Improving Medical Care
Friday, April 13, 2007
I recently had a thoughtful exchange on Slate with Darshak Sanghavi, a pediatric cardiologist. In it, we discussed how to improve the current state of medical care and how to better patient treatment. Our views differed in that I am in favor of improving the system primarily by honing the individual doctor's skills and my peer argues standardization of the medical process. It was a very productive conversation and I wanted to take the time to expand on some of the ideas here.The state of medical care is that there is going to be less and less time to do an imperfect science. While common things can be standardized, and implementation of certain routine practices may improve care, it is critical to remember that many diseases are not "standard," because there is considerable variation among individuals whose biology is, by nature, variable. That means that one microbe can act very differently in different people, that a blocked coronary artery can produce classic symptoms like crushing chest pain radiating down the arm but in another person be very atypical, presenting nausea or indigestion. Prototypes and guidelines are always worth referring to, but all care cannot fit into one format.
Beyond my discussion with Darshak, I worry that we may be deluding ourselves about what constitutes outstanding performance by physicians. The current metrics measure the simplest processes and procedures, so that scoring high may give us a false sense of reassurance. There is an art to medicine that involves creative thinking, self doubt, self questioning, and engaged dialog with a patient and his family, drawing out key information and weighing its importance. I am not sure how this can be "measured," but I do believe that it can be better taught and modeled. I know that there are many times when I fall into cognitive traps and still have a long way to go to improve "performance" after some 35 years in medicine.
The question remains, who is a good doctor, and, moreover, who is the right doctor for any individual? The best answer that I have found for myself and my family is a doctor who thinks with us, explains clearly what is in her mind, how she arrived at her working diagnosis, and why the offered treatment makes sense for us as individuals. She may refer to guidelines and "best practices," but clearly takes into account the spectrum of human biology and customizes our care to fit both our clinical needs as well as our emotional, social, and psychological dimensions.
When to ask, "What else could it be?"
Friday, March 30, 2007
There is no absolute solution for misdiagnosis since slowing down the medical process to test every patient for every possible condition given their symptoms is completely impractical. This is a very good point and one we need to keep in mind. The book is intended to get doctors to be conscious of how their thought processes can help or hinder a diagnosis as well as to get patients to stop and think about their role in helping the doctor come to an accurate conclusion.Asking, “What else could it be?” is certainly not intended to be an invitation for a laundry list of probably useless tests but instead a device the patient can use to help the doctor look at the problem from all angles and perhaps put together the pieces of information in a new way. And this is not necessarily a question for a first visit, either. If there have been the same symptoms for a long time and recommended treatments have not solved the problem, then patients and doctors should start thinking about other options. This is a way to open up that avenue of dialogue.
This was written in response to a comment in a column from a National Post article in which How Doctor's Think is referenced.
Medical Education
Wednesday, March 28, 2007
Another piece in the New England Journal of Medicine that I found of interest was a series of letters about medical education. I feel strongly that it is time to integrate cognitive psychology into the curriculum. Physicians are making decisions all the time under conditions of uncertainty, with limited data. The human mind is wired to take shortcuts, and our biases and emotions can strongly color our reasoning. Scant attention is paid to this critical cognitive dimension which underlies misdiagnosis. Over the past years, many medical educators have proposed algorithms and illness scripts to medical students and residents. These are based on prototypes, typical patients with diseases that have typical symptoms and findings on physical examination or laboratory testing. As the letters in the New England Journal of Medicine articulate, such illness scripts and algorithms are very seductive, because, working under time pressure, and with incomplete data, it is much easier to follow than to lead, much easier to just grab on to the algorithm or illness script rather than take the time to think expansively. This is not to say that such algorithms are worthless. But they have to be put into context, consulted and evaluated, but not automatically adopted. As several of the medical educators write in the New England Journal of Medicine, illness scripts can paradoxically foster misdiagnosis by causing anchoring errors and premature closure.I am heartened by the increased debate around these issues. Every misdiagnosis I made was painful – most painful, of course, for the patient, but, also for me. As physicians, we are constantly trying to do our best. We know that we are imperfect, and will always fall short of one-hundred-percent. So, we need to work in an environment that allows us to think better, and we need to be educated in self-awareness, both about our cognitive processes and how our emotional state can affect our judgment. For those interested in delving more deeply, I suggest reading the Ginsburg and Berenson article as well as the letters section of the March 22, 2007, New England Journal of Medicine.
