For anyone interested in the subject, I highly recommend How Doctors Think, a relatively new book by Dr. Jerome Groopman. Dr. Groopman gives an insider’s view of how Drs. actually consider and analyze us and make diagnostic and treatment decisions.

An extended excerpt from the book can be found by pointing your browser to: http://www.npr.org/templates/story/story.php?storyId=8892053Dr. Groopman is a staff writer at The New Yorker, a wonderful magazine of which I am a subscriber and also highly recommend. Dr. Groopman is chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston and teaches at Harvard Medical School.

 When you think about it, it should probably come as no surprise that as human beings, doctors, despite being highly educated and trained scientists, suffer from all of imperfections and frailities as the rest of us. We all have good days and bad days. More importantly, we are all pushed and pulled unconciously by many biases, good and bad habits, pre-conceptions, and the like.

Dr. Groopman shows us how the doctor’s thinking and ultimate diagnosis are influenced from the moment he greets us. By the way we shake hands. By how we carry ourselves. By the inflection in our voice. Dr. Groopman argues convincingly that this is good thing, so long as what may start as a “gut instinct” is eventually subjected to deliberative analysis.

Dr. Groopman describes his thesis thusly:

This book is about what goes on in a doctor’s mind as he or she treats a patient. The idea for it came to me unexpectedly, on a September morning three years ago while I was on rounds with a group of interns, residents, and medical students. I was the attending physician on “general medicine,” meaning that it was my responsibility to guide this team of trainees in its care of patients with a wide variety of clinical problems, not just those in my own specialties of blood diseases, cancer, and AIDS. There were patients on our ward with pneumonia, diabetes, and other common ailments, but there were also some with symptoms that did not readily suggest a diagnosis, or with maladies for which there was a range of possible treatments, where no one therapy was clearly superior to the others.

…

After several weeks of unease about the students’ and residents’ reliance on algorithms and evidence-based therapies alone, and my equally unsettling sense that I didn’t know how to broaden their perspective and show them otherwise, I asked myself a simple question: How should a doctor think?

This question, not surprisingly, spawned others: Do different doctors think differently? Are different forms of thinking more or less prevalent among the different specialties? In other words, do surgeons think differently from internists, who think differently from pediatricians? Is there one “best” way to think, or are there multiple, alternative styles that can reach a correct diagnosis and choose the most effective treatment? How does a doctor think when he is forced to improvise, when confronted with a problem for which there is little or no precedent? (Here algorithms are essentially irrelevant and statistical evidence is absent.) How does a doctor’s thinking differ during routine visits versus times of clinical crisis? Do a doctor’s emotions — his like or dislike of a particular patient, his attitudes about the social and psychological makeup of his patient’s life — color his thinking? Why do even the most accomplished physicians miss a key clue about a person’s true diagnosis, or detour far afield from the right remedy? In sum, when and why does thinking go right or go wrong in medicine?

…

My generation was never explicitly taught how to think as clinicians. We learned medicine catch-as-catch-can. Trainees observed senior physicians the way apprentices observed master craftsmen in a medieval guild, and somehow the novices were supposed to assimilate their elders’ approach to diagnosis and treatment. Rarely did an attending physician actually explain the mental steps that led him to his decisions. Over the past few years, there has been a sharp reaction against this catch-as-catch-can approach. To establish a more organized structure, medical students and residents are being taught to follow preset algorithms and practice guidelines in the form of decision trees. This method is also being touted by certain administrators to senior staff in many hospitals in the United States and Europe. Insurance companies have found it particularly attractive in deciding whether to approve the use of certain diagnostic tests or treatments.

…

Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment — distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctor needs to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact. In such cases — the kinds of cases where we most need a discerning doctor — algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they can constrain it.

Similarly, a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the canon in many hospitals. Treatments outside the statistically proven are considered taboo until a sufficient body of data can be generated from clinical trials. Of course, every doctor should consider research studies in choosing a therapy. But today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.

In addition to being a insightful analyst, Dr. Groopman is a terrific story teller. He enlivens the subject by providing real-life case studies. Each unfolds like a good mystery or who-done-it.

Dr. Groopman tells us about patient Anne Dodge, who was seen by too many doctors to count over a fifteen year period. She suffered from debilitating gastro-intestinal problems.

After a meal, she would feel as if a hand were gripping her stomach and twisting it. The nausea and pain were so intense that occasionally she vomited.

