Doctors Examine Themselves

So why have Gawande and Groopman assumed the roles of gentle whistle-blowers? Whether attempting to lower medical errors, deliver more-cost-efficient care or lower waiting times in clinics, researchers today focus on "quality improvement." Gawande cites the efforts of Donald Berwick, head of the Institute for Healthcare Improvement, who urges medicine to do two things: measure what it does and be more open about it. However, past calls for candor have hardly revolutionized medicine. For example, efforts to get physicians and other health professionals to disclose their mistakes as a way to develop better error prevention systems have met with mixed success.

The authors' hopes for medical practice based on greater self-scrutiny will be a tall task as well. We live in an era of evidence-based medicine, in which population-based studies, Bayesian analysis and clinical guidelines increasingly dictate medical care. Both authors bemoan this development insofar as it makes physicians into technicians. Doctors, Gawande writes, need to stop to "wonder" and reconsider the paths they have taken. Groopman's best physicians arrive at judgments by assessing not only their patients' complaints but their characters and by paying attention to their own emotional responses to patients.

Though such clinicians may truly excel, these descriptions hark back to the "days of the giants," when wise clinicians patrolled the wards wowing students with their brilliant diagnoses. But it is this same type of medicine, based on anecdotes and individual expertise, that evidence-based medicine finds unhelpful when trying to provide statistically sound advice to patients.

Indeed, the stories in both books, while genuinely compelling, are often unrepresentative. In many cases, the patients have atypical conditions that are initially misdiagnosed or mistreated but then successfully reevaluated by excellent physicians. But routinely searching for zebras instead of horses when one hears hoofbeats, although potentially a way to make a great diagnosis, is not a realistic way to practice medicine, especially in an era of rising health-care costs and time pressures.

Finally, it is far from clear that sick patients, even if it is in their best interest, will have the wherewithal to analyze and challenge their doctors' thought processes. Even in a world of patient autonomy, many sick people just wish to be taken care of.

Still, one cannot help but admire physicians who urge their colleagues to revisit their basic assumptions and who encourage patients to work with their doctors in a constructive manner. Even patients with chronic, debilitating illnesses should benefit from a better understanding of how their doctors think. And for those patients with as-yet undiagnosed conditions, such advice might prove invaluable. ·

Barron H. Lerner, a professor at Columbia University's Mailman School of Public Health, is author of "When Illness Goes Public: Celebrity Patients and How We Look at Medicine." Comments:health@washpost.com.