(Editor’s note: Back in February, Keith Gronczewski, an Active Surveillance patient, who also has dealt with head-and-neck cancer, had an appointment at a University of Chicago Medicine satellite office near my house in Chicago’s far south suburbs. We met for lunch at a burger joint with a 50s theme. Keith, who is an engineer by training, came with a legal pad filled with questions about finding a doctor and coping with AS. Five hours later, we were ready for dinner.
(Keith has become a good friend and helped organize the in-person Chicago Area Active Surveillors with Charles Brown III and Keith Day. We have a lot of Keiths.
(Keith G., as he’s known now, shared with me his thoughts about the book, “How Doctors Think” by Author: Jerome Groopman, M.D. Houghton Mifflin Company, 2007.
(I suggested Keith write a review for The Active Surveillor.
(Our Chicago group is in the midst of a discussion of finding a new urologist, as UChicago is losing Dr. Scott Eggener, who, next month, will become the urology chair at UCLA, creating a gap in care in the Second City. So it seems timely to run Keith’s review.
(Dr. Groopman holds the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School and is chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston. He has published over 150 scientific articles and is one of the world’s leading researchers in cancer and AIDS. He is a staff writer at The New Yorker and has written for the New Republic, the Washington Post, and the New York Times.)
By Keith Gronczewski
While on rounds with a group of interns, residents, and medical students, Dr. Groopman observed the interns not thinking properly, questioning, or keenly observing. He was concerned about the lack of give-and-take among the trainees during their discussions and disappointed in himself as their teacher. Although the students were very bright, they were not thinking deeply about their patients’ problems. Something was profoundly wrong with the way they were learning to solve clinical issues and care for people.
Dr Groopman questioned some of his own shortcomings in treating some of his patients. Medicine is not an exact science, and all doctors make mistakes in diagnosis and treatment. But these can be reduced by understanding how a doctor thinks and how they can think better. What goes on in a doctor’s mind as he or she treats a patient? What’s their thinking process? Do different doctors think differently? Is there a ‘best way’ to think?
The book is about understanding how doctors think and how we as patients can help doctors think better.
(Jerome Groopman, MD)
Summary:
Many doctors rely too heavily on intuition. They start formulating an opinion about you and your potential condition before you even speak based on your appearance, posture, body language, or prior doctor’s notes regarding your condition.
Doctors need to listen to the patient’s story carefully, but you have limited time to present this information since doctor visits are typically limited to 12 – 15 minutes. Some doctors lack patience and interrupt a patient while telling their story within 18 seconds. Some doctors structure their questions to fit their preconceived notions of the disease. Doctors should ask open-ended questions and be sensitive to patients’ emotions to get the story. Good doctors need and do communicate well.
Clinical intuition is complex and comes with many years of practice and experience. Doctors need to think differently from what they are taught in medical school. It may take 30 minutes for a medical student to develop a working diagnosis while in a clinical situation, an expert clinician will typically form an opinion in 20 seconds.
All doctors are human and make errors in judgment for various reasons; they may not think clearly or accurately and miss things. Most errors are due to flawed thinking where doctors fall into cognitive traps; 15% of all diagnoses are wrong. A good doctor realizes and learns from his/her mistakes, but their mistakes are on living people. As a patient, you want to be engaged in the process to help direct the doctor’s attention to make the correct diagnosis. What we say and how we say it shapes the way doctors think.
Dr. Groopman shares some of his experiences with learning pattern recognition to shortcut the diagnosis process and how a doctor’s ability to recognize these patterns significantly impacts the outcomes. He references various real-life cases where doctors’ judgments were flawed, leading to incorrect diagnoses and/or improper treatments.
In the book's introduction, he refers to a young female patient who had an ongoing GI issue that was misdiagnosed for 15 years until one doctor decided to take a new and unbiased approach. This doctor identified a key element that all previous doctors had missed and then made the correct diagnosis.
Dr. Groopman refers to another case where many doctors misdiagnosed an infant because the symptoms fell into a category of a common ailment. Doctors are taught to recognize a typical picture of a disorder, but sometimes they are wrong. They shy away from a rare diagnosis, and insurers put pressure on doctors not to spend dollars on unnecessary tests. In this case, the mother was not convinced of the diagnosis and pushed for additional tests and evaluation to find that the initial diagnosis was incorrect.
The point is that doctors are fallible; they do not have all the answers, and once a particular diagnosis is ‘fixed’ in a doctor’s mind, it is hard to change, but sometimes we can help them.
Dr. Groopman discusses how the efficiencies of the marketplace are squeezing clinical care. He mentions the shortcomings of the EMR, noting that doctors must enter information into the computer, which distracts them from the patient and consumes valuable time to access the patient’s condition.
He comments: “Medical care is an interaction between the doctor and the patient within a context in a social system. As such, it is not a commodity.”
