Groopman: The Doctor's In, But Is He Listening?
Jerome Groopman is a doctor who discovered that he needed a doctor. When his hand was hurt, he went to six prominent surgeons and got four different opinions about what was wrong. Groopman was advised to have unnecessary surgery and got a seemingly made-up diagnosis for a nonexistent condition.
Groopman, who holds a chair in medicine at Harvard Medical School, eventually found a doctor who helped (Audio). But he didn't stop wondering about why those other doctors made the wrong diagnoses. And he wrote about their mistakes in a new book called How Doctors Think (Excerpt).
"Usually doctors are right, but conservatively about 15 percent of all people are misdiagnosed. Some experts think it's as high as 20 to 25 percent," Groopman tells Steve Inskeep. "And in half of those cases, there is serious injury or even death to the patient."
Why do you think that doctors would be wrong that often?
Well, you know, it's very hard to be a doctor. We're working under tremendous time pressure, especially in the current medical system. But the reasons we are wrong are not related to technical mistakes, like someone putting the wrong name on an X-ray or mixing up a blood specimen in the lab. Nor is it really ignorance about what the actual disease is. We make misdiagnoses because we make errors in thinking.
Errors in thinking...
We use shortcuts. Most doctors, within the first 18 seconds of seeing a patient, will interrupt him telling his story and also generate an idea in his mind [of] what's wrong. And too often, we make what's called an anchoring mistake — we fix on that snap judgment.
Which could be based on the first thing the patient says. It could be based on something on their chart or in their file that somebody else has concluded in the past. It could be anything.
It could be anything. There's very frequently a telephone call that precedes a visit where the first doctor says, 'Oh, you know this is a very nervous woman who's in menopause and the feelings she's having are related to change of life.' And that causes what's called an attribution error or a stereotype and I write about that in the book where a woman saw five doctors. And she said, 'You know what, I really feel these explosions in my body.' And everyone thought she was crazy.
And it turned out that she had a tumor that was producing adrenaline. So every once in a while, the tumor would release this burst of adrenaline which made her jittery and sweaty and nervous. And she was indeed a high-strung person. But she said finally to the doctor who made the right diagnosis, 'I know that I'm a tense individual, but something's different. Something has changed.'
What is some advice that you would give to avoid misdiagnosing in this kind of situation?
Most importantly, I think, the patient and the doctor can partner. These thinking errors are made in the moment. They're made when the doctor is listening to the patient or examining the patient — these snap judgments.
Or not listening to the patient...
Or not listening to the patient. And so a patient or a family member or a friend who knows how doctors think well and how they don't think well can help get the doctor back on track by asking some appropriate questions.
Give me an example of a diagnosis or a meeting that's starting to go wrong and how you can get it back on track with the right questions.
Well, it's very common, for example, that people feel what's called indigestion, pressure or sometimes burning or pain in the center of their chest. And usually it's remedied with antacids. But if that symptom persists, a patient or family member can say to the doctor, 'What else could it be?' That is a central question, so the doctor doesn't anchor his thinking just on acid reflux.
Another important question is: Could two things be going on? Could I actually have acid reflux but something else? It could be angina, cardiac pain. To think that there's not just one answer for a common symptom.
Let me ask about some things that make this more difficult. The patient starts prodding the doctor to think a little bit more. The reality is the doctor has three of his or her minutes left with this particular patient and that's all the time they've got.
Well, I think both doctors and patients need to basically resist together. It's not easy, but one thing can be done, which is to schedule a follow-up appointment. But to cut off someone who's still suffering and doesn't have an answer is not the solution.
What if you're sitting there with a doctor and you think the doctor doesn't like you?
This is a setup for bad care. I actually write about one woman who irritated me and I shut my mind off to her. Her voice sounded to me like nails scratching on a blackboard. It was when I was a resident. She kept complaining and I just became deaf. And it turned out she had a tear in her aorta. And it was fatal. She may have died anyway, but it's a terrible thing.
I think if you feel that a doctor doesn't like you, then you can first say with all candor, 'I feel like we're not connecting well.' But it's interesting, when I asked physicians if they were a patient, and they felt that their doctor didn't like them, what would they do? Each doctor said to me, 'I'd find another doctor.'
Brutal bottom-line question: If everybody followed your advice, listened more carefully, spent a little more time with patients, thought a little bit more, would our health care cost more?
I think it would cost less because when you make a misdiagnosis that means that the patient gets sicker and sometimes dies. So that the intensity of treatment that's required by not detecting something early is much more costly than coming to the right diagnosis.
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