CO-CURE: What's Wrong with Doctors; How Doctors Think

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Date:    Tue, 29 May 2007 12:36:58 -0500

    LK Woodruff <lkw777

What's Wrong with Doctors; How Doctors Think

 

The New York Review of 2 Books

May 31, 2007

 

Review:

 

What's Wrong with Doctors

By Richard Horton

 

How Doctors Think

by Jerome Groopman

Houghton Mifflin, 307 pp., $26.00

 

Few can doubt that Western medicine has been a phenomenal success. Heart

disease kills two-thirds fewer people now than it did fifty years ago. The

frequency of conditions as diverse as stroke and trauma is being gradually

checked. Mortality from breast cancer has fallen by a quarter in less than

two decades. Doctors would dearly like to attribute these impressive

results in Western countries to their accumulated expertise and the

advances of science. But as Atul Gawande points out in Better: A Surgeon's

Notes on Performance, his latest collection of lucid essays,[1] the

residual contradiction is that while medicine succeeds, it never seems to

succeed well enough. A doctor's report card might look creditable today.

Yet it nevertheless conceals serious unresolved and unacknowledged

weaknesses.

 

~~~

 

" Science and skill, " Gawande writes, are " the easiest parts of care. " What

matters more, he suggests, is diligence, doing right by patients, and

ingenuity. Despite these " core requirements " for progress, and the fact

that doctors have been remarkably successful in all three, errors are still

commonly made. These mistakes badly scar the surface of medicine's success.

" Betterment is a perpetual labor, " Gawande concludes. The trick is to

understand one's limits.

 

One by one Gawande's arguments are persuasively made and elegantly

illustrated with examples ranging from antisepsis to obstetrics. He

describes, for example, Thomas, a previously fit seventy-two-year-old man,

who one day was found to have a cancer in his left kidney. The tumor was

removed surgically but, instead of Thomas's recovering, his entire body

began to swell. Eventually, he was diagnosed with Cushing's syndrome, a

condition in which the adrenal glands overproduce steroid hormone. No

matter what his doctors did, they could not stop the hormone from pouring

into his bloodstream. Thomas became sicker and sicker. He could not walk

and he had recurrent episodes of pneumonia.

 

By the time Thomas got to see Atul Gawande, there was only one option

leftto remove the source of the offending hormone. Although the operation

to take out his adrenal glands carried its own dangers, Gawande told Thomas

that his only chance of a normal life was to accept the risk. The operation

went well. But Thomas suffered a series of terrible complications,

culminating in four months of intensive care, a tracheostomy, and

incarceration in a long-term care facility. When he last saw Gawande, he

could hardly lift his head. All he could do to express himself was to cry.

Gawande implies that this was one operation that should have been avoided.

 

Many of Gawande's essays began life as magazine and journal articles. Their

original diversity and subsequent reworking to construct a larger thesis

about the failure of medicine create a difficult tension. Although the

individual foundations that Gawande lays down are strong, the overall

architecture of his work lacks form and substance.

 

~~~

 

By striking contrast, Jerome Groopman, a cancer specialist who, like

Gawande, writes for The New Yorker, delivers an altogether sharper and more

coherent critique of medicine's mistaken direction. And while Gawande's

prescriptions are gentle and well-meaning homiliesfor example, he urges

medical students to " change " and to " write something " about their

experience[2] Groopman presents a forceful and convincing manifesto that,

if implemented, would overturn many conventions of modern medical practice.

