How Doctors Think by Jerome Groopman, M.D.

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September 18, 2013

How Doctors Think

By Jerome Groopman, M.D.

Published by Houghton Mifflin Company, 2007

This book, How Doctors Think, inspired me to improve my skills as a practicing physician. This fascinating read, written by Dr. Groopman, who is a frequent medical writer and a prominent hematologist/oncologist at Beth Israel Deaconess Hospital in Boston, details the cognitive processes that most physicians use to evaluate and treat patients. For both patients and physicians, I highly recommend taking the time to understand some of the difficulties and thinking errors that can result in less than optimal medical care. Why are some patients misdiagnosed? How can we improve our accuracy in treatment?

Dr. Groopman opens the narrative with a gripping story of a woman in her thirties who had been misdiagnosed for years, leading her to severe weight loss and at the edge of malnutrition. It is not until she sees a master clinician who takes the time to listen, that the correct underlying disease is treated and her life is saved. Many patient stories like this illustrate some of the underlying themes in the book. The first concept is that physicians should ask open ended questions and let the patient tell the story. Unfortunately in today’s health care system, time is a rare commodity which allows this type of questioning. He illustrates how “the doctor has to make the patient feel that he is really interested in hearing what they have to say. And when a patient tells his story, the patient gives cues and clues to what the doctor may not be thinking about.” He likens the practice of primary care to “looking for a particular face in a moving train.” In too many health care situations, there are too many patients and too little time. Dr. Groopman also emphasizes that emotional rapport between doctors and patients is very important. He writes about studies where patients do better if they have a sense of mutual respect between doctor and patient. It is important for physicians who dislike a particular patient to be self- aware and realize that negative emotions may lead to worse care.

Interestingly, both positive and negative emotions by physicians can affect patient care. The book discusses thinking errors which doctors fall prey to which impede proper diagnosis. If a patient looks healthy, it is often hard for the physician to believe the patient is actually ill. Likewise, if a physician likes a patient too much, they also do not want to believe they can have a serious illness. Lastly, if the doctor likes the patient so much they do not want to inconvenience them with doing a particular test or examine a delicate part of the body, the doctor may miss the diagnosis. Dr. Groopman gives this advice to patients: tell your doctor this, “Don’t save me from an unpleasant test just because we’re friends.” Perhaps more predictably, doctors do not like patients that are disheveled or have a social stigma such as alcoholism or drug abuse. This dislike can also lead to misdiagnosis , as physicians often assume that symptoms are secondary to alcoholism or drug abuse and do not go further in finding an underlying problem. 

Other factors discussed in the book that can influence a doctor’s thinking are the interaction between primary care physicians and specialists. Often that interaction can be detrimental to finding the real diagnosis in a patient. A ten year old boy suffered a sudden spinal fracture for no apparent reason. The specialist told the emergency room doctor, “We see this sometimes.”, so no further workup was done. After 4 more spinal fractures, the boy was diagnosed with acute leukemia. Dr. Groopman gives a warning to not accept as an answer to a serious event, “We see this sometimes.” 

The book illustrates many more errors in thinking, such as only thinking about a common diagnosis, continuing a diagnosis because an expert agrees with it, and making a diagnosis because it is better to have a diagnosis rather than not. He also discusses how mistakes can be made in radiology and how drug companies and the medical industry can influence doctor’s prescribing habits. The language a physician uses with a patient, especially in terms of statistics, can greatly influence a patient’s decision making.

A summary of lesson from this book that can improve care:

  1. Good medical care requires time. 
  2. The patient’s symptoms and medical history are extremely important in making the correct diagnosis. Don’t complain about having to give the doctor more information.
  3. Electronic medical records, which are being required by the government, change the interaction of the physician- patient relationship. It can also cause more cognitive errors, since the doctor is busy filling in the blanks instead of thinking about the symptoms. 
  4. If you are not getting better from an illness, go back to the physician and retell your story. 90% of the diagnosis is made by the symptoms and the story you tell your physician.
  5. Articulate the fears that you have in what the diagnosis might be.
  6. You may need to have your physical exam or your laboratory tests repeated.
  7. Good questions to ask your physician: “What else could it be?”, “Is there anything that doesn’t fit?”, “Is it possible I have more than one problem?”

If you have ever wondered why it is often difficult and frustrating to get a proper diagnosis, How Doctors Think will be revealing and insightful, and reading it will help you in your quest for optimal health care.