How Doctors Think Reviews

• Groopman uses irrelevant anecdotes to support a misleading conclusion

  
  By A2Z6BXEMDDLJ5Z on 2007-04-22
  How Doctors Think, by Jerome Groopman, is enjoying near-unanimous praise. Unfortunately, as was the case with Malcolm Gladwell's awesomely over-hyped books The Tipping Point and Blink, the praise is itself enormously misleading as it comes from an audience unqualified to assess the scientific basis of the claims being made by the author.
  
  What Groopman has done in How Doctors Think is compiled a series of lengthy anecdotes about doctors he knows and some extraordinary, atypical diagnostic misadventures they've encountered. He states over and over again that many medical diagnoses are wrong (about 15% actually), and also states over and over that the reason why so many medical diagnoses are wrong has nothing to do with "misdiagnosis" proper, but rather with the heuristics that physicians rely on to make decisions in the quick and dirty real world.
  
  These heuristics, or, mental "short cuts," are essentially snap judgments made on imprecise rules garnered from experience. They are often accurate, but are subject to a breadth of biases that can lead one to irrational and inaccurate conclusions. Now, before I state what follows, let me preface it by stating that I am a decision-science researcher, which is the field Groopman is actually referring to indirectly throughout his entire book. I have also worked in the field of medical decision making, and so am intimately familiar with the field Groopman is here presenting himself as an authority on.
  
  With that preface out of the way, let it be said that what Groopman is doing in his book is both misleading and somewhat disingenuous. He wants us to know that doctors' thinking is clouded by heuristics and biased snap judgments, and yet, throughout the entire book, he BASHES evidence-based medicine, diagnostic decision aids, the use of algorithms, and Bayesian reasoning! In short, he picks up on what decision-science researchers say is WRONG with doctors and medicine, but then rejects what the same science suggests is the best way to remedy the problem!!
  
  What does Groopman tout in place of evidence-based medicine? Why, good old clinical intuition--asking open-ended questions, listening, reading "body language," etc.; in short, the exact very same things that lead to the inaccuracy of doctors' diagnoses in the first place. The main problem with Groopman's book is his sloppy methodology. He insists that evidence-based medicine actually decreases the accuracy of real-world diagnoses, and yet, to back such an outlandish claim, he falls back on nothing but anecdotes describing rare and unrepresentative instances.
  
  For instance, actual research in this area (by Corey and Merenstein) has demonstrated that an acute ischemic heart disease predictive instrument reduced false positive rates from 71% to 0. This is extraordinarily impressive, and would dramatically increase the diagnostic accuracy of physicians using it. Following the demonstration of the aid's effectiveness, how many physicians actually went on to use it? 2.8%!! Why? Because doctors like to think that their "deep clinical insight" is more accurate than actuarial (statistical) diagnosis. It's not.
  
  Actuarial diagnosis guarantees that the same input will result in the same diagnosis. This maximizes accuracy. Studies show that actuarial diagnostic procedures made off of doctors' performances are even more accurate than the very doctors they are based on. Why? Because doctors' diagnoses are idiosyncratic and inconsistent. They treat every case as though it is "unique" (which only actually increases errors) while demanding ignorantly that "group statistics don't apply to individual cases."
  
  This lunacy is obviously false. After all, if it were true, science simply wouldn't work, ever, at all. If Groopman had spent half the time he spent gathering irrelevant interviews reading some actual research in this area, his book would have greatly benefited. As an insider, as a scientist who actually conducts research on the very topics Groopman discusses throughout his book, my unfortunate conclusion is that the whole book is a complete waste of time. He spends hundreds of pages touting how important it is for us patients to know how doctors think. How much time does he spend actually discussing the biases that taint doctors' thinking? A few pages.
  
  Further--and this is a point that seems entirely lost on Groopman--the heuristics that bias doctors' thinking regarding diagnosis will also bias their thinking about their thinking! That is why, if you really want to learn "how doctors think," you will have to do more than simply ask them. That is also why I have suggested this book be renamed "How Doctors Think They Think." In a brilliant observation made in a blog (The Last Psychiatrist) this book was described as being nothing more than "porn for doctors." I agree.
  
  

• "As many as 15 percent of all diagnoses are inaccurate...a distressingly high rate of misdiagnosis."

  
  By A319KYEIAZ3SON on 2007-03-24
  This alarming statistic introduces Dr. Jerome Groopman's compelling analysis of how doctors think--and what this means for patients seeking diagnoses. Groopman is curious to discover how one doctor misses a diagnosis which another doctor gets. Interviewing specialists in different fields, he analyzes the ways they approach patients, how they gather information, how much they may credit or discredit the previous medical histories and diagnoses of these patients, how they deal with symptoms which may not fit a particular diagnosis, and how they arrive at a final diagnosis.
  
  Throughout, he considers the doctors' time constraints, the pressures on them to see a certain number of patients each day, the limitations on tests which are imposed by insurance companies or by hospitals themselves, and the many options for treating a single disease. He is sympathetic, both toward the patient and the physician, and, because he himself has had medical problems, he provides insights from his own experience to show how physicians (and patients) think.
  
  Case histories abound, beginning with the 82-pound woman, whose celiac disease was not diagnosed for fifteen years. Here Groopman analyzes the uses and misuses of clinical decision trees and algorithms used by many doctors and hospitals to assess probabilities and make decision-making more efficient. Sometimes, however, it is necessary for a doctor to depart from the algorithm and obey intuition. Recognizing when the physician is "winging it"--depending too much on intuition and too little on evidence--is a challenge for both patients and other physicians. Ultimately, Groopman focuses on language as the key to diagnosis, showing that when patients and physicians can communicate and truly share information, they have a better chance to come to correct diagnoses and appropriate treatments.
  
  The success of Groopman's book attests to the need for discussion of these issues, but I am not sure Groopman realizes the difficulty patients have in finding ideal doctors whose personalities, thinking, and communication styles are compatible with their own. Most of us are referred to specialists by our primary care physicians (some of whom we see only once a year and do not know well), and it is not possible to interview several specialists to find the one most compatible. We accept the appointment our primary care physician has set up for us, often with the specialist who has the earliest available appointment. Patients with urgent problems may have fewer choices than Groopman seems to think they have. Though we all search for the ideal, ultimately we must hope that our own diagnoses are not among the "problem fifteen percent." (4.5 stars) n Mary Whipple
  
  
  

• The Patient: Leader of the Healthcare Team

  
  By A1TPW86OHXTXFC on 2007-04-01
  "Patients and their loved ones swim together with physicians in a sea of feelings. Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents". Jerome Groopman
  
  The Patient: as an undergrad in college in my nursing program, I was educated to understand that I always needed to listen to my patient, really listen. That philosophy has always served me well. Health care providers tend to be controlling, and when we, the patients, are given a diagnosis that shakes us to our core we need some control. As patients we need a physician and health care team that has the patient as the leader of the team. We listen to all of the recommendations and weigh the evidence as best we can. In the end we need to be able to trust our physicians and have a relationship that allows humor and sadness, questions and answers and honest give and take. It is a relationship like no other- it is sometimes life and death.
  
  Jerome Groopman has written a book for everyone. Everyone needs to be their own advocate for their healthcare. His ideas that the way physicians think result in the treatment and care for each and every one of us. "Every doctor makes mistakes in diagnosis and treatment," he writes. "But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better." He discusses the physicians who 'read' x-rays and CT's and MRI's, the radiologist. An exacting science is needed here. A radiologist with experience can pick up a disease process by the thickness of a rib. There is an accepted 'error' ratio in this science, and none of us want to be in that error ratio. There is a computer program to assist in diagnosis, but it is not perfect. We all want and need the experienced radiologist. When I entered the world of health care I learned that medicine is 50% rule out or question of. It remains in that corner. That is how we want our physicins to think-rule out #1,2,3 and come to a conclusion based on science, best practice and their ability to put it all together for us, the individual.
  