 

Groopman's central claim is that there is a common flaw that undermines

much of contemporary medical education and training, as well as the

partnership between patient and doctor and even the professional values of

medicine. That flaw lies in the way doctors think. His disquiet originated

from the frustration he felt working among his students and residents at

Harvard Medical School. Whereas once they would take part in challenging

and detailed debates about the patients they met and examined on rounds,

they now " too often failed to question cogently or listen carefully or

observe keenly.... Something was profoundly wrong with the way they were

learning to solve clinical puzzles and care for people. "

 

Using a technique he has honed in his New Yorker essays, Groopman

skillfully mixes stories of patients, interviews with doctors, research

evidence, and his own personal experiences as a patient to mount an

ambitious assault against several large targets. His ire is raised

especially by what he sees as the hubris of " evidence-based medicine. "

 

It would seem axiomatic to a nonphysician that medical practice is based

on scientific evidence. Not so, according to the zealous advocates of

evidence-based medicine, a movement that has come to dominate clinical

practice during the past decade. These advocates, led originally by David

Sackett and his colleagues at McMaster University in Canada, argue that

doctors have preferred to rely on experience and 'expert opinion', as

opposed to research and statistical evidence, out of laziness and a misplaced

 

deference to the authority of received medical wisdom.

 

Worse, the same advocates argue that when doctors do consult the " evidence

base, " they often do so in ignorance of what makes good and bad science.

Groopman views the evidence-based approach, which aims to make clinical

decisions follow from statistically valid information in the form of

" systematic " reviews, guidelines, or algorithms as ill-informed by the

realities,

complexities, and uncertainties of medical practice.

 

A " rigid reliance " on numbers the numbers, for example, indicating which

medicines have been proven effective for certain kinds of disease will not

meet every need of the patient who sits in front of the doctor. Such numbers

are needed, but there can never be a purely rational or exact mathematical

solution to a patient's predicament. Groopman concludes that doctors are

" being conditioned to function like a well-programmed computer that

operates within a strict binary framework. " He disapproves of this medical

scientism.

 

Often patients have conditions or combinations of conditions that do not

easily match the supposed evidence. Sometimes patients have problems that

are not easy to study scientifically. A strict requirement for evidence

before acting may mean that physicians will stop thinking, stop evaluating

each patient as a unique human being, and stop applying their knowledge to

the particularities of the person before them. Groopman rails several times

against the " bean counters " of medicinedoctors who recommend treatments

that are seemingly supported by statistics but may not be appropriate for

the person they are facing.

 

There is a still deeper fault line within medical practice. On average,

about 15 percent of a doctor's diagnoses are inaccurate. Groopman directs

a well-aimed arrow at a system of medical training that more often than not

fails to investigate why these diagnoses are missed. Doctors are rarely

taught to ask how an error could have taken place, let alone how it could

be avoided in the future. Most are unaware of their mistakes. Even if

patients remain unwell, no systematic effort is made to find out where

doctors may have gone wrong. Doctors are uncertain about their own

uncertainties. (Although for some doctors, such as radiologists, Groopman

cites alarming research that shows the worse their performance, the more

certain they seem to be that they are right!)

 

Amid these wide-ranging attacks, the pharmaceutical industry does not

escape Groopman's scrutiny. The discovery of new medicines has delivered

huge benefits for patients. But the incentives offered to doctors, and too

often accepted by themgifts, airfares, hotel accommodation, and expensive

mealsdistort their ability to make unbiased treatment decisions. In a

recent survey of over 1,600 American physicians, for example, nine out of

ten reported a relationship with a drug company.[3] The benefits they

received ranged from drug samples to tickets for sporting events, from

payments for speaking to money in exchange for persuading patients to join

a clinical trial.

 

The pressure of increasingly aggressive marketing tacticswhich, Groopman

shows, can amount to overt harassmentby pharmaceutical sales

representatives only adds to a climate of acute misunderstanding. Most

doctors receive information about new drugs directly from the

pharmaceutical companies. Rarely do they investigate what is known about a

drug for themselves. This reliance on biased information leaves the doctor

poorly equipped to make balanced judgments.

 

But Groopman reserves some of his most bitter criticism for his colleagues

within academic medicine. They have fostered a belief that anyone can take

care of patients. This " arrogance " has created a culture at academic

medical centers where research is applauded and teaching is taken for

granted, where writing scientific papers (for journals like The Lancet)

takes precedence over developing clinical skills. He very emphatically

offers two examples of inferior, some might say even cruel, care at

Memorial Sloan-Kettering hospital in New York City:

 

In one case, he describes a patient who desperately sought treatment at this

prestigious institution. But after his cancer failed to respond to

chemotherapy,his doctor simply abandoned him, refusing even to return his

calls.

