Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, May 02, 2007

"How Doctors Think": A Disappointment

After all the hullaballoo on line and elsewhere, I felt compelled to read Jerold Groopman's How Doctors Think. So I did, and in contrast to the glowing reviews elsewhere in the blogosphere, I have to report that I was disappointed.

I'm not sure what I expected; some new insights into medical decision-making and how to improve my diagnostic acumen. What I found was a well-written compilation of material I already knew. Granted, according to the author, the target audience was patients; still, I do not think it met the needs of that population either.

A couple of things jumped out at me, starting in the Introduction. At first, the line in a footnote:
I quickly realized that trying to assess how psychiatrists think was beyond my abilities.
struck me as hilarious; the snide kind of quip we've all lobbed at our mental health colleagues. Later, though, I came to realize that the elimination of this vital medical specialty from a discussion of diagnosis was short-sighted at best and ridiculous at worst. More on that in a moment.

A major issue was the entire disregard of my specialty: Family Practice isn't mentioned anywhere in the entire book. Primary Care is specifically defined as "...pediatricians for children and internists for adults." Later on, simple problems are mentioned as cared for by "general practitioners or internists." I'm not sure if this was an intentional slight, or, more likely, the simple lack of awareness that we exist as a distinct specialty, and what our capabilities are. For example, during our training we are continuously asked questions like "What else could it be?", "Is there anything that doesn't fit?", and "Is it possible the patient has more than one problem?" not by our patients but by our preceptors to whom we present our cases. (And in the first year of residency, we present every patient we see.)

Although we may not use the cognitive terminology of affective error, anchoring, search satisfaction and so on, we certainly learn the concepts from our very first day on the job. Listening to patients, bonding with them (but not so much so that clinical judgement is impaired) is emphasized at all times. Remembering that not all patients have equal literacy skills is drilled into us early and often. I try to keep these habits of thought as fresh as possible in my day-to-day practice all these many years later, to minimize the problems with diagnosis and other misadventures described by Groopman. I'm not saying I don't make cognitive errors in diagnosis, but I am already familiar with and try to utilize the strategies he discusses to avoid them.

As I read through the book, though, I realized that the omission of psychiatry and the discussion of the proper role of psychiatric diagnosis in medicine (as opposed to the misdiagnosis with which he opens the book) renders many of his comments irrelevant to the day-to-day practice of medicine in the community. By "community" I specifically refer to the non-Harvard, non-Massachusetts General, non-assorted-other-institutional-names dropped in the name of prestige. Out here in the real world, psychiatrists think just like the rest of us. They care for diseases that are primarily mental in origin. These diseases have criteria for diagnosis, treatment protocols, risk factors and prognoses. Making these diagnoses is often straightforward -- and sometimes less so. Treatment succeeds or fails, or stops working, at which point it often helps to change the treatment or re-visit the diagnosis. Sounds a lot like medicine, because it IS medicine. Contrary to Dr. Groopman's formulation, psychiatric diagnoses are NOT diagnoses of exclusion, as he implies:
This conclusion, of course, [that what is wrong is psychological, not physical] should only be reached after a serious and prolonged search for a physical cause for the patient's complaint.
As an example, say I consult with a woman in her 40s for fatigue. Tell me about your problem, I say. Listening without interruption, she describes fatigue that has been going on for about a year. She falls asleep ok but wakes at 2:00 am every morning and cannot go back to sleep. Her appetite is increased and she has gained some weight, but she just doesn't feel like exercising. In fact, she doesn't feel like doing anything. She can't concentrate; nothing gives her pleasure; her sex drive is nil. She doesn't want to kill herself, but she wouldn't mind if she didn't wake up one morning. She cries easily, but doesn't understand why she feels so sad all the time, because her job is fine and her husband and kids are great. (That's what spills out before I say a word.) I elicit the further information that she has no heat or cold intolerance, no changes in her skin or hair, no particularly heavy periods nor signs worrisome for blood loss from her gut. There is no family history of cancer, thyroid or other endocrine disease, but she has two sisters who take antidepressants and her grandfather was an alcoholic.

