Re: First, do no assuming
- From: "TC" <tunderbar@xxxxxxxxxxx>
- Date: 13 Feb 2007 07:12:28 -0800
On Feb 13, 9:10 am, "TC" <tunder...@xxxxxxxxxxx> wrote:
http://www.boston.com/yourlife/health/diseases/articles/2007/01/28/fi...
First, do no assuming
A doctor urges his peers to think differently
By Sam Allis, Globe Columnist | January 28, 2007
Fact: A doctor in this country interrupts a patient, on average, in
the first 18 seconds of a visit.
A prominent surgeon waited about a minute and a half before issuing
his diagnosis to Jerome Groopman on his damaged hand. "He was dead
wrong," says Groopman, who got four diagnoses from six surgeons. "And
these are big names."
Fact: Over 15 percent -- some say over 20 percent -- of medical
diagnoses are wrong. At least half result in serious injury or death.
Groopman tells of a woman who saw close to 30 doctors for a
constellation of ailments that gradually sapped the life out of her.
She endured excruciating pain and was down to 85 pounds. Her immune
system was failing and she had developed severe osteoporosis. All of
them missed what was ailing her.
Finally, a fresh doctor asked a fresh set of questions. He listened to
her and found that she suffered from a gluten allergy that prevented
her from receiving the nutrients in the food she ate. After years of
agony, she quickly recovered.
Fact: Over a quarter of all radiological tests, including CAT scans
and MRIs, are misread. "Misdiagnoses are not rare at all," says
Groopman, the noted oncologist and chief of experimental medicine at
Beth Israel Deaconess Medical Center, who assembled this data.
While the patient safety movement has led to major improvements in
protocols to avoid systems errors, he points out, nothing has been
done to address a more profound issue: how doctors think. And bad
thinking is what causes countless mistakes. "No one talks about this
stuff," says Groopman.
He is struck by the lack of independent thinking among the residents
he leads on hospital rounds. "These are really smart people, and when
asked for a diagnosis they download cookbook recipes on their
computers," he explains. "If it's not that, they look blankly. How do
I teach them how to think? I realized I didn't know how I think. No
one ever taught me how to think."
Groopman addresses this touchy subject in a book, "How Doctors Think,"
due out this spring. In it are examples of bad thinking, including
plenty of his own, that produced harrowing results. None of this is
news to patients. Most of us know someone who has endured a
misdiagnosis or have done so ourselves. My friend Barbara went through
a year of agony because of one.
Groopman's first child developed a persistent low-grade fever and
stomach pain at 9 months. A doctor said not to worry, it's just a
virus. The child's condition deteriorated, but the doctor remained
unmoved. Eventually, Groopman and his wife rushed their son to an
emergency room, where they learned the child had an intestinal
obstruction that would have killed him had it gone untreated.
What went wrong here? The doctor sized up Groopman and his wife as
neurotic first-time parents and built his diagnosis around that
premise. At work, says Groopman, were two suspects common in these
nightmares.
The first is what he calls anchoring -- where a doctor interrupts you,
seizes on a symptom or complaint, and declares, "It's this." This snap
judgment anchors all ensuing thinking. The second he calls
attribution, to which women are particularly vulnerable, where
assumptions about a patient are attributed to bad data.
Groopman tells of a woman with a newborn child and two young children
who complained about constant nausea and diarrhea. "The doctor looked
at her and decided it was stress, that she was neurotic," says
Groopman. "So he attributes all of her complaints to the stereotype he
has in his mind. I saw her a few months ago. She had been diagnosed
with a tumor in her intestine but had been taking Zoloft for a year
and a half."
Time is an insidious agent in all this. "In today's medical
environment, the clinic is a factory," he says. "It's a world of eight-
minute visits. The mistakes are made in the moment. Doctors draw
immediate diagnoses rather than listen and pursue leads. And when
complaints persist, they all too often cling to their first thought
and even discount contradictory evidence.
"It's impossible to figure out a difficult problem in eight minutes,"
he continues. "A doctor has one eye on the clock and one eye on a
computer screen as he types notes. The truth is, you can't think well
in haste.
"There is no generic best treatment to a serious problem," he says.
"We delude ourselves to think the answer is the systems solution --
'We'll give you an algorithm: if it's A then B then C.' You're got to
know what A is in the first place."
