nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Saturday, September 6, 2008

How Doctors Think


I saw this article in the current issue of AARP Magazine. (BTW, this mag has some good stuff in it). The author wrote a book last year called “How Doctors Think.” I read it and thought it was a good book, and recommend it, but it does oversimplify.

This article is great because there are three questions you should ask your doctor (in bold print below, if you don’t want to read the whole thing). The mistakes he discusses are real, and in learning the practice of medicine we got chastised any time we showed cognitive bias. I’ll never forget being close to tears after a 15 minute tongue lashing from one of my professors, or the several times Dr. DeBakey asked “Doctor, don’t you care?”

A couple of caveats. The rate of misdiagnosis may be 15%, but it aint that simple.

1. About 3% of people do not have a diagnosable disease. Despite the “wonders” of medicine, some people just don’t have a definable cause for their symptoms. (BTW, the rate of so-called Desert Storm Syndrome is also 3%). This doesn’t mean they won’t ever be diagnosable…just not now.

2. About 5% of people present to the doctor before a diagnosis can be made…too early in the illness. Sometimes the signs that make the diagnosis don’t appear until much later. Appendicitis is an example.

3. If the diagnosis is not certain, and the illness doesn’t seem serious, many doctors will try a course of therapy for what is the most likely. If you think that’s not right, just ask yourself how you would feel if your doctor said “we can’t diagnose this yet, you’ll have to wait.”

3. In another 5%, patients don’t tell their doctor everything…or the right stuff…or they intentionally withhold important information.

(All percentages are my personal observations, and not scientific)

And, see #2 below. The likelihood of having two things at once is vanishingly small. So, don’t bank on this being the problem…but, it can occur.

Lastly, if your doctor won’t talk to you, or answer these and any other questions, get a new doctor.

Doc D

1. “What else could it be?” This question helps to prevent an anchoring error or an availability error, where a diagnosis is formulated too quickly in the physician’s mind because it corresponds to the initial symptom or abnormality (anchoring) or because it is most familiar to the doctor (availability).

2. “Could two things be going on to explain my symptoms?” In medical school doctors are taught to be parsimonious in their thinking, meaning they are taught to identify a single cause to explain a variety of complaints and symptoms. But sometimes a patient can have two medical problems simultaneously. Physicians sometimes stop searching once they find an initial problem, even if the patient does not fully recover.

3. “Is there anything in my history, physical examination, laboratory findings, or other tests that seems not to fit with your working diagnosis?” All physicians tend to discount information that seems to contradict their hypothesis. This bias can lead a doctor down the wrong path; his or her anchor diagnosis may be so firmly fixed that this leads to ignoring contradictory data.

Jerome Groopman, M.D., is the author of the New York Times bestseller How Doctors Think (Mariner Books, 2008).

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