Commentary

Alex Hansen

Neurobiology and Behavior

May 15, 2007

How Doctors Think

Throughout How Doctors Think, Jerome Groopman examines the thought processes that occur within the minds of varying doctors, moreover examining the imperfections that are inevitable among all humans. With a gained knowledge of these processes that occur, both patients and doctors are able to benefit through using this predictive quality to their advantage. Doctors can learn to avoid particular lurking thoughts and mannerisms which may have the potential of leading to danger, while patients can become alert to the possible mistakes of doctors, and therefore protect themselves. Although we often expect the word of a doctor to be flawless, almost as if it were the word of God, it is important to never disregard the fact that doctors posses no immortal qualities and that their words are never absolute. He writes, “Of course, no one can expect a physician to be infallible. Medicine is, at its core, an uncertain science. Every doctor makes mistakes in diagnosis and treatment. But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better” (Groopman). Thus, with each chapter new information is provided as to how doctors can be made to think more efficiently and effectively in regards to the world of medicine and their work habits.

Initially and most importantly, Groopman explores the notion pertaining to the use of language and the relationship that exists between doctor and patient. The best possible relationship is concluded as one in which the doctor allows him or herself to think in terms of a patient while the patient in turns places him or herself in the shoes of the attending physician. As the doctor begins to think as the patient, he/she is dissociated from the physical medical world and placed in a more emotional medical world. Such allows the doctor to better communicate with the patient on a level with apparent compassion and positive attitudes. As a result, with comfort, the patient becomes more thoroughly compliant and the doctor receives more information from the patient. Specifically, Groopman depicts the relationship as “how a doctor thinks can first be discerned by how he speaks and how he listens… They have shown that how a doctor asks question and how he responds to his patient’s emotions are both key to what they term patient activation and engagement…That free of patient speech is necessary is the doctor is to get clues about the medical enigma before him…maximize the opportunity for a doctor to hear new information.” With such, the doctor is able to enter the world of the patient’s mind, however, “once you remove yourself from the patient’s story you no longer are truly a doctor.” Thus, the amount of information received dictates the amount of detail within the ‘created’ story, and in turn dictates the accuracy of the medical diagnosis, which in turn dictates the quality of the doctor. Furthermore, such free speech nourishes the ability of the patient to ask questions while the doctor in response provides the answers. These patient questions often allow the doctor to think in a more productive manner and determine the correct diagnosis, avoid misdiagnosis. “Patients can learn to question and to think the way a doctor should… can offer words to prevent these cognitive mistakes.” Overall, Groopman successfully concludes that communication is the overall means for providing success among doctors and patients.

Profitable communication and the overall emotional atmosphere serve not only as a means to control the response of another, but the active individual as well. Specifically, the apparent mood and aura experienced by the doctor can affect the diagnosis that he or she deducts. For example, the emotional temperament of a doctor can lead to significant judgments and serious cognitive errors. “I wish I had been taught, had gained the self-awareness, to realize how emotion can blur a doctor’s ability to listen and think.” One such blurring to which Groopman refers is the “narrow mind set” that the doctor is often placed into as a result of his or her current emotions. This mind set can be inhibiting as the doctor will often “ignore information that contradicted a fixed notion.” More specifically, such is an example of a cognitive trap. Cognitive traps are highly regarded as a major cause of physician misdiagnosis rather than a flaw in the doctor’s inherit knowledge and learning. “Doctors fail to question their assumptions and overlook gaps in their knowledge, leading to thinking that is sometimes closed or skewed.” Thus, the appropriate mindset of a doctor dictates success on varying levels. Groopman primes the readers into understanding the role of the mind in medicine, rather than simply relying on the brain to solve the science of the body – “both mind and body have to be considered, at times independently, at times through their connections.” To develop the perfect mind is thus what differentiates the paramount doctors from the others.

