Fw: Review-a-Day: How Doctors Think

[Guest guest]

As we typically need to interface so much with professionals in the medical

community, I thought this reveiw might be interesting.

Yuka

----- Original Message -----

> Today's Review From

> Washington Post Book World

>

> How Doctors Think

> by Jerome Groopman M.D.

>

> Read today's review in HTML at:

> http://www.powells.com/n/220/wpb/review/2007_04_13

>

>

> Heal Thyself

> A review by Brown

>

> Why is it that How Doctors Think is likely to find an audience

> while How Automotive Engineers Think would be a tough sell, and

> How Bookkeepers Think wouldn't have a prayer?

>

> Part of the reason is that most of us believe, rightly or wrongly,

> that our lives might one day depend on the right decision by a

> doctor -- a belief we share about few other occupations. Most,

> as well, have watched doctors work, an experience, whether good

> or bad, that tends to lend an oracular quality to what a doctor

> does. And then there's the drama and heroism that's supposed to

> be -- and occasionally is -- part of medicine.

>

> Jerome Groopman, a physician at Harvard Medical School who is

> also a writer for the New Yorker, does not debunk the notion of

> medical " exceptionalism. " His book contains all kinds of smart,

> often selfless, occasionally heroic doctors making good decisions

> and sometimes saving lives. But it is far from a narcissistic

> paean to his profession. It is an effort to dissect the anatomy

> of correct diagnosis, successful treatment and humane care --

> and also of diagnostic error, misguided therapy and thoughtless

> bedside manner. His task is to offer practical advice to both

> patients and physicians. He succeeds at both.

>

> Groopman catalogues the many species of clinical errors, a whole

> taxonomy of misperceptions and wrong conclusions illustrated with

> real examples offered as representative types. All are fascinating,

> a few are chilling.

>

> Into the latter category falls the case of a woman who for 15

> years suffered from chronic diarrhea, vomiting and eventually

> anemia, osteoporosis and severe weight loss. Doctors said she

> had anorexia, bulimia and irritable bowel syndrome -- a proliferation

> of diagnoses that should have been a hint they were wrong. After

> initially resisting, she had come to accept this explanation of

> her problem, dutifully taking antidepressants and forcing down

> 3,000 calories of largely indigestible food each day. By the time

> she consulted one of Groopman's colleagues at Beth Israel Deaconness

> Hospital in Boston, she weighed 82 pounds. He diagnosed celiac

> disease, an allergy to the protein gluten found in many grains.

> The disease denudes the inner surface of the small intestine,

> reducing its ability to absorb nutrients; it explained all her

> symptoms.

>

> The woman " was fitted into the single frame of bulimia and anorexia

> nervosa from the age of twenty, " writes Groopman. " It was easily

> understandable that each of her doctors received her case within

> that one frame. All the data fit neatly within its borders. There

> was no apparent reason to redraw her clinical portrait, to look

> at it from another angle.

>

> Many of the mistakes Groopman describes are variants of this one.

> They come from the physician's inability to keep his or her mind

> open, a reluctance to abandon initial impressions or received

> wisdom, and a willingness to ignore (often unconsciously) contradictory

> evidence. At the same time, the facts of biology rightly steer

> physicians away from endlessly pursuing improbable diagnoses --

> a truth captured in such medical-school aphorisms as: " When you

> hear hoofbeats, don't immediately think of zebras " and " Don't

> forget that common things are still common. "

>

> " It is a matter, " Groopman writes, " of juggling seemingly contradictory

> bits of data simultaneously in one's mind and then seeking other

> information to make a decision, one way or another. This juggling...marks

> the expert physician -- at the bedside or in a darkened radiology

> suite. "

>

> This need for self-awareness during the act of thinking and working

> extends to the physician's emotional state and personal beliefs.

> How a doctor feels about a patient can have a major effect on

> the care provided to people who are obese, poor, stupid, mentally

> ill, addicted, foreign, criminal, deviant or ill-smelling -- as

> well as to those who are rich, powerful, famous, personally familiar

> or smarter than the doctor.

>

> Groopman doesn't go much into the sociology of medicine, which

> is unfortunate because it has quite a bit to do with laying the

> groundwork for the cognitive errors he describes. Many medical

> students and doctors are surprisingly incurious about human narrative,

> to which they have almost unparalleled access. Most have little

> exposure to unintelligent, inarticulate or life-weary people.

> Few have done manual labor or been in the position of taking orders

> rather than giving them (outside of medical training, that is).

> Many are poor listeners and like to hear themselves talk. If it

> is true, as one is taught in medical school, that 80 percent of

> diagnoses can be made purely on the medical history -- what the

> patient says before the physical exam or any tests are done --

> these traits can be impediments to good care.

>

> So what is Groopman's advice for ways to help doctors think better?

