Knowing the right question to ask your doctor
Fact: A doctor in this country interrupts a patient, on average, in the
first 18 seconds of a visit.
A prominent surgeon waited about a minute and a half before issuing his
diagnosis to Jerome Groopman on his damaged hand. "He was dead wrong," says
Groopman, who got four diagnoses from six surgeons. "And these are big
names."
Fact: More than 15 percent - some say more than 20 percent - of medical
diagnoses are wrong. At least half result in serious injury or death.
Groopman tells of a woman who saw close to 30 doctors for a constellation of
ailments that gradually sapped the life out of her. She endured excruciating
pain and was down to 85 pounds. Her immune system was failing and she had
developed severe osteoporosis. All of them missed what was ailing her.
Finally, a fresh doctor asked a fresh set of questions. He listened to her
and found that she suffered from a gluten allergy that prevented her from
receiving the nutrients in the food she ate. After years of agony, she
quickly recovered.
Fact: More than a quarter of all radiological tests, including CAT scans
and MRIs, are misread. "Misdiagnoses are not rare at all," says Groopman,
the noted oncologist and chief of experimental medicine at the Beth Israel
Deaconess Medical Center, who assembled this data.
While the patient safety movement has led to major improvements in protocols
to avoid systems errors, he points out, nothing has been done to address a
more profound issue: how doctors think. And bad thinking is what causes
countless mistakes. "No one talks about this stuff," Groopman says.
He is struck by the lack of independent thinking among the residents he
leads on hospital rounds. "These are really smart people, and when asked for
a diagnosis they download cookbook recipes on their computers," he explains.
"If it's not that, they look blankly. How do I teach them how to think? I
realized I didn't know how I think. No one ever taught me how to think."
Groopman addresses this touchy subject in a book, "How Doctors Think," due
out this spring. In it are examples of bad thinking, including plenty of his
own, that produced harrowing results. None of this is news to patients. Most
of us know someone who has endured a misdiagnosis or have done so ourselves.
My friend Barbara went through a year of agony because of one.
Groopman's first child developed a persistent low-grade fever and stomach
pain at nine months. A doctor said not to worry, it's just a virus. The
child's condition deteriorated, but the doctor remained unmoved. Eventually,
Groopman and his wife rushed their son to an emergency room, where they
learned the child had an intestinal obstruction that would have killed him
had it gone untreated.
What went wrong here?
The doctor sized up Groopman and his wife as neurotic first-time parents and
built his diagnosis around that premise. At work, says Groopman, were two
suspects common in these nightmares.
The first is what he calls anchoring - where a doctor interrupts you, seizes
on a symptom or complaint, and declares, "It's this." This snap judgment
anchors all ensuing thinking.
The second he calls attribution, to which women are particularly vulnerable,
where assumptions about a patient are attributed to bad data.
Groopman tells of a woman with a newborn child and two young children who
complained about constant nausea and diarrhea. "The doctor looked at her and
decided it was stress, that she was neurotic," Groopman said. "So he
attributes all of her complaints to the stereotype he has in his mind. I saw
her a few months ago. She had been diagnosed with a tumor in her intestine
but had been taking Zoloft for a year and a half."
Time is an insidious agent in all this. "In today's medical environment, the
clinic is a factory," he says. "It's a world of eight-minute visits. The
mistakes are made in the moment. Doctors draw immediate diagnoses rather
than listen and pursue leads. And when complaints persist, they all too
often cling to their first thought and even discount contradictory evidence.
"It's impossible to figure out a difficult problem in eight minutes," he
said. "A doctor has one eye on the clock and one eye on a computer screen as
he types notes. The truth is, you can't think well in haste.
"There is no generic besttreatment to a serious problem," he says: "We
delude ourselves to think the answer is the systems solution - 'We'll give
you an algorithm: if it's A then B then C.' You're got to know what A is in
the first place. And sometimes you have to go past C."
Many in the medical community will bristle at Groopman's findings. Others
will recognize the truth in what he says and, with luck, a few of the bean
counters controlling medicine today as well. They can't dismiss the book. It
is meticulously researched and written by a physician of stature.
