Valuable to folks who want to be an active participant in managing their health. Easy to read and also thorough - more than a pop self-help book. Scary, but fascinating. It reinforces my experience that the most confidence-inspiring physicians are those who are willing to say, "I don't know" when they don't, rather than, "Oh sure, I've got that covered," when really they're clueless. Jerome Groopman, M. How Doctors Think.
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The book opens with a discussion of a woman in her thirties who suffered daily stomach cramps and serious weight loss, and who visited some 30 doctors over a period of 15 years. Several misdiagnoses were made before she was finally found to have celiac disease. But the frequency and seriousness of those mistakes can be reduced by "understanding how a doctor thinks and how he or she can think better".
The book includes Groopman's own experiences both as an oncologist and as a patient, as well as interviews by Groopman of prominent physicians in the medical community.
Notably, he describes his difficulties with a number of orthopedic surgeons as he sought treatment for a debilitating ligament laxity he suffered in his right hand, which over several years had led to the formation of cysts in the bones of his wrist. Groopman spends a great deal of the book discussing the challenge posed to him by Dr. During the presentation, Groopman was discussing the importance of compassion and communication in providing medical care when Salem posed the following question:.
There are primary care physicians in every hospital who speak with great sensitivity and concern, and their longtime patients love them, but clinically they are incompetent--how is a patient to know this? At the time of the presentation, Groopman was unable to provide a satisfactory response. Salem's question reminded Groopman of his experiences with physicians at the Phillips House of the world-renowned Massachusetts General Hospital , where he trained as a resident in the s.
Per his account:. A few of [the physicians at Philips House] were highly skilled, but several were, at best, marginal in their clinical acumen. Nonetheless, their patients were devoted to them.
It was the job of the residents to plug the holes in these marginal doctors' care. Just as a physician has to be wary of his first impression of a patient's condition, as a patient you have to be careful of your first impression of a physician Thankfully, fewer students are admitted to medical school now because of social standing and family connections than at the time of my training.
America has become more of a meritocracy in the professions. Medical school admissions committees no longer accept a record of gentlemen's C's at an Ivy League college. At best, I said to Salem, a layman should inquire of friends and, if possible, other physicians as well as nurses about the clinical qualities of a doctor beyond his personality.
His credentials can be found on the Internet or by contacting a local medical board Salem's query required a much more comprehensive answer, which I hope this book will help provide. Specifically, he explores their development in the early s of a concept known as the availability heuristic.
In the theory, "availability" is defined as the tendency to judge the likelihood of explanation for an event by the ease with which relevant examples come to mind. In a clinical situation a diagnosis may be made because the physician often sees similar cases in his practice — for example, the misclassification of aspirin toxicity as a viral pneumonia , or the improper recognition of an essential tremor as delirium tremens due to alcohol withdrawal in an indigent urban setting.
Groopman argues that a clinician will misattribute a general symptom as specific to a certain disease based on the frequency he encounters that disease in his practice. Kahneman won the Nobel Prize in economics in for his work on heuristics , an honor that Groopman believes Tversky would have shared had he not died in Groopman also serves as an advocate for primary care physicians in his book.
He argues that gatekeeper physicians are underreimbursed for their work, believing this to be a legacy of the period earlier this century when surgeons headed the medical societies that negotiated with insurers about what a 'customary' payment for services was to be.
He suggests that the poor reimbursement and lack of recognition for primary care physicians is fundamentally flawed. He quotes Dr.
Eric J. A common error in thinking about primary care is to see it as entry-level medicine This is a false notion. One should not confuse highly technical, even complicated, medical knowledge--special practical knowledge about an unusual disease, treatment, condition, or technology--with the complex, many-sided worldly-wise knowledge we expect of the best physicians.
The narrowest subspecialist, the reasoning goes, should also be able to provide this [broad] range of medical services. This naive idea arises, as do so many other wrong beliefs about primary care, because of the concept that doctors take care of diseases.
Diseases, the idea goes on, form a hierarchy from simple to difficult. Specialists take care of difficult diseases, so, of course, they will naturally do a good job on simple diseases. Doctors take care of people, some of whom have diseases and all of whom have some problem. People used to doing complicated things usually do complicated things in simple situations--for example, ordering tests or x-rays when waiting a few days might suffice--thus overtreating people with simple illnesses and overlooking the clues about other problems that might have brought the patient to the doctor.
