Book Review  |   August 2009
How Doctors Think
Author Affiliations
  • Arnold Melnick, DO, MSc, DHL (hon)
    Department of Pediatrics, and Professor of Public Health, Public Health Program, College of Osteopathic Medicine; Executive Vice Chancellor and Provost (ret), Health Professions Division, Nova Southeastern University, Fort Lauderdale, Fla♦
    Professor of Pediatrics
Article Information
Book Review   |   August 2009
How Doctors Think
The Journal of the American Osteopathic Association, August 2009, Vol. 109, 464-465. doi:10.7556/jaoa.2009.109.8.464
The Journal of the American Osteopathic Association, August 2009, Vol. 109, 464-465. doi:10.7556/jaoa.2009.109.8.464
Combining 30 years of dedication to internal medicine with a reputation as an accomplished essayist, Jerome Groopman, MD, has produced a fascinating tome exploring the minds and thinking processes of physicians. How Doctors Think, a New York Times bestseller, was first published in 2007 and republished in a paperback edition last year with a new afterword. 
Dr Groopman, chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston, Mass, and occupant of the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School, begins How Doctors Think with the proverbial introduction. However, instead of the usual perfunctory segue into the main topic, Dr Groopman's introduction is a 26-page, in-depth exposition on how the practice of medicine is in essence a study in communication. 
The author intersperses his own observations with interesting details regarding the case of a female patient who was misdiagnosed as having anorexia nervosa with bulimia and irritable bowel syndrome. Dr Groopman illustrates how faulty physician-patient communication was responsible for the incorrect diagnosis and how improved communication (ie, open-ended questions and careful listening) resulted in a correct diagnosis of celiac disease. 
Throughout this fascinating account, Dr Groopman uses phrases that could well be classified as Groopman aphorisms, including “Think out of the box,” “Language is still the bedrock of clinical practice,” and “Freedom of patient speech is necessary to get clues to diagnosis.” He summarizes how physicians typically achieve competency and improved patient skills by noting, “Primarily, they [physicians] recognize and remember their mistakes and misjudgments, and incorporate those memories into their thinking.” 
Following the introduction are 10 chapters that further establish Dr Groopman's thesis—offering lessons for physicians, as well as advice for patients, on improving communication to achieve more effective treatment. Rather than pointing fingers of accusation or pressing statistical assumptions, he interviews highly accomplished, competent medical specialists (some of whom use pseudonyms) from across the United States. These physicians were willing to share with readers significant mistakes they had made in either diagnoses or treatment and to examine and reflect on their thinking—or lack of thinking—in those instances. 
For example, in chapter 2, “Lessons from the Heart,” Dr Groopman relates the story of a healthy-looking, active forest ranger who presented to a physician with a complaint of chest pain. After physical examination, electrocardiogram, chest radiograph, and blood tests all yielded normal results, the physician told the patient, “I'm not worried at all about your chest pain. You probably overexerted yourself in the field and strained some muscle.” The next evening, however, a colleague informed the physician that the forest ranger had returned to the emergency department that morning with an acute myocardial infarction. The physician, noting that he was stunned by the news, told Dr Groopman the following: 

Clearly, I missed it [the ranger's unstable angina]... And why did I miss it? I didn't miss it because of any egregious behavior or negligence. I missed it because my thinking was overinfluenced by how healthy this man looked... Happily, he didn't die.

The physician then explained: 

The unstable angina didn't show on the [electrocardiogram], because fifty percent of such cases don't... His unstable angina did not show up on the cardiac enzymes because there wasn't yet injury to the heart muscle, and it didn't show up on the chest x-ray because the heart had not yet begun to fail to pump blood, so there was no fluid backup into the lungs.

Dr Groopman reports that the physician concluded, “You have to be prepared in your mind for the atypical and not so quickly reassure yourself, and your patient, that everything is okay.” By presenting this and other cases of physician error in a respectful, collegial manner, Dr Groopman strengthens his points about the importance of physicians improving their cognitive and communication skills. 
Each of the chapters in How Doctors Think contains one or more such intriguing accounts of misdiagnosed or incorrectly treated patients. One of the other strengths of this book is that these cases are not written in formal clinical language. Rather, Dr Groopman—who is a staff writer for The New Yorker, a frequent contributor to The New Republic, The New York Times, and The Washington Post, and the author of several books—presents the cases in colorful, conversational language. His text often includes discussions with, descriptions of, and background information on the physicians and patients involved in the cases. For example, in chapter 4, “Gatekeepers,” Dr Groopman writes the following about a physician: 

JudyAnn Bigby is a compact woman with a round face, alert eyes, and a lilting, almost musical voice that often breaks into laughter. She was raised in Hempstead, Long Island. When she was a child, hers was one of the first African-American families in town... Her father worked as a mechanic for United Airlines and only later in life did her mother, a homemaker, return for a high school equivalency degree.

Besides discussing examples of mistakes made by physicians, Dr Groopman also covers various other areas of concern related to the book's subject matter. Among these areas are the association among “Marketing, Money, and Medical Decisions” (chapter 9), the influence of aggressive pharmaceutical company representatives, the error of performing treatments by rote memory even when those treatments are not effective, and the overreliance on algorithms and grids as “shortcuts around the onerous process of assessing each... complex [case].” 
In the book's epilogue, Dr Groopman concludes that while writing How Doctors Think, he realized that in addition to the usual sources of information available to physicians (eg, textbooks, medical journals, colleagues), he has “another vital partner who helps improve my thinking... my patient or her family member or friend who seeks to know what is in my mind, how I am thinking.” 
Whether the reader agrees or disagrees with Dr Groopman's points, his book provides interesting reading and cogitation—as well as an excellent opportunity for introspection for physicians. I recommend this book for all physicians, regardless of the type of medicine they practice. 
 By Jerome Groopman, MD. 319 pp, $15.95. ISBN: 978-0-618-61003-7. New York, NY: Mariner Books; 2008.
 Editor's Note: Dr Melnick writes the monthly “To the Point” column on medical communication for The DO and is one of the American Osteopathic Association's Great Pioneers in Osteopathic Medicine. For more information regarding the Great Pioneers, please see