Book Review

How Doctors Think

N Engl J Med 2007; 356:2757-2758June 28, 2007

Article

How Doctors Think
By Jerome Groopman. 307 pp. New York, Houghton Mifflin, 2007. $26. ISBN: 978-0-618-61003-7

The public image of the ideal physician has been based for some time on the television persona of Marcus Welby, M.D. Television doctors of late have largely been residents in training whose struggles to develop their own professional and personal identities overshadow their work as physicians. In print, we have Abraham Verghese's several wonderful autobiographical explorations of being a physician, though they are in many ways particular to his unique background and experiences. Then there is Kathryn Montgomery's How Doctors Think: Clinical Judgment and the Practice of Medicine (New York: Oxford University Press, 2006), which focuses on the epistemology of medicine and its relationship to science. It provides an important scholarly perspective on clinical thinking but is not a likely vehicle for better public understanding of the profession.

Jerome Groopman's new contribution, in contrast, is a likely vehicle for this understanding. His How Doctors Think — the same title as Montgomery's book but very different between the covers — is a collection of stories from Groopman's own experience that illustrate the complexities of modern medical decision making and paint very realistic portraits of physicians at work.

Groopman's prose is engaging and accessible to the lay reader but also thoroughly credible and interesting to a professional audience. But this book, as is the case with Groopman's three prior books, is not really a collection of essays. It has a coherent and purposeful theme; there is logic to the progression of the introduction, the 10 chapters, and the epilogue, and there are a number of instances in which a case from an earlier chapter is referenced as part of a new story. Notwithstanding the previous success of some of these chapters as stand-alone essays in The New Yorker, it seems important to approach them sequentially.

In his previous books, Groopman approached his themes through stories about his patients. Here, he largely absents himself from the physician role (in one case, he becomes the patient) so that he can explore the ways in which doctors think across a wide range of specialties and situations. He starts with a story about the differences between the stylized approach to diagnosis he was taught in medical school and the realities he encountered when he began his internship. In this and other chapters, he deftly introduces the reader to essential concepts in heuristics and provides a clear sense of his own attraction to Donald Schön's “reflection in action” approach to the development of professional expertise.

In the middle chapters, we are introduced to a number of physicians, some of whom are well known in academic medicine and others who are not. Some are given pseudonyms. In the chapter “Spinning Plates,” there are emergency-department physicians who make rapid decisions based on often incomplete information and may have a number of common heuristic biases. In “Gatekeepers,” Groopman describes the challenges faced by primary care physicians, who must always be alert for the infrequent signals of serious or unusual problems against a background of much more common illnesses, and whose work is increasingly routinized and quantified in the current practice environment. In “The Uncertainty of the Expert,” Groopman illustrates the importance of mature clinical judgment in the face of inadequate data by telling the story of a pediatric cardiovascular surgeon who approaches a novel presentation of aberrant vascular anatomy in a newborn. Groopman addresses the influence of the pharmaceutical industry in a later chapter and uses the complexity of interpreting clinical trials as an example of a factor outside medicine that affects physicians' decision making.

Groopman is explicit about his intent to write for a lay audience, and he emphasizes this intent in an epilogue containing advice to patients on how to frame questions that will facilitate communication and effective partnerships with physicians. I think this, and the book as a whole, will indeed help the public understand what their doctors are up to and how patients can become more active participants in their own care. Some may instead interpret the discussions of heuristic biases and uncertainty as indicative of physicians' failings. I read this book not as an expose of the profession's inadequacies, but as a tale of our emerging understanding of the pathways to more effective diagnostic reasoning and clinical care.

One shortcoming in this regard is Groopman's continued focus on individual physicians. I wish it were easier to tell compelling stories about how the best medical care now incorporates a large measure of teamwork among a variety of health professionals. Those additional portrayals of the best modern doctoring will come, I'm sure. Meanwhile, Groopman's How Doctors Think may be one of the best resources available for those wondering whatever happened to the good Dr. Welby.

Raymond H. Curry, M.D.
Northwestern University Feinberg School of Medicine, Chicago, IL 60611
rcurry@northwestern.edu