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  • Mini-Book Review — Groopman — How Doctors Think

    Posted by James McCormick on March 15th, 2010 (All posts by )

    Groopman, Jerome, How Doctors Think, Houghton Mifflin, 2007.

    This book is several years old but deals with timeless subject matter that might be of interest to cb readers. In the past decade or two, a major initiative called evidence-based medicine (EBM) has tried to improve how medical research is conducted and how it is used in everyday clinical practice. It’s the application of the scientific method (with all its strengths and weaknesses) to confirming how we know what we know about medical practice. Some examples of such efforts “organized improvement” were covered in a book I reviewed earlier on cb called Better: A Surgeon’s Notes on Performance by Atul Gawande. Like Dr. Gawande, Dr. Groopman writes extensively for the New Yorker. The resulting quality and clarity of his writing in How Doctors Think stands out. Either he or his editors are very good.

    In How Doctors Think, the author looks at a very different avenue of medical improvement. Deductive, evidence-based, medicine necessarily involves many patients and the careful collection of information about how a treatment works for large numbers of people. This is the foundation for proving the efficacy of particular treatments for particular populations, and winnowing out cases where doctors are “fooling themselves” about their treatment. Not fooling ourselves, as physicist Richard Feynman once pointed out, is one of the great challenges of science. The folks doing EBM research always give themselves a good laugh by evaluating the mathematical and statistical skills of the average GP. Interpreting the scientific medical literature is a real skill. One that needs to be taught and reinforced. As a baseline, we can aspire for a medical profession that can dependably read, critique, and interpret its own research.

    The inductive process of forming a diagnosis and executing treatment with a specific patient benefits mightily from the disciplined research of EBM, but it by no means replaces the services of skilled physicians. Checklists or AI applications in medicine can reduce egregious errors, but human judgment, matched with experience and rigorous thinking, are necessary components of health care. And that’s the focus of Groopman’s book.

    Humans present with a bewildering array of symptoms. Which ones are important? People (especially kids) may have limited language and vocabulary skills. They may have limited understanding of their own bodies. And be embarrassed by what they do know. Diagnostic tests are subject to a range of problems that can lead to “false-positive” or “false-negative” results. How much re-testing is warranted? Indeed, as I discussed in an earlier review of a book by Greg Easterbrook, diagnostic medicine is becoming inherently more complex, feeding more and more information back to the physician rather than less. For example, the recent fad for full-body CT scans can identify a wealth of physical anomalies or sub-clinical problems in any individual. Such variations from the mythical norm may, however, have little or no health impact. But when matched with mysterious symptoms or illness, the information overload created by the latest generation of non-invasive tests is guaranteed. So how does the physician separate the important from the trivial, hundreds of times a day?

    We don’t really have a handy rubric to describe this face-to-face process. “Medical decision-making” is a handy term but it masks a great deal of subtlety. Psychologists (primarily from the social and cognitive branches of the discipline) have recently been looking more closely at exactly how doctors make their clinical decisions (from diagnoses through treatment). Groopman’s book is about their most notable discoveries, and whether these new insights about how doctors make decisions can be used to alter the education and work habits of modern medical practitioners.

    A moment’s reflection by any lay person might come up with their favorite list of physician shortcomings …

    • too fatigued,
    • too busy to listen more than a few seconds,
    • jumping to wrong conclusions,
    • just plain incompetence,
    • too constrained by insurance rules
    • or legal demands
    • or subtle economic self-interest.

    Dr. Groopman touches upon all these issues in his book but because he’s a practicing doctor at a prestigious teaching hospital, he’s in a position to look at a much wider range of errors and biases in physician thinking … both from his position as practitioner and teacher, and from his experiences as a patient and the parent of a sick child. The author combines interviews with senior physicians with digestible summaries of the scientific research on how choices are identified and made in particular patient cases. The fascination in reading his book comes both from the human interest, a standard component of every medical TV show, and from the candid discussions between practicing physicians about where they’ve gone wrong and what they do, mentally, to avoid those errors in the future.

    The result of the author’s efforts is an excellent, though sobering, look at the multitude of ways that human cognitive errors are expressed in the practice of medicine. While we wait for the medical academics to translate their work into the nuts-and-bolts of medical education, and from there, one hopes, to better tools for physicians to moderate their cognitive biases, the general reader can turn to How Doctors Think.

