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Author | Jerome Groopman |
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Language | English |
Genre | Non-fiction |
Publisher | Houghton Mifflin |
Publication date | 2007 |
Publication place | United States |
Media type | Hardback |
Pages | 305 pp (first edition, hardback) |
ISBN | 0-618-61003-0 (first edition, hardback) |
OCLC | 74569241 |
610 22 | |
LC Class | R723.5 .G75 2007 |
Preceded by | Anatomy of Hope |
Followed by | Your Medical Mind |
How Doctors Think is a book released in March 2007 by Jerome Groopman, the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School, chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston, and staff writer for The New Yorker magazine. [1]
The book opens with a discussion of a woman in her thirties who suffered daily stomach cramps and serious weight loss, and who visited some 30 doctors over a period of 15 years. Several misdiagnoses were made before she was finally found to have celiac disease. [1] Groopman explains that no one can expect a physician to be infallible, as medicine is an uncertain science, and every doctor sometimes makes mistakes in diagnosis and treatment. But the frequency and seriousness of those mistakes can be reduced by "understanding how a doctor thinks and how he or she can think better". [1]
The book includes Groopman's own experiences both as an oncologist and as a patient, as well as interviews by Groopman of prominent physicians in the medical community. Notably, he describes his difficulties with a number of orthopedic surgeons as he sought treatment for a debilitating ligament laxity he developed in his right hand, which over several years had led to the formation of cysts in the bones of his wrist. [1]
Groopman spends a great deal of the book discussing the challenge posed to him by Dr. Deeb Salem, chairman of the Department of Internal Medicine at Tufts-New England Medical Center, during a presentation the author made at their hospital grand rounds. During the presentation, Groopman was discussing the importance of compassion and communication in providing medical care when Salem posed the following question:
There are primary care physicians in every hospital who speak with great sensitivity and concern, and their longtime patients love them, but clinically they are incompetent--how is a patient to know this? [1]
At the time of the presentation, Groopman was unable to provide a satisfactory response. Salem's question reminded Groopman of his experiences with physicians at the Phillips House of the world-renowned Massachusetts General Hospital, where he trained as a resident in the 1970s. Per his account:
A few of [the physicians at Philips House] were highly skilled, but several were, at best, marginal in their clinical acumen. Nonetheless, their patients were devoted to them. It was the job of the residents to plug the holes in these marginal doctors' care. Just as a physician has to be wary of his first impression of a patient's condition, as a patient you have to be careful of your first impression of a physician...Thankfully, fewer students are admitted to medical school now because of social standing and family connections than at the time of my training. 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. [1]
Early in the work, Groopman discusses the work of Amos Tversky and Nobel laureate Daniel Kahneman, psychologists from Hebrew University in Jerusalem. Specifically, he explores their development in the early 1980s of a concept known as the availability heuristic. [1]
In the theory, "availability" is defined as the tendency to judge the likelihood of explanation for an event by the ease with which relevant examples come to mind. In a clinical situation a diagnosis may be made because the physician often sees similar cases in their 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 clinicians will misattribute a general symptom as specific to a certain disease based on the frequency they encounter that disease in their practice. [1]
Kahneman won the Nobel Prize in economics in 2002 for his work on heuristics, an honor that Groopman believes Tversky would have shared had he not died in 1996. [1]
Groopman also serves as an advocate for primary care physicians in his book. 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. [1]
He suggests that the poor reimbursement and lack of recognition for primary care physicians is fundamentally flawed. 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...and, because of this, rudimentary 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. Specialists take care of difficult diseases, so, of course, they will naturally do a good job on simple diseases. Wrong. Doctors take care of people, some of whom have diseases and all of whom have some problem. People used to doing complicated things usually do complicated things in simple situations--for example, ordering tests or x-rays when waiting a few days might suffice--thus overtreating people with simple illnesses and overlooking the clues about other problems that might have brought the patient to the doctor. [1]
In a later chapter Groopman reports a frank discussion with Dr. James E. Lock, chief of cardiology at Boston Children's Hospital. During their conversation, Groopman asks the world-renowned cardiologist about the times in his career when he made mistakes in patient treatment. [1]
To the query, Lock gives the cryptic response, "All my mistakes have the same things in common." [1]
Lock then elaborates, discussing recommendations he made to repair specific heart defects in neonates that ultimately led to worse clinical outcomes and potentially avoidable deaths. The recommendations he made were based on a purely logical understanding of cardiac physiology. [1] The crucial point of Lock's discussion came with his confession:
