How Doctors Think | 
 enlarge | Author: Jerome Groopman
Publisher: Mariner Books
Category: Book
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Rating:  161 reviews
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Edition: 1
Pages: 336
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Dimensions (in): 8.2 x 5.5 x 0.7
ISBN: 0547053649
Dewey Decimal Number: 610
EAN: 9780547053646
Publication Date: March 12, 2008
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Product Description
How Doctors Think is a window into the mind of the physician and an insightful examination of the all-important relationship between doctors and their patients. In this myth-shattering work, Jerome Groopman explores the forces and thought processes behind the decisions doctors make. He pinpints why doctors succeed and why they err. Most important, Groopman shows when and how doctors can -- with our help -- avoid snap judgments, embrace uncertainty, communicate effectively, and deploy other skills that can profoundly impact our health.
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| Customer Reviews: Read 156 more reviews...
 "As many as 15 percent of all diagnoses are inaccurate...a distressingly high rate of misdiagnosis." March 24, 2007
Mary Whipple (New England)
106 out of 115 found this review 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 do not know well), and it is not possible to interview several specialists to find the one most compatible. 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 fifteen percent." (4.5 stars) n Mary Whipple
The Patient: Leader of the Healthcare Team April 1, 2007
prisrob (New EnglandUSA)
67 out of 75 found this review 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 an undergrad in college in my nursing program, 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, the patients, are given a diagnosis that shakes us to our core we need some control. As patients 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 discusses the physicians who 'read' x-rays and CT's and MRI's, the radiologist. An exacting science is needed here. A radiologist with experience can pick up a disease process by the thickness of a rib. There is an accepted 'error' ratio in this science, and none of us want to be in that error ratio. There is a computer program to assist in diagnosis, but it is not perfect. We all want and need the experienced radiologist. When I entered the world of health care I learned that medicine is 50% rule out or question of. It remains in that corner. That is how we want our physicins to think-rule out #1,2,3 and come to a conclusion based on science, best practice and their ability to put it all together for us, the individual.
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 thought about. 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 conclusion, 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 doctor'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
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Excelllent investigation inside the minds of doctors May 15, 2007
Gaetan Lion
21 out of 21 found this review helpful
This is a well written and very informative book on how doctors arrive at a diagnostics. Groopman, a doctor, acknowledges that 20% of diagnostics are incorrect. He explains why this happens by interviewing various medical experts. These describe how they arrive at diagnostic decisions and how they have made errors during their career.
From reading this book, you get that the main reason doctors make errors is time constraint. In our productivity driven health care system, doctors don't have the time to cogitate the potential diagnostic of patients' illnesses. Additionally, human physiology is incredibly complex. Each patient is unique and reacts differently to his environment, and treatment. Thus, medicine is a science of rules but with more exceptions than rules. Also as an offshoot of cost containments, doctors are discouraged to order more tests than is viewed as necessary by the health insurers. As a result, doctors make complex decisions with limited time and information. This combination of factors easily explains the 20% error rate.
A doctors' thinking mode diverges much from his medical training. In medical school doctors are taught to crack complex disease diagnostics following deductive reasoning. They are given written data on a patient, and they arrive at a diagnostic within 20 to 30 minutes of thorough analytical deliberation. However, in the real world they typically arrive at a diagnostic within 30 seconds. They don't think at all in a slow deductive reasoning mode as they were trained. Instead, they think in an intuitive light speed pattern recognition mode that immediately zeroes in on two or three potential diagnostics. Within the 30 seconds, they narrowed it down to one. Their light speed pattern recognition thinking reflects two things: first, the chronic time pressure they work under (they don't have 30 minutes to deliberate); and second, how they gather information in the real world. The physical appearance, body language, communication style of the patient will give them a ton of qualitative information that they don't get when cracking a diagnostic in med school using just data.
The author analyzes with his interviewees the different cognitive errors doctors make. A common one is the commission bias as doctors are prone to be decisive and action oriented. A surgeon will operate because that's what he does. Sometimes, doing nothing is the best policy (doing no harm). But, that's perceived as incompetent by both patients and doctors. Another prevalent error is "diagnostic momentum" where the very first diagnostic delivered by the primary care physician sends all following specialists taking care of the patient down the wrong path. Another interesting one is the "zebra retreat" where a doctor does not dare to investigate further a situation because his hypothesis represents a wild outlier (a zebra); Instead, the doctor falls back into another comfortable error "satisfaction of search" where the unrevised diagnostic fits pretty well allowing him to move forward even though it is the wrong one. The "availability error" is what is most available in a doctor's mind based on recent experience and association with a similar case. It plays into the doctor's pattern recognition mode. The author mentions many other interesting ones that are common to other professional fields.