In a later chapter Groopman reports a frank discussion with Dr. James E. Lock, chief of cardiology at Boston Children's Hospital. During their conversation, Groopman asks the world-renowned cardiologist about the times in his career when he made mistakes in patient treatment. To the query, Lock gives the cryptic response, "All my mistakes have the same things in common. Lock then elaborates, discussing recommendations he made to repair specific heart defects in neonates that ultimately led to worse clinical outcomes and potentially avoidable deaths.
The recommendations he made were based on a purely logical understanding of cardiac physiology. Impeccable logic doesn't always suffice. My mistake was that I reasoned from first principles when there was no prior experience.
I turned out to be wrong because there are variables that you can't factor in until you actually do it. And you make the wrong recommendation, and the patient doesn't survive. I didn't leave enough room for what seems [sic] like minor effects--the small fluctuations in oxygen levels, which might amount to one or two or three percent but actually can signal major problems in the heart But it's wrong These children developed right heart failure and clinically they became worse. There are aspects to human biology and human physiology that you just can't predict.
Deductive reasoning doesn't work for every case. Sherlock Holmes is a model detective, but human biology is not a theft or a murder where all the cues can add up neatly. Groopman goes on to write, "Lock averted his gaze and his face fell; to be wrong about a child is a form of suffering unique to his profession [as a pediatrician]. Groopman also discusses the work of Renee Fox, a physician and occupational sociologist who observed residents and attendings in a hospital ward setting, noting their various ways of coping with the uncertainties of medical treatment.
The mechanisms to cope that Fox observed included, for example, black humor , making bets about who would be right about a patient's prognosis, and engaging in magical thinking to maintain a sense of poise and competence in front of patients while performing circumspect procedures.
Jay Katz , a clinical instructor at Yale Law School has since termed these coping mechanisms under the rubric 'disregard of uncertainty', which he believes physicians develop to deal with the anxiety of shifting from the certainty of theoretical discussions of medicine early in their training to its more happenstance practical application.
Groopman recalls that in situations where he had been hesitant to take clinical action based on incomplete data, it had been wisest at times to follow the advice of his mentor Dr.
Linda A. Lewis: "Don't just do something, stand there. Groopman closes with an epilogue giving advice for patients. He gives the following tools that patients can use to help reduce or rectify cognitive errors:. From Wikipedia, the free encyclopedia. Dewey Decimal. Houghton Mifflin.
How Doctors Think
Do doctors think, given the crazy economic pressures they operate under these days? Do other professions think? Does anyone really think anymore — or do we all just react? Groopman is a thinker, a reflective actor.
How doctors think
The book opens with a discussion of a woman in her thirties who suffered daily stomach cramps and serious weight loss, and who visited some 30 doctors over a period of 15 years. Several misdiagnoses were made before she was finally found to have celiac disease. But the frequency and seriousness of those mistakes can be reduced by "understanding how a doctor thinks and how he or she can think better". The book includes Groopman's own experiences both as an oncologist and as a patient, as well as interviews by Groopman of prominent physicians in the medical community. Notably, he describes his difficulties with a number of orthopedic surgeons as he sought treatment for a debilitating ligament laxity he suffered in his right hand, which over several years had led to the formation of cysts in the bones of his wrist. Groopman spends a great deal of the book discussing the challenge posed to him by Dr. During the presentation, Groopman was discussing the importance of compassion and communication in providing medical care when Salem posed the following question:.
Where Does It Hurt?
This elegant, tough-minded book recounts stories about how doctors and patients interact with one other. In the hands of Jerome Groopman, professor of medicine at Harvard and a staff writer for The New Yorker, these clinical episodes make absorbing reading and are often deeply affecting. At the same time, the author is commenting on some of the most profound problems facing modern medicine. Historically, medical education has regarded communication skills with an indifference that approaches contempt. His stories show us instances where a doctor makes snap judgments that are wrong — and right; where past cases distort present perception; where rapport with, or dislike for, a patient alters diagnosis or care. But he is critical of much of the thinking now in vogue.
What’s the Trouble?
On a spring afternoon several years ago, Evan McKinley was hiking in the woods near Halifax, Nova Scotia, when he felt a sharp pain in his chest. McKinley a pseudonym was a forest ranger in his early forties, trim and extremely fit. He had felt discomfort in his chest for several days, but this was more severe: it hurt each time he took a breath. McKinley slowly made his way through the woods to a shed that housed his office, where he sat and waited for the pain to pass. He frequently carried heavy packs on his back and was used to muscle aches, but this pain felt different. He decided to see a doctor.