  He helps the layperson understand doctors' thinking with simple and accessible terms that suggest why it sometimes leads to undesired outcomes. As David Kessler in his reviews states "He introduces us to terms such as "diagnosis momentum" -- when a diagnosis becomes fixed in the mind of the physician despite incomplete evidence. Or "availability," which means the tendency to judge the likelihood of a medical event by the ease with which relevant examples come to mind. He takes phrases patients often hear, such as "we see this sometimes" and puts forth the idea that such generic comments deserve further questioning from the patients."
  
  Dr Groopman has written of fascinating case studies and the physicians who were part of them. The errors and the asute diagnoses are compiled in story after story. Physicians are open about the way and the analytical methods they use in deliniating the final diagnosis. It is difficult to forget the misfortunes of some patients. We understand a little more completely the real-life drama that physicians face in their mistakes and when their diagnosis is right on.
  
  We learn about Bayesian Perspective thinking. "We all like to know how reliable and how risky certain situations are, and our increasing reliance on technology has led to the need for more precise assessments than ever before. Such precision has resulted in efforts both to sharpen the notions of risk and reliability, and to quantify them. Quantification is required for normative decision-making, especially decisions pertaining to our safety and well being. Increasingly in recent years Bayesian methods have become key to such quantifications." says Dr Groopman. The thought processes of physicians is an insight few of us have thought about. We should all be prepared for our next encounter.
  
  It was refreshing to learn of Dr Groopman's frustrations with his medical care, and the four different opinions he received about his right hand. He carefully delineates how each physician came to their conclusion, and this is the type of thinking we need to engage in. We all have our stories of healthcare, and this book will give us more insight into the 'whys and wherefores' of our physicians' thought processes.
  
  "Dr. Groopman gives a brief mention of how modern evidence-based medicine competes with the art of using your intuition. He touches on how drug and insurance companies pressure doctors as he explores their influence via big drug company sales representatives. I would have liked him to have written more about the influence of insurance companies, an area barely touched on, and about finances. This might have given readers a more complete picture of the intersection of medicine and finances." David Kessler
  
  Most of us will be left with more respect for the art of medicine, and the careful consideration Groopman's doctors give to their patients. "How Doctors Think" is a book every patient needs to read. We, the patients have much more power than we know, and we can change the shape of the physician/patient relationship. We need to come to the doctor's office prepared to ask the right questions so that our physician's thought processes will be beneficial to both of us.
  Highly Recommended. prisrob 4-01-07
  
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  The Measure of Our Days: A Spiritual Exploration of Illness
  
  
  
  

• "Groupman"

  
  By A2K28JHMIY3XKZ on 2007-04-01
  Dr. Groopman's assertion that he can disect the thought process of physycians and neatly package them into preformed packages is absurd. As a physician, I rarely see two physicians that approach a problem using the same method. Are there doctors that jump at the first convenient diagnosis? Absolutely, however for each one of them there are multiple deliberative thoughtful physicians. Dr.Groopman arguments degenerate into anecdotal story telling. He cherry picks a few choice stories to entice and capture his audience. He reports the superficial and ignores the more complex process that goes on below. Dr. Groopman has been isolated in his ivory tower too long.
  
  Practcal matters bolster Dr.Groopman's arguments. Hospitals, insurance companies demand a diagnosis to admit and pay for hospital stays and evaluations. We are often in the position of making a best guess to get the patient in the proper environment to allow efficient evaluation and arrive at the proper diagnosis. Unfortunately, not every diagnosis is immediately evident, though Dr. Groopman must surely possess an omniscience that most of the rest of us lack. We actually have to work toward a diagnosis.
  
  Dr. Groopman's book is little more than a gossip rag. I'll be the first to admit that physicians aren't perfect. I'll be the last to claim I understand the common thread by which they think. I'll also be the last to paint the entire prfession with a broad brush.
  
  Dr. Groopman makes great fodder for the Stephen Colbert, Jon Stewart, Today Show circuits. I have watched him interviewed several times and he can never delve deeper the anecdote.
  
  Congratulations to Dr. Groopman for his financial windfall. Shame on him for trying to stain a profession for self gain. He hasn't helped anyone with this book. He continues to feed the conspiracy that physicians are more interested in their egos than in helping patients. In reality nothing is further from the truth.
  
  

• Doctors ARENT flawless

  
  By A1OBPHRXHZF8P6 on 2007-03-25
  This book should be considered the true successor to "Our bodies, Ourselves". That 1970's feminist health classic had encouraged women to proactively learn about and understand both their bodies and the politics of the American health care system, arguing that 'patients' had a right to actively participate in their own care rather than remain subjects who passively have procedures performed on them by ' the experts'.
  
  Well, it's a good thing too because the experts (for a multitude of reasons) can err in their judgments according to the thesis of Groopman's book. In the 21st century, we like to think of our self as sophisticated. However Americans still cling to a cultural perception of the doctor as a superhero-magician who can and will cure everything effortlessly.
  
  His powerfully researched book with first-hand interviews from doctors themselves dispels myths whether it is limitations of the ever-burdened medical system, their own human nature, or the ever-despised insurance companies who only see profit as the bottom line and don't care about human life.
  
  Trying to maintain clinical neutrality is a next to impossible goal. Doctors favor some patients over others--circumstances which again produces surprising results. I was prepared to believe that the patients who were favored would receive the five-star treatment, but they were the ones who the doctors did not believe needed urgent care when a more serious problem was lurking. However, it is not surprising that if you even suspect that your doctor does not like you, its time to get a new doctor--STAT!
  
  Considering that medical options are developing allegedly to help people cure symptoms and other people 'get better'--to say nothing of faster or easier, I find it interesting that they are among the culprits also named in this book, doctors honestly are bewildered by all of the treatment options now confronting them in sharp contrast to their predecessors. Technological advances aren't always a blessing if the gatekeepers then they have a case of information overload.
  
  Reading this book after switching neurologists gave me a fresh perspective on my past experiences. I no longer think of that previous doctor as having been a bad person, but somebody who had not wanted to believe that something he had prescribed for me was hurting me simply because I was a woman and the medicine yes, did have gender-specific side effects which had not been documented during the FDA's original approval process simply because the agency did not then require testing of medicine for the general population on women.
  
  
  
• Very helpful and full of revelations
  By A23YIYBDH5QK0R on 2007-03-22
  I put comments on the "Amazon Books Blog" which you get to off the Books Home Page, but I thought I'd put them here too.
  When my wife become seriously ill one of the most frustrating things was communicating with the doctors. I didn't understand most of what they said, and they didn't seem willing to "dumb it down" for me. I realized after a few days that they didn't know what was wrong with her and they didn't want to admit it. I wish I had this book then. It would have really helped me work with the doctors on my wife's behalf. It's also full of revelations about the business of medicine, and, yes, Martha, it's really all about the money. After my wife became ill I stopped believing all the marketing about how we have the best health care system in the world here in the USA. We might have the best technology, but the book confirms we don't have the best system in terms of patient care. The book also helped me understand the pressure that doctors are under. Doctors are some of the most intelligent, caring people on the planet, but adminstrators put them under incredible pressure to make snap judgements so they can see as many patients as possible in a day and thereby create as much billing as possible for the hospital.
  
