HOW DOCTORS THINK GROOPMAN PDF
book reviews n engl j med ;26 cittadelmonte.info june 28, How Doctors Think. By Jerome Groopman. pp. New York, Houghton Mifflin,. How doctors think. Jerome Groopman. Houghton Mifflin Co. Boston, Massachusetts, USA. pp. $ ISBN: ( hardcover). How Doctors Think – Jerome Groopman, MD. Chapter 9. Marketing, Money, and Medical Decisions. Chapter In Service of the Soul.
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Editorial Reviews. From Publishers Weekly. Drawing on both personal experience and Buy How Doctors Think: Read Kindle Store Reviews - cittadelmonte.info PDF | 10+ minutes read | On Jan 1, , Scott D. Smith and others published How Doctors Think. of Dr. Jerome Groopman's How Doctors Think. Cognitive. PDF | On Sep 26, , Lisa Lines and others published Book Review: How Doctors Think, by Jerome Groopman. Boston: Houghton Mifflin.
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Atul Gawande. A Surgeon's Notes on an Imperfect Science. Danielle Ofri. What Doctors Feel: How Emotions Affect the Practice of Medicine. When the Air Hits Your Brain: Tales from Neurosurgery. Groopman sheds light on the faulty decision making that leads otherwise competent physicians down the wrong path in diagnosing and treating their patients. Groopman stresses the imperative for his colleagues to balance clinical formulas and data with keen insight and for patients to engage their physicians in active dialogue.
Like the heroic fictional doctors in prime-time television medical dramas, Groopman advances a humane, patient-focused agenda that flies in the face of the bureaucratic, institutional establishment, but refreshingly, he manages to steer clear of pat answers and smug solutions that characterize much of the popular media's take on health care.
With more than titles under his belt, accomplished narrator Michael Prichard exhibits a calm, authoritative command of the material.
His less-is-more approach to conveying emotion may strike some listeners as detached and lacking passion, but his steady performance fits nicely with Groopman's sensitive—but still highly inquisitive—exploration of life and death questions. All rights reserved. Jerome Groopman, Harvard professor of medicine, AIDS and cancer researcher, and New Yorker staff writer in medicine and biology, isn't new to the popular medical-writing scene.
Here, Groopman's readable prose emphasizes the human element, the give-and-take so important to successful diagnosis and treatment. One critic, however, compares the book's medical pyrotechnics to an episode of the medical show House , while another takes issue with the author's stance against Big Pharma. See all Editorial Reviews.
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Top Reviews Most recent Top Reviews. There was a problem filtering reviews right now. Please try again later. Paperback Verified Purchase. Great reminder for physicians on common cognitive errors and how to avoid them as much as possible. The theme of trying to attach a diagnosis to a patient that doesn't quite fit, often based on their demographics or what is 'most likely' is reiterated throughout the book. Of course common conditions can present in uncommon ways, but the emphasis on trying to reach a diagnosis right away opens up the risk of missing something important - one example cited aortic dissection misdiagnosed as musculoskeletal pain and another a compression fracture that turned out to be cancer in a young boy.
While these examples are extreme they are certainly not unheard of. Another was overreliance on clinical algorithms which resonated with me. As a neurology resident we commonly evaluate patients with suspected stroke and grade the severity based on several exam findings which together make up the NIH stroke scale.
This score helps determine whether to administer a clot busting drug called tpa, which can decrease the disability caused by a stroke but comes with a nontrivial risk of bleeding, both systemically and in the brain.
While a high score indicates a severe stroke or some other global process mimicking a stroke , a low score can be deceptive, as even a low score can indicate significant disability. For example, one patient working in a very cognitively demanding field had intact motor function and speech but was unable to accurately calculate even simple equations. His score was 1 the highest score is While some may argue that the patient had a low score, without treatment he would not have been able to continue his career- a large consequence for someone in their prime.
The decision was made to give the patient the drug, and the next day his Mri indeed showed small strokes in a part of the brain important in solving calculations. He had no residual symptoms, and no untoward side effects from the drug.
The idea of treating each patient as an individual is thus emphasized. Another point made in the book was not to prematurely write a symptom off as being psychological.
I once admitted a patient with acute onset of altered mentation and agitated behavior who had recently lost their family member.
The family had reiterated that the loss was a month ago and that up until a few days prior to coming into the hospital the patient had been completely normal with the exception of some normal grief. She had gone to another hospital prior who felt that this may have been psychological, as the patient had imaging that turned out normal and labs which showed no drug ingestion.
I admitted that while I had some ideas for what may be causing it, we would need further testing to confirm. An eeg showed a pattern consistent with encephalitis and the patient was found to have suspected autoimmune encephalitis, which presents with very bizarre neuropsychiatric symptoms read the book Brain on Fire if interested.
