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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My admiration for Myron Falchuk increased when we went on from Anne Dodge’s case to discuss not his clinical triumphs but his errors. Again, every doctor is fallible. No doctor is right all the time. Every physician, even the most brilliant, makes a misdiagnosis or chooses the wrong therapy. This is not a matter of “medical mistakes.” Medical mistakes have been written about extensively in the lay press and analyzed in a report from the Institute of Medicine of the National Academy of Sciences. They involve prescribing the wrong dose of a drug or looking at an x-ray of a patient backward. Misdiagnosis is different. It is a window into the medical mind. It reveals why doctors fail to question their assumptions, why their thinking is sometimes closed or skewed, why they overlook the gaps in their knowledge. Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes. In one study of misdiagnoses that caused serious harm to patients, some 80 percent could be accounted for by a cascade of cognitive errors, like the one in Anne Dodge’s case, putting her into a narrow frame and ignoring information that contradicted a fixed notion.

Another study of one hundred incorrect diagnoses found that inadequate medical knowledge was the reason for error in only four instances. The doctors didn’t stumble because of their ignorance of clinical facts; rather, they missed diagnoses because they fell into cognitive traps. Such errors produce a distressingly high rate of misdiagnosis. As many as 15 percent of all diagnoses are inaccurate, according to a 1995 report in which doctors assessed written descriptions of patients’ symptoms and examined actors simulating patients with various diseases. These findings match classical research, based on autopsies, which shows that 10 percent to 15 percent of all diagnoses are wrong.

I can recall every misdiagnosis I’ve made during my thirty-year career. The first occurred when I was a resident in internal medicine at the Massachusetts General Hospital; Roter’s and Hall’s research explains it. One of my patients was a middle-aged woman with seemingly endless complaints whose voice sounded to me like a nail scratching a blackboard. One day she had a new complaint, discomfort in her upper chest. I tried to pin down what caused the discomfort — eating, exercise, coughing — to no avail. Then I ordered routine tests, including a chest x-ray and a cardiogram. Both were normal. In desperation, I prescribed antacids. But her complaint persisted, and I became deaf to it. In essence, I couldn’t think in a different way. Several weeks later, I was stat paged to the emergency room. My patient had a dissecting aortic aneurysm, a life-threatening tear of the large artery that carries blood from the heart to the rest of the body. She died. Although an aortic dissection is often fatal even when discovered, I have never forgiven myself for failing to diagnose it. There was a chance she could have been saved.

Roter’s and Hall’s work on liking and disliking illuminates in part what happened in the clinic three decades ago. I wish I had been taught, and had gained the self-awareness, to realize how emotion can blur a doctor’s ability to listen and think. Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment. The doctor becomes increasingly convinced of the truth of his misjudgment, developing a psychological commitment to it. He becomes wedded to his distorted conclusion. His strong negative feelings about the patient make it harder for him to abandon that conclusion and reframe the clinical picture differently.

This skewing of physicians’ thinking leads to poor care. What is remarkable is not merely the consequences of a doctor’s negative emotions. Despite research showing that most patients pick up on the physician’s negativity, few of them understand its effect on their medical care and rarely change doctors because of it. Rather, they often blame themselves for complaining and taxing the doctor’s patience. Instead, patients should politely but freely broach the issue with their doctor. “I sense that we may not be communicating well,” a patient can say. This signals the physician that there is a problem in compatibility. The problem may be resolvable with candor by a patient who wants to sustain the relationship. But when I asked other physicians what they would do if they, as patients, perceived a negative attitude from their doctor, each one flatly said he or she would find another doctor.

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

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