Healthcare and Cognitive Medicine
Tuesday, March 27, 2007
There was an item in the March 22, 2007 New England Journal of Medicine that caught my eye. It was an opinion piece by Drs. Paul D. Ginsburg and Robert A. Berenson. Ginsburg is the president of the Center for Studying Health System Change in Washington, DC and Berenson is a senior consulting researcher there, as well as a senior fellow at the Urban Institute. I admit that I never fully understood how the system of payments for clinical care evolved, and the countervailing forces at play in the effort to reform healthcare. In clear and concise language, Ginsburg and Berenson explain the background and lay out what, to my mind, is one of the most glaring problems facing both physicians and patients: the undervaluation of thinking in medicine.When you come to a doctor, he or she talks to you about your symptoms, examines you, and sits down and tries to formulate a diagnosis and explain what tests are needed and what treatments are appropriate; this aspect of practice is termed "cognitive" or "thinking" medicine, and is very poorly reimbursed by Medicare and private insurers in general. This means that physicians who practice cognitive medicine, like general practitioners, pediatricians, and internists, are pressed to see as many patients as possible in shorter periods of time in order to sustain revenue and defray overhead. On the other hand, clinical care that involves procedures, particularly surgery, or sophisticated imaging techniques, like CAT scans and MRI scans, are much more richly reimbursed. While I believe that surgeons and radiologists should be rewarded for their skills and the intensity of the treatments they deliver, it seems penny wise and pound foolish to not value cognitive medicine.
First and foremost, a correct diagnosis begins with the dialogue between patient and physician. Rushing through an appointment is a set-up for cognitive errors, particularly anchoring where you fix your mind on your first impression, and premature closure, where you shut your mind off to other possibilities. Once you miss the diagnosis, there is a real risk to the patient. In addition, for those who calculate healthcare costs, it is much more expensive to care for someone whose disease has progressed rather than having been diagnosed early. Furthermore, preventive medicine is all about communication. We have all heard, in detail, about the benefits of stopping smoking, losing weight, exercising regularly, and reducing stress in terms of heart disease, cancer, and mental health. Changing behavior is difficult, but, in my experience, most likely succeeds when there is time allotted to the discussion, a close bond between the patient and doctor, and continuing encouragement. It boils down to words and positive feelings, and the health benefits can be extraordinary. Much of what primary care physicians do involves preventive medicine. Unfortunately, the system, based on its payments, is telling us that this has meager value.
It is time to change this. As Ginsburg and Berenson point out, there are powerful lobbying forces against changing payment schedules, and even though a bone is thrown on occasion to increase payment for a certain cognitive practice, at the same time, payments are reduced for other kinds of thinking medicine. It ends up as a wash, if not a reduction in rewards for those doctors who are trying to prevent disease or make a thoughtful diagnosis that takes time. In my own specialty of blood diseases and cancer and AIDS, much time is spent talking to patients about their needs and values as they face harrowing problems. These patients seek to integrate their beliefs and values into risky choices. Such discussions take time, but they are vital, both to the physical wellbeing of the patient and his or her emotional and spiritual state. Again, this dimension of medicine seems to be discounted in the healthcare reimbursement structure.
