Tuesday, July 31, 2012

Book Review: How Doctors Think by Jerome Groopman






How Doctors Think
By Jerome Groopman

“Different doctors have different styles of practice, different approaches to problems.  But all of us are susceptible to the same mistakes in thinking.” 
              -  From How Doctors Think  by Dr. Jerome Groopman.
  

Dr. Jerome Groopman is an oncologist/hematologist and chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston.  He has written several previous books and many magazine articles on medicine and biology.  These have appeared in “The Boston Globe Sunday Magazine”, “The New Yorker” and “The New Republic”, among others.  My opinion is that How Doctors Think, his latest book, should be required reading for every medical student, intern, resident and practicing physician.  It wouldn't be a bad idea for patients who wish to better understand their medical care and insure that they are being treated for the proper diagnosis to read this as well. 

The author notes the growing public demand for “quality of care” and reduction of medical error, citing recent reports from The Institute of Medicine and the National Patient Safety Foundation.  He notes, however, that medical error differs from misdiagnosis.  “It (misdiagnosis) is a window into the medical mind.  It reveals why doctors fail to question their assumptions, why their thinking is sometimes closed or skewed, why they overlook the gaps in their knowledge.  Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes.  As many as 15 percent of all diagnoses are inaccurate, according to a 1995 report which matches classical research, based on autopsies, which shows that 10 to 15 percent of all diagnoses are wrong.”

What are the flaws in thinking that lead to these misdiagnoses?  Dr. Groopman, referencing experts in cognitive theory and psychology, discusses three main categories of flawed thinking.  The first is termed “anchoring”.  This is when the physician grabs on to the first symptoms discussed by the patient and comes to a snap judgment.  The classic example of this is the overweight patient who complains of heartburn and is diagnosed with esophageal reflux when he actually is having angina.  The second flaw derives from the first and is termed “attribution error” which is a sequence of diagnosis and treatment begun with anchoring and continuing because of the doctor’s stereotyping of the patient.  Again, the physician has formed a quick first impression and doesn’t deviate from that assumption.  The third and final flaw is called “availability error,” that is, when thinking is clouded by recent experience.  In this example, the last thirty patients with this symptom have had reflux disease, so that must be what this patient has as well. He illustrates each of these cognitive errors with very compelling true life case histories, many from his area of expertise, oncology. 

            Dr. Groopman also has unkind things to say about how physicians are taught to diagnose and treat.  He dislikes diagnosis decision trees and treatment algorithms, feeling they limit thinking and promote another form of error which is termed confirmation bias.  In this setting the physician makes the data he obtains “fit” the algorithm which often leads to misdiagnosis and failed treatment.   The author is also not a fan of evidence based medicine, feeling that it relies too much on numbers which may be generated by flawed or limited technology.  He also feels that strict use of evidence based medicine leaves no room for intuition, “hunches” or thinking outside of the algorithm.

            The author also warns against what he terms “diagnosis momentum”.  This situation occurs when a patient is given a diagnosis by a specialist or academician and that diagnosis is never called into question by other physicians.  The correctness of this diagnosis is never challenged, even if subsequent data may contradict it.

            In the most important chapter in this book Dr. Groopman decries the lack of history taking skills in modern physicians.  He quotes William Osler: “If you listen to the patient, he is telling you the diagnosis.”  One study is cited where the average time from the first open ended question from the doctor to the time of the first interruption by the doctor was 18 seconds.  “Technology has taken us away from the patient’s story” decries Dr. Groopman.  Further: “Competency is not separable from communication skills.  The art of medicine is the sensitivity to language and emotion that makes for a superior clinician.”  Profound words, those.

            Dr. Groopman suggests three questions which patients should ask their doctors when they feel they are not responding to treatment.  These are:

   1- “What else can it be?”   This question should prompt the doctor to pause, think again, and extricate himself from a cognitive trap
   2- “Could two things be going on to explain my problem?” This addresses the pitfall of “satisfaction of search”, so if the physician stopped looking after finding an initial abnormality (Ockham’s Razor), he or she will now consider multiple causes for persistent symptoms.
   3- “Is there anything in my history, physical examination or lab tests that seems to be at odds with the working diagnosis?” This question is an important safeguard against confirmation bias (making the data fit the diagnosis).