  
• Just in case
  By A1QHUSZ05SSOZI on 2007-04-03
  I bought this book after seeing terms like "availability heuristic" in the promotional material. It led me to believe that the book would include lots of info about the cognitive psychology of diagnosis and treatment. That would be a great book. I also assumed that the book would argue in favor of evidence-based medicine to overcome cognitive biases. Instead, the book contains very little about heuristics and lots of "stories". Evidence-based medicine is dismissed on page 6 with "But today's rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers...Numbers can only complement a physician's personal experience with a drug or a procedure, as well as his knowledge of whether a "best" therapy from a clinical trial fits a patient's particular needs and values."
  I think it's pretty widely accepted in the cognitive sciences that a preference for "personal experience" is precisely what gives rise to so many cognitive biases. I'm not saying this is a worthless book. It's fairly interesting reading. But I thought it might be useful to post a "realistic preview" about the book's discussion of heuristics.
  
  
• An Outstanding Analysis, But Only Part of the Problem
  By A1VX6VPXNQTNUP on 2007-05-28
  Most doctors are highly educated, hard working people. They may sometimes get a bit tetchy because they overwhelmed by the demands made on them, but most of the time they do their best. Yet in our blame culture there are places in America where you can't get a specialist to treat you: they have all been driven out of business by lawyers representing unhappy clients. The question of why this has come to pass has occupied the minds of the American medical profession for three decades.
  
  For more than a decade, Groopman's trenchant analyses have always been illuminating, and he has a rare gift for communicating them.
  
  This is one of the best books that he has written, about one of the issues that may lead to medical errors: simply not thinking well. It is a very real factor. We all - and not just doctors - jump to conclusions; believe what others tell us and trust the authority of "experts." Clinicians bring a bundle of pre-conceived ideas to the table every time that they see a patient. If that have just seen someone with gastric reflux, they are more likely to think that the next patient with similar symptoms has the same thing, and miss his heart disease. And woe betides the person who has become the "authority" on a particular illness: everyone coming through his or her door will have some weird variant of the disease. As Abraham Maslow once said, "If the only tool you have is a hammer, you tend to see every problem as a nail." To that we have to add that not all sets of symptoms fall neatly into a diagnostic box. That uncertainty can cause doctors and their patients to come unglued. Sometimes when doctors disagree it is based not on facts, but on different interpretations of this uncertainty.
  
  On this one topic the book is very good as far as it goes, thought I do think that the analysis is incomplete.
  
  I have taught medical students and doctors on five continents, and this book does not address some of the very marked geographic differences in medical practice. While I think that the book is terrific, let me point out some of the ways in which it is "Americano-centric."
  
  The first point is that the evidence base in medicine is like an inverted pyramid: a huge amount of practice is still based on a fairly small amount of empirical data. As a result doctors often do not know want they do not know. They may have been shown how to do a procedure without being told that there is no evidence that it works. As an example, few surgical procedures have ever been subjected to a formal clinical trial. Although medical schools are trying to turn out medical scientists, many do not have the time or the inclination to be scientific in their offices. In day-to-day practice doctors often use fairly basic and sometimes flawed reasoning. A good example would be hormone replacement therapy. It seemed a thoroughly good idea. What could be better than re-establishing hormonal balance? In practice it may have caused a great many problems. Medicine is littered with examples of things that seemed like a good idea but were not. Therapeutic blood letting contributed to the death of George Washington, and the only psychiatrist ever to win a Nobel Prize in Medicine got his award for taking people with cerebral syphilis and infecting them with malaria. The structure of American medicine does not support the person who questions: consensus guidelines and "standards of care" make questioning, innovation and freedom very difficult. A strange irony in a country founded on all three.
  
  The second major factor in the United States - far more than the rest of the world - is the practice of defensive medicine: doctors have to do a great many procedures to try and protect themselves against litigation. This is having a grievous effect not only on costs, but also on the ways in which doctors and patients can interact.
  
  Third is the problem of demand for and entitlement to healthcare. We do not have enough money for anything: but what is enough if the demand for healthcare continues to grow as we expect? And if people are being told that it is their right to live to be a hundred in the body of a twenty year-old? Much of the money is directed in questionable directions. There are some quite well known statistics: twelve billion dollars a year spent on cosmetic surgery, at a time when almost 40 million people have no health insurance. There are some horrendous problems with socialized medicine, but most European countries have at least started the debate about what can be offered. Should someone aged 100 have a heart transplant? Everyone has his or her own view about that one, but it is a debate that we need to have in the United States.
  
  Fourth is the impact of money on the directions chosen by medical students and doctors starting their careers. Most freshly minted doctors in the United States have spent a fortune on their education, so they are drawn to specialties in which they can make the most money to pay back their loans. In family medicine and psychiatry, even the best programs are having trouble filling their residency training programs. Many young doctors are interested in these fields, but they could die of old age before they pay off their loans.
  
  Fifth is the problem of information. It is hard for most busy doctors in the United States to keep up to date on the latest research, and many are rusty on the mechanics of how to interpret data. So much of their information comes from pharmaceutical companies. Many of the most influential studies have been conducted by pharmaceutical companies, simply because they have the resources. But there have been times when data has therefore appeared suspect. Industry is not evil, but companies certainly hope that their studies will turn out a certain way, and the outcome of any study depends on the questions asked and the way in which the data is analyzed. And like any collection of people, it is easy to fall into a kind of groupthink. There are countless examples of highly intelligent individuals who all missed the wood for the leaves. "Our product is the best there's ever been, and we are all quite sure that the stories about side effects are just a bit of "noise" created by our competitors." That topic alone could provide much grist for Dr. Groopman's mill.
  
  Another related problem is that many scientists are now also setting up companies to try and profit from the discoveries that they have made in academia. Most are working from the highest motives, but sometimes there are worries about impartiality. So once again, the unsuspecting physician may add data to the diagnostic mix without knowing its provenance. There have recently been a number of high profile examples of that.
  
  It could well be that Groopman will cover all of these points and more in his next book, and I can, of course, be accused of criticizing him for not writing the book that "I" wanted!
  
  This is a book that should be read by every doctor and patient in America.
  
  It is also good to know that there are other ways of thinking about some of the problems before us.
  
  Very highly recommended.
  
  
• A Disappointment
  By A3N1W2QSROU7CN on 2007-06-11
  Jerome Groopman's "How Doctors Think" has been given generally favorable reviews in the lay press and many readers have echoed that praise. From this physician's point of view, the book is a disappointment.
  
  On the positive side, Dr. Groopman's book is an attempt to bring to light some issues surrounding errors in medicine, a topic that is not discussed often enough in the medical and general literature. He discusses how physicians can make cognitive errors when they attempt distill an array of scattered bits of information in order to arrive at a conclusion to the question: what condition is this patient suffering from? He also tries to identify forces in the current American medical system that undermine a physician's ability to think more broadly and deeply about a patient's illness. His limited efforts in these areas can be a helpful starting point for patients, medical students, and physicians who are beginning to grapple with a simple fact: doctors are human, and they make mistakes.
  
  On the negative side, Dr. Groopman offers little in the way of concrete suggestions for clinicians to fix the problems he identifies. He indicates the current system is driving physicians to see more patients in less time, but offers no realistic proposals for doctors or patients that would allow for a less hurried atmosphere. He makes a number of suggestions on how physicians can think more clearly: think outside the box, be wary of "going with your gut", don't judge a patient by her outward appearance, be prepared in your mind for the atypical patient, consider the possibility of more than one diagnosis, and other pearls of wisdom. While they are good recommendations, they fall far short of a concrete program for improving one's diagnostic skills and thought processes. His only idea for improving medical training seems to be to push clinicians to ask themselves the above questions more often. If this was new, it would be worthy of all the praise that has been heaped on this book, but it honestly is not very new, and is simply a variation on the same ideas of how to better train clinicians that we have been working with since at least the 1970s. Given the current state of the American medical system, these old ideas clearly aren't enough, and Dr. Groopman's recommendations that we continue this strategy, only with more emphasis than before, leaves the reader desiring useful solutions feeling like he has been pushed out into the stream with only a toothpick for a paddle.
  