Suffice it to say that the differential diagnosis for fatigue is enormous. However any physician worth his salt who doesn't come up with Major Depression in one of the top three positions on the list of possible diagnoses for this patient probably shouldn't be trusted with a medical license. Once you've ruled out anemia and hypothyroidism (maybe diabetes and a few other things with routine screening blood work), it would be pretty irresponsible to continue on a "serious and prolonged search for a physical cause" of this condition instead of proceeding to at least a trial of treatment for depression (be it prescribed or referred, medication or talk therapy, or some combination.) Sure, it could turn out to be something else, but the fact remains that common things really are common. Out here in the real world, "zebra hunting" by specialists (exhaustive workups for rare entities) is far more prevalent than Groopman's "zebra retreat," despite the fact that he comes back again and again to the Celiac patient misdiagnosed as having an eating disorder.

While on the subject of that patient, although he does eventually say:
Once believed to be rare, the malady, also called celiac sprue, is now recognized more frequently thanks to sophisticated diagnostic tests.
the fact remains that fifteen years ago, when this poor lady began her medical misadventures, anyone who even thought of celiac disease would have been -- correctly -- laughed out of the conference room. I'll bet even the great GI doctor from Boston's Beth Israel Deaconess Medical Center who finally made the correct diagnosis wouldn't have been able to do so when the patient first presented, not in the least because those "sophisticated diagnostic tests" didn't exist at the time.

Which brings me to my next point; one that Groopman doesn't address, although he could have. Although pathology doesn't actually change, our understanding of it undergoes tectonic shifts. Not nearly as often or as dramatically as the popular press would have our patients believe, but still with sufficient frequency that it behooves us not only to keep up with new developments in medicine, but to keep an open mind in applying new information to our "old" patients; those who carry diagnoses yet who do not seem to be responding to our treatment. What if the physician of that celiac patient had gone to a lecture titled, "New Perspectives on Celiac Sprue: No Longer a Zebra." Would the doctor have been able to recognize that this new pattern fit her patient, and cause her to go back and re-think the diagnosis?

I have experienced this phenomenon. A patient of mine almost from the day I hung out my shingle kept having great difficulty with depressive symptoms and anger issues. Antidepressants didn't really help, nor did counseling. About two years ago I attended a seminar on Bipolar Disorder, including the fact that it's far more prevalent than previously recognized, and that it's much more than just classic manic-depressive symptoms. One of the talking points was that on average, patients waited seventeen years before being correctly diagnosed. After that, I brought tools from the seminar into my practice. I didn't go around diagnosing everyone with bipolar, but I did begin recognizing it more than I had. The first time after the seminar I saw the lady I mentioned, I listened to her telling me once more about her symptoms; her anger, her explosiveness. Whoa, I thought. I whipped out the Mood Disorders Questionnaire from the seminar to confirm my impression. Sure enough, now that I had become familiar with a diagnosis with criteria different from what I had learned, I was able to see her in a new light. I treated her with mood stabilizers, and she responded beautifully; very grateful that "something finally worked!" I looked back over her chart. Ironically, it had taken seventeen years to make the diagnosis.

I would have appreciated a discussion of the incorporation of new information into medical decision making. At what point should new information be acted on? With recent evidence-based information coming out on things like coronary stenting (only helpful acutely), chest CTs for early lung cancer screening (doesn't help) and computer-aided mammography diagnosis (increases false positives without a corresponding increase in cancer diagnosis), this is a timely topic.

Much of the time I found the book depressing. Primary Care is described as blurry vision from watching a train rushing by. Even if a patient were able to take the advice given and ask the recommended questions to help his or her physician make the correct diagnosis, what chance would they have against the neurology group in cahoots with the lawyers (Chapter 9: Marketing, Money and Medical Decisions.) If Dr. Groopman himself couldn't get a correct diagnosis of his hand problem without seeing four orthopods with different opinions and treatment recommendations, what chance does an ordinary patient have when confronted with a surgeon telling him he needs his spine operated on?

