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Dr. Groopman’s Prescription

by Eve Weiss
May/June 2007

Photo by Timothy Greenfield-Sanders

“Some of the names on the best doctors lists I wouldn’t go within 100 yards of.” Jerome Groopman

Doctors are supposed to be infallible—that’s a given, even if we know it’s not true—it’s a matter of life and death, after all. Dr. Jerome Groopman, Professor of Medicine at Harvard Medical School and Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston, would appear to have particularly little room for mistakes. Groopman has published more than 150 scientific articles, four books, and is a staff writer at the New Yorker. Yet in his pathbreaking new work, How Doctors Think, Groopman shows how all doctors are vulnerable to errors in thinking. The book is a challenge, and a guide, for both doctors and patients to work together to improve medical care. 02138 pressed the doctor for details on a subject that never fails to fascinate—our own well-being.

What would most surprise patients about how their doctors think?
Within the first 18 seconds of a visit, physicians not only will interrupt a patient telling his or her story, but also already have anchored onto a diagnosis. Patients may not realize how quickly we come to judgments. Often we’re right, but here the stakes are very high because it’s a person’s health, and about 15, even 20 percent, of the time, we’re wrong.

Why did you write this book?
In teaching Harvard medical student residents, I found that when patients had complicated medical problems, students tended to jump too quickly into diagnosis using statistical formulas, or algorithms. That seemed to close off their thinking. How can I teach them to think better? I wondered, and began to dig. I found there was a very important dimension of knowledge—thinking well in the face of uncertainty—which medicine requires. This idea seemed to provide a very important framework for explaining why we arrive at the accurate diagnosis and why we sometimes go astray.

It is a very revealing book. You take real risks by exposing your errors in print—such as the time your compassion stopped you from examining a weak patient, and he later went into septic shock due to a missed abscess. How has the book been received among your peers?
This is not a high and mighty, righteous condemnation—but instead, a well-trained Harvard faculty member coming forth and putting himself under the microscope. I make myself vulnerable, and highlight the worst errors as my own. The problem of misdiagnosis has been largely unaddressed. I think that just by opening up the conversation and using myself, the kind of backlash you’d expect hasn’t occurred. The book’s intent is to say there’s a problem. How can we improve curricula, improve training, improve our own ways of thinking so that patients can get better care?

So changing curricula is one of your goals?
The book is written for patients. It makes the argument that we doctors, need you to help us to think better. We need you to question us and engage us from a position of knowledge about how and when we think well and how and when we go astray. But it is also my hope that the book will spark conversation within medical schools as well.

What would you teach medical students?
Self-awareness about how the mind works when making decisions under uncertainty, and also self-awareness about our emotional temperature. How our likes and dislikes, our tendency to stereotype, our impulse to snap judgment, how ego or overconfidence can all distort good thinking.

Are your ideas compatible with today’s healthcare system?
A lot of very good physicians working in HMOs are under enormous time pressures. A doctor can try to work within the system to remedy a problem that’s not going away, which is a signal that either the diagnosis is wrong or the treatment is misguided. A doctor can’t think well in haste. So the only practical solution I see within managed care is for the doctor to say, “We haven’t gotten to the bottom of it, let’s have another visit. I’ll think more about it, you’ll think more about it, and we’re going to talk again next week.”

How can a patient help doctors to think and protect against misdiagnosis?
The patient can ask: What else can it be? Can more than one thing be going on? Are there any data that contradict your working assumption? As the doctor, those kinds of questions cause me to pause and start to think again.

It also may annoy a lot of doctors.
It depends how the questions are raised. It’s the kind of question that I ask my medical students, or what colleagues ask me when we’re discussing a case. It’s the kind of question I should be asking myself and that a patient can ask.

You’re helping the patient to crack the code, giving them a common language with their doctor. You’re also taking the doctor off the pedestal.
The thing about standing on a pedestal, it’s too easy to lose your balance and fall. Most of the physicians I know really don’t want to be tripped up. So what if your doctor reacts to a perfectly reasonable question and a request for explanation with a dismissive or irritated response? When I raise that scenario with other doctors on the faculty here, every single one says they’d find another doctor.

In those moments of extreme vulnerability, how can a patient push back?
You need a family member or a friend with you to both assimilate the physician’s words and to help ask questions to clarify the doctor’s thinking. I know this from being a patient myself. You’re too scared, you’re too inhibited, you’re in too much pain, you might be on medications clouding your thinking. I’ve put myself repeatedly in the hands of “concerned” doctors. If I hadn’t known how these doctors think—when they were thinking well and when they were taking detours—I really could have been harmed.

How do you know that your doctor is competent? Can we rely on best doctor lists?
This is really one of the hardest things. Some of the names on those lists are some of the most astute and wonderful men and women in medicine; some of them I wouldn’t go within 100 yards of. The lists are only a point of reference.

How do you pick?
Ask around. Nurses are often some of the best sources. Is the physician really an active listener? In today’s medical world, a lot of doctors have one eye on the clock and one eye on the computer screen. You want a doctor who explains what he’s thinking. A very wise doctor once said to me that there’s nothing in medicine so complicated that it can’t be explained in clear language and make sense to any layperson. You also want someone interested in your beliefs and goals and values because that’s a very important component of care. All of us are going to get sick at some point in our lives. And later, when important decisions have to be made, doctors should weigh not only the scientific aspects but also, if I can be a little metaphorical, the soul.

That’s a lot to ask for in a doctor.
It’s really hard to be a doctor. But it’s much harder to be a patient.