How Doctors Think

The book is titled How Doctors Think, but much of it is focused on the reasons doctors often fail to think.

Studies have shown that 10 to 15 percent of all medical diagnoses are wrong. The majority of these were not a result of technical errors or ignorance of clinical facts. The majority of errors were due to flaws in physician thinking.

Doctors often rely on a systematic approach to patient care. Take a patient history, perform an exam, order tests and analyze results. Doctors attach statistical probabilities to symptoms and abnormalities. This systematic approach describes a doctor’s actions, but how a doctor “thinks” is often discerned by how he speaks and listens.

It’s important that patients feel free to speak and participate in a dialogue, however…

On average, physicians interrupt patients within eighteen seconds of when they begin telling their story. If the patient is inhibited, cut off prematurely, or constrained into one path of discussion, then the doctor may not be told something vital.

Cognitive biases often drive this. When doctors think they have the answer, they stop asking questions. Unfortunately, doctors rely on a lot of cognitive shortcuts to arrive at a diagnosis that isn’t always correct.

It’s important to ask open ended questions when you’re not sure of the diagnosis. Closed-ended questions are often designed to confirm a diagnosis and can take a doctor down the wrong track. Open-ended questions maximize the opportunity to hear new information.

The type of question is only half of the medical dialogue. The other half is responding to the patient’s emotional cues. Patients do not want to appear stupid or waste a doctor’s time. Patients may not be forthcoming with doctors who fail to respond empathetically to the patient’s emotional cues. Listen intently and encourage the patient to continue.

Social psychologists have discovered that feelings between doctor and patient are hardly a secret on either side. Studies found that patients knew remarkably well how the doctor felt about them based mostly on nonverbal behavior (facial expressions, body language, etc.).

What patients are least liked by doctors? The sickest ones. These tend to be the smokers, alcoholics, obese patients with diabetes, or those who don’t appear to care for themselves.

The reason could be related to a sense of failure and frustration with patients resistant or unresponsive to therapy. Doctors also make assumptions that the patient is not cooperating with care.

Unfortunately, physicians who dislike their patients often cut them off and fixate on a convenient diagnosis and treatment. Patients who are “unliked” by their doctor are also frequently “unheard” by their doctor.

Patients thought to have psychological disorders also create negative feelings with doctors. As a result, physical maladies are often never diagnosed, or a diagnosis is delayed. Doctors assume the problem is “in their head.”

All of this points to the immense value of good communication skills in the exam room. Good communication should enhance trust and likeability between doctor and patient, which leads to improved compliance and clinical outcomes.

Also noteworthy is the impact of a strong likeability between doctor and patient, which can influence a doctor to under-investigate a problem, stacking the deck in favor of a positive diagnosis.

Most people assume that medical decision-making is an objective and rational process, free from the intrusion of emotion. Yet the opposite is true. The physician’s internal state, his or her state of tension, enters into and strongly influences clinical judgments and actions.

Doctors have a natural cognitive tendency to stop searching, and therefore stop thinking, when initial findings support the early diagnosis.

High workload can also impact how a doctor thinks, leading to fatigue, discontent and possible increased error rates.

“Who you see is what you get.” That was the title of a 1994 research study describing how problems are heavily influenced by the specialty the doctor is trained in. For example, a general practitioner, chiropractor and optometrist will likely treat a patient’s headache symptoms completely different.

The author proposes throughout the book that patients should ask more questions, even challenge their doctors at times. Doctors should welcome this, as it forces them to THINK about why they chose a particular diagnosis and treatment plan.

Many doctors would get defensive about this, but many doctors also admitted if their doctor was evasive with addressing their concerns, they would find another doctor.

The role of money. Is patient care influenced by economics and financial gain? While there are ethical boundaries most physicians won’t intentionally cross, does economics nevertheless cloud the judgment of doctors and the treatment options they pursue?

A common theme in the book is that doctors need to think MORE, not relying so heavily on first impressions, treatment algorithms, classification schemes and technology. Once a doctor becomes a “machine,” he/she ignores the individual characteristics of the patient.

Quote from book: “Machines cannot replace the doctor’s mind, his thinking about what he sees and what he does not see. Once you remove yourself from the patient’s story, you no longer are truly a doctor.”

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