How Doctors Think

Most doctors are highly educated, hard working people. They may sometimes get a bit tetchy because they overwhelmed by the demands made on them, but most of the time they do their best. Yet in our blame culture there are places in America where you can't get a specialist to treat you: they have all been driven out of business by lawyers representing unhappy clients. The question of why this has come to pass has occupied the minds of the American medical profession for three decades. For more than a decade, Groopman's trenchant analyses have always been illuminating, and he has a rare gift for communicating them. This is one of the best books that he has written, about one of the issues that may lead to medical errors: simply not thinking well. It is a very real factor. We all - and not just doctors - jump to conclusions; believe what others tell us and trust the authority of "experts." Clinicians bring a bundle of pre-conceived ideas to the table every time that they see a patient. If that have just seen someone with gastric reflux, they are more likely to think that the next patient with similar symptoms has the same thing, and miss his heart disease. And woe betides the person who has become the "authority" on a particular illness: everyone coming through his or her door will have some weird variant of the disease. As Abraham Maslow once said, "If the only tool you have is a hammer, you tend to see every problem as a nail." To that we have to add that not all sets of symptoms fall neatly into a diagnostic box. That uncertainty can cause doctors and their patients to come unglued. Sometimes when doctors disagree it is based not on facts, but on different interpretations of this uncertainty. On this one topic the book is very good as far as it goes, thought I do think that the analysis is incomplete. I have taught medical students and doctors on five continents, and this book does not address some of the very marked geographic differences in medical practice. While I think that the book is terrific, let me point out some of the ways in which it is "Americano-centric." The first point is that the evidence base in medicine is like an inverted pyramid: a huge amount of practice is still based on a fairly small amount of empirical data. As a result doctors often do not know want they do not know. They may have been shown how to do a procedure without being told that there is no evidence that it works. As an example, few surgical procedures have ever been subjected to a formal clinical trial. Although medical schools are trying to turn out medical scientists, many do not have the time or the inclination to be scientific in their offices. In day-to-day practice doctors often use fairly basic and sometimes flawed reasoning. A good example would be hormone replacement therapy. It seemed a thoroughly good idea. What could be better than re-establishing hormonal balance? In practice it may have caused a great many problems. Medicine is littered with examples of things that seemed like a good idea but were not. Therapeutic blood letting contributed to the death of George Washington, and the only psychiatrist ever to win a Nobel Prize in Medicine got his award for taking people with cerebral syphilis and infecting them with malaria. The structure of American medicine does not support the person who questions: consensus guidelines and "standards of care" make questioning, innovation and freedom very difficult. A strange irony in a country founded on all three. The second major factor in the United States - far more than the rest of the world - is the practice of defensive medicine: doctors have to do a great many procedures to try and protect themselves against litigation. This is having a grievous effect not only on costs, but also on the ways in which doctors and patients can interact. Third is the problem of demand for and entitlement to healthcare. We do not have enough money for anything: but what is enough if the demand for healthcare continues to grow as we expect? And if people are being told that it is their right to live to be a hundred in the body of a twenty year-old? Much of the money is directed in questionable directions. There are some quite well known statistics: twelve billion dollars a year spent on cosmetic surgery, at a time when almost 40 million people have no health insurance. There are some horrendous problems with socialized medicine, but most European countries have at least started the debate about what can be offered. Should someone aged 100 have a heart transplant? Everyone has his or her own view about that one, but it is a debate that we need to have in the United States. Fourth is the impact of money on the directions chosen by medical students and doctors starting their careers. Most freshly minted doctors in the United States have spent a fortune on their education, so they are drawn to specialties in which they can make the most money to pay back their loans. In family medicine and psychiatry, even the best programs are having trouble filling their residency training programs. Many young doctors are interested in these fields, but they could die of old age before they pay off their loans. Fifth is the problem of information. It is hard for most busy doctors in the United States to keep up to date on the latest research, and many are rusty on the mechanics of how to interpret data. So much of their information comes from pharmaceutical companies. Many of the most influential studies have been conducted by pharmaceutical companies, simply because they have the resources. But there have been times when data has therefore appeared suspect. Industry is not evil, but companies certainly hope that their studies will turn out a certain way, and the outcome of any study depends on the questions asked and the way in which the data is analyzed. And like any collection of people, it is easy to fall into a kind of groupthink. There are countless examples of highly intelligent individuals who all missed the wood for the leaves. "Our product is the best there's ever been, and we are all quite sure that the stories about side effects are just a bit of "noise" created by our competitors." That topic alone could provide much grist for Dr. Groopman's mill. Another related problem is that many scientists are now also setting up companies to try and profit from the discoveries that they have made in academia. Most are working from the highest motives, but sometimes there are worries about impartiality. So once again, the unsuspecting physician may add data to the diagnostic mix without knowing its provenance. There have recently been a number of high profile examples of that. It could well be that Groopman will cover all of these points and more in his next book, and I can, of course, be accused of criticizing him for not writing the book that "I" wanted! This is a book that should be read by every doctor and patient in America. It is also good to know that there are other ways of thinking about some of the problems before us. Very highly recommended.