In chapter 6, Dr. Groopman acknowledges the uncertainty in medicine. There are aspects of human biology and physiology that you can’t predict, and deductive reasoning does not work in all cases. Decisions regarding diagnosis, selecting procedures, and observing outcomes are very complex, and it's easy for honest people to come to different conclusions. Due to uncertainty and variation between cases, predicting outcomes with certainty is challenging. You can only talk about the probability of specific outcomes. Doctors need to acknowledge uncertainty.
In chapter 7, Dr. Groopman discusses his personal struggles with a hand/wrist issue. For 3 years, he consulted 5 doctors, each with different diagnoses and treatment options, some of which were effective, while others were not, but all were different. In the end, he finally decided on a successful surgery. Ultimately, he achieved ~ 80% of normal function after surgery, and his surgeon stated that’s about what you should expect from any surgery.
His doctor said all surgeons should be honest about expectations, but honesty is not necessarily rewarded in today’s society. Some may overstate expectations, but patients need to accept the facts. Doctors and patients need to be in sync. Patients can help the doctor by asking detailed questions, but some doctors are annoyed by this because they may not have all the answers. The type of response you receive illuminates how much he/she knows about your case.
Chapter 8 discusses the role MRIs, CT scans, and X-rays play in the diagnostic process and their shortcomings. There is much variance in the equipment, settings, image quality, technician’s skill, and the radiologist’s interpretation of the data. There will always be a certain amount of imprecision in imaging and interpretation. Attention to the language of the report can improve perception and analysis.
Chapter 9 discusses the influence of marketing and money on medical decisions. From drugs to devices, tools, robotics, and procedures, all are influenced by money. Dr. Groopman shares various eye-opening examples of these. Patients need to ask several questions regarding all the options, possible risks, and benefits to help make informed decisions when agreeing to or declining any drug or procedure. If significant, it may be wise to get second or third opinions.
Chapter 10 covers how doctors approach and discuss options to treat or not treat a particular disease or ailment influences patients’ decisions. Likely outcomes, side effects, probability of success, and quality of life should all be considered and discussed. Doctors should help guide patients to make these choices, essentially empowering the patient. How a doctor talks to a patient is essential. These decisions need to be consistent with the patient’s philosophy of life. And patients need to understand that not all cases are alike. Patients may respond differently to a particular treatment protocol. What works for one may not work for another. If running out of options, doctors should keep trying, but be consistent with the patient’s desires.
Oncologists tend to develop a special relationship with their patients that is not common in other specialties. A physician’s demeanor and personality often mirror their type of thinking. You and your physicians must have “like thinking.” You need to be on the same page, and if you sense a disconnect, it may be wise to change physicians.
Many doctors’ decisions and recommendations are based on the fear of lawsuits. You want your doctor to use rational thinking regarding your needs as a patient, not his own emotional needs. You need to have a good and honest relationship with your doctor, especially for cancer treatment. Doctors need to give their honest opinions. Sometimes, more aggressive cancer treatments are not necessarily better. Sometimes it's difficult to know. Sometimes, going for the homerun, you strike out.
Conclusion / Recommendations: What follows are my personal thoughts and suggestions.
This book is suitable for all patients and family members to better manage and optimize their limited time during medical appointments, and to provide the best information to assist the doctor in making the right diagnosis. To gain a deeper understanding of the diagnosis, it is essential to consider the significance, implications, treatment options, prognosis, side effects, and likely outcomes. Also, knowing when to question a diagnosis or test results, and in cases of uncertainty, when to seek a second opinion.
Often, misdiagnosis is caused by miscommunications. Complicated problems cannot be solved in a rush. Good thinking takes time. Cutting corners leads to cognitive errors. After reading this book, I honed my skills and approach to all my doctor appointments. Realizing the limited time allowed for a typical office visit and the opportunity for errors, you need to be well-organized and focused. I prepare a written list of notes and questions for all my doctor visits.
The following is a list of things I typically do for my doctor appointments:
Have a copy of my overall health history, including family health history
List of vaccinations, current medications, major surgeries, and illnesses
Reason for my visit: list of symptoms, timing, etc.
List of questions: what I want and need to know
It's essential to establish a connection and maintain a good relationship with your doctor. It’s important to like each other. The doctor needs to be sensitive to your needs and concerns and welcome your questions. If you're unhappy with your doctor or they're unhappy with you, it's probably time to consider finding another doctor.
Finally, does the diagnosis make sense? If you have reason to question or doubt a particular diagnosis or procedure, seek a second opinion. Any good doctor should not be offended by this.
(Keith Gronczewski in the cockpit of a WWII SBD Dauntless, which he helped restore at the Kalamazoo Air Museum. The plane currently resides in its permanent home at the Pearl Harbor Aviation Museum. )
How I chose a doctor
By Keith Gronczewski
Choosing a doctor is in my view is one of the most challenging aspects of managing your healthcare.
First and foremost, my disclaimer: this in no way intended to be advice on “How you should choose a doctor.”’
This simply is me sharing how I choose my doctors.
I have a list of doctors I see for various issues, and the list is only growing with time. In today’s medical world, the increasing number of specialists results in an even longer list of doctors.
