Authors: Jerome Groopman
Different doctors, as we will see in later chapters, achieve competency in remarkably similar ways, despite working in disparate fields. Primarily, they recognize and remember their mistakes and misjudgments, and incorporate those memories into their thinking. Studies show that expertise is largely acquired not only by sustained practice but by receiving feedback that helps you understand your technical errors and misguided decisions. During my training, I met a cardiologist who had a deserved reputation as one of the best in his field, not only a storehouse of knowledge but also a clinician with excellent judgment. He kept a log of all the mistakes he knew he had made over the decades, and at times revisited this compendium when trying to figure out a particularly difficult case. He was characterized by many of his colleagues as eccentric, an obsessive oddball. Only later did I realize his implicit message to us was to admit our mistakes to ourselves, then analyze them, and keep them accessible at all times if we wanted to be stellar clinicians. In Anne Dodge's case, Falchuk immediately recalled how he had taken at face value the statements of the patient at NIH who was secretly using laxatives. The opposite situation, he knew, could also apply. In either setting, the case demanded continued thought and investigation.
When Falchuk told me that "the picture didn't fit," his words were more than mere metaphor. Donald Redelmeier, a physician at Sunnybrook Health Sciences Centre in Toronto, has a particular interest in physician cognition and its relation to diagnosis. He refers to a phenomenon called the "eyeball test," the pivotal moment when a doctor identifies "something intangible yet unsettling in the patient's presentation." That instinct may, of course, be wrong. But it should not be ignored, because it can cause the physician to recognize that the information before him has been improperly "framed."
Doctors frame patients all the time using shorthand: "I'm sending you a case of diabetes and renal failure," or "I have a drug addict here in the ER with fever and a cough from pneumonia." Often a doctor chooses the correct frame and all the clinical data fit neatly within it. But a self-aware physician knows that accepting the frame as given can be a serious error. Anne Dodge was fitted into the single frame of bulimia and anorexia nervosa from the age of twenty. It was easily understandable that each of her doctors received her case in that one frame. All the data fit neatly within its borders. There was no apparent reason to redraw her clinical portrait, to look at it from another angle. Except one. "It's like DNA evidence at a crime," Falchuk explained. "The patient was saying 'I told you, I'm innocent.'" Here is the art of medicine, the sensitivity to language and emotion that makes for a superior clinician.
Falchuk almost rose from his chair when he showed me the pictures of dodge's distorted small intestine taken through the endoscope. "I was so excited about this," he said. He had the sweet pleasure of the detective who cracks the mystery, a legitimate pride in identifying a culprit. But beyond intellectual excitement and satisfaction, he showed his joy in saving a life.
Intellect and intuition, careful attention to detail, active listening, and psychological insight all coalesced on that December day. It could have been otherwise. Anne Dodge, with her history of anorexia nervosa and bulimia, may then have developed irritable bowel syndrome. But Falchuk had asked himself, "What might I be missing in this case? And what would be the worst thing that could be missed?"
What if he had not asked himself these questions? Then Anne Dodge, her boyfriend, or a family member could have asked them—perhaps many years earlier. Of course, a patient or a loved one is not a doctor. They lack a doctor's training and experience. And many laymen feel inhibited about asking questions. But the questions are perfectly legitimate. Patients can learn to question and to think the way a doctor should. In the chapters and epilogue that follow, we will examine the kinds of errors in thinking that physicians can make, and the words that patients and their loved ones can offer to prevent these cognitive mistakes.
In Anne Dodge's case, it was Falchuk who asked simple but ultimately life-saving questions, and to answer them he needed to go further. And Anne Dodge needed to agree to go further, to submit to more blood tests and an invasive procedure. For her to assent, she had to trust not only Falchuk's skill but also his sincerity and motivations. This is the other dimension of Roter's and Hall's studies: how language, spoken and unspoken, can give information essential to a correct diagnosis, and persuade a patient to comply with a doctor's advice. "Compliance" can have a negative connotation, smacking of paternalism, casting patients as passive players who do what the all-powerful physician tells them. But according to Roter's and Hall's research, without trust and a sense of mutual liking, Anne Dodge probably would have deflected Falchuk's suggestions of more blood tests and an endoscopy. She would have been "noncompliant," in pejorative clinical parlance. And she would still be struggling to persuade her doctors that she was eating three thousand calories a day while wasting away.