Many in the medical community will bristle at Groopman's findings.
Others will recognize the truth in what he says and, with luck, a few
of the bean counters controlling medicine today as well. They can't
dismiss the book. It is meticulously researched and written by a
physician of stature.
"My argument is the solution for misdiagnosis is a patient or family
member who knows how doctors think," says Groopman.
So what should we be asking our doctors, over and over?
"What else could it be?"
***
TC
http://www.newyorker.com/fact/content/articles/070129fa_fact_groopman
WHAT'S THE TROUBLE?
by JEROME GROOPMAN
How doctors think.
Issue of 2007-01-29
Posted 2007-01-22
On a spring afternoon several years ago, Evan McKinley was hiking in
the woods near Halifax, Nova Scotia, when he felt a sharp pain in his
chest. McKinley (a pseudonym) was a forest ranger in his early
forties, trim and extremely fit. He had felt discomfort in his chest
for several days, but this was more severe: it hurt each time he took
a breath. McKinley slowly made his way through the woods to a shed
that housed his office, where he sat and waited for the pain to pass.
He frequently carried heavy packs on his back and was used to muscle
aches, but this pain felt different. He decided to see a doctor.
Pat Croskerry was the physician in charge in the emergency room at
Dartmouth General Hospital, near Halifax, that day. He listened
intently as McKinley described his symptoms. He noted that McKinley
was a muscular man; that his face was ruddy, as would be expected of
someone who spent most of his day outdoors; and that he was not
sweating. (Perspiration can be a sign of cardiac distress.) McKinley
told him that the pain was in the center of his chest, and that it had
not spread into his arms, neck, or back. He told Croskerry that he had
never smoked or been overweight; had no family history of heart
attack, stroke, or diabetes; and was under no particular stress. His
family life was fine, McKinley said, and he loved his job.
Croskerry checked McKinley's blood pressure, which was normal, and his
pulse, which was sixty and regular-typical for an athletic man.
Croskerry listened to McKinley's lungs and heart, but detected no
abnormalities. When he pressed on the spot between McKinley's ribs and
breastbone, McKinley felt no pain. There was no swelling or tenderness
in his calves or thighs. Finally, the doctor ordered an
electrocardiogram, a chest X-ray, and blood tests to measure
McKinley's cardiac enzymes. (Abnormal levels of cardiac enzymes
indicate damage to the heart.) As Croskerry expected, the results of
all the tests were normal. "I'm not at all worried about your chest
pain," Croskerry told McKinley, before sending him home. "You probably
overexerted yourself in the field and strained a muscle. My suspicion
that this is coming from your heart is about zero."
Early the next evening, when Croskerry arrived at the emergency room
to begin his shift, a colleague greeted him. "Very interesting case,
that man you saw yesterday," the doctor said. "He came in this morning
with an acute myocardial infarction." Croskerry was shocked. The
colleague tried to console him. "If I had seen this guy, I wouldn't
have gone as far as you did in ordering all those tests," he said. But
Croskerry knew that he had made an error that could have cost the
ranger his life. (McKinley survived.) "Clearly, I missed it,"
Croskerry told me, referring to McKinley's heart attack. "And why did
I miss it? I didn't miss it because of any egregious behavior, or
negligence. I missed it because my thinking was overly influenced by
how healthy this man looked, and the absence of risk factors."
Croskerry, who is sixty-four years old, began his career as an
experimental psychologist, studying rats' brains in the laboratory. In
1979, he decided to become a doctor, and, as a medical student, he was
surprised at how little attention was paid to what he calls the
"cognitive dimension" of clinical decision-making-the process by which
doctors interpret their patients' symptoms and weigh test results in
order to arrive at a diagnosis and a plan of treatment. Students spent
the first two years of medical school memorizing facts about
physiology, pharmacology, and pathology; they spent the last two
learning practical applications for this knowledge, such as how to
decipher an EKG and how to determine the appropriate dose of insulin
for a diabetic. Croskerry's instructors rarely bothered to describe
the mental logic they relied on to make a correct diagnosis and avoid
mistakes.