>

> An entire chapter illustrates the first commandment of pediatrics:

> Always take seriously the mother's theory of what's happening,

> no matter how harebrained it sounds. Patients should feel free

> to voice what they suspect the doctor may be thinking. " With a

> disarming sense of humor, she communicated that she understood

> she fit a certain social stereotype, and that stereotype had caused

> her doctors to fail to fully consider her complaints, " Groopman

> notes admiringly of a patient who admitted she was " a little crazy "

> but doubted that menopause was the cause of her severe headaches

> and crawling skin. (She turned out to have a tumor that floods

> the body with hormones.) Another doctor tells Groopman she was

> helped when her patient said, " Don't save me from an unpleasant

> test just because we're friends. "

>

> Simple questions can help refocus a physician's attention: " What's

> the worst thing this can be? " and " What body parts are near where

> I am having my symptom? " Before calling the pediatrician, parents

> should ask themselves " what it is that scares them the most about

> their child's condition. " And everyone should be leery of lazy

> generalities: " No one -- no doctor, no patient -- should ever

> accept, as a first answer to a serious event, 'We see this sometimes.'

> "

>

> For their part, doctors should be wary of diagnoses that appear

> instantly obvious. Groopman quotes one doctor who jumped to the

> conclusion that a woman had pneumonia when, in fact, she had an

> aspirin overdose, which can cause some of the same signs and symptoms.

> " I learned from this to always hold back, to make sure that even

> when I think I have the answer, to generate a short list of alternatives. "

>

> Groopman notes that having adequate time to think helps (but of

> course doesn't guarantee) good decision making. Much of medicine,

> however, is practiced with the consumer waiting for the product

> to be delivered, whether it's the proposed work-up, the diagnosis,

> the treatment options or the long-term prognosis. This expectation

> of instant knowledge and service is something few people would

> consider reasonable for tasks such as having a will drawn up or

> even getting a pair of skates sharpened. This is perhaps worth

> keeping in mind as doctors are increasingly asked to do more in

> shorter appointments for the same or less money.

>

> When it comes to medical care, we Americans want everything --

> limitless access to drugs, diagnostic studies, surgical procedures,

> experimental therapies. We might want to push the system to give

> us more of the most potent intervention in medicine -- a doctor

> with time to think and talk.

>

> Brown, a physician, is a science reporter at the Washington

> Post.

>

> Read the review online at:

> http://www.powells.com/n/220/wpb/review/2007_04_13

>

[Guest guest]

very interesting

>

> As we typically need to interface so much with professionals in the

> medical

> community, I thought this reveiw might be interesting.

>

> Yuka

>

> ----- Original Message -----

> From: reviews@... >

> > Today's Review From

> > Washington Post Book World

> >

> > How Doctors Think

> > by Jerome Groopman M.D.

> >

> > Read today's review in HTML at:

> > http://www.powells.com/n/220/wpb/review/2007_04_13

> >

> >

> > Heal Thyself

> > A review by Brown

> >

> > Why is it that How Doctors Think is likely to find an audience

> > while How Automotive Engineers Think would be a tough sell, and

> > How Bookkeepers Think wouldn't have a prayer?

> >

> > Part of the reason is that most of us believe, rightly or wrongly,

> > that our lives might one day depend on the right decision by a

> > doctor -- a belief we share about few other occupations. Most,

> > as well, have watched doctors work, an experience, whether good

> > or bad, that tends to lend an oracular quality to what a doctor

> > does. And then there's the drama and heroism that's supposed to

> > be -- and occasionally is -- part of medicine.

> >

> > Jerome Groopman, a physician at Harvard Medical School who is

> > also a writer for the New Yorker, does not debunk the notion of

> > medical " exceptionalism. " His book contains all kinds of smart,

> > often selfless, occasionally heroic doctors making good decisions

> > and sometimes saving lives. But it is far from a narcissistic

> > paean to his profession. It is an effort to dissect the anatomy

> > of correct diagnosis, successful treatment and humane care --

> > and also of diagnostic error, misguided therapy and thoughtless

> > bedside manner. His task is to offer practical advice to both

> > patients and physicians. He succeeds at both.

> >

> > Groopman catalogues the many species of clinical errors, a whole

> > taxonomy of misperceptions and wrong conclusions illustrated with

> > real examples offered as representative types. All are fascinating,

> > a few are chilling.

> >

> > Into the latter category falls the case of a woman who for 15

> > years suffered from chronic diarrhea, vomiting and eventually

> > anemia, osteoporosis and severe weight loss. Doctors said she

> > had anorexia, bulimia and irritable bowel syndrome -- a proliferation

> > of diagnoses that should have been a hint they were wrong. After

> > initially resisting, she had come to accept this explanation of

> > her problem, dutifully taking antidepressants and forcing down

> > 3,000 calories of largely indigestible food each day. By the time

> > she consulted one of Groopman's colleagues at Beth Israel Deaconness

> > Hospital in Boston, she weighed 82 pounds. He diagnosed celiac

> > disease, an allergy to the protein gluten found in many grains.

> > The disease denudes the inner surface of the small intestine,

> > reducing its ability to absorb nutrients; it explained all her

> > symptoms.

