Editorial Reviews. From Publishers Weekly. Drawing on both personal experience and download How Doctors Think: Read site Store Reviews - How Doctors Think [Jerome Groopman] on *FREE* shipping on qualifying offers. On average, a physician will interrupt a patient describing her. PDF | 10+ minutes read | On Jan 1, , Scott D. Smith and others published How Doctors Think. of Dr. Jerome Groopman's How Doctors Think. Cognitive.

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book, Jerome Groopman, a practicing oncologist with expertise in AIDS-related malignancies, explores the interior land- scape of the physician's mind. How Doctors Think - Jerome Groopman. Footnotes . This question, not surprisingly, spawned others: Do different doctors think differently? Are different forms of. book reviews n engl j med ;26 june 28, How Doctors Think. By Jerome Groopman. pp. New York, Houghton Mifflin,.

Arrows branch from the first box to other boxes. For example, a common symptom like sore throat would begin the algorithm, followed by a series of branches with yes or no questions about associated symptoms.

Is there a fever or not? Are swollen lymph nodes associated with the sore throat? Have other family members suffered from this symptom? Similarly, a laboratory test like a throat culture for bacteria would appear farther down the trunk of the tree, with branches based on yes or no answers to the results of the culture.

Ultimately, following the branches to the end should lead to the correct diagnosis and therapy. Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment—distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctor needs to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact.

In such cases—the kinds of cases where we most need a discerning doctor—algorithms discourage physicians from thinking independently and creatively.

Instead of expanding a doctor's thinking, they can constrain it.

Similarly, a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the canon in many hospitals. Treatments outside the statistically proven are considered taboo until a sufficient body of data can be generated from clinical trials.

Of course, every doctor should consider research studies in choosing a therapy. But today's rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.

Statistics cannot substitute for the human being before you; statistics embody averages, not individuals. Numbers can only complement a physician's personal experience with a drug or a procedure, as well as his knowledge of whether a best therapy from a clinical trial fits a patient's particular needs and values.

Each morning as rounds began, I watched the students and residents eye their algorithms and then invoke statistics from recent studies. I concluded that the next generation of doctors was being conditioned to function like a well-programmed computer that operates within a strict binary framework.

After several weeks of unease about the students' and residents' reliance on algorithms and evidence-based therapies alone, and my equally unsettling sense that I didn't know how to broaden their perspective and show them otherwise, I asked myself a simple question: How should a doctor think?

This question, not surprisingly, spawned others: Do different doctors think differently? Are different forms of thinking more or less prevalent among the different specialties? In other words, do surgeons think differently from internists, who think differently from pediatricians?

Is there one best way to think, or are there multiple, alternative styles that can reach a correct diagnosis and choose the most effective treatment? How does a doctor think when he is forced to improvise, when confronted with a problem for which there is little or no precedent?

Here algorithms are essentially irrelevant and statistical evidence is absent. How does a doctor's thinking differ during routine visits versus times of clinical crisis?

Do a doctor's emotions—his like or dislike of a particular patient, his attitudes about the social and psychological makeup of his patient's life—color his thinking? Why do even the most accomplished physicians miss a key clue about a person's true diagnosis, or detour far afield from the right remedy?

In sum, when and why does thinking go right or go wrong in medicine? I had no ready answers to these questions, despite having trained in a well-regarded medical school and residency program, and having practiced clinical medicine for some thirty years.

So I began to ask my colleagues for answers.

Then I searched the medical literature for studies of clinical thinking. I found a wealth of research that modeled optimal medical decision-making with complex mathematical formulas, but even the advocates of such formulas conceded that they rarely mirrored reality at the bedside or could be followed practically.

I saw why I found it difficult to teach the trainees on rounds how to think. I also saw that I was not serving my own patients as well as I might. I felt that if I became more aware of my own way of thinking, particularly its pitfalls, I would be a better caregiver. I wasn't one of the hematologists who evaluated Anne Dodge, but I could well have been, and I feared that I too could have failed to recognize what was missing in her diagnosis.