I purchased both the book and the audio CD. After listening to the CD I circulated an e - mail to my friends saying : " Everybody ought to read How Doctors Think by Dr. Jerome E. Groopman. Read it whether you are a doctor or not. As a doctor or as a patient you may have experienced similar unfortunate events explained in the book. In that case read the book to never go through the same events. If you have not gone through such experiences read the book so that you will never have to suffer from similar inconveniences." Although a recent book "How doctors think " by Dr. Jerome E Groopman of Harvard Medical School has already caught a lot of attention and has been translated to different languages and is being sold in various countries. I am not a doctor. As patients my family and I have had to resort to the services of doctors many times. Not necessarily for big illnesses, sometimes only for check ups. In general we are quite healthy. I was attracted by the title of the book. Dr. Groopman explains very clearly what goes on in the minds of both the doctors and their patients and how their thinking styles affect their communication, the diagnoses and treatments. He gives many examples from many different branches of medicine. Everybody would agree with the assertion that better communication between patients and doctors is necessary. But how ? It is the how that Dr. Groopman explains. He shows the flawed thinking patterns in many doctors' thinking with actual detailed case studies leading to wrong diagnoses and treatments and how the doctor's thinking and reasoning should have been in each case. He says that some doctors jump to conclusions when they find a possible cause for a malady without searching for alternative causes that maybe more likely. He proposes a thinking method which generates many alternative explanations and working through the most likely ones before reaching a conclusion. This method seemed to me very similar to some of the correct thinking methods explained by a leading authority on the thinking subject : Dr. Edward de Bono. Another issue that Dr. Groopman emphasizes is the need for better listening skills for doctors. On the average they interrupt their patients 18 seconds after they start to talk and often miss out on important information that maybe crucial for a correct diagnosis. As a patient I can not agree more. Patients also have a responsibility in effective communication but I think doctors have the upper hand in this matter so doctors need to read this book more carefully than patients. In my experience the doctors' interruptions can sometimes be very rude : several years ago I went to an ear, nose, throat specialist with an ear ache. After inspection he told me I had a certain kind of ear infection. I wanted to express my thoughts on the disease and said : " Doctor, as far as I know about this infection..." He abruptly interrupted and said : " Let's not deal with his infection with what you know about it but rather with what we doctors know about it ". In another case, my family and I had gone to a summer holiday village for vacation. The air temperature dropped for several days and half of the hundreds of tourists including us in the holiday resort began to cough and have fevers. I phoned the holiday camp doctor from our room and said : " Good day doctor. My family and I are coughing with a fever. Half the tourists in the resort are also. The weather is so cold. There seems to be a flu epidemic. Do you think it is a viral or bacterial infection ? " He replied : " Are you a medical expert ? I am the doctor around here and I am the best judge. I say there is no epidemic. People can get ill that is normal ". In his book Dr. Groopman, in my opinion correctly says that there is no 100 % certainty in medicine. Even the most competent doctors can make wrong diagnoses. If the frequency of mistakes is too high then we can conclude the incompetence of the doctor. This may sound like stating the obvious but Dr. Groopman further states that despite the remarkable advances in medical technology such as brain imaging techniques etc. some doctors using these can still make the wrong diagnoses not because they are incompetent but because some of them see their patients as statistics or case studies not as real human beings. They fail to understand them as human beings. Dr. Groopman talks about the wrong thinking methods here. However, as a patient I would like to add that some doctors also have bad intentions. Most doctors I dealt with were honest and helpful, but I also came across in psychiatry several who had bad intentions. I have personally seen the improper utilization of advanced knowledge and technology : in psychiatry Quantitive EEG of the brain, questionnaires filled out by the patients such as the Beck Depression