Sunday, January 28, 2007

Doctors are from Mercury, Patients are from Uranus

John Gray is the author of Men are from Mars, Women are from Venus and innumerable sequels. He has made a mint trying to explain the differences in the way men and women think, which is one of the oldest conundrums in civilization.

There is a similar mind-bender, almost as ancient, and it may as well be entitled Doctors are from Mercury, Patients are from Uranus. (I have given doctors Mercury, as the Roman God’s caduceus or wand, at right, has been adopted as a medical symbol. I have given patients Uranus, since patients can often be a pain in the nether regions, and often ought to be for their own good).

Most patients are, quite simply, mystified by how doctors think. But coming to an understanding of how this process unfolds (when it unfolds) is crucial to developing a good relationship with one’s doctor, and to knowing if the doctor seems to be doing what’s best. Here, in our corner of cyberspace, we can pick up some clues by reading the medical commentaries of bloggers Dr. Vance Esler and Dr. Terry Hamblin (links at right). In the world at large, one hem/onc who has made a valiant attempt at explaining what goes inside the minds of medicine is Dr. Jerome Groopman, whose book Anatomy of Hope is certainly a good read.

Now Groopman has written a piece for the latest issue of The New Yorker entitled How doctors think. Not that we patients are going to come to a miraculous, Eureka-like moment anytime soon, but it’s worth a look, as it helps demystify the process a little bit more. It can be read in its entirety here.

Groopman discusses the findings of Pat Croskerry, a physician who has written a scholarly article entitled Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias.

Croskerry has been trying to figure out why otherwise intelligent doctors misdiagnose things, which research suggests occurs in about 15% of cases, but which Croskerry thinks is “significantly higher.”

“He believes that many misdiagnoses are the result of readily identifiable — and often preventable — errors in thinking,” Groopman writes.

For patients with chronic lymphocytic leukemia, misdiagnosis is rare (but not unheard of). Our main concern are the subsequent decisions doctors make -- when and how to treat, how to deal with related conditions such as anemia and ITP. These decisions can, in fact, be crucial to our survival.

Groopman has some insights into why doctors sometimes screw up. Among these are:

“Doctors make such errors when their thinking is overly influenced by what is typically true; they fail to consider possibilities that contradict their mental templates of a disease, and thus attribute symptoms to the wrong cause.”

That’s a biggie in CLL. Doctors with an unbending, outdated idea of what is “typically true,” are like bulls in china shops. CLL is by definition heterogeneous, which means it varies from patient to patient. A one-size-fits-all approach based upon the idea that CLL is an old man’s disease that doesn’t actually kill anyone does much more harm than good.

A second problem, Groopman writes, is that “Doctors can also make mistakes when their judgments about a patient are unconsciously influenced by the symptoms and illnesses of patients they have just seen.”

Read: Last CLL patient seen, or last one treated, or the one that sticks in the mind like peanut butter to the roof of the mouth. My first hem/onc, Dr. Lippencot, was forever telling me about the one patient she had who had been using fludarabine every two years for ten years and was “still going strong.” I am happy for that patient, but the results would not necessarily have translated to me.

Groopman goes on to write about a side of the issue that I hadn’t thought about:

“ . . . the errors that doctors make because of their feelings for a patient can be just as significant. We all want to believe that our physician likes us and is moved by our plight. Doctors, in turn, are encouraged to develop positive feelings for their patients; caring is generally held to be the cornerstone of humanistic medicine. Sometimes, however, a doctor’s impulse to protect a patient he likes or admires can adversely affect his judgment.”

Well, in today’s era of ten-minute office visits, who knew? Actually, I am aware of some doctor-patient interactions in CLL that have been intense, and that have gone on for a long time, and I can imagine that there is a certain degree of emotional turmoil that goes on beneath the white-coated objectivity. Failure to cope with this is what apparently drove my second hem/onc, Dr. Chopin, out of medicine.

Groopman’s piece also devotes a little space in passing to his experience treating a patient with Adriamycin, aka Doxorubicin, a component in the CHOP therapy that some CLL patients are familiar with:

“Oncologists had nicknamed Adriamycin “the red death,” because of its cranberry color and its toxicity. Not only did it cause severe nausea, vomiting, mouth blisters, and reduced blood counts; repeated doses could injure cardiac muscle and lead to heart failure. Patients had to be monitored closely, since once the heart is damaged there is no good way to restore its pumping capacity.”

Hmmm. One wonders what other nicknames oncologists have for the drugs they use on us. Every profession has its shop talk, of course. Newspaper people are among the worst offenders; I don’t recall every shorthand expression we used in the newsroom, although I do remember us referring to people who died in car fires as “crispy critters.”

At the bottom of our gruff little hearts we did, of course, care. And Groopman did too, though I doubt he went to the patient in question and said “We’re going to treat you with the ‘red death.’”

But that’s what he was thinking.


Vance Esler said...

My office visits are scheduled for 15 minutes ... because I care more ;-)

I'm not sure how one arrives at the 15% incorrect diagnosis figure. It is not uncommon for physicians to disagree, so who decides who is right and who is wrong?

I have said elsewhere that doctors get paid for being right more often than they are wrong. Still, there have been times when I have made diagnoses that others missed. I once asked a teacher, "Why do we find these things when the other doctors do not?" He replied, "Because we look."

And therein is part of the problem. Doctors are people, too. We get tired, rushed, stressed, too much caffeine, not enough caffeine, distracted by phone calls and people tugging on our sleeves.

That is why there are malpractice lawyers (at least, that's what THEY say). They keep us honest and vigilant. They make us think twice and force us to do the tests we might otherwise leave off.

Of course, that puts us at odds with the third party payors who don't want us to do ANY tests or give ANY treatments.

It is a vicious cycle sometimes.

Anonymous said...

Great information and inspiring philosophy! Thanks so much.

dx cll 2000
waiting for first MyVax injection.

Anonymous said...
This comment has been removed by a blog administrator.
Claudia said...

David, I just found your blog. My husband has CLL stage 0. I hope and pray all is OK with you. Please let us know how you are doing.