Heal Thyself

Groopman doesn't go much into the sociology of medicine, which is unfortunate because it has quite a bit to do with laying the groundwork for the cognitive errors he describes. Many medical students and doctors are surprisingly incurious about human narrative, to which they have almost unparalleled access. Most have little exposure to unintelligent, inarticulate or life-weary people. Few have done manual labor or been in the position of taking orders rather than giving them (outside of medical training, that is). Many are poor listeners and like to hear themselves talk. If it is true, as one is taught in medical school, that 80 percent of diagnoses can be made purely on the medical history -- what the patient says before the physical exam or any tests are done -- these traits can be impediments to good care.

So what is Groopman's advice for ways to help doctors think better?

An entire chapter illustrates the first commandment of pediatrics: Always take seriously the mother's theory of what's happening, no matter how harebrained it sounds. Patients should feel free to voice what they suspect the doctor may be thinking. "With a disarming sense of humor, she communicated that she understood she fit a certain social stereotype, and that stereotype had caused her doctors to fail to fully consider her complaints," Groopman notes admiringly of a patient who admitted she was "a little crazy" but doubted that menopause was the cause of her severe headaches and crawling skin. (She turned out to have a tumor that floods the body with hormones.) Another doctor tells Groopman she was helped when her patient said, "Don't save me from an unpleasant test just because we're friends."

Simple questions can help refocus a physician's attention: "What's the worst thing this can be?" and "What body parts are near where I am having my symptom?" Before calling the pediatrician, parents should ask themselves "what it is that scares them the most about their child's condition." And everyone should be leery of lazy generalities: "No one -- no doctor, no patient -- should ever accept, as a first answer to a serious event, 'We see this sometimes.' "

For their part, doctors should be wary of diagnoses that appear instantly obvious. Groopman quotes one doctor who jumped to the conclusion that a woman had pneumonia when, in fact, she had an aspirin overdose, which can cause some of the same signs and symptoms. "I learned from this to always hold back, to make sure that even when I think I have the answer, to generate a short list of alternatives."

Groopman notes that having adequate time to think helps (but of course doesn't guarantee) good decision making. Much of medicine, however, is practiced with the consumer waiting for the product to be delivered, whether it's the proposed work-up, the diagnosis, the treatment options or the long-term prognosis. This expectation of instant knowledge and service is something few people would consider reasonable for tasks such as having a will drawn up or even getting a pair of skates sharpened. This is perhaps worth keeping in mind as doctors are increasingly asked to do more in shorter appointments for the same or less money.

When it comes to medical care, we Americans want everything -- limitless access to drugs, diagnostic studies, surgical procedures, experimental therapies. We might want to push the system to give us more of the most potent intervention in medicine -- a doctor with time to think and talk. ·

David Brown, a physician, is a science reporter at The Washington Post.