How Doctors Reflect

First, I did some digging and found this article which states that "WebMD has become 'synonymous with Big Pharma Shilling' in certain circles:"

http://www.nytimes.com/2011/02/06/magazine/06FOB-Medium-t.html?_r=3&adxnnl=1&emc=eta1&adxnnlx=1297188225-sw5Vl/lB7WQPSUmOBBKY6Q

Apparently WebMD has admitted connections to pharmaceuticals and other health related companies. The website has biases towards certain medication and advertises various medications openly throughout their site. Kinda interesting no?

This is my second reading of Jerome Groopman's How Doctors Think and I believe the book serves its purpose well, demonstrating the difficult decisions and bioethical issues faced by physicians. On a slight negative note, I have always thought that while Dr. Groopman does a fair job identifying problems, he offers few concrete suggestions for reform. For example, while he does make a number of suggestions on how physicians can think more clearly (think outside the box, questions gut instinct, etc), he does not offer a concrete program for improving the diagnostic skills and thought processes of physicians in the US. His only idea for improving training seems to be to push clinicians to ask themselves the above questions more frequently. Given the success of the book, you would have thought the guy would come up with some original solutions to ethical and professional issues.

But while this shortcoming does provide a certain degree of post-reading dissatisfaction, Groopman manages to demonstrate how some physicians fail while others succeed, and raises some important questions around the profession. Americans have a various ideas on what they expect from their physicians, as demonstrated in class discussions. It is impossible to expect any sort of perfect competence from doctors, but I believe it is essential for all physicians to exhibit a strong inclination for self-development. The field of medicine will always be messy and complicated, both in terms of ethics and practicing effective medicine. It is pinnacle for physicians to be able to develop a personal philosophy around delivering effective and efficient care, alongside a permanent grasp of medical knowledge. Without constantly developing a strong, positive moral agreement and maintaining clear communication with patients, it becomes very easy for physicians to become unsatisfying with the challenges of their job. There is no silver bullet for the issues of medicine, and this is the reason for Groopman’s omission. Most of the changes that would positively contribute to patient care need to happen among the psyches of individual physicians, constantly reevaluating the care they provide and not being stuck with their egos.

Medical Ethics

Despite my extreme distaste for Forgive and Remember: Managing Medical Failure, I thought Bosk’s discussion about the “Varieties of Normal Action” and the accompanying grid of expectations and outcomes (pg. 116-120) to be were interesting and worth more detail, particularly Cell 4, expected failure. Here, doctors face the difficult situation of knowing that medical intervention will most likely be unsuccessful, but needing to care for their patients in the most ethical and humane way possible. I stumbled across this New York Times article from 1990 that touches on the same idea: http://www.nytimes.com/1990/05/15/science/the-doctor-s-world-despite-many-shifts-oath-as-old-as-apollo-endures-in-medicine.html?src=pm. In a nutshell, the Hippocratic oath, a list of axioms repeated by new doctors that essentially mean they will do no harm, has been phased out in the medical school setting and there’s a question of the validity of its origins. According to the article, it’s quite possible the Hippocratic oath (and accordingly, medical ethics) are not studied in medical school at all, which is detrimental to patients, and that the oath has paternalistic roots that don’t honor a patient’s wishes and hold the doctor above all others. It’s an interesting read, and encompasses bits of our discussions about How Doctors Think, medical ethics and our current reading.

Surprising Medical Insights

After reading the book How Doctors Think, by Jerome Goodall, I gained a lot of new, shocking insights about what goes on behind-the-scenes in the medical world. And although some of it seemed a little upsetting, I gained an entirely new respect for the work that doctors, especially pediatricians do everyday.  I definitely underestimated what it took to be an experienced, well-rounded doctor.

However, I do feel as if there are problems with the ways in which medical schools are teaching their students. He explained that in medical school when they saw patients during rounds, they would be "led through a calm, deliberate, and linear analysis of the clinical information," (Groopman 34). Even on the first night of being out of the medical school and into the hospital on his own, Groopman learned that "thinking was inseparable from acting," (Groopman 35). Nobody can truly be prepared to what can happen to a patient when they are not working under an instructor. Groopman was dealing with a patient, William Morgan, just having a normal conversation with him when his blood pressure started falling and his breathing turned abnormal and he had to idea what to do. He was getting flustered and frenzied, because obviously he had never dealt with an experience like this. This is one thing that medical schools will teach you in textbooks and writings but how do you know how to really deal with it when you face it in real life? This is definitely a flawed system because all the medical students have to rely on is that encyclopedia in their heads or index cards that they carry around with them. However, textbook definitions of diagnoses and procedures is not always how it goes with patients.