> >

> > The woman " was fitted into the single frame of bulimia and anorexia

> > nervosa from the age of twenty, " writes Groopman. " It was easily

> > understandable that each of her doctors received her case within

> > that one frame. All the data fit neatly within its borders. There

> > was no apparent reason to redraw her clinical portrait, to look

> > at it from another angle.

> >

> > Many of the mistakes Groopman describes are variants of this one.

> > They come from the physician's inability to keep his or her mind

> > open, a reluctance to abandon initial impressions or received

> > wisdom, and a willingness to ignore (often unconsciously) contradictory

> > evidence. At the same time, the facts of biology rightly steer

> > physicians away from endlessly pursuing improbable diagnoses --

> > a truth captured in such medical-school aphorisms as: " When you

> > hear hoofbeats, don't immediately think of zebras " and " Don't

> > forget that common things are still common. "

> >

> > " It is a matter, " Groopman writes, " of juggling seemingly contradictory

> > bits of data simultaneously in one's mind and then seeking other

> > information to make a decision, one way or another. This

> juggling...marks

> > the expert physician -- at the bedside or in a darkened radiology

> > suite. "

> >

> > This need for self-awareness during the act of thinking and working

> > extends to the physician's emotional state and personal beliefs.

> > How a doctor feels about a patient can have a major effect on

> > the care provided to people who are obese, poor, stupid, mentally

> > ill, addicted, foreign, criminal, deviant or ill-smelling -- as

> > well as to those who are rich, powerful, famous, personally familiar

> > or smarter than the doctor.

> >

> > Groopman doesn't go much into the sociology of medicine, which

> > is unfortunate because it has quite a bit to do with laying the

> > groundwork for the cognitive errors he describes. Many medical

> > students and doctors are surprisingly incurious about human narrative,

> > to which they have almost unparalleled access. Most have little

> > exposure to unintelligent, inarticulate or life-weary people.

> > Few have done manual labor or been in the position of taking orders

> > rather than giving them (outside of medical training, that is).

> > Many are poor listeners and like to hear themselves talk. If it

> > is true, as one is taught in medical school, that 80 percent of

> > diagnoses can be made purely on the medical history -- what the

> > patient says before the physical exam or any tests are done --

> > these traits can be impediments to good care.

> >

> > So what is Groopman's advice for ways to help doctors think better?

> >

> > An entire chapter illustrates the first commandment of pediatrics:

> > Always take seriously the mother's theory of what's happening,

> > no matter how harebrained it sounds. Patients should feel free

> > to voice what they suspect the doctor may be thinking. " With a

> > disarming sense of humor, she communicated that she understood

> > she fit a certain social stereotype, and that stereotype had caused

> > her doctors to fail to fully consider her complaints, " Groopman

> > notes admiringly of a patient who admitted she was " a little crazy "

> > but doubted that menopause was the cause of her severe headaches

> > and crawling skin. (She turned out to have a tumor that floods

> > the body with hormones.) Another doctor tells Groopman she was

> > helped when her patient said, " Don't save me from an unpleasant

> > test just because we're friends. "

> >

> > Simple questions can help refocus a physician's attention: " What's

> > the worst thing this can be? " and " What body parts are near where

> > I am having my symptom? " Before calling the pediatrician, parents

> > should ask themselves " what it is that scares them the most about

> > their child's condition. " And everyone should be leery of lazy

> > generalities: " No one -- no doctor, no patient -- should ever

> > accept, as a first answer to a serious event, 'We see this sometimes.'

> > "

> >

> > For their part, doctors should be wary of diagnoses that appear

> > instantly obvious. Groopman quotes one doctor who jumped to the

> > conclusion that a woman had pneumonia when, in fact, she had an

> > aspirin overdose, which can cause some of the same signs and symptoms.

> > " I learned from this to always hold back, to make sure that even

> > when I think I have the answer, to generate a short list of

> alternatives. "

> >

> > Groopman notes that having adequate time to think helps (but of

> > course doesn't guarantee) good decision making. Much of medicine,

> > however, is practiced with the consumer waiting for the product

> > to be delivered, whether it's the proposed work-up, the diagnosis,

> > the treatment options or the long-term prognosis. This expectation

> > of instant knowledge and service is something few people would

> > consider reasonable for tasks such as having a will drawn up or

> > even getting a pair of skates sharpened. This is perhaps worth

> > keeping in mind as doctors are increasingly asked to do more in

> > shorter appointments for the same or less money.

> >

> > When it comes to medical care, we Americans want everything --

> > limitless access to drugs, diagnostic studies, surgical procedures,

> > experimental therapies. We might want to push the system to give

> > us more of the most potent intervention in medicine -- a doctor

> > with time to think and talk.

> >

> > Brown, a physician, is a science reporter at the Washington

> > Post.

> >

> > Read the review online at:

> > http://www.powells.com/n/220/wpb/review/2007_04_13

> >

>

>

>