Book reviews

How Doctors Think

• By Jerome Groopman
• Reviewed by Dr Alison Metcalfe, MPS Head of Medical Services (London)

A more obscure pitfall is our natural preference to focus on positive – that which fits with a diagnosis – rather than negative data

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.

How Doctors Think makes a compelling case for finding that time. Groopman tries to tease out the way doctors think about their patients and where cognitive pitfalls lie. Becoming conscious of the potential origins of clinical misjudgment will, he believes, help to prevent practitioners falling into such traps.

He 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.

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 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 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.

Finally, the author proposes that, as doctors, we harness the help of the patient by encouraging them to ask those questions which will make us think again. Now there’s a challenge.

Training in Ophthalmology

• Edited by V Sundaram, et al; Oxford University Press; ISBN: 978-0-19-923759-3
• Reviewed by Dr Pallavi Bradshaw, MPS Medicolegal Adviser

Above all, the “practical skills” section of the chapters will be invaluable to inexperienced trainees faced with undertaking minor procedures

OUP has produced a series entitled “Oxford Specialty Training”, aimed at providing junior doctors with essential guides to core topics and to assist in exam preparation.

Training in Ophthalmology is written by current trainees and respected consultants, drawing from a breadth of experience. It provides a very readable overview of the key topics for ophthalmology core training under the new UK Royal College curriculum.

The text begins with an abbreviations guide, which will be useful to those unfamiliar with the jargon or new to the subject. The 11 chapters cover subspecialty areas and each chapter is subdivided to cover basic science, clinical skills and knowledge, and case-based discussions. It therefore provides an essential guide to ophthalmic conditions that trainees will face in clinic, as emergencies and at examinations, aiding trainees day-to-day and when revising.

The excellent colour images support the text well and will assist trainees to recognise essential pathology. Above all, the “practical skills” section of the chapters will be invaluable to inexperienced trainees faced with undertaking minor procedures, especially in an emergency setting.

The book also features a chapter on “professional skills and behaviour”, which covers key topics such as consent and communication, and summarises the GMC’s expectations of good medical practice. It also attempts to address some practical issues in relation to risk management, appraisal and complaints.

Overall, the book is successful as a user-friendly guide to fundamental clinical topics in ophthalmology.