How Doctors Think (35 page)

"Is it possible I have more than one problem?" We are taught in medical school and residency to be parsimonious in our thinking, to apply Ockham's razor, to seek one answer to a patient's many complaints. Usually this turns out to be the correct approach. But, again, not always. Posing this question is another safeguard against one of the most common cognitive traps that all physicians fall into: search satisfaction. Your question about multiple causes for your problems should trigger the doctor to cast a wider net, to begin to ask questions that he didn't pose before, to order tests that might not have seemed necessary based on his initial impressions. You might have acid reflux but also angina—both are common; or acid reflux and a tear in your aorta, a rarer condition. As we saw in the Introduction, Dr. Myron Falchuk reframed Anne Dodge's case to encompass two pictures, and, by doing so, saved her life.

Sometimes I come to the end of my thinking and am not sure what to do next. This may mean I made a cognitive error and don't realize it. In retrospect, analyzing my own misdiagnoses, sometimes I failed to ask the right questions, failed to find the abnormality during the physical examination, failed to identify a key bit of data because I didn't order the right tests. I had fallen unawares into a cognitive trap. At such times, ego can form another cognitive pitfall. I have learned to say to my patient, "I believe when you say something is wrong, but I haven't figured it out." And since I can't figure out your problem, I continue, I should send you elsewhere, to a physician with an independent mind who likes to tackle complicated cases. The internist caring for Anne Dodge didn't want to do this because she believed there was nothing new to find; she had exhausted all possibilities. If a loved one had not insisted, Anne Dodge would still be suffering, or worse.

When a patient tells me, "I still don't feel good. I'm still having symptoms," I have learned to refrain from replying, "Nothing is wrong with you." The statement "Nothing is wrong with you" is dangerous on two accounts. First, it denies the fallibility of all physicians. Second, it splits the mind from the body. Because sometimes what is wrong is psychological, not physical. This conclusion, of course, should be reached only after a serious and prolonged search for a physical cause for the patient's complaint.

The lingering stigma that exists in medicine, and in the larger society, about psychological distress and its ramifications through the body, stands as a roadblock to relieving the pain and misery of so many patients. Many doctors, as we have seen, dislike patients whom they stereotype as neurotic and anxious. These patients pose one of the greatest challenges to even the most caring physicians. They may relate their story in a scattershot way, hypersensitive to every ache and pain, and make it difficult for the doctor to focus his mind so that he finds the tumor in the breast or the nodule in the thyroid gland. A patient's insight into his own thinking and emotional state can be enormously helpful to a physician. Recall how one of Karen Delgado's patients told her that she knew she was a little bit "kooky," but that her complaints should not be ignored for this reason. Sometimes, of course, patients are not kooky, just terrified, but are labeled hypochondriacs by the doctor. A close friend in Los Angeles, a hard-driving businesswoman in the entertainment industry, repeatedly told her doctor about the aches in her breasts. Her mammogram was read by the radiologist as normal, and her persistent complaints were dismissed. She was told "Nothing is wrong with you." Her aches, the doctor said, were caused by stress. Only after going to another doctor, who performed more tests, was the cancer identified. Her diagnosis was delayed by nearly two years, and the cancer was found in more than a dozen lymph nodes.

We've all heard stories like this, and patients and physicians alike dread them. But if, in another woman's case, it turned out the discomfort in her breasts was not cancer but the result of psychological distress, the statement "Nothing is wrong with you" would still be misguided. She should be reassured and, if her distress and symptoms continue, be referred to a psychologist or psychiatrist who can help her.

When I was undergoing tests to diagnose the pain and swelling in my right hand, one of the surgeons sent me for a bone scan. This scan evaluates all of the bones in the body, not just those in the wrist. The radiologist who looked at the scan saw some spots over my ribs. The surgeon called me at home in the evening. I was alone; my family was away on a skiing trip. The surgeon said that there was no rush to operate on my hand because the spots on the scan looked like metastatic cancer in my ribs. I generally think of myself as reasonably well put together psychologically, but within moments my chest began to ache. When I touched my ribs, they hurt. As an oncologist, I know it is unlikely my bones would be riddled with tumors without any symptoms. But, at that moment, I was suddenly not a doctor. I was completely a patient. My mind froze. I desperately tried reaching my wife. After several hours, I found her. Pam told me not to panic. She said I should go for further x-rays the next morning. Her words, that the radiologist might be wrong, did not hold sway. I spent a sleepless night, imagining a slow death from an incurable cancer. Despite all my training and experience, I was overcome by fear. The pain in my chest was real.

