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BMJ. 2007 April 21; 334(7598): 856.
PMCID: PMC1853194
Review of the Week

Living in a box

Reviewed by David Woods, editor in chief, Rx Communications

How Doctors Think. Jerome Groopman. Houghton Mifflin, $26, pp 320. ISBN 0 618 61003 0. www.houghtonmifflinbooks.com . Rating: ***.

Most medical errors are mistakes in thinking, not in technology, claims a new book, and have a lot to do with the superhuman demands placed on doctors, as well as a measure of arrogance, as David Woods discovers

How doctors all too rarely think, says the noted oncologist and haematologist Jerome Groopman, is, in the words of the cliché, “outside the box.” This process starts early in the medical training cycle, he says, with medical students and junior doctors all too often failing to question cogently, listen carefully, or observe keenly.

What's partly to blame for this, Groopman contends, is today's rigid reliance on evidence based medicine and even, to an increasing extent, on highly sophisticated technology that “has taken us away from the patient's story.” To support this notion he points to the sobering statistic that between 1998 and 2002 the number of computed tomography investigations in the United States increased by 59%, magnetic resonance imaging by 51%, and ultrasonography by 50%.

But it's the sensitivity to language and emotion, he believes, that makes for a superior clinician. In fact, he says, technical errors account for only a small fraction of incorrect diagnoses and treatments. Most errors are mistakes in thinking. Among these are so called “attribution errors,” in which thinking is guided by stereotype and shuts out possibilities that might contradict that preconception. Groopman's main prescription to remedy this is a heavy dose of heuristics: stimulating interest as a means of furthering investigation.

Then there's “availability thinking”—the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind. “Anchoring” is another shortcut in thinking where a doctor doesn't consider multiple possibilities but quickly and firmly latches on to a single one.

Much of this book focuses on what Groopman sees as the vital importance of doctor-patient communication and of the patient's role as a partner in diagnosis and treatment. This is not easy, he says, as doctors must increasingly juggle cell phones, test results, referrals, beepers, and, yes, patient satisfaction surveys. These superhuman demands on the medical profession could “morph us into steely eyed combatants or reduce us to blithering, overwhelmed, white coated globs of jelly.” No wonder it's estimated that doctors interrupt patients on average within 12 seconds of when they begin telling their story.

Groopman doesn't shy away from attributing a measure of arrogance and hubris to his fellow professionals' thinking processes, noting that these traits may persuade them that they are always right just because they usually are. And a defence against uncertainty, he believes, is a culture of conformity and orthodoxy that begins in medical school and something he calls “diagnosis momentum”: when an authoritative senior doctor has fixed a label to a problem it usually stays firmly attached.

The author devotes a chapter to his own experience of received medical wisdom. In a sort of “blind men and elephant” scenario he goes to several doctors in an effort to treat a hand immobilised by too much typing. The first clinician showed what is called “commission bias”—the tendency towards action rather than inaction. The second made a cognitive error called “search satisfaction”—the tendency to stop searching for a diagnosis once you find something. Finally, Groopman settled on a doctor who kept searching for a cause and avoided another error called “vertical line thinking”—the hackneyed “inside the box” variety.

The author discusses how the drug industry can colour doctors' thinking. Mainly, he says, this is in their concerted effort to create a clinical disorder by medicalising the normal changes and challenges of life. For instance, he says, people who are simply very shy may be labelled with “social affective disorder.” And while a decline in libido associated with ageing might not be unusual, we now have the multibillion dollar erectile dysfunction drugs; and worse, the newly discovered “restless legs syndrome.” Drug companies, although increasingly barred from doing so, still try to influence doctors' thinking by wooing them with gifts and dinners.

Groopman says that after writing this book he realised that he has a vital partner who helps improve his thinking, a partner who may, with a few pertinent and focused questions, protect him from the cascade of cognitive pitfalls that can result in misguided care. That partner, he says, is the patient, who seeks to know what is in his mind and how he is thinking. “By opening my mind I can more clearly recognize its reach and its limits, its understanding of my patient's physical problems and emotional needs. There is no better way to care for those who need my caring.”

Throughout the book Groopman relies on many case histories and vignettes. The fact that he seems to be a novelist manqué, describing, for instance, one subject as “a compact woman with a round face, alert eyes and a lilting, almost musical voice that often breaks into laughter” and one institution as having “eucalyptus trees surrounding the hospital, and usually a soft breeze filters through their branches,” need not detract from the book's essential value in helping doctors and patients gain a better understanding of how doctors think.


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