How Doctors Think – Jerome Groopman, MD. Chapter 9. Marketing, Money, and Medical Decisions. Chapter In Service of the Soul. How Doctors Think: Clinical Judgment and the Practice of Medicine · Read more Think OCaml - How to Think Like a Computer Scientist · Read more. Risk Management Services. Susan Swiggum MD, FRCPC, FAAD, Senior Physician Risk Manager. Vancouver September How Doctors Think. Challenges.
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Editorial Reviews. From Publishers Weekly. Drawing on both personal experience and Buy How Doctors Think: Read Kindle Store Reviews - lesforgesdessalles.info PDF | 10+ minutes read | On Jan 1, , Scott D. Smith and others published How Doctors Think. PDF | On Nov 1, , Brent M. McGrath and others published How doctors think.
Falchuk intently inspected the creases in her hands, as though he were a fortuneteller reading her lifelines and future. I concluded that the next generation of doctors was being conditioned to function like a well-programmed computer that operates within a strict binary framework. But today's rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers. In Anne Dodge's case, after a myriad of tests and procedures, it was her words that led Falchuk to correctly diagnose her illness and save her life. Specifically, what you have been doing to try to gain weight.
We've all wondered why a doctor asked certain questions, or detoured into unexpected areas when gathering information about us. We have all asked ourselves exactly what brought him to propose a certain diagnosis and a particular treatment and to reject the alternatives.
Although we may listen intently to what a doctor says and try to read his facial expressions, often we are left perplexed about what is really going on in his head.
That ignorance inhibits us from successfully communicating with the doctor, from telling him all that he needs to hear to come to the correct diagnosis and advice on the best therapy. In Anne Dodge's case, after a myriad of tests and procedures, it was her words that led Falchuk to correctly diagnose her illness and save her life. While modern medicine is aided by a dazzling array of technologies, like high-resolution MRI scans and pinpoint DNA analysis, language is still the bedrock of clinical practice.
We tell the doctor what is bothering us, what we feel is different, and then respond to his questions. This dialogue is our first clue to how our doctor thinks, so the book begins there, exploring what we learn about a physician's mind from what he says and how he says it.
But it is not only clinical logic that patients can extract from their dialogue with a doctor. They can also gauge his emotional temperature. Typically, it is the doctor who assesses our emotional state.
But few of us realize how strongly a physician's mood and temperament influence his medical judgment. We, of course, may get only glimpses of our doctor's feelings, but even those brief moments can reveal a great deal about why he chose to pursue a possible diagnosis or offered a particular treatment. After surveying the significance of a doctor's words and feelings, the book follows the path that we take when we move through today's medical system.
If we have an urgent problem, we rush to the emergency room. There, doctors often do not have the benefit of knowing us, and must work with limited information about our medical history.
I examine how doctors think under these conditions, how keen judgments and serious cognitive errors are made under the time pressures of the ER. If our clinical problem is not an emergency, then our path begins with our primary care physician—if a child, a pediatrician; if an adult, an internist.
In today's parlance, these primary care physicians are termed gatekeepers, because they open the portals to specialists. The narrative continues through these portals; at each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong.
We also encounter the tension between his acknowledging uncertainty and the need to take a clinical leap and act. One chapter reports on this in my own case; I sought help from six renowned hand surgeons for an incapacitating problem and got four different opinions.
Much has been made of the power of intuition, and certainly initial impressions formed in a flash can be correct. But as we hear from a range of physicians, relying too heavily on intuition has its perils. Cogent medical judgments meld first impressions—gestalt—with deliberate analysis. This requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes.
What can doctors and patients do to find time to think? I explore this in the pages that follow.
Today, medicine is not separate from money. How much does intense marketing by pharmaceutical companies actually influence either conscious or subliminal decision-making? Very few doctors, I believe, prostitute themselves for profit, but all of us are susceptible to the subtle and not so subtle efforts of the pharmaceutical industry to sculpt our thinking.
That industry is a vital one; without it, there would be a paucity of new therapies, a slowing of progress. Several doctors and a pharmaceutical executive speak with great candor about the reach of drug marketing, about how natural aspects of aging are falsely made into diseases, and how patients can be alert to this. Cancer, of course, is a feared disease that becomes more likely as we grow older. It will strike roughly one in two men and one in three women over the course of their lifetime.
Recently there have been great clinical successes against types of cancers that were previously intractable, but many malignancies remain that can be, at best, only temporarily controlled.
How an oncologist thinks through the value of complex and harsh treatments demands not only an understanding of science but also a sensibility about the soul—how much risk we are willing to take and how we want to live out our lives. Two cancer specialists reveal how they guide their patients' choices and how their patients guide them toward the treatment that best suits each patient's temperament and lifestyle. At the end of this journey through the minds of doctors, we return to language.
The epilogue offers words that patients, their families, and their friends can use to help a physician or surgeon think, and thereby better help themselves. Patients and their loved ones can be true partners with physicians when they know how doctors think, and why doctors sometimes fail to think.
Using this knowledge, patients can offer a doctor the most vital information about themselves, to help steer him toward the correct diagnosis and offer the therapy they need.
Patients and their loved ones can aid even the most seasoned physician avoid errors in thinking. To do so, they need answers to the questions that I asked myself, and for which I had no ready answers. Not long after Anne Dodge's visit to Dr.
Falchuk is a compact man in his early sixties with a broad bald pate and lively eyes. His accent is hard to place, and his speech has an almost musical quality. He was born in rural Venezuela and grew up speaking Yiddish at home and Spanish in the streets of his village. As a young boy, he was sent to live with relatives in Brooklyn. There he quickly learned English. All this has made him particularly sensitive to language, its nuances and power.
