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.

Adults Often Skip Doctor's Treatment

In a Harris Interactive / Wall Street Journal survey titled Many U.S. Adults Disregard Doctors' Course of Treatment a surprising number of individuals (44 percent) reported not following a doctor's recommendations because they felt the treatment was unnecessary or overly aggressive. One in five sought a second opinion because the recommended treatment was perceived as too aggressive.

Over half believed the reason for this over treatment was due to doctors protecting themselves from potential lawsuits. Over 40 percent felt it was because doctors were catering to patient demands or for doctors to make more money. One out of four felt the unnecessary added care was due to faulty medical diagnosis or fast and easy decisions.

Are the results surprising? It sounds like plenty of miscommunication between patients and doctors. With face to face time with doctors getting shorter, it is even more important that you say the right things and that you are heard otherwise you may get more than you ask for.

Second Opinions - Online - Worthwhile?

What would you say are the pros and cons of getting a second opinion online through institutions like The Cleveland Clinic and Partners Healthcare (through Harvard)?
Second opinions online or consultations without seeing or examining a patient are probably helpful if someone wants to have the blessing of a major medical institution like Cleveland Clinic. The other advantage is to get advice without traveling to these medical centers. While these second opinions have access to doctors’ notes, lab results, and imaging studies, these institutions don’t usually have their doctors examine the patients. This is the biggest potential problem of these programs.

Let’s for example say you wanted to buy a car. If you wanted to buy a car online, could you make an informed decision whether to purchase it based on its description (doctors’ notes) and pictures (imaging studies)? Would you be able to tell if the engine ran smoothly, the seats were comfortable, or the handling was just right based on the information you received online? For most people, doing the research and having bits of information isn’t a substitute for a test drive.

This is no different than having an online consultation. As doctors, one of the first things we learn is to treat the patient and not test results. People are more complex than simply blood tests, MRIs, and CT scans. Often pathology and radiology reports are qualified with the phrase “clinical correlation recommended”. This is the pathologists’ and radiologists’ way of telling the doctor who ordered the test to realize that the information they provided is only helpful in the context of the patient. Pathologists and radiologists know their limitations. Their expertise provides only a glimpse of the person and his medical condition. This is the main reason that medical students today still spend much of their time learning how to interview and examine a patient before they learn what tests to order.

If the online opinion was used to reaffirm another second opinion, where a patient was examined by a doctor, then this would be reasonable. It would be very concerning if this second opinion overturned or refuted a previous opinion particularly since the patient wasn’t examined. Doctor notes, test results, imaging reports provide only a partial picture of a patient or his condition.

Second Opinions - Blinded and Two Different Options

What is a "blind second opinion"? What are the advantages and disadvantages?
A “blind second opinion” is seeing another doctor, but not providing him any of the other doctor’s notes, lab results, x-ray results, or biopsy results. Advocates feel that by not giving the second opinion doctor any information that it makes him more objective and less likely to be biased by the first doctor’s work-up and assessment. The problem is that since the second doctor is essentially starting from scratch, the patient may need to undergo repeat testing which may be costly. Also, if the second opinion differs from the first, it won’t be clear to the patient why the doctors disagreed with each other since neither one has access to the other’s information.

For a second opinion to be worthwhile, patients should provide the doctor all of the previous doctor notes and results so that he understands what has already been done. What makes it a great second opinion is having the doctor now step back, ask and examine the patient as if it was the first time seeing him, ignore the medical record, reach his own conclusion and then see how his opinion either supports or refutes the diagnosis and plans of the first doctor. If you see a doctor who keeps pushing you to talk about your symptoms and treatments and not what other doctors have said or what the tests showed then you’ve found yourself with a doctor who will give a great second opinion.

If a patient gets two opinions on a condition and they vary greatly, how does one make a decision?
If there is this situation then it means that for that particular condition there is not a general consensus or agreement on what the best treatment is. In this case, there are a few of options. One is to get a third opinion and see if it provides a middle ground between the first two cases. The other option is to get a third opinion, but have it with a guru or nationally renowned expert on the condition. It is possible that with these options that there might be three very different opinions. In this case, the best decision is to find the doctor who suggested a treatment plan the person was most comfortable with. With three opinions for the same condition, it is even more clear that there is no agreement and therefore a person can’t be truly faulted for making a less than ideal choice as three doctors couldn’t agree. What is most important at that point is that the patient makes a choice he is comfortable with.

Second Opinions - How

What is the best way for a patient to approach her doctor about getting a second opinion?
The best way is to tell the doctor that you appreciate their care.  For you to proceed further it would help you to get a second opinion.  You want to know if there are other alternatives or ideas. If you aren’t the one wanting the second opinion, then I would suggest that you tell your doctor that it is your loved one or family member that is requesting it. Reassure the doctor that you wish to continue care with them, but wanted to explore the possibility of other options.

