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How Doctors Think

Article  in  University of Toronto medical journal · January 2008

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 Book Review
How Doctors Think
Reviewed by: Scott D. Smith, M.Sc. (0T8), Faculty of Medicine, University of Toronto
How Doctors Think
First Mariner Books
ISBN: 9780618610037
320 p
P
hysicians and physicians-in-training rarely ask them-
selves how many significant errors of judgment they
will make during their career. Yet time spent in the
clinical setting as a medical student reveals an arena fraught
with uncertainty and potential pitfalls. Dr. Ian Chernoff, an
emergency physician at Mount Sinai Hospital likens working
in the Emergency Department to “walking in a minefield,”
where each mine represents a potential error or ‘miss,’ neg-
atively influencing patient care. Indeed, emergency medi-
cine, due to limited time and incomplete information, is
arguably the specialty where the potential for errors in clini-
cal decision-making is most prevalent. More generally, diag-
nostic errors can be system-based, physician-based or simply
related to the inherent uncertainty of medicine. The most
difficult type of error to address is cognitive error.
Cognitive error in medicine is, in large part, the subject
of Dr. Jerome Groopman’s How Doctors Think. Cognitive
error does not include systematic error, such as the error
incurred with a false-positive test result. Instead, it refers to
mistakes in perception, faulty pattern recognition and bias-
176
es.1 Such mental errors are not often discussed, but are eas-
ily recognizable with some introspection into one’s own
thinking during an assessment of a new patient. Some com-
mon cognitive errors described in Dr. Groopman’s book are:
Anchoring: Focusing on specific information given early in a
patient’s history and not altering an initial impression when
later contradictory information is given.
Availability error: Falsely elevating the likelihood of a diag-
nosis due to the mental availability of past cases. For exam-
ple, misdiagnosing a patient with pneumonia because you
saw two cases of pneumonia on your last shift in the
Emergency Department.
Commission bias: A tendency towards action instead of inac-
tion. This occurs when physicians are overconfident or feel
pressure from patients, or from themselves, to “do some-
thing.”
Confirmation bias: A bias towards evidence that is supportive
of your diagnosis, and a tendency to discount information
that refutes it.
Diagnosis momentum: The perpetuation of diagnostic labels
in patients’ charts and records occurs for correct and incor-
rect diagnoses. This ‘momentum’ is familiar to anyone who
has copied a patient’s past medical history from a nursing
report or old discharge summary while performing a con-
sultation.
Zebra retreat: Retreating from making a rare diagnosis
despite supporting evidence. Expensive investigations and
lack of specialized knowledge can both contribute to such a
retreat.
Over thirty types of cognitive errors, also known as cogni-
tive dispositions to respond, are documented in the medical
and psychological literature.1
How Doctors Think provides many examples of the differ-
ent types of cognitive errors committed by specialists and pri-
mary care physicians. In the primary care setting, pediatri-
cians, family physicians and general internists face the chal-
lenge of identifying the relatively small fraction of life-threat-
ening conditions from a large number of cases that will have
no serious effect on patient morbidity and mortality. In med-
ical school, we learn to recognize ‘red flags,’ so as not to miss
important clues garnered during a history or physical exam.
These clues help physicians distinguish between the needles
and the hay in the primary-care haystack.
Many specialists, often practicing at the edge of medical
evidence and technology, where uncertainty and certainty
become blurred, face different challenges altogether. These
physicians are sometimes forced to devise novel treatments
or surgical methods, because our existing practices are sim-
ply not effective enough. In these cases an epistemological
approach, that is, one that focuses on how we know what we
know, becomes important. When expert opinion is not based
on sound evidence, specialists need to be prepared to ques-
tion the evidence. Dr. Groopman interviews a pediatric car-
UTMJ • Volume 85, Number 3, May 2008

How Doctors Think
diologist from Boston who expresses this precise opinion,
since he often encounters cases so unique that only a few
case reports exist in the medical literature. In this uncertain
environment it is occasionally necessary to think laterally, or
‘outside the box,’ to devise a novel approach.
Patient-centered care is a central theme of How Doctors
Think. In this regard Dr. Groopman evokes the eminently
quotable Dr. William Osler who said: “It is much more
important to know what sort of a patient has a disease than
what sort of a disease a patient has.” However, thinking in a
patient-specific context is only half the battle. To be an effec-
tive physician, one needs to be mindful of the emotional
response to each patient. Our subconscious reaction to an
individual patient, or countertransference, colours the diag-
nostic and therapeutic relationship. A patient with a past
medical history of multiple functional or psychosomatic
diagnoses, can truncate a physician’s willingness to listen
openly to their story. Interestingly, Dr. Groopman provides
examples of situations where positive countertransference
can also lead to missed diagnoses. This can occur when a
physician’s compassion results in avoiding certain physical
exams or invasive tests to spare the patient discomfort or
anxiety, ultimately putting the patient at increased risk.
UTMJ • Volume 85, Number 3, May 2008
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Book Review
How Doctors Think is written for both patients and physi-
cians. Dr. Groopman provides examples of the types of ques-
tions and strategies that patients or their family members
can employ to help their physicians avoid certain biases or
cognitive pitfalls. This patient education is an important
resource for any layperson reading this book. However, writ-
ing for a readership of both lay public, as well as medical pro-
fessionals, means that the descriptions of physiology and
medical procedures can be somewhat tedious.
For medical students, residents and physicians, How
Doctors Think acts as an important reminder of the impor-
tance of integrating the art, with the science of medicine.
“Flesh-and-blood decision-making” must take into account
the unique features of each patient, often under time con-
straints and without access to all the relevant information. As
Dr. Groopman suggests, evidence-based medicine algo-
rithms, designed for the ideal world are not always adequate.
The quality and consistency of the decisions that physicians
make in the real-world clinical environment can only be
improved by understanding some of the common cognitive
errors and biases to which doctors are prone.
References
1. Croskerry P. The Importance of Cognitive Errors in Diagnosis and Strategies
to Minimize Them. Acad Med. 2003; 78: 775-780.
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