Review by New York Times Review
THIS elegant, tough-minded book recounts stories about how doctors and patients interact with one other. In the hands of Jerome Groopman, professor of medicine at Harvard and a staff writer for The New Yorker, these clinical episodes make absorbing reading and are often deeply affecting. At the same time, the author is commenting on some of the most profound problems facing modern medicine. Groopman powerfully conveys the complexity of the physician's role, the anxiety and uncertainty that dog his every step, the difficulties that arise in understanding patients, eliciting their stories, making a diagnosis. One of the messages of "How Doctors Think" is that patients need to be active participants in their care; and without question the best physicians encourage, and even demand, the involvement of patients. Yet a paradox lies at the heart of Groopman's subject: although the medical profession has long recognized that doctors communicate poorly with patients, physicians receive little training to improve that interaction. Historically, medical education has regarded communication skills with an indifference that approaches contempt. It's unscientific, it's hand-holding, it's bedside manner. Yet it's clearly important. Groopman focuses on one aspect of the doctor-patient interaction: how it influences a physician's diagnosis, and even his ability to make a diagnosis at all. His stories show us instances where a doctor makes snap judgments that are wrong - and right; where past cases distort present perception; where rapport with, or dislike for, a patient alters diagnosis or care. (This leads Groopman to one of the few direct recommendations in this book: if you get the feeling your doctor doesn't like you, find another one.) Unlike such simple errors as prescribing the wrong dose of medicine or reversing an X-ray, Groopman writes, misdiagnosis is "a window into the medical mind," revealing "why doctors fail to question their assumptions, why their thinking is sometimes closed or skewed, why they overlook the gaps in their knowledge." According to one study he cites, as many as 15 percent of patients receive inaccurate diagnoses, a finding that matches research based on autopsies. In recent years, Groopman writes, there has been a sharp reaction against the "catch as catch can" approach to teaching diagnosis that prevailed when he was in medical school, where trainees would watch senior doctors and somehow absorb their way of thinking. But he is critical of much of the thinking now in vogue. Today's physicians are increasingly encouraged to behave as if they were computers, and to reason from flowcharts and algorithms. This is intended to produce better diagnoses and fewer errors; it is also embraced by insurance companies, who use it to decide which tests and treatments to approve. This approach can be useful for "run-of-the-mill diagnosis and treatment - distinguishing strep throat from viral pharyngitis, for example," Groopman writes. But for difficult cases he finds it limiting and dehumanizing. He is similarly critical of generic profiles, classification schemes that draw statistical portraits of disease states. They encourage the doctor to focus on the disease, not the patient, and so may lead him to miss the particular manifestation in the particular sufferer. Groopman also discusses physician heuristics - shortcuts to decision-making that he considers "the foundation of all mature medical thinking," although they too "can lead to grave errors." But Groopman points out that heuristics aren't taught in medical school and are in fact discouraged, in favor of a much more leisurely and extended kind of thinking, typified by Socratic dialogue between students and professors. This means that young doctors enter the hospital knowing little about either the advantages or the disadvantages of heuristics. Take, for example, what psychologists call "availability," the tendency to judge the likelihood of an event by how readily it comes to mind. Thus physicians may mistake symptoms of one dis ease for those of another disease they've seen more often. Or they may fall prey to "confirmation bias," which leads them to rapidly assemble information into an accurate diagnosis - or misconstrue the evidence before them. Cognitive errors are highlighted in Groopman's account of a Vietnamese infant he calls Shira Stein, brought home by her adoptive mother to Boston. Before departure, the baby was coughing. On landing, she seemed dehydrated and refused to drink; a day later she was in the I.C.U. at Children's Hospital with severe pneumonia. Her doctors, recognizing they might be up against an exotic infection from Vietnam, struggled to oxygenate her, but even on the respirator her condition deteriorated. Saved from death by extreme measures, she was found to be infected by five potentially lethal agents: pneumocystis, cytomegalovirus, Klebsiella, Candida and parainfluenzae. Such devastating multiple infections implied an immune deficiency. Doctors concluded that Shira had SCID, severe combined immunodeficiency disorder. SCID is a rare, inherited condition. Because the gene is located on the X chromosome, it's especially rare in girls, who must inherit the gene from both parents. And because Shira's T-cells were only slightly low, she didn't show the usual SCID pattern. Her case was defined as "atypical." Groopman's account focuses on Shira's extraordinary mother, who week after week stayed in the hospital, steadfast in her belief that her daughter would recover. "Shira is going to live," Rachel tells him. "I can feel it inside of me." After more than a month in the I.C.U., Shira-, was successfully weaned from the respirator, and plans were begun for a bone marrow transplant to treat her immune deficiency. With the child improving, Rachel conducted her own research on SCID, becoming ever more convinced that her daughter did not have it. Instead, she suspected Shira had a nutritional deficiency. Rachel stubbornly insisted that immune testing be repeated, and the pediatricians reluctantly indulged her. Shira's T-cells were normal; she did not have SCID after all. The bone marrow transplant may well have killed her. Groopman reviews the clinical conference where Shira's case was discussed. Such conferences occur at every teaching hospital in the country, Groopman writes, but they generally lack "an in-depth examination of why the diagnosis was missed - specifically, what cognitive errors occurred and how they could have been remedied." He observes that the doctors at Boston Children's Hospital, one of the best pediatric hospitals in the world, had extensive experience with SCID and similar genetic abnormalities: "Familiarity breeds conclusions and sometimes a certain degree of contempt for alternatives." Physicians may be reluctant to pursue unlikely diagnoses, particularly if they will be criticized by colleagues for ordering too many tests or for being show-offs. By contrast, Boston doctors have little experience with unusual nutritional deficiencies. "I would wager that very few on the staff would know how to identify them," Groopman writes. "I admit that I don't." Thus doctors were predisposed to dismiss Rachel's theory of a nutritional deficiency - though it remains unclear whether that's what caused her condition. Finally, Shira's doctors experienced what Groopman calls "diagnosis momentum." Once the diagnosis is made, it is passed on to other doctors with ever-increasing conviction. Contradictory evidence is brushed aside. Groopman says he has made all the same errors as Shira's doctors did. "When all the pieces of the clinical puzzle did not fit tightly together," he writes, "I moved some of those that didn't to the side. I made faulty assumptions, seeking to make an undefined condition conform to a well-defined prototype, in order to offer a familiar treatment." It is this direct and honest voice that drives the narratives of this remarkable book. Here is Groopman at the peak of his form, as a physician and as a writer. Readers will relish the result. Unlike such simple errors as reversed X-rays or mismeasured prescriptions, misdiagnosis is 'a window into the medical mind.' Michael Crichton's most recent novel is "Next."
