How Doctors Think

I purchased both the book and the audio CD. After listening to the CD I circulated an e - mail to my friends saying : " Everybody ought to read How Doctors Think by Dr. Jerome E. Groopman. Read it whether you are a doctor or not. As a doctor or as a patient you may have experienced similar unfortunate events explained in the book. In that case read the book to never go through the same events. If you have not gone through such experiences read the book so that you will never have to suffer from similar inconveniences."

Although a recent book "How doctors think " by Dr. Jerome E Groopman of Harvard Medical School has already caught a lot of attention and has been translated to different languages and is being sold in various countries. I am not a doctor. As patients my family and I have had to resort to the services of doctors many times. Not necessarily for big illnesses, sometimes only for check ups. In general we are quite healthy. I was attracted by the title of the book. Dr. Groopman explains very clearly what goes on in the minds of both the doctors and their patients and how their thinking styles affect their communication, the diagnoses and treatments. He gives many examples from many different branches of medicine. Everybody would agree with the assertion that better communication between patients and doctors is necessary. But how ? It is the how that Dr. Groopman explains. He shows the flawed thinking patterns in many doctors' thinking with actual detailed case studies leading to wrong diagnoses and treatments and how the doctor's thinking and reasoning should have been in each case. He says that some doctors jump to conclusions when they find a possible cause for a malady without searching for alternative causes that maybe more likely. He proposes a thinking method which generates many alternative explanations and working through the most likely ones before reaching a conclusion. This method seemed to me very similar to some of the correct thinking methods explained by a leading authority on the thinking subject : Dr. Edward de Bono.

Another issue that Dr. Groopman emphasizes is the need for better listening skills for doctors. On the average they interrupt their patients 18 seconds after they start to talk and often miss out on important information that maybe crucial for a correct diagnosis. As a patient I can not agree more. Patients also have a responsibility in effective communication but I think doctors have the upper hand in this matter so doctors need to read this book more carefully than patients. In my experience the doctors' interruptions can sometimes be very rude : several years ago I went to an ear, nose, throat specialist with an ear ache. After inspection he told me I had a certain kind of ear infection. I wanted to express my thoughts on the disease and said : " Doctor, as far as I know about this infection..." He abruptly interrupted and said : " Let's not deal with his infection with what you know about it but rather with what we doctors know about it ". In another case, my family and I had gone to a summer holiday village for vacation. The air temperature dropped for several days and half of the hundreds of tourists including us in the holiday resort began to cough and have fevers. I phoned the holiday camp doctor from our room and said : " Good day doctor. My family and I are coughing with a fever. Half the tourists in the resort are also. The weather is so cold. There seems to be a flu epidemic. Do you think it is a viral or bacterial infection ? " He replied : " Are you a medical expert ? I am the doctor around here and I am the best judge. I say there is no epidemic. People can get ill that is normal ".

In his book Dr. Groopman, in my opinion correctly says that there is no 100 % certainty in medicine. Even the most competent doctors can make wrong diagnoses. If the frequency of mistakes is too high then we can conclude the incompetence of the doctor. This may sound like stating the obvious but Dr. Groopman further states that despite the remarkable advances in medical technology such as brain imaging techniques etc. some doctors using these can still make the wrong diagnoses not because they are incompetent but because some of them see their patients as statistics or case studies not as real human beings. They fail to understand them as human beings. Dr. Groopman talks about the wrong thinking methods here. However, as a patient I would like to add that some doctors also have bad intentions. Most doctors I dealt with were honest and helpful, but I also came across in psychiatry several who had bad intentions. I have personally seen the improper utilization of advanced knowledge and technology : in psychiatry Quantitive EEG of the brain, questionnaires filled out by the patients such as the Beck Depression Inventory, The Beck Anxiety Scale, The Obsessive Compulsive Disorder questionnaire, the Minnesota Personality Test etc. are powerful tools at the disposal of a pychiatrist to help him / her diagnose, provided that they are properly evaluated. After these tests were implemented, I understood from the very superficial and wrong comments made by the psychiatrist that he had not carefully analyzed the tests and questionnaires. He did not understand us better after those tests. It is not the tests that were wrong, they could have been very useful had he taken the time to analyze them properly. Then why did he order these tests and the QEEG ? Because the hospital charges the patients for all those tests. They make money from the tests. I would not regret paying for them had they been properly evaluated.

As patients we have the responsibility to properly listen and implement our doctors' instructions such as taking the medications given in the right doses,times and durations, stop smoking and using substances, do the exercises and diet given by the doctors. But the doctors have to listen to us first. Our primary responsibility as patients is to find doctors who not only think correctly most of the time but who are also honest and competent.

In his book Dr. Groopman explains how smart patients can proactively participate in their dignoses by guiding doctors' thinking with relevant questions such as " could it be anything else ? ". If the doctor feels insulted or annoyed by such questions from the patient,as was in my case, then go to another doctor until you find one who does not feel insulted by relevant patient questions. This is perhaps esspecially needed in psychiatry : there are many competent psychiatrists but many others wrongly prescribe psychiatric medication or start irrelevant psychotherapies for what turns out to be physical illnesses that mimic the symptoms of a psychiatric disorder. The irresponsible psychiatrist overlooks it because he / she does not consider the possibility of a somatic illness by ordering blood tests. In such situations Dr. Groopman's advice to patients to ask " Could it be anything else ? " to their doctors is most relevant.

Thank you Dr. Jerome E Groopman for writing a much needed book. I hope many doctors and patients around the world will read it and revise their approaches towards communication with one another.