Which brings me to my final point: a lesson that jumped out at me, but is either unnoticed or unacknowledged by Groopman. "Prestigious" does not always correlate with "quality." The third orthopedist consulted by Groopman for his hand was, despite his waiting room papered with plaques declaring him "Best of" this and that, a jerk. I don't care how many papers you've written or how in demand you are as a speaker worldwide; if you can't be bothered to take the time to explain your diagnosis and treatment to a patient, you are not only not "The Best"; you aren't even very good. The guy didn't even come up with the right diagnosis.

I understand the Dr. Groopman lives in the rarified world of Boston academe, and that he has access to many people with very prestigious qualifications. I enjoyed "meeting" several of them, reading along as he describes his conversations with them, and they sound like nice enough people. But the implication that those with top-tier training make better-thinking doctors is elitist and wrong.

I do not believe this book would be particularly helpful to patients, and I find myself wondering if those physicians who enjoyed the book (not noticing the absence of Family Practice or the omission of psychiatry) share Groopman's unspoken bias of the prestige-quality connection. The bottom line is that I was disappointed with How Doctors Think.


At Wed May 02, 01:48:00 AM, Blogger Dr. A said...

This is the most meaningful review I've read on this book. Thanks so much. My patients have been asking me about this book. I guess I'll have to read it now, at least, for anything, for spin control. There's a lot of hype about this book out there in the media.

At Wed May 02, 07:22:00 AM, Blogger Sara said...

Funny you mention this. I just read all of Groopman and this new one, and I had the same thought. It annoyed me again and again how he seemed to think that only high tech medicine was worth anything, and his focus on "the best" - often telling patients to leave perfectly good hospitals to be treated elsewhere because of reputation only.

I did benefit from his pointing out cognitive biases - I certainly have fallen for some of those, ie not wanting the nice patient to really have a terrible disease.

The other thing that was fascinating for me was just seeing how much technology and pharmacology has advanced since then. Often, I'd read something in one of his older books, and think, "Damn, when was it that they were using this approach?" and then look and find out that it was really only 1995 or so.

Re: bipolar: some shrink recently mentioned Akiskal's work in I've been reading that. It's rather interesting, he's a good writer, and I think one of the more decent psychiatrists. It has been extremely eye opening to ssee what a wide spectrum the DSM misses.

Good Post, Dino.

At Wed May 02, 08:56:00 AM, Blogger Big Lebowski Store said...

Full disclosure - I know Jerry Groopman personally (we daven at the same shul) - but I'm looking forward to reviewing his book, not because I expect to like it, but rather because I expect I won't. I'll read it first, of course and make up my own mind.

I like your review, but I have one quibble. Psychiatry isn't really as much like medicine as we'd like it to be. Psychiatric disorders prove devilishly difficult to diagnose at times (your example was too easy, in my view - sort of like a 5 year old who wheezes every time he's near a cat). The brain is way more complex than the respiratory system and much much harder to treat.

The example of our poor track record with anti-depressants in teenagers is a case in point. Why don't the Goddamn drugs work in kids?

Psychiatrists and other therapists ought to think differently than we do, precisely because the medical model doesn't fit psyce disorders very well.



At Wed May 02, 10:53:00 AM, Anonymous Anonymous said...

I appreciate the points you raise in Groopman's opus. And about the feeling of being left out and invisible relative to your practice specialty, may I opine that this is the same kettle of fish that confronts nurses - invisible, overlooked and unappreciated for the expertise that is brought to bear.

At Wed May 02, 01:01:00 PM, Blogger Mom MD said...

I've been tempted to spend my Meager Resident Dollars to buy the book and my even more Meager Resident Time to read the book. After your review, I'll put it in my stack of stuff to read later...the ever growing pile. Thanks for the review!