 

In a second example, a Sloan-Kettering oncologist told a woman in her

fifties with spreading bladder cancer that there was no scientific evidence

that would support any further treatment. He spoke of protocols, data,

percentages, and statistical likelihood of her survival, and the technicalities

of

research studies. He was oblivious to her needs, to her hopes and fears. And he

left her deeply distressed.

 

Doctors are trained to deal with success, not failure. This hospital may be

a cancer center of high international standing, yet Groopman makes the fair

argument that the values, attitudes, and behavior of a doctor matter far

more than the reputation of the institution at which he works. And here

Memorial Sloan-Kettering, at least on the basis of these two instances, falls

short

of Groopman's high standards.

 

So much for the prevailing environment of medicine today. But matters take

a more sinister turn when one asks just how well doctors think.

 

Groopman draws extensively on the emerging cognitive science of medicine,

which seeks to understand the mistakes doctors make in evaluating the

information they gather from a patient's history, the physical examination,

and results of investigations. He reviews the errors and biases that most

doctors unconsciously succumb to when thinking about what their findings

mean for a patient's diagnosis and treatment.

 

There is a rich and rather disturbing variety of human weaknesses to

consider when watching a doctor at the patient's bedside. Physicians can be

easily led astray by seeing the patient from only oneand often very

neg-ativeperspective, independent of what the clinical findings suggest.

Patients might be stigmatized if they are thought to have a mental health

problem, or caricatured if they are judged to have engaged in self-harming

behavior, such as alcoholism. This kind of mistake is called " attribution

error. "

 

" Availability error " occurs when a doctor makes a decision based on

an experience that is at the forefront of his mind but which bears little

or no relation to the patient before him. For instance, a specialist in

gastroenterology may only think of the gut when evaluating a woman with

abdominal pain. He may not think of gynecological causes for her symptoms.

The ready availability of his own specialized experience in his assessment

of what is wrong with a patient can seriously bias a doctor's judgment.

 

" Search satisfying error " is yet another source of misshapen medical

thinking. It takes place when a doctor stops looking for an answer to the

patient's problem as soon as he discovers a finding that satisfies him,

albeit incorrectly. He gives up too soon.

 

" Confirmation bias " intrudes when the doctor selects only some parts of

the information available to him in order to confirm his initial judgment of

what is wrong.

 

" Diagnostic momentum " takes over when the doctor is unable to change

his mind about a diagnosis, even though there might remain considerable

uncertainty about the nature of a patient's condition.

 

And " commission bias " obstructs good clinical thinking when the doctor

prefers to do something rather than nothing, irrespective of clinical clues

suggesting that he should sit on his hands.

 

Doctors are not routinely taught these cognitive pitfalls. Nor are they

trained to learn from their effects. Yet these errors and biases can prove

fatal. Most doctors are unaware that their thinking is prone to predictable

mistakes. Our systems of medical practice neither seek to detect these

mistakes nor feed their lessons back to doctors to prevent their recurrence.

 

An all too typical error is that doctors simply stop observing the patient

carefully. Add to that inattention a tendency to hurry the consultation the

economic incentives and pressures to see more patients in less time are

immenseand cognitive errors become common. In the face of acute time

pressure, doctors will come to rely more and more on shortcuts to make

judgments. Pattern recognition based on an instantaneous appraisal of the

patient will become the norm. Indeed, the capacity for spot diagnosis is a

revered skill among clinically minded physicians. But speed may well create

the conditions for further error.

 

Despite his greater knowledge, the specialist is not immune from these

missteps. Specialization can confer undue and sometimes dangerous

confidence in those who possess such knowledge. Groopman invites doctors

to question any expert who dismisses an unusual cluster of symptoms and

signs on the grounds that " we see this sometimes. " Specialists' appeals to

some kind of mystical diagnostic skill owe more to the high opinion they have of

themselves than to any kind of clinical reality.

