August 2007 | Back to Table of Contents
Book Review
Mindfulness in Medicine
By Charles R. Meyer, M.D.
Jerome Groopman’s latest book scrutinizes the thought processes of physicians.
Introspection is not a skill that comes naturally to doctors. From the time they take tentative steps across the portals of medical school to when they shut the clinic door at retirement, physicians’ minds are loaded, frequently overloaded, with information, patients, and deadlines. Mental juggling becomes a necessity of the trade; physicians were experts at multitasking before it was a word.
Overworked bodies and overfilled brains don’t easily pause for reflection. The demands of thinking about problems crowd out any chance of thinking about thinking. And thinking about thinking is what Harvard University oncologist Jerome Groopman says practicing physicians need to do.
Thinking about thinking is absent from traditional medical education, which has relied on authority and example, with white-coated oracles of medical knowledge leading the subservient faithful who are expected to observe and absorb. Groopman pictures the scene accurately: “My generation was never explicitly taught how to think as clinicians. We learned medicine catch-as-catch-can. Trainees observed senior physicians the way apprentices observed master craftsmen in a medieval guild, and somehow the novices were supposed to assimilate their elders’ approach to diagnosis and treatment. Rarely did an attending physician actually explain the mental steps that led him to his decisions.” And rarely did attendings question trainees about their mental processes.
How Doctors Think asks questions about physician thinking initially through an exploration of the language that connects patient and doctor that Groopman calls the “bedrock of clinical practice.” Indeed, he says competency is not separable from communication skills and proclaims that good doctors “activate” their patients, encouraging questions and dialogue that will reveal the soul of the patient and the heart of his problem and avoid the mistakes that are the bane of physicians’ lives.
By analyzing doctor mistakes through studies and sometimes lengthy patient stories, Groopman dissects the mental mishaps that lead to clinical catastrophe. Physicians try to frame or categorize a patient’s problem, frequently early in the encounter, looking for the square diagnosis hole that will fit the square patient peg. Deluged with symptoms, signs, and historical information all laden with uncertainty, doctors resort to shortcuts to pare away the irrelevant and the unhelpful to reach firmer footing. Although shortcuts help deal with the vagaries of clinical practice, they can be fraught with errors. Groopman identifies errors endemic in physician thinking, using sometimes-clumsy labels drawn from psychological research: the representativeness error, thinking that is driven by a prototype and that blocks out possibilities contradicting the prototype; availability error, in which the diagnosis that comes to mind most readily stays at the top of the differential; or anchoring, in which a physician lands on a diagnosis and then hangs on to the security of that anchor.
Medical practice is defined by uncertainty and the doctor–patient interaction is made even more insecure because it is the clash of two human beings each with a set of emotions. Physicians are trained to understand and deal with a range of patient emotions, but they may be blind to their own indifference, affection, or anger, which can color their thoughts and actions. Groopman urges practicing physicians to recognize their own boredom, hostility, or attachment and understand how these emotions can jeopardize the quality of their clinical work.
And he wants clinical practice to be judged by more flexible standards than those promoted by current scions of quality. Rejecting the “trivial, simpl(e) scorecards to ensure that the blood sugar was measured and a flu shot given,” Groopman opts for a wider measure of quality that recognizes “thinking broadly … making judicious decisions with limited data about children and adults, neither overreacting nor being blasé; … wielding one’s words with precision and with a profound appreciation of the social context of the patients.”
Groopman occasionally diverts into what seem like tangents to his core message such as a chapter on the influence of pharmaceutical companies and device manufacturers on physician thinking. But these don’t cloud his main theme. The doctor thinking promoted by Jerome Groopman is really physician self-questioning, a look inward, constant vigilance about where your mind is taking you, and repeatedly asking whether it’s leading you astray. MM
Charles Meyer is editor in chief of Minnesota Medicine.