In How Doctors Think, Jerome Groopman explores clinical decision making with a particular emphasis on the poor communication skills and cognitive errors that often lead to misdiagnosis and inappropriate treatment. He uses a narrative approach, filling the book with compelling stories that illustrate the world of patient-physician interactions. Why did a second doctor quickly conclude that Blanche Begaye suffered from aspirin toxicity, while her first doctor mistakenly diagnosed viral pneumonia? Why did several physicians fail to diagnose Maxine Carlson's ectopic pregnancy until the day it ruptured? Groopman's storytelling skill permits him to convey complex concepts (e.g. availability bias, anchoring, and Ockham's razor) through conversation and narrative.

Three major themes run throughout the book, and each is presented with several variations. The first theme is that doctors who don't listen to their patients are likely to make serious mistakes in diagnosis and treatment. The second is that doctors frequently don't have the self-awareness to understand their own errors, especially those that involve dealing with ambiguity and understanding the importance of emotions. The final theme is that that patients ought to be active participants in their own care. This is not a new message, but Groopman frames it in a new way. Given the complexity of clinical decision making, and the many cognitive errors physicians may fall prey to, patients can improve their own care by helping their doctors minimize or avoid such errors. Among other things this means asking thought-provoking questions like "What else could it be?", "What is the worst thing it could be?," or "Is it possible I have more than one problem?"


If How Doctors Think has one limitation, it is that Groopman tends to assume that wrong decisions were necessarily "bad" decisions. This is a reasonable assumption in many situations. However, most of his stories are concerned with "false negatives" (i.e. correct diagnoses missed), but he doesn't deal much with the harmful implications of "false positives." For example, if doctors spent more time searching for rare diagnoses (thus avoiding "zebra retreat"), what would be the human and economic implications? Groopman doesn't pay enough attention to medical errors that result in unnecessary interventions. In today's medicine this type of error ought also to be understood and communicated to patients, just as clearly as How Doctors Think does for other types of error.

The book's great strength is its emphasis on communication. Medical students still learn, as they did 50 years ago, that history-taking is by far the most important clinical skill. However, the interpersonal skills required for effective doctor-patient interaction are too often considered intuitive or self-evident, and, therefore, assumed. Moreover, students promptly forget the orthodoxy about history taking when they enter clinical training, where they soon learn that biochemical determinations and radiographic images trump talking with patients. Without adequate role modeling and systematic practice, young physicians may never master effective communication with patients.

Another strength is the focus on self-awareness. Doctors tend to ignore or minimize the importance of emotions in their thinking, mistakenly believing that feelings don't influence clinical judgment. Likewise, they tend not to acknowledge ambiguity. The traditional medical curriculum avoids dealing with internal processes and encourages trainees to concentrate their attention outward. The more that physicians develop personal awareness, the more likely they will develop the resources to listen, connect, and respond to, their patients' experiences.

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How Doctors Think


Houghton Mifflin

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