Despite the flaws of medical schools, I never realized all the different problems and things that doctors had to go through when evaluating patients. I mean, obviously I knew that being a doctor would be no cake walk, which is why only the smartest people can become one, but I never realized the extent of it until this book. For example, even when a doctor thinks they have the right answer, all the right symptoms pointing to one disease and everything, they should create a list in the back of their minds of other possibilities that it could be. The doctor cannot ask patients questions in certain ways, and there can always be misunderstandings between patients and doctors. For example, he described the pediatrician that had a regular patient that left because she thought she was being racially profiled as having dirty blood, when in fact it was just a diagnosis that her blood had been contaminated while being tested and she completely misunderstood, but left to find a new doctor anyway. Doctors have to do their best, most complete job under heavy time constraints, Groopman described it as spinning plates with people distracting you and always asking you for something at the same time. In that sense, doctors have to be able to have very good divided attention. As we discussed in lecture, there are tons of qualities that people look for in doctors, and knowledge is not even one of the top ones,, and great doctors have to encompass all of these, even after going through a flawed medical school system!

Emotions: Too Much or Too Little?

"If we feel our emotions deeply, we risk recoiling or breaking down. If we erase our emotions, however, we fail to care for the patient. We face a paradox: feeling prevents us from being blind to our patient's soul but risks blinding us to what is wrong with them (Groopman 45)." 

After reading Chapter 2 "Lessons from the Heart," in How Doctor's Think by Jerome Goopman, I am left asking myself how doctors should approach patients from an emotional standpoint. Groopman offers many examples where having no emotion or too much emotion can both lead to negative health outcomes for the patient.

On page 45, Groopman discusses that doctor's seek patient cooperation in order to feel successful  -- "Physicians like to succeed in their treatment, and an essential ingredient for that success is a patient's cooperation." Therefore, doctors do not want to help patients who do not want to help themselves, as their efforts will yield no results.  However, given Groopman's examples, it is evident that a doctor's quick judgement and influence of stereotypes can lead to terrible assumptions that lead to unwanted results. This is seen in the opening discussion of Anne Dodge, who is thought to be disregarding her doctor's order to have a caloric intake of 3,000 calories per day consisting of cereal, pasta, and bread, in order to cure her anorexia/bulemia. However, it takes careful examination by Dr. Falchuk to determine that her obedience to her doctor's orders actually caused her body to deteriorate even more as she had celiac's disease. The intial doctor's lack of emotion and frustration with Anne Dodge's "uncooperativeness" led to her misdiagnosis, as she was confined to her initial diagnosis without further investigation towards the real problem. 

However, on the other hand, we see in Groopman's discussion of his patient, Brad Miller, that having a very close relationship with a patient can lead to making decisions that can also lead to negative health problems. In this scenario, Groopman becomes close to cancer patient Brad Miller and does not fully examine him during rounds because he does not want to cause him any more discomfort. However, as Groopman later explains, his decision to spare him some discomfort led to an infection that caused Miller's white blood cell count to reach abysmally low levels. In this case, Groopman's concern for his patient led to him make a decision based on his friendship, rather than what was best for his patient.

After looking at these examples, it begs the question of how doctor's should approach treating their patients. Groopman ends the chapter by stating that doctor must remain neutral and unbiased in treatment. We often don't think of how a doctor's emotions can affect the care that they give their patient, but after Groopman's discussion and the class lecture, we ask ourselves "what makes a good doctor?" From these examples and those given in class, a good doctor is able to maintain an open mind, give unbiased care to all, disregard stereotypes, and be creative and not confined to what Groopman calls "paper cases" where medical students follow flow charts of symptoms that led to clear cut diagnoses.

Improving Medical Education

As a pre-med student I have always had my doubts about the way in which students who want to pursue medicine are prepared for medical school, and how those students who are accepted to medical school are actually chosen and trained. I've never been one to take too kindly to strict criteria or highly restrictive systems, so the whole process has always rubbed me the wrong way for various reasons. But Groopman's book really enforced my beliefs and showed me that my view on the issue is not just a result of my inherent rebelliousness, or my personal disdain for the medical school admissions and education process, but is actually a serious problem that needs to be addressed. 