Pending the nature of my ailment, I typically start with my primary care physician. However, if I know he’s likely to refer me to a specialist, I try to skip this step and go straight to the specialist. There are several mechanisms to find and choose a doctor, but here is a list of what I have used:
Referral from another physician, preferably one with whom you have established and comfortable relations. This has worked well for me on several occasions.
Well-experienced nurses or PAs (Physician Assistants), who work with one of your current providers.
Physical Therapists can very helpful in identifying competent orthopedic physicians. (They see the results.)
Support Groups: typically have guest speakers from various providers with varied backgrounds that may be suitable for your needs.
Dental Hygienists: for dentists. (They see the dentists’ work and results.)
Other patients, family members, or friends ,who have experienced good results with a particular physician. A word of caution: just because someone has a good relationship with a doctor and likes how he or she treats them does not necessarily equate to quality care.
Online searches: This is usually my last resort if I have exhausted the above options. Not that this won’t work, but I prefer hearing from a satisfied customer or someone I have experience with.
Once I’ve identified potential candidates, then I check for background information online such as:
Education: undergraduate and medical school
Internship, residency
Board Certified?
Fellowship?
Years in practice
Publications
Biography and videos (this may provide a ‘feel’ for his or her personality)
Providers they are affiliated with and locations
Final thought: This is not a complete list and I’m not suggesting this will work for you, but this is the process I use to help me choose my doctors.
Wishing you the best of health!
Keith Gronczewski bio:
I was born and raised in a close-knit community on the Northwest side of Chicago. I attended a Parochial grade school where I established many long-term friendships with many of my classmates of which I have continued relations. I attended Lane Tech high school followed by Wright Junior College where I studied Electronics and Mechanical Technology. I then worked for an Electrical Specialties company in Northbrook, Illinois as a product designer. After a few years
I was longing for my early-life passion for automotive work and accepted a job at a car dealership in Chicago, which led to my participation in a USAC Stock Car Racing team. Looking back, this was the most exciting and fun-filled part of my early life. After our driver retired, I decided to return to school and attended the University of Illinois, Chicago, where I earned a BS in Mechanical Engineering.
After spending some time in contract engineering, I accepted a position at Motorola’s Cellular division, working in a product development group on cell phone designs. Eventually, this led to a Staff Engineering position in a newly formed Design for Reliability group, where I served as a mentor and advisor to all development groups. This work included: risk identification, assessment, and mitigation, as well as failure analysis and material development projects with many of our material suppliers. Although I enjoyed design work, I found much gratification in the expanded scope of helping others solve their many design challenges.
I am single, currently reside in a northwest suburb of Chicago and enjoy many activities including: water skiing, skating, biking, some automotive repair, gardening, house projects and engaging in some volunteer work.
Share how you found your prostate cancer specialist:
https://forms.gle/Hhhdds7rSFz1NcgP6
Chicago Area Active Surveillors will be discussing how to find a new doctor at the meeting at 11:30 am, Aug. 26, at Seasons 52 in Oakbrook Center.
In other news:
Please answer this questionnaire on transperineal vs. transrectal biopsies: https://forms.gle/GShpHwegEPtAVgTs9 I have a relevant story coming, and you can take a few minutes and help if you haven’t already.
Please respond to my survey on your experience with MRIs: https://forms.gle/kuQVP4bDhEsm3RLV9
New Research Study at NYU Langone Health for Hispanic Patients with Prostate Cancer: Dr. Stacy Loeb and Colleagues are conducting a new study “Perspectives on Genetic Testing for Prostate Cancer” for Hispanic patients with prostate cancer. Participation involves an anonymous 40-minute virtual interview, in English or Spanish, to share perspectives about genetic testing. A $40 honorarium is provided for participation. For more information, please contact the study coordinator Tatiana Sanchez Nolasco (Tatiana.Sancheznolasco@nyulangone.org or 646-501-2550).
Jim Jackson, Howard, thank you! Once had a medical emergency traveling in Lisbon. Treated at a local hospital, ER physician freely admitted a lack of diagnostic tools we expect anywhere in our country. He relied on years of experience of course and made the right call. Have to believe part of my gratefulness was his lack of fear of private equity(PE) ownership. Please more on this topic to include how best to "gingerly" address subject of presenters at each webinar; it truly IS the "elephant in the room." Given we hope for "divine understanding" in our allotted 15-20 minutes-possibly an hour once annually-find like you write, Howard, more time spent by doc addressing questions in software than probing and listening to my response. Tape recording clinic appointments may at times attest to one's credibility but like in politics today and personal rights of corporations since the 1930s, integrity is everything and I argue NOT found in PE medicine. And to you readers, Howard, "et tu?"
Other concerns when choosing a doctor is your age, the doctors age, and how long you predict the issue to last. If you don't think the issue will be 100% corrected before you die, then you should find a doctor that is young enough to outlast you. Younger doctors are also more aware of what research is developing where an older doctor is more likely to just give you the common answer.