How Doctors Think

Apr 29, 2007, Patricia Pearson, The Toronto Star

A pathologist wrongly attributes dozens of child deaths; dozens of city women are left damaged by a local obstetrician and gynecologist. Patricia Pearson considers the inside view of the human weakness and doctors from a bright pair of physician writers

How Doctors Think, by Jerome Groopman, Houghton Mifflin, 307 pages, $34.95

It has been said that doctors are the new clergy, in that they are the ones these days who possess the mystique and authority that we used to reserve for our priests. We go before them on bended knee to assist with our salvation, and dare not challenge their opinion.

Not a moment too soon arrive two elegant and thoughtfully written books by a pair of New Yorker writers who are also physicians – Jerome Groopman and Atul Gawande – illuminating the ways in which doctors are human, how they err and how they can (and really must) do better.

Groopman, who teaches at Harvard Medical School, asks his readers to consider the following mystery:
A young woman is suffering from anorexia. Nothing has pulled her back from the brink of starvation – not psychotherapy, nor a sequence of anti-depressants, four hospitalizations, a high-calorie diet. By the winter of 2004, she weighs 82 pounds and is shadowed by death.

What to do?

She consults with a Boston gastroenterologist, who decides to believe her when she says that she is trying to eat, that she has been all along, that she's not deliberately throwing up the cereal and pasta and bread that the doctors have asked her to consume. Probing her carefully, asking the right questions rather than the prejudicial ones, the seasoned gastroenterologist diagnoses her with celiac disease. She is not anorexic, he establishes; her body cannot digest wheat gluten. For four years, she has been misdiagnosed by a series of medical specialists who have, in effect, written her off as a mentally unstable liar.

This is one of the classic "errors of cognition" that Groopman relays in How Doctors Think, a measured and contemplative book that reads like a companion series to the TV show House, in which a brilliant diagnostician played by Hugh Laurie consistently upends the ill-considered judgments of his hospital colleagues.

Groopman provides a running commentary on the most common mistakes made by his fellow doctors, offering a number of intriguing examples by way of explaining how "strongly a physician's mood and temperament influence his clinical judgement."

There is the retired sailor who appears at the emergency with an odour of rum on his breath, who is thought to be an alcoholic with liver cirrhosis when he is actually a moderate drinker showing the symptoms of a rare condition called Wilson's disease.

There is the super-fit Nova Scotian forest ranger who can't possibly have a heart infection, when he comes in complaining of chest pain – until he almost dies. This case was misdiagnosed by Halifax physician Pat Croskerry, who has studied doctor cognition and describes to Groopman how doctors use a kind of "pattern recognition," based on over-all physical appraisal of a patient, that can lead them to be too dismissive. If he looks healthy, he must be. If he smells drunk, he must be.

To describe any more of Groopman's cases would be to spoil the plot, as it were, since much of the pleasure in reading his book has to do with the mysteries. Let's just say one is not left with a great deal of faith in the idea of medical objectivity. Groopman's argument – that doctors must be far more self-aware and careful about reflexive perceptions of their patients – is well taken. So is his exhortation to those of us who are patients to act as our own best advocates.

In Better, the handsome surgeon Atul Gawande takes Groopman's basic point and proceeds to document the various ways in which the medical establishment can fine-tune its approach to healing.

Gawande views the basic challenges as having to do with diligence, "doing right" and ingenuity. He talks, for instance, about the simple diligence of hand washing in modern hospitals as a way to curb the spread of intractable and drug-resistant viruses. He cites the performance of U.S. Army doctors in Iraq, who have brought the death rate from battle injuries down to 10 per cent – it was 25 per cent during the Vietnam War – not through medical advances so much as more diligent care.

If you have read Gawande's work in The New Yorker, you may have come across several of these chapters – on the invention of the Apgar Score, the treatment of cystic fibrosis, the adaptive ingenuity of overworked doctors in India.

Particularly thought-provoking, in this collection, is Gawande's discussion of medical malpractice lawsuits, and why they serve no one's interest. Very often, Gawande notes, all that patients and their families want is an answer from their doctor about how or why an error was made.

But since to admit the error is to invite a lawsuit, doctors refuse to engage in a conversation, and then (paradoxically) the families have to sue for their answers.

"This is where we, in medicine, have failed," Gawande writes. "Ninety-eight per cent of American families that are hurt by medical errors don't sue. They are unable to find lawyers who think they would make good plaintiffs, or they are simply too daunted ... In the end, fewer than one in a hundred deserving families receive any money. The rest get nothing: no help, not even an apology."

Gawande suggests that there be a set cash fund, such as exists in New Zealand, that people could appeal to for compensation if they meet certain criteria of harm. It is a notion worth considering by our own medical establishment, as are many of the ideas raised in this book.