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Book Review: How Doctors Think (New York: Houghton Mifflin Company; 2007), by Jerome Groopman, MD

In his work, How Doctors Think, Dr Jerome Groopman presents a unique examination of the cognitive process that directs the modern physician through clinical interaction and aspires to demystify the physician-patient relationship. Using a combination of poignant anecdotes and personal experience, Groopman eloquently targets the most relevant outcome of an interaction of a patient with a physician, accurate diagnosis, and elucidates methodological fallibility. Written with both physician and patient in mind, How Doctors Think is not meant to read as a chronicle of physician missteps but rather as a window into the complexity of medical decision making. Focusing on the heuristics, or cognitive shortcuts, used in practice, Groopman validates the significance of a process to efficiently sift through a plethora of clinical information. However, although he suggests “heuristics serve as the foundation of all mature medical thinking,” the primary thrust of his piece frames their potential for danger. Assigning terms such as affective error, diagnosis momentum, and satisfaction of search, the piece highlights common pitfalls encountered throughout the cognitive process of establishing a diagnosis. Vividly explained in his chapter titled “Spinning Plates,” a reference to the often circus-like atmosphere of the emergency department, Groopman describes how easily a bias in the diagnostic process can lead a physician to an inaccurate clinical assessment. Within this chapter, the reader is presented with a vignette describing a female patient who after observation is diagnosed with subclinical viral pneumonia. Although the majority of the signs and symptoms match the final diagnosis, the physician is candid in disclosing that he was not able to confirm the presence of the microbe on her chest X ray and concludes that the negative finding is a result of early clinical presentation. Following protocol, the patient was admitted to the hospital and was later found to be suffering not from viral pneumonia but from aspirin toxicity. As he does on many other occasions, Groopman uses this example as a means to show a cognitive error; in this case a process of cherry-picking symptoms termed confirmation bias. Focused on subclinical pneumonia because of his exposure to many cases in recent weeks, the physician fell victim to the availability heuristic. With a pattern of pneumonia readily available in his mind, the physician emphasized positive signs and symptoms, while rationalizing any findings that may speak to a contrary diagnosis. Consequentially, he overlooked a selfdescribed case of bread-and-butter toxicology. Although Groopman is sincere in his discussion of physician imperfection, he reserves judgment, often sharing personal accounts of his own mistakes. Furthermore, the advice for physicians and patients on how to improve communication and diagnostic outcomes is entwined within his carefully chosen anecdotes. To this point, How Doctors Think should be read by the general public as a means to better understand a complex profession and by the physicians as a call for improvement. Targeting a broad audience, Groopman has created a work that will prove widely educational and will empower patients to become active participants in the management of their own medical care.