The 18-Second Doctor (US News and World Report 3/07)
Jerome Groopman knows a thing or two about medicine. A noted researcher on cancer and AIDS at Beth Israel Deaconess Medical Center in Boston and a professor at Harvard Medical School, he also writes about the practice of medicine for the New Yorker. But he had to start from scratch to understand the subject of his new book, How Doctors Think. Groopman explains how faulty thinking by doctors can lead to tragically wrong diagnoses and what patients can do to better the odds of getting the right care.
Why did you decide to look into how doctors make decisions?
I had become aware of misdiagnoses of family and friends. I was teaching three years ago, and I found that many of the students were very smart. But they were latching on to these algorithms, making very quick judgments, and following cookbook-type recipes for diagnosis and treatment. I thought to myself, “How can I teach them to think better? How is it that I have made misdiagnoses, and senior colleagues of mine sometimes miss very important diagnoses?” To do that, I had to understand how doctors think.
You’d think the process had been studied to death.
No, it hasn’t. So what I did was begin to interview physicians all across the country and talk to them about their triumphs, when they came to the correct diagnosis, and when they failed. I also very critically examined my own thinking and particularly my own errors.
You tell the story of Ann Dodge, who suffered for 15 years despite seeing almost 30 doctors. They said she had anorexia, bulimia, and irritable bowel syndrome. She developed anemia, osteoporosis, and was down to 82 pounds, even though she was eating 3,000 calories a day.
She was literally wasting away. As physicians, we rely on pattern recognition to make diagnoses, and too often we come to snap judgments. We tend to stereotype patients. You will just rubber-stamp what’s been said and done over the past 15 years. And yet here’s a doctor, Myron Falchuk, who pushes all that to the side and returns through language to her story. He asks himself one of the key questions, which is, what else could it be? Or could two things be going on simultaneously? He thinks more broadly and makes a diagnosis that had been missed for 15 years. And saved her life. She had celiac disease, an autoimmune disorder that’s essentially an allergy to gluten in food.
That doctor really listened to his patient, which is what we all hope for when we walk into a doctor’s office.
We want to be listened to, and in a high-tech age, the key to accurate diagnosis and the basis of insightful thinking comes from listening and language. The errors that we make in our thinking often come about because we cut off the dialogue. Most physicians interrupt a patient 18 seconds after they start talking.
Have you had your own experience with the 18-second doctor?
Three years ago, I had very bad pain and swelling in my right wrist. I had been banging away at the computer, my hand got caught in an elevator door when the door closed, so I had some trauma to it. I saw several different prominent hand surgeons and got four different opinions. The third one I saw was basically on roller skates. He breezed into the room, didn’t sit down, took about 10 seconds to look at my wrist, and said that he would do an arthroscopy and then figure it out. I asked him what he felt was wrong. He said, “I think it’s a form of gout,” which frankly didn’t make sense. He was rushed and harried and didn’t really want to even spend a few minutes explaining clearly why he had made that snap judgment. It was incredibly disheartening. I left.
How did you figure it out?
I went and found the fourth surgeon, who was a young and very attentive surgeon, listened very carefully, and did something quite remarkable. Not only did he examine my right hand, but he examined my left hand. Not only did he get regular X-rays and an MRI, but he had an X-ray done when I used my hand, gripped something tightly. He saw that the space between two small bones in the wrist markedly widened. He said the ligament must have torn. It didn’t show on the MRI. Everyone bows to the authority of technology, but these scans are not perfect. Errors in radiology range between 20 and 30 percent, which is remarkably high. And, indeed, he was right.
How can we avoid being misdiagnosed?
It’s very appropriate for a patient to say, “I’m not getting better. I’d like to talk to you again about what’s bothering me.” Good physicians are receptive to that. If you really feel there is not communication with a doctor, and because communication is key to good thinking, then it’s time to get a new doctor.
Can we change how doctors think?
Very much so. We should integrate deeply into medical education this new information about thinking errors that comes from cognitive psychology. It’s the basis of misdiagnosis. The second is that we’re working under such time pressure, and we think and act as doctors at the same time, in the moment. Patients or family or friends can ask just a few appropriate questions to help us avoid errors. What else can it be? The third question is: Is there anything that’s been found that contradicts the presumed diagnosis? Those are the key questions.
This story appears in the March 26, 2007 print edition of U.S. News & World Report.