Inventory, The Beck Anxiety Scale, The Obsessive Compulsive Disorder questionnaire, the Minnesota Personality Test etc. are powerful tools at the disposal of a pychiatrist to help him / her diagnose, provided that they are properly evaluated. After these tests were implemented, I understood from the very superficial and wrong comments made by the psychiatrist that he had not carefully analyzed the tests and questionnaires. He did not understand us better after those tests. It is not the tests that were wrong, they could have been very useful had he taken the time to analyze them properly. Then why did he order these tests and the QEEG ? Because the hospital charges the patients for all those tests. They make money from the tests. I would not regret paying for them had they been properly evaluated. As patients we have the responsibility to properly listen and implement our doctors' instructions such as taking the medications given in the right doses,times and durations, stop smoking and using substances, do the exercises and diet given by the doctors. But the doctors have to listen to us first. Our primary responsibility as patients is to find doctors who not only think correctly most of the time but who are also honest and competent. In his book Dr. Groopman explains how smart patients can proactively participate in their dignoses by guiding doctors' thinking with relevant questions such as " could it be anything else ? ". If the doctor feels insulted or annoyed by such questions from the patient,as was in my case, then go to another doctor until you find one who does not feel insulted by relevant patient questions. This is perhaps esspecially needed in psychiatry : there are many competent psychiatrists but many others wrongly prescribe psychiatric medication or start irrelevant psychotherapies for what turns out to be physical illnesses that mimic the symptoms of a psychiatric disorder. The irresponsible psychiatrist overlooks it because he / she does not consider the possibility of a somatic illness by ordering blood tests. In such situations Dr. Groopman's advice to patients to ask " Could it be anything else ? " to their doctors is most relevant. Thank you Dr. Jerome E Groopman for writing a much needed book. I hope many doctors and patients around the world will read it and revise their approaches towards communication with one another.

I picked up How Doctors Think by Jerome Groopman, MD as a fluke. Having accumulated more books than I can read, they gather dust on shelves or in boxes in my basement. But, around the holidays, I found myself with a gift card from Barnes & Noble, and I wandered its aisles, looking for something to grab me. It was there I spotted Dr. Groopman's book. I work in health care, in finance and have since 1988. This book a look at how physicians are trained, and how their training as well as their experience impacts the way physicians think, and diagnose their patients. Dr. Groopman put it this way. "This book is about what goes on in a doctor's mind as he or she treats a patient."(p3) The book is about cognitive errors physicians make and how patients can contribute to their physician's successful diagnosis and treatment. The author, a practicing oncologist posits comments on how healthcare economics undermines the chances of avoiding the mental errors that lead to incorrect diagnoses. (People like me get labeled "bean counter" with great aplomb. [pp90, 100, 127]) Jerome Groopman chronicles how patients access physicians, through hospital emergency rooms, primary care doctors, surgical specialists, and radiologists. During this discourse, he labels a number of thinking models, common to physicians and the intellectual errors that are linked to those models. Additionally, he spends a significant amount of time discussing how the modern practice of medicine exacerbates the conditions that may lead to misdiagnosis. Dr. Groopman repeatedly dicusses a cognitive model for diagnosing patients followed by a criticism of the model's weakness, demonstrated by a misdiagnosed patient. He criticizes the evolution of quality programs and "evidence-based medicine" programs in hospitals across the country. "Physicians should caution themselves to be not so ready to match a patient's symptoms and clinical findings against their mental templates or clinical prototypes. This is not easy. In medical school, and later during residency training, the emphasis is on learning the typical picture of a certain disorder...'Common things are common'...'When you hear hoof beats, think about horses, not zebras...Powerful forces in modern medicine discourage hunting for [zebras]." (pp126, 127) He criticizes of the economic organization of medicine, today. "...deliberate analysis...requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes...Today, medicine