Physician, Know Thyself

Review of How Doctors Think by Jerome Groopman

Michael Krasner
1 September 2007

How Doctors Think
by Jerome Groopman
Houghton Mifflin, 2007; 320 pp.; $26 (cloth)

The essence of medicine is the intimate, authentic, and mysterious meeting of two human beings, physician and patient, with the intention to relieve suffering. Both bring their entire selves, with all their levels of transparency or opaqueness, to this encounter.

The ability of the physician to listen deeply to the patient and, as a result, respond with insight and empathy to the patient’s dilemma, is one of the core elements in the Hippocratic relationship. But this vital ability is threatened by many forces at work in the contemporary health care system. Pressures related to the delivery of services, safety, financing, and unrealistic expectations about what modern medicine can provide, coupled with the demand for more compassionate and personalized health care, are leading to unprecedented levels of burnout and demoralization among practitioners and endangering the quality of care. Indeed, many physicians are leaving this esteemed and time-honored profession.

The suffering dimension in health care sits at the center of medicine and is experienced on both sides of the physician-patient relationship. This dimension has not been widely addressed within medical education, nor is it part of the ongoing process of reflection and continuing education in most busy clinicians’ lives. Once they are out of training, clinicians aren’t encouraged to focus on the nature of their relationship with their patients or on their relationship with themselves. Investigation into the nature of one’s own mind is foreign, maybe even frightening, to many of today’s physicians. As Annie Lamott writes: “My mind is like a bad neighborhood. I try not to go there alone.”

If this is true for the practicing physician, help is on the way, from the very person he or she is trying to help—namely, the patient. Dr. Jerome Groopman, in his new book, How Doctors Think, provides physicians and patients with a road map for exploring the nature of the health practitioner’s mind. He demonstrates ways in which the medical relationship, when based on trust and mutual respect, can be truly two directional, a bond that returns each partner back to his or her true self. As he writes in the conclusion of the book:

I realized that I can have another vital partner who helps improve my thinking, a partner who may, with a few pertinent and focused questions, protect me from a cascade of cognitive pitfalls that cause misguided care. That partner is present in the moment when flesh-and-blood decision-making occurs. That partner is my patient or her family member or friend who seeks to know what is in my mind, how I am thinking. And by opening my mind, I can more clearly recognize its reach and its limits, its understanding of my patient’s physical problems and emotional needs. There is no better way to care for those who need my caring.

Groopman leads the reader through a series of clinical examples and personal experiences that illustrate how the majority of medical errors are due to flaws in physician thinking. He illustrates how language and communication, with all the modern advances in technology and treatments, still form the bedrock of clinical practice. Entering the patient’s world through his or her story requires the use of both intellect and intuition, an ability that is fostered by years of training and experience, attention to detail, active listening, and psychological insight. These are all core competencies of the self- effective health care practitioner. Unfortunately, many of these qualities that constitute embodied self-awareness seem to be missing from the skill set, or pharmacopoeia, of many physicians.

Most people assume that medical decision-making is a rational and objective process, one that is free from the intrusion of emotion. They may be surprised to learn of the effect of a doctor’s feelings on the medical experience, and how, when unexamined, unrecognized, or unaccepted, these feelings can influence the course of a patient’s illness and life. Take, for instance, the case Groopman shares of a woman whose physician feels an aversion toward her, assuming her illness is psychosomatic. That physician is likely to fall into the trap of premature closure in his decision-making. A different doctor, however, one with the ability to approach this patient with curiosity and a beginner’s mind, may be able to produce a completely different (and far more satisfactory) outcome.

Groopman skillfully uncovers a number of cognitive errors common to the busy medical practitioner. The “representativeness error,” in which thinking is guided by prototypes and other possibilities aren’t considered, corresponds to the difficulty people have in bringing fresh eyes to a seemingly familiar situation. In the “attribution error,” a patient is defined by a negative stereotype, such “alcoholic” or “smoker.” These are people who are thought to take poor care of themselves, and thus are treated as less deserving of the clinician’s time and attention.
Alternatively, decision-making that is driven primarily by a physician’s affections may result in an “affective error.” “Patients and loved ones swim together with physicians in a sea of feelings,” Groopman writes. “Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents.” The ability to recognize feelings of aversion and attraction can act as a warning for the physician against the tendency to commit these types of errors.

