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Doctor Explores Decision-making and Diagnoses

May 15, 2007 at 6:30 PM EDT
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Harvard Medical School's Dr. Jerome Groopman came up with the idea for his book "How Doctors Think" while watching medical students make snap judgments while diagnosing patients. Groopman talks about how doctors get diagnoses right and sometimes wrong.

SUSAN DENTZER, NewsHour Health Correspondent: Dr. Jerome Groopman of Harvard is a leading authority on blood, cancer and HIV. He’s spent years doing research, treating patients, and training young physicians.

From personal and professional experience, he’s found that doctors frequently make mistakes in diagnosis, figuring out the nature and cause of a patient’s disease. He’s written a new book about it called “How Doctors Think.”

We met with him recently at his Boston lab and asked him what led him to write the book.

DR. JEROME GROOPMAN, Author: I was teaching Harvard medical students, and we were seeing patients in the hospital. And these are bright, motivated, compassionate young people. And I realized that they were jumping very quickly to decisions, making snap judgments, not thinking in a deep and expansive way. And often they didn’t come to the right diagnosis about what was wrong with the person.

SUSAN DENTZER: How common did you find that misdiagnosis really is?

DR. JEROME GROOPMAN: It’s remarkably common: 15 percent of all people are misdiagnosed; some experts in the field think it’s as high as 20 percent to 25 percent. And in half of all of those cases, there’s serious harm or even death to the person.

SUSAN DENTZER: And, in fact, you say this is the most common source of medical errors, not technical errors, like you wrote out the wrong prescription for the patient.

DR. JEROME GROOPMAN: In the past few years, there’s been important focus on safety issues, system solutions, make sure the bracelet has the correct name of the patient, that the blood tests are not mixed up in the lab, all very important. But when it comes to correct diagnosis, the roots are in errors in thinking.

Using shortcuts in diagnoses

SUSAN DENTZER: Now, when doctors think, you say they use heuristics -- or, in laymen's terms, rules of thumb, shortcuts. What are some examples of that? And what happens when those shortcuts take them down the wrong road?

DR. JEROME GROOPMAN: Well, it turns out that we, as doctors, from the very first moment we see a patient and listen to the first words out of your mouth, begin to develop an idea in our mind about what's wrong, and we use a shortcut.

And one of the first shortcuts is called "anchoring." We sort of throw an anchor down and latch on to our initial impression. Often, we're right, but, in my opinion, too often we can be wrong. And we don't pick the anchor up; we stick with it, and we stick with the diagnosis.

SUSAN DENTZER: You say you made an anchoring error once yourself. What happened?

DR. JEROME GROOPMAN: I was a resident at the time. An older woman was complaining of discomfort under her breastbone. I thought it was acid reflux, that the acid from her stomach was moving up into her esophagus.

I gave her antacids, and they really didn't fix the problem. She continued to complain, but I just didn't let go. My mind was anchored on this being a form of indigestion.

And then, several weeks later, I was urgently paged to the emergency room, and she was in shock. And it turned out that she had a tear in the aorta, the large vessel that takes blood from the heart, and I had missed it. I had missed it because I was anchored onto indigestion and, also, frankly, because of my own feelings. I was irritated, and I closed my mind off.

SUSAN DENTZER: So what did you do differently after that?

DR. JEROME GROOPMAN: I tried to be more self-aware. But, frankly, we're not taught as medical students, or residents, or even senior physicians about these kinds of thinking errors or, frankly, how to keep a sense of our own emotional temperature, whether we dislike a patient or sometimes even like a patient too much.

Groopman's experiences

SUSAN DENTZER: So here you are, you're one of the leading blood and cancer specialists in the country. You're at one of the leading academic medical institutions in the country, and even you have been the victim of medical misdiagnoses. What happened?

DR. JEROME GROOPMAN: Several years ago, I had trauma to my right hand. I saw six hand surgeons and got four different opinions.

The first one I saw, after doing x-rays and an MRI scan, he said, "You know, you have a hyper reactive synovium." The synovium is the lining of the wrist. I'd never heard of such a thing. I asked other colleagues, and I actually went on the Internet, and I couldn't find it. He invented a diagnosis.

So I left and went to another surgeon. This surgeon looked at every small abnormality on my MRI scan. I'm a 55-year-old man who's a tired athlete with plenty of trauma, and he said, "I'm going to fix every little thing I see with three sequential operations."

The third surgeon came zipping into the room, looked at my wrist, and said, "Maybe you have gout." And I thought, "Gout?" You know, gout on my wrist and it didn't show up on the x-ray? I said, "Well, wouldn't you have seen it, and couldn't you just put a little needle in?" And he said, "I don't know, I'll figure it out when I get in the O.R."

The fourth surgeon examined my left hand, as well as my right hand, and got x-rays of each. And he also had me clench my fist when he got the x-ray, so there was a dynamic movement in my hand. And, sure enough, one of the ligaments between two small bones had been torn. And then he did something even more remarkable. He said, "You know, I've only done a repair like this once."

And so I found a surgeon who had more experience, and repaired it, and had a reasonably good result.

What patients can do

SUSAN DENTZER: So let's talk about patients. What should patients do to help ensure that their doctors reach the right diagnosis?

DR. JEROME GROOPMAN: I think it's important for patients to know how doctors think, that doctors think with these shortcuts, they often come to a quick decision, and that their feelings often influence their judgment.

Thinking happens in the moment when we're talking to the doctor, when we're being examined. And it's completely appropriate for a patient or a family member or a friend to ask the doctor certain questions, to make sure that his or her thinking stays on track.

One of the most important questions when a doctor gives a diagnosis is: What else could it be? Now, if things are getting better, it's likely the right diagnosis. If things are not getting better, then that question should be asked again: What else could it be? And could two things be going on at once?

And the third very important question is: Have you found anything, any laboratory test, or x-ray, or physical finding that isn't in sync with your presumption, that contradicts what seems to be the diagnosis?

SUSAN DENTZER: How do you think doctors will react to this book?

DR. JEROME GROOPMAN: There may be some who react negatively, but my hope is that, by showing how we succeed and why we fail, that it will be at least the beginning of a new form of approach to the care of patients.

SUSAN DENTZER: So is the bottom line of all this that doctors are really only human after all?

DR. JEROME GROOPMAN: We are human. We're human and trying to do the best we can, but I believe we can do better. And we can do better by knowing how we think, so that we reduce this rate of misdiagnosis. And we can do better by really partnering with our patients and their families.

SUSAN DENTZER: Dr. Groopman, thank you.