“Don’t let the world around you squeeze you into its own mould, but let God re-mould your minds from within...”
Romans 12:2

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Hilary's Desk

How Doctors Think.

Hilary Butler - Sunday, October 24, 2010

You don't think you need to know?  Well, according to Dr Jerome Groopman, you do.  Dr Groopman belongs to a rare species in medicine who tell it as it is - perhaps because he's been at the butt end of a few medical bum deals in his day. He knows what it feels like to be run over by his own medical system, and has the clout to write about it.  His writing is vitally important, and utterly frustrating in the same breath.  It's vitally important, because everyone who ever walks into a doctor's surgery needs to read this book, but most never will. It's frustrating, because  Groopman misses a very important issue - which is what the next blog will be about. But first, the book itself.

Most people won't read this book, because, "After all," they will say, "I've got better things to do with my time.  Why would I need to know how a doctor thinks?  Didn't they get that way, because they are the creme de la creme, of thinkers in the first place?"

Actually no.  When you read this book, you discover that real thinking appears to be a rare commodity within the medical system, even if they "think" they think.  Groopman uses many case histories to illustrate exactly that, as well as analyse what it was in those situations, that blinded the ability of doctors to think  -  which let the patient down.

Groopman, is at the sunset end of his career.  No young doctor, making his way in the world could have written this book, because he wouldn't have the experience needed, and...  he wouldn't have a job at the end of it!  But Groopman can, because he's got a raft of experience to fall back on, as well as a good reputation having been a loyal medical man.  Furthermore, he doesn't "need" the medical system now.  In a sense, it needs him.  Groopman manages to do two things at once:

  • Tell you really important things you need to know in order to attempt to survive the medical system.
  • Keep his buddies happy at the same time, by interjecting just enough medical heroes on white horses, to help bail out all the useless wimps, who provide him with so much of the rest of his material.

This book should wake you up to why - much of the time - when diagnoses or treatments go wrong, the medical system gets away with it, because the average sheeple is none the wiser that something has happened which shouldn't have, and most doctors wouldn't say, even if they knew.  Which mostly they don't, because medicine is pretty much a conveyor belt now, with "Next One" being the most heard instruction.

Groopman explains why the medical training given at medical school, places medical students into boxes, makes them clones of their tutors, who are clones of THEIR tutors, and turns out medically trained people who can and often do, suffer seriously grandiose views of themselves, their knowledge and their own power. Who are often intolerant of patients who question.  Some doctors can become a whirlwind timebomb as they diagnose patients, based on assumption and arrogance. 

Bits of the material in this book comes from Groopman's own past, where in spite of the fact that he was a doctor, and was married to one, he often had to pull the 'doctor' card in order to protect himself from others. But even at times, being a doctor doesn't protect Groopman from himself!

He rightly puts the knowledgeable and questioning patient right in the book, as his "...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 present in the moment when flesh-and-blood decision-making occurs.  That partner is my patient or her family member or friend who seeks to know what is in my mind, how I am thinking.  And by opening my mind I can more clearly recognize it's reach and it's limits, it's understanding of my patients physical problems and emotional needs.  There is no better way to care for those who need my caring".

I couldn't agree more.  But the reality is that for most of us, finding a doctor like this, is near impossible. Most "ordinary" people going to a doctor don't ask questions, and if you told them to ask questions, they also wouldn't have a clue where to start.

One chapter called "In service of the Soul", really grated.  The discussion centred around a person who Groopman clearly reveres, and who frankly gave me the creeps.  In service of the soul is the last title I would have attached to that chapter, because Groopman's "white knight" in this case, was not only patronising, but didn't realise that it's what doctors don't think, that can matter more than what they do think.

Much of what we read is, as Groopman details, the direct result of the fact that trainee doctors aren't encouraged to keep an open mind; are educated for dogmatic certainty - to adopt that particularly school's dogma; and to always "play the game according to the rules that each institution imposes on staff, students and patients".  He points out that specialization adds a false sense of certainty, because once an "authoritative specialist" has fixed a label to a problem, it stays firmly attached, which can lead to diagnosis momentum, confirmation bias, minimising data that contradicts it, and serious cognitive errors, while all along the way, the medics parroting the specialist are often blissfully unaware that they've lost the plot. 

Chapter 5, "A new mother's challenge" is a powerful example - which every mother should read, and realise that mothers have brains, and can indeed see through the cognitive dissonance of authoritative specialists and their compounding errors, and step in to successfully prevent their child from being given a dangerous treatment for an incorrect diagnosis.

Worse, specialization can also result in competition whereby doctors have to "keep up" with the treatments of their fellow specialists, and might even offer them, even if they disagree with them, because their patient might go elsewhere if they don't.  So, in the case of useless spinal fusions for instance, some surgeons perform them, knowing they aren't going to work, simply so that they know the surgery has been done "properly".  Some of what you read will leave you regularly gobsmacked. But here, in the book - you have it all.

Having discussed the shackles into which the medical schools straight jacket doctors, Groopman presents people who are not constrained by those shackles in terms of their diagnostic ability.  But what Groopman doesn't see, is that even he and they, are still intellectually shackled, because they still believe that the very institution which shackled their thinking, really does have the only answers.

Groopman details very useful information about X-rays, ultrasounds, CT scans and MRIs making the point that radiologists have quite high failure rates, both in seeing things which aren't there (over-reading), and missing things which are (under-reading), and case-histories showing the flow-on consequences of that. ( Don't you like the use of the words "over-reading" and "under-reading"? )

This book however, has one failing which comes out of it's success.  Groopman, who has made far more strides than most doctors in a GP practice in New Zealand would ever admit to, does suffer from the delusion that there is no "life" outside of the medical profession.  Which blinds him to a parallel reality which would add a third dimension to what he writes.

Then Groopman could write a book called "How doctors don't think".  Meanwhile, if every doctor made every patient read this book, and sit an examination on it, medical practice would be revolutionised over night, because people  would "see" the enormity of these issues.. and they wouldn't stand for the current status quo of "how doctors think". There would be a patient rebellion.

I give this book, five stars out of five.  If you happen to live in Pukekohe, they do have the book.  I know, because I gave them my copy.  :)

 

Part Two: How doctor's don't think.

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