2008 Dewey Decimal Project: 610 G

This month's book was How Doctors Think by Jerome Groopman. I loved all of the fascinating case studies he uses to examine how doctors reach conclusions and either stick with them or do more investigating and questioning to make sure they haven't missed anything.

The most interesting insight, to me anyway, comes from chapter 6, "The Uncertainty of the Expert."

"Most of what we do in pediatric cardiology, we make up. In fact a fraction of what is routinely done today in my speciality, I made up," [Dr. James] Lock said with a grin. That is because children often have such unique problems with their hearts that there is little precedent. But, Lock continued, "you simply have to do something. The big problem is that most people assume that once it's made up, it's actually real. Especially the people who make it up themselves. Then they think it came straight from God."

The second most interesting, and certainly the funniest, bit is the single footnote in the book, which appears in the introduction: "I quickly realized that trying to assess how psychiatrists think was beyond my abilities. Therapy of mental illness is a huge field unto itself that encompasses various schools of thought and theories of mind. For that reason, I do not delve into psychiatry in this book."

As fascinating as the book is, it's a little loosely put together. Each chapter is its own narrative (one, or most of one, chapter appeared in The New Yorker at one point), and they don't really hold together as a coherent whole. Chapter 5, "A New Mother's Challenge," seems especially out of place. His conclusion of that tale is more about faith than medicine.

The last chapter is the practical one, which ties together all of the previous case studies and analyses of doctors' thought processes and gives the average patient "a series of touchstones that help correct errors in thinking." Groopman's touchstones are:

• Tell your story again, from the beginning.
• Tell your doctor what you're most afraid of, even if you're afraid to do so. "A relative had died of a pulmonary embolus, and she was terrified that this was the cause of her chest pain. After she told me, she admitted that she'd been scared to say it, since doing so might make it true.
• Physicians should review any tests again, and may need to repeat tests, even though it's expensive.
• You can specifically ask, "What else could it be?" "Is there anything that doesn't fit?" "Is it possible I have more than one problem?"
• Get a referral. "I have learned to say to my patient, 'I believe when you say something is wrong, but I haven't figured it out yet.' And since I can't figure out your problem, I continue, I should send you elsewhere, to a physician with an independent mind who likes to tackle complicated cases."
• Get an explanation of the treatment. "Recall the study of forty-five doctors in California caring for more than nine hundred patients. Two thirds did not tell the patients either how long to take the new medicine or what its side effects could be."
• Physicians need to make time for thinking. "The inescapable truth is that good thinking takes time. Working in haste and cutting corners are the quickest routes to cognitive errors.

The other conclusion the book reaches, which isn't explicitly laid out again in the epilogue, is that, for good treatment, doctors and patients have to be a good match. Patients whose doctors don't like them do actually get worse care, and most patients who think their doctors don't like them are right. Groopman also makes the point that a doctor who is perfect for one patient, would be terrible for another. So even though it's time-consuming and expensive to try out different doctors, it is important, and it does make a difference.