How Doctors Think
- By Jerome Groopman
- Reviewed by Dr Alison Metcalfe, MPS Head of Medical Services (London)
How often do we as doctors stop to consider how we think about our patients – their symptoms, their situation and their diagnoses? The answer is probably seldom, if ever. Time pressures are such that the opportunity for such reflection is, increasingly, limited. Jerome Groopman’s How Doctors Think makes a compelling case for finding that time which may help the practitioner avoid the hazard of falling into the cognitive pitfalls that lie in wait for the unwary.
The author tries to tease out the way doctors think about their patients and where cognitive pitfalls lie. By becoming conscious of the potential origins of clinical misjudgment he considers that this will, in itself, help to prevent falling into such traps.
Groopman explores various cognitive pitfalls, through case scenarios and interviews with experienced clinicians, who reflect on how their way of thinking may have influenced the outcome for the patient. The wide-ranging contributions to this book attest to the vulnerability of even the most experienced clinician.
Groopman was first moved to ask the question about how a doctor thinks when he saw his junior doctors scrutinising algorithms to make a diagnosis and invoking statistics to decide on treatment. He realised that they were operating in a narrow and programmed way, making little allowance for the patient as an individual. He felt that there was something profoundly wrong in approaching clinical diagnosis in this way, with a passive choice of care using linear and vertical thinking which would be confused by vague or non-specific symptoms.
Reading this book you quickly realise how easy it is to fall into those cognitive pitfalls. Take the concept of “search satisfaction” – stopping the search after the first positive finding secures a diagnosis. If you stop searching, you stop thinking; entirely understandable, but important to be aware of to avoid missing something else. Then there is categorising patients too early, making us blind to their problems. A more obscure pitfall is our natural preference to focus on positive – that which fits comfortably with a diagnosis – rather than negative data. The list continues – increasingly uncomfortable, but compelling, reading.
The point that really comes across is the importance of time to think and reflect, so this is also a book for health economists, planners and managers. It highlights the risk that decreasing a doctor’s available time to think can only lead to an increase in error. It is also a book for educators, to ensure that not only are all medical students and doctors aware of these cognitive pitfalls, but also how algorithms and statistics as a method of speeding up diagnosis and choosing treatments could channel our thinking, risking us reaching the wrong conclusion or perhaps no conclusion at all.
Finally, the author proposes that, as doctors, we harness the help of the patient by encouraging them to ask those questions that will make us think again. “What else could it be?”, “What doesn’t fit with the diagnosis?”, “Could there be more than one thing causing the problem?” Now there’s a challenge.