How Doctors Think, The Patient's Friend

How Doctors Think by Jerome Groopman

It’s that time of year. Soon, more than 15,000 medical students will be going up on University stages to receive their medical degrees. In their four years of medical school and probably another four years of  residencies, they have learned to see patients as another species, somehow different from them. Often, as they become clinicians, they feel more and more distant from their patients and their problems. Group thought tends to take over.

How many of these newbie physicians will think about—or write about-- what it means to be a doctor?  How many will substitute the computer for the stethoscope or scalpel?  How many will try to help patients cross the Great Divide between doctor and patient?

New books by doctors appear like Spring Fever, ostensibly opening doors to doctors’ experiences. But what about the patients? How do they enter the medical partnership? How can they get the doctor to listen, to pay attention, not to slide over important facts? Not to interrupt or be distracted.

The patient wants the doctor to focus on what he or she is reporting, to laser in on symptoms with treatments that might relieve them. No patient wants to hear about other patients’ problems, about the doctor’s fancy diagnoses on other people. Male or female, young or old, they want the doctor to concentrate on them, not to visit, nor to tell stories about their lives.

Whether patients wait hours or were seen promptly, they want their agendas to be front and center, to TELL the doctor what’s on their mind, what worries them. They know that the doctor controls the show but how does the patient get the doctor to listen? How does the patient gain even an illusion of control over besetting symptoms?

It’s tough. Only one of new doctor-y book will help patients. That’s Jerome Groopman’s HOW DOCTORS THINK, which aims to bridge the chasm between doctors and patients.  Groopman says he wrote HOW DOCTORS THINK  for patients, but it’s a book every doctor should read—at least once a year.

Groopman, professor of medicine at Harvard and staff writer at the NEW YORKER, speaks from both side of the bedside.  He believes that doctors are inadequately reflective about their decision-making, adding, “Experts studying misguided care…concluded the majority of errors are due to flaws in physician thinking, not technical mistakes.”

Citing chapter and verse about doctors’ unthinking “thinking” that leads them to make mistakes, Groopman enumerates certain habits of thought that lead doctors and patients down the primrose path of misdiagnosis.  He urges doctors to ask open-ended questions, to remember all the times they were wrong, to acknowledge their uncertainty—and their errors. His list of diagnostic traps is long. Doctors should avoid attribution errors, outcome bias, pattern recognition, confirmation bias which arises from “cognitive cherry-picking,” anchoring, which is the result of latching onto a single diagnostic possibility and discounting other pieces of the puzzle. He wants them to avoid “commission bias,” the urge to do something. One of Dr Groopman’s mentors warned him, “Don’t just do something, stand there,” when a diagnosis was uncertain. He doesn’t revere the MRI as much as do many physicians. He wants doctors to think outside the box, particularly if the box is an MRI, which different radiologists may interpret differently.  Groopman wants doctors to ask themselves, :What else could this be?”
What Groopman want doctors to shun “diagnosis momentum,” the common medical ambush of physicians accepting previous diagnoses without reflecting on their accuracy. The first sentence of the report may set  “Diagnosis momentum” moving, until it is “like a boulder rolling down a mountain, gaining enough force to crush anything in its way.”

Groopman knows what it is to be a patient. After “a failed operation on my spine” (which he does not detail), he goes from Doctors A, B, C, D, E for an incapacitating, swollen, inflamed right wrist. Finally, he comes to surgery, can only give 80% relief—not 100%.  Wryly, he notes, “my banged-up hand was a 1952 Studebaker, and…it would not emerge as a brand-new Lexus.” The Studebaker sounds like less than 80% but Groopman warns that surgery does not provide perfection, no matter how much we expect it.

        In the best of all possible worlds, doctors would recognize how much Groopman is talking about them. And would try to build and revamp their listening and communicating skills. But since the world is not constructed that way, Groopman advises patients how to deal with doctors who interrupt the patient’s story after only 12 second and divert the conversation to what they want to hear. 

For all these reasons, Groopman’s advice for patients bears repeating here:

Ask directly whether you’re communicating well. Ask “Is there anything that doesn’t fit your diagnosis?” “What else could it be?” “If I have more than one problem, what should I do?”

In addition, this writer urges patients to construct a one-page computer print-out. It's a patient’s best friend. Before you see the doctor, write your story from start to finish, list your medications, write your questions and leave spaces for the answers, date the entry, give a copy to the doctor and keep a copy for yourself.  Then, ask your questions no matter how much the doctor tries to keep to the 12-second interruptive course.

If you like your doctor, give him or her a copy of Groopman’s book—and keep one for yourself. Be sure to give one to any graduating medical student you know.