Doctors should think 'out of the box'

Diagnosing disease is as much an art as a science, so inspiration and dialogue with patients can play as great a role as knowledge, according to an influential book now translated into Hebrew.

vaccination health 88 (photo credit: )
vaccination health 88
(photo credit: )
As medical knowledge doubles every seven years or less, the challenge of diagnosing disease while considering all possibilities becomes so complicated that a doctor's brain would have to function like a computer. As clinical diagnosis is more an art than a science, diagnoses are influenced by subjective factors, from how many cases of a certain disorder were identified in a certain location, the doctor's mood and experience, the patient's philosophy and even the way he looks and dresses. Sometimes the subjective factors result in a brilliant diagnosis that seems to come from nowhere, while at other times it can lead to a fatal error of judgement. Prof. Jerome Groopman, a Jewish internal medicine specialist at Harvard Medical School who authors essays related to doctoring in the The New Yorker magazine, wrote a highly acclaimed, 307-page book two years ago called How Doctors Think, which was published by Houghton Mifflin. Now, the eye-opening volume appears in Hebrew as a 280-page book by Matar ( of Tel Aviv. It is titled: Rof'im, Aich Heim Hoshvim: Al Hashivut Hadialogue Bein Harofe Limetupal (How Doctors Think: On the Importance of Doctor-Patient Dialogue). The series of detailed and in many cases enthralling essays on cases that were misdiagnosed or brilliantly diagnosed is no less relevant in Israel than in the US. It is a must-read book not only for students in Israel's four medical schools, but also for those who teach them and physicians in community clinics and hospitals around the country - not to mention patients. GROOPMAN maintains that the average clinician reaches his first conclusion about a patient within 18 seconds of seeing him. Obviously, it takes longer when the case is complicated and the patient is hospitalized, and the diagnosis may change as the condition and test results change. Although the general public tend to believe most medical errors are due to technical blunders such as prescribing the wrong drug dosage, viewing an X-ray backwards or failing to note which arm or leg is diseased, errors of medical judgement are responsible for many of them. Whether in a doctor's office in a health fund clinic or at a hospital bedside or consultation room, waiting for the diagnosis of one's condition is like the apprehension one feels as a defendant in a courtroom. The suspense alone could kill. But how, Groopman ponders, does a physician decide on the diagnosis? The old school of medical training taught students to read a lot of books, meet a lot of patients and listen to experienced physicians during their clinical years - absorbing as much knowledge and case experience as they could. Today, many young doctors depend largely on diagnostic "trees" (or clinical algorithms) by which they narrow down possibilities according to which symptom or medical history details fits the patient's case. But the art of diagnosis requires more, Groopman indicates, even "reading the patient's body language." Treating patients as human beings with a story to tell rather than just "cases," and not depending mostly on medical files filled in by previous clinicians can help doctors find the real answer, he advises. The Boston author adds a special introduction for the Hebrew edition that discloses he first visited Israel nearly four decades ago as a student attending the Weizmann Institute of Science's summer course in Rehovot and working in the lab of Prof. David Lavi isolating new plant compounds that could minimize pain. Six years later, he came here for three months, learning hematology in the lab of the late Prof. Gabi Izak at Hadassah University Medical Center in Jerusalem. Fortunately, his Israeli role models were well organized, interested in detail and focused. But Groopman notes that not all Israeli doctors he met were like them: Some didn't pay attention to their patients, while others rushed to reach conclusions. While writing this book, Groopman even studied work on the methodology of risk taking and uncertainty by Hebrew University Prof. Daniel Kahneman (who later moved to Princeton and won a Nobel Prize in Economics) and Prof. Amos Twersky, who moved to Stanford and would have shared it if he had not died prematurely). "I love Israel as a state and a culture," Groopman writes, "and believe in stressing the advantages of open communications not only as a way of discourse, not only in the market or politics, but also in the clinic or hospital. This is a social and intellectual tradition suited for being part of the doctor-patient relationship." GROOPMAN does not avoid discussing his own frightful patient experiences and errors of judgement. One was a 66-year-old African-American retired postal worker named William Morgan who had high blood pressure and acute chest pain; in the middle of their conversation, his eyes dilated, his jaw fell and his chest heaved so violently he was unable to speak. Fresh out of medical school, Groopman had no idea what to do. Behind him was a cardiologist from Virginia who had come to visit former colleagues, and after about 15 seconds said Morgan needed immediate open-heart surgery. Groopman realized that much of what he had learned at medical school and the hospital was still "theoretical." A few years ago, Groopman witnessed another shocking surprise. A sturdily built forester in his 40s arrived in the hospital complaining of angina (chest pain) but was found to have normal blood pressure. Tanned and fit, he lived an active outdoor life and had never smoked. His doctor, named Dr. Pat Krosky, quickly surmised that the patient, who was handsome and wearing a forest service uniform, was a very unlikely candidate