 

As most of us who have sought medical help will testify, miscommunication

is not uncommon between patient and doctor. Many physicians have

demonstrable gaps in their ability to convey important information to

patients. They are often especially bad in giving advice about how to use

prescription medicines. Electronic decision aids devices that supposedly

help doctors to arrive at the correct diagnosis are unlikely to help, even

though many extravagant claims are made for the impact of information

technology on health. Groopman believes such electronic fixes might

actually encourage more mistakes. They are a distraction. They promote a

reductive and unthinking kind of checklist behavior. And they divert the

doctor away from what should be his primary focus: the patient's own story.

 

Groopman draws very clear and precise conclusions from his review of the

surprising array of cognitive dangers that face doctors. Most important,

perhaps, is his claim that " competency is not separable from communication. "

 

Communication skills for doctors are nothing new. There is already great

attention paid to communication during medical training. But some critics

still argue that an emphasis on communication is not relevant to all

branches of medicine. If you are going to come under the surgeon's knife,

surely, these skeptics say, you would rather have a surgeon who can cut

accurately than one who can converse beautifully. Groopman anticipates this

charge.

Based on his own labyrinthine experiences as a patient who had operations and

many other treatments for pain in the lower back and, later, his hand, he

dismisses the accusation of irrelevance: " the surgeon's brain is more important

than

his hands, " he affirms.

 

In truth, of course, a good surgeon needs both a sound brain and steady

hands.

 

Doctors must also learn to think differently. A solid base of medical

knowledge is not enough to be a good physician or surgeon. Research into

cognitive errors in medicine reveals that most mistakes are not technical.

They stem from mistakes in thinking. Intuition, a clinical sixth sense, for

example, is unreliable. But equally, the assumption that medicine is a

totally rational process is also wrong. Doctors may be reasonably smart,

but they repeatedly fall into common and well-defined traps.

 

Physicians can guard against these traps by heightening their sense of

self-awareness and becoming conscious of their own feelings and emotions,

responses, and choices. All too few doctors have this skill today. Indeed,

a doctor's training can instill utterly contrary traitsconfidence and

certainty, in particular, which might close off an awareness of one's

usually unconscious weaknesses. Instead, uncertainties should be

acknowledged. Unveiling what we are unsure about would not only be more

honest, it would also likely promote a degree of collaboration between

patient and doctor that has hitherto been lacking.

 

The corollary of admitting uncertainty is that doctors should be more aware

of their errors and should more freely and openly disclose them. Only then

will they be able to evaluate and learn from their mistakes. This statement

sounds too obvious even to deserve mention. Yet the prevailing medical

culture is still heavily weighted against revealing even the possibility of

error. Disclosing uncertainty and error will demand a deep change in

medicine's attitude toward emotion. Most physicians fail to recognize, let

alone analyze, their own emotional states in clinical encounters. This

repression of feeling misses an important variable in the assessment of a

patient's experiences and outcome. The emotional temperature of the

doctor plays a substantial part in diagnostic failure and success.

 

Possibly the most radical proposition that Groopman advances from the

doctor's point of view, anyway is that the physician should seek a new ally

in helping to correct the cognitive errors and biases inherent in his

makeup. This new ally is the patient. Patients can ask questions that pull

doctors away from the traps they might otherwise fall into.

 

Groopman concludes:

 

For three decades practicing as a physician, I looked to traditional

sources to assist me in my thinking about my patients: textbooks and

medical journals; mentors and colleagues with deeper or more varied

clinical experience; students and residents who posed challenging

questions. But after writing this book, I realized that I can have another

vital partner who helps improve my thinking, a partner who may, with a few

pertinent and focused questions, protect me from the cascade of cognitive

pitfalls that cause misguided care.... That partner is my patient or her

family member or friend who seeks to know what is in my mind, how I

am thinking.

 

What makes a good doctor? Physicians like to think of themselves as members

of a profession. But definitions of profession and professionalism change.

