Communicate--Think--Diagnose--Communicate

“Tell me, Curmudge, why we are talking about how physicians think, diagnose, and communicate with patients, some of whom may be disingenuous (hey, I looked up the word).”

“To lead the list, Jaded Julie, it will make us better patients. It will also help us be more effective at enlisting physicians in the hospital’s Lean cultural transformation. We can better collaborate with the docs if we understand them.”

“Okay, let’s get under way. I assume like last week that all quoted material is from Dr. Groopman’s book (1).”

“Let’s begin by acknowledging that not all communication is verbal. At first sight, the patient looks at the physician and thinks to herself, ’Am I going to like and trust this person?’ And the doctor begins his diagnosis before the first word is spoken. If his nose is good, he can immediately sense that the patient is a smoker. Of course, sometimes these first impressions can lead the doctor down the wrong path. It’s hard to believe a person who appears ruggedly healthy is seriously ill (perhaps he is just here to get a flu shot). One might first suspect emphysema in a heavy smoker and cirrhosis in an unkempt boozer. Groopman calls these types of first impressions—when they turn out to be wrong—‘representativeness errors.’ These may also be called ‘attribution errors,’ when the patient fits a negative stereotype.”

“Groopman mentions some other types of ill-advised shortcuts leading to incorrect diagnoses. ‘Availability means the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind’ (most of my other patients today have the flu, so this patient must have it too). ‘Anchoring’ occurs when the physician doesn’t consider multiple possibilities but firmly latches onto a single one. In ‘confirmation bias’ one sees only the expected landmarks and neglects the others. Curmudge, all of these errors resulted from docs’ taking shortcuts. Does that mean that they are a no-no?”

“Julie, a chance encounter with The Happy Hospitalist blog (2) convinced me of the multitude of mental data points that must be considered in making an accurate diagnosis. The only way this can be achieved in a reasonable time is to take appropriate shortcuts—each based on sound clinical judgment—among the possibilities. Doctors are taught to be methodical, but they must learn to be efficient. This is what differentiates a physician from a technician with a checklist or an algorithm.”

“Then according to Groopman, ‘The key cues to the patient’s problem—from medical history, physical exam, x-ray or lab tests—coalesce into a pattern that the physician recognizes as a specific disease or condition.’ But, Curmudge, what if they don’t?”

“That may be a situation where the physician should listen to the little voice that says, ‘Don’t just do something; stand there.’ If the doctor senses that missing pieces are leaving blanks in the puzzle, he should work toward filling them. He may have to say to the patient, ‘I believe when you say something is wrong, but I haven’t figured it out.’ Sometimes he just has to wait until the problem ‘declares itself,’ usually by becoming worse.”

“Curmudge, what should the doc tell the patient when the diagnosis indicates a life-threatening or debilitating disease?”

“I recall in my youth when neither the physician nor the patient’s family would share with the patient the seriousness of his diagnosis. That’s when life-threatening almost certainly meant life-ending. Now many of those diseases can be cured or at least arrested. The physician can be upbeat when it is justified, and even in the bleakest situations assure the patient that he will not be abandoned.”

Affinity’s Kaizen Curmudgeon

(1) Groopman, Jerome. How Doctors Think. (Mariner, 2008)
(2) The doctor’s doctor: How to be an internist in five minutes. http://thehappyhospitalist.blogspot.com/2008/10/doctors-doctor-how-to-be-internist-in.html