    The book is organized into a series of case studies (some involving the author) but most engaging Groopman’s medical colleagues in different parts of North America. While each chapter could stand along as an interesting New Yorker vignette, the cumulative effect of these anecdotes and professional conversations on how doctors think introduces the reader to a number of themes in human cognition.

    While EBM tries to train doctors to use the probabilistic results of medical research on thousands of people to select effective treatment for their particular patients, the cognitive scientists try to help doctors avoid jumping to conclusions and ignoring the cues that a patient’s body or conversation might be offering. “When you hear hoof beats, think horses, not zebras.” That’s a common rule of thumb in clinical practice, notes Groopman. Nonetheless, zebras do exist. We don’t want our doctors focused on horses to the exclusion of zebras. Correctly identifying them … one time in a hundred, or one time in a thousand … requires a particular mental discipline for busy physicians. Not unlike that of an athlete who must face every contest with fresh perspective to respond to the unanticipated.

    In no particular order, here are some cognitive errors which Dr. Groopman discusses:

    Mis-diagnosis by groupthink A set of symptoms with no clear diagnosis sets off a round of different diagnoses. Each new specialist offers a new or variant diagnosis that fits their own body of expertise. The patient’s deteriorating health leads to physician frustration and intimations that the patient is malingering, psychologically disturbed, or not complying with medication and treatment. An ever-expanding case file may create an unwarranted set of assumptions for each attending physician. Confirmation bias, search satisfaction and diagnosis momentum are cognitive errors, well identified by psychology, that can herd a group of physicians into making a premature diagnosis in a case and sticking with it despite contrary facts. There’s never a good or inexpensive time for a doctor to start with a blank piece of paper, re-interview a patient and ask for a brand-new round of diagnostic tests. Nonetheless, it is through such “blank sheet” reviews that errors inherent in diagnoses (both human and technological) are often caught. Recall the brief discussion during my mini-review of Easterbrook’s Sonic Boom about cost controls and medicine. To spot the zebras amongst the hoof beats, more time, more careful attention, and more money must be spent. As medical science is becoming constantly more complex, and the treatment alternatives proliferate … good, better, and best medicine may well correlate with the resources available to nail down the “possible but less likely” explanations for illness.

    Question cogently, listen carefully, observe keenly This epigram, introduced by the author, is an inadvertent introduction to the scientific literature on human attention. Attention which narrows so much as to eliminate the things in front of our nose. Attention which is so distracted by clinical pace that details are missed. Attention which is so overwhelmed by fatigue, emotion, rapid-fire pace, and information overload that the zebras all but disappear. For the physician, how does one maintain an open mind for each patient, neither over- nor under- valuing the information presented by patients.

    Two doctors, three opinions A great deal of clinical practice is learned during the course of rounds and internship. As Groopman notes, follow-up research suggests that much of this practice may reflect hospital or senior practitioner “tradition” rather than a method of diagnosis or a course of treatment that has any careful study behind it. Conflicting results, when patients seek a second opinion may reflect the fact that there is a lack of thoughtful consensus in the medical community. Not much help to a patient! Individual doctors, in the face of unknowns in a particular case, may resort to “wild-ass guessing” based on the last article they read, the last patient they successfully treated, or the last conference they attended. The psychological literature has a lot to say on how people deal with uncertainty and conflicting information.

    Last bad experience Conversely, a physician’s last bad experience with a particular ailment, medication or therapeutic action may color their actions in the next similar case that they face. The vividness of recent events is a function of human being’s short-term and long-term memory. Again, this subject of “attention” in medical decision-making has a large body of science attached to it.

    Bad diseases, bad patients Physicians form opinions about prognoses for particular diseases or conditions. They also form opinions about their patients — their likability, pliability, and curability. Some diseases, and some patients who don’t seem to improve, may receive a physician’s “second-best” effort in paying close attention to reported symptoms. Doctors need accurate feedback. Patients may come to feel that “no one’s listening.” A mute, suffering patient may be subtly resented by a doctor. All these factors … leading to how the doctor feels about their own competence and “agency” in a clinical situation, may influence the practitioner’s willingness to re-evaluate their initial assumptions about a case, about a treatment regime, about a particular medication.

