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''How Doctors Think'' is a book released in March 2007 by
Jerome Groopman Jerome E. Groopman has been a staff writer in medicine and biology for ''The New Yorker'' since 1998. He is also the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School, Chief of Experimental Medicine at Beth Israel Deaconess Me ...
, the Dina and Raphael Recanati Chair of Medicine at
Harvard Medical School Harvard Medical School (HMS) is the graduate medical school of Harvard University and is located in the Longwood Medical and Academic Area, Longwood Medical Area of Boston, Massachusetts. Founded in 1782, HMS is one of the oldest medical schools ...
, chief of experimental medicine at
Beth Israel Deaconess Medical Center Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts is a teaching hospital of Harvard Medical School. It was formed out of the 1996 merger of Beth Israel Hospital (founded in 1916) and New England Deaconess Hospital (founded ...
in
Boston Boston (), officially the City of Boston, is the capital city, state capital and List of municipalities in Massachusetts, most populous city of the Commonwealth (U.S. state), Commonwealth of Massachusetts, as well as the cultural and financ ...
, and staff writer for ''
The New Yorker ''The New Yorker'' is an American weekly magazine featuring journalism, commentary, criticism, essays, fiction, satire, cartoons, and poetry. Founded as a weekly in 1925, the magazine is published 47 times annually, with five of these issue ...
'' magazine. The book opens with a discussion of a woman in her thirties who suffered daily stomach cramps and serious weight loss, and who visited some 30 doctors over a period of 15 years. Several
misdiagnoses A medical error is a preventable adverse effect of care (" iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavi ...
were made before she was finally found to have
celiac disease Coeliac disease ( British English) or celiac disease (American English) is a long-term autoimmune disorder, primarily affecting the small intestine, where individuals develop intolerance to gluten, present in foods such as wheat, rye and ba ...
. Groopman explains that no one can expect a physician to be infallible, as medicine is an uncertain science, and every doctor sometimes makes mistakes in diagnosis and treatment. But the frequency and seriousness of those mistakes can be reduced by "understanding how a doctor thinks and how he or she can think better". The book includes Groopman's own experiences both as an
oncologist Oncology is a branch of medicine that deals with the study, treatment, diagnosis and prevention of cancer. A medical professional who practices oncology is an ''oncologist''. The name's etymological origin is the Greek word ὄγκος (''ó ...
and as a patient, as well as interviews by Groopman of prominent physicians in the medical community. Notably, he describes his difficulties with a number of
orthopedic surgeons Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
as he sought treatment for a debilitating
ligament laxity Ligamentous laxity, or ligament laxity, is a cause of chronic body pain characterized by loose ligaments. When this condition affects joints in the entire body, it is called ''generalized joint hypermobility'', which occurs in about ten percent ...
he developed in his right hand, which over several years had led to the formation of
cysts A cyst is a closed sac, having a distinct envelope and division compared with the nearby tissue. Hence, it is a cluster of cells that have grouped together to form a sac (like the manner in which water molecules group together to form a bubble); ...
in the bones of his wrist.


Salem's challenge

Groopman spends a great deal of the book discussing the challenge posed to him by Dr. Deeb Salem, chairman of the Department of Internal Medicine at Tufts-New England Medical Center, during a presentation the author made at their hospital
grand rounds Grand rounds are a methodology of medical education and inpatient care, consisting of presenting the medical problems and treatment of a particular patient to an audience consisting of doctors, pharmacists, residents, and medical students. It wa ...
. During the presentation, Groopman was discussing the importance of compassion and communication in providing medical care when Salem posed the following question: At the time of the presentation, Groopman was unable to provide a satisfactory response. Salem's question reminded Groopman of his experiences with physicians at the Phillips House of the world-renowned
Massachusetts General Hospital Massachusetts General Hospital (Mass General or MGH) is the original and largest teaching hospital of Harvard Medical School located in the West End neighborhood of Boston, Massachusetts. It is the third oldest general hospital in the United State ...
, where he trained as a resident in the 1970s. Per his account:


