Jerome Groopman is a physician who has studied himself and his
fellow doctors. He finds that they sometimes need to re-learn the
thinking process that leads them to --- occasionally ---
misdiagnose their patients.

Doctors are taught certain techniques for examining a patient. But,
says Groopman, "hypotheses about the diagnosis come to a doctor's
mind even before a word of the medical history is spoken." There
are visual impressions and prior encounters, all adding up to a
kind of profiling system individual to the doctor that can, like
any profiling, be inaccurate. The doctor is the policeman, judge
and jury, and his or her rush to judgment can prove fatal.

A simple example cited in HOW DOCTORS THINK concerns a young man
who wound up in the emergency room after being found by police
sleeping on the steps of an art museum. He appeared dirty and
incoherent, and the doctor on duty "eye-balled" him, took him for a
homeless hippie and pressed on to more urgent matters. Later,
alerted by a nurse, the doctor realized that the young man's
incoherence stemmed not from intoxication but from sky-high blood
sugar. He had collapsed, not fallen asleep. "It turned out he was
not a vagrant but a student, and his difficulties giving the police
and the triage nurse information reflected the metabolic changes
that typify out-of-control diabetes."

Groopman describes in detail his own frustration when trying to get
a diagnosis and some relief for his hand, which occasionally became
red, painful and swollen. It was not until the fourth consultation
with the fourth "expert" that he believed he had gotten a realistic
assessment. Being a medical person himself helped him, of course,
but not all of us are so fortunate, so careful and so
knowledgeable. Most people are acculturated to trust their doctors.
Most of the time the trust is justified. But not every time.

One of the most heartwrenching stories in Groopman's book concerns
Rachel, a middle-aged woman who adopted a Vietnamese baby. When the
infant failed to thrive, Rachel found herself in a nightmare but
held herself together by means of religious conviction. At every
juncture when her baby's life could have been relinquished after
medical people had done all they could, Rachel prayed and also
analyzed. The medical team had assessed the baby's problem: SCID,
severe combined immunodeficiency disorder. Treating it as such,
they watched as the baby struggled to live.

Still, Rachel prayed and did her own research. She became convinced
that the baby's problem was malnutrition. It took great persistence
and more prayer to convince a team of experts to take her
hypothesis seriously. She was right. Her baby began to pull through
and soon left the ICU once the correct diagnosis was acknowledged,
and little Shira got a place in the medical history books.

Groopman looks at the pressure that doctors are under ---
expectations from the practice that they will consult with each
patient for no more than 15 minutes, visits from aggressive drug
reps, reluctance to deal with certain kinds of patients, the idea
that they already know from a glance what a patient's problem is,
and the stress on a professional "healer" when he or she can offer
compassionate palliative treatment, but no hope, to terminally-ill
patients.

The author concludes that the patient in all cases must partner
with the doctor to keep his or her mind open to possibilities. Even
when the patient does not self-advocate, the doctor must keep the
unique individual person in mind. The question "What else could it
be?" should always be part of the diagnostic process. And that
process has to become innate, almost instantaneous. A lot to
ask.

HOW DOCTORS THINK should be required reading for medical students
and for proactive patients. After you read it, pass it along to
your doctor.