Wednesday, January 9

How Doctors Think – Jerome Groopman

Over the last fifteen years Anne Dodge had seen some thirty doctors for the digestive issue that had first manifested when she was twenty – it began as a griping, twisting pain after she ate, a pain that didn’t respond to antacids. As it progressed Anne became less and less interested in eating, and sometimes only felt relief if she induced vomiting. Her GP sent her to a psychiatrist, and Anne was diagnosed with anorexia. Over the next decade and a half she was as compliant as she could be with her prescribed treatment regime but continued to deteriorate – she took four kinds of antidepressants, participated in weekly talk therapy, ate 3,000 calories (as recommended, primarily of bread and pasta) every day, and still lost weight. Her bones became brittle, her immune system started to shut down, and her red cells and platelets dropped to dangerously low levels. The more she ate the worse she felt, and her doctors diagnosed her with the stress-related disorder irritable bowel syndrome, an indicator of her increasingly precarious mental health – Anne said she was doing everything she was supposed to but she was clearly lying.
When Anne saw gastroenterologist Myron Falchuk she was desperate, and she knew he’d be just like the rest – he’d palpate her abdomen then tell her to take tranquillisers and change her diet. But Falchuk took a different approach – he pushed the huge stack of Anne’s medical notes to one side and asked her to tell her the story of her disease, in her words, from the very first time she experienced a symptom. And when he examined her he focused on her hands, nails and mouth, rather than her abdominal organs. And then Falchuk told her that he didn’t think her symptoms were caused by irritable bowel disease or anorexia – he wanted to do another test to confirm her diagnosis, an endoscopy to look at her bowel. Anne was reluctant – she’d had so many tests – but Falchuk had listened to her, had never seemed rushed or impatient, and she agreed to the endoscopy, which revealed that Anne had the autoimmune disease coeliac disease, essentially an allergy of the gut to gluten, a component of wheat. Flachuk saved her life.
Groopman’s book examines what cognitive tools and thought processes great doctors use to arrive at accurate diagnoses. What was it, for example, separated Falchuk from the thirty other doctors, spanning a variety of specialties, that Anne had seen before him?
When we think of medical mistakes we focus mostly on technical errors – the wrong limb being amputated, a drug being given via the wrong route, or blood being given to the wrong patient. But increasingly research reveals that these errors account for only a small percentage of mistakes – most errors are caused by cognitive mistakes, mistakes in the way clinicians think, including letting how they feel about the patient or other practitioners affect their judgement.
The core of the book stems from Groopman’s own experiences, both as clinician (specialising in AIDS, disease of the blood, and cancer) and as a patient; it was when watching a group of interns round (present and examine patients, then discuss possible diagnoses and tests) that he began thinking about thinking – the students were primarily using algorithms and statistics, rather than evaluating each patient as an individual.
Groopman not only read extensively on the topic, he spoke with key practitioners, doctors respected by their peers, with a reputation for excellence. He asked them about the cases where their thinking processes allowed them, like Falchuk, to see what others had missed. What was it that they saw differently? What questions did they ask or processes did they use, that allowed them to avoid the pitfalls lurking in every medical decision?
As relevant, Groopman also asks about the cases they missed and the mistakes they’ve made, and how those errors have influenced their subsequent practice.
Illustrated by their experiences, and his own, Groopman explores cognitive mistakes individuals are at risk for, and how they may be avoided. For example, Anne Dodge had been misdiagnosed for a decade and a half in part because her case had been ‘framed’ – before each doctor saw her they already had a framework within which to site her, a diagnosis that coloured the interpretation of her new symptoms, all of which fit. All except one – Anne was losing weight despite eating 3,000 calories a day. People with eating disorders frequently lie about what they eat – within the framework of anorexia, Anne’s claim: she was losing weight, so clearly she was lying about what she was eating. Every doctor except Falchuk attributed her ongoing weight loss to her lying; Falchuk asked, “What might I be missing in this case? And what would be the worse thing that could be missed?”
Of course, he did more than that. He encouraged Anne to tell her story, he paid attention to her body language and how she spoke, and he was explicitly interested in her – he didn’t appear rushed or impatient. As a result, Anne trusted him, and agreed to the endoscopy despite being sick of having test after test.
In lesser hands this could have been a fairly dry text, but Groopman enlivens the writing – the patient narratives draw the reader in, and interweaving his own experiences, on both sides of the examination count, add another perspective. Though supremely relevant and interesting to clinicians, Groopman writes for a lay audience – technical terms are explained clearly, and he gives advice for patients who are concerned that their diagnosis may be masked or missed. This includes the following questions: what else could it be? Is there anything that doesn’t fit? And is it possible I have more than one problem?
Along the way, Groopman explores the changing face of medicine – not just the impact of managed care (exhaustively discussed in other literature) but the effect of algorithms on stifling creative thinking, the drawbacks of the medical aphorism ‘when you hear hoofbeats think horses, not zebras’ (the uncommon is less likely that the common), the limits to evidence-based practice, the pitfalls of applying a purely logical approach to the human body, the coded meaning of ‘compliance’, and the failings of tradition. I cannot recommend this highly enough to anyone working in health care; people who are current or potential health care consumers, and their relatives; and anyone interested in examining that most difficult of topics, what don’t I know about the way I think? The copy I read was borrowed, but I’m going to buy a copy for myself. It really is that good. - Alex

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