I was first in line the next day and had a series of x-rays that showed my ribs were normal. A second radiologist looked at the bone scan and concluded that it had been overread, that there were no spots. It took several hours until the ache in my chest fully subsided and my ribs were no longer tender to my touch.

I learned two lessons from this episode. First, after shocking news was delivered in a blunt and absolute way, I needed someone to guide me, to provide balance, to raise doubt, to highlight uncertainty—to think for me and with me—because even though in another setting I would intellectually consider that the spots might be artifacts, I couldn't grasp it viscerally. Second, I experienced the power of the mind over the body, of psychosomatic symptoms.

Of course, persistent but elusive symptoms sometimes are not psychosomatic, and finally a correct physical diagnosis is made. The doctor treats you, but you don't get better with the treatment. Before launching into a new therapy, the physician should talk with you and consider, as Dr. JudyAnn Bigby teaches, the context—where and how and when you are taking the therapy. Recall the study of forty-five doctors in California caring for more than nine hundred patients. Two thirds did not tell the patients either how long to take the new medicine or what its side effects could be. Nearly half failed to specify the dose of the drug and how often it should be taken. It is not enough to assume that a pharmacist or other health professional will fill in these gaps. There must be a clear mutual understanding between you and your doctor about the therapy, its rationale, and its specifics. Furthermore, as Bigby emphasizes, the doctor who pays attention to your social setting will think about the nonmedical reasons the treatment seems to be failing.

There can be other considerations as well. Karen Delgado told me that, although medicines are now color-coded, miscommunication can still occur. Delgado was concerned when an elderly female patient with an underactive thyroid was not responding to treatment. "Check the pills that the pharmacist gave you," Delgado said. "Are they purple?" The woman replied, "Yes, they're purple." For awhile Delgado couldn't figure out what was wrong, why the woman was still sluggish. Then she asked the woman to bring in all her medications. It turned out one pill containing 175 micrograms of thyroid hormone was one shade of purple, and another pill containing 75 micrograms was a slightly different shade of purple. The patient was in no position to distinguish between subtle shades of purple.

In other instances, the treatment, although correctly prescribed and taken, simply doesn't work. Each of us is unique in our biology, and there can be important differences in both the side effects we suffer and the benefits we gain from the same medication. We can share a single illness but not share its remedy, despite receiving the same drug or undergoing the same procedure. How long to persist with a treatment that has not quickly worked, and which treatment to choose as the second option, reflect the science and the art of medicine. Dr. Stephen Nimer immediately changed George Franklin's chemotherapy regimen, while other oncologists wanted to continue the protocol. Recognizing failure early and switching therapies extended Franklin's life by years.

Good treatments are the products of a robust pharmaceutical industry, and many diseases that were once incurable have now been brought to heel with new medicines. But when a physician and patient make decisions about treatment, they should be mindful of the benefits and risks, the needs and goals they share. Their choices should be free of the influences of financial gain and the biases introduced by corporate marketing.

All of this takes time, and time is the greatest luxury in today's medical care. Those who see medicine as a business rather than a calling push for care to be apportioned in fixed units and tout efficiency. A doctor's office is not an assembly line. Turning it into one is a sure way to blunt communication, foster mistakes, and rupture the partnership between patient and physician. A doctor can't think with one eye on the clock and another on the computer screen. But a thinking doctor does need to allot his time wisely. Problems that are well defined and straightforward can be addressed with clarity in fifteen or twenty minutes, and a patient and family can leave the visit feeling informed and satisfied. Complicated problems cannot be solved in a rush. The inescapable truth is that good thinking takes time. Working in haste and cutting corners are the quickest routes to cognitive errors.

For three decades practicing as a physician, I looked to traditional sources to assist me in my thinking about my patients: textbooks and medical journals; mentors and colleagues with deeper or more varied clinical experience; students and residents who posed challenging questions. But after writing this 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 the 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.

