HOW DOCTORS THINK PROVIDES REVEALING INSIGHTS

Why should medical board members care about how doctors think? The great majority of physicians are well-educated, well-trained and dedicated to their patients and profession. Does it really matter how a well-trained physician reaches a diagnosis? Can’t one just assume that physicians are thinking appropriately as they treat patients? In his insightful and myth-shattering How Doctors Think, (2007, Houghton Mifflin Company) Jerome Groopman, M.D., argues persuasively that this line of thinking is naïve. Groopman, who trained at Massachusetts General Hospital and is currently chair of Medicine at Harvard Medical School, makes the case that understanding how doctors think and what goes on in a doctor’s mind as he treats a patient is critical to minimizing misdiagnosis. His insights will be invaluable to medical board members wrestling with complex quality of care cases.

Like any good academician, before writing this book, Groopman surveyed the literature. He found research on optimal decision making, often featuring complex mathematical formulas, but little on practical considerations of how doctors think as they treat patients and how they can think better. This led to the fundamental question behind How Doctors Think: When and why does thinking go right or go wrong in medicine?

In this elegantly written book, Groopman focuses on medical misdiagnoses, rather than such medical errors as providing the wrong drug dosage or operating on the wrong leg. He provides a series of fascinating clinical case studies that illustrate his main thesis: Misdiagnoses are caused by flaws in a physician’s thinking. Usually, these flaws are the result of the physician falling, often unconsciously, into what he refers to as “cognitive traps.” In other words, most misdiagnoses result from mistakes in thinking, not ignorance of clinical facts. Groopman also argues these traps are identifiable, breaking them into a number of categories: availability error — where a physician’s diagnosis is inappropriately impacted by a diagnosis made in another recent case; confirmation bias — a tendency to confirm a diagnostic conclusion by cherry-picking data to support that conclusion; commission bias — the need to do something, even if not necessarily justified; diagnosis momentum — once a diagnosis becomes fixed, despite contrary evidence, it sticks; and satisfaction search — the tendency to stop searching once any diagnosis is made. Most inappropriate care, Groopman writes, results from the cascade of these cognitive pitfalls.

Patients, Groopman emphasizes, can play a critical role to minimize the inappropriate care resulting from cognitive traps. First, they should pay attention to how physicians speak and how they listen. This, attests Groopman, is the best way to discern how a physician thinks, because the first detour from a correct diagnosis often is caused by miscommunication. Patients also must actively partner with their treating physician. The patient/partner can hone a doctor’s thinking with a few pertinent, focused questions to help steer a physician away from cognitive errors. Asking, “What else could it be?” helps avoid some of most common traps. “Is there anything that does not fit?” encourages the physician to think more broadly. “Is it possible I have more than one problem?” is a safeguard against search satisfaction.

And what about the argument familiar to medical boards in disciplinary hearings that the physician is competent and just a bad communicator? Dismissing the acceptability of the “genius surgeon” with the “autistic personality,” Groopman asserts competency is not separable from communications skills; there is no tradeoff. While practicing in one of the meccas of modern medicine, he is decidedly old school — in the best sense of the term — in asserting that despite the availability of dazzling technology, “language is the bedrock of clinical practice.”

How Doctors Think is a remarkable and gutsy book. It is at its best when it uses case studies to illustrate the kind of cognitive errors that even the best-trained physicians can make. These descriptions provide valuable insight for even the most sophisticated patients. In fact, one of the most compelling case studies involves a very sophisticated patient: Groopman himself. Groopman suffered from inappropriate care as the result of several well-regarded hand surgeons falling into what Groopman recognized in hindsight as identifiable cognitive traps. These included the need to do something, even if not justified (commission bias), and an “invented” diagnosis unknown to anyone in the field and unrelated to his problem.

Although written primarily for lay people, it should be read by every member of a medical board wishing to understand how misdiagnoses occur and enhance quality care. Patients can gain revealing insights into what goes on in a doctor’s mind when treating a patient and the intellectual traps that can befall well-intentioned physicians. I, for one, will be consulting it again before my next doctor visit, so I can actively partner with my physician. We both will be the better for it.