Dodge’s family doctor examined her and found nothing wrong. Anne lost her appetite. Forced herself to eat. Then she’d feel sick. Sometimes she’d retreat to the bathroom to regurgitate. She was diagnosed: anorexia nervosa with bulimia.

Dr. Groopman uses Dodge’s story to show the danger of the “echo chamber.” We’ve all experienced the Echo Chamber, where we all begin to echo each other rather than to bringing to bear our own independent, critical thinking. Dodge’s story drives this lesson home. Despite intensive treatment, Dodge’s condition continued to deteriorate.

Her red blood cell count and platelets had dropped to perilous levels. A bone marrow biopsy showed very few developing cells. The two hematologists Anne had consulted attributed the low blood counts to her nutritional deficiency. Anne also had severe osteoporosis. One endocrinologist said her bones were like those of a woman in her eighties, from a lack of vitamin D and calcium. An orthopedist diagnosed a hairline fracture of the metatarsal bone of her foot. There were also signs that her immune system was failing; she suffered a series of infections, including meningitis.

But treatment was not working.

Her internist had told Anne to consume three thousand calories a day, mostly in easily digested carbohydrates like cereals and pasta. But the more Anne ate, the worse she felt. Not only was she seized by intense nausea and the urge to vomit, but recently she had severe intestinal cramps and diarrhea. Her doctor said she had developed irritable bowel syndrome, a disorder associated with psychological stress. By December, Anne’s weight dropped to eighty-two pounds. Although she said she was forcing down close to three thousand calories, her internist and her psychiatrist took the steady loss of weight as a sure sign that Anne was not telling the truth.

In truth, not only was the treatment not working, it was killing her and in all likelihood would have killed her.  Then an some one appeared. An angel? No a very good doctor, who, for whatever reason, was not inclined, was not influenced by the earlier diagnoses. He examined Dodge with fresh eyes.Dodge made her way to Dr. Myron Falchuk. Thank goodness for Dr. Falchuk. Dr. Falchuk broke the mold. Dr. Falchuk resisted the group-think. He resisted just following the other doctors’ leads. Dr. Groopman shows us how and why Dr. Falchuk did what the others did not.

Falchuk had already gotten her medical records, and her internist had told him that Anne’s irritable bowel syndrome was yet another manifestation of her deteriorating mental health. Falchuk heard in the doctor’s recitation of the case the implicit message that his role was to examine Anne’s abdomen, which had been poked and prodded many times by many physicians, and to reassure her that irritable bowel syndrome, while uncomfortable and annoying, should be treated as the internist had recommended, with an appropriate diet and tranquilizers.

But that is exactly what Falchuk did not do. Instead, he began to question, and listen, and observe, and then to think differently about Anne’s case. And by doing so, he saved her life, because for fifteen years a key aspect of her illness had been missed.

…

… Dr. Falchuk did something that caught Anne’s eye: he moved those records to the far side of his desk, withdrew a pen from the breast pocket of his white coat, and took a clean tablet of lined paper from his drawer. “Before we talk about why you are here today,” Falchuk said, “let’s go back to the beginning. Tell me about when you first didn’t feel good.”

For a moment, she was confused. Hadn’t the doctor spoken with her internist and looked at her records? “I have bulimia and anorexia nervosa,” she said softly. Her clasped hands tightened. “And now I have irritable bowel syndrome.”

…

So Anne began, as Dr. Falchuk requested, at the beginning, reciting the long and tortuous story of her initial symptoms, the many doctors she had seen, the tests she had undergone. As she spoke, Dr. Falchuk would nod or interject short phrases: “Uhhuh,” “I’m with you,” “Go on.”

Occasionally Anne found herself losing track of the sequence of events. It was as if Dr. Falchuk had given her permission to open the floodgates, and a torrent of painful memories poured forth. Now she was tumbling forward, swept along as she had been as a child on Cape Cod when a powerful wave caught her unawares. She couldn’t recall exactly when she had had the bone marrow biopsy for her anemia.

“Don’t worry about exactly when,” Falchuk said. For a long moment Anne sat mute, still searching for the date. “I’ll check it later in your records. Let’s talk about the past months. Specifically, what you have been doing to try to gain weight.”

This was easier for Anne; the doctor had thrown her a rope and was slowly tugging her to the shore of the present. As she spoke, Falchuk focused on the details of her diet. “Now, tell me again what happens after each meal,” he said.

