Medical Mysteries: After 18 years, a writer’s insights and farewell (On 'How doctors think' by Jerome Groopman)

[Jaybee00]

https://wapo.st/4iQGkKN


Ask questions, especially ‘What else could this be?’


Doctors increasingly face relentless time pressures, which may facilitate diagnostic errors. Common pitfalls include stereotyping, in which a doctor makes a snap judgment based on negative characteristics, and anchoring, the failure to consider subsequent information that doesn’t jibe with the initial picture. (These and other cognitive pitfalls are deftly explored in “How Doctors Think,” a groundbreaking book by hematologist Jerome Groopman, a professor at Harvard Medical School.)
In more than a half-dozen cases, severe and sometimes lethal physical illnesses went unrecognized for months, sometimes years. Many patients were women who were instead told they had a psychiatric or substance abuse disorder.

 

[Hutan]

https://pmc.ncbi.nlm.nih.gov/articles/PMC2776809/
How doctors think
Reviewed by: Brent M McGrath 1
AUTHOR Jerome Groopman

In each chapter, Groopman presents cases in which particular diagnoses were arrived at in error, often by separate, but not always independently thinking, physicians. He also presents cases in which difficult diagnoses were arrived at correctly, drawing attention to the important differences between the cognitive processes at play in each case and the resultant outcome. By doing this, Groopman highlights several types of common cognitive errors made by physicians. It is worth briefly reviewing them here. In fact, being more aware of these potential cognitive traps might well prevent one from making many of the clinical errors described in this book.

A commission bias is the tendency toward action rather than inaction. When considering whether the patient should be treated or not, this bias leads one toward treatment, as it is—wrongly—believed that one is therefore “doing something” for the patient.

Satisfaction of search is the tendency to stop searching for a diagnosis once one has found something of clinical interest, even though this might not be central to the presenting problem. Groopman points out that while finding something might be satisfactory, not finding everything is suboptimal.

The availability error is the tendency to apply what one commonly experiences or sees when making a diagnosis of a new patient. This leads the physician to see similar cases in the same way, often while ignoring important differences between them.

The anchoring error is the tendency to seize on an initial symptom or finding and allowing this to cloud clinical judgment.

Finally, the attribution error is the tendency to fit people into stereotyped roles based on one’s past experiences or what one might have been told by colleagues. This prevents the physician from viewing the patient’s clinical picture de novo.

I finished reading How Doctors Think at the end of my second year at medical school, having started it several months earlier but abandoning it for periods of time because of the rigours of the medical curriculum. Most of the 4-year medical programs in Canada are the preclinical or preclerkship years for students. It is the time when we learn much about the pathophysiology of disease, a bit about patient-doctor relationships, little about the process of clinical decision making, and essentially nothing about the cognitive errors and biases that might compromise the accuracy of our decisions—let alone ways of recognizing and correcting said biases.

Groopman explains that, in medicine, understanding why we sometimes get things wrong is important—if not essential—to understanding how to get things right. My only regret about this book is not having read it sooner. Even with its shortcomings, this is a book I would recommend to any medical professional, particularly new incoming medical students.

 

[Hutan]

From another thread:

From How Doctors Think, (pub. 2007 - ISBN-13/EAN:978-0-547-05364-6 (pbk.) by Dr. Jerome Groopman, M.D.

From the book cover: "Jerome Groopman explores the forces and thought processes behind the decisions doctors make."
"...Jerome Groopman, M.D., holds the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School and is chief of experimental medicine at Beth Israel Deaconess Medical center in Boston. A staff writer of The New Yorker, he is the author of The Anatomy of Hope, Second Opinions, The Measure of Our days, and other books."

Early in his book, Dr. Groopman tells the story of Anne Dodge who suffered with undetected Celiac Disease for 15 years. For much of that time she had been treated as if she had a psychological condition, but was slowly dying of malnutrition, according to the author. Medical advice appeared to have worsened this woman's condition; to counteract her severe weight loss, she was instructed to eat 3,000 calories per day, including a substantial amount of bread and pasta.

Finally, one specialist put aside his assumptions, and other's diagnoses of a mental health disorder, and tested this woman for Celiac. A positive diagnosis for this started her on a journey back to health.

I haven't finished the book, but a few passages about some physicians' attitudes to mental health disorders are relevant to the ME community.

Page 36: "The effects of a doctor's inner feelings on his thinking get short shrift in medical training and in research on decision-making." " ' Most people assume that medical decision-making is an objective and rational process, free from the intrusion of emotion,"...Yet the opposite is true."

