19 March 2007

How Doctors Should Think

I vividly remember a story told by a friend doctor about a 69-year old patient he saw years ago, who consulted very early in the morning in his clinic complaining of intense headache accompanied by mild nausea. The old patient was the father of his childhood friend, who was with the patient during the consult. He was eagerly surprised to see and examine the old man, and to talk to his long-time friend.

Vital signs and initial PE were all normal. The patient was a non-smoker, looked very fit for his age, led a clean healthy life, had no family history of heart diseases, diabetes, or any other chronic ailment. There was also no history of recent head injury or trauma. My friend doctor (who's really a great doctor, in the top ten of our medschool class, and has several published articles in medical journals) did more interview and less PE on the patient, preferring to converse more both to the old patient and his childhood friend. He didn't seem worried about the patient, and prescribed a mild painkiller, a well-known NSAID --- mefenamic acid, 500 mgs --- to be taken after a light meal. He advised the old man to rest, and assured him this was probably a mild stress headache which will go away before the day is over.

A few hours later, my friend doctor's cellphone rings. His childhood friend informed him that his father (the old patient he examined hours ago) had been rushed to the ER of a tertiary hospital. His father was incoherent, disoriented, had a slurred way of speaking, and half of his body had become very weak. He had suffered a stroke. His friend told him his father was about to be transferred to ICU.

How can my friend doctor miss that? Was it because he obtained a "normal history?" Was it because he was more happy to see his old friend than do a thorough PE of the patient?

Whatever the reason was, mistakes in a doctor's thinking process may result in fatal outcomes. This is preventable, if only the doctor hadn't been sidetracked from the truth.

When someone handles life and death decisions on a frequent basis, it is almost a necessity to be on the side of constant perfection, or near-perfection, if there is such a term. Such is the case of physicians who handle sick patients every day. It is therefore important to know how the doctor thinks, how he arrives at a specific diagnosis, and what particular algorithmic mental thoughts occur in his head when he meets his patient. This is important because the success of any treatment plan depends largely on having an accurate diagnosis.

Christine Gorman has a nice review of Dr. Jerome Groopman's latest book, How Doctors Think in TIME magazine's latest issue. She described 4 critical thinking mistakes your doctor might make while treating you:
  • Thinking Error 1: I RECOGNIZE THE TYPE - Doctors, like most of us, are often led astray by stereotypes that are based on someone's appearance, emotional state or circumstances. Thus a homeless man's disorientation might be quickly attributed to alcoholism when the real culprit is diabetes.


  • Thinking Error 2: I JUST SAW A CASE LIKE THIS - "We all tend to be influenced by the last experience we had or something that made a deep impression on us," Groopman says. So if it's January, your doctor has just seen 14 patients with the flu and you show up with muscle aches and a fever, he or she is more likely to say you have the flu--which is fine unless it's really meningitis or a reaction to a tetanus shot that you forgot to mention.


  • Thinking Error 3: I'VE GOT TO DO SOMETHING - Physicians typically prefer to act even when in doubt about the nature of the problem. And yet this kind of "commission bias" can lead to all sorts of new problems if the treatment turns out to be incorrect.


  • Thinking Error 4: I HATE (OR LOVE) THIS PATIENT - Groopman cautions that emotions are more of an issue than most physicians like to admit. Doctors who are particularly fond of a patient have been known to miss the diagnosis of a life-threatening cancer because they just didn't want it to be true. But negative emotions can be just as blinding, sometimes stopping a doctor from going the extra mile. "If you sense that your doctor is irritated with you, that he or she doesn't like you," says Groopman, "then it's time to get a new doctor." Studies show that most patients are pretty accurate in describing their doctors' feelings toward them.


[TIME, 26 March 2007 issue]

Dr Groopman's studies have led him to a discovery that only 20 percent of medical mistakes are due to technical errors (wrong drug dosage, missing a pathology on x-ray, misinterpreted doctor's handwriting, and many more). The bulk of mistakes --- 80 percent --- occur because of thinking errors, missing the truth because of obvious distractions, and sticking to a stereotype way of diagnosing illnesses.

How should doctors think then?

Well, my opinion is that we should begin training them how to think. As early as their medical school years. There should be "thinking medical conventions," which should see to it that even practicing physicians have minimal chances of committing thinking errors.

In cases when arriving at a diagnosis is both difficult and urgently needed, a team of 2 to 4 doctors should conduct a thorough brainstorming where they can combine their heads together to obtain an unmistaken diagnosis. Nowadays, doctors of a patient seldom talk to each other anymore. They usually communicate only by browsing each other's notes in the patient's medical chart.

I also think that doctors should learn how to relax more in the face of stress. Panic damages our judgment and thinking process. Medical interns and medical residents should be given healthy sleeping habits. It is already well-known from most studies how a doctor's judgement is impaired because of his sleep debts .

Being a doctor is more like being a detective. Each patient case is a unique investigation. A doctor must not be swayed by distractions and stereotype diagnoses. He must come up with a sound assessment of what is really wrong with the patient. He must do this quickly and accurately.

While erring might be a human weakness, not everyone is divine enough to forgive a doctor who fatally commits a mistake.


USEFUL LINKS:
  1. What's The Trouble?


  2. Groopman: The Doctor's In, But Is He Listening?


  3. Feeling The Pressure

14 reactions:

Rjay said...

This is a very nice post. More Power Dr. Emer!

Christine Gorman said...