Of course since I plan on pursuing a career in medicine I love the natural sciences and believe they are key for developing a solid foundation in medicine. But I don't think the way in which they are taught to students who plan on going into the medical field is at all beneficial in terms of building the foundation of becoming a great doctor. Pre-med students are constantly told that memorization is not the aim of the courses we have to take to move on to applying to medical school, but I've always felt that when it comes down to it, how much information a student can cram into their memories before an exam date is the only thing we are tested on (with very few exceptions). I think that in preparation for medical school, universities should place more value on developing critical thinking, reasoning and communication skills in students as opposed to pure knowledge retention, which would be a great step towards limiting medical errors caused by doctors who do not listen to their patients and are unable to take into account the fact that although medicine is a science, our bodies are very unique and cannot be reduced down to memorized diagnostic algorithms.

While reading How Doctors Think, two points stood out to me. The first is the importance of doctor engagement. Anne Dodge’s case in the introduction provides a particularly strong example in this regard. If anybody has ever seen multiple doctors for the same or related problem, you know how exhausting it can be to explain your condition to different people only to get the same response. It’s repetitive and frustrating; I can’t even imagine dealing with the situation for 15 years. It was shocking to me that, as it was described at least, what deviated her experience from her previous appointments was Dr. Falchuk’s open ended questions and willingness to listen. His approach to medicine should be the norm rather than the exception. This approach could make a significant difference in all realms of medical care. I can only imagine the difference it could make in psychiatry where a doctor is not merely asking questions that satisfy the conditions of depression, for example, but is asking to get a better picture of that patient’s lifestyle. As a result, that doctor will be able to make better recommendations for lifestyle approaches rather than just providing a prescription.

The second point that stood out to me is the importance for the patient to learn more about his or her (or of a loved one’s) condition. The example of Rachel Stein and her adopted daughter was a great illustration of this point. However, it’s still somewhat frustrating. While I think everybody should take a proactive approach towards improving his or her health, I doubt the practicalities of being able to evaluate his or her condition. Primarily, it takes time and effort, which many people really aren’t willing to invest when they have a specialist telling them everything they think they should know. Secondly, it can often be difficult to locate useful reading materials. The internet has certainly been helpful in making information about medicine and health more accessible, but it can also provide more confusion than guidance. I’m sure you’re familiar with the classic case: you google a symptom, or a couple of symptoms, and next thing you know you’re convinced you have a life-threatening condition. Regardless, the example of Rachel Stein emphasizes the idea that it can be good to question doctors and to not readily accept everything they say as being absolute.

On another note, I was listening to Pandora the other day when I had an advertisement to take a test for ADHD come up (See the picture below). I didn’t click on it, but I can imagine the questions were mostly universally applicable questions: difficulty concentrating on tasks, etc. I'm sure you're all familiar with similiar advertisements by now, just thought I'd share.

Questions Unanswered

Although I found How Doctors Think to be a compelling read, it left me with quite a few unanswered questions. Groopman illuminates varying reasons for medical errors in the U.S. medical system and indeed suggests helpful questions doctors and patients alike should ask themselves before making and being comfortable with a diagnosis. However, how are Groopman's suggested questions supposed to solve the issue with the system? To me it seems that the primary problem is that these facilities, unless very small practices with very small patient pools, operate similar to a factory. This concept is deeply entrenched in our system. We've already discussed how capitalism has seeped into medicalization and it's especially palpable in some hospitals and doctors' offices. For example, I go to a local ENT near my home in suburban NY once every couple of months. The practice is huge with over 15-20 doctors within it. I wait over 30 minutes, sit with the doctor for no longer than 7, and come back time and time again with the same issue (muffled hearing, vertigo.) It's not that my doctor doesn't care, or that he is so concrete a thinker he is unable to adequately fix my ear problems. It's that he's so overbooked and has such a small sliver of time to give me that he cannot adequately do his job to the best of his ability. This is an issue encompassing most systems in the U.S. There are many people requiring care and this factory-like model does the job quickly, but does it do it thoroughly?

I think Groopman had a great deal of insightful information and personal edge to add to his argument, but suggestions as how to modify the medical infrastructures in our country would have made for a much more compelling argument.