Excerpt from How Doctors Think by Jerome Groopman, plus links to reviews, author biography & more

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How Doctors Think

by Jerome Groopman

How Doctors Think
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  • First Published:
    Mar 2007, 320 pages
    Paperback:
    Mar 2008, 336 pages

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Roter and Hall also studied the effect a doctor’s bedside manner has on successful diagnosis and treatment. “We tend to remember the extremes,” Hall said, “the genius surgeon with an autistic bedside manner, or the kindly GP who is not terribly competent. But the good stuff goes together — good doctoring generally requires both. Good doctoring is a total package.” This is because “most of what doctors do is talk,” Hall concluded, “and the communication piece is not separable from doing quality medicine. You need information to get at the diagnosis, and the best way to get that information is by establishing rapport with the patient. Competency is not separable from communication skills. It’s not a tradeoff.”

Falchuk conducts an inner monologue to guide his thinking. “She told me she was eating up to three thousand calories a day. Inside myself, I asked: Should I believe you? And if I do, then why aren’t you gaining weight?” That simple possibility had to be carried to its logical end: that she was actually trying, that she really was putting the cereal, bread, and pasta in her mouth, chewing, swallowing, struggling not to vomit, and still wasting away, her blood counts still falling, her bones still decomposing, her immune system still failing. “I have to give her the benefit of a doubt,” Falchuk told himself.

Keeping an open mind was reflected in Falchuk’s open-ended line of questioning. The more he observed Anne Dodge, and the more he listened, the more disquiet he felt. “It just seemed impossible to absolutely conclude it was all psychiatric,” he said. “Everyone had written her off as some neurotic case. But my intuition told me that the picture didn’t entirely fit. And once I felt that way, I began to wonder: What was missing?”

Clinical intuition is a complex sense that becomes refined over years and years of practice, of listening to literally thousands of patients’ stories, examining thousands of people, and most important, remembering when you were wrong. Falchuk had done research at the National Institutes of Health on patients with malabsorption, people who couldn’t extract vital nutrients and calories from the food they ate. This background was key to recognizing that Anne Dodge might be suffering not only from anorexia nervosa or bulimia but also from some form of malabsorption. He told me that Anne reminded him that he had been fooled in the past by a patient who was also losing weight rapidly. That woman carried the diagnosis of malabsorption. She said she ate heartily and had terrible cramps and diarrhea, and her many doctors believed her. After more than a month of evaluation, with numerous blood tests and an endoscopy, by chance Falchuk found a bottle of laxatives under her hospital bed that she had forgotten to hide. Nothing was wrong with her gastrointestinal tract. Something was tragically wrong with her psyche. Falchuk learned that both mind and body have to be considered, at times independently, at times through their connections.

Different doctors, as we will see in later chapters, achieve competency in remarkably similar ways, despite working in disparate fields. Primarily, they recognize and remember their mistakes and misjudgments, and incorporate those memories into their thinking. Studies show that expertise is largely acquired not only by sustained practice but by receiving feedback that helps you understand your technical errors and misguided decisions. During my training, I met a cardiologist who had a deserved reputation as one of the best in his field, not only a storehouse of knowledge but also a clinician with excellent judgment. He kept a log of all the mistakes he knew he had made over the decades, and at times revisited this compendium when trying to figure out a particularly difficult case. He was characterized by many of his colleagues as eccentric, an obsessive oddball. Only later did I realize his implicit message to us was to admit our mistakes to ourselves, then analyze them, and keep them accessible at all times if we wanted to be stellar clinicians. In Anne Dodge’s case, Falchuk immediately recalled how he had taken at face value the statements of the patient at NIH who was secretly using laxatives. The opposite situation, he knew, could also apply. In either setting, the case demanded continued thought and investigation.

Copyright © 2007 by Jerome Groopman. Reprinted by permission of Houghton Mifflin Company.

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