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Summer 2007

   How Doctors Think
    By Jerome Groopman, MD
    Houghton Mifflin Co., New York, 2007

   Dr. Groopman, Harvard professor and clinician at Beth Israel Medical Center in Boston, has written a new
   book about how his fellow medical professionals think, both critically and erroneously. "Listen to the 
   patient, he is telling you the diagnosis" is an old medical saw attributed to William Osler, perhaps the most
   revered figure in American medicine. Dr. Groopman starts his narrative with the sad story of a woman
   labeled bulimic and anorexic with irritable bowel and dramatic weight loss for ten years before she finally
   saw a physician who actually listened carefully to her history and complaints. From this he was able to
   suspect that she had a malabsorption syndrome and later diagnose her celiac disease. A change to a
   gluten-free diet essentially cured her and allowed cessation of the several psychotropic drugs she had
   been taking for years.

   So how do doctors think? Not as you might imagine, by compiling lots of data: signs and symptoms and lab
   work and imaging studies, and sorting them into an algorhythmic decision tree. This may be the way in
   the medical school lecture hall or at didactic rounds at the bedside, but in the real world, rapid "pattern
   recognition" is much more likely, at least according to the author.  Recognition of the pattern of course
   requires experience and may take a while to acquire. Dr. Groopman cites his experience with acute
   shortness of breath in one of his patients on his first night of internship. Only the intercession of
   an experienced physician who just happened to be visiting from out of town averted disaster.

   The author devotes a chapter to two or three common causes of physician error. So-called stereotypic
   mistakes in which the patient fits a typical pattern and a complete clinical investigation is skipped. Or the
   doctor likes the patient and wishes to spare him or her from unpleasant or painful tests. Or the doctor
   has antipathy for the patient, say a filthy and smelly street person that reeks of alcohol is likely to
   get a shorter shrift in the emergency room that a well-dressed middle class clean type. Diagnoses are
   missed at either extreme; the young, athletic man's heart attack may be missed because the physician
   fails to do all the tests if a few are negative (say a cardiac stress test that was skipped by an otherwise
   competent emergency room doctor); or a rare disease in a man who appears to be a chronic alcoholic
   with liver disease. Dr. Groopman provides several of these attribution or stereotypical errors of his own
   and those of otherwise highly skilled physicians.

   Physician error in thinking is further explored by citing several cases that must be pursued diligently; no
   succumbing to the "we see this sometime" of the specialist or allowing the well worked up (up the yin
   yang in medical parlance) patient's symptoms to escape diagnosis. Allowing the patient to talk and tell
   his or symptoms in detail despite the distractions of other patients and professional staff may be critical.
   One of the great pitfalls in medical diagnosis is the common disorder that presents in an atypical fashion.
   Dr. Groopman relates the case of a 10 year old boy who fractured his vertebra after very minor trauma; it
   was due to leukemia that had weakened the bone, only to be discovered months later after more
   fractures.

   Another chapter deals with the tyranny of the common disorder and familiarity leading to an erroneous
   diagnosis. Doctors are taught from their earliest days in medical school that "common diseases are
   common" and that "if you hear hoof beats, think of horses, not zebras." But occasionally zebras exist
   and confound diagnoses. In his example, Dr. Groopman relates the story of a single mom who adopts
   an infant from Viet Nam that develops severe immunodeficiency and complex pneumonia. Although
   HIV infection or SCID (severe combined immunodeficiency) were the leading diagnostic possibilities, the
   child turned out to have a very rare cause of immune dysfunction, severe nutritional deficiency, and
   almost had to undergo an unnecessary bone marrow transplant before the correct diagnosis was made.

   Dr. Groopman has selected interesting patients and doctors, including himself, to relate how each thinks.
   One chapter deals with the difficulty in diagnosing his own hand inflammation by four different surgeons.
   Best of all, the narratives flow right along. There is a long history of doctor writers, from Chekhov
   to Michael Crichton or Robin Cook, but they were all composers of fiction. To make compelling prose
   from arcane medical diagnoses and abbreviations and slang requires writing skill. Drs. Groopman
   and Atul Gawande, author of several non-fiction books for laymen, are perhaps the best (and best known)
   of today's contenders. We'll review Dr. Gawande's latest effort, Better, next quarter.

   A chapter is also devoted to the influence of pharmaceutical companies on doctor's decision making and
   prescribing habits. This has been the subject of several recent books by physician authors and all outline
   the nefarious influence of gifts and travel and fraudulent claims for their drugs. While Dr. Groopman
   doesn't have any new cures for this disease, it should be eradicated in the interest of public health.

   In summary, a worthwhile book and easy to read.
 

  
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