Anne thought she had already explained this, that it all was detailed in her records. Surely her internist had told Dr. Falchuk about the diet she had been following. But she went on to say, “I try to get down as much cereal in the morning as possible, and then bread and pasta at lunch and dinner.” Cramps and diarrhea followed nearly every meal, Anne explained. She was taking anti-nausea medication that had greatly reduced the frequency of her vomiting but did not help the diarrhea. “Each day, I calculate how many calories I’m keeping in, just like the nutritionist taught me to do. And it’s close to three thousand.”

Dr. Falchuk paused. Anne Dodge saw his eyes drift away from hers. Then his focus returned, and he brought her into the examining room across the hall. The physical exam was unlike any she’d had before. She had been expecting him to concentrate on her abdomen, to poke and prod her liver and spleen, to have her take deep breaths, and to look for any areas of tenderness. Instead, he looked carefully at her skin and then at her palms. Falchuk intently inspected the creases in her hands, as though he were a fortuneteller reading her lifelines and future. Anne felt a bit perplexed but didn’t ask him why he was doing this. Nor did she question why he spent such a long while looking in her mouth with a flashlight, inspecting not only her tongue and palate but her gums and the glistening tissue behind her lips as well. He also spent a long time examining her nails, on both her hands and her feet. “Sometimes you can find clues in the skin or the lining of the mouth that point you to a diagnosis,” Falchuk explained at last.

He also seemed to fix on the little loose stool that remained in her rectum. She told him she had had an early breakfast, and diarrhea before the car ride to Boston.

When the physical exam was over, he asked her to dress and return to his office. She felt tired. The energy she had mustered for the trip was waning. She steeled herself for yet another somber lecture on how she had to eat more, given her deteriorating condition.

“I’m not at all sure this is irritable bowel syndrome,” Dr. Falchuk said, “or that your weight loss is only due to bulimia and anorexia nervosa.”

She wasn’t sure she had heard him correctly. Falchuk seemed to recognize her confusion. “There may be something else going on that explains why you can’t restore your weight. I could be wrong, of course, but we need to be sure, given how frail you are and how much you are suffering.”

Anne felt even more confused and fought off the urge to cry. Now was not the time to break down. She needed to concentrate on what the doctor was saying. He proposed more blood tests, which were simple enough, but then suggested a procedure called an endoscopy. She listened carefully as Falchuk described how he would pass a fiberoptic instrument, essentially a flexible telescope, down her esophagus and then into her stomach and small intestine. If he saw something abnormal, he would take a biopsy. She was exhausted from endless evaluations. She’d been through so much, so many tests, so many procedures: the x-rays, the bone density assessment, the painful bone marrow biopsy for her low blood counts, and multiple spinal taps when she had meningitis. Despite his assurances that she would be sedated, she doubted whether the endoscopy was worth the trouble and discomfort. She recalled her internist’s reluctance to refer her to a gastroenterologist, and wondered whether the procedure was pointless, done for the sake of doing it, or, even worse, to make money.

Dodge was about to refuse, but then Falchuk repeated emphatically that something else might account for her condition. “Given how poorly you are doing, how much weight you’ve lost, what’s happened to your blood, your bones, and your immune system over the years, we need to be absolutely certain of everything that’s wrong. It may be that your body can’t digest the food you’re eating, that those three thousand calories are just passing through you, and that’s why you’re down to eighty-two pounds.”

When I met with Anne Dodge one month after her first appointment with Dr. Falchuk, she said that he’d given her the greatest Christmas present ever. She had gained nearly twelve pounds. The intense nausea, the urge to vomit, the cramps and diarrhea that followed breakfast, lunch, and dinner as she struggled to fill her stomach with cereal, bread, and pasta had all abated. The blood tests and the endoscopy showed that she had celiac disease. This is an autoimmune disorder, in essence an allergy to gluten, a primary component of many grains. Once believed to be rare, the malady, also called celiac sprue, is now recognized more frequently thanks to sophisticated diagnostic tests. Moreover, it has become clear that celiac disease is not only a childhood illness, as previously thought; symptoms may not begin until late adolescence or early adulthood, as Falchuk believed occurred in Anne Dodge’s case. Yes, she suffered from an eating disorder. But her body’s reaction to gluten resulted in irritation and distortion of the lining of her bowel, so nutrients were not absorbed. The more cereal and pasta she added to her diet, the more her digestive tract was damaged, and even fewer calories and essential vitamins passed into her system.

Copyright © 2007 by Jerome Groopman.