November 25, 2009

A must-read for doctors

Like most of us, Jerome Groopman believes that practitioners of modern medicine are all too human and so are prone to make errors in judgment. But since the doctor’s errors can be fatal, every effort should be made to minimise them. That requires studying medical errors scientifically. This is precisely what the author does in this splendid volume

The book, he says, “is about what goes on in a doctor’s mind as he or she treats a patient.” Every physician — even the most brilliant — makes a misdiagnosis or chooses a wrong therapy. Groopman differentiates “medical mistake” from “misdiagnosis.” While the former involves prescribing a wrong dose of drug or looking at an X-ray upside down, the latter is about the way doctors think, analyse a situation, or arrive at a diagnosis taking into consideration all the factors available at that time.

A majority of medical errors, according to him, do not qualify as technical mistakes, but are attributable to flaws in the physician’s thinking. He quotes a study of one hundred cases of incorrect diagnosis where inadequate medical knowledge was identified as the reason in only four cases. The rest are all due to what he calls “cognitive-traps,” which are of three types. First is “availability,” where recent or dramatic cases come to mind and colour judgment about the case in hand. Then comes “anchoring,” or short-cut thinking, where the doctor does not consider multiple possibilities but quickly and firmly latches on to a single one. And the third is “attribution,” where stereotypes can prejudice the doctor’s thinking and lead to conclusions that do not flow from the data on hand.

“Distorted pattern recognition” can be the result of the “ecology” of the patient. (A Navajo woman with breathlessness is diagnosed as a case of pneumonia when she, in fact, was suffering from Aspirin toxicity.) “Confirmation bias” refers to selecting data which suit the already made diagnosis and ignoring the rest. “Affective error” resembles confirmation bias in selectively surveying data.

To avoid falling into these cognitive traps, Groopman has this simple but sound advice: “Even when you think you have an answer, generate a short list of alternatives.” He cites examples from each speciality to explain these cognitive errors and goes on to show that availability of time, unethical promotional activities of the pharmaceutical firms, and patterns of health coverage like insurance can ultimately influence the treatment. “Zebra-retreat” refers to doctors’ shying away from a rare diagnosis and settle for a common one. “Diagnosis momentum” refers to mental fixation of a doctor, despite incomplete evidence. (An unkempt coloured labourer who admits to taking alcohol may be conveniently branded as having alcoholic liver disease when, in fact, he may be suffering from something entirely different, for example Wilson’s disease.)

And there is a whole chapter on “uncertainty.” Based on previous studies, Groopman describes three types of uncertainty: one that results from incomplete or imperfect mastery of available knowledge; another, from the limitations in current medical knowledge; and the third, from the difficulty in distinguishing between the individual’s ignorance and the limitations of the present state of medical knowledge. The challenge of modern medicine is to make decisions “in the absence of certitude” which, according to him, forms the “core reality of practice of medicine.”

To patients, Groopman offers a very practical advice: expect from your doctors and demand of them, 3-Cs — communication, critical reasoning, and compassion. Note that he does not include academic brilliance! A medical practitioner who is able to deliver on these three counts is unlikely to err in his judgment. This book is a must-read for doctors who would like to re-evaluate their medical decisions, critically and constantly.

Link: Original Article

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