All of these seem to be reasonable questions a patient can use to refocus their diagnostic and treatment process when things are not going well.

            I have only two complaints about this book.  The first is that the author only spends one paragraph describing “defensive medicine” and the impact of litigation on decision making.  There is no denying the reality that the shadow of malpractice litigation falls on every medical decision made and I think the author underplays it.  The second complaint that I have is that he glosses over the business side of medicine.  He does spend some time describing economic pressures which have dramatically increased the number of patients physicians must see daily just to remain economically viable.  This obviously decreases the amount of time spent with each patient and increases the likelihood of cognitive as well as other errors.  He never really delves into the cost of following “hunches” or thinking outside of the algorithm.  The cost of searching for obscure or unlikely diagnoses is never really brought into the argument. 

            This book has already changed the way I practice.  I find myself reviewing lab and radiology data looking for inconsistencies with my diagnoses.  I am wary of “diagnosis momentum” and find myself asking a long-time patient the question “Let’s start over and tell me how all of this started again?”  I try not to stereotype patients and try to look past “non-compliance” as a diagnosis and try to find out why a patient is non-compliant with their treatment regimen.  I try to let a patient talk for more than 18 seconds.  Read this book, you’ll be glad you did.

Wednesday, July 18, 2012

Book Review: The Drop by Michael Connelly





The Drop
Michael Connelly


     Michael Connelly is a former “Los Angeles Times” crime reporter who writes first rate mysteries, most of which are set in Southern California.  He is very prolific, having written several stand-alone novels (Bloodwork, Chasing the Dime, The Poet), five more books in a series featuring an eccentric defense lawyer named Mickey Haller (starting with The Lincoln Lawyer) and seventeen novels in a series featuring LAPD detective Harry Bosch.  The Drop is the latest in the Bosch series. 
 
      This novel will not disappoint Connelly fans as it feature two intricate plots, takes us further into the self-righteous mind of Detective Bosch and exposes more of the intricacies of big city politics.  Bosch is facing several personal dilemmas.  First he is adapting to the role of single father.  His fifteen year old daughter Maddie is now living with him and this adds another layer of responsibility to his already crowded plate.  Series readers will know why Maddie is now living with Harry having read the 15th book in the series, 2009’s Nine Dragons.  Harry is also facing the DROP, a police acronym for a delayed retirement option plan.  His time on the force is limited and he wants to catch as many bad guys as he can before he is put out to pasture.
   
     Harry is working with a new partner, an Asian-American named David Chu.  Harry Bosch is notoriously difficult on new partners, preferring to work solo and having had many partners shot over the years.  They are investigators in the Cold Case Unit and receive a new case prompted by a DNA match.  Blood found on the neck of a rape and murder victim from 1989 was run through the DNA data bank and a match is found with a convicted child molester and sex offender.  The problem is that the person so identified is only 29 years old which would have made him eight at the time of the crime.  Bosch and Chu must investigate to discover whether this person was indeed involved in the crime at such a young age or whether there was a mix-up in the crime lab. 
   
     On the same day that they receive the cold case investigation, a presumed suicide victim is found at the Chateau Marmont, a glamorous Hollywood hotel notoriously known as the site of comedian John Belushi’s death.  The victim is an attorney and son of a city councilman.  The councilman, Irving Irvin (again, familiar to long-time readers from previous Bosch books) is a former policeman who requests that Bosch head the investigation into his son’s death.  Bosch and Irvin go way back and their relationship has been adversarial at best.  Bosch is more than a bit perplexed as to why Irving asked for him to lead the official investigation into his son’s death.
   
     What follows is an intricate police procedural as Chu and Bosch chase down leads on both cases.  The cases remain completely distinct from each other and both investigations have false starts and red herrings.  The resolutions to both cases vex Detective Bosch, one because he fails to avert a disaster he should have seen coming and the second because he realizes he was used as a pawn in what he terms “high jingo”, or backstabbing high level city politics.
  
      Michael Connelly again displays his encyclopedic knowledge of Los Angeles:  its history, geography and sociology.  His settings and descriptions are intricately authentic and add a tremendous amount of realism to this novel as well as all of his previous ones.
   
