Physician, heal thyself

As many as 15 per cent of all diagnoses are inaccurate, says Jerome Groopman.

James MacGowan
Ottawa Citizen

In a new book, the doctor explains why and what you can do about it

In Dr. Jerome Groopman’s fascinating but alarming new book How Doctors Think, the New Yorker writer and Harvard Medical School professor tells readers that on average most doctors will decide what your problem is in about the time it takes you to read this paragraph. Eighteen seconds, in fact. And while most of the time they get it right, Groopman says too often they get it wrong.

“As many as 15 per cent of all diagnoses are inaccurate,” he writes, while noting that some think the number could be as high as 25 per cent. As his book makes abundantly clear — and Groopman prefers to think of it as an empowering book rather than an alarming one — this rush to judgment can have catastrophic consequences.

“As a doctor, you can’t close your mind off,” Groopman says over the phone from his office in Brookline, Massachusetts. “You can’t take your initial impression.”

He was talking about his theory of practice, but I had also been telling him about the case of a friend who for 10 years had been concerned about a mole on her thigh. She repeatedly brought it to the attention of her family doctor and was reassured it was nothing. Eventually, she grew alarmed enough to seek out a skin specialist and was shocked to learn she had a malignant melanoma.

“The two cardinal errors a doctor can make,” Groopman says, and his voice sounds both scholarly and fatherly, “are anchoring — where we become fixed on the initial impression and initial data — and then what’s called premature closure, where we just shut off our minds prematurely and don’t consider that this skin change is persisting, that it’s bothering her, so what else could it be? Was my initial impression wrong?

“Asking those questions is the mark of a thinking doctor who questions himself and who is open to be questioned by patients, family members or friends.”

Groopman opens his book with a particularly nasty example of what happens when doctors close their minds. For 15 years Anne Dodge had been trying to find out why she would experience nausea and pain after meals, sometimes causing her to throw up. Her family doctor had found nothing, and after she consulted with numerous specialists, including psychiatrists, was diagnosed with anorexia and bulimia. As her health kept deteriorating, she was eventually hospitalized in a mental health facility, and told to eat 3,000 calories a day to restore her system. But the pain and nausea continued and she dropped down to 82 pounds at which point, having also been diagnosed with irritable bowel syndrome, she was referred to a gastroenterologist who took a different approach: He listened and didn’t base his diagnosis on what the many previous doctors had said. By doing that, he discovered she had celiac disease, “an autoimmune disorder, in essence an allergy to gluten, a primary component of many grains,” which is what she had been trying to eat to gain strength.

“Look,” Groopman says, trying not to come down too hard on the many doctors who failed Dodge, “it’s very hard being a doctor. There are patients who don’t communicate well, patients who are frightened, patients whose memory is poor — it is very, very hard to be a doctor. But it’s harder to be a patient. That’s why if you approach health care in a co-operative, positive way, we can do better together.”

What he means by that is as a patient, you can’t let yourself be intimidated by a doctor and you need to partner with him to get to the root of what ails you. And never accept, Groopman emphasizes, any initial diagnoses that involves the sentence, “We see this sometimes.”

“When you hear that sentence,” he quotes a doctor as saying, “reply, Let’s keep looking until we figure out what is wrong or know the problem has passed.”

Which means you may have to challenge your doctor, albeit it in a very diplomatic way: If that pain in your chest is not getting better, and you really don’t think it’s acid reflux, go back and ask, What else could it be? Could it be acid reflux and something else? What body parts are near where I am having my symptom? What’s the worse thing it could be? These types of questions, all of them quite reasonable and proper, can nudge a doctor’s thinking and point them in a new thought direction.

“Doctors are not going to be right all the time,” Groopman says, “but the way we can do better is by knowing that our mind can play tricks on us, and lead us to make anchoring errors or confirmation bias errors, where we ignore information that contradicts what we’re thinking and just keeps confirming our initial beliefs.”

One of the more interesting mistakes a doctor can make — if that’s what you can call a potentially fatal decision — is what Groopman calls an attribution error. This is when a doctor makes a decision based on a negative stereotype, such as the unkempt man he writes about who shows up in a Toronto ER complaining of stomach pain while smelling of booze and body odour.

“He was immediately stereotyped as a boozer,” Groopman says. “So his liver disease has got to be alcoholic cirrhosis, of course. But he wasn’t a drunk. He had just one glass of rum a night. He had a completely different problem.”

