How Doctors Think

1. Thinking Like a Doctor: Beyond Algorithms and Evidence

But today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.

Algorithms vs. Intuition. While algorithms and evidence-based medicine have their place in routine diagnoses, they often fall short when dealing with vague, complex, or unusual cases. Over-reliance on these tools can discourage independent and creative thinking, hindering a doctor's ability to discern crucial clues. The best medical judgments blend initial impressions with deliberate analysis, requiring time and a willingness to think outside the box.

The Human Element. Statistics and algorithms embody averages, not individuals. A doctor's personal experience, knowledge, and understanding of a patient's unique needs and values are essential components of effective care. The human element, including intuition and emotional intelligence, cannot be replaced by numbers alone.

The Bedrock of Clinical Practice. Despite advancements in medical technology, language remains the foundation of clinical practice. The dialogue between doctor and patient, the patient's story, and the doctor's ability to listen and interpret both verbal and nonverbal cues are critical for accurate diagnosis and treatment.

2. The Power of Language: Listening and Emotional Connection

Osler essentially said that if you listen to the patient, he is telling you the diagnosis.

Open-Ended Questions. The way a doctor asks questions structures the patient's answers. Open-ended questions maximize the opportunity for a doctor to hear new information and avoid preconceptions. By allowing the patient to tell their story in their own words, the doctor can uncover vital clues that might otherwise be missed.

Emotional Response. Responding empathetically to a patient's emotions is crucial for building trust and eliciting information. Patients are often gripped by fear, anxiety, or shame, and a doctor's ability to acknowledge and address these emotions can significantly impact the patient's willingness to share their story fully.

Rapport and Competency. Good doctoring requires both competence and communication skills. Establishing rapport with the patient is essential for gathering information and arriving at an accurate diagnosis. Competency is not separable from communication skills; it's not a tradeoff.

3. Cognitive Errors: Traps in the Medical Mind

Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes.

Misdiagnosis vs. Medical Mistakes. Misdiagnosis is a window into the medical mind, revealing why doctors fail to question their assumptions, why their thinking is sometimes closed or skewed, and why they overlook gaps in their knowledge. It differs from medical mistakes, which involve prescribing the wrong dose of a drug or misreading an x-ray.

Common Cognitive Errors:

• Representativeness error: Thinking is guided by a prototype, so you fail to consider possibilities that contradict the prototype.
• Attribution errors: Patients fit a negative stereotype.
• Availability: The tendency to judge the likelihood of an event by the ease with which relevant examples come to mind.
• Confirmation bias: Confirming what you expect to find by selectively accepting or ignoring information.
• Anchoring: A person doesn’t consider multiple possibilities but quickly and firmly latches on to a single one.

The Importance of Self-Awareness. Recognizing and remembering past mistakes and misjudgments is crucial for improving clinical decision-making. Expertise is largely acquired not only by sustained practice but by receiving feedback that helps you understand your technical errors and misguided decisions.

4. The Emotional Temperature: How Feelings Influence Diagnosis

The doctor is supposed to be emotionally neutral and evenhanded with everybody, and we know that’s not true.

Positive and Negative Emotions. A doctor's inner feelings, both positive and negative, can significantly influence their perceptions and judgments. Disgust, frustration, or dislike of a patient can lead to attribution errors and poor care. Conversely, strong positive feelings can cause doctors to underinvestigate problems or make decisions that stack the deck in favor of a patient they especially like.

The Yerkes-Dodson Law. This law describes the relationship between arousal (tension) and performance. There is an optimal level of tension, termed "productive anxiety," that sharpens the mind and triggers quick reactions. However, extreme arousal can impair thinking and lead to errors.

The Need for Emotional Awareness. Physicians must be aware of their own emotional state and how it might be influencing their clinical judgments. This self-awareness is essential for providing unbiased and effective care.

5. The Emergency Room: Snap Judgments Under Pressure

We are diagnosticians, but not comprehensive diagnosticians.

Pattern Recognition. In the fast-paced environment of the ER, doctors often rely on pattern recognition to make quick judgments. The key cues from a patient's history, physical examination, and tests coalesce into a pattern that the physician identifies as a specific disease or condition.

