How Doctors Think

Journal of Physical Therapy Education, Spring 2008 by Hummel-Berry, Kathie

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, the 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 the faulty thinking that leads to misdiagnosis in medical care. The book reads with the ease of a good novel, even as it illuminates the complex and varied ways that faulty thinking can lead to less than adequate medical care.

Groopman introduces the book with the 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 the pattern perpetrated by previous physicians and diagnosed her celiac disease. Through this case, Groopman introduces some of the 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 the way that emotional reaction to a patient affects thinking and decision making; and premature commitment to a diagnostic theory.

Each of the subsequent 4 chapters explores in greater depth a particular cognitive error. In Chapter 1, Groopman tells a story from his own internship, which illustrates the effect of stress and excess arousal on the ability to act effectively in response to a patient's cardiac event. He makes the 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 the 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 the likelihood of an event by the ease with which relevant examples come to mind." Using stories from a variety of practice settings, including some derived from the 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 the patient's signs and symptoms that should raise doubt and signifies some of the pitfalls in Bayesian analysis of patient problems.

In Chapter 4, focusing on the role of the primary care provider, Groopman explores how cultural challenges to communication can lead to mistaken evidence, and ultimately to errors in diagnosis and inadequate care. Many ways in which cultural misunderstanding can fracture the doctor-patient relationship are explored. He paints a palpable picture of the numbing effect of a practice in which most patients have minor problems, and the ways in which these monotonous experiences can blur the recognition of serious situations that are less frequently encountered.

In Chapters 5 and 6, Groopman illustrates how faulty thinking and challenged communication plays out in 3 moving and interesting stories of complex-care situations. In Chapter 5, an adoptive mother brings an apparently healthy Vietnamese infant to Boston only to enter a prolonged hospitalization. Groopman's description of the sequence of theories that finally explain the infant's immunocompromise is compelling and further serves to illustrate the important role of the patient and family in challenging wrong assumptions. In Chapter 6, the experience of a pediatric cardiologist serves to exemplify the way that imperfect science can become codified to rules for treatment that merit re-examination.

Chapter 9 is an exploration of how the pressures of marketing (eg, the sales tactics of pharmaceutical representatives) and economic pressures can influence medical decisions. Through examples that illustrate the effects of both drug marketing and surgical income on critical thinking, Groopman brings to life the ways that conflict of interest can begin to threaten the integrity of medical care.

In Chapter 10, stories from the Sloan-Kettering Institute "try to understand a patient's character and factor this understanding into... clinical judgments." Groopman ends his book by powerfully illustrating that it is his patients who keep his mind open, and the openness of his mind that gives him the greatest chance of providing expert care.

I highly recommend this book for all practicing clinicians and educators as a stimulus to self-examine and a basis for discussion on the potential folly of our own assumptions of expertise. This book could also be the basis of a wonderful assignment for students, as it can be read quickly and it stimulates important and profound questioning of the diagnostic process.