How Doctors Think (37 page)

About 5 percent of people who go to the emergency room with what is, in fact, a myocardial infarction, or who are on the cusp of developing one ("crescendo angina"), are mistakenly sent home. Thus, McKinley's case is not at all rare. Twenty percent of patients with myocardial infarction in the ER have a normal EKG, and 25 percent do not have such classic symptoms as pain radiating down the arm or shortness of breath. Blood tests, like the cardiac enzymes that Croskerry ordered, often don't show a myocardial infarction or worsening angina even though there is blockage of the coronary artery; these enzymes may only rise to abnormal levels many hours after the onset of the chest pain.

A number of cardiologists have spent years trying to perfect algorithms that would identify chest pain specifically due to increasing angina or a full-blown heart attack as opposed to the many other causes of the symptom. Dr. Lee Goldman, a friend and colleague of mine, recently concluded, after two decades of trying, that an algorithm could not be perfected. Numerous studies have addressed how to more accurately identify those patients with a cardiac cause of their chest pain. A good discussion with a comprehensive bibliography is found in Lee Goldman and Ajay J. Kirtane, "Triage of patients with acute chest pain and possible cardiac ischemia: The elusive search for diagnostic perfection,"
Annals of Internal Medicine
139 (2006), pp. 987–995. Goldman, currently the vice president of health affairs at my alma mater, Columbia, said, "One lesson, which is probably a good one for us all, is to remain humble and open to changes in our thinking." It is better to err on the side of caution and admit patients like McKinley for observation rather than discharge them from the ER. But, of course, some patients should be sent home rather than kept under observation. It will always be impossible to predict 100 percent of the time whether the chest pain is due to coronary artery disease, but the ER doctor's decision to admit the patient or send him home should be made with attention to potential cognitive pitfalls.

The role of prototypical and attribution errors in the doctor's assessment of patients is well covered in Croskerry, "Achieving quality in clinical decision making," cited above, and Donald A. Redelmeier, "The cognitive psychology of missed diagnoses,"
Annals of Internal Medicine
142 (2005) , pp. 115–120. Currently, cardiologists use computer programs to help them analyze EKGs. "Computer EKG diagnosis of life-threatening conditions, e.g., acute myocardial infarction or high-degree AV blocks [arrhythmia] are frequently not accurate (40.7% and 75.0% errors respectively)." Maya Guglin et al., "Common errors in computer electrocardiogram interpretation,"
International Journal of Cardiology
106 (2006) , pp. 232–237. A cogent article advocating that physicians should develop strategies to enhance self-awareness is Ronald M. Epstein, "Mindful practice,"
JAMA
282 (1999), pp. 833–839.

Although first impressions may be correct, medical decision-making is not a process that should rely primarily on intuition. Recently, the lay media widely reported a study from the Netherlands that concluded that first impressions are superior to deliberate analysis: Ap Dijksterhuis et al., "On making the right choice: The deliberation-without-attention effect,"
Science
311 (2006), pp. 1005–1007. This study involved consumer choices, like buying furniture. The publication was followed by an important letter from Hilary L. Bekker, "Making choices without deliberating,"
Science
312 (2006), p. 1472. Bekker, who studies healthcare in the United Kingdom, pointed out that it is dangerous to go with your gut when it comes to clinical choices. The Dutch researchers strongly agreed that their work should not be glibly generalized to include clinical decision-making.

For those interested in the life and work of Dr. Francis Weld Peabody, the biography by Oglesby Paul,
The Caring Physician: The Life of Dr. Francis W. Peabody
(Cambridge, Mass.: Harvard University Press, 1991), is an excellent source. Dr. Peabody's contributions were also celebrated in "The care of the patient,"
JAMA
88 (1927), pp. 877–882.

3. Spinning Plates

Harrison Alter's ABCs of emergency care form the kind of mnemonic that can be lifesaving when immediate action must be taken. It provides a mental checklist that is readily retrieved from one's memory in an urgent and stressful situation. Its simplicity and comprehensiveness make it a useful aid that can move a doctor away from the far end of the Yerkes-Dodson curve where anxiety impairs performance. I wish that I'd learned these ABCs before my first day of internship when I froze in front of Mr. Morgan.

