The Doctor Is In A Rut
HOW DOCTORS THINK
By Jerome Groopman, M.D.
Houghton Mifflin; 307pp; $26
The Good A rare window into the doctor's mind.
The Bad Waits to the very end to give tips for patients.
The Bottom Line Numerous tales of misdiagnosis--and valuable lessons for everyone.
Over a period of 15 years a young woman named Anne Dodge saw doctor after doctor in a quest to overcome what was consistently diagnosed as an eating disorder. Following meals she experienced nausea and intense stomach pain, and sometimes she vomited. Nothing seemed to help—not therapy, not antidepressants, and certainly not the 3,000-calorie-a-day diet her internist prescribed. Her weight dropped to 82 pounds, and she was in danger of starving to death.
Dodge consulted as many as 30 doctors before she finally found one willing to consider that her problem might be something different from what others had diagnosed. He ran a battery of tests and spent hours talking with Dodge. Finally he hit on the solution: She had a rare autoimmune disease that she could control easily by eliminating gluten from her diet. Almost instantly, Dodge got her life back.
Health-care horror stories such as Dodge's are the backbone of How Doctors Think, by Dr. Jerome Groopman, a practicing physician and a professor at Harvard Medical School. Drawing partly on his own experience, Groopman delves deeply into the cognitive processes and prejudices that can drive physicians toward faulty diagnoses. Add in industry pressures, he argues, such as profit-hungry HMOs and aggressive pharmaceutical marketing practices, and you end up with a recipe for bad medical care. In a tone that grips but is never overwrought, Groopman provides a rare window into the doctor's exam room and passes along lessons valuable to all patients.
In chapter after chapter, Groopman methodically lays out the most common pitfalls for doctors, illustrating each with compelling real-life case studies. For example, there are "representativeness errors," which occur when a doctor's diagnosis is swayed by prototypes. An emergency-room physician misdiagnoses a fortysomething forest ranger's chest pain as a strained muscle because the patient looks too healthy to have heart problems. In fact, he has unstable angina and shows up in the ER the next day with a full-blown heart attack. Then there's "diagnosis momentum," the tendency for each health-care provider brought into a case to accept blindly the initial doctor's diagnosis. "Diagnosis momentum, like a boulder rolling down a mountain, gains enough force to crush anything in its way," Groopman writes. That's what happened to Dodge.
Groopman also makes a strong case against the health-care industry, which he believes is adding to the pressure on doctors to take cognitive shortcuts. As managed-care companies cut reimbursement rates, providers respond by cramming as many patients as they can into a day. Groopman writes of one Boston practice that instructed its physicians to cut each new-patient appointment from an hour to 40 minutes and to limit follow-ups to no more than 15 minutes. Also, they were told to fill out electronic templates as they talked to each patient in the hope that their tablet computers would help speed up the billing process. Meanwhile, the pharmaceutical industry bombards consumers with ads imploring them to "ask their doctors" about new drugs. Many physicians so fear losing business that they would rather give in to patients' drug demands than figure out if the requested medicine is the solution, Groopman says.
While Groopman sprinkles in examples of his own mistakes and those made by doctors who have treated him, the cases beyond his own practice provide the book's most eye-opening moments. He introduces readers to Rachel Stein, a rabbi who adopted a baby from Vietnam. When the child, named Shira, became desperately ill just days after arriving in the U.S., hospital physicians diagnosed her with severe combined immunodeficiency disorder (SCID), an inherited disease common in Asia. The only hope, they said, was a bone marrow transplant, a treatment so harsh it would put Shira's life at risk.
Stein spent hours researching SCID and corresponding with families affected by it. She became convinced that the problem was malnourishment, not SCID, and demanded the hospital run a battery of tests. Stein was right: Shira's immune system was normal, and proper feeding put her on the road to recovery. Because the baby fit the stereotype of the typical SCID patient, doctors overlooked the simpler diagnosis.
The most practical part of Groopman's book is the epilogue. There he encourages patients to challenge their doctors and even suggests the exact language to use. He recommends broad, open-ended questions such as "What else could it be?" or "Is there anything that doesn't fit?" After reading these tales of misdiagnoses and life-threatening decisions, patients will likely decide to take his advice.
By Arlene Weintraub