Physician, heal thyself

May 22, 2007 at 3:00 am 3 comments

Kim photo taken in NamibiaI’ve had a parent in the hospital for the last four weeks. During the first week, the doctor and specialist muttered dark words of doom and gloom. They often mentioned the Big C word (cancer). They sent my mother through a barrage of tests, usually with no explanation or follow-up. By the third week, the initial prophecies of darkness had changed to “looks like she has severe osteo-arthritis”. Now, the astute amongst us will immediately think ‘but hang on, there’s a world of difference between cancer and osteo-arthritis“. You bet! so I bailed up the specialist as he darted down the hospital corridor and asked him to “please explain”. He launched himself into a monologue peppered with fancy sounding medical terminology. He looked puzzled when I asked him to speak in plain English – perhaps he doesn’t realise that the world is not entirely populated with medicos! By week four, the general practitioner (who was at pains to announce that he greatly respected the specialist’s expertise) said that he did not agree with the specialist who was still hedging his bets and saying that it was 50/50 whether it was cancer or not. The general practitioner had taken the time to consult with radiographers about the millions of x-rays they’d taken and all concurred that it was severe osteo-arthritis.

I’m sure that many ThinkingShift readers have their own sorry tales of medical dramas to tell. And I’m equally sure that many of you will agree with me that doctors need to learn how to have a meaningful conversation with their patients and their families; that they need to learn how to get the patient to tell their story; that they should explain what they are doing and thinking.

So I’m thrilled to see that one doctor has seen the light and questioned whether doctors, especially when confronted with complex cases, think in ways that run the risk of error. And that the likelihood of error is reduced if (gasp!)….patients actively participate in their consultation and treatment. Dr Jerome Groopman, Professor of Medicine at Harvard Medical School, noticed that “something was profoundly wrong with the way (doctors and medical students at a teaching hospital) were learning to solve clinical puzzles and care for people“.

Here’s a scary statistic – around 15% of diagnoses are wrong. And Dr Groopman, after three years’ research, has come to the conclusion that medical errors are not technical but cognitive. Simply put, doctors sometimes experience an error in thinking. He has also noted that there is a phenomenon known as “diagnosis momentum”, which is the tendency for a diagnosis to gain certainty as it is passed from doctor to doctor. I witnessed this phenomenon myself – in the face of tests to the contrary, the general practitioner in charge of my mother was agreeing with the specialist for over three weeks until he noted something wasn’t right (clever man!). And then there is the old classic: confirmation bias – where the medical practitioner selectively chooses evidence to support his or her diagnosis or treatment decision, and casts aside evidence that suggests otherwise.

In his book, How Doctors Think, Dr Groopman recounts the story of Blanche Begaye who was suffering from a flu-like illness. She decided to scoff down lots of orange juice and take aspirin. Her symptoms worsened and, when she presented to the doctor, she was given the diagnosis of viral pneumonia. What she really had was aspirin poisoning, but because the doctor had recently seen several cases of pneumonia, he suffered an error in thinking. A more chilling example: a young woman who suffered from a plethora of ills was diagnosed as anorexic and bulemic – she was promptly placed on antidepressants and forced to stuff down 3,000 calories per day. Her real ailment? celiac disease, which affects the ability of the small intestine to absorb nutrients, ergo people lose weight and can present with similar symptoms to anorexics and bulemics. Part of the problem was that the young woman, in the face of stern doctors, came to believe the initial (wrong) diagnosis.

Groopman talks about how doctors must juggle seemingly contradictory bits of data simultaneously in the mind and that the expert juggler is the very experienced medical practitioner with an open mind. Although the expert might recognise a pattern seen many times before, he or she does not stubbornly cling to initial impressions when contradictory evidence pops up. Groopman also delves into a doctor’s emotional state or personal beliefs, which he suggests can have an affect on how the doctor thinks about or works with a patient. Doctors are also not trained to be good listeners or show curiosity for the human narrative.

Groopman’s book offers advice for sound decision-making and I particularly liked the one about giving doctors time and space to indulge in reflection rather than demanding shorter appointment times. As patients, we often expect instant knowledge to be delivered – what is my long-term prognosis? what treatment will I be having? But as a lawyer, I wouldn’t immediately give a client my legal opinion without first consulting opinions, precedents, prior legal cases etc. So perhaps this expectation of instant knowledge results in doctors being pressured and falling prey to faulty thinking.

Lawyers (at least in Australia) had to go through the whole process of Plain English language and drafting. We had to “unlearn” the legalese and engage with clients at their level; we had to learn to be less pompous and give consideration to how the client might be scared or worried. Doctors need to go through this same re-education process and, in the meantime, they need to get their hands on a copy of Groopman’s book. Or they could get hold of Atul Gawande’s book, Complications: A Surgeon’s Notes on an Imperfect Science, which beautifully deconstructs the myth of medical infallibility.

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Entry filed under: Books, Medicine, Narratives, Rant.

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