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 by Jerome Groopman
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  • First Published:
    Mar 2007, 320 pages
    Paperback:
    Mar 2008, 336 pages

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Dodge was about to refuse, but then Falchuk repeated emphatically that something else might account for her condition. “Given how poorly you are doing, how much weight you’ve lost, what’s happened to your blood, your bones, and your immune system over the years, we need to be absolutely certain of everything that’s wrong. It may be that your body can’t digest the food you’re eating, that those three thousand calories are just passing through you, and that’s why you’re down to eighty-two pounds.”

When I met with Anne Dodge one month after her first appointment with Dr. Falchuk, she said that he’d given her the greatest Christmas present ever. She had gained nearly twelve pounds. The intense nausea, the urge to vomit, the cramps and diarrhea that followed breakfast, lunch, and dinner as she struggled to fill her stomach with cereal, bread, and pasta had all abated. The blood tests and the endoscopy showed that she had celiac disease. This is an autoimmune disorder, in essence an allergy to gluten, a primary component of many grains. Once believed to be rare, the malady, also called celiac sprue, is now recognized more frequently thanks to sophisticated diagnostic tests. Moreover, it has become clear that celiac disease is not only a childhood illness, as previously thought; symptoms may not begin until late adolescence or early adulthood, as Falchuk believed occurred in Anne Dodge’s case. Yes, she suffered from an eating disorder. But her body’s reaction to gluten resulted in irritation and distortion of the lining of her bowel, so nutrients were not absorbed. The more cereal and pasta she added to her diet, the more her digestive tract was damaged, and even fewer calories and essential vitamins passed into her system.

Anne Dodge told me she was both elated and a bit dazed. After fifteen years of struggling to get better, she had begun to lose hope. Now she had a new chance to restore her health. It would take time, she said, to rebuild not only her body but her mind. Maybe one day she would be, as she put it, “whole” again.



Behind Myron Falchuk’s desk, a large framed photograph occupies much of the wall. A group of austerely dressed men pose, some holding derby hats, some with thick drooping mustaches like Teddy Roosevelt’s; the sepia tinge of the picture and the men’s appearance date it to the early 1900s. It seems out of phase with Falchuk’s outgoing demeanor and stylish clothes. But it is, he says, his touchstone.

“That photograph was taken in 1913, when they opened the Brigham Hospital,” Falchuk explained. “William Osler gave the first grand rounds.” A smile spread across his face. “It’s a copy. I didn’t steal the original when I was chief resident.” Osler was acutely sensitive to the power and importance of words, and his writings greatly influenced Falchuk. “Osler essentially said that if you listen to the patient, he is telling you the diagnosis,” Falchuk continued. “A lot of people look at a specialist like me as a technician. They come to you for a procedure. And there is no doubt that procedures are important, or that the specialized technology we have these days is vital in caring for a patient. But I believe that this technology also has taken us away from the patient’s story.” Falchuk paused. “And once you remove yourself from the patient’s story, you no longer are truly a doctor.”

How a doctor thinks can first be discerned by how he speaks and how he listens. In addition to words spoken and heard, there is nonverbal communication, his attention to the body language of his patient as well as his own body language — his expressions, his posture, his gestures. Debra Roter, a professor of health policy and management at Johns Hopkins University, works as a team with Judith Hall, a professor of social psychology at Northeastern University. They are among the most productive and insightful researchers studying medical communication. They have analyzed thousands of videotapes and live interactions between doctors of many types — internists, gynecologists, surgeons — and patients, parsing phrases and physical movements. They also have assayed the data from other researchers. They have shown that how a doctor asks questions and how he responds to his patient’s emotions are both key to what they term “patient activation and engagement.” The idea, as Roter put it when we spoke, is “to wake someone up” so that the patient feels free, if not eager, to speak and participate in a dialogue. That freedom of patient speech is necessary if the doctor is to get clues about the medical enigma before him. If the patient is inhibited, or cut off prematurely, or constrained into one path of discussion, then the doctor may not be told something vital. Observers have noted that, on average, physicians interrupt patients within eighteen seconds of when they begin telling their story.

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

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