How Doctors Think, Jerome Groopman, MD, 2007, Boston, Houghton Mifflin Company, 320 pp., $26.00.
Since Jerry Groopman wrote The Measure of Our Days, he has become the medical profession’s spokesperson on the art of medicine. This time he has written a book that the media loves, and as a practicing medical oncologist in Boston for the past 30 years, he has experience that warrants our attention.
He is honest and critical in describing, based on interviews with many medical experts on their decision-making processes, how doctors arrive at decisions, and frank about his own decision-making process. Groopman loves to tell stories to illustrate his points, and this book is filled with them.
Emotions play more of a role in decisions than most physicians admit. We assume that the errors we make in medicine are largely technical ones — prescribing the wrong dose of a medication, transfusing a unit of blood matched for another patient, or mislabeling an X-ray. But as a growing body of research shows, technical errors account for only a small fraction of doctors’ incorrect diagnoses and treatments. Most errors are mistakes in thinking. Part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don’t even recognize. Patients are not the only people with emotions.
It has become increasingly difficult to spend the time with patients necessary for making well-informed, wise decisions. In specialties like radiology, the technological complexity of the imaging has compounded the difficulty of interpretation. Currently the bean counters are generating metrics to judge a physician’s quality, but many of these measurements are trivial, simply scorecards to ensure that easily measured things are accomplished. In this context, quality means thinking broadly and making judicious decisions with limited data.
Groopman has written an interesting chapter on specialists based on the idea that if you give someone a hammer, everything looks like a nail. He says that specialists are susceptible to “diagnostic momentum”: Once an authoritative senior physician has fixed a label to the problem, it usually stays firmly attached. Specialists tend to be didactic and fixed in their opinions; however, acknowledging uncertainty enhances a physician’s therapeutic effectiveness if it demonstrates honesty and a willingness to be more engaged with the patient.
In a disturbing chapter entitled “Marketing, Money, and Medical Decisions,” Groopman discusses the interface between physicians and industry. He addresses the issue of spinal fusion and device manufacturers, reporting that more than 150,000 lower lumbar spinal fusions were performed in the United States in 2006. Groopman, knowledgeable about spinal surgery in part from an unhappy personal experience, notes that there are serious questions about the indications for lumbar spinal fusion and whether the operation is effective, leading him to question whether spinal fusion is done for financial or medical indications since scientific proof is unavailable. He is uncomfortable with lavish treatment that spinal surgeons often accept from instrument makers. A plea is made for honest, informed choice.
He also discusses a fundamental schism in healthcare between physicians who base treatment almost entirely on data and those who are willing to individualize treatment in a holistic manner. Medicine, after all, is a mix of science and soul.
The key recommendation of this book is to get back to the basics: Listen to the patient and examine repeatedly. Groopman suggests that we never tell our patients that there is nothing wrong with them and that we always ask three questions before arriving at our diagnosis: (1) What else could it be? (2) Is there anything that doesn’t fit? (3) Is it possible that there is more than one problem?
Why should neurosurgeons read this book? How Doctors Thinkoffers a useful model for turning our practiced critical thinking skills upon ourselves. We will all be better neurosurgeons if we do, and our patients deserve no less.
Gary Vander Ark, MD, is clinical professor of neurosurgery at the University of Colorado Health Sciences Center. He is the 2001 recipient of the AANS Humanitarian Award.