Blog Discussions
Wednesday, March 21, 2007
Bloggers have been taking notice and it looks like word about the book is spreading. Kevin M.D. commented on this "intriguing new book" on his blog. Paul Levy, President of Beth Israel Deaconess Hospital, had some very kind words on his blog, Running a Hospital. Some other great blog comments regarding the book includes Wesley of Life Two who notes, "Most importantly gain an understanding of the process of diagnosis which is probably the single most important factor in becoming healthy," and Healthcare Economist has posted a brief excerpt from the book. Psych Central also has thoughtful and interesting commentary. All the blog feedback has been greatly appreciated; it's fantastic to see this dialogue.Book Release
Monday, March 19, 2007
As of today, How Doctors Think is on bookshelves and available through Amazon. It's already been getting some great coverage. This is a topic that holds a lot of interest since every one of us is a patient at some point in our lives and it has sparked some very worthwhile conversations. The reception for this book has been very warm and welcoming. Take a look at the new press area to see what people have been saying! It is great to see that there is so much interest in the thought process of doctors, which is something that deserves to be given a good deal of consideration.Also, if you happen to be watching Comedy Central tonight, check out the Colbert Report for further discussion.
New Book Announcement
Tuesday, February 27, 2007
How Doctors Think arrives on book shelves on March 19, 2007! It is a journey into the medical mind, showing how doctors arrive at the correct diagnosis and why sometimes they detour and fail to. Many of the examples are my own errors, lessons from hard experience. The aim in writing the book was to contribute to a better understanding for both laymen and medical professionals of what it takes to succeed and how to avoid misdiagnosis and misguided care. As we near this release date, some of the initial reviews have been coming out. Take a look at what the critics are saying.Publisher's Weekly Review:
I wish I had read this book when I was in medical school, and I'm glad I've read it now… I have never read elsewhere this kind of discussion of the ambiguities besetting the superspecialized—the doctors on whom the rest of us depend: "Specialization in medicine confers a false sense of certainty." Every reflective doctor will learn from this book—and every prospective patient will find thoughtful advice for communicating successfully in the medical setting and getting better care…This passionate honesty gives the book an immediacy and an eloquence that will resonate with anyone interested in medicine, science or the cruel beauties of those human endeavors which engage mortal stakes.
Kirkus Review:
A revealing, often disturbing look at what goes on in doctors' minds when treating patients, plus some advice to patients on how to work with their doctors to improve that process. Oncologist and New Yorker staff writer Groopman (The Anatomy of Hope, 2004, etc.) draws on conversations and interviews with other doctors, research in the field and his own experiences as both doctor and patient to unravel the question of how doctors reach a diagnosis and decide on a treatment. While the clinical algorithms and practice guidelines that medical students are taught and that are promoted by hospital administrators and insurance companies are useful in many cases, he argues that they discourage doctors from thinking creatively when symptoms are vague and test results inconclusive. A highly pleasurable must-read.
Advanced Feedback:
"Jerome Groopman has written a unique, important, and wonderful book about a central paradox of modern life: even though diagnosing an illness is often as much art as science, we want our doctors to speak with scientific surety. Groopman gives a rationalist's tour of the doctor’s thought processes -- or lack thereof -- and yet, unlike many rationalists, he never veers toward cynicism. You’ll never look at your own doctor in the same way again -- for better or worse."—Steven D. Levitt and Stephen J. Dubner, authors of Freakanomics
"A sage, humane prescription for medical practitioners and the people who depend on them."—O: The Oprah Magazine
"In this splendid and courageous book, Dr. Jerome Groopman lifts the veil on possibly the most taboo topic in medicine: the pervasive nature of misdiagnosis. His engrossing narrative exposes all of the subtle mental traps---the snap judgments and stereotypical thinking, the premature conclusions and herd instinct---that dangerously narrow the vision of too many physicians."—Ron Chernow, author of Alexander Hamilton, Titan, and The House of Morgan
"A cogent analysis of all the wrong ways his fellow practitioners are trained to approach the patients they treat.”—ELLE Magazine
