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how doctors think

Critical Thinking. What’s That?

No, thanks. I don't want my doc to mis-diagnose me.

No, thanks. I don’t want my doc to mis-diagnose me.

I visited my doctor the other day. Expecting a bit of a wait, I took along Critical Thinking, a textbook for one of my courses. When I walked into the doctor’s office, he read the title and said, “Hmmm … critical thinking. What’s that?” I thought, “My doc just asked me what critical thinking is. This can’t be a good sign.”

I quelled my qualms, however, and explained what I teach in critical thinking class. He brightened up immediately and said, “Oh, that’s just like How Doctors Think.” I pulled out my Kindle and downloaded the book immediately. Understanding how doctors think might actually help me get better medical care.

So how do they think? Well, first they use shortcuts. They generally have way too much information to deal with and use rules of thumb called heuristics. Sound familiar? I’ve written several articles about rules of thumb and how they can lead us astray. (Just look for “thumb” in this website’s Blog Search box). So, the first answer is that doctors think just like us. Is that a good thing? Here are some errors that doctors commonly make:

Representation error — the patient is a picture of health. It’s not likely that those chest pains are a cause for concern. With this error, the doctor identifies a prototype that represents a cluster of characteristics. If you fit the prototype, fine. If not, the doctor may be diagnosing the prototype rather than you.

Attribution error — this often happens with negative stereotypes. The patient is disheveled and smells of booze. Therefore, the tremors are likely caused by alcohol rather than a hereditary disease that causes copper accumulation in the liver. That may be right most of the time but when it’s wrong, it’s really wrong.

Framing errors — I’ve read the patient’s medical charts and I see that she suffers from XYZ. Therefore, we’ll treat her for XYZ. The medical record forms a frame around the patient. Sometimes, doctors forget to step outside the frame and ask about other conditions that might have popped up. Sometimes the best approach is simply to say, “Let me tell you my story.”

Confirmation bias — we see things that confirm our beliefs and don’t see (or ignore) things that don’t. We all do it.

Availability bias — if you’re the 7th patient I’ve seen today and the first six all had the flu, there’s a good chance that I’ll diagnose you with flu, too. It just comes to mind easily; it’s readily available.

Affective bias — the doctor’s emotions get in the way. Sometimes these are negative emotions. (Tip: if you think your doctor feels negatively about you, get a new doctor). But positive emotions can also be harmful. I like you and I don’t want to cause you pain. Therefore, I won’t order that painful, embarrassing test — the one that might just save your life.

Sickest patient syndrome — doctors like to succeed just like anyone else does. With very sick patients, they may subconsciously conclude that they can’t be successful … and do less than their best.

The list goes on … but my space doesn’t. When I started  the book I thought it was probably written for doctors. But the author, Jerome Groopman, says it’s really for us laypeople. By understanding how doctors think, we can communicate more effectively with our physicians and help them avoid mistakes. It’s a good thought and a fun read.

Thinking Outside the Frame

Make way!

Make way!

An ambulance, racing to the hospital, siren blaring, approaches an intersection. At the same time, from a different direction, a fire truck, racing to a fire, approaches the same intersection. From a third direction, a police car screeches toward the same intersection, responding to a burglary-in-progress call. From a fourth direction, a U.S. Mail truck trundles along to the same intersection. All four vehicles arrive at the same time at the same intersection controlled by a four-way stop sign. Who has the right of way?

The way I just told this story sets a frame around it that may (or may not) guide your thinking. You can look at the story from inside the frame or outside it. If you look inside the frame, you’ll pursue the internal logic of the story. The three emergency vehicles are all racing to  save people — from injury, from fire, or from burglary. Which one of those is the worst case? Which one deserves to go first? It’s a tough call.

On the other hand, you could look at the story outside the frame. Instead of pursuing the internal logic, you look at the structure of the story. Rather than getting drawn into the story, you look at it from a distance. One of the first things you’ll notice is that three of the vehicles belong to the same category — emergency vehicles in full crisis mode. The fourth vehicle is different — it’s a mail truck. Could that be a clue? Indeed it is. The “correct” answer to this somewhat apocryphal story is that the mail truck has the right of way. Why? It’s a federal government vehicle and takes precedence over the other, local government vehicles.

In How Doctors Think, Jerome Groopman describes how doctors think inside the frame. A young woman is diagnosed with anorexia and bulimia. Many years later, she’s doing poorly and losing weight steadily. Her medical file is six inches thick. Each time she visits a new doctor, the medical file precedes her. The new doctor reads it, discovers that she’s bulimic and anorexic and treats her accordingly. Finally, a new doctor sets aside her record, pulls out a blank sheet of paper, looks at the woman and says, “Tell me your story.” In telling her own story, the woman gives important clues that leads to a new diagnosis — she’s gluten-intolerant. The new doctor stepped outside the frame of the medical record and gained valuable insights.

According to Franco Moretti, similar frames exist in literature — they’re called books. Traditional literary analysis demands that you read books and study them very closely. Moretti, an Italian literary scholar, calls this close reading — it’s studying literature inside the frame set by the book. Moretti advocates a different approach that he calls distant reading….”understanding literature not by studying particular texts, but by aggregating and analyzing massive amounts of data.” Only by stepping back and reading ourside the frame, can we understand “…the true scope and nature of literature.”

In each of these examples we have a frame. In the first story, I set the frame for you. It’s a riddle and I was trying to trick you. In the second story, the patient’s medical record creates the frame. In the third, the book sets the frame. In each case, we can enter the frame and study the problem closely or we can step back and observe the structure of the problem. It’s often a good idea to step inside the frame — after all, you usually do want your doctor to read your medical file. But it’s also useful to step outside the frame, where you can find clues that you would never find by studying the internal logic of the problem. In fact, I think this approach can help us understand “big” predictions like the cost of healthcare. More on that next Monday.



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