The availability heuristic

Early in the work, Groopman discusses the work of
Amos Tversky Amos Nathan Tversky ( he, עמוס טברסקי; March 16, 1937 – June 2, 1996) was an Israeli cognitive and mathematical psychologist and a key figure in the discovery of systematic human cognitive bias and handling of risk. Much of his ...
and
Nobel laureate The Nobel Prizes ( sv, Nobelpriset, no, Nobelprisen) are awarded annually by the Royal Swedish Academy of Sciences, the Swedish Academy, the Karolinska Institutet, and the Norwegian Nobel Committee to individuals and organizations who make ...
Daniel Kahneman Daniel Kahneman (; he, דניאל כהנמן; born March 5, 1934) is an Israeli-American psychologist and economist notable for his work on the psychology of judgment and decision-making, as well as behavioral economics, for which he was awarde ...
, psychologists from
Hebrew University The Hebrew University of Jerusalem (HUJI; he, הַאוּנִיבֶרְסִיטָה הַעִבְרִית בִּירוּשָׁלַיִם) is a public university, public research university based in Jerusalem, Israel. Co-founded by Albert Einstein ...
in
Jerusalem Jerusalem (; he, יְרוּשָׁלַיִם ; ar, القُدس ) (combining the Biblical and common usage Arabic names); grc, Ἱερουσαλήμ/Ἰεροσόλυμα, Hierousalḗm/Hierosóluma; hy, Երուսաղեմ, Erusałēm. i ...
. Specifically, he explores their development in the early 1980s of a concept known as the
availability heuristic The availability heuristic, also known as availability bias, is a mental shortcut that relies on immediate examples that come to a given person's mind when evaluating a specific topic, concept, method, or decision. This heuristic, operating on the ...
. In the theory, "availability" is defined as the tendency to judge the likelihood of explanation for an event by the ease with which relevant examples come to mind. In a clinical situation a
diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
may be made because the physician often sees similar cases in their practice — for example, the misclassification of
aspirin Aspirin, also known as acetylsalicylic acid (ASA), is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and/or inflammation, and as an antithrombotic. Specific inflammatory conditions which aspirin is used to treat in ...
toxicity as a
viral pneumonia Viral pneumonia is a pneumonia caused by a virus. Pneumonia is an infection that causes inflammation in one or both of the lungs. The pulmonary alveoli fill with fluid or pus making it difficult to breathe. Pneumonia can be caused by bacteria, vir ...
, or the improper recognition of an
essential tremor Essential tremor (ET), also called benign tremor, familial tremor, and idiopathic tremor, is a medical condition characterized by involuntary rhythmic contractions and relaxations ( oscillations or twitching movements) of certain muscle groups in ...
as ''
delirium tremens Delirium tremens (DTs) is a rapid onset of confusion usually caused by withdrawal from alcohol. When it occurs, it is often three days into the withdrawal symptoms and lasts for two to three days. Physical effects may include shaking, shiver ...
'' due to
alcohol withdrawal Alcohol withdrawal syndrome (AWS) is a set of symptoms that can occur following a reduction in alcohol use after a period of excessive use. Symptoms typically include anxiety, shakiness, sweating, vomiting, fast heart rate, and a mild fever. M ...
in an indigent urban setting. Groopman argues that clinicians will misattribute a general symptom as specific to a certain disease based on the frequency they encounter that disease in their practice. Kahneman won the
Nobel Prize The Nobel Prizes ( ; sv, Nobelpriset ; no, Nobelprisen ) are five separate prizes that, according to Alfred Nobel's will of 1895, are awarded to "those who, during the preceding year, have conferred the greatest benefit to humankind." Alfre ...
in economics in 2002 for his work on
heuristics A heuristic (; ), or heuristic technique, is any approach to problem solving or self-discovery that employs a practical method that is not guaranteed to be optimal, perfect, or rational, but is nevertheless sufficient for reaching an immediate, ...
, an honor that Groopman believes Tversky would have shared had he not died in 1996.