Although Groopman simply touches on the topic of the real world in comparison to the academic world, I consider such to play a crucial role in the success of physicians and thus suggest furthering examining this relationship. The main difference between these two such worlds lies in the use of emotion and intuition. Within medical school, knowledge is taught in the classroom and many books are read, however, no two cases will ever look exactly the same for no patient is completely identical to another. Thus, although the world of academics can teach us the knowledge, when placed in a real world experience, such knowledge and the brain can only take the doctor to one level while it is the emotion and the mind which complete the picture. Groopman states that “cognition and emotion are inseparable… most errors are mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don’t even recognize.” Thus, to recognize such feelings and in turn utilize them along with cognitive thinking is what determines a successful doctor. There exists an optimal level of emotion and cognition to which yields the most accurate conclusions due to the resulting increased efficiency and efficacy. For example, “correctly adjusting the emotional temperament saved a life.” However, it is essential to recognize that such is a delicate balance, and any imbalance can lead to these medical mistakes. “We have to detach ourselves from anguish that could impede our work. But to become immune to feeling, is to diminish the full role of the physicians as a healer and relegate him to a single dimension of his job, that of a tactician. If we feel our emotions deeply, we risk recoiling or breaking down, if we erase our emotions, however, we fail to care for the patient. We face a paradox: feeling prevents us from being blind to our patient’s souls, but risks blinding us to what is wrong with him.” The relationship between mind and brain, just as the relationship between doctor and patient, is depicted as a means for success in avoiding mistakes. In terms of our class this semester, this seemed very relevant and intriguing, for Groopman essentially describes an application of the conclusions established between brain and behavior during class discussions and lectures. Thus, especially in relation to my individual life, for I intend to become a doctor, I found this book to be necessary in preparation for what lies ahead, in preparation for priming my mind and brain to the fundamental mindsets of a doctor. Moreover, not only can such be applied to the field of medicine, but these thought processes that Groopman describes can be applied to any professional in which the individual’s responsibility includes successfully communicating with another. Thus, How Doctors Think is a universally applicable book regarding types of rewarding improvements for all individuals in order to avoid life mistakes.

As Groopman describes the methods in which the mistakes are able to be prevented, he proceeds to examine the specific types of mistakes that doctors most often perform. The manner in which Groopman proceeds with his explanations is through depicting numerous different case studies, each involving a new patient, and a new problem. Therefore, the reader is allowed to observe the mistake in action instead of simply imaging the application of these numerous mistakes of doctors. I found each different chapter very compelling as I learned of a new type of error to avoid as a doctor. First, “representativeness error” is defined as “your thinking is guided by a prototype, so you fail to consider possibilities that contradict and thus attribute the symptoms to the wrong cause.” In order to compensate for such error, the doctor has to prepare his or herself for the atypical, thus preventing failure of consideration of other possibilities and preventing the quick reassurance that everything remains okay. Another error is titled “attribution error” where the patient fits into a negative stereotype. Such is explained though case studies of alcoholics, or non-obedient patients, etc. who are perceived by their doctors as patients who are not deserving of their time and attention for they are neglecting their expertise advice. As a result, mistakes arise due to this mental mindset of the doctors who place these patients into a negative stereotype. Another hindering mindset is known as “overconfident” and is described as people who convince themselves they are right because they usually are. They tend to focus on positive data rather than negative data, for “positive data is emotionally more appealing because it suggests a successful outcome.” However, such actions do not guarantee that the physician is providing the accurate conclusion, and thus the chance for a medical mistake increases. An additional medical case explains the role of “availability” which can be related to this overconfident mindset, and the availability error which arises from the “tendency to judge the likelihood of an event by the ease with which relevant examples come to mind.” Confirmation bias was described as well – “confirming what you expect to find by selectively accepting or ignoring information.” Such relates to “anchoring,” defined as a “shortcut in thinking where a person doesn’t consider multiple possibilities but quickly and firmly latches on to a single one, sure that he has thrown his anchor down just where he needs to be.” Another such mistake is termed the ying-yang mistake, “failure to think of a new direction, because you assume all have been explored.” Such various mistakes are able to be avoided as long as the doctor prepares his or herself to be aware of these possible intrinsic methods of thinking, aware of the heuristics being used and the dangers of such, aware of the affects of his emotions, aware that the answer he perceives to be correct could in fact be wrong. Groopman intelligently deducted that “we lull ourselves into thinking that what we wish for will occur when we get the first inkling, however fragmentary, that our wish may come true. In short we value too highly information that fulfills our desires,” and in turn concludes, “I learned from this to always hold back, to make sure that even when I think I have the answer to generate a short list of alternatives… That simple strategy is one of the strongest safeguard against cognitive errors.” In order to become the most successful doctor, he/she must learn from his/her mistakes and overall, avoid any need to protect the ego, for essentially, the mindsets that are present among these doctors which lead to the mistakes, can be related to his or her ego. Thus, Groopman indirectly aims to instruct all individuals upon reading his book of the needed techniques to gain success, achieved through learning from mistakes and controlling the ego.

