When we completed our medical training a medical generation or two ago, both of us knew doctors who were unique and special in their ability to listen to patients, perform a thorough physical exam, and order a minimal number of tests which often led to the diagnosis. Today, many of us, including the authors, have found that the art of listening to our patients has become lost or marginalized.
For this article we had the pleasure of interviewing Dr. Jerome Groopman who is the author of How Doctors Think, which is on the New York Times best selling list. Dr. Groopman holds a chair in medicine at Harvard Medical School and has written other best selling books about medicine for both doctors and laymen. Dr. Groopman's research indicates that doctors are accurate in their diagnoses most of the time, but conservatively about 15 percent of all people are misdiagnosed. Some experts think it's as high as 20 to 25 percent and in half of those cases; there is serious injury or even death to patients. After experiencing a personal misdiagnosis and armed with this data, Dr. Groopman has provided information for both doctors and patients about the thinking of physicians and what physicians can do to improve our ability to listen to our patients and reduce the number of medical errors that have become so well publicized in the medical and lay press. After reading this article, your ability to communicate with your patients should increase and you will enjoy more satisfaction from the interactions with your patients.
According to Dr. Groopman there has been a change in physician thinking over the last 25 years. We have become doers rather than thinkers. It was just a few years ago that physicians were more dependent upon taking an accurate history, performing a thorough physical exam, and adding a few lab tests and imaging studies and we were able to reach a diagnosis or at least a differential diagnosis. Today, physicians are faced with a reduction in reimbursements, rising costs of overhead, and, consequently, an erosion of our incomes. As a result, there are increasing pressures on physicians to see more patients and spend less time per patient per visit. Physicians are now compelled to think more quickly and often we go with our first impression and fail to explore or more thoroughly delve into the patient's history. According to Dr. Groopman, it is not surprising that we may make more errors, resulting in more litigation against physicians and thus raising malpractice premiums.
Dr. Groopman points out that physicians have become more reliant on technology to help make a diagnosis and thus guide our therapeutic decisions. Even though we are gaining more confidence in the use of imaging technology to assist us in the diagnosis and the treatment of urologic diseases, the error rate is very high. Dr. Groopman cites data from a Duke study, which reports an imaging error rate of 25%.
An example of the double-edged sword of technology is the electronic medical record (EMR). An EMR has distinct benefits of providing quick access to all patients’ medical records with the risk of losing data significantly reduced with a good back up system. The EMR is also very efficient for billing purposes and enhancing reimbursement. There is also the opportunity for increasing reimbursements by using templates that are imbedded into the EMR. The same templates that are used to increase levels of E and M coding also present a downside. The downside of an EMR is the seductive aspect of checking off the boxes in a template driven system thus reducing the use of cognitive skills. Dr. Groopman has noticed that some residents will even copy and paste the history taken by other physicians into the EMR. He believes that this is a recipe for making errors by omitting something that is important. Using templates can move you away from active listening and using open-ended questioning such as “How do you feel?” or “What's bothering you?”
Dr. Groopman cautions doctors to avoid complete dependence on evidenced based medicine (EBM). Although a good EBM study can help doctors think about certain groups of patients and can compartmentalize certain therapeutic choices, we need to remember that many of these studies are done with a homogenous group of patients, usually with a single medical problem, who receive either a treatment or a placebo if it is a double blind study. However, these EBM studies could prevent you from thinking of the patient as an individual and not part of a group of patients in a study. Also, it is important to remember that these treatment guidelines may fall apart if the patients have atypical presentations or have co-morbid medical problems, which might have excluded them from the study.
Dr. Groopman comments that previous medical experience is very important as it sharpens your intuition. He suggests that extensive experience can help identify patterns, which can be helpful in patients with similar presenting complaints, signs or symptoms. However, he cautions physicians to be careful of “availability errors” (AE). AE is defined as what is most available in your mind or perhaps what is your first impression about the patient after listening to the chief complaint. These AE's occur when there is something about a patient who has a similar problem that reminds you of a diagnosis from a previous patient. Dr. Groopman points out that what is most available in your mind may mislead you. AE’s may lead you to see resemblances or similarities that don’t exist.
Dr. Groopman recently presented his research in the way doctors think to 700 deans and medical educators at the Association of American Medical Colleges. During that presentation he pointed out that the more we learn about the thought processes that we use in practice in the real which includes both the winning ways and the pitfalls, the better we can improve our thinking and protect ourselves and our patients from costly errors. He observed that we often use mental short cuts to achieve a diagnosis and although we are right approximately 85% of the time, we are wrong 15-20% of the time and that most of those mistakes are related to thinking errors.
Dr. Groopman points out that we commonly make use of the technique of anchoring. Anchoring involves grasping the anchor for the first piece of information that appears abnormal in the history, the physical exam, an x ray or a lab test. We tend to seize on that initial abnormality and run with it. Many errors occur because we seize or grab that first abnormal bit of information. The reality is that the first anchor may not turn out to be the key to solving the clinical puzzle. Therefore, in order to be more accurate, we must resist that natural tendency.
Dr. Goodman’s book provides advice on techniques physicians can use to evaluate themselves regarding their communication skills. First, he suggests that we say to a patient at the end of a visit, “Do you understand what is wrong and why I advised the treatment that I did?” Any reasonable layperson or family member should be able to understand what the problem is and why we offered a certain remedy. He then suggests that we ask the patient to repeat back to the doctor what the answers are to those two questions. If the patients are able to do so in a coherent way, then the physician knows that he has effectively communicated with the patient. If they can't, then something potentially wrong with the communication. Either the doctor didn't communicate well or the patient is in pain, is frightened, distracted and/or didn't hear the message. He advises that it is a good idea to have the patient’s spouse, sibling or caregiver in the room during this questioning and in order to ascertain that the patient truly understood your diagnosis and plan of action.
It is a well-documented that many physicians will interrupt a patient after only 18 seconds in the interview process. Dr. Groopman suggests that you actively listen to the patient; try to process what they are saying; and make every effort not interrupt the patient especially in the first several minutes of the history taking process. He also notes that patients, both men and women, aren’t listening to the discussion with the doctor when they are undressed or lying down on the exam table trying to cover themselves with the paper gown. For that reason, he recommends that doctors should not discuss diagnosis or treatment when a patient is undressed.
Bottom Line: We all have the training as podiatrists to diagnose and treat podiatric conditions. We can also all benefit on many levels by improving our ability to enhance our communication skills with our patients. This is achieved by honing our thinking skills that includes active listening and not anchoring or fixating on our very first impression. If we can do this, we become better doctors, have more enjoyment from our practices and, most importantly, make fewer errors. This is all best achieved by making a conscious and active effort to practice and sharpen the skills discussed in this article.
Hal Ornstein, DPM and Neil Baum, MD