How Doctors Think
Jerome Groopman, M.D. (Mariner Books, 2007-8)
Treatment Kind and Fair: letters to a young doctor
Perri Klass, M.D. (Basic Books, 2007)
Better: A surgeon’s notes on performance
Atul Gawande (Picador, 2007)
I’ve read a handful of books, this month, about the art and science of medicine: it turns out that the art is the neglected side of the equation. That’s not to say that all the scientific questions are tidily resolved, but that accounting for that reality is itself an art.
What’s the relationship between the orderly, comprehensive knowledge of the classroom, and the shoot-from-the-hip shortcuts of the practicing doctor? How do we know when intuition leads to good treatment, and when it leads to error? For that matter, is the books-and-laboratory knowledge as comprehensive as it seems?
Jerome Groopman’s How Doctors Think gives doctors plenty of credit for their purely scientific expertise, but as he painstakingly documents, they are subject to errors of thinking that are not errors of knowledge. Even a very smart doctor may get attached to a single diagnostic idea, and become blind to evidence that he is treating only part of the problem, or the wrong illness altogether. It also may happen that he forms a judgment of his patient as a chronic complainer, and becomes deaf to the substance of the complaint. Groopman’s examples are harrowing, but he does present some heroes, doctors who kept working on troubling information till they sorted out the real story.
Groopman’s own training was of the old school, from a time when doctors were taught to treat diseases rather than patients. Though he trained at some of the finest hospitals, he says, “I cannot recall a single instance when an attending physician taught us to think about social context.” In How Doctors Think, he’s trying valiantly to expand that point of view, but it will always be harder for him than for those with more recent schooling.
Perri Klass’s 1987 book about her own medical training has one of my all-time favorite titles, A Not Entirely Benign Procedure; she’s no less wry in this book, but the years have, naturally, deepened her perspective. Treatment Kind and Fair is addressed to her son, who was born when she was in medical school. He is now old enough to consider applying to medical school. She’s close enough to her years of training to be empathetic, but far enough removed to have some useful advice; she’s also learning as a teacher, since she’s involved in a training program for first-year medical students on how to converse with patients. It’s a big advance over Groopman’s day.
Her book is better, too, because she trusts her reader more. Groopman writes with a naiveté that can verge on the annoying: “Lock explained that for lower middle-class people, becoming a doctor was the way to get out.” Did he need that explained? Do we?
Klass’s voice is much more direct: "As a medical student on the hospital wards, you will go in terror of making a mistake and hurting a patient--at least, you will go in terror if you have any sense.” She’s cheerfully grapples with contradictions: her tutorial group is decked out in their new white coats; but Klass is a pediatrician, so she often dispenses with hers, “because many small children, who have had a few go-rounds with immunization, will simply start screaming at the sight of a white coat. Then you can just say goodbye to any chance of observing the child’s development or listening to the heart or the lungs.” Her perspective includes the patient’s, in a practical and humane way.
Atul Gawande’s Better takes a still wider perspective. Like Groopman and Klass, Gawande assumes that doctors generally have the technical know-how they need, and some idea of how to assemble the facts to make a diagnosis. But because the stakes are so high, he commends some other cardinal virtues: diligence, ingenuity, and the desire to do the right thing.
Better is about the usually-overlooked benefits of doing well what we already know how to do. Gawande says, “We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right--one after another, no slipups, no goofs, everyone pitching in.” He applies this insight broadly, from the modern obstetrical suite, where the search for safety and reliability has progressed by leaps and bounds, to the poorest villages in India, where the World Health Organization hopes to stop the transmission of polio for good. He follows a team trying to eliminate hospital-borne, drug-resistant bacteria by making hand-washing easier, and visits the most effective cystic fibrosis clinic in the country. The science in these places is not abstract or theoretical; it consists of the close observation, and relentless pursuit, of whatever works best.
All three of these books advocate for improvements in health care that are more subtle, and far more important, than the gee-whiz science of laboratory breakthroughs or multi-million-dollar machines. Though Groopman seems to feel somewhat heretical for suggesting it, How Doctors Think could make the reader more able and willing to question a doctor’s diagnostic thinking, and possibly correct it.
Treatment Kind and Fair is a backstage tour of medical training, full of insights about what makes doctors different from the rest of us. Klass wrestles with the new difficulties imposed by the work-week limits on physicians in training. It is no longer permissable to work an intern or resident on thirty-six hour shifts, or more than eighty hours a week, but the problem of sleep deprivation has been replaced by the difficulty of a young doctor trying to cover dozens of patients she doesn’t really know anything about, because the person who does know had to sign out and go home to sleep. The laws that limit the errors of fatigue did not magically legislate a reduction in patient load; the problems caused by the solution have not yet been addressed.
I particularly enjoyed Better, which describes the kind of fresh thinking that good medicine really needs. Gawande is well aware of the overwhelming magnitude of some of the world’s medical problems; he knows that treating patients one by one, as doctors must, can feel like emptying the sea with a teaspoon. He makes some parting recommendations that both Groopman and Klass would surely subscribe to.
On the science front, he says to doctors, find something to measure, to make some sense of the flow of data whooshing by every day. “It doesn’t really matter what you count. You don’t need a research grant.” Then, if you attempt a change for the better, you can tell how well it works.
On the human front, Gawande charges them to “ask an unscripted question. Ours is a job of talking to strangers. Why not learn something about them?” (He credits this idea to a Paul Auster essay.) Putting a human face to patients (and those who work around the hospital, as well) gives shape and meaning to the doctor’s day.
And--a suggestion we can be grateful all three of these doctors have taken--”Write something. ... What you write need not achieve perfection. It need only add some small observation about your world.” Writing builds in time for thinking, which can only be a good thing, and it makes a community of its audience. “The published word is a declaration of membership in that community and also of a willingness to contribute something meaningful to it.”
So may it be, friends and neighbors, and I thank you for being my community.
Email, August 2008