  Perhaps a physician's yearning for some answers from Dr. Groopman is asking too much. But even from a patient's point of view, given the harrowing stories that lead up to his epilogue, the few extra questions he suggests patients use to push the physician ("Is it possible I have more than one problem?") seem unimpressive. Given the severity of time constraints that Groopman very correctly describes, his dearth of suggestions for patients to assist their doctors and work as a team to make the most of their short time together makes this book of only limited value for the non-physician as well.
  
  One of the great shames of the book is that, despite his clearly delineating the problems physicians face, Dr. Groopman rejects the modern tools that have been developed to aid physicians in diagnosis: evidence-based medicine, clinical algorithms, and practice guidelines. He glibly dismisses these tools again and again, arguing they "constrain" a doctor's thinking and fail "when symptoms are vague... or when test results are inexact." He goes at length to describe one oncology fellow using a particular hematology scoring system to make a poor choice of a treatment plan for a particular patient. Yet the text makes clear the fellow was applying the scoring system incorrectly. Dismissing diagnostic tools because some people misuse them is like telling someone a wrench is not a useful tool for anything because someone once used a wrench to hammer in a nail. Diagnostic tools and practice guidelines, when used in a measured way, can help physicians accurately diagnose many patients without subjecting them to a punishing series of unnecessary diagnostic procedures. Evidence-based medicine helps us determine what works and, perhaps even more importantly, what doesn't. Instead of a balanced discussion of the benefits and limitations of such diagnostic aids, he simply throws the baby out with the bath water.
  
  The most insidious aspect of the book is the underlying suggestion that when a patient does not get a swift, accurate diagnosis of what ails them, it can always be traced back to some logical or other intellectual error on the part of the physician. The fact is some conditions will, for the foreseeable future, elude our best efforts to diagnose them. He brings up an example of a man with chest pain who was sent home from the ER, but then had a heart attack several hours later. In truth, we cannot differentiate all patients with cardiac chest pain from those without cardiac chest pain with 100% accuracy. This is never stated in the text, and only briefly mentioned in the chapter notes buried at the end of the book. Right now, somewhere in America, even with the best tests and the best diagnostician at the bedside, someone with chest pain will be sent home from the ER, only to have a heart attack a short time later. While Dr. Groopman goes on at length to humanize the patients he writes about, his overall argument dehumanizes physicians, holding them up to standards of accuracy that our current body of knowledge cannot support.
  
  Even if it isn't providing many useful solutions, this book is at least raising some important questions. Take this book with a grain of salt (and perhaps even two tablets of aspirin). It is encouraging that we are openly discussing the subject of errors in medicine. It would be a great shame, though, if this book were the last word on the subject.
  
  
• Excelllent investigation inside the minds of doctors
  By A2PEVP36Y5A2EQ on 2007-05-15
  This is a well written and very informative book on how doctors arrive at a diagnostics. Groopman, a doctor, acknowledges that 20% of diagnostics are incorrect. He explains why this happens by interviewing various medical experts. These describe how they arrive at diagnostic decisions and how they have made errors during their career.
  
  From reading this book, you get that the main reason doctors make errors is time constraint. In our productivity driven health care system, doctors don't have the time to cogitate the potential diagnostic of patients' illnesses. Additionally, human physiology is incredibly complex. Each patient is unique and reacts differently to his environment, and treatment. Thus, medicine is a science of rules but with more exceptions than rules. Also as an offshoot of cost containments, doctors are discouraged to order more tests than is viewed as necessary by the health insurers. As a result, doctors make complex decisions with limited time and information. This combination of factors easily explains the 20% error rate.
  
  A doctors' thinking mode diverges much from his medical training. In medical school doctors are taught to crack complex disease diagnostics following deductive reasoning. They are given written data on a patient, and they arrive at a diagnostic within 20 to 30 minutes of thorough analytical deliberation. However, in the real world they typically arrive at a diagnostic within 30 seconds. They don't think at all in a slow deductive reasoning mode as they were trained. Instead, they think in an intuitive light speed pattern recognition mode that immediately zeroes in on two or three potential diagnostics. Within the 30 seconds, they narrowed it down to one. Their light speed pattern recognition thinking reflects two things: first, the chronic time pressure they work under (they don't have 30 minutes to deliberate); and second, how they gather information in the real world. The physical appearance, body language, communication style of the patient will give them a ton of qualitative information that they don't get when cracking a diagnostic in med school using just data.
  
  The author analyzes with his interviewees the different cognitive errors doctors make. A common one is the commission bias as doctors are prone to be decisive and action oriented. A surgeon will operate because that's what he does. Sometimes, doing nothing is the best policy (doing no harm). But, that's perceived as incompetent by both patients and doctors. Another prevalent error is "diagnostic momentum" where the very first diagnostic delivered by the primary care physician sends all following specialists taking care of the patient down the wrong path. Another interesting one is the "zebra retreat" where a doctor does not dare to investigate further a situation because his hypothesis represents a wild outlier (a zebra); Instead, the doctor falls back into another comfortable error "satisfaction of search" where the unrevised diagnostic fits pretty well allowing him to move forward even though it is the wrong one. The "availability error" is what is most available in a doctor's mind based on recent experience and association with a similar case. It plays into the doctor's pattern recognition mode. The author mentions many other interesting ones that are common to other professional fields.
  
  In chapter 8, the author indicates that technology is not so helpful. The diagnostic error rates associated with the interpretation of X rays, EKGs, MRIs, mammograms, biopsies under microscope are far higher than what one expects. Two radiologists or pathologists often reach different conclusions. Sometimes even the same ones can arrive at different conclusions at different times (after reinterpreting their earlier findings).
  
  In chapter 9, the author investigates economic incentives that distort the judgment of doctors. This includes Big Pharma relentless marketing of prescription drugs through persistent marketing reps. This also entails Big Pharma's effort to medicalize what is the normal process of aging. The author mentions the concept of Andropause (male menopause) that has no scientific bearing; but, doctors have aggressively treated this condition with testosterone supplements. These are useless. Economic incentives also lead surgeons to conduct operations way too often that provide no benefit to the patients. The author mentions spinal fusion and radical mastectomy among the surgeries that are way overdone in the U.S. Spinal fusion does not work better than not operating to eliminate low back pain. Oddly enough, insurers are responsible for excess surgeries as they offer higher reimbursement rates for invasive surgeries than for alternative therapies. The author also mentions the occasional nefarious networking between lawyers, radiologists, and surgeons creating a cycle of referrals, aggressive X ray diagnostics, and resulting unnecessary spinal fusion operation surgeries. Everybody makes money, and the patient believes his back problem was well taken care off.
  
  Thus, diagnostic errors are a function of four factors: 1) the time and cost pressure associated with today's medical environment, 2) the complexity of human physiology, 3) the cognitive errors that the human brain makes across any profession, and 4) distorted economic incentives generated by Big Pharma, insurers, lawyers, and doctors themselves.
  
  To prevent diagnostic errors ask the right type of open-ended questions suggests the author. These include: What else could it be? Is there anything that does not fit the current diagnostic? Is it possible I have more than one problem? These questions will force the doctor's thinking to slowdown his pattern recognition reflex and allow for more deliberation about a condition. These questions will also fight most of the mentioned cognitive errors that are all associated with expediting a diagnostic so as to move on to the next patient.
  