She responded beautifully to a course of treatment that dampened the immune system's abnormal response.
Of course there are the misses too- a time that I once thought a brain wave test on a child with autism and tics signified seizures, but in retrospect was artifact from repetitive hand movements the child was making. Overall, I loved this book. While the information presented is going to be familiar to most physicians, it will make you think critically about your practice behaviors and how to improve upon them, as well as the limitations of medicine.
Suzanne Marcoux Top Contributor: After suffering heart failure and a triple bypass at the age of 54, the recovery has been difficult. That was 5 years ago. What has been more difficult is communicating with my physicians. It has been an about face in my health. Blood and cardiac tests do not lie.
How Doctors Think by Jerome Groopman - Read Online
I have kept what I am doing from my doctors in order not to second guess all my efforts in such a short time. This book helped me immensely in my last primary and cardiologist appointments in finally coming off most of my meds and replacing them with supplementation.
Before reading this book I was met with raised eyebrows, but I am now able to tactfully communicate to my doctors that I am more than a "patient medical googler" and someone that has finally became responsible for my own health. There are doctors that follow the tune that the Medical Industrial Complex plays, and there are ones who buck the trend. Groopman is one of the latter, thankfully. Groopman offers a distinctive look into the structure of Big Medica in search for what exactly is the type of mindset Doctors employ when practicing their jobs.
Groopman does a compelling job throughout the book in making sure he relates the plights plaguing medicine from both sides of the coin, from the patients perspective, as well as from the perspective of a physician.
This aids in the book not being one sided. From medical, money, marketing, uncertainty, dogma, to various other components of medicine, Groopman attempts to turn over as many stones as possible in his search for what issues are the ones plaguing Doctors the most.
A notable point in the book that hit close to home, which many people will relate to is the emotional tension that can arise at times between patients and their doctors. Essentially, whether patients and doctors like each other. Groopman relates what Social Psychologist, Judy Hall discovered regarding emotional tension: In studies of primary care physicians and surgeons, patients knew remarkably accurately how the doctor actually felt about them.
Much of this, of course, comes from nonverbal behavior: Overall, doctors tend to like healthier people more. Along with the above example, the author additionally notes many other examples of issues that arise due to a crisis in communication which can arrive in myriad ways.
In fact, one of these issues that Groopman relates is that: Additionally, the institutional dogma that reigns down from the top is also touched upon in a few instances by the author.
Open-mindedness is scoffed at, while conformity was expected. Recounting an example of choosing between the availability of multiple medical options regarding a particular treatment, Groopman relates something noted by physician Jay Katz, who taught at Yale Law school at the time: This very issue has covered by other doctors such as Dr. Brogan, Dr. Numbers can only complement a physician's personal experience with a drug or a procedure, as well as his knowledge of whether a best therapy from a clinical trial fits a patient's particular needs and values.
Each morning as rounds began, I watched the students and residents eye their algorithms and then invoke statistics from recent studies. I concluded that the next generation of doctors was being conditioned to function like a well-programmed computer that operates within a strict binary framework.
After several weeks of unease about the students' and residents' reliance on algorithms and evidence-based therapies alone, and my equally unsettling sense that I didn't know how to broaden their perspective and show them otherwise, I asked myself a simple question: How should a doctor think? This question, not surprisingly, spawned others: Do different doctors think differently?
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Are different forms of thinking more or less prevalent among the different specialties? In other words, do surgeons think differently from internists, who think differently from pediatricians? Is there one best way to think, or are there multiple, alternative styles that can reach a correct diagnosis and choose the most effective treatment?
How does a doctor think when he is forced to improvise, when confronted with a problem for which there is little or no precedent? Here algorithms are essentially irrelevant and statistical evidence is absent. How does a doctor's thinking differ during routine visits versus times of clinical crisis? Do a doctor's emotions—his like or dislike of a particular patient, his attitudes about the social and psychological makeup of his patient's life—color his thinking?
Why do even the most accomplished physicians miss a key clue about a person's true diagnosis, or detour far afield from the right remedy? In sum, when and why does thinking go right or go wrong in medicine? I had no ready answers to these questions, despite having trained in a well-regarded medical school and residency program, and having practiced clinical medicine for some thirty years.
So I began to ask my colleagues for answers. Then I searched the medical literature for studies of clinical thinking. I found a wealth of research that modeled optimal medical decision-making with complex mathematical formulas, but even the advocates of such formulas conceded that they rarely mirrored reality at the bedside or could be followed practically. I saw why I found it difficult to teach the trainees on rounds how to think.
