How doctors can think better

June 6, 2008

An interview with Jerome Groopman, MD, author of "How Doctors Think."

Key Points

When Aristotle said: "To be conscious that we are perceiving or thinking is to be conscious of our own existence," he was describing metacognition-the awareness of one's own thinking process. Tuning into your own thought patterns can help you identify and change the way you think.

Doctors' thinking processes, in particular, need attention, according to Jerome Groopman, MD, hematologist and oncologist. Groopman's 2007 book, How Doctors Think (Houghton Mifflin), called "a mix of science and soul" by New York Times reviewer William Grimes, has struck a chord with physicians, insurers, and others concerned about why so many medical errors occur and how to prevent them.

Doctors typically use mental shortcuts-known as heuristics-in practice. Heuristics save time and allow physicians to function without constantly stopping to consider the next course of action. But they're also responsible for many misdiagnoses, Groopman says.

I recently had the opportunity to speak with Groopman about his latest book. Some highlights of that conversation:

Kane: You described three heuristics that doctors typically use-"the three As," as you call them. What are they?

Groopman: The first is anchoring. We quickly latch onto what we think the diagnosis is, and selectively accept or ignore information that corresponds with what we expect to find. This influences the questions we choose to ask, and how we ask them. That, in turn, tends to focus patients' answers. So we're more likely to find what we've already decided we're looking for.

The second heuristic is availability. That's the tendency to judge the likelihood of a diagnosis based on how readily relevant examples come to mind. During a flu epidemic, for instance, if you see 15 people with the flu, when the 16th person comes in saying he feels clammy and has a bit of fever, you automatically assume it's the flu. But it might be something else entirely.

Or if you've had a very dramatic case-which all doctors do-it imprints on your mind. When you see patients with similar physical findings, you superimpose that prior dramatic case on the one in front of you.

The third heuristic is attribution. We all hold stereotypes in our mind and are very quick to attribute complaints to a larger stereotype. If a patient is slovenly, hasn't shaved, has rum on his breath, and has an enlarged liver, he becomes alcoholic cirrhosis even if he says he doesn't drink much.

Kane: Doesn't everyone use heuristics to get through life? That's how people learn by experience, and make it through the day without having to evaluate every occurrence from scratch. How are doctors supposed to turn off these very human thinking mechanisms?

Groopman: You're correct. These kinds of mental shortcuts are wired in our brains. Physicians in particular invoke heuristics because we're working under conditions of time pressure and uncertainty, with limited data.

Kane: Given that heuristics are hard-wired, how can doctors overcome them?

Groopman: We need to remember that the three heuristics I mentioned are all traps. So you need to do metacognition-think about your thinking. To do that, ask yourself some simple questions when evaluating patients: "What else could it be?" Or "Am I being too quick to lump it all together?" Or "Can two things be going on at once?" Because maybe the person does drink, but that doesn't mean there can't be another problem that accounts for his enlarged liver.

These are the kinds of questions that when we were residents, we asked our attendings or the attending physicians asked us. But now that we're in practice, it becomes harder to ask these questions because we're working within our own heads.

Kane: With today's shorter patient visits, pay for performance, and evidence-based medicine, doctors are encouraged to use algorithms and decision trees to diagnose. The system doesn't encourage doctors to take more time for open-ended thinking. How can doctors find the time to think more and still make a good living?

Groopman: The system has gone headlong into checking off the boxes and following all the outcomes and decision trees. I believe medicine is still something that requires an understanding of the individual.

I've spent years in research for evidence-based medicine, and I'm very aware of the limits and deficiencies of how those data are used. They reflect a very, very cherry-picked group of patients. They use patients who aren't on seven medications, and they come up with statistical averages. How closely does the patient in your office correspond with the data-based medicine? Are you supposed to say to your patient, "Please leave my office, you don't fit the data"?

Kane: It sounds like there isn't really an answer to the situation. Hearing from doctors who are struggling with diminished reimbursements, I get the impression that the public expects doctors to be more altruistic than other human beings and not care about the financial end.

Groopman: I think this is a caring profession; it still attracts people who want to do good and people who are altruistic and dedicated. But that doesn't mean you shouldn't make a living. Being a doctor doesn't mean you're required to be a monk and give up the world. Physicians are being pushed to work ever harder, while at the same time the system is changing in ways that prevent profit from going to the people who do the work.

Kane: Any other wisdom or advice you'd give doctors?

Groopman: Learning how doctors think has helped me give better care, and has prevented me from making the kinds of mistakes I made in the past. I feel it has restored to me some degree of control because I know my mind better. And that control enables me to more effectively buck the system.

Groopman brings up important information about tuning into your own thinking. Doing so takes some attention and practice; and because thinking short-cuts are so human, it may be a challenge. But doctors have never been ones to take the easy path, especially when an activity can sharpen their expertise and enhance their patients' lives.