How Doctors Think

Many patients see doctors surrounded by an aura of infallibility. Well trained, well paid, and well dressed in the ubiquitous white coat, physicians are usually assumed to have authority, knowledge, and skills beyond ordinary mortals. Often this confidence is well placed. Doctors on the whole do make good decisions, help people to health and well-being, and care enough to listen to patients. Yet in the real practice of medicine, errors occur. Jerome Groopman’s How Doctors Think examines the multiple sources of such problems: errors in logic and thinking, lapses in diagnosis and treatment, and the emotional overlay that can impede and compromise communication on both sides of the physician’s desk. The reader will embark on a journey into the psychology of the medical profession.

Some pathological conditions resist diagnosis. Misdiagnosis can bring discomfort, disability, and perhaps even death to frustrated patients. In the routine practice of medicine, errors in judgment and choices of treatment happen; such errors are not always caught by the professionals who make them. Patients may not respond to or may react poorly to treatment choices or medication. Without a satisfactory return to health, patients often seek other opinions. They may spend years moving from doctor to doctor seeking answers to their health problems.

What is the problem? A doctor may miss key parts of the patient’s history or have preconceptions about what is wrong that block the doctor from discovering the real problem. How do doctors think? How should doctors think? What clouds the pure scientific judgment of the medical professional? The book tries to capture what happens in the doctor’s consciousness as he or she encounters a patient. Each chapter deals with a different aspect of medical practice, from the overwhelming task of the primary care physician to the more narrow (yet not necessarily less error-prone) world of specialists. The book considers everything from scientific studiesone shows that a doctor will ordinarily interrupt a patient after only eighteen seconds of narrativeto the very personal reaction of a doctor as patient, the story of Groopman’s own poignant reaction to an X ray as he is initially misdiagnosed.

Young doctors take up to one-half hour to diagnose a patient’s condition; experienced clinicians may reach a conclusion in as little as twenty seconds. This instant messaging of the physician’s process is the result of what is called pattern recognition. Often the doctor is not even aware of what is happening during the process. Sometimes the process of diagnosis results in cognitive errors, which the author ascribes to a lack of recognition of the feelings that accompany the presumed detached process of thinking. One study suggested that 80 percent of misdiagnoses were the result of what Groopman calls “a cascade of cognitive errors” by doctors.

Sometimes the emotional overlay, perhaps even a patient’s healthy appearance, may cloud the medical decision making and result in misdiagnosis. Groopman offers richly described anecdotes to illustrate the interjection of the doctor’s feelings into the encounter with patients. Sometimes these emotions result in a lack of mooring to the professional process. Such a disconnect may result in bad medicine.

Older doctors were not taught systematically how to think as clinicians. Listening skills and proper observation of patients historically were not part of medical school curricula. Rather, such techniques were supposed to be assimilated, perhaps even subliminally, from observation of wiser and more experienced practitioners. By contrast, the climate of modern medicine favors tests, algorithms, or “decision trees.” Medical students are trained to think systematically about clusters of symptoms, to rule out certain illnesses, and to arrive finally at the correct diagnosis. Modern doctors rely on these tools to lead them to quick and confident diagnoses. Modern medicine does not favor protracted listening to the patient. It assumes that the doctor, with wonderful diagnostic tools, knows the body of the patient better than the...

(The entire section is 1696 words.)


Booklist 103, nos. 9/10 (January 1-15, 2007): 21.

Business Week, March 26, 2007, p. 140.

Commonweal 134, no. 14 (August 17, 2007): 22-23.

Kirkus Reviews 75, no. 2 (January 15, 2007): 62.

The Lancet 367 (March 11, 2007): 807-808.

The New York Review of Books 54, no. 9 (May 31, 2007): 16-20.

The New York Times Book Review 156 (April 1, 2007): 17.

Publishers Weekly 254, no. 5 (January 29, 2007): 51.

The Wall Street Journal 249, no. 63 (March 17, 2007): 12.