How Readers Think: Mixed Physician Responses to Recent Bestseller

The newly published book on physician decision-making, titled How Doctors Think, by Jerome Groopman, MD, Chief of Experimental Medicine at the Beth Israel Deaconess Medical Center in Boston, Mass. has brought both controversy and conversation with its revelations-based thinking. In it, Groopman aims to “pinpoint the forces and thought processes behind the decisions doctors make…explores why doctors err and shows when and how they can avoid snap judgments, embrace uncertainty, communicate effectively, and deploy other skills that can profoundly impact our health.”

According to its publisher, Houghton Mifflin Company, “this book is the first to describe in detail the warning signs of erroneous medical thinking and reveal how new technologies may actually hinder accurate diagnoses.” Groopman’s inspiration for the true-life read? An injury.

A Real Eye-Opener

When Groopman developed pain and swelling in his right hand, he says, “I saw six prominent hand surgeons and got four different opinions. The correct diagnosis came when one of the doctors took the time to listen to me describe my injury and examined my left hand.” How Doctors Think has held steady on the New York Times non-fiction bestseller list for six consecutive weeks to date. Seems physicians and patients alike are snatching up the factual anecdotes; a recent poll revealed that several of our physician readers have some disclosures of their own to make on the topic.

“As a psychiatrist, I am acutely aware that some of the atypical antipsychotics we prescribe can cause diabetes,” says Bernard Sklar, MD, MS, a practicing psychiatrist at the Alameda County Behavioral Health Care Services in Oakland, CA. “Recently, I saw a patient on clozapine whom I had not seen for several months. He complained of frequent daytime and nighttime urination and stated he had been drinking eight to 10 cups of green tea per day. I concluded that he had developed diabetes related to clozapine and might even be in ketoacidosis and sent him for immediate blood work. The clinician phoned me in a day or two to say the patient’s problem was that he was drinking all that green tea which served as a diuretic, so that the frequent tea drinking was the cause of his problem. I had jumped to a conclusion without being clear about the history. I have counseled him to drink less green tea.”

Blink author Malcolm Gladwell’s views on the decision-making process differ from Groopman’s. Gladwell presents the case that people actually make their best decisions when thinking under pressure. He argues that by answering questions such as “What is going on inside our heads when we engage in rapid cognition?” “When are snap judgments good and when are they not?” and “What kinds of things can we do to make our powers of rapid cognition better?” we discover that “the difference between good decision-making and bad has nothing to do with how much information we can process quickly, but rather with the few particular details on which we focus.”

Naturally, our diverse audience of physician readers had thoughts on medical thinking and decision-making as well. One neurologist we spoke with identified patient history as the crucial factor when assessing a patient’s symptoms—not time spent with him or her during office hours. He related history to initial impressions and first impulses.

“I’m fascinated by the ‘12-second’ study,” says Paul Yuratich, MD, a primary care physician based in New Orleans, Louisiana. “I don’t know if it’s that soon, but certainly within the first minute or two. I suppose I’m right only 50% of the time; the other 50% go to consultants for further evaluation. I had a 15-year-old girl with classic gastroenteritis symptoms of nausea and vomiting. I treated her with phenergan and recommendation for clear liquids, with advice to go to ER if symptoms worsened. She later did go to the ER, and revealed that she had been eating cotton—she had a history of cotton pica in the past, but as far as her mom knew, that was no longer going on, so her mother did not tell me, and the patient did not tell the mother about the ongoing pica. She had an EGD and a large cotton bezoar was removed from her stomach.”

Slow and Steady

Then there are those physicians whose opinions fall somewhere in the middle. Another surveyed neurologist told MDNG that his initial evaluations were rarely incorrect, even when assessed upon immediate consultation with a patient.

“I am familiar with Dr. Groopman’s book, says Burton Pomerantz, MD, CEO of Praxis Health Management in Boca Raton, Florida. “His generalizations are quite true, and I am sure that his suggestions to patients have meaning. However, before the advent of superior diagnostic technology, we were taught that if we listened properly, the patient would tell us their problem. The majority of acute primary care requires proper history-taking technique, which allows the physician to listen and elicit the patient’s story and their problem—both current symptoms and probable emotional cause. The current crop of physicians (from the past twenty years) is thinking dollars, rushing through office visits, uncaring, and whiners. Many of them should not have chosen healthcare, but did, because of economic probability.”

Ultimately, physician consults are, and should be, based on several factors, including patient history, initial reaction, and just plain professional know-how. The continued, proven benefits of snap decision-making remains to be seen.

“I’m very interested in figuring out those kinds of situations where we need to be careful with our powers of rapid cognition,” says Gladwell.