is not separate from money. How much does intense marketing by pharmaceutical companies actually influence either conscious or subliminal decision-making? Very few doctors, I believe, prostitute themselves for profit, but all of us are susceptible to the subtle and not so subtle efforts of the pharmaceutical industry to sculpt our thinking." (p178) This book is not a "page-turner." Dr. Groopman's examples are interesting, though they make me as a non-clinician frustrated. His attacks on evidence-based medicine can feel like an attack on those that want to reduce medical uncertainty, and their motives. His description and sometimes praise for a model of diagnosis, usually to be followed by the parallel pitfalls of that model can leave me feeling in despair. The first time I tried to read it, it was over a month long period and I had only gotten half way through the book. It just didn't compel me. When I began rereading it, I pushed through and got it completed in about one and a half weeks, skipping several days. Dr. Groopman talks about how doctors know what they know, and discusses the general environmental characteristics that lead to intellectual errors in medicine. I have seen similar forces influencing the business and industry of health care. In seminars and webinars, I see ideology, groupthink, magical thinking, fashionable nomenclature and platitudes being used as substitutes for real strategic thought and planning, then becoming conventional wisdom. Many times the tools we all learned in business school are being ignored rather than to challenge the trendy idea being proffered. It is as if business strategy has more in common with finger painting than business science. This book was worth reading! This book reminds me that these problems, paradigm lock, unwillingness to challenge authority, blindness to extraneous data are pervasive. I need to listen more, respectfully question, learn from my own errors in thinking. I have drawn value from How Doctors Think. I just had to work to get at that value.

Patients are not items in an assembly line. Each individual is different externally and internally; the chemistry is also different. You cannot treat all of them using the same idea or technique or knowledge just as much as they are not molded using the same template or cookie cutter. You cannot relate the sound of hoofs merely to horses; they could be zebras. Good doctors have to think out of the box. What they studied in medical school, read in a medical journal, and heard from their peers' experiences can all be used as basis for diagnosis and treatment. But along with that, they also need to keep an open mind to think outside the box; to see that extraordinary situation that could happen to the patient. Just because it was never there before does not mean that it will never be there. Just because you have not heard something or seen something, does not mean that it doesn't exist. "For three decades practicing as a physician, I looked to traditional sources to assist me in my thinking about my patients: textbooks and medical journals; mentors and colleagues with deeper or more varied clinical experience; students and residents who posed challenging questions. But after writing this book, I realized that I can have another vital partner who helps improve my thinking, a partner who may with a few pertinent and focused questions, protect me from the cascade of cognitive pitfalls that cause misguided care. That partner is present in the moment when flesh-and-blood decision-making occurs. That partner is my patient or her family member or friend who seeks to know what is in my mind, how I am thinking. And by opening my mind I can more clearly recognize its reach and its limits, its understanding of my patient's physical problems and emotional needs. There is no better way to care for those who need my caring." -Dr. Jerome Groopman, M.D., author of `How Doctors Think'.- Dr. Groopman has nailed the critical point in this book. I have unfortunately heard doctors say, `I have not heard such a thing in my entire 30 years of practice'. Some of them are highly pressured by the organization that they work for, to come to a quick conclusion and let the patient go or make a hasty decision. They do not have time to think too much. Organizations that pressure them this way are trying to save money and not lives. Doctors are there to save lives. But unfortunately some doctors have to use the same cookie cutter or template to treat all the patients alike. Dr. Groopman's book is an eye-opener for doctors who have an ethical and moral obligation towards their patients; who have compassion towards other human beings. It is a great book with profound knowledge; it is an eye opener for both patients and doctors alike - a must read.