After nearly four decades, he has not lost his excitement about caring for patients. When he began to discuss Anne Dodge's case, he sat up in his chair as if a jolt of electricity had passed through him. She was emaciated and looked haggard, Falchuk told me. Her face was creased with fatigue. And the way she sat in the waiting room—so still, her hands clasped together—I saw how timid she was.
From the first, Falchuk was reading Anne Dodge's body language. Everything was a potential clue, telling him something about not only her physical condition but also her emotional state. This was a woman beaten down by her suffering.
She would need to be drawn out, gently. Medical students are taught that the evaluation of a patient should proceed in a discrete, linear way: Only after all the data are compiled should you formulate hypotheses about what might be wrong. These hypotheses should be winnowed by assigning statistical probabilities, based on existing databases, to each symptom, physical abnormality, and laboratory test; then you calculate the likely diagnosis.
This is Bayesian analysis, a method of decision-making favored by those who construct algorithms and strictly adhere to evidence-based practice.
But, in fact, few if any physicians work with this mathematical paradigm. The physical examination begins with the first visual impression in the waiting room, and with the tactile feedback gained by shaking a person's hand. Hypotheses about the diagnosis come to a doctor's mind even before a word of the medical history is spoken. And in cases like Anne's, of course, the specialist had a diagnosis on the referral form from the internist, confirmed by the multitude of doctors' notes in her records.
Falchuk ushered Anne Dodge into his office, his hand on her elbow, lightly guiding her to the chair that faces his desk. She looked at a stack of papers some six inches high. It was the dossier she had seen on the desks of her endocrinologists, hematologists, infectious disease physicians, psychiatrists, and nutritionists.
For fifteen years she'd watched it grow from visit to visit. But then Dr. Falchuk did something that caught Anne's eye: Before we talk about why you are here today, Falchuk said, let's go back to the beginning. Tell me about when you first didn't feel good. For a moment, she was confused. Hadn't the doctor spoken with her internist and looked at her records?
I have bulimia and anorexia nervosa, she said softly. Her clasped hands tightened. And now I have irritable bowel syndrome. Anne glanced at the clock on the wall, the steady sweep of the second hand ticking off precious time. Her internist had told her that Dr. Falchuk was a prominent specialist, that there was a long waiting list to see him. Her problem was hardly urgent, and she got an appointment in less than two months only because of a cancellation in his Christmas-week schedule.
But she detected no hint of rush or impatience in the doctor. His calm made it seem as though he had all the time in the world. So Anne began, as Dr.
Falchuk requested, at the beginning, reciting the long and tortuous story of her initial symptoms, the many doctors she had seen, the tests she had undergone.
As she spoke, Dr. Falchuk would nod or interject short phrases: Occasionally Anne found herself losing track of the sequence of events. It was as if Dr. Falchuk had given her permission to open the floodgates, and a torrent of painful memories poured forth. Now she was tumbling forward, swept along as she had been as a child on Cape Cod when a powerful wave caught her unawares. She couldn't recall exactly when she had had the bone marrow biopsy for her anemia. Don't worry about exactly when, Falchuk said.
For a long moment Anne sat mute, still searching for the date. I'll check it later in your records. Let's talk about the past months. Specifically, what you have been doing to try to gain weight. This was easier for Anne; the doctor had thrown her a rope and was slowly tugging her to the shore of the present.
As she spoke, Falchuk focused on the details of her diet. Now, tell me again what happens after each meal, he said. Anne thought she had already explained this, that it all was detailed in her records. Surely her internist had told Dr. Falchuk about the diet she had been following.
But she went on to say, I try to get down as much cereal in the morning as possible, and then bread and pasta at lunch and dinner. Cramps and diarrhea followed nearly every meal, Anne explained.
She was taking antinausea medication that had greatly reduced the frequency of her vomiting but did not help the diarrhea. Each day, I calculate how many calories I'm keeping in, just like the nutritionist taught me to do. And it's close to three thousand.
Falchuk paused. Anne Dodge saw his eyes drift away from hers.
Then his focus returned, and he brought her into the examining room across the hall. The physical exam was unlike any she'd had before.
She had been expecting him to concentrate on her abdomen, to poke and prod her liver and spleen, to have her take deep breaths, and to look for any areas of tenderness. Instead, he looked carefully at her skin and then at her palms.
Falchuk intently inspected the creases in her hands, as though he were a fortuneteller reading her lifelines and future. Anne felt a bit perplexed but didn't ask him why he was doing this.
Nor did she question why he spent such a long while looking in her mouth with a flashlight, inspecting not only her tongue and palate but her gums and the glistening tissue behind her lips as well. He also spent a long time examining her nails, on both her hands and her feet. Sometimes you can find clues in the skin or the lining of the mouth that point you to a diagnosis, Falchuk explained at last.
He also seemed to fix on the little loose stool that remained in her rectum. She told him she had had an early breakfast, and diarrhea before the car ride to Boston. When the physical exam was over, he asked her to dress and return to his office.
She felt tired. The energy she had mustered for the trip was waning. She steeled herself for yet another. This action might not be possible to undo. Are you sure you want to continue? Upload Sign In Join. Home Books Science. Save For Later. Create a List. How Doctors Think by Jerome Groopman.
Summary On average, a physician will interrupt a patient describing her symptoms within eighteen seconds. Read on the Scribd mobile app Download the free Scribd mobile app to read anytime, anywhere. Mariner Books Released: Mar 12, ISBN: Visit our Web site: Includes bibliographical references and index. Medicine—Decision making. Medical logic. In addition, Dr.
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