How Doctors Think.

Abstract

How Doctors Think. Groopman J. Boston, Mass, Houghton Mifflin Company, 2007, hardcover, 307 pp, $26.00. How Doctors Think explores, in a highly readable and engaging style, processes by which physicians make diagnoses and treatment decisions. Jerome Groopman, MD, who is professor of medicine at Harvard Medical School and chief of experimental medicine at Beth Israel Deaconess Medical Center, uses vivid storytelling from his 30 years of practice to probe faulty thinking that leads to misdiagnosis in medical care. The book reads with ease of a good novel, even as it illuminates complex and varied ways that faulty thinking can lead to less than adequate medical care. Groopman introduces book with story of Anne Dodge, whose health was deteriorating after 15 years of misdiagnosis and categorization of psychogenic origin of symptoms until she encountered a doctor who broke pattern perpetrated by previous physicians and diagnosed her celiac disease. Through this case, Groopman introduces some of errors in thinking that are explored more thoroughly in subsequent chapters, such as: being influenced by a frame or context transmitted by colleagues; lack of awareness of way that emotional reaction to a patient affects thinking and decision making; and premature commitment to a diagnostic theory. Each of subsequent 4 chapters explores in greater depth a particular cognitive error. In Chapter 1, Groopman tells a story from his own internship, which illustrates effect of stress and excess arousal on ability to act effectively in response to a patient's cardiac event. He makes point that mistakes in thinking can be caused by inner feelings that we do not readily admit to and often don't even recognize. Chapter 2 explores attribution errors, which occur when diagnostician is unduly influenced by stereotypes, and illustrates this thinking process with tales of a hale and hearty forest ranger whose cardiac disease was missed because of his swarthy appearance. He then tells a contrasting story of how disgust with a less appealing patient, in this case an elderly male with a history of alcohol abuse, can lead to inadequate depth of examination. In Chapter 3, we learn about errors that result from availability, which is the tendency to judge likelihood of an event by ease with which relevant examples come to mind. Using stories from a variety of practice settings, including some derived from experience of a colleague who practices among Navajo and Hopi in Arizona, Groopman clarifies how we rationalize early hypotheses that enter our thinking because of our familiarity with them. This rationalization occurs in spite of inconsistencies in patient's signs and symptoms that should raise doubt and signifies some of pitfalls in Bayesian analysis of patient problems. …