What I find particularly striking is Groopman's belief that we can and should help our doctors avoid such thinking errors by asking certain open-ended questions, such as "What else could it be?"

Dr. Emer said...

RJAY: Thanks and welcome to my blog.

CHRISTINE: That's an interesting solution --- letting patients help. The only problem I see there is if most doctors would be humble enough to be helped. In the local scene, for example, majority of patients are passive followers to their "all-knowing doctors." Seldom would patients ask questions, and seldom would their doctors feel open to be challenged in difficult cases. But I agree with Dr. Groopman. Healing is a 2-way process. Patient and doctor should help each other. Thanks for the comments and the visit.

watson said...

I think this post shows that doctors are humans too, and that they are prone to emotions like the rest of us (example: joy at seeing an old friend). This can have an adverse effect though... which makes dedication a real commitment in the medical profession.

Anonymous said...

Personally I find Christine Gorman's suggestion very interesting and Dr Emer's response to her suggestion even more apt. I recalled an instance when my uneducated mother visited a doctor because she was worried sick about a constant headache. I took her to this specialist who after examining her, told her that there was nothing to worry about and that the headache would eventually go away. My mother was so worried that she asked if it could be something serious. The doctor took offence and rebuked her with a sharp retort, "Now, who's the doctor? You or me?" I was so embarrassed that I told the doctor off.

Indeed, I would expect not too many doctors humble or sensitive enough to accept the patient's concern (Dr Emer being an exception, of course!).

Personally I make it a point to visit doctors who listen to me while I try to describe my symptoms and the circumstances leading to my sick condition. The doctor can ask questions to probe further and I would be more than happy to answer to the best of my ability.

Char said...

Related reading for you:
http://www.expresshealthcaremgmt.com/20050515/hospitalarchitecture01.shtml

Dr. Emer said...

WATSON: More dedication to the profession should mean being more investigative with each patient case.

ANONYMOUS: Is this you, Bayi? It would be great to live in an ideal world populated by ideal doctors and ideal patients. Yes, I have seen the same experience that happened to your mother many times, often in government hospitals here.

CHAR: Interesting read! Thanks. I might post something about that in the future.

bayi said...

My apologies, Dr Emer. That was me. I remember clicking in the appropriate place and keying in my name but my computer acts funny these days. But I can't hide from you, can I? *LOL*

Mec said...

hay... this takes me yet again back to Py and his pedia... she saw him every month for more than 2 years and didn't think that his lopsided chest meant anything... and she missed hearing that his right lung wasn't working right... and even when Py was hard of breathing, she insisted that he was ok...

she only gave in to an x-ray because my cousin insisted our nephew might have asthma...

(it may be wrong to think ill of someone but heaven help me, I really pray God will punish her in unimaginable ways)

sigh.

anyway, Doc, your post reminded me of the series Dr. House...i know it's not a medically-correct series but they do a lot of treating each case as unique... and I sure hope that there could be some training for our doctors to be more competent :)

Christine Gorman said...

One of the things Groopman told me when I interviewed him is that he's trying to get a national conversation started in the U.S. about these issues--and to get medical schools to do more training in "how to think" and "how to be open to patients' questions."

Sounds like this is something that should happen worldwide.

Dr. Emer said...

BAYI: I knew it was you!

MEC: I think that's not being blinded by stereotypes anymore, like what Dr. Groopman has suggested. I think what you described there is called negligence.

CHRISTINE: I think that's a welcome development, should it happen. As doctors, I think we do need that added advice on how to think better to better help our patients.

Moof said...

Dr. Emer, that was an excellent post. I just today made an appointment to see a new primary care, and I was very ... nervous ... about doing so. This post affirmed my reasons ... and reasoning. Thank you.

Anonymous said...

that was a very interesting story above...

let me say though that i do not believe the said physician made a mistake...like what you said...he took a good history and did his physical examination and found it to be normal...

most headaches are NOT a prodrome to strokes and Dr. Emer should know that...if it sounds like a horse and talks like a horse it must be a horse...sometimes it may be a zebra but good doctors don't look for zebras right away...the more common things are the more common diagnoses...

a physicians role is to get information from the patient regarding a certain complaint...do a "decent" physical examination...make a tentative diagnoses and then make the appropriate recommendations...

a headache in an otherwise healthy individual with no specifice abnormal findings is unlikely to be a stroke...i do not think treating it as a "plain" headache with NSAIDS was wrong or improper practice of medicine...it is unfortunate that he had a stroke a few hours after...very unfortunate indeed...

may i ask Dr. Emer...what would you have expected to find in the physical examination that would make you think this was a prodrome to a stroke? a carotid bruit? an irregular heart rate? an abnormal funduscopy? i doubt that there would be any neurologic findings at that time...

would you have ordered a CT scan of the head? would you have ordered a doppler ultrasound of the carotids? an ECG? even if you did...i doubt that it would have shown anything at that time considering the examination was normal...i hate to criticize other doctors practice of medicine...and in as much as there are a few doctors who are "quacks" so to say...i believe majority are good ones...

the case discussed above was NOT a mistake...it maybe a misdiagnoses...but NOT a mistake...

Very sincerely,

An Internist Practicing in Rural America

Anonymous said...

Reading these blogs I had the thought that Emer or Groopman could probably write a nice book (like Oliver Sacks, MD) about the art and science of differential diagnoses.

Emer's approach sounds much like one of my favorite creativity books, "De Bono's Thinking Course".

Pharma Guy in NYC