Is There a Doctor in "House"?

June 1, 2007

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.

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.

Groopman's solution

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?

Blink or think

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 (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.

References:

References


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.