article
Knowing the right question to ask your doctor
Fact: A doctor in this country interrupts a patient, on average, in the first 18 seconds of a visit.
A prominent surgeon waited about a minute and a half before issuing his diagnosis to Jerome Groopman on his damaged hand. "He was dead wrong," says Groopman, who got four diagnoses from six surgeons. "And these are big names."
Fact: More than 15 percent - some say more than 20 percent - of medical diagnoses are wrong. At least half result in serious injury or death.
Groopman tells of a woman who saw close to 30 doctors for a constellation of ailments that gradually sapped the life out of her. She endured excruciating pain and was down to 85 pounds. Her immune system was failing and she had developed severe osteoporosis. All of them missed what was ailing her. Finally, a fresh doctor asked a fresh set of questions. He listened to her and found that she suffered from a gluten allergy that prevented her from receiving the nutrients in the food she ate. After years of agony, she quickly recovered.
Fact: More than a quarter of all radiological tests, including CAT scans and MRIs, are misread. "Misdiagnoses are not rare at all," says Groopman, the noted oncologist and chief of experimental medicine at the Beth Israel Deaconess Medical Center, who assembled this data.
While the patient safety movement has led to major improvements in protocols to avoid systems errors, he points out, nothing has been done to address a more profound issue: how doctors think. And bad thinking is what causes countless mistakes. "No one talks about this stuff," Groopman says. He is struck by the lack of independent thinking among the residents he leads on hospital rounds. "These are really smart people, and when asked for a diagnosis they download cookbook recipes on their computers," he explains. "If it's not that, they look blankly. How do I teach them how to think? I realized I didn't know how I think. No one ever taught me how to think."
Groopman addresses this touchy subject in a book, "How Doctors Think," due out this spring. In it are examples of bad thinking, including plenty of his own, that produced harrowing results. None of this is news to patients. Most of us know someone who has endured a misdiagnosis or have done so ourselves. My friend went through a year of agony because of one.
Groopman's first child developed a persistent low-grade fever and stomach pain at nine months. A doctor said not to worry, it's just a virus. The child's condition deteriorated, but the doctor remained unmoved. Eventually, Groopman and his wife rushed their son to an emergency room, where they learned the child had an intestinal obstruction that would have killed him had it gone untreated.
What went wrong here?
The doctor sized up Groopman and his wife as neurotic first-time parents and built his diagnosis around that premise. At work, says Groopman, were two suspects common in these nightmares.
The first is what he calls anchoring - where a doctor interrupts you, seizes on a symptom or complaint, and declares, "It's this." This snap judgment anchors all ensuing thinking.
The second he calls attribution, to which women are particularly vulnerable, where assumptions about a patient are attributed to bad data.
Groopman tells of a woman with a newborn child and two young children who complained about constant nausea and diarrhea. "The doctor looked at her and decided it was stress, that she was neurotic," Groopman said. "So he attributes all of her complaints to the stereotype he has in his mind. I saw her a few months ago. She had been diagnosed with a tumor in her intestine but had been taking Zoloft for a year and a half."
Time is an insidious agent in all this. "In today's medical environment, the clinic is a factory," he says. "It's a world of eight-minute visits. The mistakes are made in the moment. Doctors draw immediate diagnoses rather than listen and pursue leads. And when complaints persist, they all too often cling to their first thought and even discount contradictory evidence.
"It's impossible to figure out a difficult problem in eight minutes," he said. "A doctor has one eye on the clock and one eye on a computer screen as he types notes. The truth is, you can't think well in haste.
"There is no generic best treatment to a serious problem," he says: "We delude ourselves to think the answer is the systems solution - 'We'll give you an algorithm: if it's A then B then C.' You've got to know what A is in the first place. And sometimes you have to go past C."
Many in the medical community will bristle at Groopman's findings. Others will recognize the truth in what he says and, with luck, a few of the bean counters controlling medicine today as well. They can't dismiss the book. It is meticulously researched and written by a physician of stature.
"One solution for misdiagnosis is a patient or family member who knows how doctors think," Groopman said.
So what should we be asking our doctors, over and over?
"What else could it be?"
