Chapter 6/3

How Doctors Think

Doctors think just like the rest of us. Some of us are better thinkers than others. Most of us, as adults, think within the parameters of our training. Once we are well trained, we tend to fall into habitual patterns of thought. The farmer sows his wheat in September, the teacher continues to think that grades above ninety are to be graded, “A,” the merchant begins in September, if not earlier, thinking about Christmas sales. And the physician tends to use tests and follow procedures that have worked well in the past.

After I began writing this chapter, Dr. Jerome Groopman published a book, How Doctors Think. I revised this section and it is now greatly indebted to Groopman’s book. He addresses two fundamental issues: poor thinking on the part of many doctors, and the pathway to good medical thinking. Although he does not mention the word, the book’s thesis echoes the DIALECTIC. Doctors, he says, need to recognize the fact that it is always possible they could be wrong in their initial diagnosis, to realize there is always more to be considered and to thus ask what else it could be, even, what the worst might be.

Groopman introduces his book with the story of a woman who over a fifteen-year period had seen almost thirty doctors, had been examined and tested from seemingly all angles, and had grown steadily worse. A consensus had formed that her problems comprised an eating disorder, irritable bowel syndrome, and some sort of mental illness. As she went from one doctor to another, her records followed her, thus the previous diagnoses followed her. Each new diagnosis was some variation of what the doctors read on the records they received. This is a typical pattern in human thinking. If everyone else thinks a certain idea is true, we are apt to think the same way. It is easier than thinking for ourselves.

Grudgingly, Groopman says, the lady went to one more specialist, a doctor who recognized the symptoms for the earlier diagnoses, recognized that the correct measures had been taken to treat these problems, but felt something more was involved. Do you remember that at the foundation of the DIALECTIC is the idea that “no human statement (medical or otherwise) is ever complete by itself; there is always something more?” So, one more unpleasant test was run and it was discovered that she had a condition which, at the time, was relatively unknown: gluten allergy. It explained everything, and with proper treatment, she improved rapidly.


One of the most satisfying comments ever made to me by a student was when Oma came in after class one day and commented: “I notice something different about you from other teachers. No matter what question anyone asks you, you always begin thinking about it from scratch. Unlike other teachers, you don’t seem to reach into your mental cabinet and pull out the well-prepared answer.” Often doctors make the mistake of giving a standard diagnosis when faced with what seems to be a set of standard symptoms. If flu is “going around,” and you come in with the same symptoms, you are apt to be treated for flu with no thought given to it. Like all the rest of us, Groopman says, doctors tend to go with the quick and easy answers. They have other patients waiting.

There are several reasons for this tendency among physicians. They are human. In medical school–just as in our schooling--they are not trained in thinking skills. Rather, they are trained in scientific method. They locate the medical field in the domain of science and understand themselves as scientists. They are also trained to recognize certain patterns of symptoms, tests, and treatment. But the problem is that we don’t all fit these same patterns.

Another problem that mitigates against good thinking is the patient load that limits the doctor’s time to think things through. Good thinking takes time, and doctors simply don’t have time; they seem never to have enough time for all aspects of their work. This problem explodes, Groopman notes, in the emergency room with its crises, patient overload, bed shortage, and impatient patients in the waiting room.

If the situation is to improve, we must take the initiative and ask questions such as: “Doctor, what is the worst this might be,” “what else might it be,” and “why did you say that?”. We must tell our story and the doctor must listen. It is our responsibility to help our doctors think. The DIALECTIC must work if we are to get good medical attention. If your doctor won’t enter in dialogue, change doctors. Your health is at stake.