I also saw that I was not serving my own patients as well as I might. I felt that if I became more aware of my own way of thinking, particularly its pitfalls, I would be a better caregiver. I wasn't one of the hematologists who evaluated Anne Dodge, but I could well have been, and I feared that I too could have failed to recognize what was missing in her diagnosis.
Of course, no one can expect a physician to be infallible. Medicine is, at its core, an uncertain science. Every doctor makes mistakes in diagnosis and treatment. But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better.
This book was written with that goal in mind. It is primarily intended for laymen, though I believe physicians and other medical professionals will find it useful. Why for laymen? Because doctors desperately need patients and their families and friends to help them think.
Without their help, physicians are denied key clues to what is really wrong. I learned this not as a doctor but when I was sick, when I was the patient. We've all wondered why a doctor asked certain questions, or detoured into unexpected areas when gathering information about us.
We have all asked ourselves exactly what brought him to propose a certain diagnosis and a particular treatment and to reject the alternatives. Although we may listen intently to what a doctor says and try to read his facial expressions, often we are left perplexed about what is really going on in his head. That ignorance inhibits us from successfully communicating with the doctor, from telling him all that he needs to hear to come to the correct diagnosis and advice on the best therapy.
In Anne Dodge's case, after a myriad of tests and procedures, it was her words that led Falchuk to correctly diagnose her illness and save her life. While modern medicine is aided by a dazzling array of technologies, like high-resolution MRI scans and pinpoint DNA analysis, language is still the bedrock of clinical practice. We tell the doctor what is bothering us, what we feel is different, and then respond to his questions.
This dialogue is our first clue to how our doctor thinks, so the book begins there, exploring what we learn about a physician's mind from what he says and how he says it.
How doctors think
But it is not only clinical logic that patients can extract from their dialogue with a doctor. They can also gauge his emotional temperature. Typically, it is the doctor who assesses our emotional state. But few of us realize how strongly a physician's mood and temperament influence his medical judgment. We, of course, may get only glimpses of our doctor's feelings, but even those brief moments can reveal a great deal about why he chose to pursue a possible diagnosis or offered a particular treatment.
After surveying the significance of a doctor's words and feelings, the book follows the path that we take when we move through today's medical system. If we have an urgent problem, we rush to the emergency room. There, doctors often do not have the benefit of knowing us, and must work with limited information about our medical history.
I examine how doctors think under these conditions, how keen judgments and serious cognitive errors are made under the time pressures of the ER. If our clinical problem is not an emergency, then our path begins with our primary care physician—if a child, a pediatrician; if an adult, an internist.
In today's parlance, these primary care physicians are termed gatekeepers, because they open the portals to specialists. The narrative continues through these portals; at each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong.
We also encounter the tension between his acknowledging uncertainty and the need to take a clinical leap and act. One chapter reports on this in my own case; I sought help from six renowned hand surgeons for an incapacitating problem and got four different opinions. Much has been made of the power of intuition, and certainly initial impressions formed in a flash can be correct. But as we hear from a range of physicians, relying too heavily on intuition has its perils.
Cogent medical judgments meld first impressions—gestalt—with deliberate analysis. This requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes. What can doctors and patients do to find time to think? I explore this in the pages that follow. Today, medicine is not separate from money. How much does intense marketing by pharmaceutical companies actually influence either conscious or subliminal decision-making? Very few doctors, I believe, prostitute themselves for profit, but all of us are susceptible to the subtle and not so subtle efforts of the pharmaceutical industry to sculpt our thinking.
That industry is a vital one; without it, there would be a paucity of new therapies, a slowing of progress. Several doctors and a pharmaceutical executive speak with great candor about the reach of drug marketing, about how natural aspects of aging are falsely made into diseases, and how patients can be alert to this. Cancer, of course, is a feared disease that becomes more likely as we grow older. It will strike roughly one in two men and one in three women over the course of their lifetime.
Recently there have been great clinical successes against types of cancers that were previously intractable, but many malignancies remain that can be, at best, only temporarily controlled. How an oncologist thinks through the value of complex and harsh treatments demands not only an understanding of science but also a sensibility about the soul—how much risk we are willing to take and how we want to live out our lives.
How Doctors Think
Two cancer specialists reveal how they guide their patients' choices and how their patients guide them toward the treatment that best suits each patient's temperament and lifestyle. At the end of this journey through the minds of doctors, we return to language. The epilogue offers words that patients, their families, and their friends can use to help a physician or surgeon think, and thereby better help themselves.
