by Jerome Groopman, M.D.
Houghton Mifflin Company
307 pages, $26

Even excluding diet and other self-help publications, books by doctors have become so common that they practically form a genre of their own. Fortunately, a surprising number of doctors are excellent, engrossing writers. One of the best physician-writers, Jerome Groopman, a staff writer for The New Yorker magazine, has a brand new book. Groopman is an internist with a specialty in hematology and oncology who writes from a very broad perspective about many aspects of medicine and illness, both as a doctor and patient. His new book, “How Doctors Think,” performs a great public service for doctors and patients. 

“This book is about what goes on in a doctor’s mind as he or she treats a patient,” Groopman writes. In addition to surveying the research literature, Groopman interviewed many highly esteemed doctors from around the country. He asked them to describe mistakes they had made, analyze why the errors occurred, and detail how they (and their colleagues) are trying to prevent such errors in the future. “The hardest thing about being a doctor is that you learn best from your mistakes, mistakes made on living people,” said Karen Delgado, one of the doctors Groopman interviewed. The mistakes with which Groopman is concerned do not result from incompetent physicians or sloppy hospital procedures. He instead focuses on “cognitive errors”—errors in thinking about a medical problem—that even well trained doctors can and do make. Statistics show that as many as 15 percent of all diagnoses are inaccurate, and of these misdiagnoses, approximately 80 percent are due to cognitive errors, Groopman says.

Groopman also interviewed several researchers—principally psychologists, social scientists and other doctors—who are studying the problem of cognitive errors and the closely related subject of communication between doctors and patients.

He devotes much of his attention to the “gatekeepers” of medicine—the primary care physicians who typically first encounter patients. The PCPs, as they are known in the lingo, include family care doctors, general internists, pediatricians and emergency room doctors. Groopman believes PCPs are the real heroes of medicine. Although they usually earn much less than specialists, their role is crucial and difficult, he says. While most patient complaints are not due to serious illness, “any and every problem of human biology can present itself,” Groopman writes. The challenge is picking out the critical cases and, “as a gatekeeper, knowing where to guide us” for specialized examination and care.

Throughout the book, Groopman illustrates the issues with interesting and well written clinical examples. He writes frankly about himself and the mistakes he has made. He also applies his own experiences as a patient, including several two-hour waits to see a well-known doctor, and a sudden fit of confusion and panic caused by a doctor’s misdiagnosis: a doctor once misread an X-ray, suggesting Groopman had cancer, and he immediately began having psychosomatic pain in that part of his body.

As an example of the complexity and difficulty of diagnosis, Groopman discusses in detail his own experience seeking medical help with “debilitating pain and swelling in his right hand” that seriously interfered with the routine tasks of daily life. “Over the course of three years (he) consulted six (highly regarded) hand surgeons and got four different opinions about what was wrong and what to do about it.”

Groopman demonstrates how the surgeons made various cognitive errors. Two doctors demonstrated “commission bias,” the urge to action, inventing a non-existent or false condition and recommending exploratory surgery rather than admitting their uncertainty. Another made the error of “satisfaction of search,” which the author describes as “the tendency to stop searching for a diagnosis once you find something.” The successful diagnosis was made by a young doctor who “kept searching because he was not satisfied that what he had before him was enough to account for all of my symptoms.”

Related to these cognitive errors are the biases that arise from a doctor’s positive or negative feelings about a patient. The less thoughtful care administered to patients fitting negative stereotypes (such as being obese, alcoholic, addicted, mentally disturbed or poor), is an example of “attribution error.” But a doctor may also be unwilling to subject a patient for whom he has positive feelings to unpleasant but necessary tests or treatments.

Patients who fit certain standard prototypes may lead a doctor to “representativeness error,” where possible causes are not considered because they don’t fit the prototype. Confirming what you expect to find by selectively accepting some and ignoring other information is known as “confirmation bias.” Another common error is “availability,” described as “the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind.”

Groopman is passionate about the unrealistic time pressures put on doctors by those who seek to turn medicine into a business. “Good thinking takes time,” he writes. Pharmaceutical companies and doctors who promote treatments or procedures of questionable or unproven worth also come in for strong criticism. Groopman shows how “specialization in medicine confers a false sense of certainty,” and illustrates this with a sobering chapter on radiology.

The book also includes a marvelous and inspiring chapter on the challenges and subtleties in properly and sensitively caring for people with cancer, helping patients make decisions “consistent with their philosophy of living.”

An inescapable conclusion from reading Groopman’s book is that almost all of us are too timid in dealing with the medical establishment. We passively accept what our doctors tell us and don’t ask enough questions. We are reluctant to seek other opinions and find it difficult to change doctors when we should.

Groopman suggests a number of questions patients should consider asking their doctors about diagnoses and suggested treatment, especially in cases that are not routine. “What else could it be?” encourages the doctor to avoid premature closure and consider other possibilities. “Is there anything that doesn’t fit?” can prompt the physician to consider whether all symptoms and test results are truly consistent with the proposed diagnosis. “Is it possible I have more than one problem?” is a safeguard against the cognitive error of search satisfaction.

Some in the medical community will probably say that Groopman’s standard for quality care is unrealistic and unattainable, but wouldn’t they want and seek such care for themselves and those they love?