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City Journal

 

Paint-By-Numbers Medicine

July 09, 2007

By Paul Howard

Jerome Groopman’s sobering portrait of doctors and diagnoses

How Doctors Think, by Jerome Groopman (Houghton Mifflin, 320 pp., $26.00)

If I were drawing up a summer reading list for health care, Jerome Groopman’s How Doctors Think would be at the top. Groopman, an oncologist, professor of medicine at Harvard Medical School, and staff writer at the New Yorker, has written an accessible and engaging primer on how doctors make life-saving (or life-threatening) medical diagnoses.

Groopman blends real patients’ stories with academic research to illustrate the disturbing fact that doctors misdiagnose about 15 percent of all cases. These “cognitive errors,” as he calls them, aren’t technical mistakes—like operating on the wrong body part—but derive from physician training and practice. Groopman’s criticism zeroes in on paint-by-numbers medicine: algorithms developed by insurers and statisticians that create “decision trees” for how doctors dispense care. This “insert-tab-A-into-slot-B” strategy, he warns, promotes efficiency and cost control over creativity and independent thinking. The best doctors rebel against rote decision-making and give personal attention to each patient, even if it’s for only 15 or 20 minutes during a routine office visit.

How Doctors ThinkHow Doctors Think opens with a stark example of misdiagnosis: the story of Ann Dodge, a woman in her thirties who was literally wasting away, despite consuming 3,000 calories a day under doctor’s orders. In her early twenties, Dodge had developed nausea, stomach pain, and vomiting after meals. Initially, her primary-care physician prescribed antacids. When the condition persisted, he sent her to a psychiatrist, who diagnosed her with anorexia. Over the next 15 years, 30 physicians treated Dodge, eventually concluding that she suffered from irritable bowel syndrome. Her doctors recommended that she consume massive amounts of cereals and pastas, but instead of getting better, she steadily lost weight and developed severe osteoporosis.

At her boyfriend’s insistence, Dodge sought out gastroenterologist Myron Falchuk. Falchuk inherited Dodge’s copious medical history, which attributed her illness to her fragile mental state. Falchuk, Groopman writes, “heard in [Dodge’s] doctor’s recitation of the case the implicit message that his role was to examine Anne’s abdomen . . . and to reassure her that irritable bowel syndrome . . . should be treated as the internist had recommended, with an appropriate diet and tranquilizers.” Instead, Falchuk did an extraordinary thing: he pushed her stack of medical records aside and asked her to tell her story from the beginning. After conducting a long interview and physical exam, Falchuk ordered several tests that confirmed his diagnosis: celiac disease—an allergic reaction to gluten, a substance found in many grains. In other words, Dodge’s carbohydrate-rich diet was killing her.

Why did Falchuk succeed when so many others had failed? Falchuk cites William Osler, one of the founding physicians of Johns Hopkins Medical School: “If you listen to the patient, he is telling you the diagnosis.” According to Groopman, Falchuk believes that doctors’ overreliance on technology has “taken us away from the patient’s story. . . . And once you remove yourself from the patient’s story, you no longer are truly a doctor.”

Groopman identifies other obstacles to accurate diagnoses, including liking a patient too much (and thus not wanting to find a bad outcome) and a preference for gestalt thinking (making snap judgments based on first impressions). While mistakes vary, Groopman finds that the best doctors listen carefully to patients and constantly try to learn from their own mistakes.

But listening to patients and making a thoughtful analysis of their symptoms takes time. Groopman rightly likens modern medicine to standing on a railway platform and watching a blur of faces pass by on a moving train. Busy doctors can spend just a few minutes with each patient, during which they must sort out the mundane from the life-threatening, the sore throats from the throat cancers. Groopman blames this state of affairs on market forces, but he overlooks the fact that health care is heavily regulated and hasn’t evolved to reflect market realities. Injecting more competition into the system would drive routine health care into lower-cost environments. This would “slow the blur” for doctors, and offer patients an alternative way to access care.

Clayton Christensen, a professor at Harvard Business School, calls such market-driven evolution “disruptive innovation,” by which he means “technology that brings a much more affordable product or service that is much simpler to use into a market.” Today, companies like RediClinic and MinuteClinic exemplify disruptive innovation. Both companies run “convenient care” clinics staffed by nurse-practitioners that offer affordable, routine treatments for strep throat or ear infections. Recently, Wal-Mart announced that it would add hundreds more of these clinics to its stores across the country. More disruptive innovations will emerge in years to come, if regulators don’t stand in the way.

Of course, health care will never be entirely market-driven; there will always be a large role for charity and for government subsidies for the poor. But the more we allow competition and innovation to flourish, the more time doctors can devote to getting the diagnosis right the first time. As Groopman’s book makes clear, the cost of getting it wrong is too high.

Original Source: http://www.city-journal.org/html/rev2007-07-09ph.html

 

 
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