I just finished Dr. Jerome Groopman's How Doctors Think, a thought-about-thought-provoking look at the puzzle doctors face in trying to make correct diagnoses. I enjoyed the book - it read like a mundane version of House, minus all the insults and clear ethical violations. Mainly, the book is a catalog of cognitive errors that doctors can make - availability error, search satisfaction, overreliance on Occam's (Groopman spells it Ockham's) razor, etc. The book offers lots of handy doctorish sayings for dinner parties - "when you hear hoofbeats, think horses not zebras" - but often Groopman shows why these saying can be dangerous, since maybe the doctor is looking at one zebra in a hundred horses. But as Groopman recounts tales of misdiagnosis, it shows the art, rather than science, of being a doctor - a point Keith has made to me many a time. While the book may lead the lay reader (which is its target audience) to believe doctors are just flailing away in the dark, Groopman seems simply to be advocating for openmindedness on every case and the courage (or maybe just the time!) to question initial assumptions.
While legal issues are a small part of the book, one always is aware that any misdiagnosis can lead to a malpractice suit. But Groopman isn't crucifying doctors for being wrong. He is simply taking them to task for thinking they can't be wrong or not being willing to change course when it becomes clear that they are. Nothing in this book is ground-breaking. None of the wisdom or warnings about cognitive errors would be news to doctors, but Groopman shows how the current medical system - predicated on speed of appointments, avoiding expensive tests or (horror!) redoing those tests, and the constant marketing of drugs and surgical devices - can make avoiding cognitive errors almost impossible.
Having said all that, I don't think I could cut it as a doctor. There is too much that is unknown, too many things that could be happening unseen and consequences that are too serious if things go wrong. I've come to believe that almost everything - including, in many cases, the law - is a game (the book How Lawyers Think would be boring, incomprehensible, focused on winning verdicts rather than justice, and ultimately pointless), but being a doctor is not a game. It is very important work. Throughout my reading of the book, I could not help but compare the analysis that Groopman was doing with what I would think in the same situation. (On the first day of law school they say they are going to change the way you think, and I have to admit that they are right.) But I'm not sure if the way I think is helping anyone particularly (or ever will), but I know that the way Keith and Shaleah think is helping some thankful Nebraskans.
Sometimes thinking about thinking can leave one wrapped in a confusing puzzle of meta-ness, but it is a worthwhile exercise. I know I took some things from Groopman's book that will help me make better decisions. I'm expecting that those decisions won't involve life and death, but for those who do make such decisions, remember, zebras do exist!
Today's Arizona Adventure!
10 years ago
8 comments:
The title should probably read, "How (academic and aged) doctors think." If you trained in the last 20 years you're unlikely to be dogmatic about your clinical diagnosis skills. In fact, your fallibility likely hangs over your every patient encounter like a spectre.
One of the reasons the U.S. has one of the poorest health to GDP ratios in the world is because physicians know how fallible they are, don't want to make a false assumption and miss a diagnosis, so they order unnecessary tests instead of relying on their clinical judgement.
The guiding principle of my practice is something you learn very early in your intern year. How to tell a sick person from a healthy person. Essentially, a heuristic to help you decide who you need to order expensive and time consuming tests on and who you can place your stethoscope on, give your blessing and send on their way.
It would be nice if this wasn't necessary but because medicine is such an inexact science you need to help your brain determine signal from noise. You say you couldn't be a doctor, but to become an expert in anything you just have to do it for 10,000 hours. There are studies to prove this so I won't go into detail here, but suffice to say that the most important decisions I make are automatic decisions that my brain makes for me because I've spent 10,000 hours experiencing the subtle cues that differentiate really sick people, from people who are just feeling poorly. How we think may be a mystery but how we react to a set of cues is very refined cognition through repetition.
I probably should have sent this to you before I posted it. But I think you are right. There wasn't a lot of talk in the book about how teaching medical students has changed, but the doctor who correctly diagnosed Groopman's hand problem was young, unlike the four older doctors before him who couldn't figure it out.
I think there is definitely something to be said for having enough experience that you just know what to do. I think with any expertise, after awhile, you just start feeling like you know what to do. Obviously, there is danger in hunches, but I think hunchability, for lack of a better word, does improve over time.
Apparently you guys have spent the prerequisite 10,000 hours in becoming experts in nerd.
(I've spent it smart aleck.)
I really like that author. I read another book of his called The Measure of Our Days just after I completed medical school. I was utterly burned out. I think that book helped me get back some of the love for medicine that I had lost from the terrible work hours, cut throat competition from my peers, and some really egotistical, short man syndrome afflicted surgeons.
I really wanted to pick up How Doctor's Think for myself, but I decided to give it to someone else as a gift instead (I am very cheap except when it comes to others). I did read about a third of it before I had to gift wrap it and send it on, and it looked good!
p.s. I stopped reading Keith's comment after the first 2 paragraphs because, as usual, it is cynical and pessimistic, and the world I choose to live in is a much rosier place.
Pay no attention to these "kat" people. I count that "jonesy" among their ilk. Why can't my wife disparage me in person like other wives instead of on the internet?
Oh honey, I would happily disparage you to your face... if you would come home!
I think six comments is a new record. Bravo to all of you!
hi jeff...i remembered my google/blogger account password and i really wanted to comment on how nerdy you and keith are, but i feel i'm somewhat late to that party...
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