A representativeness error works the other way, and lulled one doctor Groopman writes about into thinking the very fit-looking forest ranger standing before him couldn’t possibly be on the verge of a heart attack despite his chest pain. (He was).

“As doctors,” Groopman says, “we have to be very attentive to both our logic and our emotions.”

To his credit, Groopman, 55, does not spare himself from criticism. As an intern 30 years ago, he failed to diagnose a woman’s ruptured aorta because, as he puts it, she had “endless complaints” and her voice “sounded to me like a nail scratching a blackboard.” Wanting nothing more to do with her, he moved her along as quickly as possible. Too quickly it turned out: Several weeks later, she died.

“Although an aortic dissection is often fatal even when discovered,” he writes, “I have never forgiven myself for failing to diagnose it.”

No patient, Groopman says, should ever hesitate to find a new doctor if they feel their doctor doesn’t like them. “I’ve asked numerous doctors what they would do in that situation, and all of them said they would get a new doctor.”

Groopman himself did this a few years back, when he tried to find out what was causing the painful inflammation in his right hand. The first three doctors he went to — including one of the U.S.’s foremost hand surgeons — left him reeling, with the star hand surgeon telling him he didn’t know what the problem was but would figure it out during the operation. Luckily Groopman was with his wife, who is also a physician. (It was the fourth doctor who finally got it right.)

“I was in pain, I was scared, I was trying to be as co-operative as possible and I needed someone there — my wife, who is always right — to navigate for me. Because you’re suggestible. You’re vulnerable, and you need to know that the thinking is solid and makes sense. And again, you don’t need to be a rocket scientist. As I quote in the book: ‘There’s nothing in medicine that’s so complicated it can’t be explained to make sense to any lay person. It’s not quantum physics.'”

TO GET THE BEST TREATMENT

So what can patients do with their own doctors? It’s a question Groopman has heard before. Here’s how he responded to one interviewer:

ASK QUESTIONS

“There are three pillars of this. First, when the symptoms are not getting better, what else could it be? Could there be more than one thing going on? You need to ask this perfectly appropriate question to prompt revisiting the initial, anchored assumption, the working diagnosis.

CHECK THE TEMPERATURE

“Second, patients know how their doctors feel about them — both warm, good feelings as well as irritation. If you’re picking up vibes that are particularly negative, you need to broach that, and it’s a perfectly fair thing to do. Say, ‘I feel like we’re not communicating well, I don’t feel a sense of compatibility.’ Sometimes, the doctor will say ‘I’m sorry, I’m having a bad day,’ but as I say in the book, when I ask colleagues who are physicians about when they went to a doctor who seemed dismissive and irritated, they said, ‘I’m going to find someone else.’ I think you have to take the emotional temperature of the doctor.

CHALLENGE ASSUMPTIONS

“The third key issue is: ‘Is there any data that seems to contradict your assumption?’ Because that’s a really big cognitive error, this so-called commission bias, once you get anchored. This goes on so frequently. I used to think reading MRIs and Cat Scans was an exact science; it’s like Impressionist paintings! You’d think that with more high-performance scans, the better they are, but they’re generating so many images that it overwhelms the radiologist –”

DR. GROOPMAN WRITES:

A doctor’s office is not an assembly line. Turning it into one is a sure way to blunt communication, foster mistakes and rupture the partnership between patient and physician. A doctor can’t think with one eye on the clock and another on the computer screen. But a thinking doctor does need to allot his time wisely. Problems that are well defined and straightforward can be addressed with clarity in 15 or 20 minutes, and a patient and family can leave the visit feeling informed and satisfied. Complicated problems cannot be solved in a rush. The inescapable truth is that good thinking takes time. Working in haste and cutting corners are the quickest routes to cognitive errors.

For three decades practising as a physician, I looked to traditional sources to assist me in my thinking about my patients: textbooks and medical journals; mentors and colleagues with deeper or more varied clinical experience; students and residents who posed challenging questions. But after writing this book, I realized that I can have another vital partner who helps improve my thinking, a partner who may, with a few pertinent and focused questions, protect me from the cascade of cognitive pitfalls that cause misguided care. That partner is present in the moment when flesh-and-blood decision-making occurs. That partner is my patient or her family member or friend who seeks to know what is in my mind, how I am thinking. And 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.
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