The Patient: Leader of the Healthcare Team (16/19 people found this helpful)

"Patients and their loved ones swim together with physicians in a sea of feelings. Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents". Jerome Groopman

The Patient: as a student nurse I was educated to understand that I always needed to listen to my patient, really listen. That philosophy has always served me well. Health care providers tend to be controlling, and when we are given a diagnosis that shakes us to our core we need some control. We need a physician and health care team that has the patient as the leader of the team. We listen to all of the recommendations and weigh the evidence as best we can. In the end we need to be able to trust our physicians and have a relationship that allows humor and sadness, questions and answers and honest give and take. It is a relationship like no other- it is sometimes life and death.

Jerome Groopman has written a book for everyone. Everyone needs to be their own advocate for their healthcare. His ideas that the way physicians think result in the treatment and care for each and every one of us. "Every doctor makes mistakes in diagnosis and treatment," he writes. "But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better."

He helps the layperson understand doctors' thinking with simple and accessible terms that suggest why it sometimes leads to undesired outcomes. As David Kessler in his reviews states "He introduces us to terms such as "diagnosis momentum" -- when a diagnosis becomes fixed in the mind of the physician despite incomplete evidence. Or "availability," which means the tendency to judge the likelihood of a medical event by the ease with which relevant examples come to mind. He takes phrases patients often hear, such as "we see this sometimes" and puts forth the idea that such generic comments deserve further questioning from the patients."

Dr Groopman has written of fascinating case studies and the physicians who were part of them. The errors and the asute diagnoses are compiled in story after story. Physicians are open about the way and the analytical methods they use in deliniating the final diagnosis. It is difficult to forget the misfortunes of some patients. We understand a little more completely the real-life drama that physicians face in their mistakes and when their diagnosis is right on.

We learn about Bayesian Perspective thinking. "We all like to know how reliable and how risky certain situations are, and our increasing reliance on technology has led to the need for more precise assessments than ever before. Such precision has resulted in efforts both to sharpen the notions of risk and reliability, and to quantify them. Quantification is required for normative decision-making, especially decisions pertaining to our safety and well being. Increasingly in recent years Bayesian methods have become key to such quantifications." says Dr Groopman. The thought processes of physicians is an insight few of us have had to encounter. We should all be prepared for our next encounter.

It was refreshing to learn of Dr Groopman's frustrations with his medical care, and the four different opinions he received about his right hand. He carefully delineates how each physician came to their consclusion and this is the type of thinking we need to engage in. We all have our stories of healthcare, and this book will give us more insight into the 'whys and wherefores' of our physicians' thought processes.

"Dr. Groopman gives a brief mention of how modern evidence-based medicine competes with the art of using your intuition. He touches on how drug and insurance companies pressure doctors as he explores their influence via big drug company sales representatives. I would have liked him to have written more about the influence of insurance companies, an area barely touched on, and about finances. This might have given readers a more complete picture of the intersection of medicine and finances." David Kessler

Most of us will be left with more respect for the art of medicine, and the careful consideration Groopman's doctors give to their patients. "How Doctors Think" is a book every patient needs to read. We, the patients have much more power than we know, and we can change the shape of the physician/patient relationship. We need to come to the docotr's office prepared to ask the right questions so that our physician's thought processes will be beneficial to both of us.
Highly Recommended. prisrob 4-01-07

"As many as 15 percent of all diagnoses are inaccurate...a distressingly high rate of misdiagnosis." (11/13 people found this helpful)

This alarming statistic introduces Dr. Jerome Groopman's compelling analysis of how doctors think--and what this means for patients seeking diagnoses. Groopman is curious to discover how one doctor misses a diagnosis which another doctor gets. Interviewing specialists in different fields, he analyzes the ways they approach patients, how they gather information, how much they may credit or discredit the previous medical histories and diagnoses of these patients, how they deal with symptoms which may not fit a particular diagnosis, and how they arrive at a final diagnosis.

Throughout, he considers the doctors' time constraints, the pressures on them to see a certain number of patients each day, the limitations on tests which are imposed by insurance companies or by hospitals themselves, and the many options for treating a single disease. He is sympathetic, both toward the patient and the physician, and, because he himself has had medical problems, he provides insights from his own experience to show how physicians (and patients) think.

Case histories abound, beginning with the 82-pound woman, whose celiac disease was not diagnosed for fifteen years. Here Groopman analyzes the uses and misuses of clinical decision trees and algorithms used by many doctors and hospitals to assess probabilities and make decision-making more efficient. Sometimes, however, it is necessary for a doctor to depart from the algorithm and obey intuition. Recognizing when the physician is "winging it"--depending too much on intuition and too little on evidence--is a challenge for both patients and other physicians. Ultimately, Groopman focuses on language as the key to diagnosis, showing that when patients and physicians can communicate and truly share information, they have a better chance to come to correct diagnoses and appropriate treatments.

The success of Groopman's book attests to the need for discussion of these issues, but I am not sure Groopman realizes the difficulty patients have in finding ideal doctors whose personalities, thinking, and communication styles are compatible with their own. Most of us are referred to specialists by our primary care physicians (some of whom we see only once a year), and it is not possible to interview several specialists to find the one most suitable. We accept the appointment our primary care physician has set up for us, often with the specialist who has the earliest available appointment. Patients with urgent problems may have fewer choices than Groopman seems to think they have. Though we all search for the ideal, ultimately we must hope that our own diagnoses are not among the problem 15%. n Mary Whipple

Jerome Groopman M.D.

Reader Reviews:

An excellent book about what goes on in the minds of doctors and their patients (3/5 people found this helpful)

The Patient: Leader of the Healthcare Team (16/19 people found this helpful)

"As many as 15 percent of all diagnoses are inaccurate...a distressingly high rate of misdiagnosis." (11/13 people found this helpful)

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