How Doctors Think book

[Guest guest]

I've just finished reading Jerome Groopman's book " How Doctors Think " . Groopman

is a

hematologist/oncologist in Boston who also writes for the New Yorker magazine.

The

book is focused on the factors that lead to misdiagnoses and medical errors.

There are a

lot of really important examples, in which further suffering was avoided by

asking good

questions of the doctor. At the end, he has a chapter on how patients can work

with their

doctors to avoid such errors.

One of the basic errors doctors (all people, really) can make is to disregard

facts to make a

diagnosis fit. You can help, by offering to take her through your medical

history again. You

can also help by letting her in on your fears. " I'm worried that it might be

cancer. " If you

alert the physician to your fears, it may prompt her to probe more deeply, and

to let you in

on her thinking. If you better understand her thinking, you may be prompted to

bring in

elements of your history you thought were irrelevant to the problem at hand.

He talks about the pressures on radiologists and pathologists to read more and

more

samples in less time. Without repeating the biopsy or CT scan, you can ask for a

second

reading. Studies of radiologists show that many abnormalities are overlooked.

You can

help by making it clear to the technician or radiologist that the concerns are,

often in our

cases, cholangiocarcinoma, bile duct abnormalities, blood clots, or cirrhosis. I

encountered a radiologist unfamiliar with the risk of CCA from PSC, and he chose

the MRI

parameters accordingly, to show the ducts and to best detect CCA. Some

physicians don't

want to bias the radiologist, but since the reading of imaging studies is often

difficult, it

makes sense to focus the search, even if it is just a list of symptoms.

" What else could it be? " " Is there anything that doesn't fit? " and " Is it

possible I have more

than one problem? " are all questions that can help focus the physician's

thinking about a

difficult diagnosis. In med school, students learn to apply Occam's razor, which

says the

simplest explanation is the most likely. The questions above safeguard against

" search

satisfaction " , choosing the most obvious answer and ignoring data that don't

fit.

Physicians are taught " if you hear hoofbeats, look for horses, not zebras " . But

sometimes

it is a zebra. Or an antelope!

Finally, he talks about how to respond if the physician says " nothing is wrong

with you "

(other than strangling him with his stethoscope!). " Nothing is wrong " denies the

fallibility

of physicians, and it splits mind from body. Not to mention it's a cheap way out

of dealing

with fatigue, sleeplessness, and other PSC related problems. I highly recommend

this

book! He speaks not only as a physician, but as a patient who has experienced

misdiagnosis and damaging, pointless procedures himself.

I might add a few questions of my own to the list: " Will this invasive test

change anything

you do? " (ask this about liver biopsies, or " routine " ERCPs). And " How much

experience do

you have treating people with PSC? " . I'm sure you have many more to add to this

list, that

are perhaps more specific to PSC.

Martha (MA)

UC 1979, PSC 1992

[Guest guest]

>

> I've just finished reading Jerome Groopman's book

> " How Doctors Think " .

Excellent reading. The book was excerpted last year in the New Yorker

here:

http://www.newyorker.com/reporting/2007/01/29/070129fa_fact_groopman