     This is a great summer and beach book and keeps the reader entertained.  Despite having two distinctly different plot lines going at the same time, the author manages to balance them both and, if anything, the two plots makes the book move along at a very rapid pace.  You don’t have to be familiar with previous Connelly works to enjoy The Drop, but familiarity with Bosch and his previous exploits makes the story much more interesting.  Those of us who have “known” Bosch since he was a young Viet Nam war veteran starting on the LAPD (The Black Echo) it is interesting to see him age and adapt to the new technologies and investigative techniques.  Harry is older, wiser and even more cynical as the years go by, but he still works with uncompromising diligence and integrity on every case, including both of these.  It is interesting to see him parent his daughter Maddie.  Harry is at once overly protective and predictably indulgent.   In The Drop she declares her interest in becoming a police officer.  Bosch has trains her in marksmanship and Maddie is already very competent in regional shooting competitions.  Could this be where the series is heading?  I can’t wait to find out.  

Monday, July 9, 2012

The Virginia Creeper Bike Trail



Virginia Creeper Bike Trail
July 7, 2012

     The Virginia Creeper Trail is a 34 mile bike trail which spans Washington and Grayson counties in southwest Virginia.  The trail  is a former Norfolk and Western train right of way.  There are 47 trestle bridges which contribute to the very scenic route.  

     The trail starts at Whitetop Station trail head and ends in the quaint town of Abingdon, Virginia.  There are many restored railroad buildings along the trail which are now used as museums, shops and restrooms.  The trail parallels two creeks: Laurel and Green Cove Creeks.  The trail also crosses the Appalachian Trail at several points.  

Shortly after the take off from Whitetop Station


     You can rent bikes at multiple places along the trail, in Abingdon and also in the self-proclaimed "friendliest town on the trail" which is Damascus, Virginia.  Many of these folks will drive you and your bike up to Whitetop Station.  We stayed at The Martha Washington Inn in Abingdon and they have a shuttle package that includes bike rental, a ride up to Whitetop and a pick-up in Damascus (about 20 miles from Whitetop).  We brought our own bikes but used the hotel shuttle service.




Christmas tree farm and old barn

     We left the hotel at about 9:00 AM and arrived at Whitetop Station about an hour later.  The first part of the ride was very congested (it was a Saturday) with kids and inexperienced cyclists who were having difficulty controlling their bikes.  Once we were past this initial congestion it was smooth sailing the rest of the way.  We were surprised that the rhododendrons were still in bloom which added to the spectacular scenery on our descent.  The ride to Damascus is mostly downhill from Whitetop although there are some flat areas which require a little effort.  There were short trestles and very long trestles to cross and the creeks were flowing rapidly despite the recent dry weather.  We didn't see much in the way of wildlife.  There were some very pretty butterflies and we did see one deer.  Even though it was a very hot day with temperatures reaching into the high 90s, it was fairly cool on the canopied portions of the trail.

Green Cove Station, now a museum

     The old railroad buildings were fun to ride by and there were also many other sights to see: old barns, Christmas tree farms and the creeks as mentioned earlier.  We reached Damascus in about one hour and fifty minutes and had a picnic while waiting for the van from the hotel to pick us up.  It was getting very warm by noon so we were glad we had decided to do just that half of the trail.































     I would recommend this trail to anyone.  Serious cyclists would probably enjoy going the opposite direction more (Damascus to Whitetop) since the uphill climb would be more of a challenge.  For the amateur, the downhill route is the way to go.  We were told that the trail is much less crowded during the week.  We are already making our plans to return in October when the foliage should be at its Fall finest.


My wife and I at the end of our 19.6 mile ride - no worse for the wear!


Friday, July 6, 2012

Crosby, Stills and Nash at nTelos Pavilion, Charlottesville, Virginia, July 5, 2012




Crosby, Stills and Nash
nTelos Pavilion
Charlottesville, Virginia
July 5, 2012

"We can change the world
Rearrange the world" 
- CSN, "Chicago"


     Those of us in the grey hair population remember when we actually thought that was true.  Crosby, Stills and Nash were our spokespersons, our conscience, our collective soul.  They gave voice to a generation of war protesters, environmental activists, optimists and romantics.  Their art was (and, amazingly, stil is) more than their music.  They were relevant, important and vital.