Groopman illustrates other cognitive errors via case discussions, as well as expert opinion on medical decision-making, neuroscience, and physicians who exemplify the qualities of self-awareness, curiosity, openness, and professionalism required to be of true service to their patients. Several themes emerge, especially the importance of knowing how the physician knows what he or she knows and of regularly questioning assumptions made about that knowledge.

Knowing the limitations of knowledge—the presence of uncertainties and paradoxes, the unpredictability of outcomes, the pressures of conformity and orthodoxy in medicine—is crucial to avoiding cognitive errors. The self-aware practitioner can share some of these difficulties with patients in a sensitive and open manner. And, Groopman maintains, the patient, by questioning openly and seeking understanding, can help the physician recognize the threats posed by misguided thinking, making possible more effective medical care.

The Hippocratic oath, one of the oldest formal vows in recorded history, asks the physician who is about to take on the responsibilities of medical practice to commit to something that extends beyond the self. In one modern version, the covenant includes the following affirmations:

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over-treatment and therapeutic nihilism…I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug…and I will not be ashamed to say, “I know not.”

Reviewing Groopman’s litany of cognitive errors that physicians are prone to, we may feel that the fulfillment of this vow is as impossible and overwhelming as the bodhisattva vow (it entered the world around the same time), which pledges one to liberate the innumerable sentient beings and to penetrate the immeasurable dharma gates. So what is available to the modern physician that may help meet these ideals, however difficult to attain, with integrity, honesty, and self-compassion? Groopman points us in the direction of self-awareness. While the operative scientific paradigm of modern medicine is the third-person objective perspective, the Buddha offers a more compassionate and gracious way—first person knowing through self-discovery—that seemingly is required for medicine actually to work and for medical practitioners to fulfill their oath.

Within the four establishments of mindfulness, the busy physician may find a practical place to begin. Through the cultivation of these mindfulnesses, the busy physician can find clues to the self and to the other, as well as to the aspects of inter-being that not only set the intention of the medical encounter but also provide boundless information and the basis for right action.

The awareness of the body brings the clinician into close contact with the sensate world where perception begins. Practically speaking, noticing the contact of the hand on the exam-room door as one turns it to enter brings the physician into the real world of him or herself and of the patient. Likewise, attention to the tones of feeling that arise during the medical interview and exam, with appreciation of their tendency to move one’s attention toward or away from the object of consideration, as well as awareness of the boredom that may surface, provide vital information about how one is responding to the data taken in through the senses.

Clinicians’ understanding of themselves is deepened every time they take note of their senses and become aware of how their thoughts are forming. The knowledge acquired through this first-person inquiry is illustrated skillfully by Groopman: If each time one hears the sound of hoofbeats one forms thoughts only of horses and not of zebras, there is a risk of excluding other explanations for the sounds. This simple example serves as a reminder to the busy clinician of the tendency for the thought formations to lead rather than to serve. When that happens, the clinician may be led away from less common, although very possible, alternative diagnoses.

Finally, mindfulness of phenomena (dharmas), as in the objects of mind, returns the practitioner back to the truth of the patient’s dilemma and the suffering inherent in the separation felt by both the patient and the physician. This leads to the very real experiences of interdependence, impermanence, and compassion. This is no doubt experienced by every physician through regular contact with aging, illness, and death. The awareness brought about through the application of mindfulness leads the physician and patient together toward the uncovering of truth, the recognition of the cognitive errors inherent in the medical encounter, their prevention, and ultimately toward the relief of suffering.

Marcel Proust said that the real voyage of discovery is not in seeking new landscapes but in having new eyes. The physician’s task is one of discovery of the patient’s illness, of the patient’s sense of meaning and coherence, of the patient’s being. In How Doctors Think, Groopman shows us the ways in which the Hippocratic relationship is fraught with hazards and unseen dangers, many of them a result of the cognitive errors in the unexamined mind of the physician. But through the cultivation of self-awareness and the opportunity to realize the interconnectedness between physician and patient, new eyes and new vision can form, helping both physician and patient to see more clearly into this multifaceted, awesome, and immensely beautiful crystal of life.