How Doctors Think
Jerome Groopman, MD
Publisher ISBN-13: 9780618610037 336 pages $15.95
When we were in graduate school, we took a class with a clinical psychologist who spent a lot of time discussing cases in which he had been brought in to do second-opinion psychological evaluations. In every case he found an underlying physical cause for the mis-labeled psychological diagnosis, and was able to help the victim, er, patient, be healed. His message to us was firstly that we should look for a medical cause before accepting a psychological diagnosis, and secondly that when someone got sick, it was important to do our homework in helping the doctor reach an appropriate diagnosis and treatment.
There is some question as to exactly how many people die each year due to unfortunate medical factors, but we recall having read that it approached 210,000. By medical factors we mean either medical mistakes (looking at the x-ray backward or prescribing the wrong dose of a prescription medicine) or incorrect diagnosis (which accounts for about 80 percent of the cases in question), or avoidable drug interactions (which account for a significant percentage of hospitalizations). Jerome Groopman’s book, How Doctors Think, is designed to help patients help their doctors come to the right diagnosis.
The book begins with a puzzling case of a woman who had been wasting away for the fifteen years of her treatment. While any careful reader of ÆGIS would have made a correct diagnosis on page two of the book (And no, we are not cunning diagnosticians: We happened to discuss it briefly in the March issue, and know about it only because we have a friend who suffers from it) it took the patient fifteen years to find a doctor who would make the correct diagnosis, on page fifteen, of celiac disease.
Groopman goes through the causes of misdiagnosis, and comes up with practical you (or those acting on your behalf) can ask to help your doctor come up with the right diagnosis. To try and jog an ER physician – or any physician – into thinking widely about your problem, you cans ask “What is the worst thing this can be?” This can be helpful if the doctor doesn’t like you (doctors sometimes don’t like sick people they can’t easily diagnose, noncompliant people, or people whom they don’t like for mysterious reasons), or is fixated on a particular diagnosis. Another question is “What body parts are near where I am having my symptoms?” Also, asking “Is there anything that doesn’t fit?” might get the doctor to think about anomalous data which might be a clue rather than a mere outlier.
Another reasonable question is “What else could it be?” And if you have a fear or suspicion that you have been afraid to mention, it is a good idea to bring this up as a possibility to be looked at. An equally valid question would be “Is it possible that I have more than one problem?”
He writes that “Patients can help the doctor think by asking questions. If he mentions a possible complication from surgery, they can ask how often it happens. If he talks about pain and lingering discomfort from a procedure, they can ask how the pain compares with having a tooth pulled under Novocain, or some other unpleasant event. If he recommends a procedure, patients can ask why, what might be found, with what probability, and, importantly, how much difference it will make to find it.”
You should also ask whether a treatment is standard, or whether different specialists recommend different approaches, and why. And how time-tested a new treatment is.
Another significant issue was understanding prognosis. In one case an oncologist told a patient that there was a thirty percent reduction in mortality with chemotherapy. The numbers, however, indicated that this meant that in five years while ten out of a hundred who did not take chemotherapy would die, with chemo seven – thirty percent fewer – would die. While a thirty percent reduction might get us into chemotherapy, seven out of a hundred versus ten out of a hundred would induce us not to take chemotherapy, with its attendant loss of quality of life.
When we look at a book we tend to dog-ear it so we can pull up appropriate quotes. In this book we had 23 pages marked. Since we obviously cannot discuss here all the pieces we thought significant, we urge you to get a copy and read it several times. It is quite likely that doing so will keep you, or someone you care for, alive or less hurt.
Because How Doctors Think the critical issue of health care, and is something every reader will have to deal with at some point in time, we have added it to our list of must-read books. Past must-read books are, in alphabetical order:
• All You Need Is Love, and Other Lies about Marriage by John W. Jacobs, M.D
• Better by Atul Gawande, M.D.
• Beyond Fear by Bruce Schneier
• Corpocracy by Robert A. G. Monks
• The End ofAmerica, by Naomi Wolf
• Inside the Tornado by Geoffrey A. Moore
• Rediscover Your Native Fitness (PACE), by Al Sears, M.D.
• Reinventing the CFO by Jeremy Hope
• Taking Sex Differences Seriously by Steven E. Rhoads
• What Clients Love by Harry Beckwith
• With Winning in Mind by Lanny Bassham