Acknowledgments

T
HREE YEARS AGO
, when I returned from rounds filled with questions about how doctors think, I first shared my desire to find out with Pam, my wife and soul mate. It is a gift to live your life with a person you love who is wiser than you. As a consummate physician, Pam brought to bear knowledge and insight into clinical judgment and misjudgment that had escaped me. As the wife of a man who had been a desperate patient, as a mother of children who had been ill, and as the daughter of still vigorous but aging parents, Pam helped me see physicians' thinking and behavior from inside and outside our shared professional world. Her contributions were extraordinary, and her imprint is on every page of this book.

Suzanne Gluck at the William Morris Agency is more than my agent; she is a friend and comrade and advocate. Her keen intelligence and constructive criticisms were vital in refining the project and finding the best home for it.

Eamon Dolan, my editor at Houghton Mifflin, pushed me to probe deeper and explore more widely the questions raised in this book. He reined me in with an expert hand when I went astray. His talent in sharpening ideas and sculpting prose is something to behold. The team at Houghton Mifflin worked with unique intensity and commitment, and I am deeply indebted to Bridget Marmion, Lori Glazer, Anne Seiwerath, Sasheem Silkiss-Hero, Larry Cooper, and Janet Silver.

Youngsun Jung, my assistant of twenty-one years, never flinched from the immense burdens of fact-checking, manuscript preparation, and deadlines. She brings more than diligence to each project; Youngsun applies her intelligence to the ideas that I seek to express.

I am fortunate to have friends who lead literary lives and who generously gave their time and expertise, offering critiques that were always to the point. Foremost among these is Keith Johnson, a wordsmith par excellence. Jonathan Alter, who emerged strong and ready to reengage the world after a bone marrow transplant for lymphoma, and Emily Lazar, an accomplished TV producer, not only expressed enthusiasm for the project but also introduced me to physicians and surgeons they know around the country, some of whom appear in these pages. Although I've been writing regularly for more than a decade, I still see myself as primarily a physician and scientist, and I rely on friends who are pros for guidance and feedback. In this project I turned to Ron Chernow, Nora Ephron, Ann Godoff, Annik LaFarge, Norman Manea, Tim Noah, Francine Pascal, Nick Pileggi, Dorothy Rabinowitz, Frank Rich, David Sanford, Alvin Sargent, Stuart Schoffman, Andrew Sullivan, Melanie Thernstrom, Elizabeth Weymouth, Sarah Elizabeth Button White, Jay Winik, Alex Witchel, Rafael Yglesias, and Laura Ziskin.

While writing this book, several patients whom I counted as friends encouraged me and taught me lessons about communication, critical thinking, and the paramount importance of a person's values and spiritual needs. Marjorie Williams confided that she was keeping a running list of all of the obtuse remarks physicians had made to her, but wouldn't disclose how many times my name and words appeared in her compendium. Margaret Joskow, an elegant artist, explained how honesty is key to caring. When I visited Margaret in her hospital room, she rewarded me with a cache of pens with a wide grip to assist my injured hand; I still use them. Betty Tzafrir was an
ayshet chayil,
a woman of valor, who made sure her doctors thought about the impact of her illness on her family, not just on her. Jim Young, an ex-marine with a sharp sense of humor, wanted to know what I was thinking without any filter between us so he could deploy his forces strategically; Jim ended each conversation with "Semper Fi." Valerie Chernow, a professor of Romance languages, showed me the power of words in sustaining grace and poise despite dire circumstances, and reminded me of the value of honoring the wishes of a person in her last days. Barry Bingham, a retired publisher, made sure that we spoke first about the day's headlines before discussing his symptoms; he was telling me that he remained who he was despite his malady. As his illness overtook him, his dedicated family served as his interlocutor and taught me about the role of loved ones in making a patient's most difficult decision. Julia Thorne was writing a novel, and reminded me time and again that narrative is the most compelling form of learning and teaching. Ruth Gay sustained
joie de vivre
in the face of sustained uncertainty, invoking Yiddish aphorisms that capture the fun and folly of life. Johnny Apple, with the discerning mind of a political reporter, posed hard questions and made sure that the answers from his multiple medical sources made sense. Johnny told me that only he, a Lutheran from the Midwest, knew the best kosher restaurant in the cosmos, and that my incentive to finish the book was dinner at this unnamed place. There are many others, and I hold them in my heart. If indeed there is a heaven, I hope they can hear my thanks.