How Doctors Think
by Jerome Groopman
Houghton Mifflin, 307 pp., $26.00
Few can doubt that Western medicine has been a phenomenal success. Heart disease kills two-thirds fewer people now than it did fifty years ago. The frequency of conditions as diverse as stroke and trauma is being gradually checked. Mortality from breast cancer has fallen by a quarter in less than two decades. Doctors would dearly like to attribute these impressive results in Western countries to their accumulated expertise and the advances of science. But as Atul Gawande points out in Better: A Surgeon’s Notes on Performance, his latest collection of lucid essays,1 the residual contradiction is that while medicine succeeds, it never seems to succeed well enough. A doctor’s report card might look creditable today. Yet it nevertheless conceals serious unresolved and unacknowledged weaknesses.
“Science and skill,” Gawande writes, are “the easiest parts of care.” What matters more, he suggests, is diligence, doing right by patients, and ingenuity. Despite these “core requirements” for progress, and the fact that doctors have been remarkably successful in all three, errors are still commonly made. These mistakes badly scar the surface of medicine’s success. “Betterment is a perpetual labor,” Gawande concludes. The trick is to understand one’s limits.
One by one Gawande’s arguments are persuasively made and elegantly illustrated with examples ranging from antisepsis to obstetrics. He describes, for example, Thomas, a previously fit seventy-two-year-old man, who one day was found to have a cancer in his left kidney. The tumor was removed surgically but, instead of Thomas’s recovering, his entire body began to swell. Eventually, he was diagnosed with Cushing’s syndrome, a condition in which the adrenal glands overproduce steroid hormone. No matter what his doctors did, they could not stop the hormone from pouring into his bloodstream. Thomas became sicker and sicker. He could not walk and he had recurrent episodes of pneumonia.
By the time Thomas got to see Atul Gawande, there was only one option left—to remove the source of the offending hormone. Although the operation to take out his adrenal glands carried its own dangers, Gawande told Thomas that his only chance of a normal life was to accept the risk. The operation went well. But Thomas suffered a series of terrible complications, culminating in four months of intensive care, a tracheostomy, and incarceration in a long-term care facility. When he last saw Gawande, he could hardly lift his head. All he could do to express himself was to cry. Gawande implies that this was one operation that should have been avoided.
Many of Gawande’s essays began life as magazine and journal articles. Their original diversity and subsequent reworking to construct a larger thesis about the failure of medicine create a difficult tension. Although the individual foundations that Gawande lays down are strong, the overall architecture of his work lacks form and substance.
By striking contrast, Jerome Groopman, a cancer specialist who, like Gawande, writes for The New Yorker, delivers an altogether sharper and more coherent critique of medicine’s mistaken direction. And while Gawande’s prescriptions are gentle and well-meaning homilies—for example, he urges medical students to “change” and to “write something” about their experience2—Groopman presents a forceful and convincing manifesto that, if implemented, would overturn many conventions of modern medical practice.
Groopman’s central claim is that there is a common flaw that undermines much of contemporary medical education and training, as well as the partnership between patient and doctor and even the professional values of medicine. That flaw lies in the way doctors think. His disquiet originated from the frustration he felt working among his students and residents at Harvard Medical School. Whereas once they would take part in challenging and detailed debates about the patients they met and examined on rounds, they now “too often failed to question cogently or listen carefully or observe keenly…. Something was profoundly wrong with the way they were learning to solve clinical puzzles and care for people.”
Using a technique he has honed in his New Yorker essays, Groopman skillfully mixes stories of patients, interviews with doctors, research evidence, and his own personal experiences as a patient to mount an ambitious assault against several large targets. His ire is raised especially by what he sees as the hubris of “evidence-based medicine.” It would seem axiomatic to a nonphysician that medical practice is based on scientific evidence. Not so, according to the zealous advocates of evidence-based medicine, a movement that has come to dominate clinical practice during the past decade. These advocates, led originally by David Sackett and his colleagues at McMaster University in Canada, argue that doctors have preferred to rely on experience and expert opinion—as opposed to research and statistical evidence—out of laziness and a misplaced deference to the authority of received medical wisdom.
Worse, the same advocates argue that when doctors do consult the “evidence base,” they often do so in ignorance of what makes good and bad science. Groopman views the evidence-based approach, which aims to make clinical decisions follow from statistically valid information—in the form of “systematic” reviews, guidelines, or algorithms—as ill-informed by the realities, complexities, and uncertainties of medical practice. A “rigid reliance” on numbers—the numbers, for example, indicating which medicines have been proven effective for certain kinds of disease—will not meet every need of the patient who sits in front of the doctor. Such numbers are needed, but there can never be a purely rational or exact mathematical solution to a patient’s predicament. Groopman concludes that doctors are “being conditioned to function like a well-programmed computer that operates within a strict binary framework.” He disapproves of this medical scientism.
