The name of the book is How Doctors Think (Mariner / Houghton Mifflin, 2007, Afterword 2008, now in paperback), by Jerome Groopman, M.D., who holds the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School and is chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston. He also writes on medical issues for the New Yorker Magazine. He's been in practice for thirty years and has seen his share both as a doctor, patient, and family man.
See, here's the problem. When a doctor says something, we tend to believe him, just as we believe the president when he says that Saddam in Iraq is hiding MD. We then act on the advice of this expert. We figure that he's got this privileged source of information and who are we to question him. He, our doctor or president, would never intentionally mislead us, would he? Of course not.
Not so fast.
If our expert, the president or our physician, has something to gain by taking a particular position, and advising us accordingly, is this misleading us intentionally? Suppose the idiot really believes what he's saying, but is still wrong. Off comes the wrong leg, quite by mistake. "It was an accident." But you're sill missing a leg, or worse, your life.
Grossman writes about this, but confines his view to the mistakes that doctors make. Some doctors are in the pockets of the insurance companies that send salesmen to their offices to hand out gifts, fees for giving talks, underwriting research grants, junkets to expensive resorts to attend conferences, etc. If there's a way to suborn a doctor, the pharmaceutical companies have figured out a way to play it. It's almost as bad as federal judges being put up at expensive hotels in Hawaii to attend legal conferences, paid for by large corporations. Do large corporations ever appear in the courts of these judges? You can bet on it.
Suppose you're a surgeon who does three lower back fusions per week at $20,000 a pop. That's sixty grand a week. And suppose that the typical benefits of this operation can be achieved by another procedure costing only $5,000 each. If you were a surgeon with kids in college, which would you recommend to a patient who has medical insurance sufficient to cover either procedure. Why not let's go with the high-priced spread, considering that it's only the insurance company that's paying and hey, twenty grand is twenty grand.
But this is only a small part of what Grossman is calling attention to. His main focus is on thinking errors that doctors make.
Thinking is a subject that doesn't receive enough thought. It's been a subject of interest to me for a long time. The only book I saved from college was Meister's "Critical Thinking." I think it's in storage at the moment.
Critical thinking covers areas written about by Aristotle and Venn, of Venn Diagram fame. And Boole. Ever do a Boolean search using Google? You're using the critical thinking as described by these folks.
The problem is that knowing about something and doing something are two different things. Do you think that political candidates care that their ad homonym attacks are logical fallacies? Have you ever argued logic to a court? "The period of maximum danger is when all of the logical arguments are on your side," said Benefit Monticello. This is the director of archeology at Pompeii, responding to an associate who told him he had nothing to worry about concerning the local city council which wanted to permit building a highway over an area to be excavated, which he opposed.
We engage in sloppy thinking, mental shortcuts, and errors in logic because it feels better. Thinking is hard work. It means questioning your assumptions, and who likes to do that? Think about all the previous times when you engaged in the same type of thinking and got away with it. What happens if you change now? Are you admitting that you were wrong or stupid all those other times?
Suppose that you are a patient because something is wrong and not getting better, despite what the doctor prescribes. What can you do?
Well, the first thing you need to do is to act like a lawyer in thinking about the problem and in questioning your doctor. You need to make sure you've told him the full story of how your condition developed over time. This may spur the doctor's critical thinking ability, which we presume exists. He may not welcome the exercise. I had a doctor interrupt me recently as I tried to detail an injury to my foot that was causing unusual pain when I stepped. She was trying to tell me what the cause was before I'd finished explaining what the problem was. When I was allowed to finish, she had another, different diagnosis and we were enabled then to deal with the real problem, not the first one that jumped into the mind of the expert. Grossman calls this an availability error, meaning an explanation that occurs because it is fresh in the mind of the expert. It's so "available" that it's the first thing seized upon as the likely explanation despite it happening to be wrong. The popular expression for this might be, "When your only tool is a hammer, everything looks like a nail."
Other typical thinking errors include "Look, I found it; we can stop searching for the cause!" Grossman calls this a "search satisfaction" error, where the first explanation that seems to explain the cause of something is taken for the only possible cause. In medicine, there are often causes underlying the surface causes. But these take time, effort, and money to ferret out, and why do that when we can treat this instead? This is how physicians miss things like underlying cancer or tumors deep inside.
Did you know that radiologists, the doctors responsible for doing scans using the latest technology including X-Ray, MRI, CT, and others, often get it wrong? They see so many of the products of the scan, X-ray images and other photos of slices of the body and its parts that they seem like a bit of a blur. Sometimes the image is a bit blurry. Sometimes it is out of focus. Or the radiologist sees one thing when there is actually another that would call for attention had it not been hidden, or not prominent, or not what the observer was looking for. There are innumerable reasons for such mistakes. Grossman calls attention to some of them.
Grossman suggests that an informed patient, aware of these difficulties among doctors, might want to ask questions such as the following, to help avoid overlooking something not seen as likely, but which might, upon further consideration, be in play:
Tell the story again as though the doctor never heard it -- what you felt, how it happened, when it happened. Offer to retell it. Telling the story afresh may yield new insights, or prompt looking in new directions. P 261.
Tell him what's really frightening you. If you fear coming down with what you don't want to express, you're engaging in magical thinking. This is a patient's thinking error, not the doctor's.
Ask to revisit the diagnosis, especially if based on images, scans. Tests have shown that radiologists often disagree among themselves. Often they disagree with themselves when shown the same images at a later time. Yesterday I saw something, today I didn't, and vice versa.