In chapter 8, the author indicates that technology is not so helpful. The diagnostic error rates associated with the interpretation of X rays, EKGs, MRIs, mammograms, biopsies under microscope are far higher than what one expects. Two radiologists or pathologists often reach different conclusions. Sometimes even the same ones can arrive at different conclusions at different times (after reinterpreting their earlier findings).
In chapter 9, the author investigates economic incentives that distort the judgment of doctors. This includes Big Pharma relentless marketing of prescription drugs through persistent marketing reps. This also entails Big Pharma's effort to medicalize what is the normal process of aging. The author mentions the concept of Andropause (male menopause) that has no scientific bearing; but, doctors have aggressively treated this condition with testosterone supplements. These are useless. Economic incentives also lead surgeons to conduct operations way too often that provide no benefit to the patients. The author mentions spinal fusion and radical mastectomy among the surgeries that are way overdone in the U.S. Spinal fusion does not work better than not operating to eliminate low back pain. Oddly enough, insurers are responsible for excess surgeries as they offer higher reimbursement rates for invasive surgeries than for alternative therapies. The author also mentions the occasional nefarious networking between lawyers, radiologists, and surgeons creating a cycle of referrals, aggressive X ray diagnostics, and resulting unnecessary spinal fusion operation surgeries. Everybody makes money, and the patient believes his back problem was well taken care off.
Thus, diagnostic errors are a function of four factors: 1) the time and cost pressure associated with today's medical environment, 2) the complexity of human physiology, 3) the cognitive errors that the human brain makes across any profession, and 4) distorted economic incentives generated by Big Pharma, insurers, lawyers, and doctors themselves.
To prevent diagnostic errors ask the right type of open-ended questions suggests the author. These include: What else could it be? Is there anything that does not fit the current diagnostic? Is it possible I have more than one problem? These questions will force the doctor's thinking to slowdown his pattern recognition reflex and allow for more deliberation about a condition. These questions will also fight most of the mentioned cognitive errors that are all associated with expediting a diagnostic so as to move on to the next patient.
If you want to further understand medical errors due to economic incentives I recommend another book "What Doctors Don't Tell You" by Lynne McTaggart. Another excellent book on a similar subject is "The Last Well Person" by Nortin Hadler.
An Outstanding Analysis, But Only Part of the Problem May 28, 2007
Dr. Richard G. Petty (Atlanta)
24 out of 26 found this review helpful
Most doctors are highly educated, hard working people. They may sometimes get a bit tetchy because they overwhelmed by the demands made on them, but most of the time they do their best. Yet in our blame culture there are places in America where you can't get a specialist to treat you: they have all been driven out of business by lawyers representing unhappy clients. The question of why this has come to pass has occupied the minds of the American medical profession for three decades.
For more than a decade, Groopman's trenchant analyses have always been illuminating, and he has a rare gift for communicating them.
This is one of the best books that he has written, about one of the issues that may lead to medical errors: simply not thinking well. It is a very real factor. We all - and not just doctors - jump to conclusions; believe what others tell us and trust the authority of "experts." Clinicians bring a bundle of pre-conceived ideas to the table every time that they see a patient. If that have just seen someone with gastric reflux, they are more likely to think that the next patient with similar symptoms has the same thing, and miss his heart disease. And woe betides the person who has become the "authority" on a particular illness: everyone coming through his or her door will have some weird variant of the disease. As Abraham Maslow once said, "If the only tool you have is a hammer, you tend to see every problem as a nail." To that we have to add that not all sets of symptoms fall neatly into a diagnostic box. That uncertainty can cause doctors and their patients to come unglued. Sometimes when doctors disagree it is based not on facts, but on different interpretations of this uncertainty.
On this one topic the book is very good as far as it goes, thought I do think that the analysis is incomplete.
I have taught medical students and doctors on five continents, and this book does not address some of the very marked geographic differences in medical practice. While I think that the book is terrific, let me point out some of the ways in which it is "Americano-centric."
The first point is that the evidence base in medicine is like an inverted pyramid: a huge amount of practice is still based on a fairly small amount of empirical data. As a result doctors often do not know want they do not know. They may have been shown how to do a procedure without being told that there is no evidence that it works. As an example, few surgical procedures have ever been subjected to a formal clinical trial. Although medical schools are trying to turn out medical scientists, many do not have the time or the inclination to be scientific in their offices. In day-to-day practice doctors often use fairly basic and sometimes flawed reasoning. A good example would be hormone replacement therapy. It seemed a thoroughly good idea. What could be better than re-establishing hormonal balance? In practice it may have caused a great many problems. Medicine is littered with examples of things that seemed like a good idea but were not. Therapeutic blood letting contributed to the death of George Washington, and the only psychiatrist ever to win a Nobel Prize in Medicine got his award for taking people with cerebral syphilis and infecting them with malaria. The structure of American medicine does not support the person who questions: consensus guidelines and "standards of care" make questioning, innovation and freedom very difficult. A strange irony in a country founded on all three.