Heuristics and Shortcuts. Doctors use heuristics, or mental shortcuts, to cope with the uncertainty and demands of the ER. These shortcuts can be "fast and frugal," but they also carry the risk of cognitive errors.

The Importance of "Studied Calm." To avoid making errors, ER doctors must cultivate a "studied calm," consciously slowing their thinking and actions to avoid being distracted or pressured by the chaotic environment. Patients can help by asking questions and prompting the doctor to consider alternative diagnoses.

6. Primary Care: The Art of the Gatekeeper

The secret of the care of the patient is in caring for the patient.

The Challenge of Volume. Primary care physicians face the challenge of seeing a high volume of patients each day, often with limited time for each visit. This can lead to burnout and a reliance on rote procedures, increasing the risk of missing subtle but important clues.

The Importance of Relationships. Building strong relationships with patients and their families is essential for effective primary care. This allows the doctor to understand the patient's context, values, and preferences, leading to more personalized and appropriate care.

The Gatekeeper Role. Primary care physicians serve as "gatekeepers," opening the portals to specialists. They must carefully assess each patient's needs and determine when a referral is necessary, balancing the benefits of specialized care with the potential for fragmentation and over-testing.

7. The Specialist's Lens: Expertise and Its Pitfalls

What we know is based on only a modest level of understanding.

The Power of Pattern Recognition. Specialists develop expertise through years of practice, learning to recognize patterns and make quick judgments. However, this expertise can also lead to cognitive biases, such as overconfidence and a reliance on prototypes.

The Importance of Questioning Assumptions. Even the most experienced specialists must constantly question their assumptions and be open to alternative diagnoses. This requires a willingness to challenge conventional wisdom and consider the possibility that they might be wrong.

The Value of Humility. The best specialists are those who acknowledge the limits of their knowledge and are willing to collaborate with other experts. They understand that medicine is an uncertain science and that humility is essential for providing the best possible care.

8. The Business of Medicine: Money, Marketing, and Ethics

The secret of the care of the patient is in caring for the patient.

The Influence of Marketing. Pharmaceutical companies and device manufacturers exert a powerful influence on medical decision-making through marketing and financial incentives. Doctors must be aware of these influences and strive to make unbiased choices based on the best available evidence.

The Medicalization of Normal Changes. Some companies seek to expand the market for their products by medicalizing normal changes in life, such as aging. Doctors must be wary of these efforts and avoid prescribing medications for conditions that lack a clear medical basis.

The Importance of Ethical Practice. Ethical medical practice requires a commitment to putting the patient's best interests first, even when it means foregoing personal financial gain. Doctors must be vigilant in guarding against conflicts of interest and maintaining their integrity.

9. Cancer: Science and the Soul

The secret of the care of the patient is in caring for the patient.

The Fear of Cancer. Cancer is a feared disease that becomes more likely as we grow older. It will strike roughly one in two men and one in three women over the course of their lifetime.

The Value of Complex and Harsh Treatments. How an oncologist thinks through the value of complex and harsh treatments demands not only an understanding of science but also a sensibility about the soul—how much risk we are willing to take and how we want to live out our lives.

The Importance of Guiding Choices. Two cancer specialists reveal how they guide their patients’ choices and how their patients guide them toward the treatment that best suits each patient’s temperament and lifestyle.

10. Patients as Partners: Questions to Guide Better Thinking

Patients and their loved ones can be true partners with physicians when they know how doctors think, and why doctors sometimes fail to think.

The Power of Questions. Patients and their loved ones can play an active role in improving medical decision-making by asking thoughtful questions. These questions can help doctors avoid cognitive errors, consider alternative diagnoses, and tailor treatment to the patient's individual needs and values.

Key Questions to Ask:

• "What else could it be?"
• "Is there anything that doesn't fit?"
• "Is it possible I have more than one problem?"
• "What's the worst thing this could be?"
• "What body parts are near where I am having my symptom?"

The Importance of Trust and Communication. A strong doctor-patient relationship, built on trust and open communication, is essential for effective care. Patients should feel empowered to ask questions, express their concerns, and participate in the decision-making process.

Last updated: February 14, 2025