How Doctors Think and (Hopefully) Avoid Mistakes

Angelos Delivorrias, director of the Benaki Museum in Athens, knew at a glance that the marble statue of a young man was a fake. True, before purchasing the piece, the Getty Museum in Los Angeles had hired legions of experts, who concurred with its dating to the sixth century B.C. But Delivorrias was responding to his instinctive feeling on first seeing the piece, a sense of "intuitive repulsion." And he was most likely right, as the journalist Malcolm Gladwell recounted in his 2005 book, "Blink: The Power of Thinking Without Thinking." The Getty now lists the statue as a possible "modern forgery."

Dr. Pat Croskerry knew at a glance that the patient in his emergency room wasn't having a heart attack. True, he had a sudden onset of severe chest pain, but Croskerry relied on his initial impression of a trim, athletic man in his early 40s. His test results were normal, so Croskerry diagnosed a muscle pull and sent him home. He was wrong, as the author and physician Jerome Groopman recounts in his new best seller, "How Doctors Think." The next morning, the patient was admitted to the hospital with an acute myocardial infarct.

Just when you thought it was safe to trust your intuition—when psychologists publish studies on the "deliberation-without-attention effect" and singles practice impressing one another in five-minute speed-dating encounters—along comes the soft-spoken, white-bearded Groopman to say, maybe better take another look. And while he didn't intend his book as an answer to his New Yorker colleague's monumental best seller, he also wouldn't mind if his own field of medicine was more inclined to honor the old-fashioned virtues of deliberation, caution and systematic thinking.

In his long career, Groopman, whose research interests range from hematology and oncology to AIDS, has made his share of mistakes, and clearly learned from them. The number of ways in which a doctor can screw up make for uncomfortable reading: "satisfaction of search," the tendency to stop considering alternative explanations once you arrive at a plausible hypothesis; "diagnosis momentum," the unconscious suppression of evidence that conflicts with an existing theory; "commission bias," the preference for action for its own sake. Groopman has particular disdain for snap judgments and intuitive leaps not supported by rigorous logic. One of his heroes is a radiologist named Dennis Orwig, whose insistence on methodically tracing every loop and twist of intestine in an X-ray led him to a difficult diagnosis of a potentially fatal bowel condition.

Orwig's practice, Groopman notes, runs counter to the received wisdom of his specialty, which holds that "conclusions from first impressions, or 'gestalt,' are the mark of good training, much as 'shooting from the hip' is prized among ER doctors." And Orwig's approach also runs counter to some of the assertions in "Blink." Gladwell cites a study of how intensive-care nurses make decisions under pressure. The report found that "when experts make decisions, they don't logically and systematically compare all available options ... [They] size up a situation almost immediately and act, drawing on experience and intuition and a kind of rough mental simulation." That is, they do just what Groopman warns against.

Far be it from us to get between two of the most honored writers at The New Yorker! As Groopman says, "these are different books. Malcolm says experts can go with their gut, which is often the case. I'm saying there are different circumstances." Gladwell's book has created an influential paradigm for decision makers, but if you're wrong about a statue, nobody's going to die from it. "How Doctors Think" is well worth reading both for intellectual pleasure and as a guide to communicating with people you entrust your life to. But perhaps its warning about the limits of unexamined intuition should be heeded beyond the operating room, by those who hold the lives of all of us in their hands.

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