Editorial Reviews. From Publishers Weekly. Drawing on both personal experience and download How Doctors Think: Read Kindle Store Reviews - haiwingbasoftdif.cf PDF | 10+ minutes read | On Jan 1, , Scott D. Smith and others published How Doctors Think. of Dr. Jerome Groopman's How Doctors Think. Cognitive. PDF | On Sep 26, , Lisa Lines and others published Book Review: How Doctors Think, by Jerome Groopman. Boston: Houghton Mifflin.
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book reviews n engl j med ;26 haiwingbasoftdif.cf june 28, How Doctors Think. By Jerome Groopman. pp. New York, Houghton Mifflin,. How doctors think. Jerome Groopman. Houghton Mifflin Co. Boston, Massachusetts, USA. pp. $ ISBN: ( hardcover). How Doctors Think – Jerome Groopman, MD. Chapter 9. Marketing, Money, and Medical Decisions. Chapter In Service of the Soul.
The writing style is light and free-flowing, and he weaves narrative from his own experiences as an intern, attending physician, and patient together with interviews, analysis, and patient cases to create a highly readable book. However, it occasionally feels too self-referential; this is not autobiography, after all.
The last chapter is the most touching. In it, Groopman lauds physicians for understanding that the care of patients—who are as scared, suffering, and imperfect as their doctors—is what medicine is really about. Groopman offers patients three questions that they can ask their health care providers to spur on thinking: 1 what else could it be?
These questions reflect the main cognitive errors Groopman enumerates earlier in the book. Why do doctors err? The solution he offers to physicians is to be more thorough. The portrait he paints of the medical profession is at times worrisome. That doctors, particularly primary care physicians who treat all manner of disease and every sort of patient, can accurately diagnose so many is a testa- ment to the power of modern medicine and to the thinking of those physicians.
How do they do it? How do they think? As such, the book does not dwell deeply on the issues raised, which are ultimately philosophical. As noted, it accepts as a given the preeminent role of cognitive psychology as the means of exploring thought in medicine; Groop- man does not discuss other modes of thinking relevant to medicine. It is worth mentioning the common themes shared by both books: uncer- tainty, narrative, and time.
Osler once wrote that medicine is a science of uncer- tainty and an art of probability. Uncertainty is ineradicable and irreducible in clinical medicine, and it seems to increase with the complexity of care and the sophistication of interventions. While evidence-based medicine and clinical al- gorithms are attempts to tame uncertainty, in the view of Groopman and Montgomery, neither are completely successful.
What is required is more atten- tion to language. Hence, Groopman and Montgomery are anti-House in their fundamental ori- entation. Caring for patients without engaging in their narratives or refusing to build therapeutic alliances with them is to practice unthinking medicine.
This so-called evidence-based medicine is rapidly becoming the canon in many hospitals. Treatments outside the statistically proven are considered taboo until a sufficient body of data can be generated from clinical trials.
Of course, every doctor should consider research studies in choosing a therapy. But today's rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers. Statistics cannot substitute for the human being before you; statistics embody averages, not individuals. Numbers can only complement a physician's personal experience with a drug or a procedure, as well as his knowledge of whether a "best" therapy from a clinical trial fits a patient's particular needs and values.
Each morning as rounds began, I watched the students and residents eye their algorithms and then invoke statistics from recent studies.
I concluded that the next generation of doctors was being conditioned to function like a well-programmed computer that operates within a strict binary framework. After several weeks of unease about the students' and residents' reliance on algorithms and evidence-based therapies alone, and my equally unsettling sense that I didn't know how to broaden their perspective and show them otherwise, I asked myself a simple question: How should a doctor think?
This question, not surprisingly, spawned others: Do different doctors think differently? Are different forms of thinking more or less prevalent among the different specialties? In other words, do surgeons think differently from internists, who think differently from pediatricians?
Is there one "best" way to think, or are there multiple, alternative styles that can reach a correct diagnosis and choose the most effective treatment?
How does a doctor think when he is forced to improvise, when confronted with a problem for which there is little or no precedent? Here algorithms are essentially irrelevant and statistical evidence is absent.
How does a doctor's thinking differ during routine visits versus times of clinical crisis? Do a doctor's emotions — his like or dislike of a particular patient, his attitudes about the social and psychological makeup of his patient's life — color his thinking?
Why do even the most accomplished physicians miss a key clue about a person's true diagnosis, or detour far afield from the right remedy? In sum, when and why does thinking go right or go wrong in medicine? I had no ready answers to these questions, despite having trained in a well-regarded medical school and residency program, and having practiced clinical medicine for some thirty years.
So I began to ask my colleagues for answers.
Then I searched the medical literature for studies of clinical thinking. I found a wealth of research that modeled "optimal" medical decision-making with complex mathematical formulas, but even the advocates of such formulas conceded that they rarely mirrored reality at the bedside or could be followed practically.
I saw why I found it difficult to teach the trainees on rounds how to think. I also saw that I was not serving my own patients as well as I might. I felt that if I became more aware of my own way of thinking, particularly its pitfalls, I would be a better caregiver. I wasn't one of the hematologists who evaluated Anne Dodge, but I could well have been, and I feared that I too could have failed to recognize what was missing in her diagnosis.
Of course, no one can expect a physician to be infallible. Medicine is, at its core, an uncertain science.
Every doctor makes mistakes in diagnosis and treatment. But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better.
This book was written with that goal in mind. It is primarily intended for laymen, though I believe physicians and other medical professionals will find it useful. Why for laymen? Because doctors desperately need patients and their families and friends to help them think.
Without their help, physicians are denied key clues to what is really wrong. I learned this not as a doctor but when I was sick, when I was the patient.
