The other end of the stethoscope
How Doctors Think
By Jerome Groopman
Houghton Mifflin, 307 pp., $26
In medical school there's an old adage -- a clinical theorem really -- about the art of diagnosis that professors love imparting to their impressionable students. Attributed to Sir William Osler, the eminent physician and author of the most influential medical textbook of the late 19th and early 20th centuries, this solemn aphorism intones: "Listen to the patient, he is telling you the diagnosis."
In practice, however, medical deduction is not always as transparent as Osler once suggested.
Sometimes a patient cannot articulate precisely what is going on with his body; on occasion, his disease may be so rare or obscure that even modern medical diagnostic tools are futile when attempting to penetrate into the heart of the matter. Other times, however, well-intentioned physicians introduce errors into the way they think about a patient, illness, or the processes of diagnosis and treatment.
Expanding on ideas he has explored on the pages of The New Yorker, Harvard Medical School professor and physician Jerome Groopman contemplates this last, growing conundrum in his new collection of essays, "How Doctors Think ."
In recent years, Groopman has observed that his medical students "too often failed to question cogently or listen carefully or observe keenly. They were not thinking deeply about their patients' problems. Something was profoundly wrong with the way they were learning to solve clinical puzzles and care for people ."
This problem is hardly restricted to the upcoming crop of healers . What has changed, Groopman notes, are the types of mistakes doctors make.
After consulting the social science literature on the interactions between doctors and patients, Groopman reports that "on average, physicians interrupt patients within eighteen seconds of when they begin telling their story." Beyond being rude, this doctorly impatience often signifies a remarkably brief time between inquiring about a patient's complaints and deciding upon a likely diagnosis and treatment.
Compounding the dilemma of medical errors are the striking changes in health care that have taken place over the past few decades, including developments in how we understand and treat many diseases, advances in medical technology and patient care, unintended consequences of the ways we fund the nation's medical-industrial complex, and the disturbing trend for pharmaceutical companies to turn an increasing number of normal changes and challenges into clinical disorders demanding the expensive medications they produce.
These dynamics have inspired Groopman to pose some intriguing questions such as : Do pediatricians, surgeons, internists, and other physicians engage in different forms of medical thinking? Is there one best way to think or is eclecticism a virtue when seeking out an effective diagnosis? How do doctors think when improvising medical solutions for problems for which there is little or no precedent?
His approach to answering this set of provocative questions is a parade of detailed portraits of experts who think a great deal about the ways doctors apply evidence to making diagnoses. Accompanying these accounts are several patients' stories , including one of Groopman's forays onto the other side of the stethoscope.
A decade ago, the author experienced a serious wrist injury, but its exact cause and treatment eluded a battery of top-notch doctors. This painful crisis required more than good medical thinking on Groopman's part; it necessitated a slew of professional courtesies, long-distance consultations with several prominent surgeons, multiple MRIs, wise advice from a spouse who is a well-trained physician, and either a very generous health plan or the financial resources to pay what must have been a whopping medical bill. Sadly, this bountiful menu of diagnostic options remains shut for too many Americans today.
"How Doctors Think" offers patients some insight into the general shapes and contours of how doctors make life-enhancing or life-threatening decisions. The examples of erroneous assumptions and logical lapses described need to be drilled into the head of every practicing physician. What the book does not fully address, and I think too many medical consumers refuse to contem.plate, is the unsettling acceptance that mistakes are inimical to the practice of medicine. When faced with the urgency of life and death situations, physicians are forced to make rapid, multiple decisions based on limited, and potentially wrong, data.
Nevertheless, we can take heart that ours is an era marked by increasing numbers of doctors and patients thinking deeply about improving how they interact with one another and promoting healthier lifestyles.
Howard Markel, a pediatrician, is the George E. Wantz Distinguished Professor of the History of Medicine at the University of Michigan Medical School and the author of several books including, most recently, "When Germs Travel." 