I spent most of my youth and early adulthood avoiding doctors because I thought I was being eaten alive by a secret mysterious cancer, and I was pretty sure that once it was discovered, physicians everywhere would be mad at me. In my imagination, doctors formed a telepathically connected global fraternity that could smell fear—like a superrich, omnipotent swarm of bees—and that lived exclusively to shame anyone who dared resist its awesome power. (Also, occasionally they wrote prescriptions.) The possibility of their disapproval struck me as worse, somehow, than the possibility of actual death. In a tragic irony, my doctorphobia seemed to coincide with a spike in America’s doctorphilia: ER was drawing Super Bowl–scale audiences, metastasizing copycat shows, and introducing the word stat! into casual conversation. I fled the room whenever it came on. (In the end I survived my cancer, heroically, when it turned out to be the world’s most benign mole.)
I like to think that this irrational terror was not, in fact, unique to me but just a micro-expression of our culture’s bizarre fetish for doctors. My invented cancer was only a mirror image of the Clooney superfan’s tousled Caesar cut: an unfortunate homage to the powerful mythology of doctors. We still spend GNPs every year erecting pop-cultural monuments to their fictional surgeries and love affairs and brilliant deductions and ethical struggles. Part of the appeal is simple convenience. As with lawyers and cops (the other deep ruts cutting through our TV landscape), the doctor’s most basic professional transaction is a perfect story arc: crisis, attempted solution, result. They’re like detectives working the most fascinating crime beat of all: how our bodies are trying to murder us. (Fox’s hit show House is explicitly modeled—right down to its punning title—on Sherlock Holmes.) But there’s also something deeper. Doctors seem to tug simultaneously on just about every important string in the culture—they’re not only detectives but fortune-tellers, priests, master technicians, executioners, and kings. Although they’re the exact opposite of serial killers—serial lifers?—they occupy the same dim corner of the imagination: They have a particularly matter-of-fact access to the uncanny, a hands-on relationship with life and death.
These days, for every appointment with an actual doctor, the average person probably undergoes 300 virtual appointments—via ER, House, Grey’s Anatomy, Scrubs, and self-diagnostic sites like WebMD. This, oddly, makes real live doctors, these humans with bad breath and imperfect hair who poke us in places we wish they wouldn’t and issue boring diagnoses, some of the last remaining medical novelties.
Now, partly in an effort to bring this unfamiliar beast to light, and cure the pandemic of our doctor obsession, Jerome Groopman has published a bit of cognitive ethnography called How Doctors Think. (Among its many merits, the book suggests a promising new subgenre: Imagine the pleasures of How Supreme Court Justices Think, How CEOs Think, How Plumbers Think.) Groopman is qualified for this job both professionally—he teaches at Harvard Medical School and writes for The New Yorker—and, more important, temperamentally: He is sane, adult, and almost superhumanly conscientious. He claims to remember every misdiagnosis from his 30-year career and takes a moment in an author’s note to reassure us that “ ‘Doctors A, B, C, D, and E’ are fictitious names.” The book is a mixture of methodological theorizing, personal history (Groopman, with his endearingly gimpy wrist and painfully fused spine, has suffered much at the hands of his colleagues), and entertaining stories of misdiagnoses and miraculous saves. There is fascinating insider trivia: Doctors begin assessing your health the moment they see you in the waiting room; they tend to interrupt patients within twelve seconds and arrive at a working diagnosis within twenty; they dislike sick people; and (according to one admirably blunt source) the real mission of an ER is “to establish to our comfort, and the patient’s comfort, that what is bothering them is not going to kill them in the next three days.”
Along the way we meet several memorable characters who have been victims of errors in doctors’ thinking: Blanche, a Navajo woman with undiagnosed aspirin toxicity (doctors assumed it was just a virus that had been going around); Brad, a chemo patient with a near-fatal lesion on his buttock (Groopman liked him so much he didn’t want to bother him with an invasive exam); Shira, an adopted Vietnamese baby with a weak immune system; and (poignantly) Stan, the high-tech training mannequin who keeps getting killed with morphine by trigger-happy med students. Each story is followed by a moral explaining one of the roughly seven jillion ways a doctor’s thought process can go wrong—outcome bias, confirmation bias, diagnosis momentum, commission bias, vertical line failure, the availability heuristic, and on and on. Most of it boils down to hubris: doctors buying into our mythology of doctors, believing in the illusion of total knowledge.
Groopman is obsessed with heuristics, the often unconscious and particularly human strategies of pattern recognition that doctors use to make quick decisions. In an effort to eliminate these errors, he writes, medical schools have begun training students to abandon heuristics in favor of a purely systematic, stats-based approach—airtight algorithms, templates, prototypes, and “decision trees” that will guide them, step by rigid step, through every conceivable interaction with a patient, like an IT technician with his list of questions. (“Does your spleen hurt?” “Yes.” “Is it burning or pounding?”) Groopman, a humanist all the way down to the roots of his white beard, sets himself against this trend. “The next generation of doctors,” he writes, is “being conditioned to function like a well-programmed computer that operates within a strict binary framework.” Diagnosis via checklist, he argues, leaves little room for independent creative thought; eliminating the risk of human error also eliminates the possibility of real human achievement. (It’s like the sabermetrics debate in baseball, transposed to the hospital.) Groopman sees language—the patient’s story—as the essential foundation of the doctor-patient relationship, and he stresses that doctors will always think like humans: They’ll feel the urge to assume, overlook gaps in their knowledge, and massage partial information into a recognizable whole. The trick, as he sees it, is to be even more human, more self-conscious about moods and prejudices and cognitive processes. In the face of familiar depersonalizing trends in medicine—pressure from pharmaceutical companies to think less and prescribe more, doctors’ falling incomes producing a higher volume of patients—Groopman’s advice seems commonsensical and wise. Doctors should ask open-ended questions, stop interrupting, and embrace uncertainty rather than leaping ahead into a scripted false confidence.
Groopman also has advice for patients. Instead of being terrified and intimidated, we should say things like, “I sense that we may not be communicating well” and “Is there anything that doesn’t fit your diagnosis?” and “Is it possible I have more than one problem?” While I can no more imagine myself saying any of these things to an actual doctor than I can imagine slapping a mountain lion in the face with a piece of raw chicken, thanks to Groopman I can begin to see the wisdom of trying. n
The medical detective story of the kind that Groopman contributes to The New Yorker was, in fact, invented in those very pages. Berton Roueché, a staff writer, launched the column “Annals of Medicine” a couple of years after his arrival at the magazine in 1944, and would go on to publish several collections. Roueché, for his part, believed that the detective story had its roots in medicine: He pointed out that Arthur Conan Doyle based his methods on those of an Edinburgh diagnostician. Unlike most of his stories, Roueché did not have a happy ending. Faced with terminal illness, he took his own life in 1994.
How Doctors Think
By Jerome Groopman. Houghton Mifflin. 307 pages. $26.