May 17, 2007
A physician examines his profession’s blind spots
Zachary Sholem Berger: How can patient and doctor better understand each other?
Jerome Groopman: Language is still the bedrock of medicine, despite all the great technology we have. I have a great doctor who listens very carefully, lets me tell my story; sometimes he interrupts to guide me. He is an active listener, explaining how he understood what I said and then explaining his thinking to me.
I've tried to make myself a better doctor. Like most medical students, I was not educated in thinking about thinking. At least I've become much more self-aware. Hopefully through the process of writing this book, I'll think better for my patients.
ZSB: How can a doctor retrain himself or herself in order to listen more, be open to more diagnostic possibilities?
JG: By and large, we do a good job as doctors. We're right about 80 percent of the time -- our misdiagnosis rate is 15 percent to 20 percent, which is remarkable. But in about half of misdiagnoses, there is serious harm to the patient. My hope is that people in charge of medical education will seriously look at this and ask how can we do better in terms of educating doctors to think about their thinking and avoiding pitfalls.
This concern comes out of the experience of the patient. Because we doctors see so many people, thinking in the moment, we have to use shortcuts. If lay people become educated about how we think, with a few appropriate and directed questions, they could help us think better.
They should ask, "Could this be anything else?" or "I'm worried this is something serious."
That is the genuine partnership.
ZSB: Could it be that the issue is not only thinking, but that doctor and patient need to understand how the other feels?
JG: There's an integration of thinking and feeling; our emotions color our thought processes. In the real world, pitfalls in thinking are also influenced by our emotions. So you have to recognize feelings -- to be self-aware and know there are going to be patients that you adore. That can impair your judgment, as well. The flip side is there are patients we don't like, that we find irritating or provocative.
ZSB: Do patients have to recognize feelings, as well?
JG: It's much harder to be a patient than a doctor. Research I mention in the book shows that patients pick up accurately if doctors like them or don't like them. Patients need to defuse such a situation or open it up. There are patients who have said to me, "I can feel how devoted you are to me. I don't want you to hold back." If [on the other hand] you feel like the doctor's irritating you, as I experienced myself as a patient, that's a red flag.
ZSB: What does the Jewish tradition mean to you?
JG: I feel its importance very deeply. There is room in it for doubt and skepticism and questioning, not a sense of infallibility. There's also extraordinary psychological insight with regard to motivation and character. For example, Maimonides talks about magical thinking, and the Torah talks about not believing in sorcery -- often patients do have magical thinking, believing that they will be saved.
ZSB: Doctors, too -- magical thinking guards us against admitting our ignorance.
JG: That's right! So we should be challenging ourselves. Judaism impels you to challenge yourself. In the greatest debates in Talmud, you are able to challenge the greatest authorities.
ZSB: Do you feel recourse to spirituality, to God?
JG: As much as I wish there were miracles -- boom, my hand's fixed -- those are fantasies. What Judaism teaches us is the knowledge that we're created with reservoirs of resilience. We are created with the capacity of wisdom, which means judgment -- not just knowledge, but the ability to assess and weigh that knowledge to make choices. Very integral in Judaism is the sense of hope. There is capacity to improve. What it takes is drawing on gifts of science with mobilization of the spirit.
ZSB: How do you mobilize the patient's spirit?
JG: I try to draw from them wellsprings of their resilience, to lift them up as best I can. The diseases I deal with are serious ones. The confrontation with those kinds of realities requires energy and commitment and determination on the part of a patient.
ZSB: Is the spirituality you've talked about just a fancy name for trying to inject religion?
JG: I don't think you need to be religious to have a sense of awe or to look within yourself or around you for nonreligious sources of strength, whether they be family, friends or therapists. I care for many people who are atheist and agnostic, and I certainly don't have the hubris of imposing any religious sensibility on them. My job as a physician is to help them find that core of strength and focus.
Zackary Sholem Berger, a frequent Forward contributor, is a medical resident in the primary care program at New York University.