At Wed May 02, 05:33:00 PM, Blogger Lynn Price said...

Hmm...figures that I'd read your detailed and balanced review AFTER I ordered the book. I was hopeful that it would further my education to the medical world since I'm anal about my writing being factual. Guess I'll just stick with my tried and true method of interviewing docs. Sheesh. Thanks for the heads up, dino.

Looking forward to reading your book. I just ordered it a couple days ago.

At Wed May 02, 07:06:00 PM, Blogger Mom MD said...

Wait, Dinosaur wrote a book?? What is it called?

At Wed May 02, 07:33:00 PM, Blogger Dr. Smak said...

I agree with Dr. Anonymous, the best review I've seen of this book. Yet I suppose, like "What Your Doctor May Not Tell You About Menopause", it still may be smart reading for my the next time it comes up.

At Wed May 02, 09:20:00 PM, Anonymous Anonymous said...

I leafed through the book at Borders, and it looked ok. I do have some mixed feelings about advising us patients to ask politely if there might be another diagnosis that could explain puzzling symptoms, when a current diagnosis and treatment aren't working out.

This seems like putting a lot of responsibility on the shoulder of a patient, to be able to discern whether an existing diagnosis fits their symptoms or not. Particularly if another diagnosis is that of an uncommon condition that a patient is highly unlikely to have heard of.

This advice seems especially unworkable, given Dr. Groopman's midadventure with 4 orthopedic surgeons and their 4 differing opinions. Even he couldn't easily receive a correct diagnosis and appropriate treatment. How are the rest of us supposed to manage?

At Fri May 04, 12:18:00 AM, Anonymous Anonymous said...

Thanks for the review, Dr. Dino. For a good medical book with stories from several people in the medical field, I recommed "First Do No Harm". Sorry that I can't recall the author.

At Fri May 04, 04:33:00 PM, Blogger catherine (fairchild) calhoun said...

I think at this point no book could live up to the hype Groopman's book has received. It contained some worthwhile tips -- which would be good for folks who are not natural self-advocates (but I doubt these folks will read the book as the target audience seems to be a more informed group that probably already knows a lot of what the book covers).
My basic take-away was that ultimately patients/caregivers should be as smart as possible and go with the gut which just confirms what I already do (I can ignore the pretention as it certainly did not help Groopman). Also, I suppose he did make me feel a little better about my son who is quite the medical "zebra" --to have caught his zebra status any earlier would have been practically amazing. I disagree with you Dr. Dino, in my experience (with pediatrics in my region anyway) there is definitely a "zebra retreat", but perhaps because my son's condition will for always be a zebra. (It also confirmed that my son's orthopedist is just as fabulous as I think he is, but I already knew that too). Probably worth the $15 since it let me pass the time while riding a bus full of elementary school children on the road to visit a history museum -- Groopman beats reading Silliest Jokes with a first grader for 3 hours.

At Sat May 05, 04:38:00 PM, Blogger Dreaming again said...

I hadn't heard of this book.

As a zebra (myasthenia gravis) and the mother of a zebra (arnold chiari malformation type 1) and the daughter of, what I guess is a not so zebra anymore ..celiac ...

I've come to ignore most of the zebra/horse arguements and just present who I am and who my child and mother are, a person, to the doctor.

It seems to work better.

At Thu May 10, 11:12:00 PM, Anonymous Anonymous said...

I too was insulted by Groopman's slight of Family Practice, but then , Harvard doesn't graduate or train Family Practice Physicians do they. In my rural area, I do a damn fine job of diagnosing and treating my patients. Am I always right...I wish. But I am ALWAYS open minded and ALWAYS follow-up closely.

My beef with subspecialists Like Groopman is their inability to recognise the number of patients PCPs actualy see, diagnose and treat. Groopman cries for his pediatrician friend who had to see 12 patients in a half day! Most peds and FPs I know see that many in 2 hours and still have 6+ hours facing them.


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