On the other hand, I can’t wait to get my hands on Dr. Groopman’s book because I suspect that psychologists (or at least psychologists who have been trained in certain ways) may be able to feel a certain vindication of their nororiously slow, inefficient, and unreliable diagnostic methods. I ran across a sample chapter that I read with great interest and I have also looked at a few reviews. Over the past couple years I’ve developed a few ideas about why physicians get themselves into such tangles when they make errors and or confused, but haven’t really known how to write or talk about them since I don’t really work in a setting where I get to hang around with primary care docs. I’ve tried to test drive some of my ideas on clients or friends who are trying to get better care from physicians, though, and tried to read whatever I could about the cultural aspects of being a physician, and I really think I’m onto something here.

The way I see it, usually what physicians do works pretty well. But when things don’t go well, the skills and techniques that psychlogists
use every day aren’t really in the physician’s standard repertoire. Some of the things we can do with impunity that they can’t include:

1. Collaring a colleague in the hall and saying, “Here’s a strange thing: what do you think of this?” or “What would you do if you were me?” or some such thing. Physician’s don’t really seem to know how to consult. They ‘refer’ and the specialist takes care of the problem. They send a report back to the other doctor, but this doesn’t mean the 1st doctor knows how to do it himself next time it happens!

2. Say to a patient, “Hmmm. That’s a good one. I have some ideas (or no idea!), but I need some time to think it over. Let’s take this up again next week. First of all, physicians don’t see their patient weekly. Second of all, they don’t get paid to think: they get paid to know the answer. (Yikes! I couldn’t work like that!!!)

3. Say, “Well, I’ve never done this before, but I’m willing to learn. Do you want to be a guinea pig, or should I refer to someone with more experience?” There are some good reasons why we can say this without making a patient run for cover while physicians can’t. But then again, most things a Primary care physician does won’t kill you if he/she screws up, so why not just tell the truth? The patient can hear the risks and benefits (and running off to a specialist that you know nothing about, who may also be a total jerk is a not inconsiderable risk in any medical procedure) This might cause patients to panic — but then they’d get used to it. No client has ever panicked when I said it; some stayed and some chose another clinician. But it was always fine with both of us and didn’t involve any hard feelings on either side.

I have problems with their reliance on algorithms too because I think that in tough cases algorithms can constrain thinking too much. Also, what happens if you start with the wrong algorithm? And when you hit the final “no” in one of those flow charts, it’s hard to know where to go next. The conclusion that the patient does not have the disease under investigation and the conclusion that the person is well are entirely different, but those algorithms make it very easy to lose that distinction. Psychologists don’t have this problem because we can always fall back on personality disorders (I swear — I’m kidding about that!!!! This would be the default diagnosis for any lazy psychological diagnostician. I could have another totally separate rant on this.), but physicians are stuck with patients who keep coming back insisting that they are not getting better (i.e. – your efforts are not helping me!). I suspect that this is the moment when doctors are most vulnerable to the impulse to either start writing prescriptions willy nilly or simply get angry and start to blame the patient for his or her hypochondriasis. Obviously, no good can come of the doctor patient relationship once this pattern has set in. Do they teach medical students how to avoid this dynamic? I don’t know, but I’ve never heard that they do.

This is a long reply, but as I said, I’ve been thinking about this issue for some time. I think it would be both presumptious and useless to say that physicians (or, as I’m fond of saying, “REAL Doctors”) should be more like psychologists, I do think that between managed care and their own cultural values, medicine has a small but serious systemic problem that psychologists just might be able to help them out with.
Any thoughts on this?

Cindy M.

P.S. I don’t look at your site regularly, so forgive me if I’m stating the obvious: Ken Pope has a nice essay on logical pitfalls in interpreting psychological data on his web site. You probably know it, but just in case . . . I mention it mainly because the dearth of medical sites telling you how to avoid logical errors has been mentioned and I wanted to provide just one example of a relative wealth of resources for psychological reasoning.