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