      I have several vivid memories of this group:

1) I remember standing on a dock at the old Tidal Basin Boat Center in Washington, D.C.  where I worked summers and hearing "Ohio" for the first time on the radio.  All activity stopped while we listened to the angry rage of that song, released only weeks after the Kent State student killings.  We all felt this but CSNY put it out there in such a forceful and undeniable way. 
2)  I saw their performance (again with Neil Young) at the old Capitol Center in Washington, D.C. in 1974 which was about two or three days after Richard Nixon resigned because of the Watergate Scandal.  That was a show that is forever etched in my memory, especially the all out Stills-Young jams on "Carry On" during a lengthy encore.

3) I recall being stunned by the beauty of the vocal harmonies when the "Crosby, Stills and Nash" album was released and then being even more blown away by the follow-up "Deja Vu". 

So, it was with great mixed emotions that I purchased tickets to this show.  Would they be a shell of their former selves, resurrecting a tour to cash in on boomer nostalgia?  Would this be a "mail it in" performance of rehashed oldies but goodies like those awful rock and roll oldies videos played on NPR during their fund drives?  Or, would this somehow be a rekindling of the spirit of the '60s?  I figured it was worth the price of admission to find out.

    It was miserably hot in Charlottesville on July 5th.  The heat index was over 100 at show time.  nTelos distributed paper fans to help people cool off.  A bottle of water, though, was still $3.00.  The weather conditions were, in a word, oppressive. 

     Show time was 7:00 P.M. and there was no advertised opening act.  At about ten minutes after the hour David Crosby, Stephen Stills and Graham Nash walked on the stage unannounced and without fanfare.  Their band followed.  They picked up their instruments and boomed into "Carry On" - the same song I remembered from so many years ago.  It was obvious from this beginning that this night belonged to the Rock and Roll Hall of Famers and was going to be special.

     They played an extensive set list over nearly three hours (with one brief intermission).  They incorporated all of their hits as well as the great songs from their solo careers.  They dipped deep into their collective repertoire for such gems as Buffalo Springfield's "Bluebird" (juiced up by some great guitar playing from Stills), Crosby and Nash's "Wind on the Water" and finishing their first set with a rollicking kick-butt version of Stills' "Love the One You're With."

     The highlights (of which there were many) were from the CSN and Deja Vu albums:  "Helplessly Hoping", "Marakesh Express", "Our House" (with robust audience participation) and "Guinnevere" to name several. They validated their ongoing social consciousness with rousing renditions of "Chicago" and new songs dedicated to Bradley Manning, the U.S. Army private who leaked government secrets to Wikileaks and "In Your Name", a new Graham Nash tune which is a prayer asking God to stop the "killing in your name".  


    David Crosby really let loose in "Almost Cut My Hair".  During that song, the impossible happened.  I guess it was when Crosby bellowed/sang/screamed "I guess it was because I had the blues for Christmas" there was a time warp and it was indeed 1970 again.  I wanted to "let my freak flag fly" like Crosby, whose long, flowing white hair was billowing in the artificial wind created by an onstage fan.  The finale was a rousing "Wooden Ships" with Stills using every effects pedal known to man and destroying the whammy bar on his Stratocaster.  


     The encore was an acoustic "Suite: Judy Blue Eyes" with Stills acoustic/electric  solo leading into a full band final last verse and chorus.  This was a fitting ending to a memorable evening of music.


     Sure, there was an occasional technical lapse -  a missed solo entrance here, a slight missed harmony there, but give these guys credit.  The temperature was in the 90s for the entire show and probably hotter on stage.  These fellows aren't exactly spring chickens anymore either.  Crosby even quipped early on that we may be the audience "that gets to finally see us carried off a stage."   But for 180 minutes, Crosby, Stills and Nash turned back the clock and reminded us of when music meant something more than the bottom line on a spread sheet.  They entertained and mesmerized their audience.  They actually made me feel eighteen again, if just for a moment.  They gave a great performance for the ages under lousy conditions and, somehow, seemed to enjoy it.  They deserve to be the Hall of Famers that they are.


(Note: This was another "No Camera" event at the Charlottesville nTelos Pavilion.  I have alluded to this in previous post.  The folks at this venue have taken this to a new level, however and it is obnoxious.  The ushers climb over seats and yell at audience members who dare to brandish a smart phone or digital camera.  I did sneak the one photo during the encore, but would have really liked to have taken some more photos with a higher quality camera.  I think that Crosby, Stills and Nash should write a new song about the photo Nazis at the concert venues where they perform.)