My admiration for Myron Falchuk increased when we went on from Anne Dodge's case to discuss not his clinical triumphs but his errors. Again, every doctor is fallible. No doctor is right all the time. Every physician, even the most brilliant, makes a misdiagnosis or chooses the wrong therapy. This is not a matter of"medical mistakes." Medical mistakes have been written about extensively in the lay press and analyzed in a report from the Institute of Medicine of the National Academy of Sciences. They involve prescribing the wrong dose of a drug or looking at an x-ray of a patient backward. Misdiagnosis is different. It is a window into the medical mind. It reveals why doctors fail to question their assumptions, why their thinking is sometimes closed or skewed, why they overlook the gaps in their knowledge. Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes. In one study of misdiagnoses that caused serious harm to patients, some 80 percent could be accounted for by a cascade of cognitive errors, like the one in Anne Dodge's case, putting her into a narrow frame and ignoring information that contradicted a fixed notion. Another study of one hundred incorrect diagnoses found that inadequate medical knowledge was the reason for error in only four instances. The doctors didn't stumble because of their ignorance of clinical facts; rather, they missed diagnoses because they fell into cognitive traps. Such errors produce a distressingly high rate of misdiagnosis. As many as 15 percent of all diagnoses are inaccurate, according to a 1995 report in which doctors assessed written descriptions of patients' symptoms and examined actors simulating patients with various diseases. These findings match classical research, based on autopsies, which shows that 10 percent to 15 percent of all diagnoses are wrong.
I can recall every misdiagnosis I've made during my thirty-year career. The first occurred when I was a resident in internal medicine at the Massachusetts General Hospital; Roter's and Hall's research explains it. One of my patients was a middle-aged woman with seemingly endless complaints whose voice sounded to me like a nail scratching a blackboard. One day she had a new complaint, discomfort in her upper chest. I tried to pin down what caused the discomfort—eating, exercise, coughing—to no avail. Then I ordered routine tests, including a chest x-ray and a cardiogram. Both were normal. In desperation, I prescribed antacids. But her complaint persisted, and I became deaf to it. In essence, I couldn't think in a different way. Several weeks later, I was stat paged to the emergency room. My patient had a dissecting aortic aneurysm, a life-threatening tear of the large artery that carries blood from the heart to the rest of the body. She died. Although an aortic dissection is often fatal even when discovered, I have never forgiven myself for failing to diagnose it. There was a chance she could have been saved.
Roter's and Hall's work on liking and disliking illuminates in part what happened in the clinic three decades ago. I wish I had been taught, and had gained the self-awareness, to realize how emotion can blur a doctor's ability to listen and think. Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment. The doctor becomes increasingly convinced of the truth of his misjudgment, developing a psychological commitment to it. He becomes wedded to his distorted conclusion. His strong negative feelings about the patient make it harder for him to abandon that conclusion and reframe the clinical picture differently.
This skewing of physicians' thinking leads to poor care. What is remarkable is not merely the consequences of a doctor's negative emotions. Despite research showing that most patients pick up on the physician's negativity, few of them understand its effect on their medical care and rarely change doctors because of it. Rather, they often blame themselves for complaining and taxing the doctor's patience. Instead, patients should politely but freely broach the issue with their doctor. "I sense that we may not be communi cating well," a patient can say. This signals the physician that there is a problem in compatibility. The problem may be resolvable with candor by a patient who wants to sustain the relationship. But when I asked other physicians what they would do if they, as patients, perceived a negative attitude from their doctor, each one flatly said he or she would find another doctor.