  If you want to further understand medical errors due to economic incentives I recommend another book "What Doctors Don't Tell You" by Lynne McTaggart. Another excellent book on a similar subject is "The Last Well Person" by Nortin Hadler.
  
  
  
• Why doctors go wrong
  By ALN0TTRTLHA4E on 2007-08-17
  This book is about when doctors make mistakes. Apparently 15% of diagnoses are wrong and the book shows a number of scenarios in which things went wrong. One of the ironies of the book is that the writer, who appears independently famous of this book, has had two of his illnesses treated poorly. One was a back injury when he had an operation that fused part of his spine. Medical science suggests that there is not basis for suggesting that these operations are effective in reducing pain and he had it anyway. It didn't work. The other illness was pain in the hand. He had a number of incorrect diagnoses before one doctor took x rays of the hand in motion and was able to spot ligament damage which the other treating surgeons missed. Weirdly one of the diagnosis suggested that he had a non existent illness. One would have thought that this might have led to him starting de-registration proceedings against the surgeon but apparently someone making up a non existent illness is par for the course.
  
  The reasons for the mistakes make sense. Doctors usually make snap judgements in the first few seconds of the patient recounting symptoms. Probably with most illnesses this is a reasonable approach. However if a mistake has been made quite a number of doctors seem blind to the error. There is one case of a woman who was diagnosed with anorexia, as she could not eat. In reality she had a gluten intolerance, which led her to having cramps when she ate wheat, based products. She was told to eat pasta and other fattening starchy foods, which simply led to more cramps, and vomiting. Rather than seeing that there might be a problem with the diagnosis she was given psychiatric appointments to deal with her deeper issues. It was only a doctor who was prepared to start from scratch that prevented her starving to death.
  
  It would seem that there is a debate in the medical community about the process of diagnosis. There seems to be some computer-based application that allows doctors to feed in material and for a diagnosis to come up. This book is an attack on that system and argues that the key to good diagnosis is an empathy with the client and careful listening. The enemies of careful listening are judgements that are based on prejudice. Thus a heart attack was missed because a client seemed healthy. Doctors don't even start the process of listening if a client presents as an alcoholic, drug user or is overweight. They start with the belief that alcoholics or drug users are trying to work the system rather than having significant illnesses and the overweight will have a narrow range of illnesses related to obesity. No doubt the supporters of the computer based system would argue that their system is the sort of thing which guards against these spot judgements.
  
  The book finishes with an attack on drug manufacturers who allegedly market drugs aggressively when the prescription of their products will have minimal patient benefit and is solely commercially based. All in all a reasonably depressing book which suggests that patients should not trust doctors that much and should try to inform themselves as much as possible about what is going on. Reasonably easy to read but a bit fragmented.
  
  
  
  
  
• How Most People Think
  By AAMKGC17ZLGZL on 2007-08-24
  I'm not much of a reviewer but I worked as a chemical engineer in Silicon Valley for most of a career and am now in chiropractic college.
  
  Doctors are no different than engineers or any other scientist. We are trained in a particular field of science and learn to think in a certain way over a period of years. However, we get pigeon-holed into a method of reasoning, rightly or wrongly. In engineering school, as well as graduate school, it is just black and white. When you get into the real world, you find out there is a lot of gray.
  
  I'd imagine it is probably worse with doctors because of the status thrust on these people and that they do not interact well with one another. They rarely communicate with one another in a group setting and discuss the "strange but true" stories as engineers do (in engineering literature and within a corporate setting, even among competing companies). Once more, I would imagine that a lot of doctors, because of their intense training for so long (sometimes more than 10 years of post-graduate school!), believe that if they cannot solve it, no one can. I have seen this same phenomena in corporate engineering. In other words, if a certain engineer (or group of "special" engineers) says it is so, then it is. And if an answer doesn't come from that group of anointed engineers, then that answer must obviously be flawed. The same goes for doctors. We fail to think "outside the box". If most of the issue fits into some model, then the answer must lie within whatever the model says. So, if symptoms A & B fit into the bacteria model but symptom C does not, then most doctors ignore symptom C. The exact same thing happens in engineering.
  
  And so Dr. Groopman has compiled a book and writes about experiences of himself and other doctors - thinking inside and outside the box; paying attention to very tiny details as a forensic scientist would - or a detective in murder case on Court TV. The small seed found on the victim's sweater leads detectives to the killer. In the same way, Dr. Groopman writes about the many experiences that doctor-detectives use or should have used to find the reasons why their patients are sick; sometimes near death.
  
  A great book which has led me to prod my doctor to think outside the box.
  
  
  
  
• So So
  By A2UIXU97JYCPZG on 2007-07-14
  This book is essentially a collection of Groopman's New Yorker pieces. While most of these essays focus on diagnostic error, some of the essays and parts of a majority discuss topics such as physician-patient relations and the impact of financial incentives on practice. The recurrant theme is what Groopman refers to as cognitive errors in diagnosis. Groopman provides a series of well written vignettes that illustrate a number of pitfalls in diagnosis. Groopman is highlighting a significant problem and one that deserves public discussion.
  This is not, however, a systematic discussion of these issues. For example, what types of the cognitive errors described by Groopman are the most common? What factors predispose physicians to these errors? Are some specialties more prone to different kinds of errors? Groopman doesn't provide any information that might be useful either for physicians and patients in reducing the frequency of such errors.
  While Groopman may not have seen his task as necessitating recommendations to improve the present situation, the lack of serious discussion about improving diagnosis is a serious defect. All Groopman has to offer are nostrums about the requirement to listen to patients and that patients should forward in engaging their physicians with questions.
  Even more disappointing is Groopman's attitude towards the most serious effort to rectify this kind of problem, the evidence-based medicine movement. For example, Groopman makes several dismissive remarks about the introduction of Bayesian reasoning in diagnosis and management. This is misunderstanding of the role of Bayesian analysis. Despite what Groopman writes, there is nothing novel about Bayesian reasoning in medicine. Bayesian reasoning is actually implicit in a great deal of traditional diagnostic thinking. Formal Bayesian analysis is an effort, like much evidence based medicine, to make implicit assumptions explicit and then subject them to critical analysis. The evidence based evidence movement is an effort to make physicians self-critical about what they do on a day to day basis. This is precisely what Groopman claims is needed in clinical practice but he seems intent on disparaging the only viable path to obtaining the result he thinks is needed.
  The only alternative is to retreat to some form of traditional authoritarianism.
  
  
• Healthy Thinking
  By A2ALMW6CSEEFBE on 2007-08-07
  A pluralistic mind, like a pluralistic society, allows for a full flowering of human potential because it encourages exploration and with it, discovery.
  
  This process is most valuable when you are very sick, when a patient needs a doctor who can see around corners, who has the vision to think five steps ahead of and is able to act on, instead of just reacting to, a rapidly changing situation.
  
  And while the best practitioners of any discipline demonstrate that big picture sensibility, they temper their confidence with a deep respect for the unexpected or unknown. In effect, they anticipate being wrong or dumb or both. This is confidence infused with humility.
  
  Humility, which I thought was absent from Groopman's book "Anatomy of Hope," is on vibrant display in his latest work. Something changed in Groopman's perspective between "Anatomy," published in 2003, and "How Doctors Think," published in 2007. The voice in Anatomy was paternalistic and somewhat smug that given enough science, doctors would eventually be able to raise the dead.
  
  A more humble and candid, but excited and empowered tone is present in this work. Groopman writes like a man on fire who has discovered the path to enlightenment through admitting failure and uncertainty. It's a fast-paced and dynamic story.
  
  Groopman says, "arrogance is a product of narrow vision and ignorance." Does he speak from experience? Perhaps he'll tell all in his next book. An outstanding resource for both patients and doctors.
  