----------------
Sam Allis writes for the Boston Globe: allisglobe.com
Posted on Tue, Jan. 30, 2007
Fact: A doctor in this country interrupts a patient, on average, in the first 18 seconds of a visit.
A prominent surgeon waited about a minute and a half before issuing his diagnosis to Jerome Groopman on his damaged hand. "He was dead wrong," says Groopman, who got four diagnoses from six surgeons. "And these are big names."
Fact: More than 15 percent - some say more than 20 percent - of medical diagnoses are wrong. At least half result in serious injury or death.
Groopman tells of a woman who saw close to 30 doctors for a constellation of ailments that gradually sapped the life out of her. She endured excruciating pain and was down to 85 pounds. Her immune system was failing and she had developed severe osteoporosis. All of them missed what was ailing her. Finally, a fresh doctor asked a fresh set of questions. He listened to her and found that she suffered from a gluten allergy that prevented her from receiving the nutrients in the food she ate. After years of agony, she quickly recovered.
Fact: More than a quarter of all radiological tests, including CAT scans and MRIs, are misread. "Misdiagnoses are not rare at all," says Groopman, the noted oncologist and chief of experimental medicine at the Beth Israel Deaconess Medical Center, who assembled this data.
While the patient safety movement has led to major improvements in protocols to avoid systems errors, he points out, nothing has been done to address a more profound issue: how doctors think. And bad thinking is what causes countless mistakes. "No one talks about this stuff," Groopman says. He is struck by the lack of independent thinking among the residents he leads on hospital rounds. "These are really smart people, and when asked for a diagnosis they download cookbook recipes on their computers," he explains. "If it's not that, they look blankly. How do I teach them how to think? I realized I didn't know how I think. No one ever taught me how to think."
Groopman addresses this touchy subject in a book, "How Doctors Think," due out this spring. In it are examples of bad thinking, including plenty of his own, that produced harrowing results. None of this is news to patients. Most of us know someone who has endured a misdiagnosis or have done so ourselves. My friend went through a year of agony because of one.
Groopman's first child developed a persistent low-grade fever and stomach pain at nine months. A doctor said not to worry, it's just a virus. The child's condition deteriorated, but the doctor remained unmoved. Eventually, Groopman and his wife rushed their son to an emergency room, where they learned the child had an intestinal obstruction that would have killed him had it gone untreated.
What went wrong here?
The doctor sized up Groopman and his wife as neurotic first-time parents and built his diagnosis around that premise. At work, says Groopman, were two suspects common in these nightmares.
The first is what he calls anchoring - where a doctor interrupts you, seizes on a symptom or complaint, and declares, "It's this." This snap judgment anchors all ensuing thinking.
The second he calls attribution, to which women are particularly vulnerable, where assumptions about a patient are attributed to bad data.
Groopman tells of a woman with a newborn child and two young children who complained about constant nausea and diarrhea. "The doctor looked at her and decided it was stress, that she was neurotic," Groopman said. "So he attributes all of her complaints to the stereotype he has in his mind. I saw her a few months ago. She had been diagnosed with a tumor in her intestine but had been taking Zoloft for a year and a half."
Time is an insidious agent in all this. "In today's medical environment, the clinic is a factory," he says. "It's a world of eight-minute visits. The mistakes are made in the moment. Doctors draw immediate diagnoses rather than listen and pursue leads. And when complaints persist, they all too often cling to their first thought and even discount contradictory evidence.
"It's impossible to figure out a difficult problem in eight minutes," he said. "A doctor has one eye on the clock and one eye on a computer screen as he types notes. The truth is, you can't think well in haste.
"There is no generic best treatment to a serious problem," he says: "We delude ourselves to think the answer is the systems solution - 'We'll give you an algorithm: if it's A then B then C.' You've got to know what A is in the first place. And sometimes you have to go past C."
Many in the medical community will bristle at Groopman's findings. Others will recognize the truth in what he says and, with luck, a few of the bean counters controlling medicine today as well. They can't dismiss the book. It is meticulously researched and written by a physician of stature.
"One solution for misdiagnosis is a patient or family member who knows how doctors think," Groopman said.
So what should we be asking our doctors, over and over?
"What else could it be?"
----------------
Sam Allis writes for the Boston Globe: allisglobe.com
Posted on Tue, Jan. 30, 2007