In the catalog of hypochondriac horror fantasies, there are few nightmares worse than that of a missed diagnosis (unless it’s a correct diagnosis of, say, incurable cancer, Alzheimer’s or Ebola virus).
In one terrifying sequence, you show up at the emergency room with sharp, persistent chest pains. The doctor does a bunch of tests but finds nothing—and since you’re young and look as healthy as He-Man, she sends you home. The next day you suffer a major heart attack.
Another appalling scenario: You find that all of a sudden you’ve begun to lose your appetite, and whenever you eat you feel intense pain and nausea; sometimes you vomit. You see numerous doctors who diagnose you with everything from anorexia and bulimia to irritable bowel syndrome, but you keep getting sicker. It’s not until 15 years later that you are correctly diagnosed with the eminently treatable celiac disease.
These are stories to set a worrywart’s pulse racing. But, as it happens, they’re not the hyped-up fantasies of some raging hypochondriac, but the real stories of real patients chronicled in Jerome Groopman’s How Doctors Think.
Dr. Groopman is a professor at Harvard Medical School and a staff writer for The New Yorker, and his book is an important, if occasionally meandering, study of medical misses and near-misses. It’s the kind of study that leaves the reader marveling that anyone ever receives a correct diagnosis at all. In one particularly worrisome chapter, Dr. Groopman even manages to throw radiology—that seemingly objective, error-free science—into doubt by demonstrating all the different and distressing ways a single group of radiologists can read (and misread) the same slides.
The purpose of all these diagnostic disaster stories isn’t to scare the bejeebies out of us—though at times it has that effect—but rather to allow Dr. Groopman to map the way that physicians think, to trace the “cognitive errors” that lead decent, well-intentioned doctors to make catastrophic medical mistakes.
“When and why does thinking go right or go wrong in medicine?” he asks.
The answer is important, according to Dr. Groopman, because the majority of medical mistakes come from “flaws in physician thinking”—not technical errors, as many people assume. And while new med-school teaching trends are meant to improve the problem, to train students to streamline how they diagnose disease (think complex algorithms and decision trees), Dr. Groopman worries that they could have the opposite effect: The next generation of doctors may “function like a well-programmed computer” that can’t process ambiguity and uncertainty.
Then again, few members of the current generation were adequately trained to tackle ambiguity and uncertainty.
Dr. Groopman dedicates a good chunk of his treatise to teasing apart the various cognitive traps that ensnare so many doctors, and he comes up with some valuable observations—observations about the role that a doctor’s emotional state, fear of failure or, frankly, greed can play in making a misdiagnosis. Unfortunately, few of these observations are unexpected, and Dr. Groopman tends to dress them up in sociology-speak that does little beyond give the project a textbook feel.
Still, the book has its value. For anyone who’s suffered from White Coat Worship or placed an unholy trust in the power of the stethoscope, How Doctors Think is a necessary—if occasionally terrifying—palliative.
Lizzy Ratner is a reporter at The Observer.