Of course, no one can expect a physician to be infallible.

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Medicine is, at its core, an uncertain science. Every doctor makes mistakes in diagnosis and treatment. But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better.

This book was written with that goal in mind. It is primarily intended for laymen, though I believe physicians and other medical professionals will find it useful. Why for laymen? Because doctors desperately need patients and their families and friends to help them think. Without their help, physicians are denied key clues to what is really wrong.

I learned this not as a doctor but when I was sick, when I was the patient. We've all wondered why a doctor asked certain questions, or detoured into unexpected areas when gathering information about us. We have all asked ourselves exactly what brought him to propose a certain diagnosis and a particular treatment and to reject the alternatives. Although we may listen intently to what a doctor says and try to read his facial expressions, often we are left perplexed about what is really going on in his head.

That ignorance inhibits us from successfully communicating with the doctor, from telling him all that he needs to hear to come to the correct diagnosis and advice on the best therapy. In Anne Dodge's case, after a myriad of tests and procedures, it was her words that led Falchuk to correctly diagnose her illness and save her life.

While modern medicine is aided by a dazzling array of technologies, like high-resolution MRI scans and pinpoint DNA analysis, language is still the bedrock of clinical practice. We tell the doctor what is bothering us, what we feel is different, and then respond to his questions.

This dialogue is our first clue to how our doctor thinks, so the book begins there, exploring what we learn about a physician's mind from what he says and how he says it. But it is not only clinical logic that patients can extract from their dialogue with a doctor. They can also gauge his emotional temperature. Typically, it is the doctor who assesses our emotional state.

But few of us realize how strongly a physician's mood and temperament influence his medical judgment. We, of course, may get only glimpses of our doctor's feelings, but even those brief moments can reveal a great deal about why he chose to pursue a possible diagnosis or offered a particular treatment. After surveying the significance of a doctor's words and feelings, the book follows the path that we take when we move through today's medical system.

If we have an urgent problem, we rush to the emergency room. There, doctors often do not have the benefit of knowing us, and must work with limited information about our medical history. I examine how doctors think under these conditions, how keen judgments and serious cognitive errors are made under the time pressures of the ER. If our clinical problem is not an emergency, then our path begins with our primary care physician—if a child, a pediatrician; if an adult, an internist.

In today's parlance, these primary care physicians are termed gatekeepers, because they open the portals to specialists. The narrative continues through these portals; at each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong.

We also encounter the tension between his acknowledging uncertainty and the need to take a clinical leap and act. One chapter reports on this in my own case; I sought help from six renowned hand surgeons for an incapacitating problem and got four different opinions. Much has been made of the power of intuition, and certainly initial impressions formed in a flash can be correct.

But as we hear from a range of physicians, relying too heavily on intuition has its perils. Cogent medical judgments meld first impressions—gestalt—with deliberate analysis. This requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes. What can doctors and patients do to find time to think?

I explore this in the pages that follow. Today, medicine is not separate from money. How much does intense marketing by pharmaceutical companies actually influence either conscious or subliminal decision-making?

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Very few doctors, I believe, prostitute themselves for profit, but all of us are susceptible to the subtle and not so subtle efforts of the pharmaceutical industry to sculpt our thinking.

That industry is a vital one; without it, there would be a paucity of new therapies, a slowing of progress. Several doctors and a pharmaceutical executive speak with great candor about the reach of drug marketing, about how natural aspects of aging are falsely made into diseases, and how patients can be alert to this.

Cancer, of course, is a feared disease that becomes more likely as we grow older. It will strike roughly one in two men and one in three women over the course of their lifetime. Recently there have been great clinical successes against types of cancers that were previously intractable, but many malignancies remain that can be, at best, only temporarily controlled. How an oncologist thinks through the value of complex and harsh treatments demands not only an understanding of science but also a sensibility about the soul—how much risk we are willing to take and how we want to live out our lives.

