Not Well

As the first waves of baby boomers hit their sixties, the inexorable upward march in the nation’s median age is inexorably expanding the role of doctors in most people’s lives. Medical interactions also become more angst ridden, as thickening case files become signposts on the road to death.

But doctors bring hope as well, for advances in medical technology now often permit graceful recoveries from diseases like heart attacks and cancers which, not so long ago, were usually fatal. For medicine to work its magic, however, a doctor must first correctly interpret a patient’s symptoms and identify the right course of action. It is that crucial diagnostic challenge that Jerome Groopman, a New Yorker essayist and holder of a chair in medicine at Harvard, fears doctors too frequently bungle.

How Doctors Think might more accurately have been titled How Doctors Don’t Think. In a series of elegantly written case reports, Groopman describes an array of common mental pitfalls that entrap even the finest doctors. There is “framing,” for example. For fifteen years, a woman was described as suffering from “bulimia and anorexia nervosa,” until a gifted doctor ignored her case file and discovered that the real problem was a genetic immune reaction to wheat gluten.

Then there is “anchoring”-finding something that fits and sticking with it. A Native American woman is diagnosed with viral pneumonia. The disease is going around and she has the usual symptoms, but it is labeled “subclinical” because the viral levels are still too low to be detected. In fact, the woman has mistakenly overdosed on aspirin; the pneumonia virus wasn’t detected because it wasn’t there.

And there is “search satisficing”-a radiologist finds clear signs of pneumonia, so he writes a report and goes on to another case. But if he had kept on looking, he also would have seen a tumor. Finding one disease doesn’t exhaust the possibilities.

Groopman freely shares both his own mistakes and his own troubles with doctors, like the half-dozen top hand surgeons he went through before he found one whom he trusted. Research shows that some 10-15 percent of all cases are misdiagnosed, but it’s rarely because doctors haven’t learned to recognize the disease. The problem, Groopman suggests, is usually a failure to think “laterally.” The solution, he argues, lies as much with patients as with doctors. It’s up to you, he suggests to his nonmedical readers, to monitor your doctor’s thought processes and to be sure she’s not assuming your upset stomach is a flu symptom just because it’s flu season. If she hears hoofbeats, in other words, she should at least consider the possibility of zebras.

How Doctors Think is a pleasure to read, and Groopman comes across as an unusually thoughtful, inquiring, and humane doctor. If I ever come down with a baffling disease, I’d love to have him as my internist. But his book also carries an implicit policy argument that I don’t find especially convincing. His case stories usually involve top-flight doctors spending a lot of time with patients who have conditions that are either rare or hard to distinguish from other common disorders. The genetic test for the wheat gluten case, for example, is still fairly new, and the doctor who solved the riddle had specialized in malabsorptive disorders at the National Institutes of Health, and so may have been particularly attuned to catching it. In other words, do Groopman’s case analyses, fascinating as they are, provide a practical template for improving the overall accuracy of medical diagnostics? On the whole, I suspect not.

Given the tangled mess that passes for the American health-care system, a high rate of misdiagnoses is more likely to signal that doctors are missing herds of horses, rather than the occasional zebra. Consider some snippets of research. An alarmingly high percentage of hospital discharge test results either never get to, or are never read by, a patient’s physician. In contrast to their peers in other industrialized countries, American doctors are far less likely to have access to electronic case records and are far more likely to repeat a test because they can’t get access to a previous one. American patients, in any case, are much more likely to go to emergency rooms when they are ill because they can’t get access to their doctors in the first place. The fifth or so of Medicare patients who account for the highest spending have, on average, five major disorders and fourteen doctors, none of whom is likely to have complete access to case records, pharmaceutical orders, or test results. With symptoms like these, is “more lateral thinking” likely to be an effective prescription?

Groopman, unfortunately, tends to disparage the fledgling attempts to create electronic patient databases or to impose minimum treatment protocols to ensure that patients are not completely lost. He is the consummate clinician: his paradigm of medicine is an intensely personal interaction between a (preferably articulate) patient and an inquiring physician. For those with a high income, or with the good luck to find a Groopman with time on his hands, it is the ideal. But perhaps it’s time that great doctors, like Groopman, engage in some creative problem-solving on behalf of everyone else.