In 1990, Croskerry became the head of the emergency department at
Dartmouth General Hospital, and was struck by the number of errors
made by doctors under his supervision. He kept lists of the errors,
trying to group them into categories, and, in the mid-nineties, he
began to publish articles in medical journals, borrowing insights from
cognitive psychology to explain how doctors make clinical decisions-
especially flawed ones-under the stressful conditions of the emergency
room. "Emergency physicians are required to make an unusually high
number of decisions in the course of their work," he wrote in
"Achieving Quality in Clinical Decision Making: Cognitive Strategies
and Detection of Bias," an article published in Academic Emergency
Medicine, in 2002. These doctors' decisions necessarily entail a great
deal of uncertainty, Croskerry wrote, since, "for the most part,
patients are not known and their illnesses are seen through only small
windows of focus and time." By calling physicians' attention to common
mistakes in medical judgment, he has helped to promote an emerging
field in medicine: the study of how doctors think.
There are limited data about the frequency of misdiagnoses. Research
from the nineteen-eighties and nineties suggests that they occur in
about fifteen per cent of cases, but Croskerry suspects that the rate
is significantly higher. He believes that many misdiagnoses are the
result of readily identifiable-and often preventable-errors in
thinking.
Doctors typically begin to diagnose patients the moment they meet
them. Even before they conduct an examination, they are interpreting a
patient's appearance: his complexion, the tilt of his head, the
movements of his eyes and mouth, the way he sits or stands up, the
sound of his breathing. Doctors' theories about what is wrong continue
to evolve as they listen to the patient's heart, or press on his
liver. But research shows that most physicians already have in mind
two or three possible diagnoses within minutes of meeting a patient,
and that they tend to develop their hunches from very incomplete
information. To make diagnoses, most doctors rely on shortcuts and
rules of thumb-known in psychology as "heuristics."
Heuristics are indispensable in medicine; physicians, particularly in
emergency rooms, must often make quick judgments about how to treat a
patient, on the basis of a few, potentially serious symptoms. A doctor
is trained to assume, for example, that a patient suffering from a
high fever and sharp pain in the lower right side of the abdomen could
be suffering from appendicitis; he immediately sends the patient for X-
rays and contacts the surgeon on call. But, just as heuristics can
help doctors save lives, they can also lead them to make grave errors.
In retrospect, Croskerry realized that when he saw McKinley in the
emergency room the ranger had been experiencing unstable angina-a
surge of chest pain that is caused by coronary-artery disease and that
may precede a heart attack. "The unstable angina didn't show on the
EKG, because fifty per cent of such cases don't," Croskerry said. "His
unstable angina didn't show up on the cardiac-enzymes test, because
there had been no damage to his heart muscle yet. And it didn't show
up on the chest X-ray, because the heart had not yet begun to fail, so
there was no fluid backed up in the lungs."
The mistake that Croskerry made is called a "representativeness"
error. Doctors make such errors when their thinking is overly
influenced by what is typically true; they fail to consider
possibilities that contradict their mental templates of a disease, and
thus attribute symptoms to the wrong cause. Croskerry told me that he
had immediately noticed the ranger's trim frame: most fit men in their
forties are unlikely to be suffering from heart disease. Moreover,
McKinley's pain was not typical of coronary-artery disease, and the
results of the physical examination and the blood tests did not
suggest a heart problem. But, Croskerry emphasized, this was precisely
the point: "You have to be prepared in your mind for the atypical and
not be too quick to reassure yourself, and your patient, that
everything is O.K." (Croskerry could have kept McKinley under
observation and done a second cardiac-enzyme test or had him take a
cardiac stress test, which might have revealed the source of his chest
pain.) When Croskerry teaches students and interns about
representativeness errors, he cites Evan McKinley as an example.