Lack of recognition for gatekeepers

Groopman also serves as an advocate for
primary care Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist car ...
physicians in his book. He argues that gatekeeper physicians are underreimbursed for their work, believing this to be a legacy of the period earlier this century when surgeons headed the medical societies that negotiated with insurers about what a 'customary' payment for services was to be. He suggests that the poor reimbursement and lack of recognition for primary care physicians is fundamentally flawed. He quotes Dr. Eric J. Cassell's book, ''Doctoring: The Nature of Primary Care Medicine'', to defend his assertion:


The fallacy of logic

In a later chapter Groopman reports a frank discussion with Dr. James E. Lock, chief of cardiology at
Boston Children's Hospital Boston Children's Hospital formerly known as Children's Hospital Boston until 2012 is a nationally ranked, freestanding acute care children's hospital located in Boston, Massachusetts, adjacent both to its teaching affiliate, Harvard Medical Scho ...
. During their conversation, Groopman asks the world-renowned cardiologist about the times in his career when he made mistakes in patient treatment. To the query, Lock gives the cryptic response, "All my mistakes have the same things in common." Lock then elaborates, discussing recommendations he made to repair specific heart defects in
neonates An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used ...
that ultimately led to worse clinical outcomes and potentially avoidable deaths. The recommendations he made were based on a purely logical understanding of cardiac physiology. The crucial point of Lock's discussion came with his confession: Groopman goes on to write, "Lock averted his gaze and his face fell; to be wrong about a child is a form of suffering unique to his profession s a pediatrician"


Disregard of uncertainty

Groopman also discusses the work of Renee Fox, a physician and occupational sociologist who observed residents and attendings in a
hospital ward A hospital is a health care institution providing patient treatment with specialized health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically has an emergenc ...
setting, noting their various ways of coping with the uncertainties of medical treatment. The mechanisms to cope that Fox observed included, for example,
black humor Black comedy, also known as dark comedy, morbid humor, or gallows humor, is a style of comedy that makes light of subject matter that is generally considered taboo, particularly subjects that are normally considered serious or painful to discus ...
, making bets about who would be right about a patient's prognosis, and engaging in
magical thinking Magical thinking, or superstitious thinking, is the belief that unrelated events are causally connected despite the absence of any plausible causal link between them, particularly as a result of supernatural effects. Examples include the idea that ...
to maintain a sense of poise and competence in front of patients while performing circumspect procedures.
Jay Katz Jacob "Jay" Katz (October 20, 1922 – November 17, 2008) was an American physician and Yale Law School professor whose career was devoted to addressing complex issues of medical ethics and other ethical problems involving the overlaps of et ...
, a clinical instructor at
Yale Law School Yale Law School (Yale Law or YLS) is the law school of Yale University, a private research university in New Haven, Connecticut. It was established in 1824 and has been ranked as the best law school in the United States by '' U.S. News & Worl ...
has since termed these coping mechanisms under the rubric 'disregard of uncertainty', which he believes physicians develop to deal with the anxiety of shifting from the certainty of theoretical discussions of medicine early in their training to its more happenstance practical application. Groopman recalls that in situations where he had been hesitant to take clinical action based on incomplete data, it had been wisest at times to follow the advice of his mentor Dr. Linda A. Lewis: "Don't just do something, stand there." Groopman asserts that there exist situations in which inaction may be the wisest course of action.


Suggestions for patients

Groopman closes with an epilogue giving advice for patients. He gives the following tools that patients can use to help reduce or rectify cognitive errors: * Ask What else could it be?, combating satisfaction of search bias and leading the doctor to consider a broader range of possibilities. * Ask Is there anything that doesn't fit?, combatting
confirmation bias Confirmation bias is the tendency to search for, interpret, favor, and recall information in a way that confirms or supports one's prior beliefs or values. People display this bias when they select information that supports their views, ignorin ...
and again leading the doctor to think broadly. * Ask Is it possible I have more than one problem?, because multiple simultaneous disorders do exist and frequently cause confusing symptoms. * Tell what you are most worried about, opening discussion and leading either to reassurance (if the worry is unlikely) or careful analysis (if the worry is plausible). * Retell the story from the beginning. Details that were omitted in the initial telling may be recalled, or different wording or the different context may make clues more salient. (This is most appropriate when the condition has not responded to treatment or there is other reason to believe that a misdiagnosis is possible.)


See also

*
Availability heuristic The availability heuristic, also known as availability bias, is a mental shortcut that relies on immediate examples that come to a given person's mind when evaluating a specific topic, concept, method, or decision. This heuristic, operating on the ...
*
Diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
*
Medical ethics Medical ethics is an applied branch of ethics which analyzes the practice of clinical medicine and related scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. T ...
*'' The Deadly Dinner Party'' *'' Fatal Care: Survive in the U.S. Health System'' *'' To Err is Human''


References

{{Reflist 2007 non-fiction books Medical books Nosology Houghton Mifflin books Psychology books