Page 39: In reference to the patient called Anne Dodge, the author describes what the specialist had to do to correctly diagnose Ms. Dodge:

" Falchuk had to avoid the negative feelings that physicians have for patients labeled as 'psychiatric", seeing such people as neurotic, cloying, deranged, and generally delusional, a burden because they do not tell the truth, their physical complaints not worth taking seriously because their symptoms originate not in the chest or bowels or bones but in the mind. A wealth of research shows that patients thought to have a psychological disorder get short shrift from internists and surgeons and gynecologists. As a result, their physical maladies are often never diagnosed or the diagnosis is delayed. The doctor's negative feelings cloud his thinking." (emphasis added)

Supporters of the psychosocial theory of ME ("cfs") have said that our community should accept a diagnosis of mental illness. I can't recall if they have said there is no shame in this diagnosis. On the one hand they seem to convey this more positive view, no shame in having a mental illness, while on the other, some in this group have maligned the character of those with ME. Clearly, from the above information, there are those in the medical profession who view persons with mental health issues in a negative light. We know from lived experience that conflating the physical disease ME with mental illness has had a very detrimental effect on the medical profession's view of our character.

ETA:

Page 290 of How Doctors Think, cites research about physicians' attitudes to patients with psychological diagnoses including "Liking in the physician-patient relationship", by Judith Hall and Debra Roter, and "Taking care of the hateful patient", by J.E. Groves.

 

[Yann04]

The anchoring error is the tendency to seize on an initial symptom or finding and allowing this to cloud clinical judgment.

Finally, the attribution error is the tendency to fit people into stereotyped roles based on one’s past experiences or what one might have been told by colleagues. This prevents the physician from viewing the patient’s clinical picture de novo.

Definitely had these two a lot. I’m sure the attribution error is unfortunately way too common for ME, especially in the UK.

On the anchoring error: Before I was diagnosed I would often come with my list of dozens of symptoms because I wanted to figure out what was wrong with me. And the physicians would just kind of focus on one or two and ignore the rest. It was really frustrating, no one seemed to want to look at the big picture.

I think this image describes it well

 

[rvallee]

"Falchuk had to avoid the negative feelings that physicians have for patients labeled as 'psychiatric", seeing such people as neurotic, cloying, deranged, and generally delusional, a burden because they do not tell the truth, their physical complaints not worth taking seriously because their symptoms originate not in the chest or bowels or bones but in the mind. A wealth of research shows that patients thought to have a psychological disorder get short shrift from internists and surgeons and gynecologists. As a result, their physical maladies are often never diagnosed or the diagnosis is delayed. The doctor's negative feelings cloud his thinking." (emphasis added)

Supporters of the psychosocial theory of ME ("cfs") have said that our community should accept a diagnosis of mental illness. I can't recall if they have said there is no shame in this diagnosis. On the one hand they seem to convey this more positive view, no shame in having a mental illness, while on the other, some in this group have maligned the character of those with ME. Clearly, from the above information, there are those in the medical profession who view persons with mental health issues in a negative light. We know from lived experience that conflating the physical disease ME with mental illness has had a very detrimental effect on the medical profession's view of our character.

It's this horrible attitude that makes all the fake concern about mental illness being just as important as physical health so absurd. We know it's a lie. Those attitudes are very easy to come upon naturally when seeking help, and they are so damn obvious. Most physicians would agree about those, just never about when they apply. You can't take our nose between your fingers. We can't be pacified with hand puppets and a lollypop. Which is about the level of naiveness that it takes to fall for their lies. When they lie to our faces it's a blatant lack of respect, and when we tell them that they condescend even more.

It's truly absurd that this bigotry is never considered a problem. It's wrong. It diminishes medicine and causes far worse outcomes for everyone. We know this. We tell them this. There are studies showing this. They know it. Their attitudes explain this 100%. But still they go around lying to us about mental illness being just as serious. Which isn't even the problem in most cases, which is simply that it's wrong. Wrong category. Wrong set of problems, obviously leading to an invalid set of solutions.

But even without this, those attitudes are just plain wrong. They should not exist, should not be tolerated. A healthy professional culture would not only not have those, it would root them out to prevent them from rising anew. But instead we get this giant mess where they'd rather keep on degrading their profession, instead of improving it. Which is so damn weird, and yet another part of what they speak of us that is 100% pure projection.