Doctors can also make mistakes when their judgments about a patient
are unconsciously influenced by the symptoms and illnesses of patients
they have just seen. Many common infections tend to occur in
epidemics, afflicting large numbers of people in a single community at
the same time; after a doctor sees six patients with, say, the flu, it
is common to assume that the seventh patient who complains of similar
symptoms is suffering from the same disease. Harrison Alter, an
emergency-room physician, recently confronted this problem. At the
time, Alter was working in the emergency room of a hospital in Tuba
City, Arizona, which is situated on a Navajo reservation. In a three-
week period, dozens of people had come to his hospital suffering from
viral pneumonia. One day, Blanche Begaye (a pseudonym), a Navajo woman
in her sixties, arrived at the emergency room complaining that she was
having trouble breathing. Begaye was a compact woman with long gray
hair that she wore in a bun. She told Alter that she had begun to feel
unwell a few days earlier. At first, she said, she had thought that
she had a bad head cold, so she had drunk orange juice and tea, and
taken a few aspirin. But her symptoms had got worse. Alter noted that
she had a fever of 100.2 degrees, and that she was breathing rapidly-
at almost twice the normal rate. He listened to her lungs but heard
none of the harsh sounds, called rhonchi, that suggest an accumulation
of mucus. A chest X-ray showed that Begaye's lungs did not have the
white streaks typical of viral pneumonia, and her white-blood-cell
count was not elevated, as would be expected if she had the illness.
However, a blood test to measure her electrolytes revealed that her
blood had become slightly acidic, which can occur in the case of a
major infection. Alter told Begaye that he thought she had
"subclinical pneumonia." She was in the early stages of the infection,
he said; the virus had not yet affected her lungs in a way that would
show up on a chest X-ray. He ordered her to be admitted to the
hospital and given intravenous fluids and medicine to bring her fever
down. Viral pneumonia can tax an older person's heart and sometimes
cause it to fail, he told her, so it was prudent that she remain under
observation by doctors. Alter referred Begaye to the care of an
internist on duty and began to examine another patient.
A few minutes later, the internist approached Alter and took him
aside. "That's not a case of viral pneumonia," the doctor said. "She
has aspirin toxicity."
Immediately, Alter knew that the internist was right. Aspirin toxicity
occurs when patients overdose on the drug, causing hyperventilation
and the accumulation of lactic acid and other acids in the blood.
"Aspirin poisoning-bread-and-butter toxicology," Alter told me. "This
was something that was drilled into me throughout my training. She was
an absolutely classic case-the rapid breathing, the shift in her blood
electrolytes-and I missed it. I got cavalier."
Alter's misdiagnosis resulted from the use of a heuristic called
"availability," which refers to the tendency to judge the likelihood
of an event by the ease with which relevant examples come to mind.
This tendency was first described in 1973, in a paper by Amos Tversky
and Daniel Kahneman, psychologists at the Hebrew University of
Jerusalem. For example, a businessman may estimate the likelihood that
a given venture could fail by recalling difficulties that his
associates had encountered in the marketplace, rather than by relying
on all the data available to him about the venture; the experiences
most familiar to him can bias his assessment of the chances for
success. (Kahneman won the Nobel Prize in Economics in 2002, for his
research on decision-making under conditions of uncertainty.) The
diagnosis of subclinical pneumonia was readily available to Alter,
because he had recently seen so many cases of the infection. Rather
than try to integrate all the information he had about Begaye's
illness, he had focussed on the symptoms that she shared with other
patients he had seen: her fever, her rapid breathing, and the acidity
of her blood. He dismissed the data that contradicted his diagnosis-
the absence of rhonchi and of white streaks on the chest X-ray, and
the normal white-blood-cell count-as evidence that the infection was
at an early stage. In fact, this information should have made him
doubt his hypothesis. (Psychologists call this kind of cognitive
cherry-picking "confirmation bias": confirming what you expect to find
by selectively accepting or ignoring information.)
After the internist made the correct diagnosis, Alter recalled his
conversation with Begaye. When he had asked whether she had taken any
medication, including over-the-counter drugs, she had replied, "A few
aspirin." As Alter told me, "I didn't define with her what 'a few'
meant." It turned out to be several dozen.
Representativeness and availability errors are intellectual mistakes,
but the errors that doctors make because of their feelings for a
patient can be just as significant. We all want to believe that our
physician likes us and is moved by our plight. Doctors, in turn, are
encouraged to develop positive feelings for their patients; caring is
generally held to be the cornerstone of humanistic medicine.
Sometimes, however, a doctor's impulse to protect a patient he likes
or admires can adversely affect his judgment.
In 1979, I treated Brad Miller (a pseudonym), a young literature
instructor who was suffering from bone cancer. I was living in Los
Angeles at the time, completing a fellowship in hematology and
oncology at the U.C.L.A. Medical Center. "You look familiar," Brad
said to me when I introduced myself to him in his hospital room as the
doctor who would be overseeing his care. "I see you running with two
or three friends around the university," he said. "I'm a runner, too-
or, at least, was."