Impeccable logic doesn't always suffice. My mistake was that I reasoned from first principles when there was no prior experience. I turned out to be wrong because there are variables that you can't factor in until you actually do it. And you make the wrong recommendation, and the patient doesn't survive. I didn't leave enough room for what seems [ sic ] like minor effects--the small fluctuations in oxygen levels, which might amount to one or two or three percent but actually can signal major problems in the heart....[The proposed treatment] is very sound logic. But it's wrong...These children developed right heart failure and clinically they became worse. There are aspects to human biology and human physiology that you just can't predict. Deductive reasoning doesn't work for every case. Sherlock Holmes is a model detective, but human biology is not a theft or a murder where all the cues can add up neatly. [1]
Groopman goes on to write, "Lock averted his gaze and his face fell; to be wrong about a child is a form of suffering unique to his profession [as a pediatrician]." [1]
Groopman also discusses the work of Renee Fox, a physician and occupational sociologist who observed residents and attendings in a hospital ward setting, noting their various ways of coping with the uncertainties of medical treatment. The mechanisms to cope that Fox observed included, for example, black humor, making bets about who would be right about a patient's prognosis, and engaging in magical thinking to maintain a sense of poise and competence in front of patients while performing circumspect procedures. [1]
Jay Katz, a clinical instructor at Yale Law School has since termed these coping mechanisms under the rubric 'disregard of uncertainty', which he believes physicians develop to deal with the anxiety of shifting from the certainty of theoretical discussions of medicine early in their training to its more happenstance practical application. [1]
Groopman recalls that in situations where he had been hesitant to take clinical action based on incomplete data, it had been wisest at times to follow the advice of his mentor Dr. Linda A. Lewis: "Don't just do something, stand there." Groopman asserts that there exist situations in which inaction may be the wisest course of action. [1]
Groopman closes with an epilogue giving advice for patients. He gives the following tools that patients can use to help reduce or rectify cognitive errors:
Medicine is the science and practice of caring for patients, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness. Contemporary medicine applies biomedical sciences, biomedical research, genetics, and medical technology to diagnose, treat, and prevent injury and disease, typically through pharmaceuticals or surgery, but also through therapies as diverse as psychotherapy, external splints and traction, medical devices, biologics, and ionizing radiation, amongst others.
Pediatrics is the branch of medicine that involves the medical care of infants, children, adolescents, and young adults. In the United Kingdom, paediatrics covers many of their youth until the age of 18. The American Academy of Pediatrics recommends people seek pediatric care through the age of 21, but some pediatric subspecialists continue to care for adults up to 25. Worldwide age limits of pediatrics have been trending upward year after year. A medical doctor who specializes in this area is known as a pediatrician, or paediatrician. The word pediatrics and its cognates mean "healer of children", derived from the two Greek words: παῖς and ἰατρός. Pediatricians work in clinics, research centers, universities, general hospitals and children's hospitals, including those who practice pediatric subspecialties.
A general practitioner (GP) or family physician is a doctor who is a consultant in general practice.
Internal medicine, also known as general internal medicine in Commonwealth nations, is a medical specialty for medical doctors focused on the prevention, diagnosis, and treatment of internal diseases in adults. Medical practitioners of internal medicine are referred to as internists, or physicians in Commonwealth nations. Internists possess specialized skills in managing patients with undifferentiated or multi-system disease processes. They provide care to both hospitalized (inpatient) and ambulatory (outpatient) patients and often contribute significantly to teaching and research. Internists are qualified physicians who have undergone postgraduate training in internal medicine, and should not be confused with "interns", a term commonly used for a medical doctor who has obtained a medical degree but does not yet have a license to practice medicine unsupervised.
Medical ethics is an applied branch of ethics which analyzes the practice of clinical medicine and related scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. These values include the respect for autonomy, non-maleficence, beneficence, and justice. Such tenets may allow doctors, care providers, and families to create a treatment plan and work towards the same common goal. These four values are not ranked in order of importance or relevance and they all encompass values pertaining to medical ethics. However, a conflict may arise leading to the need for hierarchy in an ethical system, such that some moral elements overrule others with the purpose of applying the best moral judgement to a difficult medical situation. Medical ethics is particularly relevant in decisions regarding involuntary treatment and involuntary commitment.
Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts is a teaching hospital of Harvard Medical School and one of the founding members of Beth Israel Lahey Health. It was formed out of the 1996 merger of Beth Israel Hospital and New England Deaconess Hospital. Among independent teaching hospitals, Beth Israel Deaconess Medical Center has ranked in the top three recipients of biomedical research funding from the National Institutes of Health. Research funding totals nearly $200 million annually. BIDMC researchers run more than 850 active sponsored projects and 200 clinical trials. The Harvard-Thorndike General Clinical Research Center, the oldest clinical research laboratory in the United States, has been located on this site since 1973.
