Book Review

Second Opinions: Stories of intuition and choice in the changing world of medicine

N Engl J Med 2000; 342:1296April 27, 2000

Article

Second Opinions: Stories of intuition and choice in the changing world of medicine
By Jerome Groopman. 243 pp. New York, Viking, 2000. $24.95. ISBN: 0-670-88801-X

Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine, Jerome Groopman's second collection of clinical stories, illuminates the mysteries and uncertainties of serious illness and the fears it evokes in both patients and doctors. Writing for a wide audience in clear and precise, nontechnical language, Groopman offers these stories to deepen and enlarge the experiences of patients and doctors in a health care system that seems to have lost sight of its mission. More specifically, his angle of vision comes from a whirlpool of conflicting diagnoses and human error, the bureaucracies of clinical trials and managed care, chance, faith, an unyielding attention to detail, and invariably, hope.

Each of the book's eight chapters is a clinical story involving a patient with a life-threatening illness. The stories focus on people who face myelofibrosis, acute leukemia, hairy-cell leukemia, breast cancer, and marrow failure of unknown cause. Two chapters are Groopman's personal accounts: “Our Firstborn Son” is the story of his infant son who almost died because of a misdiagnosis, and “Grandpa Max” is the story of Groopman's grandfather, who had Alzheimer's dementia. Threads connect all the stories, weaving back and forth between laboratory precision and puzzling findings, rote clinical formulas and time-consuming exploration, self-confidence and uncertainty, and “attention to minutiae and a mind open to the unexpected.” Of all the stories he could have selected from many years of patient care and clinical research, Groopman chose these eight as the “critical moments that have forever shaped my thinking and practice — not only for my patients but for my family and myself.” They include, Groopman tells readers in the prologue, times “when my opinions and actions proved right and when I seriously erred.”

Groopman is a skilled storyteller. His descriptions of patients facing crises are quietly respectful, often accompanied by an unflinching critical gaze on his own practice of medicine and the difficult role he and others assume in dealing with the uncertainties of illness and recovery. His desire that all people have the means and knowledge to make informed decisions is evident in each chapter, indicated not only by the exchanges between Groopman and his patients but also by the complex information about each disease process that he provides to readers. In each case, including those involving his own family, he convincingly argues that doctoring is a “balance between the sixth sense of intuition and the tedious reiteration of diagnostic lists. You [don't] have to be brilliant to be a competent doctor, but you [do] have to be thorough.” Acknowledging that doctors cannot pass through their careers without making mistakes, he nonetheless does not forgive himself for his own. “I believed,” he writes, “that forgiving would mean forgetting and make me prone to more unwarranted assumptions.” I was reminded of David Hilfiker, another doctor who wrote candidly about a life-altering mistake he had made (Fac-ing Our Mistakes. N Engl J Med 1984;310:118-22) but who suggested the opposite — that doctors are cut off from healing when they are unable to forgive themselves.

Groopman clearly inserts himself as a major character in each of these stories, sharing his patients' crises with the firm belief that every doctor needs “deep knowledge of his patient and his disease and ready access to first-rate technology.” This statement and others like it are, of course, what all desperately ill people want to hear, especially from their doctors. I would want someone with Groopman's expertise and connections taking care of me if I were seriously ill. Yet even in my agreement with Groopman's unwavering commitment to the art and science of medicine, I was aware, as I read his book, of the astonishingly elite world he inhabits. He openly acknowledges this fact: “I did occupy a privileged position in the world of modern American medicine. . . . If I saw one person or ten in the clinic, it made no difference. If I wanted to spend an hour rather than fifteen minutes to examine and talk with a patient, I could. No one imposed `cost effective' clinical algorithms to stay my hand from pursuing a more intensive evaluation.”

Moreover, most of the patients whose stories Groopman recounts — not all, to be fair — were well-educated, assertive, and often economically privileged people: the patriarch of an old New England family with Miss Porter's School and Barnard College traditions, the chief executive officer of an international oil company, a physicist at the Massachusetts Institute of Technology, and a family friend. Even Groopman's personal stories do not escape the privilege of being well connected. Knowing how to find one of the most renowned pediatric surgeons in the United States when your child is sick and having New York's most respected specialist in dementia examine your grandfather are blessings most people cannot even imagine. I say this not to diminish the value of these stories but to point out that other stories of second opinions need to be told. For example, faced with the same illnesses, what do uninsured people do or those who are poorly educated and have no links to medical care? How would these stories be told by skilled and caring doctors in health maintenance organizations who struggle to reconcile the needs of their patients with the demands of corporate medicine? What about the isolated rural practitioner without ready access to “first-rate technology”?

Second Opinions is a finely crafted book showing how eight patients and their skilled and determined doctor worked together to make critical medical decisions. It is a book that represents one small segment of a national discussion that is needed to determine what we want our health care system to be, and for whom.

Delese Wear, Ph.D.
Northeastern Ohio Universities College of Medicine, Rootstown, OH 44272