An eye-opening view into the decisions doctors make based on information from the patient as well as influences from tests, statistics and how they were trained. We would all like to think that when we tell the doctor something is wrong, that we are uniquely listened to, but the reality is, the doctor has many influences, sometimes the least of which being your story as you tell it. They will consider: * Your previous doctor's diagnoses * Various lab results * Urgency of your situation * Urgency of all the other patients they are treating that day * The time your insurance company gives them to consider your care * Their previous training Since they are human, they are also influenced by: * Whether they find you believable or not * Whether they like you or not * How challenging your case seems. Doctors don't like to fail. Not surprisingly, doctors will tend to lean toward previous opinions even if they are wrong. They also wonder if the patient is being compliant with the doctors recommended regimen of care. This can greatly influence whether they determine if the regimen is the right one for the patient. In fact, they might opt to continue a treatment that is cleary not working, assuming the patient is not being compliant. They also tend to: * Assume there is only one thing wrong with you, though your symptoms might in fact be caused by more than ailment. * Assume due to statistics, that you have the more common ailments rather than something more exotic * May opt not to order painful or uncomfortable tests for people they like. For the most part, doctors treat patients in a very linear fashion. If you come in with complaints associated with your lower abdomen, they are going to look at your lower abdomen. But, a human being is a system. Issues in one area can cause problems in another and seem quite unrelated. It takes a dedicated doctor, to detach from previous diagnoses and look at the entire person, to try to determine what is wrong. It sometimes when it comes to reading tests, X-rays and all the data available, becomes a question of what does not look right, rather than what fits the diagnoses. There is also the case of considering the patients overall health and wishes when considering aggressive treatment versus palliative care in a disease that is sure to end in death. One person may wish to pull out the stops to live another 6 months, while another would rather have 2 months in little pain. Hard choices but doctors must allow the patient to guide this course, or be sensitive enough to a patient, to recognize this. Finally there is the part that money plays in the marketing of various drugs by drug companies. Doctors are deluged with information on many medicines. Some are medicines looking for a disease and patients will come to doctors asking for medicines by name, as they feel this treatment is what they need. It is hard to determine the right course of action, under this influence. In summary, this book covers so many situations and touches on the mistakes doctors can make. If you have been well treated by your doctor over the years, all these items noted above worked in your favor. However if you have issues that remain unresolved this book can help you understand the factors your doctor maybe dealing with. It can help you ask the right questions, or realize it is time to move on. Remember you are a partner in your own care and must advocate and educate yourself to do this in the best way possible.

There are doctors that follow the tune that the Medical Industrial Complex plays, and there are ones who buck the trend. Dr. Groopman is one of the latter, thankfully. In How Doctors Think, The New Yorker staff writer and Harvard professor of medicine & researcher Dr. Groopman offers a distinctive look into the structure of Big Medica in search for what exactly is the type of mindset Doctors employ when practicing their jobs. Groopman does a compelling job throughout the book in making sure he relates the plights plaguing medicine from both sides of the coin, from the patients perspective, as well as from the perspective of a physician. This aids in the book not being one sided. It helps greatly that he’s also a Doctor with experience in this very field. From medical, money, marketing, uncertainty, dogma, to various other components of medicine, Groopman attempts to turn over as many stones as possible in his search for what issues are the ones plaguing Doctors the most. A notable point in the book that hit close to home, which many people will relate to is the emotional tension that can arise at times between patients and their doctors. Essentially, whether patients and doctors like each other. Groopman relates what Social Psychologist, Judy Hall discovered regarding emotional tension: “..that those feelings are hardly secret on either side of the table. In studies of primary care physicians and surgeons, patients knew remarkably accurately how the doctor actually felt about them. Much of this, of course, comes from nonverbal behavior: the physician’s facial expressions, how he is seated, whether his gestures are warm and welcoming or formal and remote. “The doctor is supposed to be emotionally neutral and evenhanded with everybody,” Hall said, “and we know that’s not true.”[1] What’s worse, is that Hall’s research indicated: “…that the sickest patients are the least liked by doctors, and that very sick people sense this disaffection. Overall, doctors tend to like healthier people more.”[2] So much for quality health care. Along with the above example, the author additionally notes many other examples of issues that arise due to a crisis in communication which can arrive in myriad ways. In fact, one of these issues that Groopman relates is that: “…on average, physicians interrupt patients within eighteen seconds of when they begin telling their story.”