Four physicians work on the same patient for days at a time, continually returning to a white board, where they list the patient's changing symptoms and their own differential diagnoses. They think inside and outside the box. As data come in from tests and as interventions succeed or fail, they remain flexible in their way of thinking. The attending physician's main lesson to his 3 fellows is to remain unencumbered by preconceived notions and to constantly revise their thinking to fit the data. Only then, he tells his trainees, is there any chance of a correct diagnosis and medical treatment.
This is the weekly premise of the popular television show House, in which a fictional Dr Gregory House runs a diagnostic unit while teaching and mentoring 3 younger physicians. Although he is flawed—he is addicted to painkillers and has the bedside manner of Don Rickles—Dr House does whatever he believes is best for his patients. Costs, rules, risks, and even ethics be damned! House is a guerrilla physician, evading or outwitting hospital administrators to achieve his mission: correct diagnosis and treatment of patients. Appalled as I am at his behavior, I cannot help but admire his no-holds-barred zeal to cure his patients. In this fast-forward era of productivity requirements and insurance constraints, do we all need our own Dr House to receive good medical care?
The way that Dr House practices medicine is as remote from reality as the Twilight Zone. Today's medical care system is broken. Politicians offer fixes for the systemic problems, but manifold issues arise as well in the face-to-face arena of patient care—the examining room. Physicians have 10 minutes to evaluate sick patients and 20 minutes to review histories and perform physical examinations on new patients. With panels of 2000 patients, frenzied physicians may accrue more than 100 phone calls per day. How can weary physicians think in the multilayered, complex ways that are essential to proper treatment when they are incessantly distracted from their task?
The initial strategy to solve the problem of poor medical care was to educate the patient. Former Surgeon General C. Everett Koop produced a series of videotapes about organ systems' physiology and pathophysiology. Patients with common or obscure diseases can find a book about their particular disorder. But is it fair to ask patients to become educated consumers at the point when they are the most frightened and vulnerable? Must patients have the knowledge base of a medical student to ensure that they are obtaining good care and appropriate interventions? As a demanding and educated patient myself, I have found that being knowledgeable does not necessarily mean receiving better medical care.
Recently, Jerome Groopman, an oncologist at Boston's Beth Israel Deaconess Medical Center and writer for The New Yorker, addressed one aspect of medical care's problem list: rigid thinking. According to Groopman's new book, How Doctors Think, if we, as physicians, can notice when we have fallen into one or more modes of rigid thinking, then we can give ourselves a cognitive "shake" and rethink the diagnostic challenge.1 Groopman's book is based in part on the work of emergency department (ED) physician Pat Croskerry, whose seminal paper, "When Diagnoses Fail: New Insights, Old Thinking," describes categories of thinking that might result in misdiagnosis.2
Groopman defines terms reflecting different kinds of cognitive rigidities and then illustrates how these impact patient care by attaching them to carefully drawn and memorable cases; for example, the sinewy park ranger with cardiac symptoms, the adopted infant with malnutrition and immune system dysfunction, and the alcoholic with liver disease caused by both alcohol abuse and Wilson disease. He reveals mistakes that he has made in his own clinical practice, pointing out cognitive missteps that led him astray. In one case, Groopman's fondness for a cancer patient resulted in an unwise delay in an exhausting workup, leading to the catastrophe of sepsis.
Part of the richness of How Doctors Think comes from Groopman's interviews of physicians, who openly and honestly recount their own diagnostic errors and which internal and external forces allowed those errors to occur. In some cases, the physicians describe their own compensatory strategies to prevent them from falling into the same cognitive trap again. We would all be wise to develop our own personal "red flags" for rigid thinking.
The book suggests ways in which patients can keep their physicians from slipping into a rigid stance about their diagnosis. Crucially, patients must retain the presence of mind to consider whether the doctor's explanations make sense to them. Patients should also consider bringing an ally to their appointment—a person who can listen dispassionately, perhaps take notes, and ask questions. In addition, patients can ask a pair of simple questions to stimulate expansive thinking: Is this the only explanation for my symptoms? Is there another organ system that might also explain the symptoms?
1. Groopman J. How Doctors Think. New York: Houghton Mifflin; 2007.
2. Croskerry P. When diagnoses fail: new insights, old thinking. Can J CME. 2003:51-57.
3. Sanders L. Diagnosis. Muscle-bound. New York Times. February, 25, 2007:31.
4. Love S. To break the disease, break the mold. New York Times. April 1, 2007:12.
5. Dembner A. From retired caregivers, a spoonful of compassion. Boston Globe. February 25, 2007. Available at: http://www.boston.com/yourlife/health/other/articles/2007/02/25/
from_retired_caregivers_a_spoonful_of_compassion/. Accessed May 11, 2007
6. Gladwell M. Blink: The Power of Thinking Without Thinking. New York: Back Bay Books; 2007.