An essential prime skill for achievement within any aspect of life lies within the use of effective time management, and such is a primal necessity among doctors. Groopman successfully depicts the importance of this skill among physicians. The most esteemed doctors are ones that are able to understand the limitations of time and use such to his or her advantage. Time is of serious value and should not be taken lightly, but rather regarded with care. Groopman writes, “A good physician learns how to manage time. Symptoms that are straightforward can be accurately defined and explained to a patient and loved ones in clear accessible language within a twenty minute visit… complicated problems cannot be solved too quickly. A discerning doctor will recognize when more time is needed to ask questions and explain his thinking… finding the right answer often takes time. Haste makes cognitive errors.” It is the responsibility of physicians to improve the health of other humans, and thus, time should not inhibit or detour the doctor from making a conclusion that could end in disaster. Human biology is “inherently variable” and thus, the exact answer is not a guarantee, and while doctors need to “recognize that what they think can have its limitations,” it is essential to recognize the limitations of time and aim to prevent such a limitation from affecting the results. Time is a variable that can be kept under the control of the doctor, and thus should not act to be the cause of these possible mistakes. The “key to the art of dealing with a situation of uncertainty or uniqueness… is for the physician to express uncertainty, take time to reflect, and allow himself to be vulnerable and then restructure the problem.” Upon the restructure of the problem, enhancing the accuracy of the conclusions arises from vigilance of social context, attention to common flawed mindsets and valuable questioning. This vigilance and corresponding enhancement develops without the anxiety caused by a time constraint. Thus, a thorough combination of these qualities produces the most profitable physicians. In the end, Groopman’s goal to convey this strategy to all individuals upon reading this book was achieved, for as a reader myself, I was able to construct, what appeared to be, the most desirable doctor with respect to particular mind processes.

In personally interpreting the book, I concluded that Groopman aims to express the imperfections of humans as they apply to doctors in order to enhance future medical experiences. The main conclusion I derived included that mistakes are inevitably and thus uncontrollable, as Groopman reiterates on numerous occasions; however, there is a level of control that humans possess. Upon each chapter, Groopman grabs the reader with devastating medical stories, concluding with an intellectual remark of intelligence regarding the methods of prevention. Essentially, humans are able to control the manner in which they deal with the mistake, and control the manner in which they approach a situation. In response, they are able to prepare themselves from exhibiting preventive mistakes that often exist due to the cognitive traps. To avoid a cognitive trap is to prevent a mistake. Although as individuals, we are trained by our authority figures, we must not comply completely with their teachings, and learn to pinpoint and thus evade the traps to which our teachers may be oblivious. It is important to become aware of the mistake that we make, for the particular mistakes one doctor makes often possess a common trait. However, our ego leads us to avoid recognition of our mistakes and thus, “most doctors are unaware of their cognitive mistakes.” To control and orient our minds in the proper direction is to gain success. Through providing explicit examples of the errors and the corresponding dangers, the importance of such is reinforced, and thus, Groopman successfully portrays the ways in which doctors think and the ways in which these thought processes need to be altered to improve the medical world.