Thursday, April 1, 2010

The Doctor Is In

From now on, you can call me Dr. Monk--at least if you're one of my students. As of Tuesday, I've completed all requirements for a PhD in early American literature, which leads me to wonder--now that I am a doctor and NOT a graduate student any more (hooray!)--are there things that I should do differently? Fortunately, there is a book to answer my question: Jerome Groopman's How Doctors Think.

To be fair, Groopman's book is much more interesting than its title would suggest (which is saying something, since I found the title to be quite intriguing). It would be far more accurate to title his book, "How All People Think in Certain Situations, With Illustrative Examples from the Medical Profession." Groopman's basic point is simply this: because doctors are subject to lapses in judgment and the curious tricks that the human brain plays on us (more on this in a bit), patients need to be their own advocates (or have a relative/interested party present to be an advocate for them when they are too sick). The judgments of doctors, Groopman notes, are invariably colored by the same irrational influences that affect each one of us. Most notably, doctors are less likely to provide quality treatment to patients they dislike (for any number of reasons), who provoke "a visceral sense of disgust":

"That disgust pushes you away from him. Of course, as a doctor, it is your job to diagnose and treat him properly, but, consciously or subconsciously, you want to get the job over with and send such a man on his way. In particular, doctors consider people who seem not to be caring for themselves--alcoholics with cirrhosis, heavy smokers with end-stage emphysema, massively obese people with diabetes--as to some degree less deserving of their time and attention." (45)

This tendency to provide substandard care for people that doctors dislike shouldn't be surprising--no matter how much a doctor might try to eliminate that tendency. The most important and meaningful insight from Groopman's book (for me) was the part that heuristics play in medical diagnoses. If you watch a show like House

in which experienced doctors (read medical geniuses) teach interns how to recognize rare (impossible) diseases and medical conditions, you invariably see the older physician lead the students through a series of questions and answers: "What are the patient's symptoms?" "What conditions match those symptoms?" "What sort of tests would you run to confirm that the patient has these conditions?" Groopman confirms that this is exactly the way in which new physicians are trained--yet he also explains that research on the diagnostic process of doctors suggests that none of the experienced physicians who lead these catechetical exchanges actually uses such a logical process to diagnose their patients. Instead they use something called heuristics.

Heuristics--at least in this context--refers to the sort of immediate, intuitive understanding that Malcolm Gladwell discusses in Blink

(which is a good book, but it is really a book about race, not psychology, and since race doesn't exist, I've got issues with some of its implications). In other words, most doctors diagnose you without thinking through your symptoms and the vast store of knowledge imparted by medical school in any sort of a systematic way. Instead, what they do is recognize your illness. They've seen your type before; you have _______. In this sense, doctors are a lot like chess players. The most reliable indicator of a chess player's skill is the number of games s/he has played. Even computers can't think through all of the steps ahead in a logical fashion and guarantee a victory--there's just too much calculation involved. Instead, computers--and the best chess players--have a sort of pattern recognition system in their head. They beat you not because they can "see 10 moves ahead" but because they've played a similar game before and they recognize the way in which the pieces are arranged, the likely outcomes.

Doctors (and all of us) have the same sort of pattern recognition system, and it's a good thing they do. If doctors had to systematically think through symptoms and match them to diseases every time they examined a patient, the medical system would be even MORE inefficient than it already is. For the most part, this heuristic approach to diagnosis is a good thing--unless you're the patient that doesn't fit the pattern. Groopman's most striking example is that of a forest ranger, a wiry, fit man who has all the classic symptoms of a heart attack but who is released without treatment because he looks fit and is in his forties. the doctor didn't consider heart attack as a possibility because the patient didn't fit his experience of what a heart attack patient looks like.

So--the next time you're at the doctors and you think you might not fit the pattern, speak up. Ask questions. Be your own advocate. And if you come to Dr. Monk's class late and sleep through, be sure to let him know that you aren't hung over, that a family member just died, and you were at the hospital all night holding his/her hand. Because I think like a doctor now--just like the rest of you.


Jo Jo said...

Congratulations! I have been wondering how it went. Yeah! Alana must be sooo excited. It's too bad that this moment is always dimmed because a job is lacking. Good luck

Ben Hutchins said...

Whahoo indeed! Great job Zach - when do you walk . . . so to speak?

Aaron H. said...

You've passed your oral board? If not, I'll hold on the Doc. But you're close!

Jenny said...

By the way--I was interested in your brief comments on Blink by Malcom Gladwell. I wanted to read this, but maybe now I won't. My reading time is so valuable to me! I listened to him speak on a TED segment, and it was impressive.

Becky said...

First of all...CONGRATS my brother. I'm so proud of you. Secondly, I found this post really interesting to read because I LIVE in the medical world. Thankfully I do NOT think like a doctor but as a mother and thankfully the doctor's listen to ME rather than trying to diagnose
Heuristically. (is that a word?) Anyway, I too was interested in the book would you recommend it? Have you read any of his other ones? Love you brother.

The Renaissance Man said...

ahh how lucky i am to have you for an uncle