A century ago a doctor was considered to be part of a social elite. He and

medicine was then very much a masculine endeavorhad a unique mastery of a

special body of knowledge. He professed a commitment to levels of

competence and integrity that he expected society to respect and trust.

This commitment formed the basis for a social contract between the

profession and the rest of the community. In return for the moral values,

knowledge, and technical skills displayed by doctors, society bestowed on

them the authority, autonomy, and privilege to regulate themselves. This

version of professionalism is now moribund.

 

Doctors are no longer masters of their own knowledge. For a start, in many

Western countries women now outnumber men at medical schools. The public

is also far more educated than it was a century ago. Patients have access to

the same information as doctors. They may know more than most doctors about

their own condition. Meanwhile, doctors increasingly work in teams. Their

responsibilities are shared with many other professionals, nurses,

therapists, and pharmacists, for instance. The clinical hierarchy might still

favor the doctor.

And it is true that the doctor still takes final responsibility for a

patient's care.

But the notions of absolute mastery and control no longer hold.

 

Ideas of privilege, autonomy, and self-regulation are also outdated. For

usually good reasons, doctors have been cut down to size in our society.

Partly this graying of their public image is because doctors are now seen

as fallible. Society is less willing to bow to a doctor's once sacred

authority. As a result, doctors are being made more accountable than ever

before to the public. This process has not been without pain. In some

countries, such as the UK, they have finally lost the power to govern

themselves. Instead, public agencies have the final responsibility for

judging their performance.

 

Competence, knowledge, judgment, commitment, vocation, altruism, and

a moral contract with society remain at the heart of what it means to be a

doctor. But there are new dimensions to professionalism which herald

something of a revolution in the philosophy of medicine. It is these

domains that underpin the cognitive science set out by Groopman.

 

The patient is a far more powerful force in a doctor's professional life

today than in past generations. The patient expects to be more the equal

partner of the doctor. Medicine's goal is not only to cure or palliate

disease. It is also to promote a person's well-being and dignity. Many

patients want to be engaged participants in a doctor's thinking, not just

its passive recipients. Whereas once doctors spoke of the doctorpatient

relationship, they now increasingly talk of the patientdoctor interaction.

The inversion is significant as well as symbolic. It denotes a shift of

power from professional to patient. Interaction also better indicates the

greater equality in their alliance. The word " relationship " often carried a

strong hint of paternalism.

 

The expectations society has of medicine have changed. Doctors have

duties to society, as well as to patients and themselves. They are part of

an expensive system of health care which has to be managed responsibly.

Doctors have to be good stewards of that system and not merely

practitioners working with single patients. These wider responsibilities

sometimes run counter to a doctor's well-developed sense of independent

identity. The pace of change in medicine is also so fast that doctors must

demonstrate their continuous ability to keep up-to-date as knowledge

advances. They should be willing to concede that they are part of a

multidisciplinary health team. And patients expect a little compassion to

leaven their doctor's technical expertise.

 

In research conducted in Britain, doctors seemed to value this more modern

description of professionalism, despite their inherent conservatism.[4]

Physicians have also developed a strong sense of social commitment,

despite their having less power and authority. In the US, for example, nine

out of ten doctors rate community activity, politics, and patient advocacy

as important aspects of their work.[5] Doctors seem to be adapting to

changing social mores. However, rather than expect doctors to somehow

absorb these values randomly during the meandering course of their

training, some medical educators are now designing programs to teach

professionalism, assess and evaluate it, and identify the best conditions

for strengthening and protecting professional values in often highly

pressured clinical settings.[6] This is why Groopman's argument is so

timely.

 

Good doctoring is about listening and observing, establishing a trusting

environment for the patient, displaying authentic empathy, and using one's

skills and knowledge to deliver superb care. But a neglected aspect of this

professionalism is getting doctors to think about their own thinking. Only

by doing so are doctors likely to reduce the number of errors they make.

What should they do?

 

Encouraging patients to tell and retell their stories is essential.