  
  
• How Doctors Think is a very interesting book
  By AE31M52VLKOG6 on 2007-04-04
  How Doctors Think is an interesting book about the medical field. I was drawn to the title, because my health is so important to me. I learned that the way a doctor communicates with a patient about medication or a problem is very important. In one study Groopman cited in this book, 45 doctors caring for 909 patients did not tell the patient how long to take a new medication or what side effects it might cause. Nearly half of the doctors failed to specify the dose and duration of the medication. This is because doctors are in hurry to see as many patients as they can.
  
  Doctors look for symptoms when a patient is sick. They can make the mistake of focusing solely on one medical possiblity while overlooking others. This is called the error of anchoring. Groopman also talks about why doctors are uncertain sometimes. I found out that doctors are uncertain in making decisions because of limitations of current medical knowledge and incomplete mastery of available knowledge. Doctors are not gods, and they don't always have all the answers. The chapter in which Groopman talks about his friend and her faith in God. This chapter is very touching. Her adopted infant daughter from Vietnam is incorrectly diagnosed with pneumonia and other medical problems. Groopman devotes another entire chapter on the subject of how aggressively new medications are being marketed to doctors. These companies offer doctors free gifts and trips just to get the doctor to use the product on their patients.
  
  I also learned that the way a doctor phrases his response to a patient is important. If a doctor phrases a response in a positive manner using percentage increase of improvement instead of just ramdom numbers, the patient will feel better about treatment. Groopman encourages patients to ask questions of their physician like "What else can it be?" Upon listening to a patient ask that question, a doctor will investigate deeper to find the cause of the patient's problem. This is a fascinating honest book about how doctors really think. I have a greater appreciation of the difficult job they have after reading this book.
  
  
• A must-read for all doctors (and their patients)
  By A31C9V1BLJ7JA4 on 2007-05-17
  As Groopman notes repeatedly, doctors leap to conclusions and then twist the facts to support their conclusions. I have experienced this myself. Doctors first blamed my symptoms on being married (even though they started when I was single), and then on being divorced (even though I had them while married); in fact, they result from post-viral neurological damage. Timelines were twisted around so that the result became the cause: I didn't stop exercising because I got deathly ill and collapsed just trying to get out of bed, I got sick because I stopped exercising.
  
  Unfortunately, it is not enough for the patient to be aware of the pitfalls of misdiagnosis. The doctor needs to be aware of the consequences to the patient of being treated for the wrong thing. Perhaps if my doctors had listened in the way that Groopman recommends, with open mind and holding off on a conclusion until they heard all the facts, they would have reached the correct diagnosis in time to prevent permanent disability.
  
  However, even when I presented the doctors with the correct diagnosis (first from my own research and later after receiving that diagnosis from two specialists), they called me a hypochondriac and refused to accept that they were wrong. Just as Groopman describes.
  
  I wish I had had this book back then to make them re-examine the thought processes that led to their wrong conclusions.
  
  
• Cognitive Science in the Clinical Office and Diagnostic Process
  By A3OIK9GQJOYP4H on 2007-06-17
  This book by Dr. Jerome Groopman, in my opinion, should be required reading of all medical students. Further since it is new (2007), I believe that all physicians whether they work directly with patients or interpreting diagnostic fims behind the scenes should read it, as well. Lastly, any potential or actual patient, which means everyone, should read it to understand the system they are being diagnosed and treated within, and the demands and limitations placed upon their well-meaning doctors.
  
  Physicians are not infallible. Some external constraints placed upon them derive from their administrative officers and, in turn, from the cost-efficiency efforts of HMO's. The time spent with each patient has been pared down and leads to more rigid and habituated diagnoses. Yet a proper and accurate diagnosis is critical since it is the engine that governs the treatment to follow.
  
  In addition to external constraints, the doctor's mind is all too often, by virtue of his or her training, locked into a template that leads to a stereotyping of the diagnostic process. As certain symptoms are relayed by the patient they are automatically made to fit an a priori template, hence, imposing closure on more creative and flexible thinkiong that may discern an unlikely or unexpected, but accurate diagnosis. Alternative, but potentially fruitful perspectives are overlooked if they fall outside the boundaries of the learned template.
  
  Dr. Groopman does not hesitate to acknowledge and emphasize that mood and temperament can influence the judgment of the diagnostician. The physician who is aware of this and is not defensive about it, is more likely to transcend the limitations imposed by the subjective thinking brought to the process.
  
  The book is written with sensitivity, insight, restraint, yet it is direct and to the point. Clinical vignettes are sprinkled throughout the book, adding clear illustrations, enhancing the author's meaning, and contributing a humane touch to every page.
  
  This work is a tour de force that will be compelling and illuminating to any reader.
  
  By Hugh Rosen, Philadelphia, PA, Autor of "Silent Battlefields: A Novel."
  
  
• A good read, as far as it goes...
  By AWTX8RVNQPZDW on 2007-06-28
  On a personal level, this book validated my own unfortunate experience with the medical profession. While it did not tell me anything of which I wasn't aware, I believe its value lies in exposure of these issues by a physician/author with high name recognition, such as Dr. Groopman.
  
  Unfortunately, many readers will meet counterparts of themselves and their doctors in this book, which reveals some of the more obvious pitfalls of medical care. However, Dr. Groopman's candid exposure of certain faults in a doctor's thought process, personal bias, and self-serving actions, only scratches the surface of deeper, more pervasive problems in medicine.
  
  I would like to believe that this book will encourage doctors who need
  it most to reflect upon and change the ways in which they misjudge, misread and mistreat their patients. Realistically though, I believe these are the very doctors whose thinking will remain unchanged. I hope I am wrong.
  
  It would take more than this book to change the thinking of those doctors whose misdeeds destroyed my own health. Certain unethical behaviors long accepted as the norm are too deeply ingrained in our society. Unfortunately, for the most part, "rightness" in our world exists more as a concept, than in deed. For every patient who survives years of misdiagnosis and harmful treatment and whose life is saved by an exceptional doctor, there are countless others who are further victimized BECAUSE of that first doctor's mistake.
  
  I would have liked to see Dr. Groopman take this book a step further into the realm of cover-ups and the conspiracy of silence in the medical profession, a major influence on doctors' thoughts and actions. How many doctors have seen patients injured by a colleague's negligence and acted to help that patient? Not many. More often, the patient is written off with a "functional" diagnosis, which sticks to and precedes them and sets the stage for repeated useless and humiliating medical encounters.
  
  Studies have proven that patients do not sue doctors who are open and honest, yet doctors continue defending their furtive behavior, using potential lawsuits as justification for their duplicity. How many doctors have been threatened with exclusion from hospital privledges should they dare blow the whistle on a colleague? And how many see patients injured from negligent surgery and refuse to "see" serious injury caused by faulty surgical technique? Not many.. Instead, he gives his colleague the benefit of the doubt, regardless of how blatant the error, and thinks "There but for the grace of God go I".
  
  "How Doctors Think" is a good and easy read.. entertaining with just the right amount of shock value to hold the average reader's interest..which is not too much. There's lots more dirt beneath this rug that needs to surface before any change for the better can take place. Dr. Groopman has opened the door for deeper investigation, exposure and accountability of the profession in which we entrust our lives.
  
  
• About time
  By A3T5G6OORYIH3Q on 2007-04-10
  In the world of modern American medicine patients often feel like victims, and doctors who were only a half century ago as near to gods as a mortal could be have been knocked off their pedestals in the 21st century.
  
