In my 32 years of clinical practice I have seen an inexorable shift from listening to the patient and employing techniques of medical deduction to the often mindless use of imaging and laboratory tests, often supported by algorithms and flow charts. Much of this is the result of the litigious atmosphere of medicine in the US that casts a long shadow over human fallibility. Jerome Groopman, MD, cites diagnostic errors confirmed by autopsy results at close to 15%.

Patients’ unreasonable expectations are, in part, medicine’s fault. Major medical and scientific advances have raised expectations that must be moderated. In How Doctors Think, Dr Groopman adds the message that patients must be active participants in their own care.

Professor of Oncology and Immunology at Harvard Medical School, Dr Groopman is a nationally renowned physician and author of three other books and innumerable articles. He has further distinguished himself by his ability to distill multiple clinical episodes gathered over the years into absorbing, elegant narratives with many insights.

One such insight is the need for continued improvement toward an optimal physician-patient relationship. It has long been recognized that too often physicians communicate poorly or not at all. As a result, we are sometimes called arrogant or stand-offish. Recognition of such lack of communication skills has generated multiple remedial programs in all Kaiser Permanente regions, some of which have been described in The Permanente Journal.1,2 Meaningful communication with patients has recently secured a position as one of the six competencies now required in US graduate medical education.

In story after story Dr Groopman explores both rational and irrational factors that bear on medical decision making; he explains in detail where and how misdiagnosis can occur. A snap judgment that leads to a right decision can just as easily lead to a wrong one. A prior experience can influence a current case. Rapport with a patient or lack thereof can affect a potential diagnosis.

In the hurly burly of everyday medicine, the Socratic principle of well thought-out diagnosis often gives way to what Dr Groopman and others have called “pattern recognition.” This quick gestalt is often subtly influenced by one of several premises: availability--the reach for the most plausible explanation; commission bias--the need to do something; confirmation bias--the selective use of information supporting what one expects to find; attribution errors--the use of stereotypes that then bias decision making; and diagnosis momentum--where a diagnosis is accepted as definitive despite contrary or incomplete data.

A quick read and easily digestible, replete with wonderful and multiple stories, this exposition of the art and science of medical decision making is geared to the lay consumer but is perhaps more valuable for physicians who interact with patients. I highly recommend the book.

References

1. Stein T, Nagy VT, Jacobs L. Caring for patients one conversation at a time: musings from the Interregional Clinician-Patient Communication Leadership group. Perm J 1998 Fall;2(4):62-8.

2. Stein T. A decade of experience with a multiday residential communication skills intensive: has the outcome been worth the investment? Perm J 2007 Fall;11(4):3.