Patients and their loved ones can be true partners with physicians when they know how doctors think, and why doctors sometimes fail to think. Using this knowledge, patients can offer a doctor the most vital information about themselves, to help steer him toward the correct diagnosis and offer the therapy they need.
Patients and their loved ones can aid even the most seasoned physician avoid errors in thinking. To do so, they need answers to the questions that I asked myself, and for which I had no ready answers. Not long after Anne Dodge's visit to Dr. Falchuk is a compact man in his early sixties with a broad bald pate and lively eyes. His accent is hard to place, and his speech has an almost musical quality.
He was born in rural Venezuela and grew up speaking Yiddish at home and Spanish in the streets of his village. As a young boy, he was sent to live with relatives in Brooklyn. There he quickly learned English. All this has made him particularly sensitive to language, its nuances and power. After nearly four decades, he has not lost his excitement about caring for patients.
When he began to discuss Anne Dodge's case, he sat up in his chair as if a jolt of electricity had passed through him. She was emaciated and looked haggard, Falchuk told me.
Her face was creased with fatigue. And the way she sat in the waiting room—so still, her hands clasped together—I saw how timid she was.
From the first, Falchuk was reading Anne Dodge's body language. Everything was a potential clue, telling him something about not only her physical condition but also her emotional state.
This was a woman beaten down by her suffering.
She would need to be drawn out, gently. Medical students are taught that the evaluation of a patient should proceed in a discrete, linear way: Only after all the data are compiled should you formulate hypotheses about what might be wrong. These hypotheses should be winnowed by assigning statistical probabilities, based on existing databases, to each symptom, physical abnormality, and laboratory test; then you calculate the likely diagnosis.
This is Bayesian analysis, a method of decision-making favored by those who construct algorithms and strictly adhere to evidence-based practice. But, in fact, few if any physicians work with this mathematical paradigm. The physical examination begins with the first visual impression in the waiting room, and with the tactile feedback gained by shaking a person's hand. Hypotheses about the diagnosis come to a doctor's mind even before a word of the medical history is spoken.
And in cases like Anne's, of course, the specialist had a diagnosis on the referral form from the internist, confirmed by the multitude of doctors' notes in her records. Falchuk ushered Anne Dodge into his office, his hand on her elbow, lightly guiding her to the chair that faces his desk. She looked at a stack of papers some six inches high. It was the dossier she had seen on the desks of her endocrinologists, hematologists, infectious disease physicians, psychiatrists, and nutritionists.
For fifteen years she'd watched it grow from visit to visit. But then Dr. Falchuk did something that caught Anne's eye: Before we talk about why you are here today, Falchuk said, let's go back to the beginning. Tell me about when you first didn't feel good. For a moment, she was confused.
Hadn't the doctor spoken with her internist and looked at her records? I have bulimia and anorexia nervosa, she said softly. Her clasped hands tightened. And now I have irritable bowel syndrome. Anne glanced at the clock on the wall, the steady sweep of the second hand ticking off precious time. Her internist had told her that Dr. Falchuk was a prominent specialist, that there was a long waiting list to see him.
Her problem was hardly urgent, and she got an appointment in less than two months only because of a cancellation in his Christmas-week schedule. But she detected no hint of rush or impatience in the doctor. His calm made it seem as though he had all the time in the world. So Anne began, as Dr. Falchuk requested, at the beginning, reciting the long and tortuous story of her initial symptoms, the many doctors she had seen, the tests she had undergone.
As she spoke, Dr. Falchuk would nod or interject short phrases: Occasionally Anne found herself losing track of the sequence of events. It was as if Dr.
Falchuk had given her permission to open the floodgates, and a torrent of painful memories poured forth. Now she was tumbling forward, swept along as she had been as a child on Cape Cod when a powerful wave caught her unawares.
She couldn't recall exactly when she had had the bone marrow biopsy for her anemia. Don't worry about exactly when, Falchuk said. For a long moment Anne sat mute, still searching for the date. I'll check it later in your records.
Let's talk about the past months. Specifically, what you have been doing to try to gain weight. This was easier for Anne; the doctor had thrown her a rope and was slowly tugging her to the shore of the present.
As she spoke, Falchuk focused on the details of her diet. Now, tell me again what happens after each meal, he said.
Anne thought she had already explained this, that it all was detailed in her records. Surely her internist had told Dr. Falchuk about the diet she had been following. But she went on to say, I try to get down as much cereal in the morning as possible, and then bread and pasta at lunch and dinner. Cramps and diarrhea followed nearly every meal, Anne explained. She was taking antinausea medication that had greatly reduced the frequency of her vomiting but did not help the diarrhea.
Each day, I calculate how many calories I'm keeping in, just like the nutritionist taught me to do. And it's close to three thousand.