How Doctors Think

My most recent chronic illness/chronic pain support group meeting was on the topic of communication with your doctor.  In today's post and the next one, I will share some highlights of that session. I started with a review of the book HOW DOCTORS THINK, by Dr. Jerome Groopman. 

Dr Groopman stated that medical students these days are taught to diagnose by using decision trees. The trunk of the clinical decision tree is a patient's major symptom or laboratory result, contained within a box. Arrows branch from the first box to other boxes. For example, a common symptom like "sore throat" would begin the tree, followed by a series of branches with "yes" or "no" questions about associated symptoms.

This can be useful for run-of-the-mill diagnosis and treatment — distinguishing strep throat from viral pharyngitis, for example. But they don’t work when a doctor needs to think outside the box. This method of diagnosing ignores the fact that each person is different, shows symptoms differently and reacts differently to treatment.

Dr Groopman concluded that the next generation of doctors was being conditioned to function like well-programmed computers that operate within a strict binary framework.

Doctors are supposed to be emotionally neutral, but this isn’t always the case. The sickest patients are often the least liked by some doctors. The doctor may feel frustrated, and feel a sense of failure with disease that resists treatment. People with chronic pain and chronic illnesses tend to fit this category. It’s important to find doctors who can work with us.

On average doctors tend to interrupt patients within 18 seconds of when they begin telling their story. Doctors end up making thinking errors, by stereotyping, or jumping to conclusions based on assumption. They fail to consider possibilities that contradict their mental templates of a disease, and thus attribute symptoms to the wrong cause. Once there is a label, they stop looking, ignoring details that don’t fit.

After surveying the significance of a doctor's words and feelings, the book looks at how different types of doctors think. An ER doctor needs to use a different thinking style than a primary care doctor. For either one, though, sound medical judgments meld together first impressions and deliberate analysis. This requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes. There is a factory mentality w/ managed care.

This book is worth the time to read it.  It will give you insight into how your doctor may be thinking, and that insight can guide how you interact with him/her.  Dr. Groopman gives some suggestions of what we, as patients, can do to help our doctors give us the best care:

• Offer to retell your story-how you felt, when and how it happened/. This can remind the doctor of a clue he had overlooked or forgotten, or prompt him to think in another direction.
• There is a 20-30% error rate in radiology- esp. w/ more sophisticated scans, where there are thousands of images. Ask that scans be re-examined, or even redone.  Radiologists do best if they know why the scan was ordered. If the doctor didn’t specify, you tell them. If other tests were inconclusive, they may also need to be redone.
• Patients can ask questions to guide the doctor off the automatic expected path. “What else could it be?” “Is there anything that doesn’t fit?” “Is it possible I have more than one problem?” “What is the worst thing this could be?” “What body parts are near where I am having symptoms?” If treatment isn’t working or if the doctor suggests something that didn’t work in the past, or you had a bad reaction to, tell him, and ask “What else can I try?”
• Tell your Dr how you feel, what you think, what you fear. Ask questions if you don’t understand. Take notes. Take someone with you if you want, to be an extra set of ears.
• Sometimes a doctor does not want to be asked questions. It is your body; you have a right to be informed, and to get the best care possible.
• If you feel you and your doctor are not communicating well, you can find a new doctor, or bring up the issue with the doctor. Sometimes clarifying expectations can help.
• Dr Groopman concludes that doctors are learning to partner with the patient and family. Patients need to be more educated and informed. Look on the internet (but be picky about what sources you believe.) Talk to other people. Give your doctor info about your illness, etc. The more they understand, the better they will be able to help you.

In my next post I will share a list of other ideas to help you communicate better with your doctor.