"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.