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Doctors Examine Themselves
Books Explain How Errors Happen, How Patients Can Cope

By Barron H. Lerner
Special to The Washington Post
Tuesday, March 20, 2007

Media-friendly doctors have captured Americans' imagination with their diagnostic skills -- from Dr. Phil (a.k.a. clinical psychologist and TV host Phil McGraw), who dispenses advice about the mind, to Dr. Oz (cardiothoracic surgeon and diet author Mehmet Oz), who shares his expertise about the body. Now, two physician-authors are seeking to capture our attention not by providing clinical recommendations but by offering insights into how medicine is practiced -- insights that could change the way patients deal with doctors. They do so by exploring two of today's knottiest problems: how to make sense of individual stories of illness in an era that prizes statistical knowledge, and how to empower patients to advocate for themselves in the doctor's office.

The new books -- "Better: A Surgeon's Notes on Performance" by Atul Gawande and "How Doctors Think" by Jerome Groopman -- share a similar message: The performance of physicians is less than perfect. The question is whether scrutiny of such imperfections can lead patients to become better medical consumers and thus receive better care.

Gawande's opening chapter, "On Washing Hands," should alert any patient or family member to the role he or she can play in reminding doctors to do just that: "Having shaken hands with a sniffling patient, pulled a sticky dressing off someone's wound, pressed a stethoscope against a sweating chest, most of us do little more than wipe our hands on our white coats and move on," Gawande writes. Similarly, after describing some of the mistakes he and his colleagues have made, Groopman invites patients to learn to ask the kinds of questions that can avoid the misunderstandings and misdiagnoses that, he says, bedevil modern medical care.

Physician-writers have only recently detailed the deficiencies of medicine to the public. For most of the 20th century, doctors urged one another to conceal medical errors, largely because they feared lawsuits. But as a result of a series of research scandals in the 1970s, charges of paternalism and spiraling health care costs, medicine could no longer remain insular. Greater scrutiny of what doctors do came from journalists, bioethicists, insurers and economists -- and, eventually, from doctors themselves.

Gawande and Groopman, both of whom regularly write for the New Yorker, are the latest manifestation of this trend. Gawande, a general surgeon at Harvard Medical School and the recent winner of a MacArthur "genius" award, completed his training only recently. Groopman, trained as a hematologist-oncologist and currently the Recanati Chair of Medicine at Harvard, has been practicing medicine for 30 years. Gawande's book argues that physicians need to be more diligent and ingenious. Groopman's offers a glimpse into a growing field of research: how physicians arrive at medical decisions and the flaws that exist in that process.

Gawande travels the world in search of his stories. In India, he explores the barriers to eradicating polio and other infectious diseases; in the United States, he interviews doctors who participate in the ethically dubious practice of executing prisoners; at Walter Reed Army Medical Center, he examines the latest breakthroughs for saving the lives of soldiers severely wounded in Iraq.

But Gawande is most engaged when discussing the challenges of clinical medicine. He is candid about the mistakes he has made -- for example, rendering a patient permanently hoarse during thyroid surgery, and failing to diagnose a breast cancer for months. And he wants other physicians to be open as well. But, Gawande states, because of the silence that still exists, it is difficult to know which physicians need to do a better job.

One exception to this lack of disclosure involves the care of patients with cystic fibrosis, for which medical centers now share outcomes with one another, thus identifying the superior programs and challenging the less successful ones to improve. Studying and emulating how the "positive deviants" treat this disease and others, Gawande believes, is the best way to enhance the performance of physicians and thus do right by patients.

Groopman not only wants doctors to do better, he also wants to understand what goes wrong when they make mistakes. Interweaving moving clinical anecdotes with the latest science, he argues that physicians have insufficiently scrutinized how they arrive at decisions. "Experts studying misguided care," he writes, "have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes."

Groopman then reports on these data. His book is full of terms from cognitive science, surely unfamiliar to most physicians, such as representativeness errors, attribution errors and confirmation bias. Each of these flaws may lead doctors down the wrong diagnostic or therapeutic pathway by prompting them to make faulty assumptions about their patients. In one case, Groopman's sympathy for a cancer patient with a fever led him to defer a complete examination, sparing the man the discomfort of being rolled over during hospital rounds. As a result, Groopman missed an abscess in the patient's buttocks, which other doctors discovered only after the patient fell dangerously ill.

Groopman concludes that patients deserve to know that "misguided care results from a cascade of cognitive errors." Physicians, he warns, too often rely on their first impressions and are unwilling or unable to revisit their initial conclusions.

To rectify such mistakes, Groopman wants to transfer considerable responsibility to patients and families. He thus provides a series of questions that patients should ask their doctors: "What else could it be?" "Is there anything that doesn't fit?" "Is it possible I have more than one problem?"

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. ยท

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.

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