From the AEGIS e-Journal, Volume 11 Number 3, March 2008
How Doctors Think Jerome Groopman, MD Publisher ISBN-13: 9780618610037 336 pages $15.95 http://www.houghtonmifflinbooks.com/mariner When we were in graduate school, we took a class with a clinical psychologist who spent a lot of time discussing cases in which he had been brought in to do second-opinion psychological evaluations. In every case he found an underlying physical cause for the mis-labeled psychological diagnosis, and was able to help the victim, er, patient, be healed. His message to us was firstly that we should look for a medical cause before accepting a psychological diagnosis, and secondly that when someone got sick, it was important to do our homework in helping the doctor reach an appropriate diagnosis and treatment. There is some question as to exactly how many people die each year due to unfortunate medical factors, but we recall having read that it approached 210,000. By medical factors we mean either medical mistakes (looking at the x-ray backward or prescribing the wrong dose of a prescription medicine) or incorrect diagnosis (which accounts for about 80 percent of the cases in question), or avoidable drug interactions (which account for a significant percentage of hospitalizations). Jerome Groopman’s book, How Doctors Think, is designed to help patients help their doctors come to the right diagnosis. The book begins with a puzzling case of a woman who had been wasting away for the fifteen years of her treatment. While any careful reader of ÆGIS would have made a correct diagnosis on page two of the book (And no, we are not cunning diagnosticians: We happened to discuss it briefly in the March issue, and know about it only because we have a friend who suffers from it) it took the patient fifteen years to find a doctor who would make the correct diagnosis, on page fifteen, of celiac disease. Groopman goes through the causes of misdiagnosis, and comes up with practical you (or those acting on your behalf) can ask to help your doctor come up with the right diagnosis. To try and jog an ER physician – or any physician – into thinking widely about your problem, you cans ask “What is the worst thing this can be?” This can be helpful if the doctor doesn’t like you (doctors sometimes don’t like sick people they can’t easily diagnose, noncompliant people, or people whom they don’t like for mysterious reasons), or is fixated on a particular diagnosis. Another question is “What ÆGIS, March 2008 20 body parts are near where I am having my symptoms?” Also, asking “Is there anything that doesn’t fit?” might get the doctor to think about anomalous data which might be a clue rather than a mere outlier. Another reasonable question is “What else could it be?” And if you have a fear or suspicion that you have been afraid to mention, it is a good idea to bring this up as a possibility to be looked at. An equally valid question would be “Is it possible that I have more than one problem?” He writes that “Patients can help the doctor think by asking questions. If he mentions a possible complication from surgery, they can ask how often it happens. If he talks about pain and lingering discomfort from a procedure, they can ask how the pain compares with having a tooth pulled under Novocain, or some other unpleasant event. If he recommends a procedure, patients can ask why, what might be found, with what probability, and, importantly, how much difference it will make to find it.” You should also ask whether a treatment is standard, or whether different specialists recommend different approaches, and why. And how time-tested a new treatment is. Another significant issue was understanding prognosis. In one case an oncologist told a patient that there was a thirty percent reduction in mortality with chemotherapy. The numbers, however, indicated that this meant that in five years while ten out of a hundred who did not take chemotherapy would die, with chemo seven – thirty percent fewer – would die. While a thirty percent reduction might get us into chemotherapy, seven out of a hundred versus ten out of a hundred would induce us not to take chemotherapy, with its attendant loss of quality of life. When we look at a book we tend to dog-ear it so we can pull up appropriate quotes. In this book we had 23 pages marked. Since we obviously cannot discuss here all the pieces we thought significant, we urge you to get a copy and read it several times. It is quite likely that doing so will keep you, or someone you care for, alive or less hurt. Because How Doctors Think the critical issue of health care, and is something every reader will have to deal with at some point in time, we have added it to our list of must-read books. Past must-read books are, in alphabetical order: • All You Need Is Love, and Other Lies about Marriage by John W. Jacobs, M.D (http://www.lubrinco.com/ejournal/ej200504.pdf) ÆGIS, March 2008 21 • Better by Atul Gawande, M.D. (http://www.lubrinco.com/ejournal/ej200708.pdf) • Beyond Fear by Bruce Schneier (http://www.lubrinco.com/ejournal/ej200309.pdf) • Corpocracy by Robert A. G. Monks (http://www.lubrinco.com/ejournal/ej200802.pdf) • The End of America, by Naomi Wolf (http://www.lubrinco.com/ejournal/ej2000711.pdf) • Inside the Tornado by Geoffrey A. Moore (http://www.lubrinco.com/ejournal/ej200211.pdf) • Rediscover Your Native Fitness (PACE), by Al