Tuesday, April 1, 2008

Book Review - How Doctors Think

Fascinating read and written in the same spirit as Malcolm Gladwell's Blink. Dr. Jerome Groopman investigates how doctors make misjudgments and misdiagnoses because of their failures to understand and acknowledge cognitive limitations and errors in thought that affect all of us and unbeknownst to us. He feels that if doctors take a step back, are introspective and insightful about these deficiencies and take appropriate steps to minimize these problems, we can be better clinicians. The doctors he profiles are truly inspirational, remarkable, and masters in their fields, not only because of their medical knowledge, but because of their recognition of what it takes to be superb people and clinicians.

If there is an area of disagreement, then it is the fact that Dr. Groopman suggests that the pressures of managed care and inadequate time are the cause of many of these cognitive errors. Yet, he never actually proved this in the book. He never showed that doctors were more likely to make the correct diagnoses in an era with fewer time constraints. In fact, he laments that doctors in training, where he teaches at Harvard, don't know how to think and then realized that he hadn't be trained how to think either over thirty years earlier (and hence the reason for his investigation and this book). He claims that quality of medical care shouldn't be simply defined as whether or not a patient with diabetes has his blood sugar checked routinely, but Dr. Groopman also doesn't acknowledge that the major reason the United States ranks last in the world in keeping people healthy it is because the quality of care delivered never was measured as carefully as it is today. Research shows that 80,000 Americans die prematurely (twice the number of breast cancer deaths) simply because the right preventive care wasn't delivered. Had the nation adopted those health insurance plans, hospitals, and doctors, who performed at the top 10 percent of providing this care, these individuals would be alive today. How do they do so well? It is because of implementation of systems that promote excellence. As a practicing primary care doctor I understand the concerns of my colleagues of showing and proving that they are doing what they say. But we all know if you don't measure something and then re-evaluate it, how do you know if you are doing better? If anything, Dr. Groopman seems to suggest that medical care would be better if doctors didn't have to prove that they performed these metrics to the level of what the evidence shows to be effective even though other industries like financial services, manufacturing, and the airline industry do so rigorously to maintain their high levels of reliability, consistency, and safety.

Although he encourages patients be advocates for themselves, to ask questions, and how to slow a doctor down and think more clearly with certain comments, from his own examples it is clear that it isn't easy to do and frankly somewhat intimidating. The book Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System has more practical tips and suggestions on how to get the right care.

If there is a lesson to be learned, then it is that as doctors we need to understand that our thought processes can be clouded by emotions and can be limited simply because we too are human. To overcome this problem, which affects all of us, we need to be deliberately thoughtful and systematically introspective when caring for patients. As a practicing primary care doctor, I believe that we, not the patients, bear this responsibility and that I hope doctors in training are being taught this routinely in this country and that others welcome the opportunity to do better. While it should be a required reading assignment for medical students, interns, residents, and practicing physicians, better thinking doctors alone aren't going to improve healthcare quality in the United States. Dr. Groopman's subtle suggestions that they might are simply his error in thinking and his inability to remain open-minded and see that the world he trained in is far different than the world his trainees are about to enter.

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