[3] Another salient aspect of Big Medica that the author sunk his teeth into was the psychological aspect of medicine. Predictably, far too often doctors/western medicine view the patients psychological components as being apart from the body, rather than taking a much-needed holistic approach. Additionally, the institutional dogma that reigns down from the top is also touched upon in a few instances by the author. Open-mindedness is scoffed at, while conformity was expected. Recounting an example of choosing between the availability of multiple medical options regarding a particular treatment, Groopman relates something noted by physician Jay Katz, who taught at Yale Law school at the time: “In both [treatments]…we were educated for dogmatic certainty, for adopting one school of thought or the other, and for playing the game according to the venerable, but contradictory, rules that each institution sought to impose on staff, students and patients.”[4] Another disturbing component that doctors acquiesce to that is covered by Groopman is how doctors far too often give into to corporate interests. This very issue has covered by other doctors such as Dr. Brogan, Dr. Breggin, Dr. Mercola and many others. This book sheds much needed light into the inner workings of how doctors operate – how they think. While the author notes that a sizeable amount of the issues have a variety of roots at the outset, such as communication, what he conveys still leads to much concern within the Medical Industrial Complex. In the end, individuals will need to become much more proactive/responsible in their health if they plan to breakaway from the conventional medical system that puts profits over people. ____________________________________________________________________________________ Sources & References: [1] Dr. Jerome Groopman, M.D., How Doctors Think, pg. 19. [2] Ibid., pg. 19 [3] Ibid., pg. 17 [4] Ibid., pg. 153 Kindest Regards, Zy Marquiez TheBreakAway.wordpress.com

This book is a bit longer than it really needed to be, but it does provide good insight into how doctors are accustomed to approaching things, for better or worse. People do things a certain way because it seems to work for them most of the time, but the flip side is that there may be times when it doesn't. In addition to noting how and why doctors are taught or encouraged to approach diagnosing and treating people, there are a series of case examples, and one example is the long-running thread that it returns to repeatedly throughout the book, ultimately showing how "the usual" approach almost killed a patient until a different doctor entered the picture and set things right. Anyone considering a career in medicine should read this, but anyone who may ever, possibly become sick or see a doctor (meaning, everyone) should be aware that doctors can get on a wrong track or make assumptions or mistakes, and a person needs to be their own advocate and press for different approaches if the existing one isn't working. Can't expect miracles nor flawless, error-free care, but never hurts to question and re-assess things. This author has written many books, all seem highly rated, but this is the only one from him that I've read so far. We have some doctors in our family and more coming, and we are all patients at one point or another, so it's an interesting and helpful book. It is a bit longish and at times a bit redundant, but not oppressively so. The subject is compelling and the author is highly knowledgeable in the profession.

Through of series of moving stories, Dr. Groopman describes the real thinking processes of physicians. The practice of medicine is an art as well as a science, meaning that all physicians need to use their individual judgment in deciding how to proceed in difficult or ambiguous cases. Even though the lay public is used to thinking of X-rays or other diagnostic tests as providing definitive proof of the existence of (or lack of) an injury or illness, Dr. Groopman cites studies that challenge this idea (for example even the best radiologists had a diagnostic accuracy rate of 95%; and radiologists will even disagree with their own earlier determination on a case 5 to 10% of the time). Many diagnostic errors are due to the inadequacy of diagnostic tests or the lack of scientific data to guide decision making. However, other diagnostic errors occur because physicians, like all of us, are vulnerable to certain types of thinking errors. Starting in the 1970s psychologists Daniel Kahnemann, Amos Tversky, and others identified thinking habits, shortcuts, or heuristics, that all people engage in such as the availability heuristic ("the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind" p. 64), anchoring, or the confirmation bias. The problem is that these thinking habits sometimes cause thinking errors. Dr. Groopman describes these thinking patterns in the context of the practice of medicine. He describes examples where the thinking errors led to a misdiagnosis, but also where physicians were able to compensate for such thinking errors, leading to good outcomes. In reading this book, I found myself involved in the lives and health issues of the patients described. I was also moved by the acts of kindness and competence that Dr. Groopman described, such as the oncologists who "feels a desperate urge to always do the right thing," (p. 250) or the busy and renowned specialist who insisted that the patient take her time in telling her story, her entire story ("I want to hear your story, in your own words" p. 12). This is an engaging way to learn about thinking errors and the practice of medicine as well.