Sears, M.D. (http://www.lubrinco.com/ejournal/ej2000711.pdf) • Reinventing the CFO by Jeremy Hope (http://www.lubrinco.com/ejournal/ej200708.pdf) • Taking Sex Differences Seriously by Steven E. Rhoads (http://www.lubrinco.com/ejournal/ej200411.pdf) • What Clients Love by Harry Beckwith (http://www.lubrinco.com/ejournal/ej200508.pdf) • With Winning in Mind by Lanny Bassham (http://www.lubrinco.com/ejournal/ej200509.pdf) 7. Subscription/Unsubscription/Copyright Information •• ÆGIS is supported and maintained by voluntary efforts. This publication is owned, published, and copyright © 2008 by The LUBRINCO Group Ltd, Inc. and Financial Examinations and Evaluations, Inc. It is edited jointly by Richard Isaacs (RBIsaacs@lubrinco.com), L. Burke Files (LBFiles@feeinc.com), and Terry Philips (TPhillips@aegisjournal.com). LUBRINCO provides services in three high-threat areas, too specialized to be dealt-with in-house, that can adversely affect domestic and international bottom lines. • Identification, valuation, and protection of intellectual assets and critical information. • American businesses lose $300 billion in revenues annually to competitive intelligence, economic espionage, inappropriate disclosure, and information theft. • LUBRINCO provides private sector consulting access to OPSEC, the government-standard process for identification, valuation, and protection of intellectual property and critical information. ÆGIS, March 2008 22 • Implementing an OPSEC program is likely to increase revenues for an at-risk operating group by $75 million. • International asset location and due diligence. o Location of concealed assets in fraud, theft, and divorce. o Due diligence to prevent fraud and loss in China, Central and Eastern Europe, Central Asia, the offshore financial centers, Latin America, and the Caribbean. o Financial fraud, anti-money laundering, and anti-corruption program development and training. • Protection of management, staff, and families. o In the high-threat environments of Latin America, Africa, the Mid- East, and Southeast Asia. o When traveling and living overseas. o When transporting items of substantial value. LUBRINCO identifies and quantifies threats and vulnerabilities, and their associated risk, then manages the vulnerabilities so you can transfer or live with the residual risk. We prevent disastrous financial loss to your company, and physical harm to you, your family, and your staff. For information on LUBRINCO and its services, or for the archive of all past issues of ÆGIS in PDF format, please go to http://www.aegisjournal.com/. Subscription to ÆGIS is available for $15 per year in North America and $20 per year outside of North America. To sign up for a complimentary subscription to ÆGIS or the ÆGIS PDF notification list, send an email to subscribe@aegisjournal.com. To subscribe to our AvantGo channel, go to http://avantgo.com/channels/_add_channel.pl?cha_id=1773 To be removed from the subscription list, send an e-mail to unsubscribe@aegisjournal.com. If you know of anyone else who should be receiving ÆGIS, please send their e-mail address to subscribe@aegisjournal.com. If there is a topic that you would like to know more about, send it to editor@aegisjournal.com and the editors will consider it as the topic for an article in an upcoming issue. ÆGIS, March 2008 23 If you would like to submit an article for publication in ÆGIS, send it as an attachment to an e-mail to editor@aegisjournal.com. Submission of an article certifies that (a) all information in the article is in the public record, or (b) that you are authorized to release any personal or corporate proprietary information contained in the article, and (c) that none of the article has previously been copyrighted. The submission of materials for publication in ÆGIS constitutes a license to LUBRINCO, and/or Financial Examinations and Evaluations, Inc, their assigns, associates, or affiliates, to abridge and/or edit said submission, and to copyright and publish/republish any submitted materials in whatever written and/or electronic form they may choose. If you would like to go beyond normal fair-use in reproducing articles from this issue of ÆGIS, you may do so freely as long as appropriate source, copyright, accreditation, and link to the ÆGIS Web site is included. 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Article Title, from the March 2008 ÆGIS (© 2008 LUBRINCO and FE&E), to be found at http://www.aegisjournal.com/. ÆGIS is a forum for the exchange of information, ideas, operating styles, theories, and related topics for corporate managers who make decisions about threats typically outside the expertise available in-house, yet which have the potential to affect their company’s domestic and international bottom lines. Nothing appearing in ÆGIS should be construed as legal advice. The information provided is “general information,” not “specific advice.” The solution to any problem is highly dependent upon the precise facts involved. Thus, before making any reliance upon anything said here, you should consult with an appropriately skilled professional. Opinions expressed by contributors are not necessarily endorsed by the publisher, and may be presented to encourage a dialogue among subscribers. The publisher and any re-publisher cannot be held responsible for any loss incurred as a result of the application of any information published in ÆGIS. Please be safe, and be smart.