  Jerome Groopman's "expose" "How Doctors Think" is a book that every future, current and past patient should read. The medical profession is rift with closed minds when it comes to listening to patients - really listening. As someone who has been on the sharp end of hypodermic needles for more than fifty years I realize, after reading this book, how extrordinary most of the medical care I have received, and how absolutely fortunate I am that my primary care physician has been taking care of me for all of my adult life and he is unusual in that he spends time, not only with me, but with my family when they accompany me. He is open to new age treatments like Theraputic Touch and Reiki. I have met too many doctors who poopoo alternate therapies without even trying to understand.
  
  The medical profession is a complex conglomerate that is crashing under its own weight and growing incompetence. Insurance companies carry a large part of that same burden too because of the "bottom line is all that matters" attitude.
  
  If nothing else Groopman's book is an eye opener, and a call to action. We, as consumers need to take an active roll in our own care and not be afraid to ask questions, refuse treatments that are not fully understood and to constantly demand that we be allowed a second and even third opinion - and as consumers we need to keep after insurance companies, federal and state governments to stop wasting time and create a useful, meaningful and effective universal health policy that treats everyone equally and that we all have access to the best possible medications and treatments without having to compromise because of financial considerations.
  
  Doctors need to start listening more, and using the information they are hearing to help their patients to better understand why certain options are suggested, and giving them the choice to refuse or ask for more options.
  
  "How Doctors Think" is a reasonable discusion of important issues and is written in an easy to understand style without any hype.
  
  
• Dr. Groopman's honesty is appreciated and admired.
  By A1UF2ZR23QOS4W on 2007-04-24
  First of all, I applaud and admire Dr. Groopman's honesty and the admission that doctors are fallible. Although this book is dedicated to helping patients communicate with doctors by helping them understand how doctors think, it appears to focus more on helping physicians avoid diagnostic mistakes by reminding them of the consequences of short sighted and odds-based reasoning. This book offers numerous case study examples showing the consequences of physicians' focusing only on symptoms that fit their preconceived diagnosis rather than truly listening to the patient and asking smart questions to get more information from the patient. Dr. Groopman writes that miscommunication leads to misdiagnosis but does not really outline a method to help patients communicate better with their doctors.
  
  I think a major benefit of this book to patients is that it will encourage them to speak up and to seek out other physicians for help if they do not receive the help they need from their physician. Dr. Groopman has indeed written a book describing how doctors think that will help patients understand doctors better. That's half the information that patients need. The other half is contained in a book written by Jane Williams. That book, Patient Self-Help Guide: How to Talk to Your Doctor contains the rest of the information that patients need to communicate with doctors. Ms. Williams agrees with Dr. Groopman that miscommunication leads to misdiagnosis and covers this at the beginning of her book. However, she teaches patients how to accurately and quickly describe their symptoms to help the physicians make accurate diagnoses the first time and avoid the diagnostic problems outlined in Dr. Groopman's book, and does so in plain language that the average patient can easily understand.
  
  I own both of these books and have found them to be very good books with each having different but beneficial information. The two books together make an outstanding patient resource. Perhaps these two authors should consider a collaborative effort, since their works are so complimentary.
  
  
  
  
• Another great Groopman product.
  By A2XSXFIT6EKH5N on 2007-08-07
  As a healthcare professional I have this absurd need to read all the books written by MDs. Groopman is a gifted MD and a gifted writer and his insights are extraordinary. How I wish he could be cloned and then be a professor at all med schools. He is able to simplify very complex topics. This is a book that anyone over the age of 40 should study - and all MDs should be required to read before renewing their licenses.
  
  
• RECOMMEND IT TO ALL MY THERAPY CLIENTS
  By AYA9WPN56336D on 2007-04-08
  I'm not finished with this book yet, but I'm already recommending it my clients, especially the women because many of our complaints (even more so as we age) have been so discounted by doctors in general. It's a fascinating and important book. Pamela D. Blair, Author The Next Fifty Years: A Guide for Women at Mid-Life And Beyond
  
  
• A must read if you are not immortal
  By A19XXVHG7C0GU4 on 2007-05-13
  HOW DOCTORS THINK is a must read for anyone over the age of puberty who does not consider him or herself to be immortal. There are so many ways in which doctors can mis-read our symptoms and bodies, that we must all become advocates for ourselves. One must assume our doctors are wrong. Radiologists are the most suspect. Groopman writes well on his subject. He helps us to discard the notion that our doctors are perfect, and helps us to bring some logic to the diagnostic exercise.
  
  
• What every patient should know!
  By A225FWM15FNCMP on 2007-08-12
  As an author writing a new book on how one should manage one's one health care, the Groopman book has been a valuable asset. People don't seem to realize that doctors are humans too - and make snap judgements about peope, jump to the wrong conculsions, misdiagnose, and just plain make mistakes. Groopman makes us see doctors, not as magicians, but as very hard working, dedicated people who need our help in the form of questions, background information, invovlement and encouragement so that as a team we can all be winners. Very honest book. However, not for the faint of heart patient who wants to retain the doctor on a pedestal!!
  
  
• Beware of Doctors
  By A1WMVV2AHMONSO on 2007-04-22
  If I am ever in a serious accident, take me to a trauma center, and do what it takes to save my life. Then just as soon as humanly possible, send me home to recover. Why? Well according JAMA, doctors are the third leading cause of death in America. Let me repeat, according to the profession's own trade journal doctors are the third leading cause of death in America. Behind heart disease, and cancer. SPOOKY.
  
  When you visit your doctor, for an ailment, three things will happen. You will be loaded up on a bunch of pharmaceuticals, which are more likely to kill you, than they are to make you well. Then if the drugs do not work, and they are not designed to do so, the Doctor will next put you into the hospital, and then the cutting begins. Hey all those big medical machines have to be made useful sometime. Never mind if these proceedures do not heal your ailment, they produce money.
  
  In today's medical schools they have tossed out the Hypocratic Oath, and replaced it with thou shalt make the drug companies rich.
  
  Doctors think no differently because the have not been trained any differently. First do no harm. The very drugs administered to heal, will do harm. In all cases one cannot only blame the Doctor. He is only doing what he or she has been trained to do. If you have a back pain, or a headache, or trouble breathing they toss a bunch of pills at you. Look at a medical trade journal and all you see are ads for this pill, and that. The medical schools get bushels of money from the Pharmaceudical Companies. This in effect makes it next to impossible for medical schools to teach that which may be of true benefit. If they do the money is cut off. So the medical schools teach in a manner that keeps the money flowing. In turn this is why Doctors do not try to find out why your joints are swelling. They give an anti-inflammatory drug, which may in turn give you an ulcer, in you stomach, or colon. Then you go back to the doctor for medications for the ulcers, which may in turn destroy your liver. Then you need a liver transpalnt, and a great many anti-rejection drugs, which may destroy your kidneys. Around, and around we go.
  
  If you have arthritis, drop the dairy products from your diet, and the symptoms subside.
  
  In short doctor are not given complete information while attending Med School, and this is why they think as they do. This book admonishes us to ask questions, and ask more questions. More or less educate your self, do not just take your doctor's word for everything, and for tips how to do this read this book. Informative, a good read, but it should be read on an empty stomach.
  
  
• Useful and interesting in a limited way
  By A2MFUK442KQAPQ on 2007-05-06
  Anyone whose own state of health or the state of health of someone who they care for requires more than occasional or limited interaction with the medical-industrial establishment should read this book.
  
