I had no ready answers to these questions, despite having trained in a well-regarded medical school and residency program, and having practiced clinical medicine for some thirty years. So I began to ask my colleagues for answers.* Nearly all of the practicing physicians I queried were intrigued by the questions but confessed that they had never really thought about how they think. Then I searched the medical literature for studies of clinical thinking. I found a wealth of research that modeled optimal medical decision-making with complex mathematical formulas, but even the advocates of such formulas conceded that they rarely mirrored reality at the bedside or could be followed practically. I saw why I found it difficult to teach the trainees on rounds how to think. I also saw that I was not serving my own patients as well as I might. I felt that if I became more aware of my own way of thinking, particularly its pitfalls, I would be a better caregiver. I wasnt one of the hematologists who evaluated Anne Dodge, but I could well have been, and I feared that I too could have failed to recognize what was missing in her diagnosis.
Of course, no one can expect a physician to be infallible. Medicine is, at its core, an uncertain science. Every doctor makes mistakes in diagnosis and treatment. 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. This book was written with that goal in mind. It is primarily intended for laymen, though I believe physicians and other medical professionals will find it useful. Why for laymen? Because doctors desperately need patients and their families and friends to help them think. Without their help, physicians are denied key clues to what is really wrong. I learned this not as a doctor but when I was sick, when I was the patient.
Weve all wondered why a doctor asked certain questions, or detoured into unexpected areas when gathering information about us. We have all asked ourselves exactly what brought him to propose a certain diagnosis and a particular treatment and to reject the alternatives. Although we may listen intently to what a doctor says and try to read his facial expressions, often we are left perplexed about what is really going on in his head. That ignorance inhibits us from successfully communicating with the doctor, from telling him all that he needs to hear to come to the correct diagnosis and advice on the best therapy.
In Anne Dodges case, after a myriad of tests and procedures, it was her words that led Falchuk to correctly diagnose her illness and save her life. While modern medicine is aided by a dazzling array of technologies, like high-resolution MRI scans and pinpoint DNA analysis, language is still the bedrock of clinical practice. We tell the doctor what is bothering us, what we feel is different, and then respond to his questions. This dialogue is our first clue to how our doctor thinks, so the book begins there, exploring what we learn about a physicians mind from what he says and how he says it. But it is not only clinical logic that patients can extract from their dialogue with a doctor. They can also gauge his emotional temperature. Typically, it is the doctor who assesses our emotional state. But few of us realize how strongly a physicians mood and temperament influence his medical judgment. We, of course, may get only glimpses of our doctors feelings, but even those brief moments can reveal a great deal about why he chose to pursue a possible diagnosis or offered a particular treatment.
After surveying the significance of a doctors words and feelings, the book follows the path that we take when we move through todays medical system. If we have an urgent problem, we rush to the emergency room. There, doctors often do not have the benefit of knowing us, and must work with limited information about our medical history. I examine how doctors think under these conditions, how keen judgments and serious cognitive errors are made under the time pressures of the ER. If our clinical problem is not an emergency, then our path begins with our primary care physician if a child, a pediatrician; if an adult, an internist. In todays parlance, these primary care physicians are termed gatekeepers, because they open the portals to specialists. The narrative continues through these portals; at each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong. We also encounter the tension between his acknowledging uncertainty and the need to take a clinical leap and act. One chapter reports on this in my own case; I sought help from six renowned hand surgeons for an incapacitating problem and got four different opinions.
Copyright © 2007 by Jerome Groopman. Reprinted by permission of Houghton Mifflin Company.
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No Man's Land
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