But that is exactly what Falchuk did not do. Instead, he began to question, and listen, and observe, and then to think differently about Anne’s case. And by doing so, he saved her life, because for fifteen years a key aspect of her illness had been missed.


This book is about what goes on in a doctor’s mind as he or she treats a patient. The idea for it came to me unexpectedly, on a September morning three years ago while I was on rounds with a group of interns, residents, and medical students. I was the attending physician on “general medicine,” meaning that it was my responsibility to guide this team of trainees in its care of patients with a wide variety of clinical problems, not just those in my own specialties of blood diseases, cancer, and AIDS. There were patients on our ward with pneumonia, diabetes, and other common ailments, but there were also some with symptoms that did not readily suggest a diagnosis, or with maladies for which there was a range of possible treatments, where no one therapy was clearly superior to the others.

I like to conduct rounds in a traditional way. One member of the team first presents the salient aspects of the case and then we move as a group to the bedside, where we talk to the patient and examine him. The team then returns to the conference room to discuss the problem. I follow a Socratic method in the discussion, encouraging the students and residents to challenge each other, and challenge me, with their ideas. But at the end of rounds on that September morning I found myself feeling disturbed. I was concerned about the lack of give-and-take among the trainees, but even more I was disappointed with myself as their teacher. I concluded that these very bright and very affable medical students, interns, and residents all too often failed to question cogently or listen carefully or observe keenly. They were not thinking deeply about their patients’ problems. Something was profoundly wrong with the way they were learning to solve clinical puzzles and care for people.

You hear this kind of criticism — that each new generation of young doctors is not as insightful or competent as its forebears — regularly among older physicians, often couched like this: “When I was in training thirty years ago, there was real rigor and we had to know our stuff. Nowadays, well . . .” These wistful, aging doctors speak as if some magic that had transformed them into consummate clinicians has disappeared. I suspect each older generation carries with it the notion that its time and place, seen through the distorting lens of nostalgia, were superior to those of today. Until recently, I confess, I shared that nostalgic sensibility. But on reflection I saw that there also were major flaws in my own medical training. What distinguished my learning from the learning of my young trainees was the nature of the deficiency, the type of flaw.

My generation was never explicitly taught how to think as clinicians. We learned medicine catch-as-catch-can. Trainees observed senior physicians the way apprentices observed master craftsmen in a medieval guild, and somehow the novices were supposed to assimilate their elders’ approach to diagnosis and treatment. Rarely did an attending physician actually explain the mental steps that led him to his decisions. Over the past few years, there has been a sharp reaction against this catch- as-catch-can approach. To establish a more organized structure, medical students and residents are being taught to follow preset algorithms and practice guidelines in the form of decision trees. This method is also being touted by certain administrators to senior staff in many hospitals in the United States and Europe. Insurance companies have found it particularly attractive in deciding whether to approve the use of certain diagnostic tests or treatments.

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