Two cancer specialists reveal how they guide their patients' choices and how their patients guide them toward the treatment that best suits each patient's temperament and lifestyle.

At the end of this journey through the minds of doctors, we return to language. The epilogue offers words that patients, their families, and their friends can use to help a physician or surgeon think, and thereby better help themselves. Patients and their loved ones can be true partners with physicians when they know how doctors think, and why doctors sometimes fail to think.

Using this knowledge, patients can offer a doctor the most vital information about themselves, to help steer him toward the correct diagnosis and offer the therapy they need.

How doctors think

Patients and their loved ones can aid even the most seasoned physician avoid errors in thinking. To do so, they need answers to the questions that I asked myself, and for which I had no ready answers. Not long after Anne Dodge's visit to Dr. Falchuk is a compact man in his early sixties with a broad bald pate and lively eyes. America has become more of a meritocracy in the professions. Medical school admissions committees no longer accept a record of gentlemen's C's at an Ivy League college.

At best, I said to Salem, a layman should inquire of friends and, if possible, other physicians as well as nurses about the clinical qualities of a doctor beyond his personality. His credentials can be found on the Internet or by contacting a local medical board Salem's query required a much more comprehensive answer, which I hope this book will help provide. Specifically, he explores their development in the early s of a concept known as the availability heuristic.

How Doctors Think

In a clinical situation a diagnosis may be made because the physician often sees similar cases in his practice — for example, the misclassification of aspirin toxicity as a viral pneumonia , or the improper recognition of an essential tremor as delirium tremens due to alcohol withdrawal in an indigent urban setting. Groopman argues that a clinician will misattribute a general symptom as specific to a certain disease based on the frequency he encounters that disease in his practice.

He argues that gatekeeper physicians are underreimbursed for their work, believing this to be a legacy of the period earlier this century when surgeons headed the medical societies that negotiated with insurers about what a 'customary' payment for services was to be.

He quotes Dr. Eric J. Cassell's book, Doctoring: The Nature of Primary Care Medicine, to defend his assertion: A common error in thinking about primary care is to see it as entry-level medicine This is a false notion. One should not confuse highly technical, even complicated, medical knowledge--special practical knowledge about an unusual disease, treatment, condition, or technology--with the complex, many-sided worldly-wise knowledge we expect of the best physicians.

The narrowest subspecialist, the reasoning goes, should also be able to provide this [broad] range of medical services. This naive idea arises, as do so many other wrong beliefs about primary care, because of the concept that doctors take care of diseases. Diseases, the idea goes on, form a hierarchy from simple to difficult.

That said, this does not nullify the central thesis of the book.

I finished reading How Doctors Think at the end of my second year at medical school, having started it several months earlier but abandoning it for periods of time because of the rigours of the medical curriculum.

Most of the 4-year medical programs in Canada are the preclinical or preclerkship years for students. It is the time when we learn much about the pathophysiology of disease, a bit about patient-doctor relationships, little about the process of clinical decision making, and essentially nothing about the cognitive errors and biases that might compromise the accuracy of our decisions—let alone ways of recognizing and correcting said biases.

Groopman explains that, in medicine, understanding why we sometimes get things wrong is important—if not essential—to understanding how to get things right. My only regret about this book is not having read it sooner. Even with its shortcomings, this is a book I would recommend to any medical professional, particularly new incoming medical students.

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Journal List Can Fam Physician v. Can Fam Physician. Reviewed by Brent M. Author information Copyright and License information Disclaimer.Medical logic. Patients and their loved ones can aid even the most seasoned physician avoid errors in thinking. But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better.

Open in a separate window The author makes an apt point when explaining that even with the myriad technologies available, language is still the foundation of clinical medicine. Home Books Science.

Includes bibliographical references and index.

Groopman explains that, in medicine, understanding why we sometimes get things wrong is important—if not essential—to understanding how to get things right.