The second major factor in the United States - far more than the rest of the world - is the practice of defensive medicine: doctors have to do a great many procedures to try and protect themselves against litigation. This is having a grievous effect not only on costs, but also on the ways in which doctors and patients can interact.
Third is the problem of demand for and entitlement to healthcare. We do not have enough money for anything: but what is enough if the demand for healthcare continues to grow as we expect? And if people are being told that it is their right to live to be a hundred in the body of a twenty year-old? Much of the money is directed in questionable directions. There are some quite well known statistics: twelve billion dollars a year spent on cosmetic surgery, at a time when almost 40 million people have no health insurance. There are some horrendous problems with socialized medicine, but most European countries have at least started the debate about what can be offered. Should someone aged 100 have a heart transplant? Everyone has his or her own view about that one, but it is a debate that we need to have in the United States.
Fourth is the impact of money on the directions chosen by medical students and doctors starting their careers. Most freshly minted doctors in the United States have spent a fortune on their education, so they are drawn to specialties in which they can make the most money to pay back their loans. In family medicine and psychiatry, even the best programs are having trouble filling their residency training programs. Many young doctors are interested in these fields, but they could die of old age before they pay off their loans.
Fifth is the problem of information. It is hard for most busy doctors in the United States to keep up to date on the latest research, and many are rusty on the mechanics of how to interpret data. So much of their information comes from pharmaceutical companies. Many of the most influential studies have been conducted by pharmaceutical companies, simply because they have the resources. But there have been times when data has therefore appeared suspect. Industry is not evil, but companies certainly hope that their studies will turn out a certain way, and the outcome of any study depends on the questions asked and the way in which the data is analyzed. And like any collection of people, it is easy to fall into a kind of groupthink. There are countless examples of highly intelligent individuals who all missed the wood for the leaves. "Our product is the best there's ever been, and we are all quite sure that the stories about side effects are just a bit of "noise" created by our competitors." That topic alone could provide much grist for Dr. Groopman's mill.
Another related problem is that many scientists are now also setting up companies to try and profit from the discoveries that they have made in academia. Most are working from the highest motives, but sometimes there are worries about impartiality. So once again, the unsuspecting physician may add data to the diagnostic mix without knowing its provenance. There have recently been a number of high profile examples of that.
It could well be that Groopman will cover all of these points and more in his next book, and I can, of course, be accused of criticizing him for not writing the book that "I" wanted!
This is a book that should be read by every doctor and patient in America.
It is also good to know that there are other ways of thinking about some of the problems before us.
Very highly recommended.
Cognitive Science in the Clinical Office and Diagnostic Process June 17, 2007
Hugh Rosen (Philadelphia, PA United States)
14 out of 14 found this review helpful
This book by Dr. Jerome Groopman, in my opinion, should be required reading of all medical students. Further since it is new (2007), I believe that all physicians whether they work directly with patients or interpreting diagnostic fims behind the scenes should read it, as well. Lastly, any potential or actual patient, which means everyone, should read it to understand the system they are being diagnosed and treated within, and the demands and limitations placed upon their well-meaning doctors.
Physicians are not infallible. Some external constraints placed upon them derive from their administrative officers and, in turn, from the cost-efficiency efforts of HMO's. The time spent with each patient has been pared down and leads to more rigid and habituated diagnoses. Yet a proper and accurate diagnosis is critical since it is the engine that governs the treatment to follow.
In addition to external constraints, the doctor's mind is all too often, by virtue of his or her training, locked into a template that leads to a stereotyping of the diagnostic process. As certain symptoms are relayed by the patient they are automatically made to fit an a priori template, hence, imposing closure on more creative and flexible thinkiong that may discern an unlikely or unexpected, but accurate diagnosis. Alternative, but potentially fruitful perspectives are overlooked if they fall outside the boundaries of the learned template.
Dr. Groopman does not hesitate to acknowledge and emphasize that mood and temperament can influence the judgment of the diagnostician. The physician who is aware of this and is not defensive about it, is more likely to transcend the limitations imposed by the subjective thinking brought to the process.
The book is written with sensitivity, insight, restraint, yet it is direct and to the point. Clinical vignettes are sprinkled throughout the book, adding clear illustrations, enhancing the author's meaning, and contributing a humane touch to every page.
This work is a tour de force that will be compelling and illuminating to any reader.
By Hugh Rosen, Philadelphia, PA, Autor of "Silent Battlefields: A Novel."
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