One of the cases in Groopman's book is that of gastroenterologist Myron Falchuk and "Ann Dodge," a critically ill patient weighing 82 lb and carrying the diagnosis of eating disorder with irritable bowel syndrome. Falchuk is asked to render his opinion about Dodge's long-standing and seemingly intractable illness. Despite the fact that Dodge's voluminous medical chart seems to confirm the diagnosis, Falchuk decides to start from scratch and get the entire history of her illness, from her very first stomachache 15 years earlier to her perilous, present-day condition.
Falchuk indicated that he had had an almost immediate sense that Dodge was indeed doing everything in her power both to gain and retain weight. It was within the context of that trust that Falchuk pursued alternative diagnoses. After a short period, he discovered what a long list of prior clinicians had missed: Ann Dodge's condition stemmed not from an eating disorder but from celiac disease.
When I was taught the art of diagnosis in medical school, I was told to rely on the old saying, "If you hear hoofbeats, think horse, not zebra." Well, it was precisely their own rigid adherence to that dictum that blinded Ann Dodge's previous physicians to the true source of her affliction. I have to ask myself whether I, too, would have failed her. Somehow, Falchuk heard the hoofbeats of the zebra and, against a mountain of contrary opinions, pushed for the necessary diagnostic steps and interventions to help the patient.
Lisa Sanders, a physician at Yale-New Haven Hospital in Connecticut, recently related in the New York Times a dramatic medical mystery concerning a young, healthy male teacher who passesa pulmonary embolus and almost dies.3 This true story is a powerful example of the rigid thinking that Groopman warns us to avoid. After the usual workup for embolus formation turns out to be negative, the patient is given warfarin(Drug information on warfarin) (Coumadin) to prevent further emboli. This medication requires constant monitoring of blood levels and the usual restrictions in lifestyle: no activities in which the patient is likely to sustain an injury and no foods that would interfere with the metabolism or absorption of the medication.
After a host of clinicians fail to pinpoint the cause of his embolus, the patient seeks an opinion from Yale hematologist Thomas Duffy. Duffy considers all the "usual suspects" that cause emboli but remains open to more unusual causes.
On physical examination he realizes that the man's bulky upper arm and torso musculature might, in fact, be too developed to be healthy. With a simple diagnostic maneuver he learned in medical school, Duffy identifies a fixable problem: thoracic outlet syndrome. Had he been bogged down by previous medical opinions, Duffy might have missed the true cause of the embolus and the patient might still be taking warfarin.
Breast cancer researcher Susan Love pointed out that even medical research can be held back by cognitive blinders. In a recent op-ed piece in the New York Times,4 Love characterizes the com-mon treatments for cancers as "cuts," "burns," and "poisons." She points out that the thrust of cancer research has, until recently, focused on finding stronger and more effective poisons. Now researchers are thinking in multimodal ways. Judah Folkman has developed antiangiogenic drugs to fight cancer, and other researchers are looking at tumor receptor sites with the intent of developing drugs that might block the receptors and stall the progression of the cancer.The bedside advocate
To ensure that doctors don't get stuck in their thinking about complex patients, Cambridge, Mass, physician Jonathan Fine has started the Bedside Advocacy program.5 Retired physicians, nurses, and other qualified caregivers assume limited responsibility for 1 or 2 elderly patients with multisystemic problems. The advocates accompany their "patient-clients" to appointments and hospitalizations.
My 82-year-old mother could have used a bedside advocate last year when she had massive bleeds into both calves while using warfarin. The blood was resorbed and the swelling had remitted in one leg but not the other. No one was concerned about the asymmetric course of her healing. Eventually, one physician became curious and ordered an abdominal ultrasonogram to determine whether there might be a blockage that was preventing the drainage of blood and lymph from the swollen leg. A benign abdominal mass was discovered and resected. Her abdomen healed and her leg got better. Would the presence of a bedside advocate have broadened her physicians' thinking more quickly? The physicians caring for my mother meant well, but had cubbyholed her as a frail, sick, and elderly woman who would take time to heal.
Dr Fine had a similar experience when he accompanied a friend with significant pain to the ED. Bursitis was the working diagnosis and the ED physicians could not get beyond this conclusion. Fine knew that his friend would not have complained if the pain were due to bursitis. Acting as an advocate, he asked for a CT scan, which revealed life-threatening retroperitoneal bleeding. The patient was then able to receive proper treatment with hospital admission and transfusions. What happened here? Simply put, Fine shook up the thinking of the caregiving physicians and contributed to saving a life.Into the future
After reading How Doctors Think, I feel a renewed sense of hopefulness about the practice of medicine. The system may be broken, but Groopman's book takes on a significant aspect of the problem and moves us toward a fix that involves self-awareness and integrity. The best news is that Groopman's solution does not require time or money—only a check on rigid thinking. The forthrightness of Groopman and those he interviewed makes me feel more at ease when presenting my own cases to consultants and mentors. In this way, I hope to stretch my ways of thinking about psychiatric diagnosis and treatment. I will not go as far as Dr House to render care to my patients, but I will go as far as Groopman.
In his book, Blink, Malcolm Gladwell poses an alternative to Groopman's unbiased, open-ended, decision-making process.6 Go with your initial instinct, Gladwell recommends, instinct borne from long personal experience. After all, instantaneous judgment is frequently correct. Myron Falchuk describes his diagnostic process as a cross between Groopman's and Gladwell's: an immediate, intuitive sense is important in diagnosis but must be coupled with extensive thoughtfulness. Or—blink, then think, and then think again.