Jerome Groopman, in How Doctors Think, reviews ways in which doctors can make poor choices, identifies potential causes, and suggests some practices, for both doctor and patient, that can help to prevent them. I find this interesting for a couple of reasons: first, I work in the health space, although not in a therapeutic area and, second, I like to reflect on my own thought processes.
I'll take three broad themes from Groopman's analysis: the business of healthcare and how that impacts a physician's ability to practice; the doctor-patient relationship and how that impacts the experience of both sides; and the cognitive failings that impact a correct and timely diagnosis for any given patient. Naturally, these overlap.
The book is written from the perspective of the notoriously commercialised American medical system and is around 20 years old, so doubtless some of the details are different outside of the US and have changed since publication.
Taking this into account, and even with a healthy scepticism about the ability of businesses to prioritise anything other than the business, it is still chilling to hear about the extent to which pharmaceutical companies, insurers, lawyers, and the healthcare providers pressure and constrain doctors: marketing materials, financial and other inducements, significantly higher compensation rates for surgery over other interventions, the threat of litigation, actual litigation, paperwork, business "efficiencies," and service "quality" metrics.
Sadly, most practitioners can do little about this list. The Hippocratic Oath must be turning in its grave.
All of those things, and more, conspire to reduce the quality and quantity of face-to-face contact between doctors and their patients, something which is of the utmost importance to patients and, it seems, almost universally disregarded by the systems in which doctors work.
Patients feel it when they are in front of the doctor physically but not front of mind mentally. They notice the doctor talking while looking at the screen and typing, they can tell that the focus is not on them when nurses are interrupting their doctor to ask about other cases, they recognise a cursory examination and a rushed bedside manner, and they know whether they have been passively looked at and listened to or actively seen and heard.
Groopman often makes his case through anecdote, his own as doctor and patient and those of many other practitioners that he's come into contact with across his career. They all have war stories about the times they were able to find the key that unlocked the diagnosis for a patient and the times they still lose sleep over where they failed to see what they could have seen if only they'd looked in the right place at the right time or from the right perspective.
With reference to those examples, and also research in the area, he identifies specific behaviours and biases. This is a taster:
- Doing something rather than deliberately taking no action. This can be driven by practitioner ego, thinking that they know what's right, but also by patient pressure. Sometimes time is what's required for a symptom to clear itself naturally or for enough data to be gathered that a diagnosis can be given.
- Availability bias: giving undue weight to factors that are already in the context, for example if it's flu season, assuming that the coughing patient in front of you has flu.
- Confirmation bias: tending to downplay aspects of a case that don't align well with the diagnosis on the table. Perhaps unhelpfully the medical profession has a (useful and valid) term for this kind of case: atypical.
- Relying only on logic or precedent. Patients are unique and their specifics are critical.
- Satisficing and Occam's Razor can result in less common conditions being missed. More mundanely, most doctors have never seen most rare conditions and are simply less likely to consider them.
You'll have noticed, as did Groopman, that these biases can also be tools and so are heuristic, context-sensitive, and require skill, experience, and intuition to apply and interpret.
You'll also have expected, because this joke writes itself, that Groopman hands out prescriptions. He does.
For patients there are questions that could prompt the doctor to think more broadly, such as what else could it be? is there anything that doesn't fit? might there be multiple problems? and is there another way?
For doctors there is more and I wanted to boil Groopman's insights down into something memorable that covers both patient interactions and their own thinking, those things that practitioners have direct influence over. I came up with this:
Open your mind
I read it two ways. Doctors should:
- share their thinking and reasons with patients in a relatable way. When patients can see where the doctor is coming from and the extent to which they were understood, they might respond with more information or questions that help to determine the best next step.
- be prepared to change their thinking, be humble about their current hypothesis, and always wonder whether there is something else that could better explain the symptoms in front of them.
And, although we don't all work in a medical domain, I'd bet that most of us
collaborate closely with other people on problems that are important to them. so perhaps we should open our minds
too.
Image: Amazon