Saturday, May 5, 2007

Limits of technology, electronic medical records - How Doctors Think, By Jerome Groopman, MD, Houghton Mifflin Company, 2007


My Blog Book Review

Jerome Groopman, MD, a 1976 medical school graduate, oncologist at Massachusetts General Hospital, professor of medicine at Harvard Medical School, and staff writer at The New Yorker, has written a book on how doctors arrive at diagnoses.

Doctor Groopman is a skilled essayist. In essence, this book consists of essays on doctors’ cognitive thinking. It has ten chapters and features case studies on why doctors make errors. Groopman speaks of his own mistakes and those of others. He says mistakes come from thinking too narrowly, not always listening carefully to patients, rushing too much , relying on “gut” decisions, and not considering “worst” options.

Here sums up his career and how he feels:

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 and more varied clinical experiences; 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 a 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.”

The book’s strengths are clarity and eloquence, relevant case studies, an epilogue on questions patients should ask doctors, end notes on sources and what he learned from them, and stress on medicine as an art and a science.

The book’s problems are two-fold:

1, Groopman’s deep skepticism and reluctance to recommend diagnostic-support or computer-aided information systems;

2. Groopman’s lack of answers on how doctors can adapt his thinking to primary care practices outside the medical center setting where doctors may have to see two dozen patients each day to make ends meet.

His comment on the latter is:

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.”

In an ideal world, i.e., a major teaching center backed by residents and other support systems, Groopman’s thinking makes sense, but for a busy practitioner, seeing 25 to 30 patients a day, what’s the option?

Groopman gives scant attention to information technologies that enrich patient-doctor relationships by suggesting diagnostic alternatives, place patients’ past health record at the doctor’s fingertips, and reduce mistakes of omission and commission. To impart, gain, share information, and to partner with patients, IT will be vital – from the physician, as well as the patient’s side of the partnership.The book provokes thought, but offers few answers to practitioners on the ground in non-academic settings.

As a roadmap for exploring doctors’ thought patterns, and the beartraps, pitfalls, potholes, and necessary detours along the path towards the right diagnosis, Groopman’s book is a tour de force.

1 comment:

Val said...

Excellent review. You might also like Dr. Dinosaur's perspective: http://dinosaurmusings.blogspot.com/2007/05/how-doctors-think-disappointment.html

The disconnect between "town and gown" is ever increasing...