Often patients have conditions or combinations of conditions that do not easily match the supposed evidence. Sometimes patients have problems that are not easy to study scientifically. A strict requirement for evidence before acting may mean that physicians will stop thinking, stop evaluating each patient as a unique human being, and stop applying their knowledge to the particularities of the person before them. Groopman rails several times against the “bean counters” of medicine—doctors who recommend treatments that are seemingly supported by statistics but may not be appropriate for the person they are facing.
There is a still deeper fault line within medical practice. On average, about 15 percent of a doctor’s diagnoses are inaccurate. Groopman directs a well-aimed arrow at a system of medical training that more often than not fails to investigate why these diagnoses are missed. Doctors are rarely taught to ask how an error could have taken place, let alone how it could be avoided in the future. Most are unaware of their mistakes. Even if patients remain unwell, no systematic effort is made to find out where doctors may have gone wrong. Doctors are uncertain about their own uncertainties. (Although for some doctors, such as radiologists, Groopman cites alarming research that shows the worse their performance, the more certain they seem to be that they are right!)
Amid these wide-ranging attacks, the pharmaceutical industry does not escape Groopman’s scrutiny. The discovery of new medicines has delivered huge benefits for patients. But the incentives offered to doctors, and too often accepted by them—gifts, airfares, hotel accommodation, and expensive meals—distort their ability to make unbiased treatment decisions. In a recent survey of over 1,600 American physicians, for example, nine out of ten reported a relationship with a drug company.3 The benefits they received ranged from drug samples to tickets for sporting events, from payments for speaking to money in exchange for persuading patients to join a clinical trial.
The pressure of increasingly aggressive marketing tactics—which, Groopman shows, can amount to overt harassment—by pharmaceutical sales representatives only adds to a climate of acute misunderstanding. Most doctors receive information about new drugs directly from the pharmaceutical companies. Rarely do they investigate what is known about a drug for themselves. This reliance on biased information leaves the doctor poorly equipped to make balanced judgments.
But Groopman reserves some of his most bitter criticism for his colleagues within academic medicine. They have fostered a belief that anyone can take care of patients. This “arrogance” has created a culture at academic medical centers where research is applauded and teaching is taken for granted, where writing scientific papers (for journals like The Lancet) takes precedence over developing clinical skills. He very emphatically offers two examples of inferior, some might say even cruel, care at Memorial Sloan-Kettering hospital in New York City. In one case, he describes a patient who desperately sought treatment at this prestigious institution. But after his cancer failed to respond to chemotherapy, his doctor simply abandoned him, refusing even to return his calls. In a second example, a Sloan-Kettering oncologist told a woman in her fifties with spreading bladder cancer that there was no scientific evidence that would support any further treatment. He spoke of protocols, data, percentages, the statistical likelihood of her survival, and the technicalities of research studies. He was oblivious to her needs, to her hopes and fears. And he left her deeply distressed. Doctors are trained to deal with success, not failure. This hospital may be a cancer center of high international standing, yet Groopman makes the fair argument that the values, attitudes, and behavior of a doctor matter far more than the reputation of the institution at which he works. And here Memorial Sloan-Kettering, at least on the basis of these two instances, falls short of Groopman’s high standards.
So much for the prevailing environment of medicine today. But matters take a more sinister turn when one asks just how well doctors think.
Groopman draws extensively on the emerging cognitive science of medicine, which seeks to understand the mistakes doctors make in evaluating the information they gather from a patient’s history, the physical examination, and results of investigations. He reviews the errors and biases that most doctors unconsciously succumb to when thinking about what their findings mean for a patient’s diagnosis and treatment.
There is a rich and rather disturbing variety of human weaknesses to consider when watching a doctor at the patient’s bedside. Physicians can be easily led astray by seeing the patient from only one—and often very negative—perspective, independent of what the clinical findings suggest. Patients might be stigmatized if they are thought to have a mental health problem, or caricatured if they are judged to have engaged in self-harming behavior, such as alcoholism. This kind of mistake is called “attribution error.” “Availability error” occurs when a doctor makes a decision based on an experience that is at the forefront of his mind but which bears little or no relation to the patient before him. For instance, a specialist in gastroenterology may only think of the gut when evaluating a woman with abdominal pain. He may not think of gynecological causes for her symptoms. The ready availability of his own specialized experience in his assessment of what is wrong with a patient can seriously bias a doctor’s judgment.