Terminal illness or end-stage disease is a disease that cannot be cured or adequately treated and is expected to result in the death of the patient. This term is more commonly used for progressive diseases such as cancer, dementia or advanced heart disease than for injury. In popular use, it indicates a disease that will progress until death with near absolute certainty, regardless of treatment. A patient who has such an illness may be referred to as a terminal patient, terminally ill or simply as being terminal. There is no standardized life expectancy for a patient to be considered terminal, although it is generally months or less. Life expectancy for terminal patients is a rough estimate given by the physician based on previous data and does not always reflect true longevity. An illness which is lifelong but not fatal is a chronic condition.
A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.
A medical specialty is a branch of medical practice that is focused on a defined group of patients, diseases, skills, or philosophy. Examples include those branches of medicine that deal exclusively with children (paediatrics), cancer (oncology), laboratory medicine (pathology), or primary care. After completing medical school or other basic training, physicians or surgeons and other clinicians usually further their medical education in a specific specialty of medicine by completing a multiple-year residency to become a specialist.
Bernard Lown was a Lithuanian-American cardiologist and inventor. Lown was the original developer of the direct current defibrillator for cardiac resuscitation, and the cardioverter for correcting rapid disordered heart rhythms. He introduced a new use for the drug lidocaine to control heartbeat disturbances.
Medicine in ancient Rome was highly influenced by ancient Greek medicine, but also developed new practices through knowledge of the Hippocratic Corpus combined with use of the treatment of diet, regimen, along with surgical procedures. This was most notably seen through the works of two of the prominent Greek physicians, Dioscorides and Galen, who practiced medicine and recorded their discoveries. This is contrary to two other physicians like Soranus of Ephesus and Asclepiades of Bithynia, who practiced medicine both in outside territories and in ancient Roman territory, subsequently. Dioscorides was a Roman army physician, Soranus was a representative for the Methodic school of medicine, Galen performed public demonstrations, and Asclepiades was a leading Roman physician. These four physicians all had knowledge of medicine, ailments, and treatments that were healing, long lasting and influential to human history.
Jerome E. Groopman has been a staff writer in medicine and biology for The New Yorker since 1998.
The doctor–patient relationship is a central part of health care and the practice of medicine. A doctor–patient relationship is formed when a doctor attends to a patient's medical needs and is usually through consent. This relationship is built on trust, respect, communication, and a common understanding of both the doctor and patients' sides. The trust aspect of this relationship goes is mutual: the doctor trusts the patient to reveal any information that may be relevant to the case, and in turn, the patient trusts the doctor to respect their privacy and not disclose this information to outside parties.
The University of North Carolina School of Medicine is a professional school within the University of North Carolina at Chapel Hill. It offers a Doctor of Medicine degree along with combined Doctor of Medicine / Doctor of Philosophy or Doctor of Medicine / Master of Public Health degrees.
Medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as a diagnosis with the medical context being implicit. The information required for a diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as medical tests, are also done during the process. Sometimes the posthumous diagnosis is considered a kind of medical diagnosis.
Michael D. Lockshin is an American professor and medical researcher. He is known for his work as a researcher of autoimmune diseases, with focus on antiphospholipid syndrome and lupus. He is Professor Emeritus of Medicine and the Director Emeritus of the Barbara Volcker Center for Women and Rheumatic Disease at Hospital for Special Surgery. He retired from HSS on January 31, 2023.
A doctor's visit, also known as a physician office visit or a consultation, or a ward round in an inpatient care context, is a meeting between a patient with a physician to get health advice or treatment plan for a symptom or condition, most often at a professional health facility such as a doctor's office, clinic or hospital. According to a survey in the United States, a physician typically sees between 50 and 100 patients per week, but it may vary with medical specialty, but differs only little by community size such as metropolitan versus rural areas.
Medical malpractice is a legal cause of action that occurs when a medical or health care professional, through a negligent act or omission, deviates from standards in their profession, thereby causing injury or death to a patient. The negligence might arise from errors in diagnosis, treatment, aftercare or health management.
VIP medicine is a variety of the VIP syndrome—the phenomenon of a perceived "VIP" using his or her status to influence a given professional or institution to make unorthodox decisions under the pressure or presence of said VIP—that relates to the accessibility and quality of health care. It is essentially health care in which a physician or hospital accommodates a wealthy, important or famous patient who can afford to pay the full medical bill outright, usually with luxury amenities, and seclusion from the ordinary run of patient, as added benefits. As a result, such a patient may receive something other than the normal standard of care; the deviation may be in the direction of either greater or lesser safety and quality.
Mamun Al Mahtab is a Bangladeshi doctor, hepatologist, medical scientist, and author. With 290 publications in national and international peer-reviewed journals to his credit, Mahtab works as the Head, Division of Interventional Hepatology, Bangabandhu Sheikh Mujib Medical University (BSMMU).He has some scandals about wrong treatment.Some case are running still three years. Also did same mistake in 2023 and february 2024. Most pathetic mistake he did with a young doctor who died for professor's wrong treatment.