    Feeling good about your doctor vs. feeling good Some cognitive biases in the doctor-patient relationship can lead the physician way off track. The desire to be seen as competent and successful can steer a physician to make decisions that will impress or satisfy their patient but have less and less to do with treating a condition. Groopman talks about a cadre of physicians in his region who have wonderful social skills and are well-liked by their patients (often across generations of patients) but whose clinical skills are deficient. In some cases, they assist their patients more by referral than by direct diagnosis or treatment. Medicine is a big tent. Its practitioners can leverage all their skills and attributes … whether a cheerful disposition, vast reservoirs of physical energy, a capacious memory, a brilliant intellect, or a manipulative psychology … to attain career success. Groopman wants to outline all the different ways that physicians can go off track in providing medical care for the patients.

    The examples highlighted above are just a sample but they give a sense of the narratives that the author discusses in his book.

    Why I Found This Book Particularly Compelling

    As someone who switched from prehistoric archaeology to medical anthropology twenty-five years ago, and went back to school to pick up credentials in health care and medical writing, I’m quite impressed with How Doctors Think. It covers the subject of physician-patient relationships humanely, broadly, and with a great deal of insight. As someone who’s further spent the last ten years grinding through the generic literature on decision-making (the work in behavioral economics is most well-known), How Doctors Think is a particularly welcome addition. Finally something compelling, written for the general public.

    Some years ago, inspired by how important the subject is, I joined the Society for Medical Decision Making. In retrospect, my membership has been more “charitable donation” than intellectual satisfaction because the scientific (or social science) literature on this topic is very advanced. It bears all the advantages and burdens of modern scientific research … arcane statistical analyses that are de rigueur, the burdens and logistical challenges of conducting studies and getting adequate case numbers, and the narrow and/or tentative applicability of any results. It seems like a discipline that creeps forward at great expense and struggles to convert its results into everyday clinical practice that an ordinary lay person might experience.

    For me as an anthropologist, however, after years of watching practitioners inside and outside mainstream medicine, it was interesting to contrast Groopman’s comments with my own observations of how much traditional medicines control the physician-patient encounter. The timing of interviews, the uncertainties of symptoms and results, the environment of the clinic, the emotions of all concerned — medicine and health care are fraught with circumstances that can lead treatment astray. While the efficacy of “alternative medicine” will never be subjected to the rigor of evidence-based analysis, it seems to me that the cognitive and social gamesmanship used by various shamans, healers, and ancillary practitioners nonetheless explain a great deal of their popularity. “Feeling better” counts for something … even if it’s not “getting better.” The nebulous obligations of “alternative healers” to the State, the insurance companies, and the legal profession, often means that they benefit from superior psychological conditions for helping others to those available to a beleaguered medical doctor.

    How to give the ordinary medical doctor a leg up on the “competition” is a subject that Groopman doesn’t cover. The obligation to avoid cognitive errors in medical decision-making can be proclaimed. The long list of cognitive biases which may trip up a doctor can be listed (and matched to those everyone makes in daily life). Nonetheless, a rigorous training and environmental regime by which such physician errors can be avoided seems a long way away. Some obvious solutions, like limiting physician work hours, evaluating physician personality traits, extending patient interviews, or self-conscious training in methods for reducing cognitive error seem very unlikely to be introduced to medical education or practice. And yet, I’ve seen such solutions applied in the least convincing alternative medical practices one could imagine. The cognitive psychologists, at least, would approve.

    There’s an irony there.

    Conclusion

    How Doctors Think is a well-written treatment of the subject of medical decision-making on the front lines. It does suffer, I think, from a lack of tighter integration with the scientific literature on decision-making as a whole. I struggled to match the chapter themes to the specific phrases from psychology that science uses to discuss cognitive biases that we all are prey to in ordinary life. A table or summary or illustration organizing the pattern of cognitive biases in medical decision-making would have been very welcome in this book. It’s hard to tell if this was an author’s preference, an author’s oversight, or editorial opinion that general readers wouldn’t want such graphic material in How Doctors Think. Nonetheless, I think the use of graphics would have provided complementary information to the scientific articles cited in the End Notes. Especially for readers with a motivation to go further.