"One solution for misdiagnosis is a patient or family member who knows how
doctors think," Groopman said.
So what should we be asking our doctors, over and over?
-->"What else could it be?"
Sam Allis writes for the Boston Globe: allisglobe.com
This is a problem all too commonly reported among CFS patients. Doctors see that you are female, and leap to the conclusion that you are depressed, neurotic, or menopausal.
In the early days of the epidemic, one of the virologists researching AIDS was asked to evaluate some CFS patients for viral involvement. Every one of the seriously-ill women was returned to the referring doctor with a psych diagnosis. Finally, a male patient who was not nearly as impaired was sent over. The same symptoms, lesser intensity, produced a conclusion that there was some virus at work, but it was not one that they could test for.
I have had doctors cling for dear life to their diagnosis of depression even after receiving psych evals that say there is no sign of depression. They could not accept that they were wrong, so they had to either ignore the psych eval entirely, or arrogantly claim that the psych expert was wrong, and that their one semester of Psych 101 makes them better-qualified to make a psych diagnosis than the guy with Ph.D. or Psy.D. after his name. A doctor who never once addressed my emotions was positive I was depressed, even though the depression diagnosis absolutely requires an emotional component. The symptoms I had were those that anyone with the flu would have, but he wouldn't accept that rationale from the person with better psych credentials. After telling me that he would not look further for a physical reason until I had a psych eval, he still didn't want to look further for a physical reason after being told that it was definitely not depression. As Dr. Groopman notes in his book, once the doctor had made the diagnosis, nothing, not even contradictory expert input, was going to change his mind.
When my symptoms were contradictory to depression, and I complained that anti-depressants were making me sicker, the doctor could not, would not, reconsider "what else could it be?" He simply turned around in his head what I said to him until he could make it fit the diagnosis he wanted to make. The medical records reflect what he wanted me to say, and not what I actually did report. He had himself convinced that I refused to take anti-depressants because I didn't want to get well and "have to" go back to work; nowhere in the records does it say that I took them a couple days and each time, within half an hour, became violently ill -- I could not continue taking them due to the severity of the side effects.
More than 15 years ago, Dr. David Bell cited statistics that fully half of all patients who initially got a "psychosomatic" diagnosis were eventually diagnosed with a real physical problem. In some cases, the patient is extremely sensitive -- I've known people who could tell when some test value fluctuated by as little as 1% -- they would know that something was going wrong before a blood test could pick it up; a few weeks or months later, the fluctuation would have increased enough to become an abnormal test result.
In other cases, the doctor leapt to a diagnosis of "psychosomatic" without getting all the facts. As Dr. Groopman notes, this happens often to women, who are tagged "neurotic" because male doctors have a stereotype about women, that they exaggerate everything in order to get attention. We women joke about it that a man with the sniffles takes to his bed and acts like he's going to die; a woman with the sniffles just keeps going. Male doctors see it the other way around. As a friend points out quite regularly, people assume that everyone does what they do: someone who eats a steady diet of fast food from the burger place next to the hospital is going to assume that the patients find it equally convenient to eat greasy garbage, and will pooh-pooh the patient's own reports that she eats mostly fresh produce from the farmer's market which is much closer to her work place.
And, unfortunately, autoimmune diseases tend to strike women more frequently than men. They may not show up on the standard blood tests, resulting in assumptions that the patient is just looking for sympathy or attention or permission to quit her job. In 20 years of dealing with CFS symptoms, I've found that female doctors are more likely to accept my reports of impairments as true and entirely accurate, and male doctors are more likely to attribute it to some cause other than a virus or accuse me of exaggerating frequency and intensity because I don't want to work, or I've figured out a way to get my husband to take care of me, or that I'd rather scrape by on a few hundred dollars a month Disability benefit than earn $50,000+ a year and be able to buy anything my heart desires (because no one who has not been on Disability would ever guess that benefits leave you below the poverty level).
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