Patients' fears about what might be wrong or their anxieties about the future

course of their illness should be drawn out into the open. Whatever the

doctor's own attitudes about the patient, it is a critical element of any

mutually respectful therapeutic partnership that the doctor acknowledges the

patient's version of the truth of his or her story.

 

-->This acknowledgment may mean repeating tests or reconsidering a long and

strongly held diagnosis.

 

In their encounters with patients, irrespective of the financial incentives

to be more efficient and productive, doctors must try to remain systematic

and thorough when they take a patient's history and conduct physical

examinations. Shortcuts are dangerous. Thinking requires the investment of

time. Groopman repeats the same lesson again and again: slow down. The

more time a doctor takes, the fewer cognitive errors he will make. (It is

just this kind of slowing down that may be more and more difficult under the

time pressures imposed by some HMOs and other insurance organizations as

part of their demands for efficiency.) And once a decision is made, always

retain an element of doubt. That sliver of uncertainty will leave the

doctor not only better able to recognize failure early but also free to

revise his opinion as new information comes to light.

 

This change in behavior cannot be brought about at the flick of a mental

switch. Groopman gives a telling example of what might be involved in

changing the cognitive culture of medicine. Victoria Rogers McEvoy is a

former Wimbledon tennis star who now works as a pediatrician in Boston.

To ensure that her self-awareness and so her ability to detect her own

cognitive errorsis maximal, she prepares herself psychologically before

each clinical encounter, just as she used to do before every tennis match.

If doctors understood the biases they were prone to make and briefly but

formally prepared themselves to be ready for those biases before seeing a

patient, a great deal of medical error might be prevented.

 

-->But while we are expecting more insight from doctors, it is also fair to

ask: What makes a good patient? Posing questions to improve a doctor's

thinking is certainly part of Groopman's answer.[7] If the consultation

with a doctor is going badly, the patient might ask, " I feel that we are

not communicating very well with each other. What is going wrong? How can

we do better? " When considering a diagnosis, the patient might suggest,

" What else could it be? Is there anything you have discovered that doesn't

quite fit? Is it possible that I have more than one problem? What other

parts of my body are near where I am having my symptoms? " And when a

treatment is being prescribed, the patient might inquire, " How well tested

is this drug for the condition I have? "

 

Groopman's investigation into how doctors think has important potential to

recalibrate the way medicine looks at itself. Doctors are imperfect, to be

sure. But their errors carry valuable information that can be put to good

clinical use. A doctor's mistakes are perhaps best seen as signs of a mind

at work. The patient and doctor together share a common purpose in getting

this mind thinking straight.

 

Notes

[1] Metropolitan, 2007.

 

[2] His advice includes: " don't complain, " " ask an unscripted question, "

and " count something. "

 

[3] Eric G. Campbell et al., " A National Survey of PhysicianIndustry

Relationships, " New England Journal of Medicine, April 26, 2007, pp. 1742

1750.

 

[4] The quite substantial recent changes in British ideas of

professionalism are set out more fully in Doctors in Society: Medical

Professionalism in a Changing World (London: Royal College of Physicians,

2005). Full disclosure: I was a member of the working party that gathered

evidence for this inquiry, and I wrote its final report.

 

[5] See Russell L. Gruen and colleagues, " Public Roles of US Physicians, "

JAMA, Vol. 296, No. 20 (November 22/29, 2006), pp. 24672475.

 

[6] See Frederic W. Hafferty, " ProfessionalismThe Next Wave, " The New

England Journal of Medicine, Vol. 355, No. 20 (November 16, 2006), pp.

21512152.

 

[7] Again through a revealing story, Groopman endorses faith as an

additional means to help someone become " a productive partner in the

uncertain world of medicine. " Although trained in science, many doctors

will resist those pure scientists who consider religion an outmoded and

medieval relic of our age. Religious belief many have a powerful and

valuable point to play in some patients' response to their illness. See,

for example, James Randerson, " The God Disunion: There Is a Place for Faith

in Science, Insists Winston, " The Guardian, April 25, 2007, p. 3.