I had a case where a two-year-old, being minded by her uncle who was seated in an easy chair in the living room while the grand-parents were busy in the kitchen while the parents were at work, fell off the couch, hurting her arm. They took her to the emergency room where the arm was X-rayed. This is how the family, from Afghanistan, lost their child. The radiologist saw the thin white line of a healed scar on the arm bone of this infant and called the child protective service. Scars on bones in a child's arm can indicate that the child was abused and received a broken arm. The child was placed in foster care in a black home where no one spoke Farsi. The family was going nuts. I was called. I arranged to review the X-ray image with the chief radiologist of the nearby hospital. He agreed that there was no scar and that even if there was, it might have been caused accidentally. There was no fresh scar. It took weeks for the baby to be returned. The parents were granted visitation rights while the case was pending. It took months to get rid of the case. It was a false alarm. Some medical people think that they need to "err on the side of caution" when it comes to allegedly protecting children. The cure here was worse than the disease.
The Foxglove case resulted from medical mistake. The medical examiner involved in investigating an alleged poison murder scheme drew a blood sample and tested it himself. He was the only one of many laboratories to conclude that the sample tested positive for poison. On cross-examination by yours truly he admitted that he'd used the wrong test and drew the wrong conclusions, ending the case, not without further wrangling by a very disappointed prosecution team that had invested years and huge amounts of money in trying to prove something that never existed.
Alarm induces error.
Dr. Grossman suggests asking your physician, "What else could it be?" This is to protect against the 'search satisfaction' error that cuts off further needed thinking.
"Is it possible that I have more than one problem?" is another way of spurring further thought along this line. P 263.
"There's nothing wrong with you." This is a mistake for a doctor to tell a patient who is hurting. It means that the doctor is unable to explain why the patient claims to be still hurting. It's a way of telling the patient "to get out of my operating room." Such patients are sometimes called "GOMERS," as in "Get out of my operating room." Sometimes seen after the walletectomy proves disappointing, as in no savings and no insurance to pay the freight of costly medical procedures.
Grossman concludes by saying that a medical office is not an assembly line, nor should it be a business office when it comes to treating patients. Thinking takes time, but time is money. Better for a physician to advise the patient that he needs time to think about the diagnosis or treatment than shoot from the hip and risk making a thinking error. "Working in haste and cutting corners are the quickest routes to cognitive (thinking) errors." P. 268.
About the best thing that you can do to help your doctor help you is to ask him, yourself or through a family member or friend, what is in his mind and how he is thinking about your problem. This opens the doctors mind, to himself and to you. "There is no better way to care for those who need my caring," he says.
I was interviewing a client in jail the other day. The first story was such an obvious lie that I was forced to conclude that the allegations contained in the police report were far more true than false. Caught fleeing the police along with two others following a crime spree involving multiple robbery and carjacking, followed by a high-speed chase, the story was that he was simply standing innocently on a sidewalk far from the scene when this vehicle almost ran him over, so he fled, followed by unknown assailants who wanted to kill him. Who would want to kill you, I asked. Lots of people, he said, but was unable to name one, or why.
Later he admitted being present, but not actively participating.
Meanwhile, a deal I was trying to make for him (called the deal of the century by the psychologist I sent out to interview him) was coming unraveled.
I visited him again to advise that when working off false facts my advice is terrible, but that when I have the truth, I can do better with the truth than others can with a lie. This is a belief based on experience. Truth telling is a sign of acceptance of responsibility, it often produces an expression of remorse. The criminal justice responds better to these than to denials and lies.
Finally the young man admitted the responsibility that belonged to him and dropped the innocent bystander pretense. I was able to check him against the statements of the victims and bystander witnesses. Now I have a chance to do something for him based on an appreciation of the relevant facts and other factors; before I couldn't.
Dr. Grossman, in an Afterword, lists some of the main errors causing misdiagnosis by physicians. They include: anchoring, attribution, and availability.
The constructive questioning he recommends to help the physician/diagnostician include:
1. What else can it be?
2. Could two things be going on to explain my problem?
3. Is there anything in my history or physical examination or lab tests that seems to be at odds with the working diagnosis? [To counter confirmation bias, the feeling that we have the correct diagnosis already, so why look for other explanations...even if they're correct and this isn't. In this regard, what you, and your doctor think you have, is provisional, or a working diagnosis, unless and until something better comes along, which is what you want to be alert to investigate and consider. There are many examples of where the working diagnosis has required correction. It doesn't help to treat for the wrong thing while ignoring the underlying problem.]
Grossman, citing a patient who wrote down the above three questions, calls them "a broad-spectrum antibiotic" to remedy a diversity of "bugs" in thinking.
***
I've heard it said that a student attends law school to learn to think. Law school doesn't teach anyone how t think. It provides examples of how others have thought, rightly or wrongly. Which sort of thinking you choose to use on a particular occasion is up to you. Lawyers are no more able to think clearly and accurately in all situations than doctors.
Medical school, it appears, tries to provide data and recommends some ways of thinking, such as "When you hear hoof-beats, think of horses, not a zebra."
Nevertheless, you can carry a good aphorism too far, such as when advising a Laplander or a Chukchi (in NE Russia) to think of horses when his life depends on his herd of reindeer. Or when there is no horse, but a zebra present. In short, the diagnostician must thing of the rule and recognized that there are exceptions to keep a sharp eye peeled for.