  Not because it any breaks new ground, which it doesn't, but because Jerome Groopman MD's documents for laypeople the fact that doctors make an extraordinarily high number of diagnostic and therapeutic errors. An error rate of at least 15% according to sources cited by Groopman but, according to one peer reviewed study, possibly as high as 45%. And that's before factoring in negligent - as opposed to systematic - malpractice, steering people into unneeded or risky treatments for financial gain or just plain old oops-type mistakes. Most people don't realize this or don't really want to think about it. So Groopman's message may save lives and distress by encouraging people to take at least enough responsibility to seek second or third or, in the case of Groopman's own pursuit of remedy for a hand ailment, even a fifth opinion before proceeding with therapeutic or invasive procedures.
  
  The shortcomings in this accessible and relatively interesting and entertaining book are twofold. First, as some other reviewers point out, Groopman uses research and statistics to document the fact that his fellow doctors misdiagnose an average of at least one in seven patients who seek their help. He also points out that many accepted treatments have no documented basis in science but are simply repetition of methods a doctor's medical school instructor liked to use. And high tech medical data and mathematically systematic decision processes can also lead to errorsl. So what does Groopman propose? Only that doctors "slow down" and think more "creatively". This is science? And doesn't such an approach presume all doctors are above average in mental creativity much less common sense and concern for patients?
  
  Second, Groopman fails to provide enough specific recommendations for 1) ways patients can assist doctors by better communication and better use of the medical system or 2) detect when a doctor is just guessing or is simply not competent concerning a particular situation or 3) effectively obtain and utilize all those extra opinions and retests in a system resistive to change or spending even more money on a particular patient.
  
  I give How Doctors Think five stars for exposing and documenting the problem - hence my recommendation to read it - but only one star for providing enough suggestions for ways individual patients can improve their experiences and regain their health or minimize their suffering. This might be an especially good choice for a book club as long as the the discussion moves beyond the personal anecdotal stage - e.g., "my sister had this same situation" - to the solution stage - e.g., "I addressed this problem and got a better result by... ".
  
  
• Disappointing
  By AGRL4RBLTWTMC on 2007-05-15
  The book was poorly written in my opinion. The stories that demonstrated the points were often laid out in a haphazard manner. The bottom line was that it really did not tell us how doctors think and what to do about it. I finally just quit rather then go on
  
  
• Doctors and diagnosis
  By A2F6N60Z96CAJI on 2007-05-29
  Jerome Groopman is a physician who has studied himself and his fellow doctors. He finds that they sometimes need to re-learn the thinking process that leads them to --- occasionally --- misdiagnose their patients.
  
  Doctors are taught certain techniques for examining a patient. But, says Groopman, "hypotheses about the diagnosis come to a doctor's mind even before a word of the medical history is spoken." There are visual impressions and prior encounters, all adding up to a kind of profiling system individual to the doctor that can, like any profiling, be inaccurate. The doctor is the policeman, judge and jury, and his or her rush to judgment can prove fatal.
  
  A simple example cited in HOW DOCTORS THINK concerns a young man who wound up in the emergency room after being found by police sleeping on the steps of an art museum. He appeared dirty and incoherent, and the doctor on duty "eye-balled" him, took him for a homeless hippie and pressed on to more urgent matters. Later, alerted by a nurse, the doctor realized that the young man's incoherence stemmed not from intoxication but from sky-high blood sugar. He had collapsed, not fallen asleep. "It turned out he was not a vagrant but a student, and his difficulties giving the police and the triage nurse information reflected the metabolic changes that typify out-of-control diabetes."
  
  Groopman describes in detail his own frustration when trying to get a diagnosis and some relief for his hand, which occasionally became red, painful and swollen. It was not until the fourth consultation with the fourth "expert" that he believed he had gotten a realistic assessment. Being a medical person himself helped him, of course, but not all of us are so fortunate, so careful and so knowledgeable. Most people are acculturated to trust their doctors. Most of the time the trust is justified. But not every time.
  
  One of the most heartwrenching stories in Groopman's book concerns Rachel, a middle-aged woman who adopted a Vietnamese baby. When the infant failed to thrive, Rachel found herself in a nightmare but held herself together by means of religious conviction. At every juncture when her baby's life could have been relinquished after medical people had done all they could, Rachel prayed and also analyzed. The medical team had assessed the baby's problem: SCID, severe combined immunodeficiency disorder. Treating it as such, they watched as the baby struggled to live.
  
  Still, Rachel prayed and did her own research. She became convinced that the baby's problem was malnutrition. It took great persistence and more prayer to convince a team of experts to take her hypothesis seriously. She was right. Her baby began to pull through and soon left the ICU once the correct diagnosis was acknowledged, and little Shira got a place in the medical history books.
  
  Groopman looks at the pressure that doctors are under --- expectations from the practice that they will consult with each patient for no more than 15 minutes, visits from aggressive drug reps, reluctance to deal with certain kinds of patients, the idea that they already know from a glance what a patient's problem is, and the stress on a professional "healer" when he or she can offer compassionate palliative treatment, but no hope, to terminally-ill patients.
  
  The author concludes that the patient in all cases must partner with the doctor to keep his or her mind open to possibilities. Even when the patient does not self-advocate, the doctor must keep the unique individual person in mind. The question "What else could it be?" should always be part of the diagnostic process. And that process has to become innate, almost instantaneous. A lot to ask.
  
  HOW DOCTORS THINK should be required reading for medical students and for proactive patients. After you read it, pass it along to your doctor.
  
  --- Reviewed by Barbara Bamberger Scott
  
  
  
• Make your doctor work harder
  By ADNMVWSZUJZEA on 2007-06-11
  As a PCP I was intrigued to read this book. I've read Groopman in the New Yorker and he has pushed me to be more introspective about the way I deliver care.
  
  His book is no exception. I think he is asking a lot of physicians in terms of being able to make a diagnosis. He wants us to use guidelines and evidence rationally but know when to discard them for patients to whom guidelines should not apply. That's a tall order. Overall, though, I think his book speaks well for the medical profession and for those of us who try to be good patient advocates and judicious users of health care resources. I think readers could learn more about what to expect from their doctor and how to be good advocates for themselves.
  
  
• A fascinating and illuminating book
  By A2I0HEWMZPFFXI on 2007-06-14
  I have been "listening" to a fascinating book called "How Doctors Think" by Jerome Groopman. It is an illuminating trip through the nightmare world of how doctors can go wrong in their thinking and their diagnoses. It features several stories. One story, the first in the book, describes how a woman who was wasting away from celiac disease and had seen doctors for years and years finally had her disease because she finally met a doctor who was patient enough not to jump to a conclusion about what was wrong. Another story is about a woman who adopts a child from Vietnam and how the child with a mysterious immunodeficiency goes through a harrowing series of near-death experiences, wrong diagnoses, and almost goes through with a bone marrow transplant that was not needed. It is an astonishing book. It is rather technical in places but absolutely gripping.
  
  
  
  At the end of the book Groopman discusses the fallibility of radiologist's reading of CAT scans and X-rays and the melancholy business of the decisions oncologists make between treatment and accepting the fact that the disease will probably overtake most patients who have gotten to a certain stage in their illness.
  
  
  
  This last, about the oncologists was heard with a certain amount of deja vu in my case. I have certainly been there with my wife. She was diagnosed with breast cancer in 2001 and died in 2005. Especially there, with the ambiguities and often agonizing choices faced by cancer patients, rings very true in my experience. Perhaps as a previous reviewer has noted, it is short on concrete suggestions, but it eloquently lays out the difficult problem of diagnosis and treatment in a science that can never be exact or free of uncertainty.
  
  

• Better: A Surgeon's Notes on Performance
• Complications: A Surgeon's Notes on an Imperfect Science
• The Anatomy of Hope: How People Prevail in the Face of Illness
• Final Exam: A Surgeon's Reflections on Mortality (Vintage)
• How Doctors Think: Clinical Judgment and the Practice of Medicine