Turn on the TV and zap through the
channels and the chances are you'll come across an
infallible doctor - either a talking head such as
"Dr Phil" or one of the good looking fictional
doctors of House, ER, Grey's Anatomy
et al who, in a mere 60 minutes including commercial
breaks and side-plots, manage to diagnose and cure
the most obscure of illnesses. Reality is a little
different - doctors are supposed to be emotionally
neutral and even-handed with every patient; they're
explore every avenue before reaching their
considered opinion - but at the end of the day, they're just fallible humans like the rest of us,
working in an extraordinarily stressful field - and,
as a result, get about 15% of their diagnoses wrong.
How Doctors Think by Jerome Groopman and Better by Atul Gawande (published in paperback last month) recognize the imperfections in the current medical system but differ in their approach. Groopman focuses on the thinking process that doctors go through in order to reach a diagnosis; whereas Better takes a more philosophical slant.
In a similar vein to Malcolm Gladwell's Blink, Groopman suggests that if doctors can become more aware of the thinking process that they go through to reach a diagnosis, and in particular to the role that their first impression plays in that process, they can become better diagnosticians.
Groopman's message to the patient is to recognize that doctors are simply well-educated but fallible humans and that "misguided care results from a cascade of cognitive errors", and thus it is up to the patient to present his or her symptoms in such a way that the correct diagnosis can be made. Groopman suggests that patients and their families should be ready with questions that will probe the doctor's thought process, such as "What else could it be?" "Is there anything that doesn't fit?" "Is it possible I have more than one problem?"
Fine words indeed but, considering the time and financial constraints virtually all doctors work under, is the advice practical? And is the system as it stands so bad? If 15% of diagnoses are wrong, 85% are right. If a tennis player was to ace 17 out of 20 of his serves, or a baseball player scored home runs 85% of the time, they'd be considered exceptional!
There is an old medical aphorism that states "When you hear hoofbeats, think horses, not zebras". In other words, when all things are equal, the simplest solution tends to be the best ones. On that basis a few reviewers who are also doctors caveat their otherwise positive reviews by saying that the cases that Groopman highlights are all zebras - cases that, if time and money were not issues might have been correctly diagnosed, but in the real world where time and money are issues it's not surprising that they were misdiagnosed.
There is some truth in this but not all of the cases Groopman highlights can be easily written off as "zebras". For example, the woman diagnosed with anorexia and bulimia who, for fifteen miserable years, was put on a high carb diet and treated for mental instability, before being correctly diagnosed with celiac disease*. Not only did multiple doctors fail to diagnose her correctly but she does not appear to have made much effort to question the diagnosis that she was mentally unstable herself! Perhaps if her original doctor, or one of the many she saw afterwards, had taken a little more time to talk to her as a person, and perhaps if she had had more confidence in her right and ability to question the diagnosis, she wouldn't have suffered for fifteen years.
The bottom line appears to be that, in the vast majority of cases, doctors are very wonderful and dedicated human beings, but there's always room for improvement; which means that if both doctors and patients can become a little more aware of the diagnostic thought process it might be possible to push the batting average up a few percentage points which, if you're one of the 15% misdiagnosed, could be the difference between pain and cure, or even life or death.
As always, you can form your own opinion of How Doctors Think by reading an extensive excerpt at BookBrowse, in this case the full 23 page Introduction. In addition, there are about 10 essays by Groopman available on the web (see sidebar), some of which are reprinted in How Doctors Think.
In addition, 20 BookBrowse members received copies of How Doctors Think - you can read their opinions here.
*Celiac disease, which effects an estimated 1 in 133 Americans, is an autoimmune disease which prevents the body from absorbing nutrients. It is triggered by gluten, found in most grains; thus a high carb diet is absolutely the worst thing for a person with celiac disease.
This review was originally published in April 2007, and has been updated for the March 2008 paperback release. Click here to go to this issue.
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