Earlier, I cited the extraordinary insights of Amos Tversky and Daniel Kahneman. Their exploration of availability errors is found in "Availability: A heuristic for judging frequency and probability,"
Cognitive Psychology
5 (1973), pp. 207–232.

Note how incomplete communication and cognitive pitfalls are linked in the case of Blanche Begaye. Once Alter had anchored his assumption that she had a viral infection, he limited his dialogue with her. In revisiting the reasons for missing the diagnosis of aspirin toxicity, he pinpointed that he did not define what "a few" meant. Alter is now an expert in emergency medicine, and that level of performance comes from listening to feedback and understanding past mistakes. This is consistent with the studies of Ericsson and Norman referred to previously: K. Anders Ericsson et al., "The role of deliberate practice in the acquisition of expert performance,"
Psychological Review
100 (1993), pp. 363406; Geoff Norman et al., "Expertise in medicine and surgery," in
The Cambridge Handbook of Expertise and Expert Performance,
ed. K. Anders Ericsson et al. (Cambridge: Cambridge University Press, 2006), pp. 339–353.

A physician considering which test to order is aided by a knowledge of its predictive value, and this is one instance where Bayesian analysis works well, so long as there is a solid database about how the test performs in populations with the specific symptoms or findings on physical examination.

Many of the technical errors that have plagued clinical care, like mislabeling an x-ray with the wrong patient's name or incorrectly transcribing the dose of a medication, have been remedied since the Institute of Medicine report referred to earlier. Nearly all hospitals have adopted procedures with checks and double checks to help safeguard against such mistakes. Recently, after an injury to my hand, the nurse practitioner made sure to mark the injured limb with an X so that the technician would place the correct hand on the x-ray plate to generate the film. Similarly, in my own field of hematology, patients who are anemic and need a blood transfusion wear bracelets with their name, hospital identification number, and date of birth. The nurse asks the patient to say his or her name and birthday, and then the nurse reads the bracelet to check that the spoken name and birthday match it, as well as the name and date of birth on the unit of blood that the patient will receive.

Maxine Carlson's story echoes, in some ways, that of Anne Dodge. The work of Roter and Hall is again relevant with regard to how doctors and nurses feel about patients who are characterized as neurotic or hypochondriacal. When such patients have been extensively evaluated in the past, and their medical records weigh several pounds, the physician's challenge is to think about what has not been examined. All of us tend to rely on previous laboratory tests and x-rays, but we should be equally attentive to the patient's current words. In both Anne Dodge's and Maxine Carlson's case, they were telling the doctors that something was different, that they were getting worse rather than better. The benefit of the doubt, meaning taking them at their word, can be a key trigger to thinking afresh about their symptoms and distinguishing them from their longstanding illnesses and prior complaints.

The disturbing story about the resident acting spitefully highlights the points made by Ronald M. Epstein, "Mindful practice,"
JAMA
282 (1999), pp. 833–839. Among senior clinical staff, there is increasing attention to providing constructive feedback to residents who behave inappropriately, with patients or with other healthcare providers, like nurses, technicians, and fellow physicians. Alter and the senior staff at Highland Hospital did provide such feedback in this case.

4. Gatekeepers

For readers interested in more details about how our first child, Steve, almost died, see Jerome Groopman,
Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine
(New York: Viking, 2000), pp. 9–37.

A study of the issues raised by McEvoy about communication is L. S. Wissow et al., "Pediatrician interview style and mothers' disclosure of psychosocial issues,"
Pediatrics
93 (1994), pp. 289–295.

Dr. McEvoy's article appeared in "They are fearless, they're mighty, they're ... The Incredibles,"
Harvard Medical Alumni Bulletin,
Winter 2006.

An engaging book about cultural differences and medical care is Anne Fadiman,
The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures
(New York: Farrar, Straus and Giroux, 1997). Her book should be required reading for every healthcare provider.

The study of forty-five physicians based in Sacramento, California, practicing in either a university center or community clinic is cited in Derjung M. Tarn et al., "Physician communication when prescribing new medications,"
Archives of Internal Medicine
166 (2006), pp. 1855–1862.

