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| title | chunk | source | category | tags | date_saved | instance |
|---|---|---|---|---|---|---|
| How Doctors Think | 2/2 | https://en.wikipedia.org/wiki/How_Doctors_Think | reference | science, encyclopedia | 2026-05-05T08:54:02.501926+00:00 | kb-cron |
The narrowest subspecialist, the reasoning goes, should also be able to provide this [broad] range of medical services. This naive idea arises, as do so many other wrong beliefs about primary care, because of the concept that doctors take care of diseases. Diseases, the idea goes on, form a hierarchy from simple to difficult. Specialists take care of difficult diseases, so, of course, they will naturally do a good job on simple diseases. Wrong. Doctors take care of people, some of whom have diseases and all of whom have some problem. People used to doing complicated things usually do complicated things in simple situations--for example, ordering tests or x-rays when waiting a few days might suffice--thus overtreating people with simple illnesses and overlooking the clues about other problems that might have brought the patient to the doctor.
== The fallacy of logic == In a later chapter Groopman reports a frank discussion with Dr. James E. Lock, chief of cardiology at Boston Children's Hospital. During their conversation, Groopman asks the world-renowned cardiologist about the times in his career when he made mistakes in patient treatment. To the query, Lock gives the cryptic response, "All my mistakes have the same things in common." Lock then elaborates, discussing recommendations he made to repair specific heart defects in neonates that ultimately led to worse clinical outcomes and potentially avoidable deaths. The recommendations he made were based on a purely logical understanding of cardiac physiology. The crucial point of Lock's discussion came with his confession:
Impeccable logic doesn't always suffice. My mistake was that I reasoned from first principles when there was no prior experience. I turned out to be wrong because there are variables that you can't factor in until you actually do it. And you make the wrong recommendation, and the patient doesn't survive. I didn't leave enough room for what seems [sic] like minor effects--the small fluctuations in oxygen levels, which might amount to one or two or three percent but actually can signal major problems in the heart....[The proposed treatment] is very sound logic. But it's wrong...These children developed right heart failure and clinically they became worse. There are aspects to human biology and human physiology that you just can't predict. Deductive reasoning doesn't work for every case. Sherlock Holmes is a model detective, but human biology is not a theft or a murder where all the cues can add up neatly. Groopman goes on to write, "Lock averted his gaze and his face fell; to be wrong about a child is a form of suffering unique to his profession [as a pediatrician]."
== Disregard of uncertainty == Groopman also discusses the work of Renee Fox, a physician and occupational sociologist who observed residents and attendings in a hospital ward setting, noting their various ways of coping with the uncertainties of medical treatment. The mechanisms to cope that Fox observed included, for example, black humor, making bets about who would be right about a patient's prognosis, and engaging in magical thinking to maintain a sense of poise and competence in front of patients while performing circumspect procedures. Jay Katz, a clinical instructor at Yale Law School has since termed these coping mechanisms under the rubric 'disregard of uncertainty', which he believes physicians develop to deal with the anxiety of shifting from the certainty of theoretical discussions of medicine early in their training to its more happenstance practical application. Groopman recalls that in situations where he had been hesitant to take clinical action based on incomplete data, it had been wisest at times to follow the advice of his mentor Dr. Linda A. Lewis: "Don't just do something, stand there." Groopman asserts that there exist situations in which inaction may be the wisest course of action.
== Suggestions for patients == Groopman closes with an epilogue giving advice for patients. He gives the following tools that patients can use to help reduce or rectify cognitive errors:
Ask What else could it be?, combating satisfaction of search bias and leading the doctor to consider a broader range of possibilities. Ask Is there anything that doesn't fit?, combatting confirmation bias and again leading the doctor to think broadly. Ask Is it possible I have more than one problem?, because multiple simultaneous disorders do exist and frequently cause confusing symptoms. Tell what you are most worried about, opening discussion and leading either to reassurance (if the worry is unlikely) or careful analysis (if the worry is plausible). Retell the story from the beginning. Details that were omitted in the initial telling may be recalled, or different wording or the different context may make clues more salient. (This is most appropriate when the condition has not responded to treatment or there is other reason to believe that a misdiagnosis is possible.)
== See also == Availability heuristic Diagnosis Medical ethics The Deadly Dinner Party Fatal Care: Survive in the U.S. Health System To Err is Human
== References ==