How Doctors Think begins with the story of Anne Dodge who, over the past 15 years, had seen nearly thirty doctors. Diagnosed with irritable bowel syndrome, anorexia nervosa and bulimia, her condition was worsening, despite the prescribed treatments. At 82 pounds, she continued to lose weight even though she was eating 3,000 calories a day—much of it in the form of pasta, bread, cereal, and other complex carbohydrates.

Gastroenterologist Dr. Myron Falchuck, Anne’s latest doctor, did not simply examine the woman and accept the previous diagnoses. Rather, he started "to question, and listen, and observe, and then to think differently about Anne’s case." Falchuck began his interview with the patient by stating, "[L]et’s go back to the beginning. Tell me about when you first didn’t feel good."

Falchuck thought about Anne Dodge and her medical problems in a new way. "And by doing so," writes Groopman, "he saved her life, because for fifteen years a key aspect of her illness had been missed."

Anne Dodge had, in fact, celiacs, a digestive disease. She was unable to tolerate the protein gluten (found in pastas, cereals, and other common foods she had been eating). When she ingested gluten, her immune system responded by damaging her small intestine.

How could Anne’s previous doctors have missed the real cause of her illness? Part of the blame stems from what Groopman refers to as "clinical algorithms." "Medical students and residents," he notes, "are being taught to follow preset algorithms and practice guidelines in the form of decision trees . . . The trunk of the clinical decision tree is a patient’s major symptom or laboratory result, contained within a box. Arrows branch from the first box to other boxes . . . Ultimately, following the branches to the end should lead to the correct diagnosis and therapy." The key word here is should. In Anne Dodge’s case it did not.

Doctors should be wary of clinical algorithms, writes Groopman. They can be "useful for run-of-the-mill diagnosis and treatment
. . . but they quickly fall apart when doctors need to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact. In such cases—the kinds of cases where we most need a discerning doctor—algorithms discourage physicians from thinking independently and creatively. Instead of expanding the doctor’s thinking, they can constrain it."

Groopman notes that the impetus for the book came to him in the form of a question: "What goes on in a doctor’s mind as he or she treats a patient?" That question led to others: "How should a doctor think? Are different forms of thinking more or less prevalent among the different specialties? . . . How does a doctor think when he is forced to improvise, when confronted with a problem for which there is little or no precedent? Do doctor’s emotions—his like or dislike of a particular patient, his attitudes about the social and psychological makeup of a patient’s life—color his thinking?" He asked his colleagues these questions. Astoundingly, his colleagues, while intrigued by the questions, "had never really thought about how they think."

Granted, metacognition does require time for reflection. And time, notes Groopman, is "perhaps the rarest commodity in a healthcare system that clocks appointments in minutes." Still, writes Groopman, "[m]edicine is, at its core, an uncertain science. Every doctor makes mistakes in diagnosis and treatment. But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better."

So what can a patient—a layman—do? In a nutshell: Speak up. Do not feel inhibited about asking questions. "While modern medicine is aided by a dazzling array of technologies, like high-resolution MRI scans and pinpoint DNA analysis," writes Groopman, "language is still the bedrock of clinical practice." He offers, in the epilogue, questions that patients can, and should, be asking their doctors. Questions such as: "What else could this be? Is there anything that doesn’t fit? Is it possible that I have more than one problem?"

While most physicians do offer accurate diagnoses, Groopman offers a disturbing statistic: According to 1995 report, as many as 15 percent of all diagnoses are inaccurate. "Patients and their loved ones," writes Groopman, "can be true partners with physicians when they know how doctors think, and why doctors sometimes fail to think."

Highly recommended.

Reviewed by the teachers at Education Oasis