Dr. JudyAnn Bigby wrote an important book about context:
Cross-Cultural Medicine
(Philadelphia: American College of Physicians, 2003). A few months after I interviewed her, Dr. Bigby was appointed to head the Massachusetts Department of Health and Human Services.

Dr. Eric Cassell's book is an illuminating exploration of the art of medicine:
Doctoring: The Nature of Primary Care Medicine
(New York: Oxford University Press, 1997), pp. 16, 27, 28, 34, 38.

There is no simple way to find a physician who is right for you. Competence and character are the key criteria. Dr. Kent Sepkowitz addressed this in his lively article "A few good doctors: Don't look for them on a magazine top-10 list,"
Slate,
June 13, 2006.

5. A New Mother's Challenge

More information about ECMO can be obtained from reliable Internet sources that explain the machine, its uses, and risks. Among these are

www.nichd.nih.gov/cochrane/Elbourne/Elbourne.htm
www.childrenshospital.org/clinicalservices/Site459/mainpageS459P4.html
www.vanderbiltchildrens.com/interior.php?mid=959&mod

Pat Croskerry's phrase "zebra retreat" is found in his taxonomy of cognitive errors: "Achieving quality in clinical decision making: Cognitive strategies and detection of bias,"
Academic Emergency Medicine
9 (2002), pp. 1184–1204.

Harold Koenig, Michael McCullough, and David Larson have assembled a comprehensive and scholarly review of how faith influences patients:
Handbook of Religion and Health
(New York: Oxford University Press, 2001).

6. The Uncertainty of the Expert

A review of congenital heart disease is found in Ariane J. Marelli, "Congenital heart disease in adults," in
Cecil Textbook of Medicine,
22nd ed., ed. Lee Goldman and Dennis Ausiello (Philadelphia: Saunders, 2004), pp. 371–383.

There are numerous biographies and Web sites devoted to the life of Arthur Conan Doyle. I particularly enjoyed reading the material at
www.sherlockholmesonline.org
.

The illustration of the heart is adapted from Enchanted Learning, LLC.
www.enchantedlearning.com/subjects/anatomy/heart/labelinterior/labelanswers.shtml
.

The story about the medical meeting where cardiologists voted is derived from my interview with Dr. James Lock.

Lock's perspective on what is needed to achieve a high level of expertise in cardiac catheterization and other procedures is supported by the work of K. Anders Ericsson et al., "The role of deliberate practice in the acquisition of expert performance,"
Psychological Review
100 (1993), pp. 363406; Geoff Norman et al., "Expertise in medicine and surgery," in
The Cambridge Handbook of Expertise and Expert Performance,
ed. K. Anders Ericsson et al. (Cambridge: Cambridge University Press, 2006), pp. 339–353.

For those interested in learning more about fetal distress and how the aspiration of meconium can injure the newborn, see Michael G. Ross, "Meconium aspiration syndrome—More than intrapartum meconium,"
NEJM
353 (2005), pp. 946–948.

The challenges that pediatric cardiologists like James Lock face in caring for such patients as Baby O'Connell, particularly the lack of instruments designed for these children, is explored in my article "The pediatric gap: Why have most medications never been properly tested in kids?,"
New Yorker,
January 10, 2005.

The lack of awareness among most physicians that they have made cognitive errors is supported by Mark L. Graber et al., "Diagnostic error in internal medicine,"
Archives of Internal Medicine
165 (2005), pp. 1493–1499; Tejal K. Gandhi et al., "Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims,"
Annals of internal Medicine
145 (2006), pp. 488–496; Pat Croskerry, "Cognitive errors in clinical decision-making: A cognitive autopsy,"
Quality Healthcare Network,
May 2004; Donald A. Redelmeier et al., "Problems for clinical judgment: Introducing cognitive psychology as one more basic science,"
Canadian Medical Association Journal
164 (2001), pp. 358–360; Donald A. Redelmeier, "The cognitive psychology of missed diagnoses,"
Annals of Internal Medicine
142 (2005), pp. 115–120.