We've all wondered why a doctor asked certain questions, or detoured into unexpected areas when gathering information about us. We have all asked ourselves exactly what brought him to propose a certain diagnosis and a particular treatment and to reject the alternatives.
Although we may listen intently to what a doctor says and try to read his facial expressions, often we are left perplexed about what is really going on in his head. That ignorance inhibits us from successfully communicating with the doctor, from telling him all that he needs to hear to come to the correct diagnosis and advice on the best therapy.
In Anne Dodge's case, after a myriad of tests and procedures, it was her words that led Falchuk to correctly diagnose her illness and save her life. While modern medicine is aided by a dazzling array of technologies, like high-resolution MRI scans and pinpoint DNA analysis, language is still the bedrock of clinical practice. We tell the doctor what is bothering us, what we feel is different, and then respond to his questions.
This dialogue is our first clue to how our doctor thinks, so the book begins there, exploring what we learn about a physician's mind from what he says and how he says it. But it is not only clinical logic that patients can extract from their dialogue with a doctor.
They can also gauge his emotional temperature. Typically, it is the doctor who assesses our emotional state. But few of us realize how strongly a physician's mood and temperament influence his medical judgment. We, of course, may get only glimpses of our doctor's feelings, but even those brief moments can reveal a great deal about why he chose to pursue a possible diagnosis or offered a particular treatment. After surveying the significance of a doctor's words and feelings, the book follows the path that we take when we move through today's medical system.
If we have an urgent problem, we rush to the emergency room. There, doctors often do not have the benefit of knowing us, and must work with limited information about our medical history. I examine how doctors think under these conditions, how keen judgments and serious cognitive errors are made under the time pressures of the ER. If our clinical problem is not an emergency, then our path begins with our primary care physician — if a child, a pediatrician; if an adult, an internist. In today's parlance, these primary care physicians are termed "gatekeepers," because they open the portals to specialists.
The narrative continues through these portals; at each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong. We also encounter the tension between his acknowledging uncertainty and the need to take a clinical leap and act. One chapter reports on this in my own case; I sought help from six renowned hand surgeons for an incapacitating problem and got four different opinions.
Much has been made of the power of intuition, and certainly initial impressions formed in a flash can be correct. But as we hear from a range of physicians, relying too heavily on intuition has its perils. Cogent medical judgments meld first impressions — gestalt — with deliberate analysis. This requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes.
What can doctors and patients do to find time to think? I explore this in the pages that follow. Today, medicine is not separate from money. How much does intense marketing by pharmaceutical companies actually influence either conscious or subliminal decision-making? Very few doctors, I believe, prostitute themselves for profit, but all of us are susceptible to the subtle and not so subtle efforts of the pharmaceutical industry to sculpt our thinking.
That industry is a vital one; without it, there would be a paucity of new therapies, a slowing of progress. Several doctors and a pharmaceutical executive speak with great candor about the reach of drug marketing, about how natural aspects of aging are falsely made into diseases, and how patients can be alert to this. Cancer, of course, is a feared disease that becomes more likely as we grow older.
It will strike roughly one in two men and one in three women over the course of their lifetime. Recently there have been great clinical successes against types of cancers that were previously intractable, but many malignancies remain that can be, at best, only temporarily controlled. How an oncologist thinks through the value of complex and harsh treatments demands not only an understanding of science but also a sensibility about the soul — how much risk we are willing to take and how we want to live out our lives.
Two cancer specialists reveal how they guide their patients' choices and how their patients guide them toward the treatment that best suits each patient's temperament and lifestyle. At the end of this journey through the minds of doctors, we return to language.
The epilogue offers words that patients, their families, and their friends can use to help a physician or surgeon think, and thereby better help themselves. Patients and their loved ones can be true partners with physicians when they know how doctors think, and why doctors sometimes fail to think.
Using this knowledge, patients can offer a doctor the most vital information about themselves, to help steer him toward the correct diagnosis and offer the therapy they need. Patients and their loved ones can aid even the most seasoned physician avoid errors in thinking. To do so, they need answers to the questions that I asked myself, and for which I had no ready answers. Not long after Anne Dodge's visit to Dr.
Falchuk is a compact man in his early sixties with a broad bald pate and lively eyes. His accent is hard to place, and his speech has an almost musical quality.
He was born in rural Venezuela and grew up speaking Yiddish at home and Spanish in the streets of his village.
As a young boy, he was sent to live with relatives in Brooklyn. There he quickly learned English. All this has made him particularly sensitive to language, its nuances and power. In fact, being more aware of these potential cognitive traps might well prevent one from making many of the clinical errors described in this book.
A commission bias is the tendency toward action rather than inaction.
Satisfaction of search is the tendency to stop searching for a diagnosis once one has found something of clinical interest, even though this might not be central to the presenting problem. Groopman points out that while finding something might be satisfactory, not finding everything is suboptimal.
The availability error is the tendency to apply what one commonly experiences or sees when making a diagnosis of a new patient. This leads the physician to see similar cases in the same way, often while ignoring important differences between them. The anchoring error is the tendency to seize on an initial symptom or finding and allowing this to cloud clinical judgment. The author makes an apt point when explaining that even with the myriad technologies available, language is still the foundation of clinical medicine.
With respect to the omnipresent diagnosis and treatment algorithms, Groopman describes a case to illustrate how important it is that physicians apply algorithms within the context of the specific patient being treated. The ability to know when algorithms work for patients and when to choose different treatments, which might conflict with algorithms, becomes clearer the more patients one treats. Groopman also illustrates that how we present choices to patients can strongly influence the choices patients make.
Moreover, in a situation like this, it is important to define what is meant by improvement, as this might be misinterpreted to mean cure.