How Doctors Think, By Jerome Groopman M.D.

by Polly Cleveland

Two years ago, an urgent call from my father: My mother, then 84, was ill. Gray skin, sunken eyes, confused. At the hospital, her blood tests showed abnormally high levels of calcium. She had calcium poisoning. Calcium poisoning? Six weeks prior, it turned out, the family doctor had instructed her to start taking calcium tablets and drinking three glasses of milk a day. Unknown to him, she was nibbling Tums all day for heartburn; little rolls of Tums nestled in every drawer in the house.

Jerome Groopman might better have titled his bestseller, "How Doctors Screw Up." Despite those professional white coats, doctors make the same kinds of cognitive errors as the rest of us. To begin with, they stereotype patients from first impressions. Groopman cites a case of a fortyish forest ranger with chest pains, who looked so fit and healthy that the examining doctor dismissed the possibility of an impending heart attack. Doctors apply rules of thumb: old women lose bone density, so my mother's doctor ordered calcium. Doctors jump to conclusions based on their particular specialties or their recent experience. Groopman himself saw six different doctors for a wrist injury and got four different diagnoses. Doctors pay closer attention to patients they like than to those they don't--especially those with apparent psychosomatic disorders. Groopman presents a young woman who nearly died after a whole series of doctors dismissed her complaints of intestinal pain, and attributed her weight loss to anorexia.

Groopman takes a dim view of pharmaceutical industry sales tactics, notably the strategy of turning the natural aging process into a disease. Drug companies learn from pharmacies exactly how much of their products each doctor prescribes, enabling them to reward big prescribers. Groopman describes an industry rep harassing a top endocrinologist who refuses to prescribe his brand of testosterone. "You will write three prescriptions this month." But many doctors yield to incentives or pressure, which they also feel from their patients--inspired by advertising. A recent report in the New England Journal of Medicine found that 94% of the 1,662 physicians surveyed had accepted gifts or money from pharmaceutical or medical device manufacturers. Over three quarters had accepted meals or samples; 35% had accepted reimbursements for attending drug company "educational" conferences--usually held at resorts. (WSJ 4/26/07.)

My parents each take over a dozen different pills a day. Sometimes I help them fill their weekly dispensers: the ones for getting up, for breakfast, for dinner, for bedtime. Tiny white pills, fat grey pills, clear golden capsules, skinny red lozenges, thick purple lozenges, round yellow tablets, cream octagonal tablets and flat pink tablets shaped like little shields. Names to conjure by: Zocor, Spironoloactone, Lisinopril, Lasix, Paroxetine, Protonix, Fossamax, Ecotrin, and Ambien. The doc once prescribed testosterone for my father; fortunately he had the good sense to Google it and learn it would aggravate his prostate.

Groopman admonishes doctors to look out for cognitive traps, and even more important, listen carefully and respectfully to patients. He advises us, the patients, to ask questions, do our own research and don't hesitate to consult other doctors.

After my mother's bout of calcium poisoning, I checked her medications on the web, and then with my own doctor. Half were inappropriate and possibly harmful, especially since she has borderline kidney failure. I wrote her doctor a polite letter, questioning the meds. I also suggested he might refer her to a kidney specialist. A scribbled note came back: the medications were "necessary" and he would refer her "only if she requests it." Of course my parents wouldn't dream of asking tough questions or requesting a referral--that would be rude.

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5/17/2007 09:46:00 PM