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
    Mar 2008, 336 pages

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Anne Dodge had lost count of all the doctors she had seen over the past fifteen years. She guessed it was close to thirty. Now, two days after Christmas 2004, on a surprisingly mild morning, she was driving again into Boston to see yet another physician. Her primary care doctor had opposed the trip, arguing that Anne’s problems were so long-standing and so well defined that this consultation would be useless. But her boyfriend had stubbornly insisted. Anne told herself the visit would mollify her boyfriend and she would be back home by midday.

Anne is in her thirties, with sandy brown hair and soft blue eyes. She grew up in a small town in Massachusetts, one of four sisters. No one had had an illness like hers. Around age twenty, she found that food did not agree with her. After a meal, she would feel as if a hand were gripping her stomach and twisting it. The nausea and pain were so intense that occasionally she vomited. Her family doctor examined her and found nothing wrong. He gave her antacids. But the symptoms continued. Anne lost her appetite and had to force herself to eat; then she’d feel sick and quietly retreat to the bathroom to regurgitate. Her general practitioner suspected what was wrong, but to be sure he referred her to a psychiatrist, and the diagnosis was made: anorexia nervosa with bulimia, a disorder marked by vomiting and an aversion to food. If the condition was not corrected, she could starve to death.

Over the years, Anne had seen many internists for her primary care before settling on her current one, a woman whose practice was devoted to patients with eating disorders. Anne was also evaluated by numerous specialists: endocrinologists, orthopedists, hematologists, infectious disease doctors, and, of course, psychologists and psychiatrists. She had been treated with four different antidepressants and had undergone weekly talk therapy. Nutritionists closely monitored her daily caloric intake.

But Anne’s health continued to deteriorate, and the past twelve months had been the most miserable of her life. Her red blood cell count and platelets had dropped to perilous levels. A bone marrow biopsy showed very few developing cells. The two hematologists Anne had consulted attributed the low blood counts to her nutritional deficiency. Anne also had severe osteoporosis. One endocrinologist said her bones were like those of a woman in her eighties, from a lack of vitamin D and calcium. An orthopedist diagnosed a hairline fracture of the metatarsal bone of her foot. There were also signs that her immune system was failing; she suffered a series of infections, including meningitis. She was hospitalized four times in 2004 in a mental health facility so she could try to gain weight under supervision.

To restore her system, her internist had told Anne to consume three thousand calories a day, mostly in easily digested carbohydrates like cereals and pasta. But the more Anne ate, the worse she felt. Not only was she seized by intense nausea and the urge to vomit, but recently she had severe intestinal cramps and diarrhea. Her doctor said she had developed irritable bowel syndrome, a disorder associated with psychological stress. By December, Anne’s weight dropped to eighty-two pounds. Although she said she was forcing down close to three thousand calories, her internist and her psychiatrist took the steady loss of weight as a sure sign that Anne was not telling the truth.

That day Anne was seeing Dr. Myron Falchuk, a gastroenterologist. Falchuk had already gotten her medical records, and her internist had told him that Anne’s irritable bowel syndrome was yet another manifestation of her deteriorating mental health. Falchuk heard in the doctor’s recitation of the case the implicit message that his role was to examine Anne’s abdomen, which had been poked and prodded many times by many physicians, and to reassure her that irritable bowel syndrome, while uncomfortable and annoying, should be treated as the internist had recommended, with an appropriate diet and tranquilizers.

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

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