Good doctors shouldn’t be offended. If they are comfortable with their diagnosis and treatment plan, they know that you aren’t likely to find alternative therapies. Good doctors also know that they don’t know it all and they welcome the opportunity to learn something new from a second opinion. Finally doctors are notorious for asking for second opinions when they are patients, as they all understand some of the uncertainly of practicing medicine, and aren’t shy about asking for one. It is your health. Having regret of not asking for a second opinion is worse than having to perhaps bruise an ego. Again, good doctors aren’t offended, often expect to be asked for second opinions, and will suggest a patient get a second opinion in a particularly serious medical condition.


What should patient and doctor discuss under these circumstances?
Say that you very much appreciate their care and value their advice. You wondered if there were alternative treatment options or therapies that other doctors might be familiar with that he would recommend for a second opinion. Reassure the doctor that you will be coming back to his practice and this request is simply more for your piece of mind, or that of your loved one. Explain that you are very satisfied with his care.

Don’t demand a second opinion. If your doctor won’t help you, you can still get a second opinion. You might also want to consider switching doctors as a doctor who won’t help you get a second opinion, particularly for a potentially serious medical problem, may be more worried about his ego rather than putting you first as a patient.

How can a patient best get his primary care doctor on board if the patient decides to go a route not recommended by his doctor?
Patients need to realize that much the same way doctors can’t force patients to do certain things, like exercise more, lose weight, quit smoking, and take prescription medications, that they also can’t force their primary care doctor, whether an internist or family physician, to get on board to an alternative treatment plan. If their doctor wishes to work with them and both parties can compromise, that would be great. If not, it is best that the patient find another doctor they can work with.

Doctors are available to provide patients their medical expertise. Depending on the doctor, his experience can vary widely. Rather than trying to force a primary care doctor to get on board to a plan he doesn’t agree with, it would be better to find another doctor with the expertise you need.

Second Opinions - Where to Get One

How do patients find doctors to do a second opinion?
Patients should ask their primary care doctor, either an internist or family physician, who to see for a second opinion. Often their doctor refers patients to specialists and will be familiar with different doctor groups in the community.

Another option to find a doctor is by using the physician directory of a professional medical society. For example to find an orthopaedic surgeon, going to the American Academy of Orthopaedic Surgeons website, one can find doctors by zip code, city, or state.

The third option is to find the nearest medical school or university hospital and ask to see a doctor who is staffed there. Through these medical centers' websites you often can get a name and an idea of the individual doctor's background and experience. Because are often teaching hospitals, be sure to clarify if you only want to see that doctor or if it would be ok to be seen by one of the doctors in training. The doctors in training, interns, residents, fellows, are supervised by the doctor.


Is there an advantage of seeking a second opinion at a research and teaching hospital?
Doctors at research and teaching hospitals typically have the latest treatments and technologies available to them. They also have valuable expertise in treating rare medical problems. Patients with especially difficult diseases which has failed conventional therapies or patients with rare illnesses will often seek out these large research and teaching hospitals. Because these doctors see a large number of these uniquely challenging medical cases, their experience is far better than a doctor in the community who may only see one case in an entire career.

Patients who would get the most benefit from a research and teaching hospital are those with medical problems that are rare or that have failed traditional treatments.

Second Opinions - When and Why

When is it a good idea to get a second opinion?

Second opinions should strongly be considered when there is a potentially life threatening medical condition, like cancer, when the proposed treatment options are intensive or demanding, like chemotherapy or major surgery, or when there is a chance for a very bad outcome or complication, i.e. brain surgery. By having a second opinion, particularly in these high stakes situations, patients and their families will have the opportunity to have a second set of eyes double check to see if the original diagnosis and treatment plan are reasonable as well as a chance to hear someone else explain the problem which may be more understandable and enlightening.

With any other big decision — purchasing a new car or deciding to get married, for example — people instinctively seek out multiple opinions. Others voice their unsolicited opinion. When making a decision which could mean the difference between life or death, patients should not be shy about getting a second opinion. Patients should also ask their primary care doctor about their thoughts and understanding of the treatment plan of the first doctor and the need for a second opinion.

Why are patients reluctant to get second opinions?
Patients may be afraid that their doctor won’t take care of them in the future because they are asking for a second opinion. They may not feel the need to get a second opinion since they are comfortable with their doctor. They may not be aware that getting a second opinion is a good idea. They don’t know how to ask for a second opinion.

Do philosophies and treatment options vary among hospitals and medical practices?
Philosophies about treatment options can vary greatly depending on where and who the physician trained with, the physician’s field of practice, when the physician did their training, and the physician’s personal belief. Often for the same medical problem, different doctors, even within the same specialty, will have different recommendations and treatments. This is often a result of who they trained with and their clinical experience. Practice styles and philosophies also differ from the East Coast and West Coast.

For the example of leg pain due to a pinched nerve, some back surgeons will recommend early surgical intervention, while others suggest non-operative conservative therapy. If a doctor trained at a program that advocated watchful waiting, then it is more likely his philosophy is to be conservative. If his mentor, however, always recommended surgery quickly, then it is likely his own belief is that operating is more beneficial. After one year, research has shown that patients do equally well with either option.

For patients to see what the varying philosophies are, they will need to seek out different hospitals and practices. Even within a group practice, the doctors may have different approaches for the same problem.