    Understandably, Dr. Groopman’s conclusions about “how doctors think” are less easily translated into how we, as patients, can ensure that we get doctors that are swayed by as few cognitive biases as possible. As a result, the book seems to limp across home plate. Perhaps a second book will appear, turning knowledge into action. In a sense, we’re asking doctors to perform like mental athletes … responding reflexively with the benefit, but not hindrances, of experience. In the absence of all but the most coarse-grained “quality assurance” that now exists in the medical profession, it’s hard to know how an ordinary physician could be evaluated and make improvements on their own. For the moment then, Dr. Groopman’s discussions with his senior colleagues that he has shared in his book seem like the only uncertain (if informal) way forward. Disappointing but understandable.

    As individuals, we may be more comfortable with authoritative physicians who brook little discussion, let alone skepticism. Or we may prefer a doctor who will review all the details of our case and outline how they come to a conclusion. Our choice. Not everyone wants the “agency” and responsibility to confront disease as a patient. While we might like a calm, well-rested, well-trained, focused physician with wide experience and the time to listen to us for as long as we have something to say, modern health care (short of the Mayo Clinic or platinum-care options) means that we sometimes take “pot luck,” even with a physician we know and trust. This book gives us a sense of how much randomness is in the system.

    This book is highly recommended as a gift for college students in psychology, medicine, or the health care industry. Most general readers would find Dr. Groopman’s anecdotes, case studies, and discussions very thought-provoking. I do think that readers who’ve had bad experiences with the medical profession in the past would NOT enjoy this book. Doctors are human. And humans are prey to many mistakes in thinking. This book highlights the ways that medical diagnoses and treatment can go astray, up close and personal. Once you know how sausage is made, you never look at sausage quite the same way again. And second-guessing one’s treatment can lead to a lot of enduring anxiety. Barring such a caveat though, How Doctors Think is a great read.

     

    7 Responses to “Mini-Book Review — Groopman — How Doctors Think”

    1. onparkstreet Says:

      This is an enormous topic – as you know :) – and a complicated one. As a physician (hospital-based pathologist) there is one particular source of bias that interests me.

      Emotion.

      Doctors are human and, at times, don’t take outside criticisms of their profession very well, or, feel beleaguered and overworked and don’t have time to process constructive criticisms. So, you may feel threatened. Sometimes yes. Sometimes no. A caveat: I speak from the depths of teaching hospital world, and it’s been true of some places I’ve worked, and not true of others.

      Another area we don’t do very well: creating the correct environment for the best cognitive function. Hospitals do not do this very well, particularly given the constant pressures to increase RVUs. It’s all about how many patients you can fit into a day. This is not always bad – the more you see, the better you might become. However, it reaches a point where decision-making is altered, and not for the better.

      Anyway, enormous topic, interesting post, and I always mean to read this book :)

      – Madhu

    2. onparkstreet Says:

      “Individual doctors, in the face of unknowns in a particular case, may resort to “wild-ass guessing” based on the last article they read, the last patient they successfully treated, or the last conference they attended. The psychological literature has a lot to say on how people deal with uncertainty and conflicting information.”

      So I deal, sometimes, in diagnosing rare tumors where there is very little literature to guide you. I have been taught by my mentors to be honest in my reports – here is what we know and here is what we don’t know. What I find is that clinicians and patients do not care for this in most instances, so they “doctor shop” until they will find someone who will give them a black-and-white answer where none exists. The relationships, and pressures, are myriad and run in many directions.

      – Madhu

    3. Jonathan Says:

      Great review, and the book seems worthwhile too.

    4. Lexington Green Says:

      My only objection: In what universe does the prefix “mini” apply to this (excellent)almost 3,000 word review-essay?

    5. J. Scott Says:

      A client recommended this several years ago, and I’m glad. While providing insight into “how” doctors think, he also provides ideas for creativity. His description of the oncologist who asks “what else could it be?” is instructive for the curious. Good mini-review. The book is highly recommended.

    6. Le Mur Says:

      As individuals, we may be more comfortable with authoritative physicians who brook little discussion, let alone skepticism.

      As individuals, we don’t have much choice: they all come from the same mill.

      Doctors’ gov’t-backed “gatekeeper” status (you need their “permission” for almost any non-trivial treatment relating to your own body and health, enforced by criminal law) insures that they’ll always be, for the most part, incompetent and either snotty or condescending to their customers, and far too special to lower themselves to advertising their prices and services like the peasants do. Western medicine, as it’s legally structured, is one of the world’s greatest scams. (If you don’t think it’s a scam, that just shows how effectively you’ve been scammed).