Chapter 1
Flesh-and-Blood Decision-Making
O
N A SWELTERING MORNING
in June 1976, I put on a starched white coat, placed a stethoscope in my black bag, and checked for the third time in the mirror that my tie was correctly knotted. Despite the heat, I walked briskly along Cambridge Street to the entrance of the Massachusetts General Hospital. This was the long-awaited moment, my first day of internship—the end of play-acting as a doctor, the start of being a real one. My medical school classmates and I had spent the first two years in lecture halls and in laboratories, learning anatomy, physiology, pharmacology, and pathology from textbooks and manuals, using microscopes and petri dishes to perform experiments. The following two years, we learned at the bedside. We were taught how to organize a patient's history: his chief complaint, associated symptoms, past medical history, relevant social data, past and current therapies. Then we were instructed in how to examine people: listening for normal and abnormal heart sounds; palpating the liver and spleen; checking pulses in the neck, arms, and legs; observing the contour of the nerve and splay of the vessels in the retina. At each step we were closely supervised, our hands firmly held by our mentors, the attending physicians.
Throughout those four years of medical school, I was an intense, driven student, gripped by the belief that I had to learn every fact and detail so that I might one day take responsibility for a patient's life. I sat in the front row in the lecture hall and hardly moved my head, nearly catatonic with concentration. During my clinical courses in internal medicine, surgery, pediatrics, obstetrics and gynecology, I assumed a similarly focused posture. Determined to retain everything, I scribbled copious notes during lectures and after bedside rounds. Each night, I copied those notes onto index cards that I arranged on my desk according to subject. On weekends, I would try to memorize them. My goal was to store an encyclopedia in my mind, so that when I met a patient, I could open the mental book and find the correct diagnosis and treatment.
The new interns gathered in a conference room in the Bulfinch Building of the hospital. The Bulfinch is an elegant gray granite structure with eight Ionic columns and floor-to-ceiling windows, dating from 1823. In this building is the famed Ether Dome, the amphitheater where the anesthetic ether was first demonstrated in 1846. In 1976, the Bulfinch Building still housed open wards with nearly two dozen patients in a single cavernous room, each bed separated by a flimsy curtain.
We were greeted by the chairman of medicine, Alexander Leaf. His remarks were brief—he told us that as interns we had the privilege to both learn and serve. Though he spoke in a near whisper, what we heard was loud and clear: the internship program at the MGH was highly selective, and great things were expected of us during our careers in medicine. Then the chief resident handed out each intern's schedule.
There were three clinical services, Bulfinch, Baker, and Phillips, and over the ensuing twelve months we would rotate through all of them. Each clinical service was located in a separate building, and together the three buildings mirrored the class structure of America. The open wards in Bulfinch served people who had no private physician, mainly indigent Italians from the North End and Irish from Charlestown and Chelsea. Interns and residents took a fierce pride in caring for those on the Bulfinch wards, who were "their own" patients. The Baker Building housed the "semi-private" patients, two or three to a room, working- and middle-class people with insurance. The "private" service was in the Phillips House, a handsome edifice rising some eleven stories with views of the Charles River; each room was either a single or a suite, and the suites were rumored to have accommodated valets and maids in times past. The very wealthy were admitted to the Phillips House by a select group of personal physicians, many of whom had offices at the foot of Beacon Hill and were themselves Boston Brahmins.
I began on the Baker service. Our team was composed of two interns and one resident. After the meeting with Dr. Leaf, the three of us immediately went to the floor and settled in with a stack of patient charts. The resident divided our charges into three groups, assigning the sickest to himself.
Each of us was on call every third night, and my turn began that first evening. We would be on call alone, responsible for all of the patients on the floor as well as any new admissions. At seven the following morning, we would meet and review what had happened overnight. "Remember, be an ironman and hold the fort," the resident said to me, the clichés offered only half jokingly. Interns were to ask for backup only in the most dire circumstances. "You can page me if you really need me," the resident added, "but I'll be home sleeping, since I was on call last night."