Copyright (c) The New York Times Company [October 27, 2009]
Review by Booklist Review
By far the largest number of examples New Yorker 0 staff writer and Harvard physician Groopman adduces to show how doctors think shows them thinking well for the good of their patients. In the initial example, one doctor seen by a woman with a long-standing weight-loss condition concedes being stumped and sends her to a specialist who finds the cause of her woes and, most probably, saves her from an early death. Both physicians are praiseworthy, the second more than the first only because he believed a patient whom others had come to pooh-pooh as a complainer and then thought of examining for something that the others had missed. The lesson? A doctor has to think with the patient, not despite or against her or from an assumption of superior knowledge. Subsequent chapters show doctors thinking in resistance to economic pressure by hospitals and insurers, in thorough solidarity with parents about their children's care, against a host of professional assumptions and in resistance to pestering by drug companies--all to help patients achieve their own goals as far as possible. An epilogue suggests a few questions patients should ask to help their doctors think clearly and, as the last chapter's title puts it, "In Service of the Soul." A book to restore faith in an often-resented profession, well enough written to warrant its quarter-million-copy first printing. --Ray Olson Copyright 2007 Booklist
From Booklist, Copyright (c) American Library Association. Used with permission.
Review by Publisher's Weekly Review
Drawing on both personal experience and extensive field research, Dr. Groopman sheds light on the faulty decision making that leads otherwise competent physicians down the wrong path in diagnosing and treating their patients. Groopman stresses the imperative for his colleagues to balance clinical formulas and data with keen insight and for patients to engage their physicians in active dialogue. Like the heroic fictional doctors in prime-time television medical dramas, Groopman advances a humane, patient-focused agenda that flies in the face of the bureaucratic, institutional establishment, but refreshingly, he manages to steer clear of pat answers and smug solutions that characterize much of the popular media's take on health care. With more than 450 titles under his belt, accomplished narrator Michael Prichard exhibits a calm, authoritative command of the material. His less-is-more approach to conveying emotion may strike some listeners as detached and lacking passion, but his steady performance fits nicely with Groopman's sensitive-but still highly inquisitive-exploration of life and death questions. Simultaneous release with the Houghton Mifflin hardcover (Reviews, Jan. 29). (June) (c) Copyright PWxyz, LLC. All rights reserved
(c) Copyright PWxyz, LLC. All rights reserved
Review by Library Journal Review
In a hotly contested book won by the publisher in a preemptive bid, a Harvard Medical School professor explains how issues like a doctor's age, gender, and relationship with the patient can affect care. (c) Copyright 2010. Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.
(c) Copyright Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.
Review by Kirkus Book Review
A revealing, often disturbing look at what goes on in doctors' minds when treating patients, plus some advice to patients on how to work with their doctors to improve that process. Oncologist and New Yorker staff writer Groopman (The Anatomy of Hope, 2004, etc.) draws on conversations and interviews with other doctors, research in the field and his own experiences as both doctor and patient to unravel the question of how doctors reach a diagnosis and decide on a treatment. While the clinical algorithms and practice guidelines that medical students are taught and that are promoted by hospital administrators and insurance companies are useful in many cases, he argues that they discourage doctors from thinking creatively when symptoms are vague and test results inconclusive. Groopman categorizes the kinds of errors in thinking that doctors can make (drawing on stereotypes, thinking too narrowly, clinging to an original diagnosis while ignoring later evidence), and he uses real cases as examples. In one, doctors who diagnose a Vietnamese infant as having a rare inherited disease are only persuaded otherwise by the adoptive mother's insistence on retesting her blood. In another, various doctors continue to accept an initial misdiagnosis over a 15-year period until one doctor makes the correct diagnosis by taking the time to question and observe the patient closely and pay attention to her answers. When Groopman receives four different diagnoses and plans for treatment for his painful, inflamed right hand, he consults a fifth specialist, and together they analyze the types of cognitive errors that led to the series of misdiagnoses. His revelations about the performance records of radiologists and others who must read and interpret tests will be disconcerting to anyone expecting technology to produce certainty, and his chapter on the influential marketing tactics of pharmaceutical manufacturers will dismay those expecting doctors to demonstrate objectivity. In an epilogue, Groopman speaks directly to the would-be patient, offering pertinent questions that one might direct to his or her physician to promote broader thinking about an ailment. A highly pleasurable must-read. Copyright ©Kirkus Reviews, used with permission.
Copyright (c) Kirkus Reviews, used with permission.
