How the Medical Mind Works

Article excerpt

A Review of How Doctors Think by Jerome Groopman, Houghton Mifflin, 2007. 320 pp., $26. ISBN-10: 061-861-0030

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JEROME GROOPMAN'S BOOK HOW Doctors Think is a superb commentary on the intersection between medical science, compassionate personal interactions, and critical thinking. My only caveat is that it may be exploited by "doctor-bashers" because it shows how doctors make mistakes; but the overall impact of the book is very positive. It is a good lesson in critical thinking about any subject, not just about medicine. It shows how people make up their minds and then resist changing them, twisting or disregarding subsequent evidence to make it fit their first hypothesis. It covers a number of other common mental foibles, illustrating them with memorable clinical vignettes. Groopman cites a recent study of 100 incorrect diagnoses: only four of them were due to inadequate medical knowledge; in the rest of the cases the doctors fell into cognitive traps. He targets errors that are particularly hazardous to doctors, such as poor communication with patients, buying into fad diagnoses, bowing to economic pressures, and succumbing to pharmaceutical company influences.

Doctors may be well educated, but they are no less subject to the various cognitive biases that plague the rest of humanity, educated or not. Thus, Groopman offers several guidelines to improve performance: don't stop thinking after you reach a diagnosis; keep an open mind so you can reconsider if new data suggest another possibility; don't skip steps in a misguided attempt to spare your patient discomfort; guard against treating patients differently because of your own emotions or prejudices; listen to the patient's own story and make UP your own mind rather than accepting the diagnosis of a previous doctor.

Groopman also gives practical advice to patients so they can help theft doctors think better. They can offer to tell theft story again from scratch to allow a fresh reassessment. They can ask, "What else could it be? Is there anything that doesn't fit? Is it possible I have more than one problem?" If they have their own ideas about what might be wrong, or if they are worried about something the doctor hasn't mentioned, they should speak up.

In the push towards evidence-based medicine, we encounter pitfails. The evidence may have been derived from a group our patient doesn't belong to. The Women's Health Initiative showed that hormone replacement therapy did more harm than good, but it studied an older population: a later study on younger women showed that it did offer some benefits when used earlier in menopause. A treatment that is right for the "average" patient may not apply to the individual who falls on either end of the bell curve and has other co-existing health problems. This doesn't mean we can disregard the evidence-based consensus. It means we should take the patient's risk factors, concomitant illnesses, physiologic variants, current medications, allergies, life situation, personal preferences, etc. into account when choosing the best evidence-based option for that individual-not that we should exit the evidence-based playing field and try to invent a unique treatment for a unique patient using guesswork or intuition. Medicine is not an art, it's an applied science; we need to make sure we' re applying it appropriately.

There is a place for clinical intuition. In an emergency, we don't have the leisure to go through a lengthy process of weighing all the information--we have to make snap decisions to save lives. An experienced clinician may pick up on subtle clues he is not even conscious of. Of course, intuition can be misleading. Plus, medical science is messy. One clinical study is followed by another with a different conclusion. No test is 100% accurate. No treatment is guaranteed to work for every individual. Uncertainties abound.

The public believes x-rays and biopsies give clear yes-or-no answers, but that is not the case. …