Wednesday, March 19, 2008

How Dinah Thinks

I just finished Jerome Groopman's book
How Doctors Think. My beloved Co-Blogger, Roy, notes that we talked about this book in our last podcast-- to see those show notes and/or download the podcast, CLICK HERE. They also have a direct link to Dr. Groopman's book, which I'm too lazy to create here.

So Roy mentioned that I said Jerome Groopman purposely avoided talking about psychiatry. Per his footnote on page 7 of my hardcover copy:

I quickly realized that trying to asses how psychiatrists think was beyond my abilities. Therapy of mental illness is a huge field unto itself that encompasses various schools of thought and theories of mind. For that reason, I do not delve into psychiatry in this book.

I read the book and I actually thought all of it applied to psychiatry. Psychiatrists make the same cognitive errors in diagnosis, our thoughts are colored by the patients we just saw, the mistakes we've already made. The time we stopped a medication believing it was safe, only to find it wasn't. The one patient who had a horrible response to a medication. He talks in depth about uncertainty (one of my favorite topics) and oncology. I didn't think the issues one faces about whether to have chemotherapy for cancer-- given the fear of side effects-- was much different from the issues that surround the decision to take medication for mental illnesses. There could be side effects, there could be adverse effects, and in case you forgot how I think about those things or never got there in our now-enormous blog, click here for Medicines: The Good, The Bad & The Ugly. The issues for shrinks are the same. And when you get down to it, much of doctoring, any kind of doctoring, is about hearing the patient and the current pressures placed on doctors squeeze them out of taking the time it takes to do this. I'll grant Dr. Groopman that psychotherapy, one mode of treatment for psychiatric conditions, follows different rules than what he discusses. But in terms of diagnosis, risk, uncertainty, weighing the possible benefits of treatment against the possible harm that treatment can confer, re-thinking the clinical assumptions when things don't go well--- this book is completely relevant to psychiatry.

I loved Groopman's honesty-- he talks about himself as both doctor and patient, he tells stories well, he talks about complicated things simply. I liked that he starts by discussing the work of Debra Roter who studies doctor-patient communication patterns. Why? Because Debra is my friend and neighbor and it's always fun to stumble across someone I know on the pages of a book.

What I didn't quite jive with was the idea that diagnosis is an exact and elusive thing. It felt like there's a gold standard out there, something to compare with, and the reality of medicine is that so much of the time it's about best guesses. Perhaps not so in oncology-- there is a tumor or there isn't a tumor, it's malignant or benign-- even there I can tell some gray-area stories. In infectious disease a bug grows or it doesn't, but maybe we treat even when the bug doesn't grow. Often we don't get answers, and I'd like a dime for every time my childrens' pediatrician has told me over the phone "it's a virus." Oh, but all those illnesses resolved, generally without a prescription or further ado, and so by default, they were viruses. In Groopman's story, there was a diagnosis, one that was missed and then found, and the bottom line to keep thinking critically, to ask questions and not give in our own narcissism, is well worth hearing.

Okay, here's the link to How Doctors Think. I just sent a copy to my aunt.


Roy said...

I'm starting to think that everyone is Dinah's neighbor.

ClinkShrink said...

Nice post. I think there are gold standards, but the standards change as science evolves. The psychiatric gold standard would be the DSM or the SCID/DIS interview, or it will be until we get diagnostic brain scans and useful genetic tests.

I guess the bigger question is how useful are the gold standard tests in the day-to-day practice of psychiatry? That's an entirely different question.

Anonymous said...

Who else is my neighbor?

No, the DSM isn't a gold standard. Major Depression and Grief have the same symptom list. Oh, and let's see, do you have Bipolar disorder, anxiety with a naturally bright and productive mind (so you talk fast, have a zillion projects going at once)) or ADD?

It's not that different in medicine. Cough and a fever? Smudge on the xRAy, you get abx. If you're not coughing something up to culture, you never know what the bug is, could be a bacteria, could be a virus. Blood cultures will only be positive if you're REALLY sick. No smudge? Then we call it bronchitis. Do we do a bronchoscopy on every person to see if those bronchi are inflamed? Of course not. People are given diagnoses that there is no proof for all the time.

Friend's father recently had major surgery, went home, wife called an ambulance when he had a new seizure. Hospital work up and they were told he passed out from stress, no seizure. Ummmm...what test shows "stress" and how do you disprove a seizure after the fact? People are told that there problems are from stress, fatigue, exhaustion, 'dehydration' all the time. These aren't provable entities. Mostly it inspires them to take better care of themselves and hope it doesn't happen again.

Kutu Cat said...

It's so true! Psychiatry is both amazing and perplexing because the mind is such an uncharted territory. Was a medical student. Am now sitting at the other end of the consultation table. I found it soooo hard to "connect" with the therapist when communication styles and expectations are different.

ClinkShrink said...

I probably should have used the term 'reference method' rather than gold standard. I agree that there are no definitive tests for psychiatric disorders and that making a diagnosis is an ongoing process rather than a discrete event.

Midwife with a Knife said...

I guess I'm going to have to read the book one day. ;)

I agree that medicine really is more often shades of grey other than black and white. It is, actually possible to be "kind of pregnant" in a number of different ways (embryonic demise, ectopic pregnancy, etc.)