Saturday, May 05, 2007

Book review: How Doctors Think

Dr. Jerome Goopman's How Doctors Think is a thoughtful and engaging book that could also save your life. Replete with anecdotes, it examines the thought processes of doctors and the errors in thinking to which they are prone. It also discusses elements outside of cognition that influence medical treatments. Throughout Dr. Goopman makes suggestions for how patients can help physicians think better when things go wrong.

Doctors are people, and people make mistakes in thinking, especially in the face of uncertainty. Dr. Goopman goes over many types of cognitive errors. Some are classic, such as "availability," which is the tendency to judge how likely an event is to occur by the ease with which it comes to mind. Others are specific to doctoring, such as "diagnostic momentum." This is the tendency for physicians to accept a diagnosis once it has been made rather than reconsidering the data from scratch when treatments are not working as expected.

Dr. Goopman also discusses cultural and personal factors surrounding diagnostic mistakes. A big one is managed care, which encourages speed and standardization in order to keep costs down. While many people can be treated adequately in 15 minutes (i.e., the generally healthy), the system makes it more difficult for doctors to distinguish between the routine and the rare, which takes time and thought. Another element is temperament of both doctor and patient. If there is a good match — if,for instance, the doctor is aggressive about treatment and you like that approach — there is more likelihood of a successful outcome. If not, communication can go awry, and mistakes may follow.

This honest and eye-opening book can be a little frightening, but Dr. Goopman's aim is not to scare people. Instead, he wants to help patients help their doctors. "Doctors desperately need patients and their family and friends to help them think. Without their help, physicians are denied clues to what is really wrong." Dr. Goopman supplies a set of simple questions the patient can ask a doctor when an initial treatment does not appear to be working. Asking such questions, he contends, can stop a doctor's train of thought and refocus him.

This is essential information for patients. Dr. Goopman recognizes it might be difficult for a patient to question his physician and suggests having a family member help out. Dr. Goopman has been a patient himself and tells the story of a wrist ailment he suffered. He had the marked advantage of being a doctor, having a physician spouse, and having colleagues he knows and trusts to turn to. Still, it took him three years and as many diagnoses before his problem was solved.

I hope, therefore, that doctors will read this book, too. Patients can help, but they will not always run into physicians who are willing to reconsider diagnoses, and they need to have the resolve and resources to stick to their guns. Doctors need to be aware of their cognitive vulnerabilities and keep their minds as open as possible.

In this age of technology and managed care, sometimes we need to be able to step back and let the art, and not just the science of medicine take place. How Doctors Think is one giant leap in this direction. It's also a just plain good read. Dr. Goopman has several other books under his belt and writes regularly for The New Yorker magazine, and it shows. This book should be required for everyone, and happily, reading it won't hurt a bit.

Cross-posted to Blogcritics.

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