what is the normal process of aging. The author mentions the concept of Andropause (male menopause) that has no scientific bearing; but, doctors have aggressively treated this condition with testosterone supplements. These are useless. Economic incentives also lead surgeons to conduct operations way too often that provide no benefit to the patients. The author mentions spinal fusion and radical mastectomy among the surgeries that are way overdone in the U.S. Spinal fusion does not work better than not operating to eliminate low back pain. Oddly enough, insurers are responsible for excess surgeries as they offer higher reimbursement rates for invasive surgeries than for alternative therapies. The author also mentions the occasional nefarious networking between lawyers, radiologists, and surgeons creating a cycle of referrals, aggressive X ray diagnostics, and resulting unnecessary spinal fusion operation surgeries. Everybody makes money, and the patient believes his back problem was well taken care off.
Thus, diagnostic errors are a function of four factors: 1) the time and cost pressure associated with today’s medical environment, 2) the complexity of human physiology, 3) the cognitive errors that the human brain makes across any profession, and 4) distorted economic incentives generated by Big Pharma, insurers, lawyers, and doctors themselves.
To prevent diagnostic errors ask the right type of open-ended questions suggests the author. These include: What else could it be? Is there anything that does not fit the current diagnostic? Is it possible I have more than one problem? These questions will force the doctor’s thinking to slowdown his pattern recognition reflex and allow for more deliberation about a condition. These questions will also fight most of the mentioned cognitive errors that are all associated with expediting a diagnostic so as to move on to the next patient.
If you want to further understand medical errors due to economic incentives I recommend another book “What Doctors Don’t Tell You” by Lynne McTaggart. Another excellent book on a similar subject is “The Last Well Person” by Nortin Hadler.
Rating: 5 / 5