    7. Michael Kennedy Says:

      I’ve spent ten years teaching in a first and second year program called Introduction to Clinical Medicine at USC. That program began the year before I started USC medical school and there is to be a 50th anniversary celebration honoring the founder of the program, an orthopedic surgeon. It was unique (I think) in 1961, when I began and is still one of the highlights of that medical school. Over the years, it has expanded from the original focus (Called the doctor-patient relationship) on interviewing and coping with the anxieties of a first year medical student, to include physical diagnosis skills and the beginning of clinical decision making. One of the unique features at the time had to do with the presence of many would-be actors and actresses in Los Angeles. A neurology professor named Howard Barrows taught some of these actresses to simulate neurological syndromes and included them in his course. They are now a big part of the ICM course and are now used to teach interviewing skills with standardized patient scenarios. It has now become quite common in other schools and the National Board Exams include these standardized patient interviews for all medical students.

      Some of the scenarios portray typical problems in diagnosis. For example, the first scenario the students encounter is the depressed patient who answers in monosyllables and must be encouraged to tell her story. It is a bit of a detective story because she thinks she has cancer of the stomach even though a gastroscopy exam showed only an ulcer. The more skillful students will eventually learn that her mother died of cancer of the stomach and had been told it was benign. Furthermore, she is single with a ten year old daughter and had moved from Iowa to care for her mother. Now, she is far from any support system and has no one to help care for the daughter. The student must elicit this story and then suggest that the biopsy shows that it isn’t cancer and doctors don’t lie to patients about diagnoses to make them “feel better.” If she is treated carefully, she will tell the whole tale and respond to a sympathetic set of suggestions (neighbors to watch the daughter, etc). If she is treated roughly or peremptorily, she will retreat to a mute immobility. Some of the actresses (This is a female scenario) are very good and many are also doing TV commercials etc.

      Other scenarios include the angry patient, a teenager who does not want to admit she might be pregnant, a musician who is gay but resists talking about it with has early symptoms of AIDS and, my favorite, an airline attendant who is secretly taking extra thyroid hormone after treatment for Graves disease with radioactive iodine because she is convinced she is hypothyroid and getting fat. She talks a mile-a-minute, is obviously hyperthyroid and constantly clicks a ballpoint pen which is very distracting. The student must get a word in edgewise without being rude and must eventually figure out she is taking extra medication and convince her that she is really hyper, not hypo.

      Physician bias and decision making are part of the program. In the second year, the scenarios are mostly combined with physical exam and are classical cases like appendicitis. One case is a woman with angina who has come in “just to be checked” and who is supposed to leave on a cruise the next day. All she wants is to be reassured and the student can easily make a mistake. I always warn students against the tendency to reassure patients. I tell them that they are perceived by patients as doctors, not students, and reassurance, which is seen as sympathy in a lay person, becomes very powerful coming from a doctor. She has a sternotomy scar that has been glued to her chest but you would be surprised by the number of students who look at it and do not realize the significance. They have to resist the temptation to reassure her and must tell her she cannot go on the cruise. She had a CABG and has stenosis of a graft.

      Another case is a woman with many alternative health beliefs and they must learn how to cope without causing such a patient to clam up and keep information away from the doctor who is too judgmental.

      Anyway, this book, which I should read, fits well into that teaching program and, while I don’t know if the USC program was the origin of the technique, it has now become a major part of medical education. It is a great attraction for applicants. One year they followed my group around the hospital and in the “standardized patient” sessions and videotaped it. They sent a tape to all the applicants. It had an amazing effect. USC is a mid-level medical school and usually got half of the applicants they accepted in the first group. Since the class was 150, they usually accepted about 200 in the first pass. The year after the tape was sent out, all 200 accepted. They had to add a classroom and some students were asked to wait a year. The classes now are about 190.

      It is a lot of fun to teach. A lot of those scenarios have had real life equivalents in my own surgical practice and all are based on real patients treated by the faculty who designed the program. Another second year scenario is the “dying patient” who has a daughter arrive from out of town who wants everything done. She, of course, is the one who hasn’t had anything to do with the father for years. I’ve seen many of those.