I told Brad that I hoped he would be able to run again soon, though I
warned him that his chemotherapy treatment would be difficult.
About six weeks earlier, Brad had noticed an ache in his left knee. He
had been training to run in a marathon, and at first he thought that
the ache was caused by a sore muscle. He saw a specialist in sports
medicine, who examined the leg and recommended that he wear a knee
brace when he ran. Brad followed this advice, but the ache got worse.
The physician ordered an X-ray, which showed an osteosarcoma, a
cancerous growth, around the end of the femur, just above the knee.
Several years earlier, the surgical-oncology department at U.C.L.A.
had devised an experimental treatment for this kind of sarcoma,
involving a new chemotherapy drug called Adriamycin. Oncologists had
nicknamed Adriamycin "the red death," because of its cranberry color
and its toxicity. Not only did it cause severe nausea, vomiting, mouth
blisters, and reduced blood counts; repeated doses could injure
cardiac muscle and lead to heart failure. Patients had to be monitored
closely, since once the heart is damaged there is no good way to
restore its pumping capacity. Still, doctors at U.C.L.A. had found
that giving patients multiple doses of Adriamycin often shrank tumors,
allowing them to surgically remove the cancer without amputating the
affected limb-the standard approach in the past.
I began administering the treatment that afternoon. Despite taking
Compazine to stave off vomiting, Brad was acutely nauseated. After
several doses of chemotherapy, his white-blood-cell count dropped
precipitately. Because his immune system was weakened, he was at great
risk of contracting an infection. I required visitors to Brad's room
to wear a mask, a gown, and gloves, and instructed the nurses not to
give him raw food, in order to limit his exposure to bacteria.
"Not to your taste," I said at the end of the first week of treatment,
seeing an untouched meal on his tray.
"My mouth hurts," Brad whispered. "And, even if I could chew, it looks
pretty tasteless."
I agreed that the food looked dismal.
"What is to your taste?" I asked. "Fried kidney?"
I had told Brad when we met that I had studied "Ulysses" in college,
in a freshman seminar. The professor had explained the relevant Irish
history, the subtle references to Catholic liturgy, and a number of
other allusions that most of us in the class would otherwise not have
grasped. I had enjoyed Joyce's descriptions of Leopold Bloom eating
fried kidneys.
Brad was my favorite patient on the ward. Each morning when I made
rounds with the residents and the medical students, I would take an
inventory of his symptoms and review his laboratory results. I would
often linger a few moments in his room, trying to distract him from
the misery of his therapy by talking about literature.
The treatment called for a CAT scan after the third cycle of
Adriamycin. If the cancer had shrunk sufficiently, the surgery would
proceed. If it hadn't, or if the cancer had grown despite the
chemotherapy, then there was little to be done short of amputation.
Even after amputation, patients with osteosarcomas are at risk of a
recurrence.
One morning, Brad developed a low-grade fever. During rounds, the
residents told me that they had taken blood and urine cultures and
that Brad's physical examination was "nonfocal"-they had found no
obvious reason for the fever. Patients often get low fevers during
chemotherapy after their white-blood-cell count falls; if the fever
has no identifiable cause, the doctor must decide whether and when to
administer a course of antibiotics.
"So you feel even more wiped out?" I asked Brad.
He nodded. I asked him about various symptoms that could help me
determine what was causing the fever. Did he have a headache?
Difficulty seeing? Pressure in his sinuses? A sore throat? Problems
breathing? Pain in his abdomen? Diarrhea? Burning on urination? He
shook his head.
Two residents helped prop Brad up in bed so that I could examine him;
I had a routine that I followed with each immune-deficient patient,
beginning at the crown of the head and working down to the tips of the
toes. Brad's hair was matted with sweat, and his face was ashen. I
peered into his eyes, ears, nose, and throat, and found only some
small ulcers on his inner cheeks and under his tongue-side effects of
his treatment. His lungs were clear, and his heart sounds were strong.
His abdomen was soft, and there was no tenderness over his bladder.
"Enough for today," I said. Brad looked exhausted; it seemed wise to
let him rest.