for heart disease. Krosky diagnosed a muscle pulled while working and sent him home. The next morning, the forester was admitted with an acute heart attack. Krosky admitted his judgemental error. "I gave too much importance to his healthy appearance. How fortunate that he didn't die." Another sad case was that of an unshaven 73-year-old man with alcohol on his breath, a swollen belly and a hard liver. It seemed to the doctor who received him that this was a drunkard with cirrhosis; the case disgusted him, as he felt that people who neglect their own health almost deserve the consequences. But it turned out that the elderly man had Wilson's disease, which made his body unable to remove the copper from his cells. The alcohol on his breath had been the harmless glass of rum he drank every night before bed. "Doctors must be careful not to go with their first impression when it is a strong feeling," warned Groopman, "a negative one or even a positive one." Prof. Myron Falchuk, an eminent gastroenterologist at Beth Israel Deaconness Hospital and Harvard Medical School in Boston, is given much space in the book. (As that surname is the married name of Hadassah Women's Zionist Organization of America national president Nancy Falchuk, I checked and found that Myron is the brother of her husband, Prof. Kenneth Falchuk, an internal medicine specialist also at Harvard.) He admitted to reaching the wrong diagnosis when a friendly octogenarian Jew born in Europe came in complaining of "heartburn." Falchuk relished his sense of humor and their conversation in Yiddish. "I really wasn't keen on sending him for invasive tests," he recalled after changing his medications over four months. But then the old man complained of tiredness and dizziness. He was clearly anemic. To his horror, the gastroenterologist found in an endoscopy of the small intenstine that he had large growths that clearly indicated intestinal lymphoma. "It is a type of cancer that can respond to treatment. I just hadn't wanted to force the discomfort of an invasive test on this nice elderly man." The delay in diagnosis fortunately did not harm him, but it taught Falchuk a lesson. BUT THE Beth Israel Deaconess Hospital specialist is also Groopman's first example of hero clinicians who "think out of the box." One day a 35-year-old woman named Anne Dodge arrived in his office who had been previously diagnosed by dozens of doctors (including internal medicine specialists, gastroenterologists, hematologists and psychiatrists) as having inflammatory bowel syndrome and anorexia nervosa with bulimia. She had suffered for 15 years from lack of appetite, forcing herself to eat and then vomiting; when a doctor advised her to consume 3,000 calories a day, mostly from cereals and pasta, her condition became much worse, and her weight dropped to only 36 kilos. To Dodge's surprise, Falchuk pushed away all the medical reports and assessments and asked her to "go back to the beginning," when she "first didn't feel good." Dodge had thought Falchuk hadn't even bothered to look at her medical file, but he gave her much time even though he had a long queue of patients. He conducted a careful physical exam, looking mostly at her hands, nails, skin and inside her mouth rather than her abdomen. Falchuk voiced his doubts about the "official diagnosis" of irritable bowel, anorexia and bulimia, and sent her for an endoscopy and more blood tests. He soon concluded that she was a victim of the autoimmune disease known as celiac, in which her body could not absorb food containing gluten - a major component of ordinary flour, pasta and cereals. When she changed her diet, she gained weight and felt like a new person. ONE OF THE most moving accounts in the volume is that of Rachel Stein, a single Jewish woman who succeeded in business but felt empty for not having children. She went all the way to Vietnam to adopt a baby whom she named Shira. Before taking off for Boston, the baby was coughing, and by the time they landed, Shira was dehydrated and refusing food. Rachel took her new baby to Boston's Children's Hospital with severe pneumonia, but even on a respirator her condition deteriorated. Saved from death from multiple infections by extreme measures, Shira was diagnosed with a rare inherited condition called severe combined immune deficiency (SCID) - even though she was not a typical case, and SCID is almost always found in boys. Rachel, who had been completely secular, became a believer during her adopted child's six weeks in the hospital. She prayed incessantly and regarded God as a friend who could help, Groopman recalled. Unwilling to accept the doctors' diagnosis of SCID and a bone-marrow transplant that could have killed her, Shira conducted scoured the Internet and became increasingly convinced that the problem was a nutritional deficiency. Finally, the doctors confirmed that Rachel's amateur diagnosis was the correct one. After being treated for the nutritional deficiency, Shira was taken home healthy. Groopman calls the doctors' error "diagnosis momentum" - that after a diagnosis is made, other physicians ignore contradictory evidence. "How a doctor thinks can first be discerned by how he speaks and how he listens," Groopman concludes. "Time is needed, [even though] in modern medicine it is a luxury. He who sees medicine as a business and not as a mission pushed for allocation of a limited number of units for medical care and praised efficiency. A doctor's clinic is not a production line, and those who try to turn it into a factory will harm communication with patients, encourage errors and harm the partnership between patient and doctor." A doctor who divides his time between looking at his watch and his computer cannot think about the patient, he adds. "Hurried work and shortcuts are the surest way to errors of judgement." It is a valuable book indeed, and promises to make the whole healthcare system think and rethink.