30 Jul 2011

How doctors think by dr. Jerome Groopman is not really about how doctors think. It’s about how people think, and how this affects our work as doctors. Groopman states he primarily wrote the book for patients, to explain how doctors come to their decisions: which may well be wrong and may have devastating consequences. Practicing medicine is time-pressured decision making in the face of many uncertainties, over and over again. You only need a distraction, a bad night’s sleep, or a stressful situation to miss a bit of information that would have been vital for correct diagnosis.

How doctors think

Groopman proposes four simple questions to ask yourself to avoid making mistakes in diagnostic decision making:

  1. What else could it be?

    Deals with errors such as premature closure, framing effect, availability from recent experience, bias towards more common disease. It helps to keep an open mind, forces to think of alternatives that are maybe less common. As students, we were taught to think in terms of differential diagnosis, but this concept is often sacrificed in a busy medical practice.

  2. Is there anything that doesn’t fit?

    Deals with diagnostic momentum: once a patient receives a diagnosis, it is very difficult to change it. Critically assessing signs and symptoms that don’t fit with the given diagnosis, instead of brushing them aside, again helps to come to an alternative diagnosis.

  3. Is there maybe more than one problem?

    Deals with search satisfaction. In my profession, this is a common pitfall. We read our scans, and stop looking when we’ve found something, particularly if it fits the given diagnosis. Obsessively going through all images, assessing all organs and structures is the way I deal with this issue.

  4. Should I consult a colleague?

    Deals with our - oversized - ego! We’re often stuck in our own ways of thinking, unable to get a fresh perspective. A colleague can help.

The problem with cognitive errors is that we’re not really aware of them at the time. In my experience, they are the main cause of mistakes I made, mostly when I was exhausted after working too many hours… The trouble with exhaustion is that although you’re aware of your attention is slipping, you’re too tired to correct for it. And that’s when you stop being critical about your own thinking. Maybe the four questions should be printed on the on call beepers as a constant reminder.

From the above you would think that Groopman’s book is in fact written for doctors, and not for patients. Interestingly, however, Groopman also places some responsibility with the patients, advising them to ask their doctors these same four questions.