Later that day, I was in the hematology lab, looking at blood cells
from a patient with leukemia, when my beeper went off. "Brad Miller
has no blood pressure," the resident told me when I returned the call.
"His temperature is up to a hundred and four, and we're moving him to
the I.C.U."
Brad was in septic shock. When bacteria spread through the
bloodstream, they can damage the circulation. Septic shock can be
fatal even in people who are otherwise healthy; patients with impaired
immunity, like Brad, whose white-blood-cell count had fallen because
of chemotherapy, are at particular risk of dying.
"Do we have a source of infection?" I asked.
"He has what looks like an abscess on his left buttock," the resident
said.
Patients who lack enough white blood cells to fight bacteria are prone
to infections at sites that are routinely soiled, like the area
between the buttocks. The abscess must have been there when I examined
Brad. But I had failed to ask him to roll over so that I could inspect
his buttocks and rectal area.
The resident told me that he had repeated Brad's cultures and started
him on broad-spectrum antibiotics, and that the I.C.U. team was about
to take over.
I was furious with myself. Because I liked Brad, I hadn't wanted to
add to his discomfort and had cut the examination short. Perhaps I
hoped unconsciously that the cause of his fever was trivial and that I
would not find evidence of an infection on his body. This tendency to
make decisions based on what we wish were true is what Croskerry calls
an "affective error." In medicine, this type of error can have
potentially fatal consequences. In the case of Evan McKinley, for
example, Pat Croskerry chose to rely on the ranger's initial test
results-the normal EKG, chest X-ray, and blood tests-all of which
suggested a benign diagnosis. He didn't arrange for follow-up testing
that might have revealed the source of the ranger's chest pain.
Croskerry, who had been an Olympic rower in his thirties, told me that
McKinley had reminded him of himself as an athlete; he believed that
this association contributed to his misdiagnosis.
As soon as I finished my work in the lab, I rushed to the I.C.U. to
check on Brad. He was on a respirator and opened his eyes wide to
signal hello. Through an intravenous line attached to one arm, he was
receiving pressors, drugs that cause the heart to pump more
effectively and increase the tone of the vessels to help maintain
blood pressure. Brad's heart was holding up, despite all the
Adriamycin he had taken. His platelet count had fallen, as often
happens with septic shock, and he was receiving platelet transfusions.
The senior doctor in the I.C.U. had told Brad's parents, who lived
nearby, that he was extremely ill. I saw his parents sitting in a room
next to the I.C.U., their heads bowed. They had not seen me, and I was
tempted to avoid them. But I forced myself to speak to them and
offered a few words of encouragement. They thanked me for my care of
their son, which only made me feel worse.
The next morning, I arrived before the residents to review my
patients' charts. Rounds lasted an hour longer than usual, as I
insisted on double-checking each bit of information that the residents
offered about the patients in our care.
Brad Miller survived. Slowly, his white-blood-cell count increased,
and the infection was resolved. After he left the I.C.U., I told him
that I should have examined him more thoroughly that morning, but I
did not explain why I had not. A CAT scan showed that his sarcoma had
shrunk enough for him to undergo surgery without amputation, but a
large portion of his thigh muscle had to be removed along with the
tumor. After he recovered, he was no longer able to run, but
occasionally I saw him riding his bicycle on campus.
Medical education has not changed substantially since Pat Croskerry
and I were trained. Students are still expected to assimilate large
amounts of basic science and apply that knowledge as they are taught
practical aspects of patient care. And young physicians still learn
largely by observing more senior members of their field. ("See one, do
one, teach one" remains a guiding maxim at medical schools.) This
approach produces confident and able physicians. Yet the ideal it
implies, of the doctor as a dispassionate and rational actor, is
misguided. As Tversky and Kahneman and other cognitive psychologists
have shown, when people are confronted with uncertainty-the situation
of every doctor attempting to diagnose a patient-they are susceptible
to unconscious emotions and personal biases, and are more likely to
make cognitive errors. Croskerry believes that the first step toward
incorporating an awareness of heuristics and their liabilities into
medical practice is to recognize that how doctors think can affect
their success as much as how much they know, or how much experience
they have. "Currently, in medical training, we fail to recognize the
importance of critical thinking and critical reasoning," Croskerry
told me. "The implicit assumption in medicine is that we know how to
think. But we don't."
****
TC
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